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
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AmcriGIn College of 0
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Family Physicians
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Lippincott Williams & Wilkins a
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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
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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
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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 : •
•
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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.
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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
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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
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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 ress i o n fract u re
Plan of Treatment M e d i c a l m a n a g e m e n t p e r sta n d a rd of care was i m p l e m e nted and is n ot fu l l y item ized h e r e . Osteopath i c m a n i p u l at i o n was used i n seve ra l ways. The i n i t i a l intent i n t h e t h o r a c i c reg i o n w a s t o expedite o pt i m a l t h o r a c i c c a g e co m p l i a nce a n d ease of resp i ra t i o n . I n this case, however, t h e re was n e e d to work with i n the context of h e r
T1 0
dysf u nct i o n and its re l a t i o n s h i p to her a n t i - i n f l a m m at o ry u s e
a n d gastritis. As a n o l d i nj u ry, it re p resented a c h r o n i c p ro b l e m . With t h e p a t i e n t seated at b e d s i d e, t h e T 1 0 verte b ra l a rea was a p p r o a c h e d b y a p p l y i n g a n a rt i c u l a r proced u re a s descr i b ed p r ev i o u s l y. I n t h i s a p p l i cat i o n,
(Continued)
256
Sect i o n I I I • C l i n i ca l Cond itions
h oweve r, m o d ificat i o n was m a d e to a c c o m m odate t h i s p a t i e n t i n severa l ways. F i rst, the m a n e u vers were a p p l i e d u s i n g d e f i n i t i ve b u t g e n t l e a p p l i c at i o n of force, e m p h a s i z i n g d u ri n g the rotat i o n a l exc u rs i o n the i n d i rect p o rt i o n of r a n g e of m o t i o n , a n d t h e n o n ly l i g ht l y e n g a g i n g t h e d i rect b a r r i e r ove r seve ra l repet i t i o n s . S p e ci a l e m p h a s i s was p l a ced o n so l i d l y s u p po rt i n g t h e p a t i e n t so as to g i ve a ss u ra nce a n d o pt i m ize re l axati o n . Th i s p rocess took 3 0 seco n d s a n d was fo l l owed b y several cycles of seated r i b a rt i c u l at i o n , e m p h a s iz i n g t h e s i d e bend i n g a n d l atera l g l i d e of the r i bs . T h e n the patient was asked to l i e s u p i n e . The occ i p itoat l a nt a l area was l oosened with trac t i o n , then soft tissue i n h i b it i o n a n d a rt i c u l at i o n
(1 5
seco nds): The abdomen was
exa m i ned for e p i ga stric tender ness. Th i s a rea was avo ided, wh i l e tract i o n upon the d i a p h ra g m , a nterior a bd o mi n a l m u s c l es, and deeper tissues was a p p l i ed over the left u p p e r a b d o m e n . The focus of t h i s i n te rvention was to i nd u ce d i a p h rag matic relaxat i o n and a lso poss i b l y reset t h e sto mach a n d gastroes o p h a g e a l j u nc t i o n with i n the a bd o m i n a l cavity in the poss i b i l ity that there m i g ht be some aspect of h i ata l hern i a and associated ref l u x present
(2
to 3 m i n utes) .
T h a t e n d e d t h e ost e o p at h i c ma n i p u l at i ve p o rt i o n of t h e v i s i t fo r t h e f i rst d ay. R e p et i t i o n of m a n i p u l at ive p roced u res by h o u se staff l ater i n the day was r e q u ested a n d p ro p o xy p h e n e was o rd e re d on a s h o rt-te r m b a s i s to re p l ace t h e i b u p rofe n .
Pro gression On d a y
2 the
p a t i e nt was rest i n g comfort a b l y o n
2
L of oxyg e n , a n d oxyg e n sat
u r at i o n was 9 6 % . G a st r i c pa i n a n d b a c k p a i n were n ot present, a n d the pat i e n t h a d s l ept c o m f o rta b l y. Seated exa m i nation revea l ed that the f l e x i o n component of the thoracic dys f u n ct i o n was l ess p ro m i n e n t . R i b excu rs i o n a n d a bd o m i n a l protubera nce had n ot c h a n g e d i n a p pearance. There was less tissue t e n s i o n in t h e u pper cervica l a re a . Trea t m e n t o n d a y 2 was d i rected at r e i n f o rc i n g t h e p rev i o u s d a y's treat m e n t . T h e a rt i c u l a r tre a t m e nt o f T 1 0 was s l i g htly m o re forcefu l d u r i n g d i rect e n g a g e m e n t of t h e b a r r i e r.
Days 3 to 5 O M T was co n t i n u ed as t h e p a t i e n t g a i ned stre n g t h . G e n e ra l l y, a bd uct i o n of t h e a rms was used to e n h a nce i n h a l a t i o n . D u r i n g treatment, the use of t h e a r m s as long l evers o pt i m i zed f l ex i b i l ity of the u p p e r t o rso and stretch e s of accessory m us c l e s of res p i ra t i o n ; atte n t i o n to t h e se rrat u s a nte r i o r a n d serratus poste r i o r was e n h a nced b y use of co n n ective t i ss u e o r myofasc i a l r e l e a s e . The pat ient was i n st r u cted to exercise by ra i s i n g h e r a rm s a bove h e r h e a d a n d ta k i n g a d e e p breath to expa n d t h e c h est.
Comment O l d e r patients ofte n accrue a l i st of m u scu l o s k e l eta l d i a g noses att r i buted to a g e . I f a strategy to o pt i m ize f u n ct i o n rat her t h a n fata l i st i ca l ly accept i n g a rt h r i t i c c h a n g e a s a g e related i s a d o pted, st r i d e s can be m a d e to i m prove funct i o n a l i nd e p e n d e n c e a n d comfort, req u i ri n g l ess d e p e n d e n ce o n p h a rmaceut i c a l s a n d m a k i n g t h e i r u s e , w h e n necessa ry, more effect ive. O M T s h o u l d not be a d j u nctive. It m u st be fu nctio n a l ly i ntegrated i nto the treat m e n t of t h e com p l e x of m o r b i d i t i es t h a t p l a g u e t h e i n d i v i d u a l p a t i e n t . The O M T pres c r i pt i o n m u st be ta i l o re d to t h e u n i q u e n e e d s of t h e p a t i e n t .
Chapter 1 7 • T h e Pa t i e n t w i t h a Lowe r Res p i r a t o ry Tract I n f e ct i o n
257
T h i s case i l l ustrates t h a t s i g n i f i c a n t i m p rove m e n t ca n b e a c h i eved w i t h l i m ited t i m e on t h e p a rt of the treatment p h ys i c i a n . A dj u n ct i ve exercises a re a way of expa n d i n g t h e p h ys i c i a n 's i m pact w h i l e g i v i n g i n d e pe n d e nce and motiva t i o n to patients. Th is em powers pati ents to a ct o n t h e i r o w n be h a lf a n d to avo i d fee l i n g v i ct i m i zed b y t h e d i sease a n d b e i n g p a s s i ve i n i t s treatm e n t . F u rt h e r, t h i s h e l p s to c o u n t e r t h e d e p ress i o n so oft e n associ ated w i t h c h ro n i c or recu r rent d is e a se i n t h e e l d e r l y.
Case 2 History A 5 8-ye a r-o l d m a l e construct i o n s u p e rv i s o r went to t h e fa m i ly c l i n i c co m p l a i n i n g of s h o rt ness of breath, feve r, a n d ch i l l s w i t h prog ressive o n set over t h e p re vious 3 h o u rs . H e h a d a 40 p a c k-yea r h i st o ry of c i g a rette smo k i n g a n d h a d b e e n d i a g n osed with C O P O . Ad d it i o n a l l y, h e h a d h y p e rte n s i o n a n d sta b l e a n g i n a . C a rd i a c cathete r i z a t i o n 1 yea r prev i o u s l y reve a l e d n o tota l c o ro n a ry a rtery occ l u s i o n b u t p l a q u e a n d 3 0 % occ l u s i o n i n t w o vesse l s . A d ec i s i o n w a s m a d e i n favor of conservative treatment. The pati e nt's m e d icat i o n s i n c l u d e d l o n g-act i n g m eto p ro l o l 50 m g d a i ly a n d sa l m ete ro l i n h a le r 5 0 I-I g twice a d ay.
Physical Examina tion Vita l s i g n s i n c l u d e d t h e fo l l owi n g : h e i g ht, 5 feet 1 1 i n c h es; we i g ht, 1 68 I b; te m peratu re, 1 03 ° F; b l ood p ressu re, 1 3 8/88 m m H g ; a nd res p i ra t i o n , 28 p e r m i n ut e . P u l s e o x i m etry s h owed oxy g e n satu rat i o n of 9 2 % ; h e a rt r a t e w a s reg u l a r; a n d f i n e crack l es were h e a rd at t h e e n d of i n s p i ra t i o n , but t h e re w a s p o o r expa n s i o n of t h e c h est o n res p i rat i o n . R a d i o g r a p h y revea l e d i nf i ltrate i n b i l at eral bases, hyperae rat i o n c o n s i stent with COPO, and a n o d u l a r d e n s ity o n t h e r i g ht u p per l o b e u n c h a n ge d f r o m fi l ms t a k e n 2 y e a r s a g o . M uscu l oskeleta l exa m i nation revea led p o o r thoracic com p l i a nce w i t h heavy i n vo lve ment of the accessory m uscles of resp irat i o n . T2 was f l exed, s i de-bent r i g ht, rotated rig ht; and T4 was flexed, s i d e-bent l eft, a n d rotated l eft, with ma rked stiffness and bog g i ness in t h i s area. R i bs 4 to 8 r i g ht were restricted in exh a l a t i o n . Hyperto n i a of the ste r n ocl e i d o m astoi d a n d sca lene m uscles w a s n oted b i l atera l l y.
Assessmen t
1.
Com m u n ity a cq u i red p n e u m o n i a
2.
COPO w i t h exace r b a t i o n
3.
Hyperte n s i o n
4.
H i story of c a rd i ac d isease
5.
N icot i n e d e p e n d e n ce
6.
S o m a t i c dysf u nct i o n t h o r a c i c, r i bs, a n d cervi ca l reg i o n
Plan of Treatment The p a t i e nt d ec l i ned h o s p i t a l i z at i o n . B ro n c h o d i l ator treatm e n t was g i ven i n the office a n d oxyg e n saturat i o n rose t o 94 % . O M T was i n i t i ated g e n t l y b u t d efi n i t i ve l y. I n t h e presence of a c ute i l l n ess and an e n g a g ed i m m u n e system, t h ere is often an i ncrease i n t e n d e r n ess i n
(Continued)
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Sect i o n II I • C l i n i c a l Co n d i t i o n s
a re a s of dysfu n ct i o n . Ca re s h o u l d b e ta k e n t o avo i d a d d i n g t o t h e stress a n d d i sc o m fo rt associ ated with i l l n ess b y a g g ress ive t r e a t m e nt. R a t h e r, g e n t l e con t a ct ca n be soot h i n g a n d comfort i n g . S o a l so in t h i s case osteo pat h i c treatment s h o u l d p ro g ress in sta g e s . U s e of OMT h a s seve ra l p u rposes i n t h i s c a s e . O n e i s i f poss i b l e to e n h a nce t h o r a c i c com p l i a n ce and t i d a l vo l u m e a n d decrease sym pathetic to n e . T h i s p a t i e n t h a d a k e y r i b, r i b 4 r i g ht, t h at w a s l i m it i n g expa n s i o n o f t h e c h e st c a g e . R e l i ef of te n s i o n i n t h e c e rvi c a l a ccess o ry m u s c l e s a l so offe red l o n g -term bene f i t . Ad d it i o n a l l y, h e h a d dysf u nct i o n s c o rr e l ated with h i s hyperte n s i o n 2 7 as we l l a s w i t h h i s coro n a ry d i s e a s e . 3 To l e r a n c e b e i n g c l os e l y m o n itored, i n i t i a l O M T i nc l u d e d s e a t e d p a rasp i n a l s o ft t i s s u e-co n n ective t i ss u e r e l e a s e fo l l owed by g e n t l e a rticu l a r r e l e a s e i n the i d e nt i f i e d dysf u n ct i o n a l s e g m e nts, w i t h focus on r e l e a s i n g T4 and a ssoci ated r i b dysfu n ct i o n . M u sc l e e n e r g y is my p referred a p p roac h . S u p i n e treat m e nt ca n be a d d e d to do g e n t l e k n ea d i n g a n d soft t i ss u e cross-f i b e r a n d l o n g i t u d i n a l stretch to t h e c e rv i c a l m uscu l at u r e . Late ra l rec u m b ent p e r i sca p u l a r myofasc i a l re l e a se fo l l ows. A c o u rse of levofl o x a c i n 7 50 m g d a i l y fo r 7 days was beg u n . Arra n g e m e nts were m a d e to have a n off i ce recheck in 2 d a y s . If in the i n t e r i m t h i n g s got worse, i n c l u d i n g o n set of c h est p a i n, the p a t i e nt was i n str ucted t o proceed to t h e e m e rg e ncy d e p a rt m e n t . At fo l l ow- u p i n 2 d ays, if feve r h a d a bated a n d the patient i m p roved, he wo u l d be reassessed at a l l dysfu n ct i o n a l s e g m e nts with a n eye a l so to a n y p r o b l e m a re a s m i ssed o n t h e i n it i a l cu rsory exa m i n a t i o n . Tre atm ent of w h a t i s fo u n d i s t h e r u l e . A g reater l a t i t u d e of p roce d u res i s a va i l a b l e w i t h t h e i n c re a s e i n p a t i e n t comfort a n d to l e ra nce, as l o n g as a p p l icat i o n i s t i ss u e focused a n d dose a p pr o p r i ate . F o l low- u p i n a w e e k wo u l d be advised to d eve l o p a m a i n te n a nce strategy a n d treat res istant dysfu n ct i o n s .
Comment T h i s case i l l ustrates the fact t h a t osteop a t h i c d i a g n o s i s a n d t r e a t m e n t a re i n teg rated i nt o p a t i e n t m a n a g e m e n t a n d as s u c h a re not j u st a d d ed t i m e . A p p a r e n t l y ext ra t i m e m a y a d d d iv i d e n d s b y red u c i n g t h e n u m be r of d i ag n ost i c tests by a d d i n g a d d i t i o n a l tra c k i n g p a r a m et e rs, a s we l l a s d i rect l y s u p p o rt i n g t h e b o d y's s e l f - h e a l i n g c a p a c ity. If d iffi c u l t p a t i e nts a re n o t g i ven extra c a re in t e r m s of i n t e n s i ty, t h ey a re oft e n i n stea d g i v e n extra t i m e ove r a p r o l o n g e d t r e a t m e nt c o u rse.
Case 3 History An 89-ye a r-o l d wo m a n w a s tra n sf e r r e d f r o m a s m a l l n u rs i n g h o m e b e c a u s e s h e w a s n ot r e s po n d i n g to o r a l cefd i n i r s u s p e n s i o n a n d h a d b e g u n d e m o n strati n g i n c r e a s e d c o n f u s i o n a l o n g w i t h a n i n c re a s e i n te m pe r atu re, 1 0 1 ° F recta l ; w h i t e c o u nt, 1 8, 000; a n d a p o rta b l e c h e st r a d i o g r a p h s u g g es t i ng l eft lower lobe p n e u m o n i a . The p a t i e n t was i n c a p a b l e o f swa l l o w i n g m e d i c a t i o n i n p i l l form a n d h a d a n a d v a n c e d i rect i ve n o t t o resuscitate o r a p p l y h e r o i c m e a s u res o f l ife su p p o rt . D i s c u ss i o n with h e r n i ece, w h o h a d m e d ica l power of atto rn ey, however, l e d t o h o s p ita l i z a t i o n for a co u rse of i ntrave n o u s a n t i b iotics.
Chapter 1 7 • T h e Pati e n t w i t h a Lowe r Resp i rato ry Tract I n fectio n
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Physical Examination T h e pat i ent was a cach ectic-a p p e a r i ng w o m an w h o was respons i ve only t o pa i nful st i mu l i . V i t a l signs were t e m p e rature, 1 0 2 ° F, recta l ; b l ood pressu re, 90/64 m m Hg; res p i rati on, 3 2 , with m out h b reathing. Ch est ra d i ogra p h s u p on a d m i ssi on reve a l e d l eft lung i nf i l t rates, b l unt i n g of t h e l eft cost o p h ren i c angle, and overa l l osteo p en i a . The l eu kocyt e count was 1 8, 00 0 w i t h a l eft s h ift; culture sa m p l es of a i rway-suct i oned flui d s and b l ood were o btaine d . A rte r i a l b l ood gas (ABG) on room a i r d e m onst rated oxygen sat u rat i on 84 % ; Pa02, 78 m m Hg; H C03, 3 0 m E q/L; p H , 7 . 48; PaC02, 3 2 . T h e patient's r i b cage m oved st i ff l y b u t with fa i r ex pansi on . Ret racti ons i n i ntercosta l s paces w e r e noted and h e r a b d o m e n w a s scap h o i d . Ce rvical s pine stiffness overa l l, with tension in t h e subocci pita l t r i angl e on the right great e r t h a n l eft, w a s n oted .
Assessment 1.
Pneu m o n i a
2.
Cach e x i a o f c h ronic d i sease
3.
S o m at i c dysfunct ion r i b s, c e r v i ca l and a b d o m en
4.
D e m ent i a
Plan M e d i ca l m a nage m e nt of t h i s i n d i v i dua l was c r i t i ca l and c o m p l ex and was m od ifi e d d a i l y. T h e d eta i l s of t h at manage ment a r e not g e r m ane t o t h i s discussion and a re not e l aborated h e r e . This pat i e nt's A B G s a n d t h o rac i c structura l exam inati on suggest i neffi c i ent res p i rati on and uncompensated a l ka l osis on top of a c h ro n i c c o m pensa ti o n pat tern inv o l ving multi p l e system c o m p r o m i s e . OMT can b e sup p o rtive w i t h out t h e pat i ent's cooperati on. During routi ne rounds, several m inutes o f d o ing r i b rai s i ng from t h e l ate ra l posit i on and an ant e r i o r-app roach subocci pital re l ease m ay cont ri bute to opt i mizing respirato ry effort. T h ese procedures are d escr i b ed previous ly.
Comment D e a l i ng with t h e pat i ent w i t h m u l t i syst e m fai lure and poss i b l e nea r l y t e r minal status is a c h a l l enge. G oa l sett i ng i s som etimes c o m p l ex and d e l i c a t e . Knowing one has d one t h e best possi b l e j o b by b e i ng c o m p l ete and c o m pass i onate is grat ify i ng and often p r oductive . It a l s o c l e a r l y c o m mun i cates to t h e fa m i l y your ded i cated intent i on to care for this pat i e n t . Life sup p o rt includes issues o f qual ity o f l ife besides durat i on. Oste opat h i c manage m e n t and attent i on to t h e w h o l e pe rson m ay be d i rected toward c o m fort o r rea ssu ra nce m e a sures dur ing a pat i e nt's last days o r h ou rs. Yes, t h i s costs somet h i ng i n t i m e, but one neve r knows the fu l l i m pact of one 's l i m ited actions.
S U M M ARY Pneumonia is a
fea tures. In m o s t cases, even wi th pne u monia , it is hel pful to think in res o u rces to sel f-hea l . P h a rma cothera py is a
d i verse c l i n i c a l a re n a w i t h common
the c o m m o n streptococc a l co m m u n i ty - a cqu i red terms of o p t i m i z i ng
the
p a t i e n t 's h o s t
Section III • C l i n i ca l Con d it i ons
260
strong p l ayer i n this s i tu a t i o n . Sta n d a rd - of-care protocols for treati ng pneu mon ia emphasize c h o ice o f anti bi otic a nd decisions a bo u t h ospita l i zation . B u t the status o f the ind igen o us resou rces o f t h e patient s h o u l d n o t b e overlooked . Osteopath i c med ici ne h a s tra d itiona l l y contr i b u ted a v a r iety of models a i med a t d esigning a manip u l ative prescription for t he patient with pneu m on i a . Prescr i pt i o n is t h e key i d ea . A s with a n y d isea se or i n firmity, trea t men t is m o s t effective i f speci ficity o f tis s u e i mp a irment is employed a s the ratio n a le for ph ysio l ogic im pro vement. S i mp l e th i n gs at the right p l a ce a nd ti me a re often i m porta nt. Not a l l med i c i ne m u st be h i gh - tech , h igh-p riced , a n d hero i c . T h is c h a pter is a n a ttempt to b e b o t h moti vatio n a l a n d p r a ctica l i n s u ggesting w a y s to a d d OMT to the m a n a gement o f the pneu m o n i a p a tient.
eME co u rse
review, progres s i o n in s k i ] Is, a nd u se o f the c h a p ter refere nces a re en c o u raged .
References 1 . B r i t i s h T h o racic Society G u i d e l i n es fo r t h e M a n age m e n t of Co m m u n i ty Acq u i red P n e u m o n i a i n Ad u l ts . T h o r a x [seria l o n l i n e ] . D e c 2 0 0 1 ; 5 6 ( s u pp l 4 ) : i v 1 -i v 6 4 . U pd a te M a y 2004 ; 5 9 : 3 64-3 6 6 .
[ d a ta b a se
Ava i l a b le f r o m Th o r a x
o n l i ne] a t http : //www. t h o ra xj n l . co m . Acc�ssed Fe b r u a ry 2 0 ,
2005 . 2 . Sto l l e r J K , A h m a d M, Longworth D L, e d s . The C l e v e l a n d Cl i n i c Intensive Rev i e w of Interna l
M e d i c i n e . 3 rd e d . P h i l a d e l ph i a : Li p p i ncott W i l li a ms & Wi l k i n s , 2 0 0 2 . 3 . Wa rd R C , ed .
Fo u n d a ti o n s fo r O s teopa t h i c Med i c i n e . 3 rd e d . P h i l a d e l p h i a : L i p p i ncott
Wi l l i a ms & Wi l k i n s , 2 0 0 2 . 4 . R i l e y GW. Osteopa t h i c s u cce s s i n t h e trea t m e n t o f i n f l u e n za a n d p n e u m o n i a . Pa pe r be fore t h e
C h i c a g o ses s i o n o f t h e A m e r ica n O s teopa t h i c A s s o c i a tion,
July 1 919. J
A m O s te o pa th Assoc
2 0 0 0 ; 1 0 0 : 3 1 5-3 1 9 . 5 . Centers fo r D i se a s e C o n t r o l a nd Preve n t i o n .
D rug-res i s t a n t Strep toco ccus pneumoniae d i s
e a s e . Av a i .l a b l e a t : h ttp :// www . cd c . gov/n cid od/d bmd/d i se a se i n fo/d rug res i s s t re p p n e u m_t . ht m . Accessed Fe br u a ry 2 0 , 2 0 0 5 . 6 . S t i l l AT. R e s e a r c h a n d Practice. K i rk s v i l l e , M O : A u thor, 1 9 1 0 . Re p r i n ted in Sea ttle: E a s tl a n d
Press, 1 9 9 2 ; 8 3-8 9 . 7 . H a z z a r d C . P n e u m o n i a . I n : T h e P r a c t i ce o f Ap p l i ed Thera peu t i cs o f O s t e o p a t h y. 1 9 0 5 .
Repr i n ted a t h ttp://m e r i d i a n i n s t i t u t e . c o m . Accessed F e b r u a r y 2 0 , 2 0 0 5 . 8 . J o r d a n T, S c h u ster R , e d s . S e l ected Wr i t i ngs o f Ca r l Ph i l i p M c Co n n e l l , D O . C o l u m b u s , O H : S q u i r rel's Ta i l , 1 9 94 ; 9 0 . 9 . B a r be r ED . O s teo p a t h y C o m p lete, 1 8 9 8 . R e p r in ted i n : E a r l y Am e r i ca n M a n u a l T h e rap y.
Vi rgi n i a B e a c h , VA : L i feLi ne, 1 9 9 8 .
1 0.
K u c hera M , Ku che ra W. O s teo p a t h ic C o ns i d e r a t i o n s i n S y s temic D y s fu nc t io n . 2nd ed . Co l u m b u s , O H : G reyd e n , 1 9 9 4 ; 4 5 .
1 1 . Zi n k JG.
R es p i r a to r y
and
c i rc u l a t o r y
ca r e :
[ h e c o n ce p t u a l
m od e l .
O s teo p a t h
Ann
1 9 77;5 ( 3 0 ) : 1 08-1 1 2 .
1 2 . B a r ra l J P. The Th o r a x . Sea ttle, WA : Ea s t l a n d , 1 9 9 2 ; 1 5 6- 1 5 9 . 1 3 . S m i t h R IC O n e h u n d red t h o u s a n d cases o f i n fl u e nza w i t h a d e a t h r a te o f o n e - fo r t i e t h of t h a t
offic i a l l y reported u n d e r c o n v e n t i o n a l med i c a l
tr�a tment. 1 9 1 9 . J A m O s teopa t h Assoc
2 0 0 0 ; 1 0 0 : 3 2 0-3 2 3 . 1 4 . N o l l D R , S h o res
JH, G a m b e r R G , et a l . Be n e fits o f o s te o p a t h ic m a n i p u l a ti v e tr ea t m e n t fo r
hos p i ta l i ze d e l d e r l y p a t i e n ts w i t h p n eu m o n i a . 1 5 . N o l l D R, S no r e s
]H,
J
A m O s te o p a t h A s s oc 2 0 0 0 ; 1 0 0 : 776-7 8 2 .
B r y m a n PN, M a s terson EV A d j u nc ti ve osteo p a t h i c m a n i p u l a t i ve tr e a t
m e n t i n t n e e J d e r l y h o s p i ta l i zed w i t h p n e u m o n i a : A p i l o t s t u d y. J A m Osteo p a t n A s s o c 1 9 9 9 ; 9 9 : 1 4 3- 1 5 2 .
1 6 . S t i tes E . Somatic d ys fu ncti o n i n h o s p i ta l p r a c ti ce . Osteo pa t h A n n 1 9 7 9 ; 7 ( 1 ) : 4 9-5 2 .
1 7 . A m u n d s o n D , Pe r r i
J
].
C o m m u n i ty - a cq u i red p n e u m o n i a i n t h e m a naged care e n v i ron m e n t .
A m O steop a t h Assoc 1 9 9 6 ; S ( 4 ) : S 1 6-S 1 9 .
1 8 . Adler R , F e l t en D , C o h e n N . Psyc h o n e u ro i m m u n o l ogy. 3 rd e d . A m sterd a m : Elsevier Scienti fic, 2000.
Chapter 1 7 • The Pat i e n t w i t h a Lowe r Res p i rato ry Tra ct I n fect i o n
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1 9 . J o h nsron WL, Fr ied m a n H D . F u n c t i o n a l Method s : A M a n u a l fo r Pa l p a rory S k i l l Deve l o p m e n t i n Osteopa t h i c Exa m i na t i o n a nd M a n i p u l a ti o n o f M o r o r F u n c t i o n . I n d i a n a p o l i s : A m e r i c a n Aca d e m y of O s teopa thy, 1 9 9 4 .
20.
S t r eta n s k i M F, K a i s e r G . Osteo p a t h ic p h i lo s o p h y a n d e m e rgency trea t m e n t i n a c u t e res p i ra tory fa i l u re .
J
A m O s teo p a t h Assoc
200 1 ; "10 1 : 4 4 7-4 4 9 .
2 1 . Nelson K E . T h e p r i m a r y res p i r a to r y mech a n is m . A A O j 2002 ; 1 2 ( 4 ) : 25-34. 2 2 . Comea u x Z. R o b e r t F u l fo rd , D O , a nd t h e P h i l os o p h e r P h y s i c i a n . S e a t t l e : E a s t l a n d , 2 0 0 2 . 2 3 . C o m e a u x Z. Faci l i ta ted osc i l l a rory release. A A O J 2 0 0 2 ; 1 2 ( 2 ) : 2 4 -3 5 . 2 4 . C o m e a u x Z. F a c i l i ta ted osc i l larory rel e a s e : A method o f d y n a m i c a s s e s s men t a n d t r e a t m e n t of somatic d y s f u n c t i o n . A A O J 2 0 0 3 ; 1 3 ( 3 ) : 3 0 - 3 4 . 2 5 . Comea u x Z . The ro le o f v i b r a t i o n a n d osci l l a ti o n i n t h e d ev e l o p m e n t o f osteopathic t h o u g h r . A A O J 2 0 0 0 ; 1 0 ( 3 ) : 1 9-2 4 .
26.
Co l l i n s F W. O r i g i n a l O s teo p a t h i c M o v es a s Ta u g h t b y A . T. S t i l l . 9 t h e d . Pomeroy, WA :
27.
joh nston
Hea lth R e s e a rc h , 1 9 9 7 .
WL, K e l s o AF.
C h a nges i n p resence o f a seg m e n t a l d ysfu n C [ i o n p a rre w assoc i a te d w i t h
hyperte n s i o n : 2 . A l o ng-term l o n g i t u d i n a l stud y. j A m O s teop a t h A ssoc 1 9 9 5 : 9 5 : 3 1 5 -3 1 8 .
The Patient with Hypertension David M. Driscoll
"Much depends on the heart and great care should be given to its study, because
a
healthy system depends almost wholly on a normal heart.
A T Still7
INTRODUCTION The first person to measure blood pressure was Steph e n Hale, a clergyman, who
1733 i nserte d a piece of tubing into the caro tid artery of a horse.2 He was aston 9 feet in a glass column. This method, however, was not practical for regula r use in humans. It was not until 1876 that the sphygmo
in
ished to see the blood rise
manometer, invented by Ritter von Basch, was used as a noninvasive device to measure blood pressure. Blood pressure was found to be equal to
the pressure in
the inflated cuff compressing the arm at the point when t he first pulse co u l d be heard as the cuff was deflated-the force of ventricular contraction (systole).3 In
1905, almost 30 years later, Korotkoff described the region where the pulse sound disappeared as ventricular rel a xation (diastole).4 The measurement of b l oo d pres sure as we know it today, the r efo r e, is o n l y
100 y ea rs old. 1892, A.T. Still elo qu ent ly described elevated blood pressure in The Philosophy and Mechanical Principles of Osteopathy by viewing distu rba nces in the heart in terms of increased resistance: "I thin k any man with anatomical and physiological In
262
Chapter 18 • The Patient with Hypertension
263
knowledge will be able to reason and come to the conclusion that if an obstruction in the least toe, and that at the greatest distance from the heart, disturbs its regular ity and pulsation, that other causes of irritation and stoppage of either arterial or venous blood will cause demands that the heart use greater energy to force blood through the involved channels, just in proportion to the resistance it has to meet."1 In today's terms, this is better understood as increased peripheral vascular resistance. It is estimated that 50 million or more Americans have high blood pressure.s Worldwide, that number may be 1 billion; approximately 7.1 million deaths annu ally may be directly linked to hypertension.6 Of the 167 countries surveyed, more than 50% of the population aged 60 to 69 have hypertension.? The incidence and prevalence continue to increase; it is estimated that 75% of those over age 70 have high blood pressure.s A recent analysis from the Framingham Heart Study revealed that a normotensive individual 65 years old had more than an 80% chance of developing high blood pressure within 20 years.s Hypertension, therefore, is the most common condition the family physician will encounter in clinical practice. The Seventh Report of the Joint National Commission on the Prevention, Detection, Evaluation and Treatment of Hypertension ONC 7) released the latest recommendations in August 2004.9 Hypertension is defined as systolic blood pres sure (SBP) 140 or above, diastolic blood pressure (DBP) 90 or above, or taking antihypertensive medication. The normal range for blood pressure is defined as SBP less than 120 and DBP less than 80 for individuals without certain high-risk cardiovascular conditions.9 Blood pressure readings between 120/80 and 140/90 are considered prehypertension, and blood pressure readings equal to or greater than 140/90 are classified as hypertension in otherwise healthy individuals with out certain high-risk conditions. Home blood pressure readings or self-monitoring readings 135/85 or greater are also classified as hypertension. to It is well recog nized that early detection and effective treatment of hypertension lead to a signif icant decrease in cardiovascular mortality and morbidity. According to JNC 7, in individuals 50 years and older, systolic blood pressure above 140 is a more impor tant cardiovascular risk factor than diastolic blood pressure. Starting at 115/75, the cardiovascular risks double for each increment of 20110. Normotensive indi viduals at 55 years of age have a 90% lifetime risk of hypertension.s
EVALUATION The evaluation of patients with documented hypertension has four main objectives:
(1) Identify a cause of hypertension. (2) Assess the effect of hypertension on target organs. (3) Evaluate the response to therapy. (4) Identify other cardiovascular risk factors or concomitant disorders that may alter prognosis and guide treatment.9,11 For most individuals with hypertension, the cause is unclear and the disease is clas sified as essential hypertension. Recent studies have shown several identifying risk factors for the development of hypertension;12,lJ nonetheless, secondary causes of hypertension also should be considered. These include renovascular disease; chronic renal disease; coarctation of the aorta; states of glucocorticoid excess, such as Cushing's syndrome; medications and herbal formulations; primary aldosteronism;13 mineral corticoid excess; pheochromocytoma; sleep apnea; and thyroid disease.14 Certain lifestyles have been shown to contribute to and to enhance the effects of hypertension, while other lifestyles can reverse and prevent some of the devas tating affects of hypertension. Smoking, sedentary lifestyle, high sodium intake, and excessive alcohol intake contribute to the development of hypertension.12 Weight reduction, moderate alcohol use, a high-potassium diet high in fresh fruits
264
Section III • Clinical Conditions
and vegetables with low fat , physical activity, and smoking cessation help to pre vent and to control high blood pressure.15,l6 In eval uation of patients for hypertension, the medical history shoul d include
the known duration of the hypertension. The direct correlation between duration of hypertension and extent of end-organ damage has been well established. Evidence of l ongstanding hypertension can be seen in patients with coronary heart disease, congestive heart failure, peripheral vascular disease, renal disease, and sex ual dysfunction.
A medical history should include weight change, level of physical
activity, smoking, and alcohol use. Dietary assessment should take into account intake of sodium, saturated fat, and caffeine. The osteopathic physician shoul d also record musculoskeletal complaints that suggest lumbar, thoracic, cervical, or craniosacral somatic dysfunction. For diagnosis of hypertension, the physical examination sflOuld include the aver
2 minutes, with the 5 minutes.17 Caffeine,
age of at least two blood pressure measurements, separated by patient seated quietly in a chair, feet on the floor, for
at
least
exercise, and smoking should be avoided for at least 30 minutes prior to the meas urements. If home blood pressure monitoring is used, the cuff should be verified for accuracy in the office. If home blood pressure readings are consistently less than 130/80 despite elevated office blood pressure and there is no end-organ damage, treatment is not needed. IS High readings shoul d be verified in the contralateral arm. If the values are different, the higher reading should be used. Measurements of height, weight, and waist and body mass index (BMI)19 should be recorded. BMI
=
weight Kg/[height MF
Funduscopic examination should be done to detect retinal hemorrhages, atrioven tricular
(A-V) nicking, exudates, disc edema, or Holl enhorst pl aques. Examination
of the neck is done to check for carotid bruits, jugular vein distention, or thy romegaly. Lungs should be auscultated for evidence of rales or bronchospasm. The abdomen should be examined for abdominal bruits and organomegaly; the extrem ities, for edema and diminished or absent arterial pulsations. The musculoskeletal system should be evaluated for tissue texture changes or other signs of somatic dys function, particularly in the cervical and thoracic regions. Routine laboratory tests are recommended prior to initiating treatment for hypertension. These are done to assess damage to end organs or to identify under l ying causes of hypertension. Pertinent tests include urinalysis, complete blood cel l count, potassium, sodium, creatinine, fasting gl ucose, calcium, total cholesterol, high-density lipoprotein (HDL), and an electrocardiogram.9 Measurement of high sensitivity C-reactive protein (HS CRP) al ong with homocysteine levels also may be hel pful . Analysis of the Framingham Heart Study revealed that individuals with low HDL levels and elevated HS
eRP had a higher risk of developing cardiovas
cular disease than cohorts with normal or low HS eRP and high HDL.20
OSTEOPATHIC APPROACH TO TREATMENT Once the diagnosis of hypertension has been esta blished, treatment begins with risk stratification. The Worl d Health Organization
(WHO) and Joint National
Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure
ONe) recommend a similar approach to treatment. Major risk factors for
the devel opment of cardiovascul ar disease are smoking, dyslipidemia, diabetes mellitus, age older than 60 , sex (higher in males and postmenopausal females), and a family history of cardiovascular disease (women under
65 or men under 55).21
The risk groups defined for hypertension are given in Tabl e 18.1.
Chapter 18 • The Patient with Hypertension
265
Risk Stratification and Treatment Recommendations9 Blood Pressure Stage (mm Hg) Normal
Risk Group A 1a
Risk Group B2b
Risk Group C3'
Lifestyle modification
Lifestyle modification
Drug therapy
Lifestyle modification
Lifestyle modification
Drug therapy
< 120/80
Pre hypertension •
120/80-139/89 Stage 1
140/90-159/99 Stage 2
(up to 12 months)
> 160/100
(up to 6 months) Drug therapy
Drug therapy
Drug therapy
'No organ damag e , no cardiovascular disease.
bAt least 1 risk
factor for
heart disease
not Including
diabetes
mellitus; no organ damage or cardiovascular disease.
'Organ damage, cardiovascular disease, and/or diabetes mellitus with
or without risk
factors.
Lifestyle Modification Lifestyle modification offers the opportunity to lower blood pressure and cardiac
risks without medications. All patients, regardless of what stage or risk group they are in, should be encouraged to participate in aerobic physical activity; the American Council on Aging recommends 30 to 45 mi n utes a day at .least 4 days
a
week.22,23 Patients should lose weight if needed, Even a 10-lb loss in total body weight c a n lead to a significant reduction in cardiac risk.15,24 D ietary saturated fats and cholesterol should be reduced. Alcohol intake should be limited to 1 oz of ethanol, equivalent to 24 oz b eer, 10 oz wine, or 2 oz 100-proof whiskey (vodka) per day for males and half that quantity for females and lighter individuals.25 Sodium intake should be limited to 2.4 g-6 g sodi um chloride-daily.26,27 Adequate potass ium intake (90 mmol da ily) is recommended along with adequate intake of calcium
and magnesium . ls
A modified DASH (Dietary Approaches to Stop
Hypertension) diet, high in fresh fruits and vegetables and low in sat urated fats, should be encouraged.28 Finally, smo king cessation cannot be stressed enough. S mo king cessation aids with nicotine contain a lower amount of nicotine than cig arettes and us ually do not significantly raise blood pressureY
Medications
Decreasing blood pressure thro u g h the use of medications has been c l ear ly shown to reduce cardiovasc u la r mort a l ity and mor bidi ty in several la r ge long-term pop u l ation studies.2�-;(' It is evident that the most effective medication for treatment of h ype rtension is the one medication or combin ation of medications that low ers the blood pressure into a safe range with the least number of side effects. Optimal formulations sustain normal blood pressure for 24 hours with once-a-day dosing. There
are
sever a l reasons for once-a-day dosing: (1) to provide smoother, persist
ent blood pressure control instead of fluctuating , intermittent cont rol ; (2) to pro mote better adh erence to the (on ce- a - day) dos ing reg im en ; (3) to protect against the risk of stroke or heart attack secondary to the a brupt increases se e n with
s horter-acting agents; (4) to reduce the expen s e for the patient if cost is a factor in com plian ce .
266
Section III • Clinical Conditions
Conditions to Consider When Selecting or Avoiding Certain Hypertensive Medications6 Indication
Medications Reducing Cardiovascular Morbidity and Mortality
Diabetes mellitus
ACE 1, diuretics, beta-blockers, ARB, CCB
Heart failure
ACE I, diuretics, beta-blockers, ARB, aldosterone antagonists
Isolated systolic hypertension (elderly)
Diuretic (preferred), long acting DHP CCB
Post myocardial infarction
Beta-blocker, ACE 1, aldosterone antagonists
Chronic kidney disease
ACE I, ARB
High-risk coronary disease
Diuretics, beta-blockers, ACEI, CCB
Recurrent stroke prevention
Diuretic, ACE I
Indication
Medications That May Have a Favorable Effect on Comorbid Conditions
Beta-blockers, CCB
Angina Atnal tachycardia and fibrillation
Beta-blockers, CCB (non-DHP)
Cyclosponne-induced hypertension
CCB
Diabetes mellitus type I and II with proteinuria
ACEI, CCB
Diabetes mellitus type II
Low-dose diuretic
Dyslipidemia
Alpha-blockers
Essential tremors
Beta-blockers (non-CS)
Heart failure
Carvedilol, losartan potassium
Hyperthyroidism
Beta-blockers
Migraines
Beta-blockers (non-CS), CCB (non-DHP)
Myocardial infarction
Diltiazem, verapamil
Osteoporosis
Thiazides
Preoperative hypertension
Beta-blockers
Benign prostatic hypertrophy
Alpha-blockers
Renal insufficiency (caution with renal artery stenosis or creatinine �3mgldL [2652 � moles/L]
ACEI
Indication
Medications That May Have Untoward Side Effects on Comorbid Conditions
Bronchospasms
Beta-blockers
Depression
Beta-blockers, central alpha-agonists, reserpine
Diabetes mellitus I and II
Beta-blockers, high-dose diuretics
Dyslipidemia
Beta-blockers (non-ISA), high-dose diuretics
( Continued)
Chapter 18 • The Patient with Hypertension
267
Conditions to Consider When Selecting or Avoiding Certain Hypertensive Medications6
Gout
Diuretics
2° or 3° heart block
Beta-blockers, CCB (non-DHP)
Heart failure
Beta-blockers (except carvedilol), CCB (except amlodipine, felodipine)
Liver disease
Labetalol, methyldopa
Peripheral vascular disease
Beta-blockers
Pregnancy
ACE 1, ARB
Renal insufficiency
Potassium-sparing diuretics
Renovascular disease
ACE 1, ARB.
According to jNC
7
recommendations,
based on the outcome of the
Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study, a thiazide-type diuretic is still considered the initial drug of choice for most cases of stage 1 hypertension.9.J6,J7 Patients whose blood pressure is greater than 20
mm
Hg above the systolic goal or greater than 10 mm Hg above
the diastolic goal should initially take two agents to achieve goal readings. Also, there are compelling reasons to use a different class of antihypertensive medication in patients with diabetes, heart failure, kidney disease, isolated systolic hyperten
sion in the elderly, or ischemic heart disease ( Ta b le 18.2).
OSTEOPATHIC APPROACH The osteopathic approach recognizes the human body as a unit. It is the duty of the osteopathic physician primarily to treat patients, not disease. This is in contrast with practitioners who allow the disease to take center stage, leav i n g the patien t to play a secondary role. When this occurs, the musculoskeletal and psychosocial aspects of the management of the disease entity are lost. Since hypertension has a global effect on the body, all systems must be taken into consideration, including not only the vascular and cardiac systems but the renal, neurologic, endocrine, ocular, and musculoskeletal systems. Osteopathic manual medicine is traditionally thought of as a method for diag
nosing and treating nonsurgical orthopedic problems such as back pain. This sim p l ist ic view fails to recognize the role the musculoskeletal system plays in health and disease. The osteopathic approach to hypertension is best used when it draws upon its rich heritage along with implementing the latest in science and technol ogy. By recognizing the role of the musculoskeletal system in cardiac disease, osteopathic physicians can use their keen sense of touch to aid in the diagnosis and treatment of hypertension.38 Changes in blood pressure are sensed by the afferent neurons innervating the carotid sinus and aortic baroreceptors. A rise in blood pressure that stimulates the baroreceptor afferent nerve fibers results in both direct and indirect stimulation in the parasympathetic vagal innervation of the heart.J9 The vagus nerve emerges
268
Section III • Clinical Conditions
from the medulla of the brain and exits the skull through the j u g u lar foramen. The vagus nerve has four basic components: (1) The brachial motor component (effer ent) innervates the striated muscles of the pharynx, tongue, a nd most of the lar ynx. (2) The visceral motor component (efferent) innervates smooth muscle and glands of the pharynx, larynx, thoracic, and abdominal viscera.
(3) The visceral
sensory component (afferent) innervates larynx, trachea, esophagus, and abdomi nal viscera, the stretch receptors in the aortic arch, and chemoreceptors in the aor
tic bodies adjacent to the aortic arch.
(4) The general sensory (afferent) component
innervates the skin at the back of the ear, external acoustic meatus, part of the tym panic membrane, and pharynx.4o Dilation of the coronary arteries and heart rate are conrrolled by the interactions of the sympathetic and parasympathetic nerves. The cardiac sympathetic nerve sys tem arises from the upper five thoracic segments via the cervical ganglia. These sym pathetic nerves are responsible for dilation of the coronary arteries and for acceler ation of the heart rate. The parasympathetic nerves form from branches of the vagus nerve, which in turn is responsible for deceleration of the heart rate. These autonomic nerves form the superficial and deep cardiac plexuses. Preganglionic sympathetic fibers arise from the nucleus intermediolateralis in the lateral horn at the level of T1 to T5. The higher thoracic segments innervate the ventricles,
while
the lower innervate the atria.41 The anatomic location of these nerve fibers and
tracts is the basis for looking at th e cervical and thoracic vertebrae in the individ ual with suspected cardiac disease.
RESEARCH BACKGROUND The effective management of hypertension with medications has changed radically over the past
20 years and continues to evolve. It was not until the 1960s that ran
domized, controlled double-blind studies started to show the benefits of drug treatment in patients with severe diastolic hypertension (DBP �
115). As a result
of the Veterans Administration Cooperative Study Group on Antihypertensive Agents
(1967), there was a substantial reduction in cardiovascular morbidity.42
Prior to that, in the early part of the twentieth century, the ability to treat hyper tension was limited. Foxglove (digoxin), nitrates, bromides, barbiturates, iodides , reserpine, and other herbal remedies were commonly used.43 Because of the side effects of many substances and questionable efficacy of several others, many osteo pathic physicians resorted to manipulation in the treatment of hypertension. Spinal manipulation was prescribed to decrease sympathetic outflow to the myocardium and arterioles.44 Visceral manipulation was also used to decrease passive liver con gestion.45 The rational for such rreatment was based on studies involving viscero somatic and somatovisceral reflexes.46 In the early
1900s, using human and animal models, Louisa Burns47 studied vis
cerosomatic and somatovisceral spinal reflexes. Burns's findings revealed that stimu lation of visceral pericardium and the heart
resulted in contractions of the second to T5 in dogs
sixth intercostal muscles and to paraspinal muscles at the level of T2 to
(viscerosomatic). Furthermore, local stimulation at the upper thoracic region resulted in lower systolic blood pressure and lower pulse rate than did local stimulation in the lower thoracic region (somatovisceral). Burns observed that the somatovisceral reflexes were much less circumscribed and direct than were viscerosomatic reflexes. Burns further stated, "Since abnormal conditions of the viscera follow sllch pressure upon somatosensory nerves as is sufficient to lessen conscious sedation , and since sec tion of somatosensory nerve is followed by abnormal conditions of the viscera, it is
Chapter 18 • The Patient with Hypertension
269
inferred tnat normal visceral activity depends in part upon the stimulation derived from tne somatosensory nerves." Sne further suggested that abnormal viscerosomatic reflexes may be used as an aid to tne diagnosis of certain conditions.47 These studies p rovided tne early foundations for Cnapman's reflexes, which would not be published for anotner 30 years. Frank Chapman was
a
practicing osteopathic p h y s icia n from Tennessee who kept
a personal account of his findings. It was not until after his deat h that his wife, Ada Hickey Chapman, and his brother-in-law, Charles Owens,48 made them public by publishing An Endocrine Interpretation of Chapman's Reflexes. Chapman observed reproducible tender points tnat were commonly paired anteriorly and posteriorly and that corresponded to specific visceral elements. He discribed these tender points as ganglioform contractions. Not only were these tender points used in the diagno sis of certain conditions, he and others used these reflex points to treat various aiJ
,
m en ts. 4 8 4 9
In J 979, Mannin050 examined 35 hypertensive and 10 normotensive
patients after 7
v is i t s
over a 3-week period. Blood pressure and aldosterone levels
were measured at each visit after treatment of the posterior adrenal component of Chapman's reflex (TIl and T12). The results showed no significant decrease in blood pressure over the test period. There was a significant decrease in aldosterone levels, however, in patients treated with a "make-break circular motion" at Tll and
T12, when compared to patients treated at T8 using tne same procedure.50 As tne profession evolved, a generation of clinical researchers, such as Myron Bea l
and William Johnston, applied osteopathic principles to clinical medicine. Their efforts provided a framework for osteopathic physicians to record their findings in a reproducible systematic fashion. What is intriguing about these studies by Beal, Jonnston, and otners are the corrunon findings described in the thoracic and cervical region. [n
a
prospective study of 108 patients conducted in 1983, Beal developed spe
cific palpatory procedures for examining cardiovascular disease.51 The examination was performed witn the patient supine. The cervical and thoracic spine was screened for tissue texture changes and segmental response to deep compression. (See Beal's compression test, Chapter 5.) Areas of somatic dysfunction were recorded in the upper thoracic and at C2 and C6. Changes in tissue texture, vasomotor reactions, temperature changes, skin moisture, muscle hypertonicity, hyperesthesia, and seg mental musculoskeletal restriction in the vertebrae and ribs were observed. These changes demonstrated a unique pattern attributable to cardiac disease.5 1 Johnston and his associatesS2,S3 later reported somatic findings in hypertensive patients over a period of 4 to 8 months in a single (physician) blinded study using a standardized palpatory examination. T he 253 patients who participated in the study were classified as normotensive, borderline hypertensive, or hypertensive, according to JNC guidelines. There were 61 normotensive, 25 grade 1 hypertensive, and 167 grade 2 or higher hypertensive patients. Johnston noted a repeated pattern of somatic dysfunction, with asymmetry centered at C6, T2, and T6. During the ini tial examination, the C6, T2, T6 pattern was observed and recorded in 24 of the 61 normotensive patients (31 %), 18 of the 25 grade 1 hypertensive patients (72%), and 134 of the 167 grade 2 or greater patients ( 80%).52 A 4- to 8-month follow-up revealed that this pattern was present in 25 of 35 normotensive patients and 133 of 149 hypertensive patients who had continued with the study.53
Johnston further observed that the rib or costal component of the corresponding vertebra demonstrated different palpable characteristics depending on whether the examiner was observing a purely somatic component or a viscerosomatic component. If the somatic dysfunction at the vertebral level is a primary dysfunction, the costal segments behave opposite (mirror image) of the corresponding vertebral segment.
270
Section III • Clinical Conditions
Summary of Osteopathic Findings in Patients with Cardiovascular Disease
Reference. Date
T1
T2
Snyderll (1924)
X
T3
T4
X
X
X
MacBain56 (1933)
X
X
X
SingietonS7 (1934)
X
X X
Robuck58 (1935)
TS
T6-T10
X
,
1, 2, 5 X
X
X
Pottenger60 (1938)
X
X
X
X
X
T6
Becker6! (1939)
X
X
X
X
X
T6
Long61 (1940)
X
X
X
X
X
T6-T10
X
X
Burns6J (1944)
X
C7 3,4,5, left
Beasley64 (1944)
1,2 left
Korr65 (1949)
X
X
X
X
Wilson66 (1956)
X
X
X
X
Patriquin67 (1957)
X
X
X
X
X
X
X
Koch68 (1961)
X
Left ribs 1--4 left
X
T6
X
Johnson69 (1972) Walton70 (1972)
X
X
X
X
Burchett7! (1976)
X
X
X
X
X
X
X
Kelso7l (1980)
X
X
X
X
Bealsi (1983)
X
X
X
X
Larson72 (1976)
Johnston et a1S2.53
Rib
C 1 C2
X
Hartl9 (1937)
(1-(7
X
2 left
X
C2 lef t C3-C6
C2, C6 T6
C6
2 left
(1995) Modified from Beal MC Palpatory testing for somatic dysfunction in patients with cardiovascular
1983;82822-831.
disease.
J .-'lm Osteopath Assoc
If the primary dysfunction was visceral, such as might be the case in hypertension, the costal segments at C6, T2, and T6 then behave the same as the vertebral segment. These ribs would be linked or demonstrate linkage.54 Table 18.3 summarizes osteo pathic findings in patients with cardiovascular disease.
OSTEOPATH IC MANIPULATION Osteopathic treatment through manipulation to the thoracic and cervical area should not be controversial if one considers manipulation as adjuvant treatment. To date, no long-term outcomes study has been conducted to determine if indeed manip ulation is beneficial in the treatment of hypertension. Morgan and associates74 car ried out an 18-week randomly controlled crossover study with 29 subjects. By the end of 18 weeks, no significant difference in blood pressure was seen in either group.
Chapter 18 • The Patient with Hypertension
271
Other studies have shown a short-term improvement, but these are based on small
pilot studies or are anecdotal.44,45 Larger long-term trials are needed not only to assess reduction of blood pressure but also to look at end-organ damage.46,75,76 On the other hand, no long-term study has shown manipulation to be harmful with the use of proper procedure. Adverse outcomes have been reported, albeit rarely, with the use of cervical manipulation. The American Academy of Osteopathy has printed a position statement on the subject.77 When considering cervical spinal manipulation for the adjuvant treatment of hypertension, it is best to avoid high-velocity, low amplitude and other thrust procedures, especially with older individuals. Most patients with hypertension have associated paravertebral tissue texture changes.51,52 These may be a result of viscerosomatic changes involving the kidneys seen in renal artery stenosis, for example. Somatic findings in the thoracolumbar region in hypertensive patients may be associated with altered adrenal or renal function seen in conditions such as pheochromocytoma and renal disease,46,48 Once hypertension is established , the osteopathic physician should turn his or her attention to the midthoracic, lumbothoracic (kidney, adrenal, splanchnic outflow), and lower cervical regions.
CONCLUSION Lifestyle modification continues to play an important role in the treatment and management of hypertension. To these ends, physical activity is paramount in
maintaining the cardiovascular system. For patients to participate in an exercise program, t h e musculoskeletal system should be properly aligned. Somatic dysfunc tion remains a major barrier to the proper development of an exercise program. The osteopathic physician can play a pivotal role with manipulation to improve body dynamics and remove barriers to exercising so that the patient can improve cardiovascular fitness, lose weight , and decrease t he dosage and number of hyper tensive medications. Hypertension continues to be the condition most frequently encountered by the osteopathic family physician. The osteopathic diagnosis and treatment of hyper tension are unique. The most effective treatment starts with early diagnosis and treatment of the whole person, The use of medications and lifestyle modification guarantees the best outcome for our patients. In addition, the osteopathic physi cian has a unique role in managing hypertension. The recognition and treatment of the neuromusculoskeletal system by the osteopathic physician provides a unique
approach to the management of this common condition. Procedures Bill Johnston and his associates52,53 studied the relationship between spinal somatic dysfunction and hypertension, and although any of the manipulative procedures described in this text can effectively treat somatic dysfunction in the hypertensive patient, it is appro priate to consider the treatment of the somatic component of these patients in the context of his functional approach. He worked extensively to define a
mechanical model of spinal somatic dysfunction that differs from the standard
description in its appreciation for subtle translatory motions and the recognition of the total body impact of respiratory excursion.54 Segmental spinal dysfunction (type II) is typically defined in terms of the dysfunctional segment relative to the seg ment immediately below. (See Chapter 3.) Although the intersegmental spinal mechanics are essentially the same, Johnston78 considered the dysfunctional segment
272
Section III • Clinical Conditions
in relation to the vertebral segment immediately above as well as the segment below. He identified an alternating relationship wherein the segments above and below move in the opposite direction of the mechanics of the dysfunctional segment. Thus, if the dysfunctional segment is rotated right (resists rotation to the left), the segments above and below will be relatively rotated left; that is, they will resist rotation to the right. In the diagnosis of segmental dysfunction, Johnston considered the standard spinal mechanics of flexion and extension, side bending left and right, and rotation left and right. To these he added motion assessment of horizontal translations ante rior and posterior and left and right, cephalad traction against caudad compression, and respiratory inspiration against expiration . The functional assessment begins with a screen for asymmetry of tissue tex ture, position, and motion. This screen is followed by a local scan of the region to be diagnosed and then by the segmental definition of somatic dysfunction in the context of fl exion and extension, side bending left and right, rotation left and right, horizontal translations anterior and posterior and left and right, cephalad and caudad motions, and finally inspiration and expiration. The pas sive motion testing can be described as an appreciation for articular and soft tis sue compliance as much as it is the assessment of actual motion. In the absence of somatic dysfunction, the perception of this motion will be equal and unen cumbered for each of the paired motions described previously. Somatic dysfunc tion, however, results in a sensation of immediate resistance when forces are applied in the direction of the dysfunctional barrier as opposed to unencumbered motion in the opposite paired direction. The forces employed when motion test ing are the very lightest that can be applied and stil l obtain the sensation of resistance or freedom. Once the intersegmental dysfunctional mechanics have been delineated, treat ment is administered using indirect principles. The various motions are combined in the direction of freedom of motion, and at this point the patient is asked to inhale and exhale slowly. One phase of respiration will result in increased tension in the region being examined, while the other phase of respiration will produce more relaxation in the area. It is at this point that the patient is instructed to inhale or to exhale and hold the breath , taking the dysfunctional segment into the posi tion of maximum relaxation and allowing a release to occur. This, when precisely done, requires no more than 3 to 5 seconds. Because of the association Johnston demonstrated between hypertension and somatic dysfunction at levels C6, T2, and T6, this chapter focuses on the func tional treatment of the cervical and thoracic regions. In any patient, the somatic dysfunction that should be treated is dictated by the dysfunctional mechanics of that individual and not by preordained expectations of the examining physician. The following discussion rests on the assumption that the initial screen has been performed and that indications of somatic dysfunction have been identified in the cervical and thoracic regions, respectively. Local Scan of the Cervical Area (Functional Diagnosis) Diagnosis
This procedure is employed to screen the cervical spine for segmental somatic dys function. It is performed by applying rotational forces to the right and then to the left to each segment of the cervical spine and observing for the alternating left, right, left (or right, left, right) pattern in three adjacent vertebral segments that Johnston identified as the hallmark of segmental somatic dysfunction. Patient position: seated upon the side of the treatment table. Physician position: standing behind the patient (Fig. 18.1).
Chapter 18 • The Patient with Hypertension
FIGURE 18.1
273
Functional diagnosis: local scan of the cervical area.
Procedure
1.
Place one hand posteriorly upon the patient's neck. in contact with the cervical seg ment to be evaluated. Palpate one vertebral lateral mass with your thumb and the same point on the other side with your index or middle finger.
2.
Place your other hand on the patient's forehead and introduce rotation of the head and cervical spine alternately to the right and left.
3.
Observe cervical segmental rotation left and right and determine whether the motion pattern is symmetric or one direction demonstrates greater ease.
4.
Move down one spinal segment and repeat steps 1 to 3 until you have screened the entire cervical region.
5.
Note any three-segment alternating rotational patterns indicative of somatic dysfunction. and further evaluate these segments.
Segmen tal Defini tion of Cervical Somatic Dysfunction (Functional Diagnosis and Treatmen t) Diagnosis
This procedure is employed when a primary dysfunctional segment has been iden tified. It is the method by which motion tests for defining the specific characteris tics of the dysfunction are used. Once the diagnosis has been made, the procedure blends seamlessly into an indirect treatment. Patient position: supine upon the treatment table with the head off the end of the table to facilitate posterior translation during the examination. Physician posi tion: seated at the head of the table (Fig. 18.2).
274
Section III • C l i n ica l Conditions
F I G U R E 18.2
Fun cti o n a l diag n osis a n d t reat m e n t : segm ental definiti o n o f ce rvical som atic dysf u n cti o n .
Once a segmental d i agnosis has been establ ished , commence indirect treat ment i n the same pos i tion . P roced u re
1.
Rest you r elbows com fortably u pon your thi ghs and cradle the patient's head in you r hands.
2.
Place your Index f i ngers bilaterally over the lateral masses of the vertebral segment to be eval uated and yo ur m iddle f ingers in contact with the articular facets.
3.
Using m i n i mal force, seq uentially i ntrod uce flexi on and extension, side bending left and r i ght rotation left and r i gh t , horizon tal translations anterior and posterior and left and r i g h t and cephalad and cau dad traction and compress ion .
4.
At the i nitiati o n of each motion test, i d entify the motion in each of the pairs that res ults in t h e percept ion of res i stance. The oppos i te direct i on in each pa i r is the direct i on of ease.
5.
C omb ine the ind i vidual elements to pos ition the dysf u nctional segment in the di rection of greatest ease, and i n str uct the pat i e n t to inhale slow l y and deeply and then slow ly exhal e . N ote the phase of respi ration that is accompa n i ed by add i t i on al rela xat ion.
6.
The pati ent, pos i t i oned in the d irection of greatest ease, should either i nhale or exhale deeply (dependi ng upon the phase of respirat ion that res ults in the furt her ease) and hold the breath briefly until a release occurs
(3
to 5 second s) . Ret urn the
pat i ent to the neutral position and reassess.
Segmen tal Defini tion of Thora cic Soma ti c Dys fun ction (Functional Diagnosis and Trea tment) D i a gnosis
This procedu re is employed w hen a p r i m a ry dys function a l segment h a s been iden tified. It i s t h e method by wh ich motion tests to define the specific characteristics
Chapter
1 8 • The Patient with Hypertension
275
of t h e d y s f u nct i o n are u sed. Once t h e diagnosis has been made, the procedure
blends seam less l y into a n in d irect treatme n t . Patient posi t i on : seated upon the edge of t he treatment table w i t h the arms fo l d ed on the c hest . Phys ician position: standing behind the patient. Procedu re
1.
P l a c e yo u r i n d ex f i n g e r a n d t h u m b over t h e t h o ra c i c seg m e n t to be m o n i t o re d o n e i t h e r s i d e of t h e s p i n o u s p rocess . Th i s i s yo u r m o n i t o r i n g h a n d .
2 . W i t h yo u r o t h e r h a n d , reach i n fro n t o f t h e p a t i e n t a n d g ra s p t h e f o l d e d a r m s . Th i s i s y o u r active h a n d .
3 . W i t h yo u r a ct i ve h a n d , u s i n g m i n i m a l fo rce, s e q u e n t i a l l y i n t ro d u c e f l e x i o n a n d exte n s i o n , s i d e be n d i n g l eft a n d r i g h t , rotat i o n left a n d r i g h t , h o r i zo n t a l t r a n s l a t i o n s a n t e r i o r a n d poste r i o r a n d l eft a n d r i g ht, a n d c e p h a l a d a n d c a u d a d tract i o n a n d co m p ressi o n .
4.
A t t h e i n i t i a t i o n o f e a c h m ot i o n test, u s e yo u r m o n ito r i n g h a n d t o i d e n t ify t h e m o t i o n i n e a c h of t h e p a i rs t h a t res u l ts i n t h e percept i o n of re s i st a n ce a n d t h e o p posite d i rect i o n i n e a c h p a i r, t h at i s , t h e d i rect i o n of e a s e .
5.
C o m b i n e t h e i n d i v i d u a l e l e m e n ts t o p o s i t i o n t h e d y sf u n ct i o n a l s e g m e n t i n t h e d i re c t i o n o f g re a test e a s e , a n d i n st r u ct t h e p a t i e n t to i n h a l e s l ow l y a n d d e e p l y a n d t h e n s l ow l y exh a l e . N o t e t h e p h a se o f res p i ra t i o n t h a t i s a c co m p a n i e d by a d d i t i o n a l re l ax a t i o n .
6 . T h e p a t i e n t , pos i t I O n ed i n t h e d i rect i o n o f g reatest e a s e , e i t h e r i n h a l e s o r ex h a l es d e e p ly ( d e p e n d i n g u po n t h e p h a se of res p i ra t i o n t h a t res u l t s i n t h e f u rt h e r ease) and h o l d s t h e b reath b r i ef l y u n t i l a r e l e a s e o c c u rs
(3 to 5 seco n d s ) Return the
pati e n t to t h e n e utra l p o s i t i o n and reassess .
References 1 . Still
AT.
T h e P h i l os o p h y a n d M ec h a n ic a l P r i n c i p l es of Osteo p a t h y. K a n s a s C i ty, M O :
H u d s o n - Kim b e r l y, 1 9 0 2 ; 1 2 1 -1 2 8 . 2 . H o e l D , H o w a r d R B . H y p e r te n s i o n : T h e s i l e n t k i l l e r. Postgrad M e d 1 9 9 7 ; 1 0 1 : 1 1 6- 1 2 l .
3 . U n i v e r s i t y o f Ca l i fo r n i a Los Ange l e s . H i story of B l o o d Pressure Mea s u re m en t . Avai l a ble a t h t t p : // w w w. m e d p h y s . u c l . a c . u k / te a c h i n g/u n d e r g r a d/proj e c ts /2 0 0 3 /g r o u p_ 0 3 / h i s t o r y. h t m l . Accessed J u n e 2 1 , 2 0 0 5 . 4 . Ly o n s A S , P et r ucel li
JR.
Med i c i ne : An I l l u s tra ted H i s tor y. New Yor k : H a r r y N . A b r a m s ,
1 9 8 7;593. 5 . Burt V L , W h e l to n P, R occe l l a EJ , e t a l . Preva lence o f h y p e r t e n s i o n i n t h e U S a d u l t p op u l a t i o n : R es u l ts from t h e T h i r d N a t i o n a l Hea l t h a n d N u tr i t i o n Exa m i na t i o n S u rvey, 1 9 8 8- 1 9 9 1 . Hypertension 1 9 9 5 ; 2 5 : 3 05-3 1 3 . 6 . Wo r l d H e a l t h r e p o n 2 0 0 2 . Ava i l a b l e a t h ttp ://w ww. w h o . i n t/whr/2 0 0 2 . Accessed J u n e 2 1 , 2005 . 7. Va s a n R S , La rson M G , Le i p EP, et a l . Assessm e n t of fre q u e n c y of progression to h y pe r te n s i o n i n n o n h yperre n s i v e parti c i p a n ts i n t he F ra m i n g h a m H e a r t S t u d y : A cohort s t u d y. L a n c e t 200 1 ; 3 5 8 : 1 6 8 2-1 6 8 6 . 8 . Va s a n R S , Be i s e r A , Ses h a d r i 5 ,
et
a l . R e s i d u a l l i fe t i m e r i s k fo r d e v e l o p i n g h y perte n s i o n i n
m i d d l e aged women a n d m e n : T h e Fra m i n g h a m
Heart
S t u d y.
JAMA
2002;2 8 7 : 1 003-1 01 0.
9 . T h e S e v e n t h R e p o r t of t h e J o i n t N a t i o na l Com m i ttee o n Pre v e n ti o n , Detection , Eva l u a t i o n a nd Trea t m e n t o f H igh B l oo d Press u r e . Bethesda M D : NIH p u b l i ca t i o n 04-5 2 3 0 , 2 0 0 4 UNC 7 ) . 1 0 . W h i te W B , B e r s o n A S , R o b b i n s C , e t a l . N a t i o n a l sta n d a rd fo r m e a s u r e m e n t o f rest i n g a n d a m b u l a to r y
blood
1 9 9 3 ; 2 1 : 5 0 4 -5 0 9 .
p re s s u re s
with
a u t o m a te d
sphygmoma n o m eters .
H y p e r te n s i o n
276
Section I I I • C l inica l Con d i tions
1 1 . H a j j a r I, Kotchen TA . Tre n d s in prev a lence, a w a re ness, trea t m e nt, a n d contro l of h y perten sion i n t h e U n i ted S t a te s , 1 9 8 8 -2 0 0 0 . J AM A 2 0 0 3 ; 2 9 0 : 1 99-2 0 6 . 1 2 . Bode n - A l b a l a B , Sacco R L . L i fe s t y l e fa ctors a n d stroke r i s k : Exercise, a l c o h o l , d i e t , o b e s i ty, s m o k i n g , d r u g use, a n d stress. C u r r Arherosc l e r Rep 2 0 0 0 ; 2 : 1 60-1 6 6 . 1 3 . Bigl i e r i E G . P r i m a r y a l d o ste r o n i s m . C u rr Ther Endocr i n o l Meta b 1 9 9 7 ; 6 : 1 70-1 7 2 . 1 4 . T h e S i x t h R e p o r t o f t h e J o i n t N a tio n a l Com m i ttee o n Pre v e n t i o n , D e tecti o n , Eva l u a t i o n a n d Trea r m e n t of H ig h B l o o d Pressure. Bethesda M D : N I H p u b l ic a t i o n 98-4 0 8 0 , 1 9 97 U N C 6 ) . 1 5 . H e J , W h e lton P K , A p p e l Lj , e t a l . Long-term e f fects o f w e i g h t loss a n d d i etary sod i u m r e d u c t i o n on the i n c i dence o f h ypertension. H y p e r te n s i o n 2 0 0 0 ; 3 5 : 5 4 4-5 4 9 . 16. A ppel
Lj ,
C h a m p a g n e C M , H a r s h a D W, e t a l . Effe c t s o f c om p r e h e n s i v e l i fe s t y l e mo d i fi c a
t i o n o n b l o o d p r e s s u re c o n t ro l : M a i n res u l t s o f t h e PR E M I E R c l i n i c a l t r i a l .
JAMA
2 0 0 3 ; 2 8 9 : 2 0 8 3 -2 0 9 3 . 1 7 . Perio H D, G r i m C, Flack j , e t 3 1 . H u m a n blood press u r e dete r m i n a t i on b y s p h y g m om a n o m etry. C i rc u l a t i o n 1 9 9 3 ; 8 8 ( 5 pt 1 ) : 2 4 60-2 4 7 0 . 1 8 . P i c k e ri n g T G , C o a t s A, M a l l i o n J M , e t a l . B l o od Pressu re M o n i to r i n g . Ta s k Force V : W h i te c o a t h yperte n s i o n . Blood P r e s s M o n i t 1 9 9 9;4 : 3 3 3-3 4 1 . 1 9 . C a l c u l a te y o u r b o d y m a s s index. N a tiona l Heart, L u n g , a n d B l o od I n s t it u t e , N a t i o n a l I n s titu tes o f H ea l t h . http ://n h l b i s u p p o r t . c om/bmi/b m i c a lc . h t m . Accessed J u n e 2 1 , 2005 . 2 0 . R i d k e r P M , R i fa i N, Rose L, et a l . Comparis o n of C - r e a c t i v e prote i n a n d low-d e n s i t y l i po p r o te i n c h o l e s terol levels i n t h e pred iction of f i r s r c a r d i ovascu l a r e v e n t s .
N Engl
j
Med
2 0 0 2 ; 3 4 7 : 1 5 5 7- 1 5 6 5 . 2 1 . Expert p a n e l o n t h e Detection, Eva l u a t i o n , a n d Tre a t m e n t o f H i g h B l ood Chol esterol i n A d u l ts . S u m m a r y o f t h e second report o f t h e n a t i o n a l Choleste r o l E d u c a t i o n Progra m ( N C E P ) . Expert p a n e l on t h e d e tection, e v a l u a r i o n , n n d trea tm e n t of h i gh b l ood cholesterol i n a d u l t s (Adult Tre a t m e n t P a nel ll ) . NIH p u b l ica t i o n 9 3 -3 0 9 5 . 2 2 . W h e l to n SP, C h i n A, X i n X, He
J.
Effect of aerobic exercise on blo od p ress u r e : A meta -a n a l ysis
of r a n d om ized , controlled t r i a l s . Ann I n tern Med 2002 ; 1 3 6 : 4 9 3 -5 0 3 . 2 3 . K e l l e y G A , Ke l ley K S . Progres s i v e re s i s t a nce exercise a n d resting b l oo d pressure: A m c t a a n a lysis o f r a n d o mized c o n t r o l t r i a l s . Hy perte n s i o n 2 0 0 0 ; 3 5 : 8 3 8 - 8 4 3 . 2 4 . Tr i a l s o f H y p e r t e n s i o n P reve n t i o n Co l l a b o r a tive Resea rc ll Grou p . Effects o f w e i g h t l oss a n d s o d i u m r e d u c t i o n i n te r v e n t i o n on b l o o d pres s u re a n d h y pe r t e n s i o n i nc i d e n c e in overwe i g h r p e o p l e w i t h h i g h - no r m a l blood pres s u r e : T h e Tr i a ls o f H y pertens i o n P re v e n t i on, p h ase I I . Arch I n te r n Med 1 9 9 7 ; 3 5 : 5 4 4 - 5 4 9 . 2 5 . X i n X, He j , Fro n t i n i M G , et a l . Effects of alcohol red uction on b l o o d p ress u re : A meta-a n a lysis of ra ndom iLed , control led tri a l s . Hy perte n s i o n 2 0 0 1 ;3 8 : 1 1 1 2-1 1 1 7 . 2 6 . Vo l l me r WM, S a c k FM, Ard j , e t a l . E ffects o f d i e t a n d s o d i u m i n ta ke o n b l o od pres s u re : S u bg r o u p a n a l y s i s of t h e D A S H-sod i u m tr i a l . A n n I n tern M e d 2 0 0 1 ; 1 3 5 : 1 0 1 9- 1 0 2 8 . 2 7 . S a c k s FM , S v e t k e y LP, Vo l l m e r
WM,
e t a l . Effects on b l oo d press u re of red uced d i e t a r y
s o d i u m a n d the D i eta ty A p p r o a c h to S r o p H y p e rten s i o n ( D A S H ) d i e t . D A SH-Sod i u m Col l a b o r a t i v e Research G ro u p . N Eng l
j
Med 2 0 0 1 ; 3 4 4 : 3 - 1 0 .
2 8 . U . S . D e p a r t m e n t of Hea l t h a n d Huma n S e r v ices, N a t i o n a l I n s t i t u tes of Hea t h , N a t i o n a l Heart, L u n g a n d Blood I n s t i tu t e . Facts a b o u t D A S H p l a n . Ava i la b l e a t h t t p ://w ww. n h l b i ,n i h . go v/h e a l thip u b l iclhea rt/h pUdash/. Accessed j u ne 2 1 , 2 0 0 5 . 2 9 . Wing L M , R e i d C M , Ry a n P, et a l . A co m p a rison of o u tcomes w i th a ngio rens i n -co nve rting e nzyme i n hi b i tors and d i u retics for hypertension i n the elderly. N Engl 3 0 . B l a c k HR, E l l i o n
Wj,
j Med
2003;34 8 : 5 83-5 9 2 .
G r a n d its G, e t a l . P r i n c i p a l re su lts o f the Contr ol led O n s e t Ve r a p a m i l
In vestigation of Card i o v a scu l a r E n d Points ( C O NVI N C E ) Tr i a l . j A!v[ A 2 0 0 3 ; 2 8 9 : 2073-2 0 8 2 . 3 1 . D a h lo f B , Devereux R B , K j e l d se n S E, et a l . C a r d i o v a s c u l a r mo r b i d i ty a n d m o rta l i ty in the L o s a r t a n I nr e r v e n r i o n For E n d p o i n r red u c t i o n i n h y p erte n s i o n s t u d y ( LIF E ) :
A
r a n d o m ised
trial a g a i nst a ten o lo l . Lancet 2 0 0 2 ; 3 5 9 : 9 9 5 - 1 0 0 3 . 3 2 . C u t l e r .l A , M a c M a h o n SW, F u r b e rg C D . Contro l led c l i n i c a l t r i a l s o f d r u g trea t m e n t fo r h y pe r t e n s i o n : A review. Hyperte n s i o n 1 9 8 9 ; 1 3 ( 5 S u p p l ) : 1 3 6-1 4 4 . 3 3 . Co l l i n s R , Pero R , G o d win j, M a c M a h o n S . B l o od pressur e a n d c o r o n a r y hea r r d iseas e . L a n c e t 1 9 9 0 ; 3 3 6 : 3 7 0-3 7 1 . 3 4 . Psaty B M , Sm ith NL, Siscovick DS, et a l . Hea l th outcomes associa ted with a n t i h y pertensi ve ther apies u sed as first l i ne agents: A systematic review a nd meta - a n a l ysis.
JAMA
1 9 97;277 : 7 3 9-74 5 .
C h a pter 1 8 • The Pat ient with H y pe rtens i on
277
B M , L u m ley l� Fu rberg C D , e t a l . Hea l th o u tc o mes associa ted w i t h v a r i o u s a n ti h y p e rten
3 5 . P S J ry
s i ve therapies used a s fi rst- l i n e agents: A n e twork m e ta - a n a l ys i s . JAM A 2 0 0 3 ; 2 8 9 : 2 5 3 4- 2 5 4 4 . 3 6 . The
A LLHAT O fficers a n d C o o rd i n a t o r s fo r t h e A LL H AT Col l a b o r a t i v e Resea rch G r o u p .
M a j o r o u tcomes i n h i g h - r i s k h y p ertensive p a t i e n ts r a n d o m i zed t o a n g i o te n s i n - c o n v e r t i n g e n z y m e i n h i b i to r o r ca i c i u m c h a n n e l b l o c k e r v s d i u re t i c : T h e A n t i h y p e r t e n s i v e a n d L i p i d L o w e r i n g Tre a t m e n t t o P r e v e n t H e a r t A t t a c k Tr i a l ( A L L H AT ) . J A M A 2 0 0 2 ; 2 8 8 : 2 9 8 1 - 2 9 8 7 .
N M , G i f fo r d
37. Kaplan
RW
J r.
C h o i ce
of
initial
t hera py
fo r
h y p e r t e n si o n .
JAMA
1 9 9 6 ; 2 7 5 : 1 5 7 7- 1 5 8 0 . 3 8 . S l ic k G 1. . H y p ertens i o n . I n : Wa rd R C , e d . Fo u n d a t i o n s fo r Osteopa t h i c M e d i c i n e . B a l t imore:
Wi l l i a n1s & W i l k i n s , 1 9 9 7 ; 3 1 9- 3 2 7 .
lW. The a u to n o m ic n e r v o u s s y s te m . In : K a n d e l ER, S c h w a rtz J H , J e sse l l TM,
3 9 . D o d d J , R o l.e
cds. P rinc i p l es o f N e u r a l S c i e n ce . 3rd ed . N o r w a l k , CT: A p p l e t o n & La nge , 1 9 9 1 ; 7 6 9-77 1 . 4 0 . Wi l so n - P a u we l s
EJ,
L , A kesson
S t e w a r t PA .
C ra n ia l N e r v e s :
Anatomica l a n d C l i n ical
C o m m e n t s . P h i l a d e l p h i a : Decker, 1 9 8 8 ; 1 2 6 - 1 3 2 . 4J
. W i l l a r d F H . A u tono m i c n e t v o u s s y s te m . I n: Wa rd R C , e d . F o u n d a ti o n s fo r O s teo p a t h i c Me d i c i n e . 2 n d e d . Ba l t i m o r e : W i l l i a m s & Wilk i n s , 2 0 0 3 ; 9 0 - 1 1 9 .
4 2 . Ve te r a n s A d m i n istra t i o n Coo pera t i v e S t u d y G r o u p o n A n t i h yp e r r e n s i v e Age n t s . E ffec t o f
trea t m e n t o n m o r b i d ity i n h y pertens i o n : 1 . R e s u l ts i n p a t i e n t s w i t h d i a s to l i c b l o o d press u res a ve r a g i n g 1 1 5 - 1 2 9
mm
H g . J A M A 1 9 6 7 ; 2 02 : 1 0 2 8 -1 0 3 4 .
4 3 . Be a s l e y H E . A r te r i a l hyperte n s i o n . Osteopa t h i c P r o fe s s i o n 1 9 4 3 ; 1 1 ( 1 } : 1 3- 1 9 .
E , K oen i g AJ , C e l a n d e r D R . E ffects o f o s t e o p a t h i c m a n i p u l a t i v e t h e ra p y o n a u to
4 4 . Ce l a n d e r
as
n o m i c tone
e v i d e nced b y b l ood pres s u r e c h a nges a n d a c t i v i ty of t f-t e fi b ro l y t i c s y s t e m . J A m
Osteo p a th Assoc 1 9 6 8 ; 6 7 : 1 0 3 7-1 0 3 8 [a b s t r a c t] .
4 5 . Ti l l ey R M . The somatic component i n heart d isease.
J
Am Osteopath Assoc 1 9 70;69 : ] 035-EOA
[a bstract1 ·
T1..
46. North up
Ma n i p u l a ti v e
management
of
h ypertensio n .
J
Am
O s te o p a t h
Assoc
1 9 6 1 ; 6 0 : 9 73-9 7 8 .
1.. V i s cero-soma t i c a n d som a to - v isce r a l s p i n a l r e f l e x e s . J A m Osteopath Assoc
47. Burns
1 90 7 ; 7 : 5 2-6 0 . 48. Owens
e . A n Endoc r i n e I n terpre t a ti o n o f C h a p m a n 's Reflexes. C a r m e l , CA : A merican
A c a d e m y of O s te o p a t hy, 1 9 3 2 . 4 9 . Tet t a m be l
MA.
O bs te t r i c s .
I n: Wa rd RC, e d . Fou n d a ti o n s fo r O s t e o p a t h i c Med i c i n e .
Ba l t i m o r e : W i l i i a lllS & W i l k i n s , 1 9 9 7 ; 3 4 9-3 6 1 .
JR.
5 0 . Ma n n i no
T h e a p p l i c a t i o n o f n e u r o l og i c r e flexes t o t h e t r e a t m e n t o f h y perte n s i o n .
J
Am
O s t e o p a t h Assoc 1 9 7 9 ; 7 9 : 2 2 5-23 l . 5 1 . Be a l
M e . Pa l p a t o r y tes t i ng fo r s o m a t i c d ys fu n c t i o n i n p a t ie n ts w i th c a r d i o v a sc u l a t d i s e a s e .
J A m O s t e o p a t h A s s o c 1 9 8 3 ; 8 2 : 8 2 2- 8 3 l .
W L , K e l s o A F, Ba bco c k H B . Cha nges i n t h e p resence o f
5 2 . J o h nston
a
segme n r a l d y s fu n c t i o n
p a t t e rn a s s o c i a ted w i t h h y p e r te n s i o n : 1 . A s hort-term long i tu d i n a l s t u d y.
J
A m O ste opa t h
Assoc 1 9 9 5 ; 9 5 : 2 4 3 -2 5 5 . 5 3 . J o h nston W L , Kelso A F. Cha nges i n t h e presence of a segme n t a l d y s fu n c t i o n p a ttern a s s o c i
a ted
w i th
h y pe r t e n s i o n :
2 . A l o ng - t e r m l o n g i t u d i n a l s t u d y. J A m O s teo p a t h A s s o c
1 9 9 5 ; 9 5 : 3 1 5-3 1 8 .
W L , Fried m a n H D , E l a n d De. F u n c t i o n a l M e th o d s . Ind i a n a p o l i s : A m e r i c a n
5 4 . J o h n ston
Acad e m y of Osteopa thy, 2 0 0 5 ; 2 75 -2 9 2 . 55. Snyder
C Po
Hea r t c o n d i ti o n s c o m m o n l y
fo u n d
i n p ra c t i c e . J A m O s te o p a t h Assoc
1 9 2 4 ; 2 4 : 3 99--4 0 1 . 5 6 . Mac B a i n R N . Tec h n i c fo r t h e t r e a t m e n t o f c a r d i a c c o n d itions. J
Am O s teopa t h A ssoc
1933;33:68.
RH. A n g i n a pectoris a n d i ts m a n i p u l a t i ve t re a t m e n t .
5 7 . Si ngleton
A m O s t e o p a t h A s soc
1 9 3 4 ; 3 4 : 73-77. 5 8 . Robuck
Sv. B o d y mec h a n i c s i n r e l a t i o n to c a rd i ac c o nd i t i o n s .
J Am
O s teo p a t h Assoc
1 9 3 5 ; 3 5 : 1 --4 . 5 9 . H a r t R e . A n g i n a pecto r i s : A n osteopath lc co nsidera t i o n o f c o m m o n a n d se r i o ll s h e a r t m a l a d y.
J
Osteop 1 9 3 7 ;44 : 2 1 -2 5 .
6 0 . Pottenger
FM . S y m p to m s of Visce r a l D i sease. 5 t h ed . S r . L o u i s : JVl o s b y, 1 9 3 8 .
Section
278
6 1 . B ec k e r
AD.
III • C l i n i c a l Co n d i t i o n s Ma n i p u l a t i v e
os te o p a t h y
in
cardiac
t h e r a py.
J
Am
Os te o pa t h
Assoc
1 9 3 9 ; 3 8 : 3 1 7-3 1 9 . 6 2 . L o ng FA . S o m e obs e r v a t i o n s o n s p i n a l m o ti o n . J A m O s t e o p a t h Assoc 1 9 4 0 ; 3 9 : 4 0 5 -4 1 5 . 6 3 . B u rns L . Pr i n c i p les g o ve rn i n g t h e t r ea t me n t o f c a r d i a c c o n d i t i o n s . J A m O s teo pa t h A s s o c 1 9 4 4 ; 4 3 : 2 3 1-234 . 6 4 . B ea s l e y HE. O s t e o p a t h i c factors in c a u s e a n d t r e a rrn e n t of h e a r t d i s ea s e . J Am O steo p a t h Assoc 1 9 4 4 ;4 4 : 1 3 4 - 1 3 7 . 6 5 . K o r r 1 M . S k i n resista n c e p a t t e r n s " ss o e i a t e d w i th v is ce r a l d i s e a s e . Fed PtOC 1 9 4 9 ; 8 : 8 7-8 8 . 6 6 . W i lson
P T. Os teo p a t h i c c a r di o l o g y. A ca d e m y o f A p p l i e d O s t e o p a t h y "[ 9 5 6 Ye a r bo o k .
Colora d o S p r i n g s : Aca d em y of A p p l i e d O s te o p a t h y, 1 9 5 6 : 27-3 2 . ( N o w a v a i l a b l e f r o m t h e A m e r i c
DA.
O s te o p a t h i c
m a n ageme n t
o f co rona ry
d i sease.
A ca d e m y
o f A p p l ied
O s te o pa t h y 1 9 5 7 Yea rboo k . C a r m e l , CA : Ac a d e m y o f A p p l i e d Osteop a t h y, 1 9 5 7 : 2 7-3 2 . ( N o w a v a i l a b l e fro lll the A m e r i ca n Ac a d e m y o f Oste o p a t h y, I n d i a n a po l i s . ) 6 8 . Koch R S . A s om a ti c c o m p o n e n r i n h e a r t d is e a s e . J A m O s te o pa t h Assoc 1 9 6 1 ; 6 0 : 7 3 5 -74 0 . 6 9 . J o h n so n FE. Some o b ser v a t i o n s o n rhe u s e o f osteo p a t h i c r h e r a p y i n the care o f p a t i e n ts w i th c a rd i a c d i s e a s e . J Am O s te op a t h Assoc 1 9 7 2 ; 7 1 : 79 9-8 0 4 . 7 0 . Wa l ton WJ . Te x t book o f O steo p a th i c D i a g n o s i s a n d Tec h n i q u e P ro ce d u r e s . 2 n d e d . S t . Lo u i s : Ma t t h e w s , 1 9 72 . 7 1 . Burchett C D . So ma t i c m a n i festa tions of isch e m i c hea rt d i sease. Os te o p a t h Ann 1 9 7 6 ; 4 : 3 73-3 7 5 . 7 2 . L a r s o n NJ . S u m m a ry o f s i te a n d o cc u r re nce o f p a r a s p i n a l soft r i s s u e c h a n g e s o f p a t i e n ts i n
t h e i n te n s i v e ca re u n i t . J A m Osteo p a th Assoc 1 9 7 6 ; 7 5 : 8 4 0-84 2 . 7 3 . K e l s o AF, La rs o n NJ, K a ppler R E. A c l i n ica l i n vestiga t i o n o f t h e o s teo p a t h i c exa m i n a t i o n .
J Am
O s te o p a th Assoc 1 9 8 0 ; 7 9 : 4 6 0-4 6 7 .
74 . M o rga n
J P, D i c k e y JL, H u n t H H , H u d g i n s P M . A controlled t ra i l o f s p i n a l m 'l n i p u l a t i o n i n
t h e m a n a g e m e n t o f h y p e r t e ns i o n . J A m O s te o pa t h Assoc 1 9 8 5 ; 8 5 : 3 0 8 -3 1 3 . 75 . B a y e r J D .
An oste o p a r h ic a p p roa ch to t h e m a n a g e m e n t of h y pe r r e n s i o n . DO
1 971; 1 1 :
1 4 3-1 5 1 . 7 6 . A n d erson RA . A n o s t e o p a t h i c method for n o r m a l i z i n g b l ood press u r e . J A m O s t e o pa th A ssoc 1 935;35 : 1 28-134. 7 7 . A m erica n Ac a d e m y o f O ste opa t h y. Position pa p e r o n o s te o p a t h i c m a n i p u l a t i o n o f t h e ce r v i
ca l s p i n e , I n d i a n a po l i s , I n d i a n a . A A O Ne w s l e t ter 2 0 0 3 : 2-3 . 7 8 . Joh n s ton WL. Seg m e n t a l b e h a v i o r d u r i n g m o tion : I. A pa l pa tury s t u d y of s o m a t i c re l a t i o n s .
J
A m O s teo p a t h Assoc 1 9 7 2 ; 7 2 : 3 5 2-3 6 1 .
The Patient with Congestive Heart Failure Kenneth E. Nelson
INTRODUCTION A bnormality of cardiac function resulting in the failure to pump blood commen surate with the requirements of the body is congestive heart failure. Diastolic fail ure occurs when cardiac muscle fi ber length ( preload) is insufficient
for adequate
cardiac filling. Systolic failure occurs when the heart's pumping is insufficient to overcome arterial resistance (afterload). Certain aspects of the pathophysiology of conges tive heart failure are found in association with somatic dysfunction. Congestive heart failure is associated with increased beta-adrenergic tone and an altered baroreflex response. Som a tic dys function of the thoracic spine is known to result in spinal cord-level facilitation, with increased sympathetic efferent s timula tion of segmentally related struc rures.1,2 The Trau be-Hering oscillation, a manifestation of the fluctuating auto nomic tone associated with the baroreflex, has been demonstrated to correspond to the palpable o bservation of the cranial rhythmic impulse (CRT) a fundamental component of cranial osteopathy.3 Furthermore, cranial manipulation has been shown to increase the Traube-Hering component of blood flow velocity,4,5 Restriction of movement of the thoracic cage is known to complicate and even induce congestive heart failure, Somatic dysfunction is associated with articular motion restriction.6,7 Every adul t has some degree of somatic dysfunction of the thoracic spine and ribs with resultant res tric tion of thoracic cage motion tha t 279
Section I II • Clinica l Conditions
280
progresses w ith age. Somatic dysfunction of the thoracoa bdominal diaphragm results in decreased diaphragmatic excursion that further decreases effic iency of thoracic cage movement.
DISCUSSION Congest ive heart failure is the pathophysiologic state in which an a bnormality of car diac function is responsi ble for the fa ilure of the heart to pump blood at a rate suf f ic ient to meet the requirements of the meta bolizing tissues. In some patients with heart failure, however, a s im ilar clinical syndrome is present but w ithout any detecta ble a bnormality of myocardial function. Heart failure should be dist inguished from noncardiac and potentially reversi ble causes of inadequate cardiac output.8 Cardiac output is determined by the interplay between the heart and t he periph eral c irculation. The force of ventricular contraction is a function of the end d ias tolic length of cardiac muscle, which is a manifestation of end-diastolic ven tricular volume (the Frank Starling relation). Stroke volume correlates d irectly w i th cardiac muscle fi ber length (preload) and in versely with arterial resistance (afterload). The stroke volume of the ventricle is de termined by three influences:
(1) length of the muscle at the onset of contraction, that is, preload; (2) the inotropic state of the muscle, that is, the pos it ion of its force- velocity-length rela tion; and
(3) the tension that the muscle is called upon to develop dur ing contrac
tion, tha t is, afterload. Depressed ejec t ion fract ion (stroke volume/end diastolic volume
=
59 to 75%, normaJly) and lowered cardiac output may occur in the pres
ence of normal cardiac function if preload is decreased. This is diastolic failure. Decreased inotropic state of the cardiac muscle and/or increased tension required of the cardiac muscle during contraction results in systolic failure. At any level of inotropic state and afterload, the perfo rmance of the myocard ium is influenced profoundly by ventricular end-diastolic fi ber length and therefore by diastolic ventr icular volume. Among the major determinants of preload is distribu tion of blood volume.9 The distr i bution of blood volume between the intrathoracic and extrathoracic compartments is determined by the follow ing: 1. Body posi tion: Upr ight posture augments extra thoracic at the expense of
in trathoracic blood volume and reduces ventr icular work.
2. Intrathoracic pressure: Normally mean intra thoracic pressure is negative, wh ich increases thoracic blood volume and ventricular end-diastolic volume and enhances the return of blood to the heart, particularly during inspiration, when this pressure becomes more nega t i ve.
3. Intrapericardial pressure: Constriction of the myocardium from increased intrapericardial pressure (tamponade) decreases cardiac f ill ing and ventricular diastol ic volume and, consequently, stroke volume. 4. Venous tone: Venoconstriction occurs, among o ther t imes, during muscular
exercise and during deep inspiration, and it tends to augment in trathoracic and intraventr icular blood volumes and ven tricular performance. 5. The pumping act ion of skeletal muscle: During muscular exercise the muscular
(1) to d im inish extrathoracic (2) to augment intrathorac ic blood volume, (3) to augment ven tricular end-diastolic volume, and (4) to augment ventricular work.
pump d isplaces venous blood centrally, tending blood volume,
Factors 1,2,4, and 5 are affected by the individual's level of musculoskeletal func tional capa bility. Although factor
1, upr ight posture, tends to reduce preload
Cha pter 19 • The Patient with Congestive Heart Failure
281
and consequentl y stroke vo l ume, factor 5, the m usc u l a r p u m p , co unters t h i s pre l o a d reduct i o n and augments e n d -d i a sto l ic volu me.
Mean Systemic Filling Pressure The ra te of retu rn of b l ood to the heart is d e te rmined by both card i a c and periph eral fac tors b u t i s pro port i o n a l to the press ure g r a d ie n t across the veno u s b e d . The pre ssure g r a d i en t for v e n o u s ret u r n i s the mean systemic fi lli n g press u r e . S i nce t h e ca pacitance o f t h e veins i s
18 t o 20 times t h a t o f the arteries, t h is pressure i s l arge l y If t h e tota l periphera l res i s tance incre a s e s by 20%
a f u nctio n o f the venous s y s t e m.
with all of t h e resista n c e occu rring i n the a rteri o l e s , ve nous retu rn is reduced by
about
6%. If the 20% res i s tance c h a nge occurs e n t i re l y on the v e n o u s s ide v e n o u s ,
return i s red uced b y abo u t 53% ( a n i ne fo l d difference).lo
Pulmonary Circulation T he pul m o n a r y c i rcula tion serves a second ary fu nction as for the l eft heart. It c o n ta ins approxima tely
blood volume reserv o i r
a
10% of the tota l b l ood v o l ume. I t s high
distensibility allows it to a djust rea d i l y to l a rge increa ses in blood flow.ll Pressures in the p u l mona ry circ u l a tion are
low. The m e a n pressure
in the pulmonary artery i s
about 1 5 m m Hg. T h e mean press ure i n the a o rta is abo u t 100 times
mm
H g , m ore t h an 6
that of the pu l m onary artery. Pulmonary capi l l aries receive v ery l i ttle sup p ort
fro m the su r rounding l ung, so they are liabl e to coll apse or d is tend depe nding upon the pressures wi thin and around the m . The e ffective pressur e o u ts i d e the capil l a ries is
al veola r pressure; when this rises above the press u re inside the capi l l a ries, they col
lapse. The pressure aro u n d p u lmona ry a rte ries and veins tends to be less tha n a l veo lar pressure. As the lung expa nds, these l a rger vessels a re pul l ed open by the radia l traction from the elasticity of the ti ssue tha t surrounds them. P u l monary vasc u l a r resis tance i s a manifes tation of the pu lmo n a ry press ure gra d ie n t d i vided b y pulmon ary b l ood flow. The p ressure gra d i ent in the pulmonary system i s about
10 mm Hg.
Another dete r m i n a n t of pu l m onary v a sc u l a r res i s ta nc e is l u ng volume. Bec a use of the effect of p u l m o n ary pa renchyma upon t h e c a l i ber o f extra a l ve o l a r vesse ls, pul mon ary res i s tance i s lower duri ng i n h a lation. Inha l a t i o n tends to co mpress pul monary capillaries, w i t h res u l ta n t i nc r e a s e in v a s c ular resis tance. 12
Noncardiac Congestive Heart Failure A variety of d is o rd ers of the neuromusc u l a r a ppara t u s , d i a phragm, and chest wa l l
c a u se pulmonary hypertension and cor pu l m o n a le s eco n da ry t o chronic hypoxia a nd/or compression of t h e pulmona r y vessels.13
Chronic Hypoventilation C h r o n i c hypove n tila t i o n c a n be t h e result of •
Defec t i v e respiratory
n e uro m u scul a r
sys tem, impa i re d func tion of the respira
tory m u sc l es •
Impa i red
ventila tory a pp a r a t u s fro m
restricti o n of the
chest wa l l, a s
in
ky phosco lios i s and o b e s ity
Obesity Hypoventilation Syndrome A small pro portion of o bese persons devel op ch ronic hypercapnia, hypoxem i a , and eventually polycythemia , pulmonary hy pertens i o n, and r ight s ided heart fai lure . 14 -
282
Section I I I • Clinical Conditions
The m o tiva ting force that has the greatest effect upon p e riphera l venous and ly mphatic return is the movement of a d ja c e n t structures, collectively referred to as the muscular pum p ( ite m 5 in the factors affec t i n g d ist r i bu ti on of blood volume). To a sig n i ficant extent but not
entirely, this is due to the voluntary action of stri
ated muscle. Movement of the muscles dynamically changes fascial tensio n s . T hese movements compress adjacent vessels, moving their contents centra lly. The vessels possess valves that prevent r etrograde flow of venous blood and ly mph.
Circulatory Return to the Heart: The Two-Chambered Pump The dia phr a g m is s it u a ted b etween the thoracic and abdominal cav i ties. Thi s rela tionship creates a two-chambered pump that dr a ws b l ood a n d lymph to the cen ter. Durin g i n spira tio n the thoracic cage a c t i v e l y expands in all of its dimensions.
The di aphragm c o n t ract s , and its dome descends. Th i s produces t h e decrease in
intrathoracic pressure associated
with ins p i ratory f il l ing of the lungs. At the same
time, the descent of the diaphragm compresses the abdominal contents , causing i n c r e a sed intra-abdominal pressure. IS
During expiration the thoracic cage passively recoils aga i n s t the a i r-fi l l e d lungs;
the di a p h ra gm rela xes and ascends ba c k i nto the t h o rax. The re s u l t i s decreased
intra-abdominal pressure and i nc r e a s e d intrathoracic pressure. This mechanism, in association with the o n e-way valves of the ve i n s a n d l ympha t i c vessels, squeezes fluid f r o m t h e abd o m en when n egative intrathoracic pressure ( inspira t ion) is s u c k
i n g a i r and low-pressure fluids into the thorax. Alternately, expiration squeezes air from the lungs and blood and lymph from t h e v e i n s a nd thor acic duct as the con comi ta n t drop in intra-abdominal pressure sucks venous blood and lym ph from the periphery in preparation for the next cycle. The drivi n g mechanism of this two-chamber p u m p is d epe nde n t upon the effi
c i e n t movement of the thoracic cage a n d diaphragm. Dy s f u nct io n al m echa nics of either will greatly reduce the pumping effect. Venous return to the right a tri u m i s affected by dysfunction of the peripheral muscular pump a n d the mec h a n ics of respiration. This results in increa sed periph eral venous resistance and decreased cardiac p relo a d . The l ow-pre ss u re pul mona ry circulation i s s i m ilarly affected b y thoracic cage dysfu nctio n, reducing left-sided pre l o a d .
Somatic Dysfunction: Definition Somatic d y sfu n c tio n is i m p a i r ed or altered function of re la ted components of the somatic (body framework) system:
skeletal, arthrodia l, and myo fa sci a l structu res
a n d related va scular, lymphatic, and neural elements. Somatic dysfunction is
t rea table using o ste o p a t h ic manipulative treatment (OMT). The p o siti ona l and
one of (1) the position of a body part as determ i n e d by p a lpa tion and referenced to its adjacent defined structure, (2) the directions in wh i c h motion is m o t i o n aspects of somatic dysfunction are best described using at l e a s t
three pa ram eters :
freer, a nd ( 3) the dire c ti o n s in which motion is res t r i cted . 1 6 Van Bu skirkl7 offers a nociceptively initi a ted model for spinal somatic dysfunc tion as follows: 1. A periphe ra l foc u s of irrita t i on results in activa tion of nociceptive n e u rons.
These may be somatosensory or general visceral afferent neurons.
2. These primary afferent neurons s y n a pse in the dorsal horn of the spin a l cord with int e r nunc i a l neurons.
Chapter 19 • T h e P a t i e n t w i th Co ngestive Hea rt Fa i l u r e
283
3. Ongoing afferent stimulation of insufficient intensity to reach fir i n g po tential esta b l ishes a state of ir r ita b il ity (facilitation) of the i nte rnuncial n euro n s. 4 . Ad ditio na l afferent activity from any s ource results in a s e gme n ta l response to s i g n i ficant ly less stimulus than would normally be required. 5 . Su c h activity f rom internuncial neurons, which synapse with ventral horn motor neurons, results in segmentally related myospasticity. Stimulation of int ernu n ci a l neurons, which synapse in the interme d i o l ate ral cell column of
the th ora cic and u p per lumbar cord, p r od uc e a s e gm e n tally related sympa thetic response ( somatic and/or visc e ral ) . The s a m e response to stimulation a p p l ie s to the p arasy m p athetic efferent system. Moreover, internuncial neu rons traverse u p a n d down the s p in a l cord fo r seve ral segme n ts and synapse with the spinothalamic tract. Thus, the s e neurons are capa ble of initiating a
broad respo n se. Somatovisceral reflexes also occur a s the result of facilitation. In this case, the i rrita b i l i ty of central nervous system affects a target o rga n th r ough increased auto nomic p a rasympat he tic o r sy m path e tic activi t y.
Integration of OMT into the Therapeutic Protocol When treating a patient with congestive heart failure, as when treating a patient with any other p ro blem, the p hy s i cian can de t e rmine how to integrate the treat ment of somatic dysfunction into t he t h e ra p e utic pr o tocol by asking the follow ing questions: 1. How is musculoskeletal dysfunction af fecti ng the p atie n t 's ability to r e s p o n d
to the disease process? 2. What sympa th e ti c somatovisceral mechanisms are present? S p inal fa cil itation
with resultant i ncreased sympa thetic tone increases vascu l a r tone tha t decreases tissue perfusion.
3. W h at parasympa the tic somatovisceral mechanisms are present? Spi n al facili tation w i t h r e sultan t i ncr eas ed p arasym p a th e tic tone slows the heart rate. 4. How is c irc u la tory s t a s i s a ffect i n g the pati e n t ? The mechanical component of somatic dysfunction re stricts motion. Efficient movement of the tho ra c i c inlet, thoracic cage, abdominal dia p h ragm, m esenteries, and pelvic dia ph rag m is neces sary for op timal low -pre ssure fluid (lymphatic and venous) dynamics. Inef ficie ncy of this m e c h a nism further adds fluid shift into the venous and lymphatic systems and decreased card i a c pre l oad .
Somatic Dysfunction: Effects on Circulation Contemporary medicine does not recognize the full extent to which anatomic d ys function ( a reversible condition) cont r i b utes t o the overa ll hea lth status and recu perative ability of t h e patient. The low-pressure venous (and lymphatic) return sys tem is very sus cep tib l e to external compromise resul t in g from pressur e s placed upon i t b y dysfunctional musculoskeletal structure s. Ci rc u latory e ffic i e ncy o f the venous and l ym phati c systems may be enhanced by (1) red ucing local myofa s c i a l tensions that can com press and obstruct p eri p he ra l vesse ls, (2) ensurin g m ec h a n i ca l e ffic i en cy of t h e thoracoabdominal two-chambe r p ump b y t r e a ting d ysfunction of the thora cic cage, thoracoabdominal d iaphra g m, thoracic inlet, and pel vis, and (3) tre a t i ng thoracic so matic d y sfu n ction to red u ce the e ffects of facilitation and incre a sed sy m path e tic tone upon peripheral v as c ulatur e and the heart.
284
Section III • Clinical Conditions
CONCLUSION OMT is classified as a form of alternative medical therapy.lg It is applied to over
come a functional restraint to normal anatomic mobility diagnosed through the structural examination. Mechanical force applied to such a restra int results in free ing the anatomic region from that restraint.6 Somatic d ysfunction is associated with increased spina l cord neurologic activity, facilitation. I The facilitated spinal segment results in increased segmentally related efferent activity and somatovis ceral reflexes. OMT reduces the spina I fac ilitation and somatoviscera I effect. 1.19
Therefore, a protocol for the application of OMT in the treatment of patients suffering from congestive heart failure was developed. It consists of cervical spine, soft tissue, articulation , and facilitated positional release; scalene release; thoracic inlet release; bilateral scapular release; thoracic ly mphatic pump; range of motion upper
thoracic region,
including rib balancing and rib raising; respiratory
diaphragm release and the cran ial procedure, compression of the fourth ventricle (CVA).20 The sequence of application of the manipulative procedures is not impor tant. Rather, it is appropriate to identify somatic dysfunction as it presen ts in the individual patient and treat what is found. Certain areas, however, s hould be specifically looked for. Thoracic cage compliance may be addressed by treating restrictions in the thoracic spine and ri bs. Additionally, attention should be paid to the thoracoabdominal diaphragm, the thoracic inlet and the accessory muscles of respiration, particularly the scalene muscles. Diaphragmatic function may be fur ther addressed by treating the cervical s p ine , C3 to C5, where spinal fac ilitation can affect the phrenic nerve. The upper cervical spine can be treated to reduce vagal somatovisceral effects, and upper thoracic dysfunction should be treated to reduce sympathetic somatovisceral effects. CVA may be performed for its appar ent effect u pon baroreflex physiology. Congestive heart failure is a chronic condi tion with increasing incidence in asso ciation with aging. The clinical presentation of congestive heart failure is ty p ica lly the result of the interplay between cardiac function and peripheral circulation . A significant noncardiac cause of congestive heart failure is restrictive mechanics of the thoracic cage. Aging tends to be accompanied by progressive loss of articu lar motion, hence progressive fu nctional impairment. Disorders of the respiratory neuromusculoskeletal system can increase the workload of the myocardium through their effects upon pulmonary, venous , and lymphatic systemic circu lation. This is encountered in kyphoscoliosis. Similar spinal mechanics, although of lesser degree , are found in most individuals.l,21,22 Somatic dysfunction of the thoracic spine , ribs, and thoracoabdominal diaphragm results in decre ased motion of the thoracic cage with diminished negative intrathoracic pressure during inspira tion.1S,23 This in turn results in decreased cardiac preload, which aggravates the cardiac component of congestive heart failure. OMT employed to enhance tho racic cage mechanics should increase preload . Increasing preload and consequently diastolic ventricular volume will increase effiCIency of the failing heart, thereby reducing the debilitating symptoms of congestive heart failure. Upper thoracic somatic dysfunctions with associated spinal facilitation result in an increase of sympathetic tone to the myocardium and lu ngs. 2 Furthermore, somatic dysfunction of the thor a ci c spine is associated with increased efferent sym pathetic activity that can increase cardiac afterload. Appropriately applied OMT results in peripheral vasodilation.19 Such vasodilation can contribute to reducing afterJoad stresses placed upon the failing heart. OMT is not to be considered as pri mary treatment of congestive heart failure to replace appropriate pharmacotherapy. Appropriately applied OMT should therefore have adjunctive therapeutic value in
Chapter 1 9 • T h e P a tie n t w i t h Co n gestive He a rt Fa i l ure
285
the treatmenr of co ng e s t i ve heart failure. It offe rs benefit without side effects, and in the case of the ind i vidual
with c a rd iov a scula r compromise, a sma l l percen tage of
functional gain ca n exert t r eme n d ous e ffec ts .
Procedures Cervical (Soft Tissue/Articulation) (See Chapter
10, Fig. 10.2)
This p roce dur e is e m p l o y ed to decrease cervical tissue tension and enhance the symmetric range of motion of the cervical spine. (For diagnosis, see C h a p te r 3.) Cervical (Facilitated Positional Release) (See Chapter
19, Fig. 19.1)
This p roc e d ur e is e mp loy e d to relax cervical muscle te n s io n and trea t articular somatic dysfunction. (For d i a gno s is , see Chapter 3.) Patienr positi o n : supine. Physician position: seated at the patienr's head, one hand employed to act i ve ly int;-oduce the co rr ect iv e positioning while the other hand mo n i to r s the area of dysfunction. Proce d u re (Ex a m ple: Pa ra verte b ra l M u sc l e Te n sio n o n t h e R i g h t Associ ated with Fryette II, C5 u p o n C6, Exte n d e d , S i d e Be nt R i ght, R otated R i ght)
1.
Place your left hand palm up transversely from left to right at the level of (5.
2.
The thumb of your left hand should rest lateral to the patient's neck on the left, and the distal pad of your index finger palpates (monitors) the tight right-sided paraver tebral musculature at the level of (5.
3.
With your right hand, grasp the top of the patient's head and lift it from the table to straighten the cervical lordosis.
4.
In this position use your right hand to apply a compressive force through the patient's head and down the cervical spine to the level of C5. This force should begin to induce paravertebral relaxation at the level of (5 on the right and should be maintained throughout the remainder of the procedure.
FIGURE 19.1
Cervical facilitated positional release, employed to relax cervical muscle tension and treat articular somatic dysfunction.
286 5.
Section III • Clinical Conditions With your right hand, translate the head and upper cervical spine posteriorly to introduce extension at the level of C5 and monitor the tension in the paravertebral muscles for relaxation.
6.
With your left hand, introduce right side-bending by laterally translating C5 to the left and monitor for continued paravertebral relaxation.
7.
With your left hand, introduce right rotation by applying anteriorly directed pres sure to the patient's left paravertebral musculature with your thenar eminence while continuing to monitor for paravertebral relaxation.
8.
Hold C5 in the relaxed position for 3 seconds
9.
Slowly remove the compressive force from your right hand and return the patient's head and neck to the neutral position while monitoring with your left hand to ensure continued paravertebral relaxation.
10. Reassess C5 as it relates to C6. Ultimately the purpose of this procedure is to induce paravertebral relaxation. The palpable softening of the tissue beneath your monitoring finger is the guide to proper positioning. The specifically localized combination of compression, forward and back ward bending, side-bending, and rotation is key. If you introduce forces and the tissues tighten, move in the opposite direction; this will often result in the desired relaxation.
Thoracic Inlet (Myofascial Release) (Fig. 19.2) This procedure is employed to release restrictions and thereby permit symmetric movement in the transverse fascial tissues of the thoracic inlet. It may be per formed either as a direct or i n d i r ec t procedure. Patient position: supine. Physician position: seated
to
the side of the patient
at
the level of the shoulders. Procedure (Example: Superficial Fascia of the Anterior Chest Wall Freely Moves to the Left)
1.
Place one hand transversely beneath the patient posterior to the thoracic inlet at the level of the first and second ribs.
FIGURE 19.2
Thoracic inlet myofascial release, employed to release restrictions and thereby result in symmetric movement in the transverse fascial tissues of the thoracic inlet.
Chapter 1 9 • T h e Patient wit h Congesti ve Heart F a i l ur e
287
2.
Place the other hand at the same level upon the chest wall anteriorly.
3.
With the hand on the anterior chest. introduce left and right translation, rotation or twisting, and superior or inferior translation to evaluate available motion for myofascial restrictions .
4.
Once asymmetric tension has been identified, the area may be treated indirectly by moving the anterior hand to the position of fascial ease or directly by engaging the soft tissue barrier. Having the patient take a few deep breaths can facilitate a release.
5.
With either the direct or indirect method, hold the position and wait for a release, the perception of relaxation of tension, to occur.
6.
Reassess the thoracic inlet
Scapulothoracic (Myofascial Release) (Fig.
19.3)
This procedure is employed to increase the range of motion of t he scapula in rela tion to the thoracic cage. Patient position: lying upon the sid e with the dysfunctional side up. Physician position: standing facing the patient at the level of the shoulders
.
Procedure ( E xa m p l e : Decre a s e d R a nge of Motion of t h e Left Sca p u lothora c i c Rela tio n s h i p )
1.
Abduct the patient's left shoulder and place the patient's left forearm upon your left shoulder.
2.
Side-bend your neck to the left and hold the patient's forearm between your neck and shoulder.
FIGURE 19.3
Scapulothoracic myofascial release, employed to increase the rang e of
motion of the scapula in relation to the thoracic cage.
288
Section III • Clinical Conditions
3.
Lean back and apply gentle traction upon the patient's scapula through the arm.
4.
Grasp the patient's scapula with both hands and assess its range of motion relative to the posterior chest wall by introducing superior, inferior, medial, and lateral glide and clockwise and counterclockwise motions.
5.
Once dysfunctional myofascial tension has been identified , treat the area indirectly by moving the scapula to the position of fascial ease or directly by engaging the soft tissue barrier. Having the patient take a few deep breaths can facilitate a release.
6.
With either the direct or indirect method , hold the position and wait for a release, the perception of relaxation of tension, to occur.
7.
Reassess the range of motion of the scapula in relation to the thoracic cage.
Lymphatic Pump (Oscillatory Modification) (See Fig. 16.19) This procedure is employed to facilitate lymphatic and venous return to the heart and to reduce pulmonary congestion through the introduction of alternating pos itive and negative intrathoracic pressure and improved thoracic cage mobility. Patient position: supine. Physician position: standing at the head of the table or bed. To prevent aspiration be sure the patient does not have any foreign objects
(food, gum, or dentures) in the mouth. Procedure
1.
Place your hands palm down upon the patient's anterior chest wall over the pectoralis major muscles.
2.
Straighten your arms and lock your elbows.
3.
Instruct the patient to exhale in a relaxed fashion through the open mouth.
4.
Lean gently upon the anterior thoracic cage with your hands and follow the exhalation.
5.
Toward the end of exhalation, exert a rhythmic pumping action with your hands by an alternating pressure through your hands to produce a slight alternating positive and negative intrathoracic pressure.
Thoracic Soft Tissue Articulation Procedure (Patient on Side) (See Chapter 5 and Fig. 5.3) This procedure is employed to decrease paravertebral muscle spasm and soft tis sue tension of the thoracic spine. (For diagnosis, see Chapter 3.)
Rib Raising (See Chapter 5, Fig. 5.6 and Chapter 17, Fig. 17.1) This procedure is employed to enhance rib motion and thoracic cage compliance. Consequently it augments venous and lymphatic return to the chest. It is also tbought to affect sympathetic tone, initially stimulating regional sympathetic out put but eventually resulting in reduction in sympathetic activity from the spinal levels treated.
Thoracoabdominal Diaphragm Release (Fig. 19.4) This procedure is employed to relax the diaphragm and increase the diaphragmatic component of respiratory excursion. Patient position: supine. Physician position: standing to the side of the patient at the level of the diaphragm and facing the patient's head. Procedure
1.
Place your hands on either side of the thorax at the level of the diaphragm with your fingers pointing posteriorly toward the thoracolumbar junction and your thumbs pointing anteriorly toward the xiphoid process.
Chapter 19 • T h e P a t i e n t w i t h Co n gestive He a rt Failure
FIGURE 19.4
289
Thoracoabdominal diaphragm release, employed to relax the diaphragm and increase the diaphragmatic component of respiratory excursion.
2.
Instruct the patient to breathe slowly and deeply.
3.
Laterally compress the lower ribs between your two hands.
4.
Follow respiratory excursion, palpating for asymmetric motion.
S.
Once asymmetric tension has been identified, treat the area indirectly by moving your hands in the direction that reduces tension or directly by engaging the soft tis sue barrier. Having the patient take a few slow deep breaths or hold the breath to tolerance in exhalation (indirect) or in inhalation (direct) can facilitate a release.
6.
With either the direct or indirect method, hold the position and wait for a release, the perception of relaxation of tension.
7.
Have the patient breathe deeply and reassess diaphragmatic excursion.
Compression of the Fourth Ventricle (CV-4) (See Chapter
10 And Fig. 10. 1)
This procedure is employed to stimulate the body's inherent recuperative ability by promoting fluid interchange. It is thought to especially influence lymphatic and cerebrospinal fluid circulation.
References 1. Korr 1M, Wright HM, Chace jA. C u ta n eous patterns of sympathetic activity in clinical abnor mal i t i es of t h e musculoskeletal system. Acta Neuroveg (Wien) 1964;25:589-606. 2. Beal MC, ed. Louisa Burns, DO, Memorial. 1994 Yearbook. Indianapolis: American Academy of Osteopathy, 1994.
3. Nelson KE, Sergueef N, Lipinski CM, et al. Cranial rhythmic impulse related to the Traube Hering-Mayer oscillation: Comparing laser-Doppler fJowmetry and p a l pat i o n . J Am Osteopath Assoc 2001;101:163-173.
Section III • Clinical Conditions
290
4. Sergueef N, Ne l so n KE, Glonek T. The effect of cranial m anipul ation on the Traube-Hering Mey e r oscillation as measured by laser- D oppler fl owmerry. Altern Ther Health Med 2002;8(6):74-76. 5. Nelson KE, Sergueef N, Glone k T. Cranial manipulation induces s eq uential changes in blood flow
v el oc i ty on demand. AAO J 2004;14(3):15-17. HH. P r in ci pl es of Osteopathic Technic. I nd i a na pol i s : American Academy of
6. F r ye ( [e
Osteopathy, 1954, 1980. 7. Kappler RE. P a lpato r y skills and exercises for de v elopin g the sense of touch. In: Wa r d RC, ed. Foundations for Oste opathic Medicine. 2nd ed. Philadelphia: Lippin c o t t Williams & Wilkins, 2002;557-565.
8. Braunwald E. Heart failure. In: Fauci AS,ed. Harrison's Principles of I merna I Medicine. 14th ed. New York: McGraw Hill, 1998;1287. 9. B r au nw a l d E. N orma l and abnormal
m yocardial function. In: Fauci AS, ed. Harrison's
Pri n ciple s of Inte rna l Medicine. 14th ed. N ew York: M cGraw Hill, 1998;1278-1282. 10. Ross J lr, Covell jW. F r a me w ork s for ana l ysis of ve m ricu lar and circulatory function: Integrated responses. In: West lB, ed. Best and Tay l or 's Phys i olo gical Basis of Medical Practice. 12th ed. Baltimore: Williams & Wilkins, 1990;296-299. 11. Ross
1 Jr. In tr od uct i on to the cardiovascular s ystem. In: West JB, ed. Best and Taylor 'S
Phy s i ological Basis of Medical Practice. 12th ed. Baltimore: W i llia m s & Wilkins, 1990;112. 12. Wes t JB. Pulmonary blood flow and metabolism. In: West J B , ed. Bes t and Taylor'S Physiological Basis of M ed ical Practice. 12th ed. Baltimore: Williams & Wil k ins , 1990;529-531. 13. B r a u nwa ld E. Cor pu lm ona le. In: Fauci AS, ed. Harrison's Principles of Internal Medicine. 14th ed. New York: McG r a w Hill, 1998;1327. 14. P h i ll ipson EA. Disorders of vent i l ation. In: Fa u c i AS, ed. Harrison's Principles of Inrernal Med ic ine. 14th ed. New York: McGraw Hill, ]998;1476-1479. ]5. Miller CEo The m ec h a ni cs of lymphatic c i r cul a t ion : Lymph hearts. J Am O s te op ath Assoc 1923;22:397-398,415-416. 16. Glossary of o s teopathic
ter min olo gy. In: Wa r d RC, ed. Founda ri ons for Osteopath ic
Medicine. 2nd ed. Philadelphia: L i pp in co t t Williams & Wilkins, 2002;1249. 17. Van Buskirk RL. Nociceptive reflexes and the somatic dysfunct i on: A
m ode l. J Am Os teopat h
Assoc 1990:90:797-809 [review] . 18. National Institures of Health. The Nationa l Center for Complementary and Alternarive Medicine (NCCAM). S rrategic Plan (Stephen E. St raus , Director). hrtp:llnccam.nih.gov/nccam/strategic. Page expired. For past and present NCCAM strategic p lans visir http://nccam.nih.gov/ or contacr
the NCCAM Clearinghouse, P.O. Box 7923, Gaithersburg, MD 20898·7923. 19. K ap pler RE, K el so AF. Thermographic sru dies of skin temperature in patien ts receiv ing osteo pathic
manipulative
treat m en t for pe rip h e ral nerve problems. J Am Os teopath Assoc
1984;84: 76-EOA. 20. Schellnemen GM, Mnabhi AKS, Papp MA, er al. Oste o p ath i c manipulative t re a tme nt and congesrive heart fa i l u re. J Am Osteo path Assoc 2003;103:379-EOA [a b s t ract]. 21. Schwab WA. P r i ncip l e s of
man i p u la t i ve treatment: The low back pro blem. 1965 Yearbook.
Vol 2. Indianapolis: American A cade m y of Osteopat h y, 1965;95. 22. Nelson KE. The management of low back pain: Shorr leg syndrome/postural
ba lan ce. AAO 1
1999;9(1 ):33-39. 23. Rumney Ie. Osteopathic 1974;2(7):29-30, 32-33.
m a ni p u la tive treatmenr of infectious dise a ses . Os teopath Ann
Th e Pa t i e n t w i t h G a st ro i ntest i n a l P ro b l e m s K e n n et h E . N e l s o n a n d A n n L . H a b e n i c h t
I NTRO D U CTI O N G a stroe n te r o l ogy, as a s u bspec i alty o f i n ternal m e d ic i n e , m a y not i n i t i a ll y a p p e a r to lend itse l f to t h e a p p l ica t i o n of o s teo p a t h i c pri ncip l e s . I n d ee d , i f i t is a ppr o ac h e d s o le l y a s the d i ag nos i s a n d treatment o f gastroi ntestina l d i seases, i t ma y be exclu
sive o f o s t e o p a t h i c p r i ncip l es . Osteopath ic p h i l o so phy i n practice i s pa tient orie nted rathe r t h a n d isease o r i ente d . The p a ti e n t is v iewed a s a n i n t eg r a t e d m a n i fe s t a t i o n o f a l l t h e va r i o u s s y s tems ( h o l i s m ) . T h e n e rvou s a n d c i rc u l a t o r y systems a re g i v e n p a r t icula r con s i d e r a t i o n i n t h is a p p roach beca u s e of t h e i r c o n t a c t with all oth er s y s t e m s . The y l i n k t h e c o m p o n e n t parts o f t h e b o d y i nto a hol istic mecha nism. The m u sc u l oskel eta l system is a l s o of g rea t i mporta nce i n o ste o p a t h i c med ici n e . D y s fu nc t i o n o f t h e m uscu l os k e l eta l system, s o ma t ic d y s fu n c t i o n c a n a ffect t h e t o t al health sta t u s o f t b e pa tie n t . I t d o e s this directly t b ro u g h mech a n ical in fl u e nces and ind i rect l y th ro u g h t h e n ervo u s and c i rc u l a to ry s y s te m s . S o m a tic d y s func t i o n is a revers i b l e cond i t ion a n d i s not i tself a d i s e a s e process. I t m a y be the res u l t of m echanica l s t r e ss e s , or i t m a y be a m a ni fe s t a ti o n o f n e u rol o g i c ac t i v i t y, a s i n t h e case o f v i sc e r o s o m a tic re flexes . T h ese re l ations h i ps s peci fica l ly app l y t o t h e gast r o i n tes t in a l tract. The g a s tro i n t es t i n a l tract i s o b v i o u s l y l i n k e d to the bol i stic m ecb a n ism througb th e v a scu l a r syste m . The l y m ph a t i c a nd venous d r a i n a g e of th e g a st r o i n t e st i n a l tra ct i s a m a j o r ,
29 1
292
Section I I I • C l i n ica l Conditio n s
p o r t a l o f e n try o f n u tr i e n t s a nd occa s i o n a l l y nox i o u s s u bsta nces i n t o t h e b o d y. T h e g a s tro i n te s t i n a l t r a c t i s a l s o u n ited w i t h t h e r e s t o f t h e b o d y by t h e n e r v o u s system through v i sceroso m a t i c , s o m a to v i s c e r a l , and v i scero v i scera l refl exes . I f the p a ti e n t w i t h a p ro b l e m o f the gastro i n tes t i n a l s y s te m is a p p r o a c hed fro m th i s perspect i v e , t h i s s u bspecia lty s u bject is ea s i l y l i n ke d i n t o t h e h o l i s t i c pra ctice of osteo p a t h i c m e d i c i n e . N u tr i t i o n is a n i m p o rta n t c o m po n e n t o f a h o l istic a p p r o a c h to hea l t h c a r e . There i s a p a r t i c u l a r l y o b v io u s re l a t i o n s h i p b e t w e e n d i et, g a s troi n te s t i n a l fu ncti o n , a n d nu tri tio n a l s ta t u s . I t i s e a s y t o s e e h o w g a s t ro i n te s t i n a l d ysfu n c t i o n c a n u n to w a r d l y a ffec t n u tr i t i o n a l sta t u s a n d how d ietary i n to l e r a n c e ca n re s u l t i n ga stro i n testi n a l d ysfunc t i o n . I t i s a l s o e a sy t o s e e h o w n u tr i t i on a l d e fi c i e n c i e s a n d excesses a ffec t hea I th s ta t u s .
1£ t h e te r m
functional p re c e d e s a d i s e a s e p r o c e s s ( e . g . , fu nc t i o n a l g a s t r i tis ) , i t
i m p l ies a co n d i t i o n w i t h o u t d e m o n s tr a b l e orga n ic p a t h o logy. Sym ptoms s u c h a s d ys p e ps i a ,
n a u sea , v o m i t i ng, be lc h ing, fla t u s , a nd d i a r r hea m a y be f u n c t i o n a l o r
t h e res u l t o f s o m e orga n i c p a t h o l ogy. I The pa tient with c h o l e c y s t i t i s h a s a n orga n i c c a u se fo r the sympto m s . The p a t i e n t with p o s tc h olecystecto m y s y n d ro m e has pers i ste n t s y m p t o ms a fre r the o rg a n i c p a t h o l o gy
has
been e ffectively
removed . " Th i s
functiona l
co n d i t i o n
a p p e a r s to be t h e re s u l t o f a pers i s t e n t s o m a toviscera l r e fl e x . A necdota l e v i d e n ce i n d i c a tes t h a t w h e n osteop a t h i c ma n i p u l a t i v e trea tme n t ( O MT) is e m p loyed to treat s o m a t i c d y s fu n c tion of t he l o w t h o r a c i c regi o n , the symptoms of p o s tc h o l e c y s tecto m y s y n d rome q u ic k l y reso l v e . 3 S i m i l a r l y, c o n s t i p a tion is t y p ic a l l y t h e re s u l t o f i n a d e q u a te con s u m p t i o n of d i etary fi b e r and wa ter, poss i b l y e x a c e r b a t e d b y d i m i n is h e d p e r i sta l s i s . I n c reased s y m p a t h e t i c t o n e c a n d ecre a s e p e r i s ta l s i s . T h o r a co l u m b a r s o m a t i c d ys f u n c t i o n can h a ve th i s e ffec t upon the i n testin e s t h r o u g h s o m a t o v i scera l reflex a c t i v i ty.4 Physical a c tiv ity m ec h a n ic a l l y s t i m u l a te s per i s ta l s i s . D i sc o m fo r t a s s o c i a ted w i t h s o m a t i c d ysfu n c t i o n i nte rferes w i t h e a s e o f move m e n t . I n e l d e r l y i nd i v id u a l s w h o a re pre d i s p o s e d to c o n s t i p a t i o n , d i m i n i s h ed a c t i v i ty beca use o f treata b l e s o m a t i c d y sfu ncti o n c a n c o ntr i b u te s i g n i fica ntly to i n testi n a l s ta s i s . Pro l o n ged g a s t r o i n te s ti n a l tr a n s i t t i m e i s a ssoc i a ted w i t h t h e d eve l o p m e n t o f p a t h o l ogy, i n c l u d i ng d i v e r t i c u l o s i s of t h e co l o n . 5 T h i s ch a p ter a d d resses th e osteopa th ica l l y d i s t i nctive compo n e n t of the d iagnosis and tre a t m e n t of g a s t ro i n te s ti n a l d i sord ers .
V I S C E RO S O M AT I C A N D SO M ATOV I S C E RA L R E F L E X E S V i s c e r o s o m a tic reflexes a r e d i s ti n c t i v e l y o s te o p a thic d i a g n o s t i c too l s . T i s s u e tex ture c h a nge a n d te n d erness to p a l p a t i o n a re fo u nd in soft t i s s u e as a refl e x m a n i fes t a t i o n o f seg m e n ta l l y ( spinal c o r d ) re l a ted v i scera l p a t h o logy. Vi sceroso m a t i c ref lexes occ ur a s fol l o w s : 6 1 . A periphera l foc u s o f i rr i ta tion ( e . g . , v i scera l pa t h o l og y ) re s u l ts i n increased gen era l v i scera l a ffere n t
( GVA ) n e u ra l a c t i v i ty. These a re the a ffe rent ne rves of the tra v e l wi th the s y m p a t h etic and p a r a sympa
a u ton o m i c n ervo u s system. They thetic nerve s .
2 . GVA n e u ro n s s y n a p s e i n t he d orsa l h o r n o f t h e s p i n a l c o r d w i t h i n te r n u ncia l n e u r o n s . The i n c r e a s e i n GVA a c t i v i ty p rod uces a c o n d i ti o n of i r r i ta b i l i ty ( fa c i l i ta t i o n ) of the i n te r n u n c i a l n e u r o n s a n d c o n s e q u e n t l y o f t h a t s p i n a l seg m e n t . In severe cond i tio n s , the fa ci l i t a t i o n w i ll spre a d u p a n d d o w n the th r o u g h t h e i n te r n u n c i a l n e u r o n s to i n v o l v e a d j a c e n t segme n t s .
cord
Chapter 20 • T h e Pat i e n t w i t h G a st r o i n t e st i n a l P r o b l e m s
293
3 . The segme n t a l fa c i l ita tion m a n i fests itsel f as increased e fferent activ i ty to a l l
a reas innerva ted by that sp i n a l segment, with resu l t a n t pa raverte b ra l changes i n muscu l a r a nd-in t h e thoracol u m bar region-vasomotor ton e (tissue texture change ) . This same phys i ology p ro d uces somatoviscera l and viscerovisce r a l r e a c t i o n s th rough sympathetic a nd pa rasympa thetic efferent neurons. 4 . S p i n a l fac i l i ta ti o n a lso m a k es segmenta l l y re l a te d tiss ues more sensitive to e xoge n o u s sti m u l a t i o n ( te n d e rness ) . S . These m a n i festations a re d i rect l y p r o p o rt i o na l to t h e i ntens i ty o f i n p u t fro m t h e visce ra l foc u s of i r r i ta t i o n a n d t h e refore are q u a nti fia b l e . Bec a u se viscerosomatic reflex patterns a re rel atively segmenta lly speci fic a n d d e m o nstra te proport i o n a te reac t i v i ty, t he y p rovid e d i a g n os tic i n formation a s to the s i te and severity of the u nderlying conditio n . The q u a n tita tive aspect of t h e reflexes a lso o ffe rs the os teopa th i c practi tioner a s i m p l e method to m o n itor the progress of the d isease p rocess. Vi scerosom a t ic re flexes a ugment d iagnosis and a re not i n tended to rep lace other as pects of p hy s i c a l d iagnosis or la boratory a nd ra d io l ogica l studies. As an exa m p l e , a n a w a reness o f visceroso m a t i c pa tterns may assist i n d i fferen t ia t i n g between upper gastro i n testi n a l symptoms resu l ti n g fro m myocard i a l d is ease ( T l -TS left-s i d e d ) a n d gastric d isease (TS-TI 0 l e ft-s i d e d ) 6 Som a toviscera l re flexes a l s o o cc u r as t h e resu lt of fa c i l itati o n . In t h i s case, th e i r r i t a b i l i t y of the centra l nerv o u s system a ffects a ta rget o rga n throu g h i ncre a s e d para sym p a t h e t i c or s y m p a t hetic a u tonomic activity. Visceroso m a tic reflexes a re c l a ss i fied a s p a r a s y m p a t h e ti c or sy m pa t h e t ic accord i ng to the s o m a tovi scera l reflexes segmenta lly a ssocia ted with them . Viscerosomatic re flex fin d i n gs with p a rasympathe tic a ssoci a tion are p a l p a ble i n t h e para verte bra l soft tissues of t h e h igh cervi ca l a n d sacral regi o n s . T he h i g h cerv i c a l para s y m p a thetic viscerosoma tic r e fl e x is the vaga l r e fl e x . After e x i t i ng t he s k u ll , t h e v a g u s n e rve i nterd igita tes w i t h C l and C2 within t h e cervica l plex u s . 7 Va ga l r e fl e xes a r e fo u n d a t t h e level o f the occ i p u t, C l , a nd C 2 , w i t h greater tend ency f o r a right- s i d e d reaction from pancreas, liver, gallbla d d e r, sm a l l i n testi n e , ascend ing colon, a n d the right h a l f of the transverse colon . The le ft- s i d e d u p per cerv i c a l reacti o n occu rs c l a ssica l l y with u pper gastrointestina l pro b lems (esop hagus, stom ach, a n d d u o d e n u m ) . The sacra l pa ras y mpa th e ti c reflex ( S 2 , S 3 , S4 ) i s associa ted w i t h co n d i t i ons a ffect ing t h e left h a lf of the tra nsverse colon, d escen d i ng co lon, s igmoi d , a n d rec t u m Visce rosoma tic refl e x fi nd i ngs with symp a t he t ic assoc i a tion a re palpa b l e a s tis s u e t e xt u r e c h a nge and te n d erness in the thoraco l u m b a r pa raverte b r a l soft tissues a s fo l l ows: .
.
T3 TS T6 TS
to T 6 , r i ght-s i d e d reaction to TIO, l e ft-s i d e d rea c t i o n t o T 8 , r i g h t s i d ed reacti o n t o T 9 , b i l a tera l b l o c k r eacti o n
TS t o T 1 0 , T9 to T 1 0 , T8 t o T I O , T9 to T 1 2,
-
r i g h t-sided rea ction r ight-s i d e d rea c t i o n b i latera l rea c t i o n ( R > L) r i g h t- s i d e d rea c t i o n
TI l to Ll , right- s i d ed react ion Ll to L3, l eft-s i d e d reactio n
Esop hagus Stomach D u o d en u m P a n c re a s ; i n c h r o n i c pa ncrea t i t i s a re a ten d s to be fixed i n exte n s i o n L i ve r G a J l b l a d der Sm a l l intestine Appe n d ix; a ssoc i a ted w i t h ten d e r n ess over the ti p of the 1 2t h rib on the ri g h t ( a nterior Cha pma n 's tender point) Cec u m a n d a scen d in g colon Desce nd ing colon
294
Section III • C l i n i c a l Co n d i t i o n s
T h e combinat ion o f C2 l e ft , T3 to T 6 right, T 5 to T I O left, and T6 to T 8 right is re ferred to as the upp er gastrointestinal pattern . The locations of the somatic manifestations of visceral dysfunction or pathology are generally predicta b l e . The i nte nsity of the tissue te xture c hange m i rrors t h e severity of the viscera l problem. Visceroso matic reflexes a d d greatly t o physical diagnosis and may also be use d to follow the clin ical progression o f
a
d isease .
N eoplastic diseases do not p roduce typical visce rosomatic reflex responses. The cord level response for th e invo l v ed visc u s will occur, but bec ause neoplasm ty p i call y deve lops wi thout i n n ervation, there is no direct source of affere nt input. Reflex activity occurs as a result of visc era l disp l a c ement and i n flammation from the presenc e of the neopl asm, not from the neoplasm itself. As s u c h , the re fle x, when encountere d , is often l ess intense than would be anticipated con s i dering the severity of the disease .
C h apma n 's re flexes , another visc erosomatic -somatov iscera l system, are a group of palpable nodular areas of tissue texture change that have diagnostic and therapeuti c sign ificance. They are considered to be a ne uroly mphatic reaction. Treatment of these points using in h ibitory pressure is repo rted to be an effective treatment of visce ral complaints. 8 The posterior re flex points in Ch apman's syste m in many instances app roximate the locations of the visce rosomat i c re flexes l isted previously. The i ntegration of the treatment of somatic dysfun ction into t h e therape utic protocol w ith OMT is indi cated for the spec ific treatment of so matic dysfu nction . A s stated previously, somatic dys func tion i s functional impai rme nt o f the neuro musculosk eletal system. Alth ough it may exist in the p rese n c e of patho l ogy, it is not in itself pathology. OMT for treatment of somatic d ysfunction is used to increase available motion, modi fy activity of the nervous syste m , or i ncrease tissu e perfusion. The integration of th e diagnos is and treatment of somatic d ysfunction into the p ractice of gastroente rology may initi ally seem superfluous. The seve rity of i llnesses en countered a n d the fact that t h e gastrointestinal syste m is consid e red to be sepa rate from the musculoskeletal system make the diagnosis of somatic dys fun ction seem inconsequential. Furthermore , OMT is not directly used for t h e t reat m e n t of gastrointestinal disease processes. Why then should one diagnose and treat somati c dysfunction in the patient with gastrointesti nal comp l ai nts an d/or patho logy ? It is b e n e ficia l , if a pati ent comp lains of a pain that resembles a gast rointesti nal probl em, to dete rmine wheth e r it is ac tually
a
pri mary m usc u loske letal pro b le m
amena ble t o OMT. If th e probl e m is gastrointe stina l , is it f unctiona l or organic ? Fu n c tiona l com plaints that res u l t from somatovisceral r e fl exes respond to the treatme n t of under ly i ng somatic dys func tion. When treating a patient w i t h an organic gastroi n test inal disease process , the physic ian can dete r m i n e how to integrate the treatment of somatic dysfunction into the th erapeutic protocol by answering the following questi ons:4 1 . How is musc u los kel etal dy sfunction affecting the patient's abil ity to re spond
to the disease p rocess? 2. What sympathetic somatovisce ral mecha nisms are present? Spinal facilitation
with resultant increased sympathetic tone i ncreases vascular tone, hence decreases tissue perfusion and nutrie nt and oxyge n supply to tissues and the reby increases any need for anaerobic glycolysis. It relaxes the ga llbladder and b i liary d u cts and decreases the glandular secre tions and pe ristalsis, produc i ng constipation or ile us.
C h a pter 20 • T h e Pat i e n t w i t h G a st r o i ntest i n a l P r o b l e m s
295
3 . W h a t parasy m pa thetic s o m a tovisceral m ec h a n i s m s a re prese n t ? S p i n a l faci l i
t a t i o n w i t h re su lta n t i n c reased p a r a s y m p a th e t ic t o n e increases t h e secret i o n of the d igestive enzymes a m y l a se and l ipase. It ca uses co n tractio n o f the gall b l a d der a nd b i l iary d ucts a n d i ncrea sed gla n d u l a r secretions a n d perista l s is , pro ducing d iarrhea . 4 . How is ci rc u l a tory stasis a ffecting the pa tie n t ? The m ec h a n ica l com p o n ent o f soma tic d ys fu ncti o n res u l ts in restrict i o n of motio n . Effic i e n t movement of the thoracic inlet, thoracic cage, a bd o m i n a l d ia p h ragm, mesen teries, and pe l vic d i a p h ragm is necessa ry for o p t i m a l low-press u re fl u i d ( lympha tic a n d ven o u s ) d y n a m ics a nd tissue perfu s i o n . Inefficiency of th is mech a n is m fu rther a d d s t o the tend ency toward tissue congestion . Viscerosoma tic reflexes ca use muscle spasm, tenderness, a n d p a i n . Part o f the d i ag nostic d i lemma is the d i fferentiation between a viscerosomatic reflex and p r i m a ry soma tic dysfu nctio n . The pe lvic d i a p luagm is i nnerva ted by the p u d enda l nerve (52-54 ) o f the pelvic sp l a nchn ic nerves. Pain i n this area may be viscerosoma tic, p e l vic pa rasym pathetic, o r simply the res u l t o f sacrope lvic somatic dysfuncti o n . Proper appl ica tion of O MT resolves p rima ry somatic dysfu nction. A l t hough viscerosomatic refl exes ca n be a ffected by OMT, the associa ted soma tic find i ngs wi l l not resolve u n t i l t h e u n derlying v iscera l cond ition is trea ted . Fa i l u re of soma tic dysfu nction t o respond to O MT should lead to the consideration of a viscerosomatic etiology. Indeed, part o f the eva luation of any somatic d ysfunction shou ld include i n q u i ry a bo u t segmenta l ly re l a ted viscera . Appen d icular complaints may result from viscerosoma tic-somatic re flexes, as in the exa m ple of l eft arm pain resu l ting fro m myoca rdia l ischemia .
C H OO S I N G A N D U S I N G TH E P R O C E D U R E H a v i n g d ecided what t o treat a n d h o w t h e tre a t m e n t is i n te n d e d to a ffect the patient, the p hysici a n m u s t d ecide u p on the m a n i p u la tive proce d u re to e m p loy. Patient to l e rance d ictates the leve l of a ggress iveness of the proced u re chose n . A somewhat a r t i fici a l conti n u u m o f proce d u re ca n b e cre a te d based u p on the relative aggressiveness o f the proced u r e . • • • • • • • • • •
High-veloci ty, low-a m p l i t u d e (HVLA )-most aggressive A rticu l a t i o n S o ft tissue D i rect fa scia I re l ease M u scle e n e rgy Cou n terstra i n Fac i l ita ted positio n a l release I n d i rect fasc i a l release I n h i bitory pres s u re Ind i rect cra n i a l-least aggressive
As stated , this l is t is q u ite a r b itrary a n d open to d e ba te , b u t the i d e a i s v a l i d . A lso, bes i d es t h e aggress iveness of t h e proced u re type, t h e t i m e req u i re d fo r a ppli c a t i o n a ffects p a t i e n t to l e r a nce. The l onger a proced ure takes, the less the patient m a y be a bl e to tolerate i t . As a r u le, the more aggress ive the p roce d u re , the less time req u i red for its a pp l ica t i o n . How m u c h O MT is e noug h ? Treat the patient u nti l a response occurs. Wha t k i n d of response? Relaxa tion o f t h e soft tissue i n t h e a rea being treated i s a good response. Altered a u tonomic tone is a lso an i n d ication o f a response. Peripheral vasod i la ti o n
296
Section III • Clin ical Cond i t i ons
res u l t i n g i n i ncre ased s k i n tempera ture or red ness a n d i ncreased s u d om o to r ( swea t i n g ) a c t i v ity i n d i c a te i t i s time to stop. Increased h e a r t o r res p i ra tory r a te a l so i n d i c a tes tha t t h e p a t i en t's l evel o f tolerance h a s b e e n reached . I f the p a t i e n t feels t h a t i n terve n t i o n i s t o o unco m forta ble, t h e physician s h o u ld s t o p a n d c h oose a n other a p p roa c h o r ret urn l a ter a n d try a ga i n .
Clinical Example: Pancreat itis The Disease
Pa n c r e a t i t i s i s c l a ssi fied a s a c u te or c h r o n i c . A c u te pa n c r e a t i t i s is m o s t freq u e n tly enco u n tered a s the res u l t o f gallstone o b s t r u c t i o n of the c o m m o n d uct ( c h oledo c h o l i th i a s i s ) . The c o n d ition resolves c l i n i c a l ly and h istologic a l l y once the o bstruc tion is e l i m i n a te d . Chron i c re l a ps i n g p a n c rea ti tis, w h ich t y p i c a l l y res u l ts from a l c o h o l a b u se , p e rs ists h is tol ogica l l y a fter cess a t i o n o f t h e e t i o l ogic c i r c u m s t a n c e . B o t h a c u te a n d c h ro n i c rel a p s i n g ( h istolog i c ) p a n c reatitis a r e m o s t o fte n enc o u n tered cJini c a l l y a s a c u te p a ncrea t i t i s . There a r e m a n y o t h e r c a uses of pa ncrea t i t i s . Choledocho l it h i a sis a n d a l co h o l i sm, however, acco u n t f o r m o s t c a s e s . 9 The p a t i e n t h a s s e v e r e c o n s t a n t u pper a b d o m i n a l p a i n a n d re fe rred p a i n t h a t r a d i a tes th r o u g h to the m i d t o l ow t h o r a c i c r eg i o n of t h e bac k . There may b e cep h a l g i a . There i s n a u s e a , v o m i t i ng, d i a p h o re s i s , t a chycard i a , a nd
s ha llow
t a c h y p n e a . The p a t i e n t's tempera ture ma y b e n o rma l o r s l i g h t l y e l eva ted . The a bd o m i n a l wa ll may be r i g i d , with r e b o u n d te n d e r n e s s . Bowel s o u n d s a re h y p oac tive. I n severe c a ses, t h e l i be r a t i o n of p a ncre a t i c e n zy m e s res u l ts in pa ncre a t i c a u t o l y s i s and s h oc k . The Pain Pa ttern
In i t i a l l y, t h e a c u tely i n fl a m e d pa ncre a s is p e r c e i v e d as
a
d eep d u l l pa i n . As the
i n fl a m m a tory p rocess i n volves the pa n c re a t i c v i s c e r a l p erito n e u m , w h i c h c o n ta i n s u n m y e l i n a te d n o c i c e p t i v e nerve e n d i ngs, the p a i n becomes s e vere . A t t h i s p o i nt, p e r i to n e a l signs d e v e l o p . Fur ther s pread of the i n fl a m m a to r y process i n v o l v e s the p a r i e t a l p e r i t o ne u m o f the a nterior a bd o m i n a l w a l l . Th i s res u l ts in the r i g i d a bd om i n a l w a l l s p l i n t i n g see n i n p a ncrea ti t i s . T h e p a ti e n t perceives referred p a i n i n t h e i ntersc a p u la r regi o n . O cc i p i t a l h ea d a c h e m a y a l s o be p rese n t . T h e ge n e r a l ized upper a b d o m i n a l p a i n a s soci a ted w i t h a c u te p a n c re a t i t i s seems e a s y to u n d ersta nd . Th e pa ncreas is an upper a bd o m i n a l m i d l i n e o rga n . T h e vis ceroso m a t i c r e fl e x fr o m p a n c rea s ma kes this p a i n d i s t r i b u t i o n even more l ogica l . T h e pa ncre a s refl e x is b i l a te r a l fr o m T 5 to T9 . T h e T5 t h r o ug h T 9 d e r m a t o m e s s u p p l y the upper a bd o m i n a l w a l l . S p ina l fa c i l i t a t i o n p r o d u ce s segm e n t a l hypera l ges i a . The b i l a te r a l i n v o l v e m e n t o f t h e p a n c re a s reflex re s u lts i n s e n s i t i z a t i o n o f t h e e n t i re u pper a bd o m i n a l w a l l . Pa n cr e a t i c r e ferred p a i n i n t h e m i d to low t h o r a c i c reg i o n i s a d i rect m a n i fes t a t i o n o f the loca t i o n o f the p a n c re a s i n a ss oc i a t i o n w i t h t h e b i la te r a l T 5 t h r o u g h T9 p a ra verte bra l tend erness o f t h e v i sceroso m a t i c refl e x . T h e occip i t a l h e a d a c h e i s a res u l t o f t h e v a g a l v isceroso m a t i c re flex t h rough t h e gre a ter a n d l e s s e r occ i p i t a l nerves t h a t origi n a te fr o m C 2 a nd C3 . The Musculoskele tal Palpa tory Findings
The s y m p a th e t ic v i scero s o m a tic reflex from t h e p a n c r e a s is fo u n d b i l a tera l l y fro m T5 to T9 . P a r a v e r te b r a l t i s s u e texture c h a nge is pa l p a b le a t these le v e l s . T h e m o re
severe the c o n d i t i o n , t h e gre a te r t h e a re a of t i s s u e text u r e c h a n g e . In l o ng s ta n d i n g c a s e s of c h r o n i c pancre a t i t i s , t h i s a rea beco mes exte n d e d , d e m o n stra t i n g fl a ttening or revers a l o f the th o r a c i c k y p h o s i s . The p a r a sympa thetic ( v a ga l ) viscerosoma tic
C h a pter 20 • T h e Pa t i e n t w i t h G a stro i n test i n a l P ro b l e m s
297
reflex is fo u n d i n t h e u p per cerv i c a l reg ion ( o c c i p u t to C2 ) . It is u ni l a tera l , w i t h a grea ter incidence on the right. T h i s reflex is p a r t i c u l a rly u s e fu l fo r m o n i t o r i ng pro gress i o n of the i l l ness beca use its su bocc ipita l loca t i o n makes i t e a s i ly access i b le i n the bed r i d d e n p a t i e n t . I f pa ncrea titis d e ve l o ps a s t h e res u l t o f cho lecystitis a n d choledochol i t h i a s i s , a ga l l b l a d d e r reflex w i l l b e presen t a t T I O right. I f i t develops i n a ssoci a t i o n w i t h a lco h o l i c hepa t i t i s , a s l i gh t l y b roa d e r rea c t i o n , T9 to TI O right, c a n be e xpected . W i t h the deve l o p ment of i le u s , a s ma l l i n testi n a le reflex wi l l be p rese nt, T8 to T I O b i l a te r a l , right greater tha n left. The u pp e r gastro i ntesti n a l irr i t a t i o n a ssocia ted w i t h t h e n a u sea a nd v o m i t i n g t h a t accompa ny p a n c re a titis pro d u ces an upper gastrointes t i n a l reflex pattern o f occ i p u t to C2 l eft ( va gu s ) , T3 to T6 right (esop h a g u s ) , T5 to no left ( s t o mach ) , a nd T6 to T8 r ight ( d u o d e n u m ) . The accompa nying perito n i tis i n v o l ves the pa rieta l a nd viscera l perito n e u m . The p a r i eta l peri to n e u m i s i n n e r v a ted by s o m a t i c nerves; therefore, pa rieta l p e r i to n i t i s p rod uces a s o m a toso m a t i c p a r a v e r te bra l refl e x w i t h pa l pable f i n d i ngs i n the low thoracic a n d m i d cervica l ( p h re n i c ) region s . T h e s o m a t i c fi n d i ngs pa raverte b r a l l y i n the upper c e r v i c a l r e g i o n a nd fro m T 5 to T9 b i l a tera ll y i n a s s o c i a t i o n with t h e signs a n d sym ptoms of pa ncre a titis a r e v e r y u s e f u l i n fo rm a ti o n . As can rea d i ly be seen, t h e m o r e c o m p lex t h e presentation and the m ore i n tense the p a t h o l ogy, the grea ter the area o f v i sceroso m a tic reflex parave rte bra l tissue texture c h a nge. In severe p a ncre a t i tis, the e n t i re cerv ica l , tho r a c i c , a n d u p per lumbar regi o n s m a y become reac t i v e . Viscerosomatic r e f l e x fi n d i ngs a re a part of the complete p hysica l exa m i n a t i o n . T hey a re not i n tended to r e p l ace exa m i na t i o n of t h e rest o f t h e p a t i e n t . O n t h e contra ry, t h e p a l p a tory s k i l l leve l necessa ry to pe rfo r m t h e osteo p a t h i c m uscu loskeleta l e x a m i n a tion has gre a t va l u e for pa l pa t i n g the a c u te a bd omen a n d else where. A com plete h i story and phys i ca l exa m i n a ti o n give the i n form a t i o n n eces s a ry to fo r m u l a te d i f fe re nt i a l d i agn oses . The more i n formation a va i l a b l e , the m o re precise t h e d iagnos i s . D i a gn oses a re c o n firmed or r u led o u t u s i ng tec h n o l ogica l m e t h o d s ( e . g . , l a bo r a tory, u l traso u n d , r a d i ography, co m p u ted tomogra p h y, mag netic res o n a nce i m a g i ng ) . The more precise t h e d i a g n oses a re, the more cost effec tive t h e use of tech no-d iagnostic p roced u res. Treatment
A c u te pancreatitis m a y v a ry in i n te n sity fro m m i ld to l i fe t h r e a te n i ng . The b a s ic tre a t m e n t is s u p po rtive, w ith speci fic trea tment d irected a t u n d erlying c o n d i t i o n s . O MT used a t t h i s t i m e is i n t e n d e d to red uce the i nte n s i ty o f the a c u te cond i t i o n . The patien t'S tolerance is red uced, a n d c a re m u s t be t a k e n not to use a p roce d u re t h a t is u n necessa r i ly st i m u l a t i ng. The s y m p a t hetic v i scerosom atic refl e x e s assoc i a ted w i t h pancre a t i tis and c o n s e q u e n t l y the a re a s t h a t a re trea ted fo r somatoviscera l e ffect a re fo u n d i n the m i d t o low t h o racic region . T h e p a r a s y m p a thetic reflexes a re fou nd in the upper cerv i c a l a n d s u bocc i p i ta l regio n . T h e i n tens ity of t h e viscera l pa thology d etermines t h e a mount of spi n a l fa c i l i ta t ion p resent. Parave rte bra l tissue te xture c h a nge is d i rectly p ropo rti o n a l to the severity of v i scera l p a t h o l ogy. The use of O M T to prod uce a somatovisceral response is not s i mp l y " p u s h ing the bu tton " a t the a n ticipated reflex l e ve l . Os teop a t h i c p h y s i c i a ns must use th e i r p a l p a tory s k i l l s to d e t e r m i n e the a reas of maxi m u m tissue texture c h a nge, then, with an appreci a t i o n for the d egree o f to l e ra nce o f t h e p a ti e n t d e c i d e upon the type of p roce d u re to use. For trea t i n g a n a c u te v i scerosoma t i c reflex for s o m a tov isceral effect, i n h i b itory press u re is usefu l . I n h i b i to ry press u re is a d i rect proce d u re t h a t may be d escri bed a s extremely l o w veloci t), a nd l o w a m p l i t u d e . Pressu re i s a pp l i e d over the a re a o f ,
298
Secti o n I I I • Cl i n ica l Cond i t i o ns
m a x i m u m t i s s u e te x t u re c h a nge using the d i sta l p h a l a n ge a l pa d of the fi nger o r t h u m b . T h e pressure i s i n c r e a s e d v e r y s l o w l y a s t h e t a r ge t t i s s u es re l a x . T h e d ev e l o p m e n t o f r e a c t i v e m u s c l e s p a s m i nd i c a tes t h a t t h e p roced u re i s too aggressive a nd s h o u l d be s t o p ped . When t o l erated , t h e press u re is a p p l ied a n d h e l d u n t i l press u r e a n esthes i a d e v e l ops in t h e trea t i n g p h y s i c i a n 's t h u m b or fi nger. ( I f p ress u re a n es thesia i s sensed by t h e tre a t i ng p hys i c i a n , it is pro b a b l e t h a t press u re a n e s t h e s i a a l s o has been prod uced i n t h e tiss ues b e i n g trea ted . ) A t t h i s t i m e , the p ress u re is very s l owly r e l e a s e d . This p r o ce d u r e may b e r e p e a ted i n 1 or 2 h o u rs d e p e n d ing upon th e p a t i e n t 's t o l e rance. It may be e m p l oyed in the t h o r a c i c reg i o n for s y m pa
th e t i c effect a n d i n the u p per cervical region fo r pa r a s y m p a t h e t i c effec t . T h e periton itis associa ted w i t h a c u te p a n crea t i t i s lim i ts d i a p h ragmatic exc u rs i o n . This pred i sposes t h e patient t o lower p u l m o n a ry a te l ecta sis a nd p n e u mon i a . G e n tl e
thoracic a n d costal m o b i l i z a tion a n d r i b ra i s i n g t o to lerance a re a pp ro p r i a te here. As the peri tonitis beg i n s to su b s i d e , myofa scia l p roced ures for the a bd o m i n a l w a l l , d i aph r a g m a t ic r e l e a s e , a n d thoracic p u mp p roce d u r e s s h o u l d be employe d . The l i mi t a t i o n of t h o ra c i c cage a n d a b d o m i na l w a ll m o b i l ity a n d decreased d i a p h ragm a tic excurs i o n seve rely l i m i ts t h e retu r n of lymph to t h e genera l c i rc u l a tion . Th i s h a s e n o r m o u s c o n s e q u e nces w h e n p a n c re a tic i n fla mma t i o n h a s s h i fted fl u i d i n to the i n ters t i t i a l s p a c e . The p resence of c e l l u l a r d e bris a n d m a c romolec u l e s i n the fl u i d exert s ign i fi c a n t o s m o t i c fo rce, m a k i n g l y m p h a t i c d r a in a ge t h e o n l y ro u te of egress. T h e p r oced u res i d ent i fi e d previously a re a l so a p propria te the r a p y h e r e . A s s o o n a s p a t i e n t tolera nce p e r m i t s , lym p h a t i c ( pe d a l p u m p a n d t h ora c i c
p u m p ) proce d u res s h o u ld b e i n i t i a ted .
C l i n i c a l Exa m p l e : C h o l ecystitis The Disease
Ch o l e c y s t i tis is very c o m m o n i n the U n i ted S t a t e s . A p p r o x i m a t e l y 9 0 % of p a t i e nts with c h olecystitis have ga l l s t o n e s with th e potent i a l for o b s t r u c t i o n .
In
In 1 996,
3 0 m i l l i o n people were d i agnosed w i t h c h o lecy s t i t i s w i t h l i t h i a s i s a n d nea r l y 9 0 0 , 0 0 0 c h o l ecystec t o m i e s were p e r formed . T h e
re ma i n i
ng 1 0 % o f t h ese p a tients
a re described a s ha v i n g a c a l c u l o u s c h o l ecystitis, o r c h olec y s t i t i s w i t h o u t g a l l s t o ne forma t i o n . 1 1 It i s t h i s 1 0 % of cases of cho l e c y s t i t i s t h a t t h e osteopa t h i c p l1ysic i a n m a y o ften d i agnose th rough t h e u s e of v i sc e roso m a t i c refl e xes. The d iagnosis of c h o lecystitis is often d i ffi c u l t , a s i ts common sym ptoms o f belch i ng, bl o a t i ng, hea r t b u r n , fatty fo od i n tol erance, chro n i c rig h t u p per q u a d ra n t p a i n , r i g h t shoulder pain, a n d m i d epiga stric pa i n m a y a l s o be s y m ptoms of peptic u lcer d is ease, a ppend icitis, ileitis, and he patitis. A lso, c h o lecystitis may cause r i gh t l ower q u a d
r a n t p a i n, l e ft upper q u a d r a n t p a in , a n d even c hest p a i n a s at ypica l presenta t i o n s . I
1.12
Ga l l b l a d d er d i sease i s often cons i d e red only a fter the patient w ith sym ptoms o f peptic u lcer d isease is u n responsive to the use of H2 b loc kers or p ro to n p u m p i n h i b i tors.
Cho lecyst i t i s does not h a ve a ny speci fic l a b o r a t o r y m a r k e rs to h e lp with d i a gno sis. If a b i l i a ry d u ct o b s t r u c t i o n h a s been persiste n t , m i ld l y e l e v a te d transa m i nases w i th leuko cyto s i s m a y r es u l t
,
b u t a l c o h o l ic hepa titis will a lso p rod uce these
c h a nges . " Proced u res such a s h e p a t i c a nd ga l l b l a d d e r
ul
t r a s o u n d s may h e l p w i t h
t h e d i a gnosis when ga l l b l a d d er wa l l t h i c k e n i n g a n d stones a re prese n t . The p resence of g a l l stones d oes n o t necessa rily mea n the p a t ie n t h a s c l i n ica l l y s i g n i ficant d i sease .
Many p a t i e n ts have g a l l s to n e s w i t h o u t a c u te d i sease. I
I
Nuclear i maging may a l so be usefu l i n the d i a g n os i s . B i l i a ry tract i m a g i ng, hipoto i m i nod i acetic acid (HIDA ) , p a ra - i s o p ropyl aceta n i l id o - i minod i a cetic acid ( PIPIDA), or d i isopropyl i minod iacetic a c i d ( D ECID A , prono u nced d es-i-d a ) sc a ns a re u seful in d e term i n i n g o b struction of the b i l i a ry tra c t . I f c h o lecystitis i s present, the ga l l b l a d d e r
Cha pter 20 • T h e P a t i e n t w i t h G a stro i ntest i n a l P r o b l e m s
299
will not fi l l with ra d i oactive c o n tra s t by retrogra d e flow t h r o u gh t h e cys tic d u ct. The a s s u mption i s tha t the cystic d u ct wa l l i s too e d e m a to u s and i n fla med to perm it flow o f tbe ra d i o n u c l e o t i d e fro m t h e common d u ct through the cystic d uct and i n to the gall b l a d d er. W h e n used i n co n j u nction w i t h u l traso u n d fi n d i ngs o f t h ickened d u ct and ga l l b l a d d e r wa l l s , t h i s i n fo r m a t i o n c a rries a h igh proba b i l i ty that the d i agnosis of acute c h o l ecystitis i s co rrect, but i t i s n o t
a lways concl u s i ve . 1 3
Th e Musculoskele tal Palpatory Fin dings
T h e v i sce roso m a t i c r e f l e x fro m l iv e r a n d ga l l b l a d d e r h a s been i d e n t i fi e d a s r i g h t 7 s i d e d pa r a v erte b r a l t i s s u e texture c h a nge fro m TS to T I O p o s te r i o r l y. 6 , 1 4- 1 Rece n t l y, M i ll e r a n d assoc i a tes l S studied the re l a ti o n s h i p of the viscera l ga l l bl a d d e r affe rent projections i n t h e mouse t o deter m i n e t h e n e u roana to m i c a l re l a t i o n s h i p o f viscera l ga l l b l a d d e r n e u rons t o soma tic i n tercosta l n e u rons v i a t h e d o r s a l root ga n g l i o n . Fast b l u e dye w a s p l a ced i n the ga l l b l a dder o f the experi m e n t a l m ice. A second d ye , n u c l e a r y e l low, was p l aced o n severed ends of t h o racic intercosta l nerves. The
48 to 72 h o u rs, O f the expe r i m e n ta l m ice, 8 0 % revealed the p resence o f d yes
dyes tra ve l ed retrogra d e a l ong the a xons v i a a x o n a l tra nsport. A fter the m i ce were k i l led .
fro m both t h.e ga l l b l a d d er and the i ntercosta l nerves i n the d orsa l root ga ngl i a a t the
T9 to T I 2 l e vels on t h e r i g h t . The fi n d i ngs of t h i s experi ment c onfirm the presence of b i fu rcating v iscerosom atic d o rs a l root g a n g l i o n ce l l s ( b i furca t ing pe r i pheral processes fro m i n d i v i d u a l d o r s a l root ga n g l i o n ce l l s to the ga l l bl a d d e r a n d i n tercos ta l nerves ) in the mouse. Thus, M i l l e r 's fi n d i ngs d em o n s t r a te that a t least fo r m ice t h e viscerosom a t ic reflex from ga l l b l a d d er is between the levels of
T9 to T I 2 o n the right.
T h e pa l p a tory ex a m i n a t i o n d u r i n g a n a c u te episode o f c h o l ecys t i t i s will revea l tiss u e t e x t u re c h a nges i n t h e a re a s of the costotra n s v e r s e a r ti c u l a t i o n a n d t h e r i b a n g l es o n t h e r i g ht, m o s t i n tense l y a t
T 9 a n d T I O . These c h a nges i n c l u de m o i s t u re ,
p u ffi ness, te n d e r n e s s , w a r m t h , a n d red n e s s . T h e p a t i e n t m a y a l so h a ve fi n d i ngs consiste n t with t h e v i sce rosoma tic pa ttern fro m upper g a s t ro i n test i n a l i r r i t a t i o n
( C 1 -C2 l e ft , T3-T6 r i g h t , TS-T I O l e ft ) . T h e y m a y a l so d e m o n s t ra te a res tr i c t i o n
of m o t i o n o f the r i g h t h e m i d i a p h r a g m . S p i n a l c o rd segme n t fa c i l i ta t i o n t h u s a l l ows t h e tra i n e d osteopa t h i c p h y s i c i a n to d i fferentia te betwe e n d i ffe re n t d i s e a s e p rocess e s . T h i s i s parti c u l a rly u s e fu l w h e n sta n d a r d p h y s i c a l a n d l a b o r a t o ry fi n d i n g s a re i nc o nc l u s ive. Trea tmen t
I n i t i a l trea t m e n t o f the p a t i e n t w i t h c h o l ecys t i t is d e pe n d s o n t h e s e v e r i ty of the p a t i e n t's sympto m s . S y m p to m a t i c p a t i e nts who a re a m b u l a to r y a n d a fe br il e , w i t h o u t d e h y d r a t i o n o r s i g ns o f a n a c u te a bd o m e n , m a y be g i ve n d i etary res t r i ct i o n s a s t h e f i r s t l i n e o f trea t m e n t . R e d u c t i o n o f fa tty foo d s m a y p r e v e n t fu r t h e r ga l l b l a d d e r a tt a c k s , e s p e c i a l l y i n p a t i e n ts w i t h o u t s t o n e fo r m a t i o n . Tre a t me n t o f a r e a s o f s o m a t i c d y sfu n c t i o n wi l l a l s o i m p r ove n e u r a l fu nct i o n t o t h e a re a s . S o m e p a t i e n t s w it h d i s e a s e acco m p a nied by s t o n e fo r m a tion c a n b e m a i n t a i n e d w i th t h e fa tty food restr i c t i o n s , b u t o ften t he chro n i c i rr i t a t i o n o f the g a l l b l a d d e r fro m t h e stones a n d t h e cha nce o f e x p u l s i o n of s t o n e s a n d poss i b l e o bs t r u c t i on of the cy s t i c or c o m m o n d u cts rema i ns q u i t e h ig h . As a res u l t , s m a l l a m o u n ts of fa rry fo o d s m a y trigger an a tt a c k p r e c ip i t a t i n g a s u rgica l e m erge n c y with i ncre a s e d m o r b i d i t y a s opposed to a n e l ective s u rgica l i n te r ve n t i o n . S u r g i c a l r e m o v a l o f the ga l l b l a d d e r, therefore, is often recom mended t o p a t i e n t s w i t h ga l l b l a d d e r d is e a s e
and s t o n e fo rm a t i o n .
T h e d i a g n o s i s of s o m a t i c d ysfu n c t i o n i s n o t o n l y i m po rta n t i n the effective treat ment o f m u s c u l o s k e l e ta l compl a i n ts b u t a l s o Llsefu l i n d i a g n o s i ng viscera l patholo gy. Visceroso m a r i c refle xes res u l t i n somatic d y s fu n c t i o n that is res ist a n t to
OMT.
Section III • C l i n i c a l Condit i o ns
300
OMT works o n l y a fter the viscera l component is trea ted . Reocc u rring a reas of somat ic dysfunction, espec ia l l y w hen the a reas are consistent with a visceroso m a t i c reflex pa ttern should a l ert the p hys i c i a n th a t under lyi ng viscera l p a t h o l ogy may be present. ,
This is true especially with the recurre n t gastro i n testi na l pa ttern. A com pla i n t of per sistent righ t s h o u lder p a i n in the a bsence of tra u ma s ho u l d be
a
red flag to the osteo
pathic phys ic i a n and r a i se a high susp icion of u nder lying gaJ J b ladder d isease. S u rgical rem o v a l o f the d i seased g a l l b l adder m a y re move the c a use of the p a tien t's d iscomfort, b u t often some of the p a t ient's s y m p to m s rem a i n or retu rn. Care ful eva luation of the t h oracic area w i ll reve a l t he per s i sten t reflex patte r n . Tre a t ment o f t h e res id u a l v iscer o s o m a t i c reflex using O MT w i l l h elp res o l ve the pati ent'S s y m p to m s . Tre a t me n t of the reflex a reas w i l l help to reset the neu ra l i n p u t a n d norma l i ze the fa ci l i t a ted a rea s .
CONCLUSION L i t t le h a s bee n said here a bout the i m p o r t a nce o f n u tr i t i o n i n th e ca re o f t h e gas t r o i ntes t i n a l p a tien t . W h i l e this is an extrem ely i m porta nt s u bject, i ts i n c l u s i o n here wo u l d h a ve grea t l y expa nd ed the s i ze o f t h i s c h a p ter. T h i s d i sc u s s i o n stresses m u s c u loskeleta l d i a g n o s i s a n d trea tment, t h e foc u s of this c h a pter. M u s c u los keletal d i a gnosis a n d treatment m u s t be i n tegrated into the tota l d i ag nostic a nd therapeutic protocol for the p a t i e n t with gastroi ntesti n a l p a t h o l ogy. O MT is not i n tended as a repl acement thera p y. It is i n tended to e n hance thera py by fa c i l i ta ti ng the bod y 's i n herent c a p ac i ty to hea l i tself. The u se of osteo pathic d i ag n o s i s a nd trea t me n t proced ures s ho u ld red uce the m o r b i d ity a n d mo rta l i ty a ssoc i a ted w i th gastro i n tes t i n a l p a t h o logy. A l t h o u g h this ma kes sen se, t h e sta tistica l sup port for i t d oes n o t yet exi st. M u c h of w h a t has bee n prese n ted here i s a n ecd o ta l , ba sed u p o n m o re t h a n 1 0 0 years of osteop a t h i c c l i n i c a l empiric i s m . T h e c h al l enge to s u bstanti a te this d i sti n c t i ve a p p r oa ch to p a t ient ca re rests u p o n the osteopa t h ic
p r o fess i o n . It i s hoped tha t by descr i b i ng the i n tegr a t i o n of t h e d iagnos i s a n d trea t ment of s o m a tic d y sfu nction fo r p a tients w i th gastrointestinal path ology the p rofes s i o n ca n iden t i fy protoc o l s u p o n w h i c h to b a se fu t u re outcomes stud ies .
P roce d u res Plea se note : The proced u res t h a t fo l lo w a re e x a m p l es of m a n i pula t i ve treatment t h a t y o u m a y w i s h to e mploy. The a c t u a l c h o i ce of pr oced u res u sed s h o u l d be deter m i ned by the u niq ue c i rc u m s t a n ces of eac h i ndividual p a t ie n t . The fo l l o w i ng proced u res a r e usefu l w h e n treati ng t h e s o m a tic dysfu n c t i o n a s i t re l a tes to the ga stro i ntesti n a l p a t i e n t .
Thoracic Soft Tissue, Deep Articulation PATI E N T ON S I D E
See t h e p rocedure desc r i p t ion i n Cha p ter 5 a nd F i g u re 5 . 3 . T h i s p roced u re i s e mployed to d ecrea se parave rte bral mu scle s p a s m a nd s o ft t i s s u e tens i o n o f t h e t h orac i c spi ne.
Thoracic Soft Tissue Deep Articulation PATI E N T PR O N E
See t he descr i p t i o n o f the procedure i n Cha pter 5 a nd F i g u re 5 . 5 . Th i s proced u re i s e m p l o yed t o decrease p a r a ve rtebr a l m u s cle s p a s m a n d soft t i s s u e te n s i o n of the thoracic s p i ne . P a t ient p o s i ti o n : p r o n e on t h e treatment ta b l e . P h ys i c i a n p o s i t i o n : s ta nd i n g bes ide the p a tient opposite the side to be trea ted .
C h a pter 20 • T h e Pa t i e n t w i t h G a st ro i ntest i n a l P r o b l e m s
301
Rib Raising for Thoracic Cage Dy sfunction
T h i s p r oc e d u re is e mp l oyed to e n h a n ce r i b motion a n d t h o r a c i c cage com p l i a n c e . C o n s e q u e n t l y i t a ug m e n ts venous a n d l y m p h a t i c retu r n to the chest. It i s a l so t h o u g h t to a ffec t s y m p a th etic tone, i n i t i a l l y s t i m u l a ti n g regi ona l sym p a t hetic o u t p u t b u t e v e n t u a l l y r es u l t i ng i n red uced s y m p a t he tic acti v i ty from the s p i n a l levels treate d . ( See the desc r i pt i o n o f the p ro ce d u r e in Cha pter 5 a nd Fig. 5 . 6 . ) Patient Supine for Flexed or Extended Thoracic S om atic Dy sfunction, HVLA (Fig.
20. 1)
This proced ure is e m p l o y e d to treat a rticu l a r soma tic d y s fu nc t i o n , type II mechan ics, i n t h e mid to l o w t h o r a c i c spine. I t m a y be e m p l o y e d for flex ed or e x tended dysfu ncti o n s . In e i t h e r c a s e , the p h ys icia n 's h a n d p l a c e m e n t i s t h e same. T h e p a t i e n t p o s i t i o n ed with the h a n d s b e h i n d the neck works w e l l fo r a p a t i e n t wi t h l o ng a rms a nd a t h i n torso; t h is is the p o s i t i o n d e sc r i bed next. Fo l d i n g t h e a r m s a c ross t h e c h e s t w o r k s better, h o we ve r, if t he pa ti e n t i s stoc ky w i t h s ho r t a r m s . P a t i e n t posi t i o n : s u pi n e . P h y s i c i a n p os i t i o n : sta n d i n g bes i d e t h e patient, o n the s i d e toward w h i c h the dysfunct i o n i s side bent and rota ted , fac i n g the p a t i ent 'S h e a d a t a pp roxi m a tely t h e leve l of the a bd o m e n . Proced u re ( E xa m p l e : N o n n e utra l Ty pe I I A rt i c u l a r Dysfu n ct i o n of T 5 u p o n T6, F l e x e d , S i d e B e n t Left, a n d Rotated Left)
1.
Tell the patient to clasp the h a nds together behind the neck and to approximate the elbows .
2.
Stand on the patient's left side and grasp the elbows with your right forearm and ha nd. This will allow you to use the patient's pectoral girdle to introduce side bend ing a nd extension or flexion.
F I G U R E 20. 1
Patient s u pine thoracic H V LA for flexed or exte nded thoracic somatic dysfunction.
302 3.
Secti o n I I I • C l i nical Cond i t i ons R o l l the p a t i e n t 's u p p er body to the l eft so t h at o n l y the le ft s h o u l d e r is in co ntact with t h e ta b l e .
4.
R e a c h a c ross w i t h yo u r l eft a r m a n d p l ace yo u r l eft h a n d , p a l m u p , u po n t h e ta ble a t t h e level of T 6 . In this pos i t i o n , with yo u r l eft h a n d open, yo u r f i n gers s h o u l d be p o i n t i n g towa rd t h e p a t i e n t 's l eft s h o u l d e r.
5.
R o l l t h e p a t i e nt's s h o u l d ers a n d u p p e r torso b a c k onto the ta b l e a n d p o s i t i o n t h e t h e n a r e m i n e n ce of y o u r l eft h a n d so t h a t it i s i n c o n t a c t with t h e r i g h t tran sverse p rocess of T6 . T h i s asym m e t r i c p l a c e m e n t of yo u r le ft h a n d b e n ea t h the p a t i e n t wi l l i n tro d u c e ext e n s i o n a n d r i g h t rota t i o n o f T5 u p o n T6 .
6.
A d d i t i o n a l s i d e b e n d i n g m a y be i n t ro d u ced with yo u r r i g h t a r m a n d h a n d t h ro u g h t h e p a t i e n t's a r m s a n d pectoral g i r d l e .
7.
P l a c e y o u r c h est f i r m l y a g a i nst t h e p a t i e n t 's e l bows a n d p i n t h e m t o t h e ta b l e . Yo u m a y w i s h to p l a c e a p i l l ow betwe en the p a t i e n t 's e l bows a n d yo u r c h est to protect yo u r c h est .
8.
T h e f i n a l correct i v e force i s a p p l i e d as a q u i c k t h r u st down t h e s h a ft o f t h e p a t i e n t 's h u m e r u s , i n tro d u c i n g exte n s i o n a n d rot a t i o n to t h e r i g h t a n d s i d e b e n d i n g to t h e r i g h t o v e r t h e asym m e t r i ca l l y p l a ced f u l c r u m of yo u r l e ft t h e n a r e m i n e n c e .
9.
Reas sess t h e dysf u n ct i o n a l a rea . To t reat a n exte n d e d dysfu n c t i o n (T5 u po n T6 exte n d e d , s i d e b e n t l eft a n d rot ated
left) with t h i s p roc e d u re , the p o s i t i o n i n g of both the p a t i e n t and the p h ysi c i a n re m a i n s exactly t h e s a m e . T h e f i n a l co rrective force, h owever, is d e l ivered by u s i n g t h e p a t i e n t 's a r m s as levers to i n t r o d u c e f l e x i o n by b r i n g i n g t h e e l b ows c l oser to t h e chest.
Transabdominal Stimula tion
Th is proced ure is e m p l oyed to tre a t a bd o m i n a l soma t ic d y s fu n c t i o n ( I CD - 9 CM
73 9 . 9 ) . T h e proced u r e i mproves bowel fu nction by mechanica lly s t i m u l a t i n g peri sta lsis, t h u s i n crea s i ng gastro i n testi n a l moti lity a n d a l l e v i a t i n g or preven t i n g con s t i p a ti o n ( l CD-9CM 5 6 4 ) . It i s u s efu l fo r h o sp i ta l ized p a t i e n ts or o t h e r bed r i d d e n i n d i v i d u a ls . Beca use i t is m o s t effective w h e n a p p lied severa l t i m e s a d a y, t h i s pro ced u re may be t a u g h t to pa t i e n t s fo r self- a d m i n i stra t i o n i f they a re s u ffi c ie n t l y a l ert, o r i t c a n be ta u g h t t o a fa m i l y m e m ber. P a t i ent po s i ti o n : s u pi n e . P h ysici a n positi o n : st a n d ing bes i d e t h e b e d . Proced u re
1.
P l a c e t h e p a d s of the f i n g e rt i p s of o n e h a n d u po n t h e l eft l ower q u a d ra n t of t h e p a t i e n t 's a b d o m i n a l wa l l ove r t h e s i g m o i d c o l o n .
2.
Place t h e f i n g e rs o f t h e o t h e r h a n d over t h e fi rst fo r re i n force m e n t .
3.
A p p l y r h yt h m i c p ressu re w i t h t h e p a d s of t h e f i n g e rs , s l o w l y a n d d e e p l y t h ro u g h t h e a b d o m i n a l wa l l to sti m u l a te t h e co l o n .
4.
N ext a p p ly a d e e p s t ro k i n g p ress u re ce p h a l a d t o c a u d a d a l o n g t h e a ccess i b l e por tion of the s i g m o i d c o l o n .
5.
R e p e a t steps 3 a n d 4, p r o g ress i n g p roxi m a l l y a l o n g t h e l e n g t h of t h e desce n d i n g , tra n sv e rse, a n d asce n d i n g co l o n . For i n d iv i d u a l s w h o a re d e b i l itated or w h o h ave a b d o m i n a l t e n d e r n ess, t h e p roced u re
may be m o d if i e d as a n i n d i rect ma n i p u l ati o n :
1.
Be g i n n i n g i n t h e l eft lower q u a d ra n t , p l ace o n e h a n d ove r t h e ot h e r u p o n t h e a b d o m i n a l wa l l , as i n steps 1 a n d 2 .
2.
P a l pate W i t h a s m u c h p ress u re a s wi l l be t o l e rated b y t h e p a t i e n t .
3.
S e q u e n t i a l l y a p p l y a l t e r n ati n g c e p h a l a d-ca u d a d , l e ft-r i g ht, a n d c l ockwise-co u n ter c l o c k w i s e p res s u re s .
C h a pte r 20 • T h e Pat i e n t w i t h G a st r o i ntest i n a l P r o b l e m s 4.
303
M ove t h e abd o m i nal wall and und erlying abdo minal contents in t h e d i rect i o n of least resistance.
5.
H o l d u n t i l you pe rc e i ve a sense of f u rther l oo s en i ng or re l a x a t i o n i n the t i ssues beneat h your h ands.
6.
Repeat t h i s proced u re s e q u e n t i a l l y thro u g h o u t t h e abd omen, right u pper q ua d rant, left u pper q u ad rant and left lowe r q uad rant , i n that o r der. ,
Pedal Dalrymple Pump See the d e s c r i p t i o n of t h e proced u r e in C h a pter 1 0 and Figure 1 0 . 3 . T h i s p roce d u re is e mp l o y ed t o e n h a n ce ven ous a n d l y m p ha tic low-press ure re t u r n to the hea rt a n d thereby red u c e p a s s i v e co ngesti o n of t he lower extrem ities, a b d o m i n a l c o n te n ts, a n d l u ngs .
Refe re n ces 1 . R o t h s re i n R L F u n ct i o n a l g a s t ro i n tes t i n a l d i se a s e . In: N o b l e ], G reene H L , Levinson W, et a i ,
eds. Te x t b o o k o f P r i m a r y Ca re Med ici n e . 3 r d e d . S t . Lo u i s : Mos b y, 2 0 0 1 ;9 9 9 - 1 0 0 9 . 2 . A b u Fa rsa k h N A , S t i e t i e h M, A b u Fa rsa k h FA . T h e postc h o lecysrect o m y s y n d r o m e : A r o l e fo r d u o d e n o g a s t r i c r e fl u x . 3 . W i l s on
j
C l i n G a s t r o e n t e r o l 1 9 9 6 ; 2 2 : 1 97-2 0 1 .
PT, Nl i l l e r ES. I n t e rn a l m e d i c i n e : A n osteo p a t h ic a p pro a c h . O s t e o p a t h An n
1 9 79 ; 7 : 2 5 9-2 7 3 . 4 . K u c h e ra M L , K u ch e r a WA . Osteop a t h i c C o n s i d e ra t i o n s i n Syste m i c D y s fu n c t i o n s . 2 n d e d . Co l u m b u s , O H : G r e y d e n , 1 9 9 4 . 5 . Ca m i l l e r i M , Lee
]S,
V i r a m o n tes B , e t a l . I n s i g h ts i nto t h e p a thoph y s i o logy a n d mec h a n i s m s
o f c o n s t i p a t i o n , i r rita b l e b o w e l s y n d rome, a n d d ivertic u l o s i s i n o l d e r peo p l e . ] A m Geria tr Soc 2 0 0 0 ; 4 8 : 1 1 4 2 - 1 1 5 0 [rev i e w ] .
6 . Bea l !'vI C Visceroso m a t i c re fl e xe s : A review. j A m Osteopa t h Assoc 1 9 8 5 ; 8 5 : 7 8 6-8 0 1 . 7. W i l l i a m s PL, ed. G ra y's A n a tomy. 3 8 t h ed . Ed i n b u rgh: C h u rc h i l l Livi n gstone, 1 9 9 5 ; 1 2 5 1 - 1 2 5 2 . 8 . P a t r i q u i n D A . C h a p m a n 's r e f l e x e s . I n : Wa rd RC, ed . Fo u n d a t i o n s f o r Osteopa t h i c M e d i c i n e . 2 n d eel . 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 & Wi l k i n s , 2 0 0 2 ; 1 0 5 1 - 1 0 5 5 . 9 . D i M a g n o EP, S u re s h C. A c u te p a n c rea t i t i s . I n : F e l d m a n M, F r i e d m a n L S , S l e i se n g e r MH, Sc h o r sc h m i d t B F, cds. S l e i se n g e r and Ford t ra n 's G a s t ro i n testi n a l and Liver D isease. 7th ed. Ph i l a d e l p h i a : Sa u nders, 2 0 0 2 ; 9 1 3- 9 4 2 . 1 0 . Ti e r n e y L M
J r, ed .
C u rr e n t M e d i c a l D i a g n o s i s a n d Trea tment. 3 9 th e d . N e w Yo r k : L a n ge,
2000;6 8 5 .
1 1 . N o b l e j , Greene H L , Le v i n s o n W, e t a l . , e d s . Textbook o f P r i m a r y Care Me d ici n e . 3 rd ed . S t . Lo u i s : M o s b y, 2 0 0 1 ;920-9 2 7 . 1 2 . Ti n t i n a l l i .l , R u i z E, K r o m e RL Emerge n c y M e d i c i n e : A C o m p r e h e n s i v e S t u d y G u i d e . 5 t h e d .
New Yo r k : M c G r a w H i l l , 2 0 0 0 ; 5 7 7 . L l . A d cock D . N u c l e a r m ed i c i n e . U n i v e r s i t y o f S o u t h Ca ro l i n a S c h o o l o f M e d i c i n e h o me page. Acces s i b l e a t h rtp :!lra d i o logy. me d . s c . e d u /4 n u c me d a b c . h t m . Last u p d a ted j u l y 1 1 , 2 0 0 2 . A c cessed A p r i l 1 0 , 2 0 0 5 . 1 4 . C o n l e y GJ. Th e r o l e of [he s p i n a l j o i n t l e s i o n in ga l l b l a d d e r d i s e a s e . J Am Os teo p a t h Assoc. 1 944;44: 1 2 1 - 1 2 3 .
1 5 . Ma l o n e EP. M a n i p u l a t ive t h e r a p e u tics fo r ga l l b l a d d e r d i s e a s e . I n : N o r t h u p TL, Osteopa thic Ma n i p u l a t i v e T h e r a p e u t i c a n d C l i n ica l Resea rch Assoc i a t i o n . Morristo w n ,
NJ :
American
Osteo p a r h i c Assoc i a t i o n , 1 9 4 1 ; 4 : 4 4-4 5 .
1 6 . W i l s o n PT. G a l l b l a d d e r d i s e a s e . I n : A m e r i c a n Aca d e m y o f App l i ed O s teopa t h y 1 9 4 9 Ye a rboo k . A n n A r bor, M I : Ed w a r d s Bros, 1 9 4 9 : 1 8 2- 1 8 4 . ( N o w a v a i l a b l e through t h e 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 napo l i s . ) 1 7 . Bec k e r
A R.
Conse r v a t i v e
t r e a tmen t
o f ga l l b l a d d e r
d isea s e . j
Am
Osteopath
Assoc
1 9 5 1 ;5 1 : 1 0 4- 1 0 7 . 1 8 . M i l l e r WJ, Co l l i n s G , K os i n s k i f o r v i sce roso m a r i c r e f l e x e s .
J
Rj ,
e t a l . T h e d o r s a l r o o t gangl i o n c e l l a s a pote n t i a l m o d e l
A m Osteo p a t h A s s o c 1 9 9 7 ; 9 7 : 4 8 0-E O A .
The Patient with Thyroid Disease Douglas J. Jorgensen
INTRODUCTION A key relationship in osteop at hic medicine since its inception has been systemic
pathology and somatic dysfunction, meaning subluxation or mechanical interruption of the spinal nerve supply as described in the early osteopath ic texts and literature
the osteopathic model. Still sought to achieve a health care model focused on health and the body's inherent self-regulatory and self-healing phys iologic capacities, not
simply identification andJor treatment of disease, the allopathic model. To understand health, however, intimate k no w l edge of the pathologic mechanisms and their seque
lae are paramount. Normal physiology includes a dynamic system of health respon
sive to protection andJor immune defense coupled
w it
h rudimentary housekeeping
functions. This system is orchestrated via neurophysiologic mechanisms, with the endocrine system being a primary driving force because of its ubiquitous systemic effects. Early osteopathic literature focused on the thyroid gland as a somatovisceral responder and as a viscerosomatic source of diffuse somatic dysfunctions.l•2 Modern medicine has affirmed this early observation, as the thyroid gland influences virtually every organ system in the body.
This chapter is a review of thyroid development, p h ys i o l ogy pathology, systemic ,
interactions, and pathophysiologic responses as they relate to somatic dysfunction and other tissue changes from viscerosomatic and somatovisceral relationships and to treatment approaches. An exhaustive compilation of neuroendocrine thyroid 304
Cha pter 21
• The Pat i ent w i t h Thyroid Disease
305
pa thophysi o l ogy is beyond t h e scope of t h i s chap ter, b u t basic structure a nd fu nc tion a re revi ewed as a fo u n d a ti on on w h ich the u ndersta nding o f systemic str u c tur a l c h a nges m ust b e ground ed .
Thyroid Development and Hi stology3-S Developing fro m t h e root of t h e t o n g u e by the m i d d le of t h e first trimester of feta l deve l o p ment , t h e d ista l end of the r u d i mentary thy roi d re ma i ns as the m i d a n d prox i m a l portions d issi p a te , l e a v i n g the thyroid gla n d located a n teri o r l y, para m i d lin e t o the trachea. I n the 10-w e e k - o l d fetus, t h yrotro p h i c ce l l s i n t h e a n te rior p i tu ita r y beg i n secre t i n g thy r o i d -stim u l ating h o r m o n e ( TSH), w h i c h regulates thyro id size, bi osy nthesis, and storage and re l e a se of t h y ro i d h or m ones. B y a d ulth o o d , the thyroid c a n be H sha ped to U sh aped a n d c a n exte n d a n terior l y fro m the l eve l o f Cl t o the leve l o f T l o r some where in betwe e n . It typica l l y weighs 20 to 3 0 g
(slig h tly h e a v i e r in fe m a l es) , with two l ate r a l l obes a n d a bro a d mid l i ne isthmus. Each l obe is further div i d ed i nto l obu les v i a septa d e r i v e d from the inner thy roid ca psu l e . T h e fibrous isthmus is typic a l l y 12 t o
1 5 mm i n height a n d occasi o n a l l y is asso
cia ted with a p y r a m id a l or c o n ical l obe superiorl y. The lev a tor of the thyroid , a myofascia l ele m e n t more c o m m o n on the left, m a y attach to the hy oid bone a n d crea te a d irect a n a tomic re l a t i o nship a nd be a fac tor i n so m a tic d ysf unc t i o n fro m both a viscerosoma tic a n d so m a t o v iscer a l perspec t i v e . S h o u l d ve s ti g i a l tubu l a r tis sue re m a i n , t h ere is the pote n t i a l for d eve l o p m e n t of thyr oglossa l d u c t c ysts. Ad d itiona l l y, multiple va ri a n ts fro m i n c o m plete e mbryol ogica l d escent or d e v i a tio n be y o n d norm a l a n a tomi c a l posi tion i ng c a n resu l t in the g l a n d being abnor ma l l y d isplaced , pro mpti ng workup for a susp i c i ous m ass. Histologically, the l obu l es are d i v ided i n to foll i c l es, the fu n c t i ona l u n i ts of the gla nd. The foll i cles a re c o m p ose d of spherical ce lls a n d l i n e d w i th e p i t h elium c o n sist ing of regu l a r cubo i d ce l ls e nclosi ng a c olloid-fi l l e d c a vity. There a re two types o f epi thel i a l ce l ls: pri nc i p a l ( i .e., f o ll i c u l a r ) and p a r a fo l l i c u l a r. The p r i n c ipal e p i th e l i a l cells develop collo id, w h ich c o n tains i o d o thyrogl obu l i n , the precu rsor to thy roid h o rmo nes. The p a rafo lli c u l ar ep i t h e l i a l c e l l s develop C cells, d escribed l a ter. The typica l orga ne l l es a re present, a n d fi n e m icro v i l l i exten d into the folli c u l a r c o l l oid. De nse sy mpathetic fibers, l y m p h a t i c vessels, a n d fe nest rated c a p illaries cre a te a sophi stic a t e d , ubiqu i tous, a n d highly reg ula ted n e urovascul a r p l exus for trop h i c a n d feedbac k function in t h i s fo l lic u l ar mix. Thy rogl obu l i n stores the thy r oid ho r mone, a n d the micro vi lli assist in i ts mobi liza t i o n . T h e foll i c l es are sep a r a te d by stro ma or fibrous septa . C cells, d e r i ve d from the neu roecto d e r m , are ca l c i to n i n sec reting c e l ls They pred o m i na te i n the u pp e r a n d m i d dle third o f the l a te r a l l obes. They a re loca ted in the basa l lamina a d j a ce n t to the fo l l i c l es. T h e i r p rese n c e is sig n i fi c a n t in the p a t h o logy o f hy perca l ce m i a a nd hypergastrine m i a , a n d they are p r o m i n e n t in n e o n a t a l d e v e lopme n t . The p a r a fo l l ic u l a r cel ls a re central pla yers in systemic calcium ho meostasis by v i r tue of the i r calc i to n i n producti o n .
The active thyroid hormones a re tri i odothyro n i n e (T,) a n d thyroxine (T 4 ) . They a re merely a combina tion of the a mino acid tyrosine with eithe r three or fo u r i o d i ne ato ms, respect i v e l y. The i r synthesis is controHed by a nega t i ve feedback i n h ib i tory
process mod erated by TSH (pituitary) and thy rotro pin-releasi ng hormone (TRH), secreted from the h ypotha la m us. Briefl y, the biochemistry is as fol l ows. Iod i d e is trapped with i n the fo l licu l a r thy ro i d cel ls a n d then oxid ized (io d i d e peroxidase ) to become capable
of iod inat ing tyrosi ne resid ues i n the thyroglobulin. After iod i n a ting
at the level o f the microvi l l i, monoiodotyrosi n e ( MIT) a n d diiod otyrosine ( D IT) fo rm.
306
Section III • Clinical Conditions
Coupling results in T3 or T4, depending on whether two DITs make a T4 or an MIT and a DIT make a Ty Then, by endocytosis, T3 and T4 are released from the thy
roglobulin. Roughly 80% of thyroid hormone is T4, and the balance is Ty Because
of its availability, however, the predominantly active thyroid hormone is T3. Once in
the blood, T4 is heavily protein bound (mostly to alpha-globulin), leaving little available for hormonal activi ty
.
SYSTEMIC EFFECTS FROM AN OSTEOPATHIC PERSPECTIVE In general, the osteopathic model of spinal segmental facilitation and subsequent hypersympathetic output and tone were the basis for etiologic explanations even in the early 1900s.1 Visceral abnormalities (somatovisceral reflex), in terms of hor monal response, are primarily seen as an autonomic dysfunction or in some cases a reflexive secondary et iol o gy. 7 In the thyroid gland , histopathology shows a predom
inance of sympathetic autonomic fibers, and the tenth cranial nerve, the vagus ner ve, provides the parasympathetic portion. In response to stress, the thyroid enlarges; the cuboid cells elongate to columnar cells, and the gland increases in size. If the stressor (e.g., menses, peripheral nociception of pain, trauma, ill ness) abates, the hyperplasia is transient; the cells resorb and normal histology is restored.3 Without proper osteopathic treatment of somatic dysfunction, distortion of normal innervation occurs secondary to the facilitated segment. This stressor alters
physiologic function of the thyroid, hence its response and ability to respond to endogenous or exogenous stimuli (e.g., chemotherapeutics, T3, T4, TSH). Because of the heavily sympathetically mediated modification of normal innervation sec ondary to somatic dysfunct ion, this can result in facilitated spinal segments, which cause persisting abnormal thyroid autonomic innervation. This autonomic dys
function is primarily hypersympathetic, which would follow based on the predom inance of sympathetic fibers found histologicaIly.3,8
In the allostatic model, long-term facilitation impedes hypothalamic-pituitary
adrenal (HPA) axis function via amygdala stimulation with catecholamine increases.
This establishes a feed-forward loop in which the facilitated segment remains indef initel y. The pathologic relationship, with its visceral structure, propagates further abnormal viscerosomatic stimulation. Thus, the thyroid pathology worsens the somatic dysfunction and, in turn, the somatic dysfunction continues to worsen the thyroid function, further worsening the neuroendocrine crisis and potentially mak ing it a ch ro ni c, irreversible pathologic relationship.9 Websterl described a series of experiments on humans and animals demonstrat ing the premise for somatoviscera I reflexes. Subsequentl y, Larson 10 detailed the physiologic mechanisms involved, specifically loo king at the t hyroid Research to .
prove these reflexive relationships is nearly as old as osteopathic medicine itself. Two notable figures, McConnell and Burns, who were Still's students and subse quently his colleagues, provided some of this research grossly linkin g the viscero somatic and somatovisceral relationships.
As early as 1906, C. P. McConnell experimented with an animal model creat
ing segmental lesions (spinal somatic d ysfunction) at the site of origin for visceral innervation . Vertebral and rib dysfunctions induced in healthy dogs resulted in seg
mentally related visceral pathology. Among the specifically noted induced patholo gies were goiters. Subsequent treatment of the induced dysfunctions was followed by goiter resolution, while goiter in control animals did not resolve.I•11
At the same time, Louisa Burnsl2 used both animal and human models to study viscerosomatic relationships. Using anesthetized cats, dogs, guinea pigs, and white
Chapter 21 • The Patient with Thyroid Disease
307
rats, she induced vertebral lesions with digital pressure and record ed the effects of the experimental somatic dysfunction upon segmentally related viscera . The results of the animal studies were compared to the effect of pressure a pplied to the verte bral spinous processes in human subjects and to retrosp ectively reviewed clinical
records. Of particul ar i nterest w as the observed rel ationship between somatic dy s function i nv o l v ing C4 to C7 and response obs erved in the t hyr oid .13 She observed
increased su sce pt ibilit y to infection in the affected organs. She also noted restora tion of tissue and function f o llo wing treatment of the somatic dysfunction, with symptom resolution at the target sites. I
While some of these studies did not report how long the somatic (segm en t al ) dysfunction was maintained , one could postulate that these were no t longstanding dysfunctions, for tissue restoration did occur except where frank destruct ion was noted. lacki ng the histopathologic techniques available today, this was excep tional and really timeless work, for these results have pragmatic application nearly a centu r y later.
Thyroid Function and Dysfunction Hypothalamic (medial division of paraventricular nuclei of t he median eminence) TRH stimulates release of pituitary (anterior) T SH in the face of low serum Tj and T4•
This results in stimulation of the follicular colloid with resulting increases in
T 3 and T , as described previously. In normal t h y roid physiology, this is a dynamic 4 relationship, and the inh ibitory a nd stimulatory functions are autoregulated.
Normal subjects ty pically have a T S H of 0.5 to 5.0 fLU/ml, with higher levels noted
nocturnally. TRH, in ad ditio n to T SH stimulation, causes the release o f prol actin .14
In the hypothyroid state, TRH will stimulate T SH to increase biosynt hesi s and release of thyroi d hor mone . Simultaneously, prolactin level s will increase secondary
to the hy pothalamic response to lo w thyroid hormone and its e ffect on pituitary lac totr oph . Hypothyroidism can be primary or secondary, depend ing on the etiology.
Primary Hypothyroidism (T hyroprivic or Goitrous) Primary hypothyroidism is thyroid gland failure and is the most common form of hypothyroidism, accounting for 95% of cases. The most common cause is a b lative therapy (radioactive or surgical) for Graves' disease, but thyropr ivic hypothyroidism can be congenital or id iopathic . Biosynthetic defects, iodide de fi ciency, fetal-maternal antithyroid transmission, and drug - induced, iatrogenic, and immune-mediated
causes fall into the goitrous category. I nade quate gland synthesis occurs despite max imal stimulation and can lead to second ary or compensatory thyrotrophic hypertro phy in the pituitary. This can le a d to pituitary-mediated crowding in the sella turcica
with p o s sible visual field deficits. Hyperprolactinemia may occur here too, second
ary to the process noted earlier. If medical thyroid replacement therapy resolves the
hyperprolactinemia, the diagnosis is essentially confirmed. Other pitui tary - mediated
disease (pituitary myxedema) can occur in severe primary hyperthyroidi sm, but again it is reversible with thyroid replacement therapy. Children left untreated can
develop cretinism. In iatrogenic causes, the implicated medications are amiodarone, lithium, aminosalicylic acid, and iodine.14,11
Secondary Hypothyroidism (TrophoprivicJ Secondary (central) hypothyroidism is due to hypo t h ala mic or pituitary dysfunc tion; it is suprathyroid in local etio logy. In the primary disease, T SH is elevated
before Tj or T4 declines. Moreover, simple t hy roid replacement medication will
308
Section III • Clinical Conditions
not correct the scenario. TSH may be mildly elevated. Exogenous TRH stimula tion will result in TSH increases. F urther mor e , the mild TSH elevation is typically associated with a marked decrease in T4 concentration. This is the reverse effect that elevation of TSH should h ave, and this sce n ario strongly suggests central hypothyroid disease. Because of the unreliability of TSH here, T4 m u st be used to monitor this state. The euthyroid-hypothyroid pati ent typically falls into this cat egory, but eu thyroid sick syndrome can have many manifestations.14•ls Hyperthyroidism3,5,15-17
Graves' disease, the most common form of hyperthyroidism, is relatively common, with a 0.4% prevalence in the United States. It is thought to be
mu
lt i f a ctorial in
its etiology, but the exact cause is not known sav e that it is an autoimmune disor der. The result is a hype r functi oning thyroid gland that becomes diffusely hyper trophic, an associated in filtrative ophtha Imopath y, and sometimes in filtrative der mopathy. It affects women more than men (5:1 to 8:1, female to male), with incidence in the fou rth and fifth decades; it rarely occurs
a fte r
a
peak
50 years of age.
There is a strong familial predisposition with specific human leukocyte antigen
(HLA) markers noted by race. It can be preceded by Hashimoto's thyroiditis and has been associated wi th other autoimmune disorders, such as pernicious anemia, system i c lup u s erythematous, rheumatoid arthritis ,
Sjogren's
s yn d ro m e
, and
chronic hepat i t i s . It is a gamma-globulin-mediated autoimmune reaction on the plasma membrane resulting in hypertrophic thyroid tissue with increased colloidal T3 and T4 production. As with Hashimoto's thyroiditis, there is a defect in the
antigen-specific suppressor T cells. Since hyperthyroidism worsens T cell function, this process may be self-perpetuating. Diagnosis of thyrotoxicosis is not difficult, as p r oblems affect multiple systems.
We a kn ess , weight loss despite good appetite, palpitations, hyperdefecation, tremors, nervousness, sweating, and heat intolerance are all symptomatically related. These coupled with a goiter with
an u n detect a b l e TSH and elevated . If detected early or in rel a t ivel y mild cases, particularly those lacking palpable goiter or ophthal mic manifestations,
thyroid hormones make it difficult to
m i ss
suspicion must be h i gh for associated symptoms. Goiter too, which is not always uniform or symmetric in Graves' presentation, must be distinguished from other causes of thyroid masses. Symptoms can be relapsing and remitting, so index of suspicion should remain high to diagn ose and commence treatment. Treatment for Graves' disease is to address the thyroid h ypertrophy, with medical or surgical management focused on limit in g thyroid hormone production. Antiadrenergics have been used to assist in symptom control
as w ell
. Antithyroid
medications (i.e., propylthiouracil ) inhibit thyroid synthesis but work only when the medication is given. Leukopenia is the primary adverse effect of the antithyroid med ications, so serologic monitoring must be pe rfor med. Radioactive iodine is ablative but is seen as s i m p ler and more eco n omi c . It too carries risks, especially if used in chil dren, as carcinogenesis must be vigilantl y monitored. Even in adults, if rad i oactive treatment is used, the longer the life expectancy post treatment , the greater the risk of carcinoma. Surgery is a more permanent solution than nonradioactive pharmaceuti cal management, but it poses risks perioperatively. Postoperatively, indefinite thyroid replacement will be necessary, and there is the potential for inadvertent parathyroidec tomy because of the parathyroid's intimate anatomic relationship to the thyroid gland. Thyrotoxic crisis or storm used to be precipitated by surgery ( em e r gen c y) or a complicating illness (i.e., sepsis). Proper preoperative and intraoperative medical man agement and appropriate timely diagnosis can control this life-threatening associated syndrome, making death a rare outcome today.17
C h a pter 21
• The Patie n t w i t h Thyro i d D i sease
309
Pituitary (T SH-induced) hyperthy roidism is not the typical eti o l ogy for a h yper thyroid sta te. There are two types: pituitary tumors and pitu itary resistance to t hy ro i d ho rmone. T h e t u mors ( m a c r o a d enomas) a uto n o m o usly sec rete TSH o u ts i de of the normal feedb a ck i nh i bition process of the anterior pituitary, resu l ti n g i n excess t h yroid h o r m one. The resist a n ce to T3 and T 4 results i n a fa ilure to i nhi b it TSH pro duction o n ce sa t i sfactory levels o f ho rmone a re present. Thus, the pitu ita ry fa ils to shut off T S H p roduction (again not fol l o wing the negative feedback loop) and
a
hyperthyro i d state resu lts.
Thyroiditis3. 74.16. 77 Thyroi ditis, or inflammation of the thyroid , has many eti o l o gies . S u b a c u te, chronic, and Hashimo to's thyroiditis a re t h e most common fo rms. Suba c u te thyroiditis (de Querv a i n's, g i a nt cell, o r gra n u l o m a tous thyroiditis) is
viral. Typica lly, this follows an upper respi ratory in fect i o n , and the pa t i ent has marked weakness and mala ise with pain over the thyroid g l a n d. Usu a lly, these sympto ms a re present for weeks, but a cute cases, t h o u g h ra re, do occ ur. In these ra re i nstances, fever a nd thy roid pain are the primary c o m p l a i n ts, a nd the poten tial for thy rotoxicosis exists. A l t h ough thyroid p a i n is the m ost c o m m o n presenta ti on, some patients have no thyro i d pa i n despite the oth er sy m pto ms. Chronic thyroid i tis is a disorder in which self-lim ited t h yrotoxicosis occurs wit h
out prev i ous thyroid issues, a n d h istology subsequently sho ws chro n i c l ymph ocytic thyro iditis distinct from Hashimoto's thy roid itis. La bo ratory values for the erythro cyte sedimentation rate usu a l l y sta y below 50 mm/ho ur, a nd antithyr o i d antibodies have
a
low ti ter. The thyrotoxicosis typica l ly a b ates i n 2 to 5 mont hs, but some
patients ha ve recurrent episodes. T h e etio l ogy is u nclear, fa vors women, a n d ca n occur at a n y age . Postpartu m, this is the m ost com m o n fo rm o f thyroiditis. Hashimoto's thyroid itis is lymph a d eno i d g o i ter, w i t h a uto i mmu ne even ts bei n g the primary etio l ogy. A s the most c o m m o n fo r m of g oitro u s hypo thyroid ism in reg i ons with su fficient iodine, it was fi rst descri bed by Hash imoto i n 1912. It is most common i n m iddle-a ged wo men a n d i n chi ldren; it is the m ost commo n c a u se of spo r a d ic goiter. Goiter is the most pro m i nent fea ture, a f fecting the ent i re gland, t h o u g h it is not necessarily uniform or symmet r i c. The a utoi m m u ne evidence exists serologic a lly, with l ym phocytic proliferati o n a n d i m munoglobu l ins r a i sed a g a inst several components of t h y r o i d t i ssue. Ear l y l aboratory findings ma y indic a te euthy roid, but the g l a nd event u a l l y b u rns out a nd TSH increases. A c o rre l a tion with concurrence of Gra ves' disease a nd Hashi m oto's thyro iditis exists. Here a b l a tive thera py is used less often, as the a u to immune respo nse i n Hashimoto's t h y roiditis typi ca lly slo ws t h e p rogress i o n of t h e hy perthyroid state associated w ith Gra ves' disease. Py ogen i c thyroid i tis u sua lly has antecedent p y ogenic infectio n so mewhere other than the thy r oid. The patient has ten d erness and warm eryt hem a over a swo l l e n t h yroid gl and and the t y p i c a l constitu t i o n a l signs of systemic infecti o n . I t i s fortu na tely ra re but m ust be c o n sidered in i m m u noco mpromised p atients. Treatment consists of ant i b i o tics and d r a i n a ge if a fl occ u l ent a rea exi sts. The following d i s c u ssion is a breakdown o f the body systems and their relatio n shi ps t o a nd with the th y r o i d p h ysio l o gy a nd/or path ology. Some a re o bservati ons from Sti l l and his students a nd collea g u es; others a re p a th o p hysiolog i c expla na tio ns interwoven w i th longsta nd i n g osteopa thic c o n cepts. Ma n y of the early o bser vatio ns, although well doc u mented a nd repeatedly o bserved, had no q u a ntifia ble or measur a ble proof. W h ere possi ble, patho p h ysi o l og i c d a ta have been su p plied to exp l ain or el u c i d ate the l ikel y p hysi o l o g i c d y n a mics that were o bserved but l a c ked object i ve explanati ons in ea rly osteopa thic research and tea c h i ngs.
310
Section III • C l i n i ca l Condit i o n s
Co n stitut i o n a l A case study o f goiter status post tonsillectomy resulted i n sleep disturbance and a
general sense of emotiona l lability 2 Posts u rgica l treatment of the somatic dysfunc .
tions resulted in improved mood and normalization of sleep. N otable in this case was the inability of high-velocity, low-amplitude (HVLA) proced ures ro result in a fa vorable outcome. "Relaxation, movement (and) f1exibiJity"2 were the key to somatic dys f unction resolution in what would be best described today as myofas cial release. T h is patient presen ted for
care
because of the cosmetic appearance of
the goiter and the thyroid, and subsequent somatic d ysfunctions were found via history and physical examination. H ypothyroidism can result in wea kn ess , l e thargy sleepiness, fa tigue , we ight ,
gain, cold intolerance, and/or general malaise. With appropriate treatment, these symproms are poten tiall y reversible.ls
Eyes Still regarded exophthal mic goite r (exophthalmos, p roptosis) as being second ary to venous congestion. However, in d oing so he specificall y referenced the lack of knowledge at that time regarding the hypothalamic and pituitary in teraction in thyroid disease and funct ion
,
which has since been elucid a ted
.
N ever the less, he
reported cases of successful treatment of exophthalmos presumably thy ro id medi ,
ated
via d econ gesting venous
,
return to the heart whic h
proved effective.6
Proptosis, or protuberant eyes, occ u rs secondary to immunoinfl a m matory changes
that are part of the inflammation or congestion to which Still referred b u t did not histo logical l y note in his diagnosis or treatment.6 To address this, he began with the inquiry of the etio logy behind the "conges tion. Beginning at the clavicles, he moved medially to the sternocla vicular junc "
tion and then l aterally to the coracoid processes, treati ng myofasc ial structures as he found impaired t issue motion. He then moved his attention to the ri bs , with the first two being his primary focus. Focus next moved to the u pper thoracic and cer vical spine and then the occip itoatlantal j oin t hyo i d and maxillae, investing tissue, ,
,
and reI ated vascular structu res. 6 Eye involvement in thyroid disease is typica l ly thoug ht of in the hyperthyroid state, specifically Graves' disease, and is again autoi mmu nologic with histologic ,
co nfi r mation possible Proptosis, noted by Still, is the most associated feature, but .
early in the course of the disease there ma y be no apparen t ophthalmic effects. As the disease p rogresses however, periorbital soft tissue, periorbital muscl e , e ventu ,
a l ly the cornea and finally the optic nerve can all be a dverse l y affected if the diag ,
nosis is missed or tr eat men t not initiated.l7 In hypoth y roidism, there are myxedematous periorbital changes and slow muscu lar response. The face has been descri bed as cret i noid because of the associated cretinism if hypothyroidism is left unt reated indefinitely. Despite
an
ede matous look,
there are I i k e l y fine wr in kl es particular l y in p i t ui tary-base d hypothy roidis m ,
.
'R
E ar, N ose, a nd Thro a t Vascular congestion o f the thyroid has been i mpl icated i n tonsillar hype rtro p h y and pain as well as dysphagia secondary to mass obstruction of the esophagus.2,6 Goiter demands serologic and/or radiograp hic work up, wit h the potential for surgi cal intervention shou ld the histopathology and/or radiographic findings warrant It.
C a u t i o n is essential in addressing an abnormal thyroid mass with osteopathic manipulation, as enh a n cing vascular and lymphatic drainage has the potential to metastasize cells. Fine-needle biopsy and/or surgical referral is paramount if tumo r is suspected.4,6
Cha pte r 21 • T h e Pat i e nt w i t h T h yro i d D i sease
311
The deep cervica l fa scia forms a s heath a ro u nd the thyroid g l a nd, fi r mly a ttach ing i t to the l a ryngos keleton. Ligamento u s a ttachme nts sti ck each lobe to the cricoid a nd thyroid cart i l a ge, a n d the posteromed i a l p o rtion a ttaches to the side of the cricoid cartilage and the first a nd second trachea l ring. Du ring s w a l lowing , these a ttac h m e n ts c reate adherent t h y roid move m e n t . The rec u rrent laryngeal nerve typically passes inferi o r to the postero l a te r a l l iga m e n t o u s a tta chme n t s . La tera l to the nerve i s a posteromed i a l portion o f the thyroid lobe tha t can be for gotten d ur i ng t hyroid s u rge ry.s Goiter is the most com m o n e a r, nose, a n d thro a t ( ENT) iss u e assoc i a ted with the thyroid g l a n d other t h a n the a n a to m y described prev i o u s l y. Goiter is s i m p l y e n l a rged t h y roid g l a n d , a nd the etiologic event is i ndeed variable. His tory, exa m i n a tio n, a nd l a boratory or ima g i n g ( wh e n wa rranted) work u p a re importa n t in d e term i ning the e t i o l ogy so that appropr i a te trea t m e n t can be rendered. Tre a tmen t i s based on u nderstand i ng the p a t h o l ogy a nd a n a tomy well e n o u g h to allow for app l ication of osteopa t h i c proced u res u n i q u e l y s u i ted for a pa rtic u lar patie n t'S malady. Card i ovascul a r The e a rliest osteopathic w r i t i ngs spea k o f Sti l l's s a y i n g that t h e "rule o f t h e artery remains supre m e . " Rega rding t h yroid vasc u l a r s u p pl y, i mpeded a rte riove n o u s f l o w i s funda mental t o t h e osteop a t h i c approach to the t h yro i d . Before t h e neu roe n d o c rino l ogy was u nderstoo d , the a n a to m i c a b norm a l i ties s poke vol umes to the base p a t h ologic mecha nism s a ffec ting the thyro id; t h a t is, congesti o n o f ve n o u s dra i n a ge o r i mpeded a r teria l s upply resulted i n abn o rm a l t h yroid tis s u e wit h sys temic e ffects. This was confirmed i n v i v o and postmo rtem by Still a nd h i s s tu dents . Thu s, keeping cervicothoracic vasc u l a r (a n d pres u m a b l y l y m pha t i c ) a n a tomy patent, pa rtic u l a r l y i n the a n te r i or neck a nd thora c i c o u tlets, was p a r a m o u nt. T h i s approac h, combi n ed wit h n o r m a l iza t i o n o f the surro u nd i ng structure a nd fu n c tion, res u l ted in d o c u m e n ted su ccess i n the trea tment of goi ter, exoph thalmos, myxede m a , a nd t h y ro iditis . A l t h o u g h only gener a l arteri ove nous n o rmaliza tion was rec o mmended for goi ter, t h y ro iditis was specifically n o ted to need un impeded flow of "blood a nd l ymph from t h e thyroid g l a n d i n to the i n te r n a l j ugula r a nd i n n o m i n ate ve i n s"19 o n to the s u peri o r vena cava a n d the right a uricle of t h e heart.6 In m yxedema , relief from o bstruction of the thyroid a nd/o r c a rotid a rteries has been associa ted w i t h symp tomatic i m proveme n t .3 The likely rea s o n for s u ccess i n these p a t i e n t s was t h a t despite not k n o w i ng t h e exa ct h i s topa thology o r ne uroe ndocrine cause be h i nd t h e symptoms, t h e trea tment allowed f o r t he imm u n e-media ted i nfl amma tion t o d ra in. In some of these m a l a d i es, the d i sease w a s self-l imited. In others, t h e thyroid tis s u e would eve n tu a l l y b u r n o u t, a l l owing the ly m p h a tic a nd vascu l a r s tructu res to flow u nimpeded , permitting rem a rka b l e s y m ptoma tic i m prove ment. For the physi cia n to do this effectively, a n u ndersta nding o f the ana tomy i s a ga i n p a ramo u nt. The spec i fic vascu lar a n a to m y of the thyroid i ncludes th ree p a i rs o f veins. Adj a c e n t to the s u p e r i o r thyroid a r tery is the s u perior thyroi d vein, which d rains i nto the internal jugula r vein . The left inferior t hyroi d vein goes to the b r a chio cepha lic ve in, a nd the righ t takes o n e of two paths. On the right, the i n ferior thy r o i d ve i n co u ld dra i n eit her to the left or r i g h t brachiocephalic veins, depend ing on its c o u rse. A n other vari a n t for both the inferior veins, however, is to j o i n a nd form the thyroid ima vei n, dra i n ing into the left bra c h i ocephalic vei n .s T he arteria l s upply to the t hyroid g land comes from the supe r i o r a n d i n fe rior t h yroid a rteries a nd occasio n a l l y the thyroid ima. Bi l a tera l colla tera l c i rc u l a ti o n i s
312
Section III • Clinical Conditions
abundant here. The superior thyroid artery runs adjacent to the omohyoid and sternohyoid muscles, and typically the external branch of the recurrent laryngeal nerve runs with this artery. This artery is cut during thyroidectomy, which puts this nerve branch at risk during this procedure. Additionally, this is the arterial vessel that can be cut during an emergency cricothyroidotomy. The inferior thyroid artery is intimately related to the recurrent laryngeal nerve, but its anatomic rela tionship is highly varia ble. Furthermore, what is found on one side in terms of this relationship between nerve and artery is not necessarily the same relationship con tralaterally. A ga in surgical impairment of this nerve is possible because of its vari ,
able course. This is likely to manifest as phonation problems.5,J6 In hypothyroid disease, pulse rate, stroke volume, and cardiac output are diminished. If the disease is left untreated, pericardial effusion and hypertrophic myocardium can result. In
hyperthyroid states, dysrhythmias, cardiomegaly,
hypertension, and thyrotoxic cardiomyopathy are all p ossi b le secondary to the
hypersympathetic state that results from increased catecholamine in circulation.
Electrocardiogram, echocardiogram, and hemodynamic changes also consistent with sustained catecholamine states can be found. Some studies have suggested a marked increase in mitral valve prolapse in thyrotoxic patients. The usual cause of
death from thyroid storm is cardiac arrest.16-IS Pulmonary
The lungs provide a site for metastatic lesions of papillary thyroid adenocarci noma. Pulmonary symptoms in the face of a new thyroid mass or a thyroid nod ule of long standing warrants a chest radiograph or other pulmonary i m agi ng to rule our related pathology. Pulmonary metastasis of thyroid carcinoma worsens the overall prognosis.6 P u lmo nary arterial hypertension (PAH) has been found to be strongly associated with autoimmune thyroid disease. If a patient is diagnosed with PAH, part of the sys temic workup should include thyroid function studies to examine for occult disease.19 In the thyroid storm, respiratory distress is an important and life-threatening complication. Gastrointestinal
Thyroid effects on the gastrointestinal system in general terms are hypermobility in the hyperthyroid and hypomobility in the hypothyroid state. Hypothyroid patients have anorexia, flatus, and constipation. Gastric emptying is slow, with long intestinal transit time, decreased absorption, and occasionally ileus. Ascites may be present, as may elevated liver function test fi n dings; the gallbladder may have insufficient tone. Finally, autoimmune hypergastrinemia is associated with autoimmune thyroid
disease as much as previously mentioned autoimmune
pathologies that tend to group together. In a patient with achlorhydria, thyroid workup again is indicated.2o Genitourinary
While current literature does not emphasize the re lationship between thyroid and the genitourinary system, early osteopathic literature noted an ovarian connection. One may speculate that our osteopathic predecessors had a better understanding of the HPA axis and endocrine-related issues than we have evidence to prove or dis
prove. It has been confirmed, however, that thyroid size fluctuates with pregnancy and menses. Furthermore, early literature noted improvement of menstrual regular ity once goiter was resolved with osteopathic treatment.2-6 Struma ovarii, an ovar ian teratoma, is made up of mature thyroid tissue. Moreover, this monodermal
Chapter 21 • The Patient with Thyroid Disease
31 3
teratoma can result in hyperthyroidism. There is no evidence to suggest the case studies in the early osteopathic literatur e had such tumors or related carcinoid syn dromes; this could have been part of the differential diagnosis in addition to the affected and dysfunctional endocrine system.3 Musculoskeletal
The musculoskeletal system has been noted to be very rigid in the hyperthyroid state, with poor mobility and range of motion. At the very least, this represents autonomic dysfunction, but most of the literature suggests that the pathologic results are sym pathetically mediated. Increased musculoskeletal tone is likely secondary to the hypersympathetic stimuli associated with cyclic enhancement of somatic segmental irritation by the viscera and subsequent increased sympathetic response upon the vis cera. These two cycles, if not interrupted, continuously enhance one other in a feed forward mechanism that is a truly pathologic relationship locally and systemically. Specific findings in terms of the musculoskeletal system are found, with the sternum often twisted and with posterior displacement potentially impeding vascular f1ow.3 Another specific finding is the rotation of C2 to the left. Unlike the sympathetically mediated effects, this finding is thought to be parasympathetically mediated via cra nial nerve 10 (vagus) at the second spinal segment.6 Hypothyroidism can present as myalgia and arthralgias, and thyroid work up for nonspecific myofascial and/or joint pain is warranted in addition to the usual rheumatologic tests.3•14 Neurologic
Of anatomic importance are the relationships of the recurrent laryngeal nerve. Thyroid surgery can harm this nerve, especially when a parathyroid ecto my, intentional or not, occurs with a complete or partial thyroidectomy. Phonation problems postoperatively are often the first sign of recurrent laryngeal nerve damage. The anatomic basis for this is outlined in the section on the ENT.
While the recurrent laryngeal nerve is of anatomic interest and importance,
the primary innervation for the thyroid gland is autonomic. Cranial nerve 10 provides parasympathetic innervation, while the superior, mid dle, and infe rior ganglia of the cervical sympathetic trunk distribute the sympathetics.lO The latter are, again, the most highly concentrated histologically and are intimately related to the vascular and lymphatic supply.3 The sym pathetic nerves can be further broken d o wn into afferent and efferent supplies. The afferent supply to the thyroid is derived from cerebral and meningeal bloo d vessels, and the nerve fibers foll o w branches of the internal carotid and vertebral arteries traversing the upper cervical spinal nerves. The visceral afferents are carried along the vagus nerve or get to the sympathetic trunk via the pharyngeal plexus and then pass through the rami communicantes to C5 to C6 spinal nerves and/or the upper thoracic spina I nerves. The sympathetic efferents have three ganglia, the superior cervical, middle cer vical, and stellate. The superior cervical ganglion is the largest in the cervical sym pathetic system, with the first two spinal nerves more active than are the third and fourth. The middle cervical ganglion (fifth and sixth spinal nerves, or the thyroid nerves) create a plexus inferior to the inferior thyroid artery. The stellate ganglion is a combination of the inferior cervical and the first thoracic sympathetic ganglia . It connects via the gray rami of the sixth, seventh, and eighth cervical spinal nerves and the first two thoracic spinal nerves.1O,21 A denervated thyroid gland retains its capacity to respond to central nervous sys tem triggers. In this state, however, it is not adaptive, and the response is excessive,
314
Sect i o n I I I • C l i n i c a l Co n d i t i o n s
b o t h te m p o r a l l y a n d i n h o r m o n e o u t p u t . I O F u r t h e r, w it h o u t centra l regu l a t i o n , pro tein synthesis i s i nte r r u p t e d . Once i n n e r v a t i o n is restored , norma l prote i n s y n t h e s i s ret u r n s , s u ggesting a tr ophic response t o th e a u to n o m i c n e r v o u s syste m . I I I Hypot h y r o i d is m ma y pres e n t a s hyporefl e x i a , d e a fn ess, a nd/or memory i m p a i r m e n t . 1 6 H y perth yroid is m ca n be a s s o c i a ted w i t h h y p e rreflexia . Psyc h i a t r i c
A d i s t i n c t i o n s h o u l d b e m a d e between a n xiety a s i t s o w n d i sord er a n d hype r t h y
ro i d i s m . Sim i l a r ly, hypoth y r o i d i s m s h o u l d be cons i d ered a s a poss i b l e etiology o f d e p ressi o n . Th y r o i d tes t i ng s h o u l d be i n c l u d e d i n t h e wor k u p fo r e i t h e r psyc h ia tr i c c o n d i t i o n . In t h e h y p o t h y r o i d s t a t e , fa t i g u e m a y a p p e a r a n h e d o n i c ; t h u s , h y p o t h y r o i d ism m a y m a n i fest a s psy c h ia t r ic d i s e a s e t o o . D e l i r i u m i n t h y rotox icosis i s a l s o a pos s i b i l i t y a nd p a r t of an a c u te me n ta l s t a t u s c h a n ge; t h y r o i d l a b o r a tory tests a r e clea r l y i n d ic a ted. 1 4 E n d o c r i n e a n d I m m u n o l o g i c3 , 7, I O . 1 4
A k e y fe a t u re of the e n d ocrine sy stem is t h y r o i d function a n d i ts s y s temic ma n i fes ta t i on s . The t h y ro id gl a n d i ts e l f, i f s u bj e c t to m u l t i p le form s o f i m mu n e - m e d ia ted i n fla m m a tory d is e a s e s a n d thyr o i d i t i s , i s the most common p a t h o l ogic s i te assoc i a ted w i t h i m m u n e fu n c t i o n a n d d y s f u n c t i o n . I n th e i m m u n ocompro m i s e d s t a t e , StatJ h ylococcus
a u re u s ,
streptoco cci, Salm o nella, E n tero b a c te r, tu bercu los i s , a n d
fu ngi are t h e most freq u e n t ca u s es of i n fecti o u s thyro i d i t i s . These a re r a r e . Tre a t m e n t i s i n c i s i o n a l d r a i n a ge and org a n i s m -spec i fi c a n t i b i o t i c s . Vi r a l t h yroid i t i s a l s o c a n occu r a n d i s d i sc u ssed b r iefly l a te r. Th e m o s t c o m m o n a n d c l i n i ca l l y i m p o r ta n t y e t less w e l l d e fi n ed t h y r o i d itis pro b l e m s a r e the a u to i m m u n e fo r m s . Of t h e s e , Ha s h i moto's t h y ro i d i t is i s t h e b e s t k n o wn . O t h e r types i n cl u d e s u b a c u te gra n u l o m a t o u s , s u bac u te l y m p h o c y tic, a n d R i e del 's t h y r o id i t i s . T h e exact eti o l ogy of H a s h i m o to 's thyroi d itis i s u n kn o w n , b u t i t i s t h o u g h t t o be ge n e t i c a nd m e d i a te d via a n tigen -specific s u p p ressor T cel l s . S u bseq u e n t l y, t h e r e i s a n u n i mpeded a ttack o n fol l i c u l a r cel l s , w i t h res u l t i n g l y m p h o i d ce l l u l a r p ro l i fera t i o n . The co llo i d becomes a tr o p h i c a n d sparse, d ec re a s i n g fa c i l i ta t ion of T3, T4 , or th yrogl o b u l i n pro d u c t i o n . Th us, typ ic a l l y i t is assoc i a ted w i t h a h y p o t h y r o i d state. Yet a l t h o u g h most l o ng-term s u fferers deve l op a h y pothyro i d s t a te, some become t h yrotoxic (hash i-toxicos i s ) i n m i d cou rse. Aga i n , the e t i ology h e re i s u n c l e a r. H a s h i m oto's th yroi d i tis is the m o s t c o m m o n e t i o l ogy of go i t r o u s h y p o t h y roid i s m i n regi o n s with i o d ine d e fi ciency and a m a j o r c a u s e of non e n d e m i c go i t e r i n c h i l d r e n . Fe m a le to m a l e p r e d i lection is 1 0 : 1 , a n d it typ ica l l y occ u rs between
3 0 and 5 0 years o f age. The genetic rela ti o n s h i p is a s socia ted with h u m a n l e u k o c y te a n t i gen D R S , a n d t h e r e is a s t r o n g c o r r e l a t i o n a m o n g these p a t i e n ts i n t h a t they a re l i k e l y to h a ve other a u to i m m u n e d i s o rd ers a s well. Of the
other
t h y r oid i ti s
s u btypes,
s u b a c u te gra n u l o m a t o u s
t h y roid itis is
th o u g h t ro be seco n d a ry to specific v i r a l i n fecti o n s with res u l t i ng pa infu l go i t e r. Fe m a l e ro m a l e p red i l e c t i o n is 3 : 1 , w i t h pre v a l e n c e in the seco n d to fift h d eca d e s . S u b a c u te l y m p h o c y t i c th y r o i d i t i s is d i ffer e n t i n h i sto logy, a n d i t i s p a i n less c o m pa red to t h e gra n u l o m a t o u s for m . T h e s e m a y be p r e s e n t f o r months, b u t eventu a l l y nor m a l i z a t i o n of the thyroid re t u r n s . Asp i r i n a l o n e s u ffi ces fo r m i l d cases; however, i n severe fo r m s , ora l s t e ro i d s may be n ec e s s a r y. A beta - bloc k e r a l so m a y be i n d ic a ted t o pre v e n t t h y r o i d sto r m . T 4 a n d r a d i o a ctive iod i ne t r e a t m e n t s h o u l d
be m o n i tored, a n d o n c e n o r m a l i zed , the rapy c a n be s top ped .
Rie d e l 's thyro i d i t i s is ra re b u t i mp o r ta n t in t h a t i t m u s t be i n t h e d iffe re n ti a l wit h thy roid carci noma when a h a rd thyroid mass o r gland i s fou n d . I t is
a
fi brosing
C h a pte r 2 1 • The Pati e n t wit h Thyroid Dise a s e
31 5
rea c t i o n t h a t esse n t i a l l y destroys the t h y r o i d gl a n d a nd some o f the s u r ro u n d ing s o ft tissue. It e x h i b i ts t h e same 3 : 1 fem a l e- to - m a le pred i lection but occurs in the fo urth to seventh d eca d e s of l i fe . As w i t h the other a u toi m mu n e t h yro i d i ti s pro b l e m s , its e t i o l ogy i s u nknow n . Osteo p a t h ic trea tment c a n hel p t o exp e d i te hea l i ng a n d n o r m a lize thyroid e n d oc r i ne fu nctio n . In one s t u d y, u n i l a tera l e l ectri c a l st i m u l a ti o n of cervica l sym pa thetic gangl i a res u l ted in TS H - i nd uced t h yr o i d horm o n e p rod ucti o n . Th i s was seco n d a ry to i p s i l a teral v a s oconstriction, w i t h s u bseq u e n t parasympa thetica l l y co n t r o l l ed e n h a nced fo l l i c u l a r s e n siti v i ty t o t h e T S H i tself. 1 0 Th u s , s ym p a t h e tico to n i a fro m s o m a ti c d ys function c o u l d res u l t i n a s i m i l a r p hy s i o logic res p o n s e . Fu rthermore , i t w o u l d s u ggest tha t oste o p a t h i c m a n i p u l a tive tre a t m e n t ( O MT) c a n s h o rten cou rses o f t h y r o i d d i s e a s e . T h i s was fo u n d by S t i l l , a s noted e a r l i er, in a d d i t i o n to others. H a sh i m o t o 's t h y ro i d i t i s speci fical l y responded w i t h a shortened cou rse of i l l n e s s . A h igh i ndex of s u s p i c i o n fo r thyroid disease must be p resent when other a u toi m m u n e d isease i s pres e n t . H e m atolog i c a l a n d Lym phatic
Sti l l based most o f his trea t m e n t in this a rea o n the p a l p a tory find i ng of co nges tion in the t h y r o i d a nd s u rro u n d i n g t i s s u e s . P r o x i m i t y to p a r a thyro i d m a kes this a rea p a r t i c u l a r l y v u l ne r a b l e to meta s t a t i c or i n f l a m m a t o r y d i s s e m i n a t i o n . 3 T h y r o i d l y mp h a t i c d ra i n a ge i s e x te n s i v e a n d m u l t i d i recti o n a l . T h e i m me d i a te d ra i na ge fo l lo w s a l o ng the rec urrent la ryngea l nerve v i a the perigla n d u l a r, pretra c heal, p r e l a ry ngea l , and pa ra trachea l nodes o n to t h e m e d i a s t i n a l nodes. Meta static s p read ty p i cally moves c e p h a l a d a l o n g the i n tern a l j u g u l a r v e i n due to para g l a n d u l a r o bs t r u c tion b l o ck i ng i n fe r i o r d r a i n a ge. D e r m atolog i c 3, 7 , 1 4, 1 7
I n s u ffi c i e n t t h y ro i d h o r m o n e c a n res u l t in h y po t h y ro i d i s m o r myxed e m a . Treatment i s focused on t h y roid re p l a c e ment. Myxe d e m a is a l oc a l t h i c k e n i n g o v e r t h e l a tera l d i sta l l o wer extre m i ty s u p e r i o r to the a nk le. I t i s typica l l y b i l a tera l , w i t h the s u r fa ce us u a l l y s h i n y, b u t i t ma y be sca l y o r even p u c k e r e d , l i k e t h e s k i n of a n o r a nge. T h e l egs ap pea r e d e m a t o u s b u t d o not have p i t t i n g e d e m a . M y x e d e m a c a n a l so occu r o n t h e d o r s u m o f t h e fee t or p h a l a nges a n d r a r e l y t h e stomach . Pret i b i a l d e r m o p a th y w i t h G r a v e s ' d i sease occ u rs i n a p p rox i m a te l y 1 0 to 1 5 % o f cases . I t is i n s i d i o u s i n p resenta t i o n , b u t o nce i t i s e v i d e n t , da mage is irrevers i b l e . Alon g w i t h s k i n fi n d i ngs, t here i s evidence f o r cogn i t ive d e l a y. I n c h i ld ren, cretinism m a n i fests a s p h y s ica l a n d mental s l o w i n g, both of w h i c h c a n be a v o i d e d w i th v igila n t scree n i ng a n d trea tme nt. Iodine-deficient c o m m u n ities a re m o s t a t ri s k . There c a n b e spora d i c c a s e s w i t h o u t i o d i n e d efic i e n c y ; howev er, t h ese ca ses typ i c a l ly a re the re s u l t o f a genetic d i sease a ffec ting thyroi d h o r m o n e synthesis, S i nce thyroid d is ease c a n a cco m pa n y o t h e r p a t h ology, part i c u l a r l y a u to i m m u ne, p a t i e n ts with sar c o i d m a y h a v e t h y ro i d i nv o l ve m e n t a s we l l . Manipulative Treatment o f Thyroid Disease StatesU•8, 10 Th e use of OMT is intended to address s o m a tic dysfu n c tion that is fo u n d in asso ciation with thyro id disease. [t is in tended to augment and n o t to replace s tandard medical therap ies.
Trea t m e n t a s descri bed b y Sti l l was focused on o p e n i ng a rte r i o v e n o u s , nerv o u s , a n d l y m p h a t i c flow. It i s wel l d e s c r i b e d i n h i s e n c o u nters w i t h exop h tha l m o s . T h i s w a s desc r i b ed b y h i m a s trea t m e n t u n der eye-re l a te d t h y r o i d d i se a s e , a s eye m a n i festa tions w e r e l i ke l y t he f i r s t presenting s y mptoms o ther tha n a go i ter. Without
31 6
Secti o n I I I • C l i n i ca l C o n d i t i ons
t he c u r r e n t se rologic, histop a t h o l ogic, a n d i m a g i ng a d v a n ce m e n ts, the histor i c a l t r e a t m e n t was nevertheless re m a r k a b l y a c c u r a te. To d a y the m a i n trea tment, h o w ever, s h o u l d b e to reso lve the u n d e rl y i ng p a thologic m e c h a n ism . T h is w i l l a l l ow str u c ture a n d fu n c t i o n to retu r n to the i r norma l i n te rp l a y. Oste o p a thic m a n i p u l a t i o n d o es ha v e a p o t e n t i a l l y significa n t r o l e in t h is a re n a . However, c a u t i o n must be exercised to m a tc h the d osage of the m a n i pulative i n terv e n t i o n to t h e d isease p rocess, so tha t no h a r m is d o n e . ( See C h a pter 4 . ) I n t h e h yp e r t h y r o i d sta te , m a n i p u l a tive procedures m ust n o t b e a ggressive o r sti m u l a to r y. F u r thermore, t h e m o r e a cute t h e i l l n ess, the more l i m i te d the p roce d u re sho u l d be, a nd a pprop r i a te m e d i c a l prop h y l a xis ( e . g . , beta - b l oc k e rs ) should be presc r i bed . I n t h e case o f hyp erth yroid i s m , l iterature d i rects us to C4 to C 6 , w i t h the l ik e l i h o o d of a s i n g l e -seg m e n t d ysfu nctio n be i n g fo u n d . A myofasc ial release, faci l i ta te d positio n a l release, a n d/or Sti l l tec h n i que may be effective; a r tic ul a tory o r h ig h - v e locity proced ures are contra i n d i c a ted . Tre a t m e n t interva l s can be a s fre q u e n t as two to three ti mes a day a s n e e d e d . I n the chro n ic t h y r o i d state, tre a t m e n t is a g a i n a i m e d at reso l v i ng the u nd e rly i n g h o r m o n a l , i m m u n e , o r i n fectious etiol ogy. S i m u l ta n eous i n i t i a ti o n o f osteo p a t h i c proce dures as deemed appropr i a te sh ou l d be i m p l e m e n te d . The upper tho r a x is pre d o m i n a n t l y i n volved here, w i th a flex ion d ysfunc t i o n o f T2 b e i ng m ost c o m m o n l y noted . 6 Freq u e n c y and i n tensity of trea tment are i n d i v i d ua l i zed u n t i l reso lut i o n of t h e c h ro nic s y m p to m s a n dlor d isease state. Wh i l e loc a l tre a t m e n t i s a ppropr i a te , the t h y ro i d is a m a j o r e n d o c r i n e o rga n . As suc h , cra n i a l d ysfu nction and trea t m e n t m ust be a d d ressed bec a u se o f the p i tuita r y 's p r o x imity to t he sphe n obas i l a r sy n c h o n d rosis a n d the co nsequen t effec t o f the c ra n i a l mec h a n ism o n the HPA a x is. A ga i n , oste o p a t h i c tre a t m ent sho u l d include a com p r e h e nsive tre a t m e n t of t h e u n d e r l y i n g pa tho logy a nd the asso c i a ted sym ptoms. Thyroid ma l ignancy (pri m a r y or metasta t i c ) s h ould n o t be a d d ressed w i t h osteop a t h i c trea tment because o f the risk o f metastases. Pyoge n ic i n fect i o n s h o u l d be add resse d o n a case - b y -case basis, but s i m ila r caut i o n shou l d b e noted , as m ost cases of pyogen ic thyro i d d isease a re in i m m u n o c o m p r o m ised i n d i v i dua ls, and sys temic d isse m i n a tion c a n resul t in sepsis a n dlor m u l t i o rga n i n v o l v e m e n t . 7 C o m m o n si tes of t h y r o i d -related so ma tic d ys fun c t i o n are l isted i n Ta b l e 2 1 . 1 .
Common S ites of Thyro i d - Related Somat i c Dysfu n ction Maxil lae6 Occ i p itoat lantal j o i nt2.6 Atlantoaxi a l joi n t2 Hyoid6 C e rvical spine (C 2 rotated left)6 C e rvicothoracic (CT) j u n ction2 C lavicles2.6 Ribs 1 a n d 2 6 T 1 - T4 (myxedema)6
T 1 -T8 (goiter)6 Sacro i l i ac j o i n t2
Cha pter 21 • T h e Pat i e n t w i t h Thyro i d D i sease
31 7
Proce d u res P lease note: The proced u res that fo llow a re exa mp l es of m a n i pul a t i ve trea tment th a t you m a y w i sh to em ploy. The a ctual choice of p roced u res used s ho uld be dete r m i ned by the uni que c i rcumstances of each i n d i vidual patient . T he use of O MT to treat t h e som a t i c com ponent for patients w i t h t h y roid d i s ease s hou ld , therefo re, logica lly inc l u d e t h e fol lowing : •
U p pe r thor a c i c HVLA
•
Tho racic i nlet release
•
Ribs 1 a n d 2
•
Dee p cervi cal fasc i a , musc u l a r and l i g a mentous atta chments to the h yo i d and ,
cricoi d , and thyro i d ca rti l a ges •
C4 to C6
•
Occipitoa tla nt a l myof a sc i a l release
m yofasc i a
l release
Upper Thoracic on Side, Extended: HVLA and Articulatory Treatment (Fig. 2 1 . 1) T h is p rocedure is e m p loyed to trea t type II a r ticular soma tic d y s function of the u p per thoracic s p ine . In lea rni ng to d o this procedure, it is o ften eas ier to e m p loy it genera l l y to i n t roduce a r t ic u la r range o f m otio n . ( For d i a gnos is, see C h a pter 3 . ) Pat ient pos i t ion: l y ing o n the s i de . Physic i a n posi tion : stan d ing at the level o f the p atie nt'S shou lders , fac ing the patien t .
P rocedure ( E xa m p l e : T2 o n T3 E xte n d e d , S i d e B e nt Left, a n d R o t a t e d Left) 1.
The p a t i e n t l i es on the l eft s i d e so that the re l at i v e l y poste r i o r t r a n sverse p rocess of T2 i s down .
2.
C ra d l e t h e l eft s i d e of t h e p a t i e n t 's h e a d i n t h e p a l m of yo u r r i g h t h a n d .
3.
W i t h yo u r l eft h a n d , fi r m l y g ra s p t h e s p i n o u s p rocess o f 1 3 betwe e n yo u r t h u m b a n d i n dex f i n g e r. Yo u r l eft h a n d m u st re m a i n t i g h t l y i n c o n ta ct w i t h T 3 t h ro u g h o u t t h e re m a i n d e r of t h e p roced u re to e n s u re t h a t fo rces i n t ro d u ced with yo u r r i g h t h a n d a re l o ca l i zed betwee n T2 a n d 13 .
FIG U R E 2 1 . 1
P a t i e n t o n s i d e , u p p e r t h o ra c i c type I I , ext e n d e d , h i g h -v e l o c i ty, low a m p l itude.
318 4.
Sect i o n I I I • C l i n i ca l Cond it i o n s R o l l t h e p a t i e n t s l i g h t l y towa rd y o u a n d l e a n f o rwa rd , p i n n i n g t h e p a t i e n t 's u p per torso to the t a b l e b y p l a c i n g you r c h est a g a i nst t h e p a t i e n t 's right s h o u l d e r. Yo u may wish to p l ace a s m a l l p i l l ow between yo u r c h est and the s h o u l d e r.
5.
W h i l e cra d l i n g t h e p a t i e n t's h e a d w i t h y o u r l eft h a n d (step 2 ) I n trod u ce r i g h t s i d e b e n d i n g b y l i fti n g t h e h e a d a w a y f r o m t h e t a b l e u n t i l you fee l r i g h t s i d e be n d i n g
6.
occ u rri n g between T 2 a n d
13 .
Tra n s l ate t h e p a t i e n t 's h e a d a n d cerv i c a l s p i n e a n t e r i o r l y with y o u r r i g h t h a n d u n t i l w i t h yo u r l eft h a n d y o u f e e l f l ex i o n betwe e n T2 a n d
7.
13 .
Rotate 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 ri g h t with yo u r r i g h t h a n d u n t i l w i t h you r l eft h a n d you f e e l r i g h t rota t i o n between T2 a n d n . I t i s I m p o rta n t t h a t you c o n s c i o u s l y m a i n ta i n t h e r i g h t s i d e be n d i n g d e s c r i b e d i n s t e p 5 a b ove d u r i n g t h i s p a rt o f t h e p roced u re .
8.
A p p l y t h e f i n a l c o r rect i ve force t h ro u g h yo u r r i g h t h a n d as an H V LA i n crease of flex i o n , r i g h t s i d e be n d i n g , and r i g h t rotat i o n of T2 a g a i n st the h o l d i n g fo rce of yo u r l eft h a n d u po n n .
9.
R e a ssess t h e m o t i o n betwe e n T2 a n d
13 .
Upper Thoracic on Side, Flexed: H VLA and Articulatory Treatmen t (Fig. 2 1.2) a r t i c u l a r som a t i c dysfu n c t i o n of t h e to d o t h i s proced u re, it i s o f t e n e a s i e r to e m p l oy
Th i s p roce d u r e is employed to tre a t t y p e II u p p e r t h o racic sp i n e . I n l e a rn i n g
i t genera l ly to i n t rod u c e arti c u l a r ra nge of m o ti o n . ( F o r d i a g n o s i s , see C h a pter 3 . )
P a ti e n t p o s i t i o n : lying o n t h e s i d e . P h ys i ci a n pos i t io n : sta n d i ng
at
t h e l e v e l of
t h e p a t i e n t 's s h o u l d e rs , fa cing t h e p a t i e n r . P roced u r e ( E x a m p l e : T 2 on T 3 F l exed, S i d e B e n t R i g ht, a nd Rotated R i g ht)
1.
The patient l i e s o n t h e l eft side so t h a t t h e re l a t i v e l y poste r i o r tra n sverse p rocess of T2 i s u p .
2.
C ra d l e t h e l eft s i d e o f t h e p a ti e n t 's h e a d i n t h e p a l m o f you r r i g h t h a n d .
FI G U R E 2 1 . 2
Pat i e nt o n s i d e, u p p e r t h o r a c i c ty p e I I . flexed. h i g h -v e l o c ity. low-a m p l it u d e .
C h a pt e r 2 1
3.
• T h e Pati e n t wit h Thyroid Disease
W i t h yo u r l e ft h a n d , f i r m l y g ra s p t h e s p i n o u s p rocess of
13
31 9
between yo u r t h u m b
a n d i n d ex f i n g e r. Yo u r l eft h a n d m u st rem a i n t i g h t l y i n c o n ta ct w i t h 13 t h ro u g h o u t t h e re m a i n d e r o f t h e p roce d u re t o e n s u re t h a t f o rces i nt r o d u c e d w i t h yo u r r i g h t h a n d a re loca l i zed betwe e n T 2 a n d 13 .
4.
R o l l the pati e n t s l i g h t l y towa rd you a n d l e a n forwa rd , p i n n i n g t h e p a t i e n t 's u p p e r torso to t h e ta b l e by p l a c i n g yo u r c h est a g a i n s t t h e r i g h t s h o u l d e r. Yo u m a y w i s h t o p l a ce a s m a l l p i l l o w betwe e n yo u r c h est a n d t h e s h o u l d e r.
5.
W h i l e c ra d l i n g t h e p a t i e n t 's h e a d (step 2 ) , a l l ow t h e d o rs u m of yo u r r i g h t h a n d to rest on t h e trea t m e n t t a b l e . T h i s i n t ro d u ces s i d e b e n d i n g to t h e l eft. It is i m p o rt a n t t o k e e p yo u r r i g h t h a n d a s c l ose to t h e ta b l e a s poss i b l e t h ro u g h o u t t h e re m a i n d e r of t h e p roced u re to e n s u re t h a t t h e s i d e ben d i n g i s c o r rect l y a p p l i e d .
6.
Tra n s l ate t h e p a t i e n t 's h e a d a n d cerv i c a l s p i n e poste r i o r l y w i t h yo u r r i g ht h a n d u n t i l w i t h y o u r left h a n d y o u fee l exte n s i o n betwe e n T2 a n d
13 .
I t is i m p o rta n t t h a t t h i s
move m e n t be a p p l i e d a s a stra i g h t poste r i o r t ra n s l a t i o n t o p reve nt h y p e rexte n s i o n o f t h e l o w cervi ca l s p i n e .
7.
Rotate t h e p a t i e n t 's h e a d a n d cerv i c a l s p i n e to t h e l eft w i t h yo u r r i g h t h a n d u n t i l w i t h y o u r l eft h a n d y o u fee l l eft rota t i o n betwe e n T 2 a n d 13 . I t i s i m p o rt a n t t h a t y o u c o n sc i o u s l y m a i n ta i n t h e l eft s i d e be n d i n g d e s c r i b e d i n s t e p 5 d u r i n g t h i s pa rt of t h e p roce d u re . A l so , for p ra ct i t i o n ers w i t h re l a t i v e l y s h o rt forea r m s , it is i m p or t a n t not to com p ress t h e p a t i e n t 's face betwe e n yo u r f o re a r m and u p p e r a rm .
8.
A p p l y t h e f i n a l correct i ve fo rce t h ro u g h yo u r ri g h t h a n d a s a n HVLA i n c rease of exte n s i o n a n d left rota t i o n of T2 a g a i n st t h e h o l d i n g force of yo u r l eft hand u p o n B .
9.
Rea ssess t h e m o t i o n between T 2 a n d B .
Thoracic Inlet Myofascial Release
See the p roced u r e d escrip t i o n in Cha pte r 1 9 a n d F i g u re 1 9 . 2 . Th i s p roced u re i s em ployed to release restric t i o n s of t h e t h o r a c i c i n l e t a n d t h e r e b y p ro d uce symmetric m o v e ment of t h e t ra n s v erse fa sc i a l t i s s u e s . It m a y be p e r fo r m e d e i t h e r a s a d i rect or in d irect proced u re. Upper Rib Diagnosis and Trea tmen t D I A G N O S I S O F E L EVAT E D F I RST A N D S E C O N D R I B S
The u p per ribs, 1 a n d 2, ten d to d e m o n s trate restr i c ted b u c ket h a n d le m o t i o n as t h e i r d y sfu n c t io n a l m ec h a n ic s . T h a t i s , th e i r a n te r i o r sternocosta l a rtic u la ti o n a n d th e i r posterior costove rte bra l a rticu l a ti o n s re m a i n re l a t i vely fi x e d , w h i l e t h e l a t era l portion o f t h e r i b bod y moves u p a n d d ow n l i ke a b u c k e t h a n d l e . U p p e r ri b d y s fu n ct i o n s are o ften p os i ti o n e d a s e le v a ted b u c ke t h a n dle mech a n i c s . The pos tero l a tera l a s pect o f the d y s fu nc t i o n a l ri b is i n a s l ightly cepha l a d pos i t i o n a n d resi sts d ow n ward press u re. It m a y b e d iagnosed a s fo l l ows: P a t i ent pos i t i o n : sea ted . P h y s i c i a n p os i t i o n : stand ing behind t h e p a t i e n t . Proced u re
1.
B e g i n by exa m i n i n g t h e u p per t h o racic s p i n e fo r somatic dysf u n ct i o n . (See C h a pter
3)
Seg menta l ly re l ated s p i n a l dysfu n c t i o n s h o u l d be treated before r i b dysfu n c t i o n 2.
Pal pate t h e sca l e n e m u s c l e s l a tera l l y at t h e b a s e of t h e n e c k i n t h e t r i a n g u l a r s p a c e su p e r i o r to t h e c l a v i c l e , poste r i o r to t h e s t e r n o c l e i d o m asto i d , a n d a n t e r i o r to t h e trapezi u s . S p a s m of t h e a n te r i o r a n d m i d d l e sca l e n e s w i l l e l evate t h e f i rst ri b . The sca l e n es s h o u l d b e stret c h e d before you treat a n e l evated f i rst o r seco n d ri b .
3.
Pa l pate t h e l a tera l a s p ect o f t h e f i rst rib a t t h e base o f t h e n ec k . A p p l y d ownwa rd force to t h e r i b . An e l evated fi rst r i b resists t h i s m o ti o n .
320
Section III • Clinical Conditions
FIGURE 21.3
First rib facilitated positional release to reduce muscle tension associated with
4.
a
dysfunctional first rib.
Palpate the angle of the second rib just above the superior border of the scapula. Again, apply downward force over the angle of the second rib. An elevated second rib resists this motion.
FIRST RIB, FACILITATED POSITIONAL R EL EAS E (FIG 21.3)
This procedure is employed to reduce muscle tension associated with a d y s func
tional first rib. Patient position: supine. Physician pos ition: standing beside the treatment table on the side of the dysfunctional rib and facing the pa tie nt S head. '
Procedure (Example: Elevated First Rib on the Right)
1.
Standing on the patient's right side, position the patient in such a way that the right shoulder is slightly flexed and adducted and the right elbow is flexed so that the right hand lies upon the anterior chest near the left shoulder.
2.
Place your right hand upon the patient's right shoulder with your index finger touching the area of tissue texture change over the angle of the first rib on the right. Maintain your hand in this position throughout the remainder of the proce dure to monitor the fi rst rib.
3. 4.
With your left hand, grasp the flexed right elbow. Flex the patient's right shoulder until the right forearm is brought into contact with your right forearm.
5.
With your left hand, apply a compressive force to the patient's right elbow through the humerus until with your right index finger you feel decreased tension in the soft tissue over the first rib. This compressive force should be maintained throughout steps 6 and 7.
6.
Slowly further extend the patient's right shoulder, bringing the right forearm firmly into contact with your right forearm, thereby introducing internal rotation of the right shoulder.
C h a pter 2 1
7.
• T h e Pat i ent w i t h Thyro i d D i sease
321
Exte n d t h e p a t i e n t 's s h o u l d er a s m u c h a s poss i b l e a n d t h e n a b d uct i t , m o v i n g t h e r i g ht e l bow i n a n a rc of c i rc u m d u ct i o n , f i rst cep h a l a d , t h e n l a t e r a l l y, a n d f i n a l l y ret u r n i n g to t h e p o s i t i o n of step 1 .
8.
Reassess ava i l a b l e f i rst r i b m ot i o n .
F I RST R I B , H V LA
See F ig u r e 1 6 . 2 . T h i s proced u r e i s e m p l oyed to restore n o r m a l resp i r a to r y exc u r s i o n o f the fi rst rib to esta blish physiol ogic r a n ge of m o t i o n to the costoverte bra l j o int between T 1 a n d r ib 1 . Patie nt po s i t i on : seated . Phys icia n p os i t i o n : s ta n d i ng beh ind the p a t i e n t . Proc ed ure ( E xa m p l e : E l evated F i rst R i b o n t h e R i g ht) T h e postero l atera l portion of the r i b I S e l evated and res i sts d ownwa rd m ot i o n , w i t h s u r ro u n d i n g t i ss u e textu re c h a n g e a n d te n d e r ness .
1.
P u t yo u r l eft foot u p o n t h e ta b l e j u st to t h e l eft of t h e p a t i e n t's p e l v i s .
2.
R e s t t h e p a t i e n t 's l eft a rm u p o n yo u r k n e e . Yo u m ay w i s h to p l a c e a p i l l ow between t h e p a t i e n t 's axi l l a and you r k n e e .
3.
P l a ce yo u r r i g h t h a n d at t h e b a s e of t h e p at i e nt's n e c k o n t h e r i g h t ove r t h e e l e vated f i rst r i b so t h a t yo u r i n d e x f i n g e r is d i rected a n teri o r l y a n d y o u r t h u m b i s d i rected post e r i o r l y.
4.
P l a c e y o u r l eft fo rea r m a n d h a n d a g a i n st t h e l eft s i d e of t h e p at i e n t 's h e a d a n d n e c k to s p l i n t t h e cerv i c a l s p i n e
5.
W i t h yo u r l eft h a n d , u s e t h e p a t i e n t 's h e a d a n d n e c k a s a l ever t o rotate a n d s i d e
6.
W i t h yo u r r i g h t h a n d , a p p l y d ownwa rd p ress u re t o r i b 1 o n t h e r i g h t .
b e n d t h e c e rvica l s p i n e to t h e r i g h t d ow n to t h e l ev e l of T 1 a n d t h e f i rst r i b .
7.
H o l d i n g t h e p a t i e n t 's c h est between yo u r r i g h t h a n d a n d l eft k n ee, t r a n s late t h e to rso to t h e l eft t o i n c rease r i g h t s i d e b e n d i n g of t h e c e rv i coth o ra c i c j u n ct i o n .
8.
I n st r u ct t h e p a t i e n t to i n h a l e d e e p l y a n d exh a l e , a n d i n c re a s e t h e d ow n w a rd p res s u re over t h e fi rst r i b w i t h yo u r r i g h t h a n d d u r i n g t h e e x h a l a t i o n .
9.
A p p l y a n H V LA t h rust dow n wa rd , m ed i a l l y, a n d a n t e r i o r l y t h ro u g h yo u r r i g ht h a n d a g a i n st t h e dysfu n cti o n a l fi rst r i b .
1 0 . Reassess ava i la b l e fi rst r i b moti o n . S E CO N D R I B , H V LA
See F i g u r e 1 6 . 3 .
Second r i b H V L A i s e m ployed t o restore no r m a l respira tory exc u r s i o n o f the seco n d rib to esta b l i sh p h ysiologic ra nge o f motion to the costotr a n s v erse j o i n t . Patient pos i t i o n : sea ted u p o n t h e trea tment ta b le . Physic i a n p os i t i o n : s t a n d i n g beh i n d t h e p a t i e n t . P roced u r e ( E xa m p l e : Second R i b on t h e R i g ht) T h e re i s t i s s u e text u re c h a n g e su rro u n d i n g the a n g l e of r i b 2 o n the r i g h t , w h i c h is h i g h e r t h a n rib 2 on t h e l e f t .
1.
Put you r l e f t foot u p o n t h e ta b l e J u st to t h e l eft of t h e p a t i e n t 's p e l v i s .
2.
R e s t t h e p a t i e n t's l eft a rm u po n yo u r k n e e . Yo u m a y w i s h t o p l a ce a p i l low betwe e n t h e p a t i e nt's axi l l a a n d yo u r k n e e .
3.
Pl ace y o u r r i g h t h a n d over t h e patie nt's r i g h t s h o u l de r, w i t h y o u r t h u m b contact i n g the a n g l e of r i b 2. Yo u may find i t easi e r to do this jf you p u l l t h e p a t i e n t 's right arm to the l eft across t h e c h est . T h i s p rotracts t h e s h o u l d e r a n d d raws the sca p u l a l atera l ly.
4.
Place yo u r l e ft e l bow i n fro n t of t h e pat i e n t 's l eft s h o u l d e r, w i t h y o u r fo re a r m t o u c h i n g t h e l eft s i d e of t h e n e c k a n d f a c e . Yo u r l eft h a n d s h o u l d be h o l d i n g t h e t o p of
322
Section III • C l i n i c a l C o n d i t i o n s t h e h e a d . T h i s a r m a n d h a n d p l a ce m e n t a l l ows y o u to s p l i n t t h e p a t i e n t 's cerv i c a l s p i n e with y o u r l eft fo rea r m .
5.
W i t h yo u r l eft h a n d , s l owly rota te t h e p a t i e n t 's h e a d a n d n e c k to t h e l eft, d i s e n g a g
6.
W i t h yo u r l eft h a n d a n d fo rea r m , s i d e - b e n d t h e pat i e n t 's n e c k to t h e r i g h t d own to
7.
W i t h yo u r r i g h t h a n d , a p p ly a d ow n wa rd d i rected p ress u re to t h e a n g l e of r i b 2 .
8.
W i t h yo u r l eft h a n d , i n trod uce s l i g h t l y m o re l eft rot a t i o n of t h e p a t i e n t 's h e a d a n d
i n g t h e r i b h e a d f ro m t h e h e m ifacet a s T 1 rotates a w a y fro m i t the level of rib 2 .
n e c k w h i l e exe rt i n g s i m u l ta n e o u s d ownwa rd p ress u re o n t h e 2 n d r i b w i t h yo u r r i g h t h a n d . T h i s f u rt h e r d i se n g a g e s t h e r i b h e a d from t h e h e m i f a cets . Stop t h e rota t i o n w h e n you s e n s e t h a t the rib ex h i b i t s less res i sta n ce to the d ownward p ressu re f r o m yo u r r i g h t h a n d .
9.
I n st r u ct t h e pat i e n t t o i n h a l e d e e p l y a n d ex h a l e , a n d i n c rease t h e d ownwa rd p res s u re over the f i rst rib with yo u r r i g h t h a n d d u r i n g t h e ex h a l a t i o n .
10
T h e f i n a l c o r rective f o rce is a n H V LA t h rust d i rected d ownwa rd , m ed i a l l y a n d a n te r i o rly t h ro u g h yo u r ri g h t h a n d a g a i n st t h e a n g l e of the dysfu ncti o n a l seco n d r i b .
1 1 .
R e a ssess ava i l a b l e seco n d r i b m ot i o n .
An terior Neck Soft Tissue (Lymphatic) Procedure
See the description of the proced u re in C h a pter 1 6 a nd Figure 1 6 . 1 8 . T h i s p roced u re i s e m pl oyed t o reduce co n gest i o n of t h e soft tissues a nd e n h a nce lym p h a tic dra i nage o f the neck . The fa s c i a o f the neck m a y be c o n s i d e red as a n external cylinder tha t sp l its t o enc lose t h e sternoc l e id o m a s to id a n d tra pez i u s m u s cles and s u rr o u nd s t h e d e e p fascia tha t i n vests the deeper s t r u c t u re s of t h e n eck a nd fil l s the s p a c e betwe e n them . The s u pe r fi c i a l l ymph a tic drain a ge of the head l i e s o u tsid e the exter n a l fa scial c y l i n d er a nd m u s t p a ss throu g h i t to d ra i n i n to the deep cerv i c a l l y m p h a t i c v e sse l s The first p a r t o f t h i s proce d u re is d i rected a t mov ing l y mp h fro m t h e s u p e r f i ci a l to the deep l y m p h a t i c vesse ls. The second part o f t h i s p r o c edure i s d i rected a t the deep s t r u c t u res a nd m a y a lso be e m p l oyed t o decrease te n s i o n in t h e s u pra h y o i d a nd i n fra h y o id m u sc le s . .
Cervical. Indirect Balancing
See the d escrip tion of the proced u re i n C h a p ter 1 6 a nd Fig u re 1 6 . 6 . T h is p r o c ed u r e i s employed to decrease cerv ica l tiss ue te nsion a nd enhance the s y m m e tric a l ra nge of m o t i o n of the cervica l sp i n e . Occipitoatlantal Direct Myofascial Release
See the descripti o n of the p r o c edu r e in C h a p t e r 1 6 a nd Figure 1 6 . 1 2 . T h i s proced u re i s e m p l oyed t o trea t gene ra l a rt i c u l a r a n d soft t i ss u e , myofa s c i a l , s o m a t i c d y s fu n c t i o n o f t h e o cc i p u t rela tive t o C 1 , the a t l a s , to red u c e m y o fa s c i a l ten s i o n , and to esta b l i s h s y m m e t r i c m o t i o n between the occipu t a nd the a t l a s .
Refere n ces 1 . We bste r G W. Concer n i ng O s teop a t h y. Revised ed . N o r w o o d , M A : P l i m pton, 1 9 1 7; 1 02- 1 04 , 1 3 6- 1 4 2 .
2 . U n v e r ferth E C . G o i te r : A c a s e re port. A p p l ied A c a d e m y o f Osteopa t h y 1 9 4 0 Yea r book. 1 9 4 0 .
Vo l 3 ; 1 02-1. 0 8 . ( Now a v a i l a b l e th rough t h e Amer ica n Aca d e m y o f O s te o pa thy, I n d i a na po l is . )
3 . Rob b i n s
S L , K u m a r V, Corra n R S . R o b b i n s P a t h o l o g i c B a s i s o f D i s e a s e . 4 th e d . P h i l a de l p h i a :
S a u nders, 1 9 8 9 ; 1 2 1 4- 1 2 4 2 .
Cha pter 21
• T h e P a t i e n t w i t h Thyro i d D i sease
323
4 . N o r m a n E n d o c r i n e S urge ry C l i n i c . H o w YO U ( T h y r o i d Wo r k s . Ava i l a b le a t h r r p :llw ww. e n d o c ri ne lVc b .comlr h yfu ll c tion . h t m l . Accessed Ma y 2 8 , 2 0 0 5 . 5. La m a i re D, D o r i o n D. T h y r o i d d n a to m y. h c r p :ll w w w. e m e d i ci ne . c o mienr/ro p i c 5 3 2 . h tm ; l a s t u pd a ted M a y 3 , 2 0 0 5 . A ccessed M a y 2 8 , 2 0 0 5 .
6 , S t i l l A T. Resea rch a n d P r a c t i c e . K i r k s v i l le , M O : A m h o r, 1 9 1 0 ; 8 2-8 3 , 1 0 6-1 1 5 .
7 , K u c h e ra M , K u c h e ra W. O s teop a t h i c Cons i d e r a t i o n s i n S y s te m i c D ys f u n c ti o n . 2 n d e d . Co l u m b u s , O H : G r e y d e n , J 9 9 4 ;4-6, 11 , 1 7 , 1 8 7 , 1 9 2 .
8 . W i l l a rd F H , M o k l e r
DJ,
M o rgane PJ . N e u r o e n d o c r i n e - i m m u n e s y s t e m a n d h o m eo s ta s i s . I n :
Wa rd R C , e d . Fo u n d a t i o n s fo r O s teo p a t h i c Med i c i n e , Ba l t i m o r e : Wi l l i a m s & Wi l k i n s ,
1 9 9 7 ; j 0 7- 1 3 5 . 9 , W i l l a rd F H , M o k l e r DJ , M o rga ne PJ . N e u ro e n d o c r i ne - i m m u ne s ystem a n d h o m e o s ra s i s , I n : Wa rd R C , e d . F o u n d a t i o n s for O s teo p a t h i c Medici n e , Ba l t i more: W i l l i a m s & W i l k i ns , 1 997; 1 26-1 3 1 . 1 0 . La r s o n
NJ .
Osteo p a t h i c
approach
to
thyroid
d isease,
I n : P h y s i o l og y, D i se a s e a n d
M a n a ge m e n t o f t h e T h y ro i d . Ev,l n S t o n , I L : A . R e r l a w, 1 9 7 6 ; 1 0-1 9 ,
1 1 . Furrher p r o o f o f the osteo p a th i c t h e o r y : D r. M c C o n n e l l 's exp e r i m e n r s . J O s te o p a t h y [ 9 0 6 ; 1 3 : 1 60-1 6 1 , ] 2 . B u r n s L . V i s c e ro-s o m a t i c a n d S o m
s p i n a l reflexes , J
A m O s t eo p a t h A ssoc
1 9 0 7; 7 : 5 1 -6 0 . 1 3 . B u r n s L . T h e i m m ed i a te effecr o f b o n e y l e s i o n s . A , T. S t i l l B u l le t i n 1 . Ci n c i n n a ti, O H : ER Booth Press, JY[o n r fort, 1 9 1 0 ; 3 0-44 . 1 4 , I s se l b a c h e r K], K a s p e r D L , Ma rt i n J B . H a r r i so n 's P r i n c i p l es o f I me r n a l M e d i c i n e . Vo l 2 , New Yo r k : McGraw H i l l , 1 9 9 4 ; 1 8 8 3-205 8 , 1 5 , J e l o v s e k F R . Wo m e n 's d i a g n o s r i c c y b e r d is e a s e p r o f i l e : P r i m a ry h yp o t h y ro i d i s m . Av a i la b l e a t
h r r p :llw ww. w d x c y b e r. c omid x b l d O O l . h r rn . L a s t mod i fi e d N o v e m b e r 2 0 0 1 . Accessed M a y 2 8 ,
2005 .
1 6 , N o r m a n E n d o c r i n e S u rge r y C l i n i c . H y p e r t h y ro i d i s m : O v e r a c t i v i r y of r h e t h y r o i d gl a n d : 2 . C a u s es
of
H y pe r t h y r o i d i s m .
Ava i l a b l e
ar
h t t p : //w ww. e n d o c r i n e we b . c o m /h y pe r 2 . h r m l .
Accessed M a y 2 8 , 2 0 0 5 . 1 7 . H en n e m n ,l n
G,
G r a v e s ' d i se a s e : C o m p l ica r i o n s , R e v i s e d No v e m b e r 2 5 , 2 0 0 3 .
I n : The
T h y ro i d a n d I ts D i se a s e s . Av a i l a b l e f r o m E n d o c r i n e Ed u c a t i o n a t h rr p : ll w w w. t h y ro i d m a n a g e L o rgic h a p ter 1 211 2-tex t . h t m . Accessed M a y 2 8 , 2 0 0 5 , 1 8 . \V i e r s i nga W M. Ad u l t h y p oth y ro i d i s m . R e v i s e d M <1 r ch 4, 2 0 0 4 , I n : T h e T h y ro i d a n d Its D i s e a s e s , Ava i l a b l e from End ocrine Ed u c a t i o n
at
http ://w ww, t b y ro i d m a n a ger. o rgiC h a p t e r 9/
9-fra rn e . h t m . Accessed M a y 28, 2 0 0 5 . 1 9 , Chu
J \V,
K a o P N , Fa u l
JL.,
D o y l e R L . H ig h p reva l e n c e o f a u to i m m u n e t h y r o i d d i se a s e i n
p u l m o n a r y a rte r i a l h yp e r te n s i o n , C h e s r 2 0 0 2 ; 1 2 2 : 1 6 6 8 - 1 6 7 3 . 2 0 . R a d e b o l d K , Ach l o rh yd r i a . Ava i l a b le a t h t t p : //www. e m e d i c i n e . co m/med/ro p i c 1 8 . h t m . L a s r u p d a ted J u l y 1 1 , 2 0 0 2 , Accessed May 28, 2 0 0 5 . 2 1 . C l e m e n re C D , A n a t o m y : A R e g i o n a l A r i a s o f the H u m a n Bod y, 4 t h ed , B a l t i m o re : Li p pi nc o [ [ W i l l i a m s & W i l k i n s , 1 9 9 7; 2 3 7-3 4 0 .
C H A PT E R
22
T h e Pati e n t with Pa r k i n so n 's D i se a se C h a r l es J . S m u t n y, I I I
I N TRO D U CT I O N The P a r k i n s o n s d i sease ( P D ) p a t i e n t represents a u n i q u e o p p o r t u n it y fo r osteo p a th ic m ed i c i n e to d emonstrate i t s a b i li ty to a ffect the ce n t r a l ne r v o u s system v i a t h e m u s c u l o s k e l e t a l syste m . T h e fu nd a m e n t a l s o f a strong osteopa t h i c trea tm e n t p l a n w i ll i n d iv i d u a l i ze t h e t r e a tm e n t o f a p a t i e n t s s o m a t i c d y s fu n ctions, w i t h se l ec ted proced ures wor k i ng towa rd b a l a n c i n g t h e t o n e i n t h e s o m a t i c syste m . T h i s moveme n t toward b a la nce i n t h e so m a is a ssoci a te d w i t h s i m u l t a n e o Ll s c h a n g e s toward balance i n t h e a u t o n o m i c nervo u s s ys tem. These c h a nges c a n be m e a s u red in the p a t i e n t w i t h P D b y p h y s i o l o g i c m a r kers i nc l u d ing d ecreased h y p e r t e n s i o n decreased m u scle tone , d ecreased l iga men tous te ns i o n ( me a s u red as p a s s i v e j o i n t ra nge o f mot i o n ) , a n d wh e n prese n t , d ec re a s e d cogwheeling. T h e ta rget o f th e trea tme n t p l a n is to d e m o n s tr a te a decre a s e i n the seve r i ty o f t h e p h y s i c a l expres s i o n of t i1e d i sea se th a t c a n be mea s u red a s a n i n c re a s e in a c t i v i ties of d a i l y l i v i n g ( A D L) a nd a n increa se i n q u a l i ty of l i fe mea s u res . 1 Lessons lea r ned from tre a t i n g PD c a n be extrapola ted to t h e tre a t m e n t of other neu rodegenera tive d isorders, g i v e n t h at the pri n c i p les a re simi l a r, t h o u g h the physica l expressions of t h e v a ried d iseases d i ffer.2 Th i s c h a pte r d iscusses recen t os t e op a thic resea rch tha t h a s demonstra ted s t a tisti ca l l y s igni fican t i m provement i n p a t i e nts' q u a l ity o f l i fe, i ncreased i n depe n d e n c e i n ADL, a n d red uction of a n u m ber of r i s k fa ctors for ioj u ry. l.4 Gait was i mproved , sti ffness a nd rig i d i ty were r e d u c ed and pati e nt '
'
,
,
324
Chapter 22 • The P a t i e n t with Park i nson 's Disease
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psycho l ogic sta tes were s h o w n to be i m p roved . O f 3 5 pa tients, 25 ( 7 1 % ) h a d m e a s u ra b l e posi t i v e c h a n ges i n a l l a reas o f assess m e n t . 3 T h e tota l n u m ber o f fa l l s du ring the study was lo wer than both fa ll freq u ency prior to the s t u d y 's sta rt and to age m a tched a n d sev e r i ty-ra n ke d PD pa tient controls. No p a t i e n t req u ired a n i ncrease in med ica t i o n d osage d u ri n g the 3 - m o n r h i n iti a l p h a se, w h i l e 9 of 3 5 controls ( 2 6 % ) had
a t least one i n crease a n d/or a d d itio n a l med ici nes a d d e d to their tre a t m e n t protocol . A l so, 5 p a t i e n ts i n t h e trea tment g r o u p s uccessfu ll y d e crea sed t l1eir d osage o f c o m bi ned c a r b i d opa a nd levod opa d u ring the s a m e p h a se ( a u thor's u n p u b l ished research ) . F i n d ings assoc ia ted w i th c r a n i a l d ysfunctions i m proved d ra m a t ica l l y. The p u rpose o f a n o t h e r s t u d y w a s to c o m p a re the recorded o bserva t i o n s of cra n i a l stra i n patterns o f p a t i e n t s with PD for t h e d e tection o f common cra n i a l fin d
ings . Records of cr a n i a l s tra i n pa tterns from p h y s i c i a n - recorded o bserva t i o n s of
3 0 p a t ie n ts w i t h id iopa t h i c PD a n d 2 0 a g e - m a tched n o r m a l contro l s were com p i l e d . T h i s i n forma t i o n w a s used to d eter m i n e w h ether d i ffere n t p h y s i c i a ns o b served p a r t i c u l a r stra i n p a t t e r n s in g r e a t e r fre q u ency between PD pa tients a n d c o n t ro l s . P a t i e n ts w i t h P D h a d a sign i fica n tl y h ig h e r fre q u en c y of bi l a te ra l occipi toatl a n ta l com press i o n ( 8 7 % vers u s 5 0 % ; P < . 0 2 ) a n d b i l a t e r a l occ i p i t o m a s toid co m p re s s i o n ( 4 0 % ve r s u s 1 0 % ; P < .05 ) compa red with nor m a l c o n tro l s . O v e r su bseq u e n t vis its a n d t rea t m e n ts , t h e freq u e n c y o f both stra i n pa tte rns w e r e red uced s i g n i fi c a n t l y ( oc c i p i toa t l a n t a l c o m press ion , P < . 0 1 ; occi p i to m a s t o i d compres s i o n , P a
<:
. 0 5 ) to l e ve ls fou n d i n t h e contro l g ro u p . 5
O s t e o p a t h i c a s sess m e n t a n d trea t m e n t o f t h e n e u r o m u sc u l osk e l e ta l s y s t e m a s u n i t o f fu nc t i o n h a s m o r e c l e a r l y d e f i n e d t h e tota l p h y s i c a l expression o f P D i n
t e r m s th a t prov i d e trea t m e n t o p t i o ns n o t c o n s i d e red i n t h e p a s t . O s teopa t h ic p h y s i c i a n s a re u n i q u e l y q u a l ifi e d to d e l i v er t h e se tre a t m e n ts by v i r t u e of the i r spe cia l ized t ra i n i n g i n m a n ip u l a t i v e s k i l ls a pp l i e d a c c o r d i n g to h i g h l y d i sc i p l i n e d med ica l tra i n i n g i n n e u r o m u sc u l o s k e l e t a l r e l a t i o n s h i p s a n d p h a r m a cologic i n ter v e nt i o n s . C o m bined osteo p a t h i c m a n i p u l a t ive treatment ( O MT) with cl osely s u per vised ph ysica l th era py, s trength tra i n i ng, fl ex i b i l i ty tra i n i ng, propri oceptive a w a ren ess tra i n i ng, n e u ro m u sc u l a r ree d u ca t i o n , and the restructuring of basic n u trit i o n prov i d ed t h e strongest trea tme n t o u tcomes in a l l patie nts.
PA R K I N S O N ' S D I S EAS E PD i s a c h ro n i c p rogressive ne u rodege n e r a tive d i sease in w h i c h d o p a m i nergic c e l l s
i n t h e s u bsta n t i a n igra b e g i n to d i e p re m a t u re l y ( a p optosi s ) , a ffec t i n g the m o t o r syste m 's a b i lity t o c o n t r o l fine m o t i o n a n d t o m a i n t a i n b a l a nced m u sc u l a r tone ( p o s t u re ) , e v e n t u a l l y l ea d i ng to gross m o t o r d y s fu n c t i o n and cogn i t i v e d ysfu nc t i o n . PD h a s an e s t i m a ted p r e v a l e n ce of 3 1 to 3 2 8 p e r 1 00 , 0 0 0 p e o p l e worl d w i d e . I t i s es t i ma ted t h a t m o r e t h a n 1 % of t h e popu l a t i o n over a g e 65 a re a ffl i c te d with P D ; i n c idence a n d preva l e n ce i n c re a se w i t h age . 6 D i se a s e o n s e t is most often u n i
la tera l , p rogress i n g to b i l a tera l wit hin a w i d e l y v a r i a b l e t i m e s p a n . I t a ffec ts peo p l e of a l l a ges a n d is o ften m i s d iagn osed in i ts e a r l y s ta g e s .
The d i a g n o s i s o f PD is n e a r l y a lw a y s b a se d o n c l i n i c a l s i g n s a nd s y m pt o m s .
A t y p i c a l prese n t a t i o n wo u l d be a p a t i e n t with u n i l a tera l re s t i n g trem or, red u c e d arm swi ng, a n d s l o wed hand movement w h o h a s noticed a c h a nge i n g a i t , dexterity, a n d e n e rgy l e ve l . T h e c l in i c a l d i agnos i s m a y be less certain fo r a p a tie n t w i t h b ra d y k i nesia w i t h o u t a res t i n g t r e m o r. I n th is case, o t h e r p a rk i n s o n i a n d isord ers, s u c h as progress i ve s u p r a n u c l ea r p a lsy, m u l t i p l e system atrophy, o r v a s c u l a r pa r k i n s o n i s m m u s t be co n s i d ered. U l t i m a tely, t h e best i n d ic a t o r o f PD is a ro b u s t res p o nse t o l e v o d o p a o r o n e o f the d o p a m i n e agon i s t s . 7
Secti o n III • C l i n i c a l Co n d i t i o n s
326
T h e three c a r d i n a l signs of PD a re resting tremor
( 3-6 H z ) , cogwheel rigi d i ty, a n d
bra d y k i nesia . Postu ral insta bil ity, ty pica l l y not recogn ized u n t i l l a te i n t h e progression of t h e d i sease, is the fou r t h card inal sign . This fo urth s i gn is a centra l parameter of the osteopathic struct u r a l exa mination . Physicia ns tra ined a s d octors of osteopathy a re in a unique position to assess postura l dysfu nction beca u se they have extensive ed uca tion i n a p p l ied a n a to m y a n d the structure a n d fu nction re la tionsh i p . There fore, P D m a y be u ncovered earl ier i n i ts o n s e t by d octors o f osteo pathy t h a n by med ica l p h ysi c i a n s . A d d itional common fi n d i ngs a re asymmetric onset of s y m ptoms and sympto matic response to levodopa ( levodopa ) . D i agnos i s of PD i s pro b l e m a tic beca use of the lack of
a
reference standard test. The d iagnos is i s genera l l y made c l i n ically, a lthough
up to 25 % of p a t i e n ts with c l i n ic a l diagnoses of PD h a ve received d i ffe rent p a tho log ic d i agnoses at a u to psy. 6 B y t h e time the d i sease s y m p t o m s a re cl early d e l i n e a ted , m o s t p a t i e n ts h a v e s u b sta n t i a l cell l oss i n t h e su bsta n t i a nigra t h a t i s visi ble o n positron emiss i o n tomogra phy and single proton em ission c o m p u te d tomography.8 " P a thol ogjc studies suggest th a t pa tients may be s y mptom free until
60 to 8 0 % of su bsta ntia n igra l neu rons have
degenerated . " 9 I n teresti ngly, e a r l y d etection of t h e d i sease is u n l i ke l y, even with a va riety of ra d i ologic proce d u res, as reported i n a rev iew of r a n d o m l y control led tria l s eva l u a t i ng P D d i agnostics i n an Agency fo r Heal thca re Research and Q u a l i ty review artic l e . 6 •
3 s t u d ies o f m a g netic reso n a n c e ima g i n g : i n s u ff i c i e n t e v i d e n c e to d e term i n e r o l e
•
8 s t u d i e s of p o s i tron e miss ion tomogr a p h y : insu ff i c i e n t e v i d e nce ro d e te r m i ne
•
i n d ia g n os i n g P D r o l e i n d ia g n o s i ng P D 1 3 s t u d i e s of s i n g l e p h o to n e m i ss i o n c o m p u ted tomogra p h y : i n s u f fi c i e n t e v i
dence to s u pp o r t ro l e i n d ia g n o s i n g P D •
2 s t u d i e s of o t h e r sca n s ( n u c le a r m a g n e t i c reson a nce, u l t raso u n d ) : i n s u ffic i e n t
e v i d e n c e to s u pport r o l e i n d ia g n o s i n g P D 6 There continues to be grea t spec u la tion a s t o t h e ca uses o f PD, a n d as y e t there a re no c l e a r a n s wers . Therapy ta rgeted at d ea l i ng with the m u sc u la r tone a n d tremors h a s c o n s i sted p r i m a r i l y of vario u s pha rmaco logic agents. " Levodopa w a s the first a g e n t s h o w n t o s i g n i fica n tl y impact t h e d isease a n d h a s rema i ned the g o l d sta n d a rd . " 8 Most p h y s i c a l mod a l i ti e s h a v e b e e n u s e d w i t h s o m e s h o rt-te rm ga i n . A review o f r a n d o m ized contro l l ed s t u d i e s by t he Coc h ra n e Col l a b o r a t i o n cou l d not fi n d s u ffici e n t e v i d e nce fo r or a g a i n s t physica l th e r a p y, occ u p a t i o n a l thera py, or
a
best-practice g u i d e l i ne . l o D o p a m i n e a g o n ists ( D A s ) a re a l so used , e i t h e r a lo n e or i n com b i n a ti o n w ith levod opa . DAs act d i rectly on d o pa m i n e rece ptors, m i m ic k i ng e n d ogen o u s dop a m i n e . Monoa m i n e o x i d a se B i n h i bitors a c t by in h i biting d o pa m i ne c a t a b o l i s m thereby i ncreas ing d o p a m i n e levels i n t h e basa l gangl i a . C a techol 0methyl tra n s fe ra s e i n h i bitors act by i n h i biting c a ta bolis m o f d o p a m i n e , thereby exten d i ng levo d o p a 's periphera l ha l f- l i fe . Despire
the l arge selection o f med ications
a v a i l a ble to trea t PD, a l l PD p a tients u l t i m a te l y req u i re levod opa . In patients with early P D , the goa l of treatment is to a l leviate symptoms a n d m a i n ta i n i ndependent fu nction. In a d va nced PD, the foc u s is on m a x i m i z i ng " o n time" ( t i m e when medica tion is e ffective ) , m i n i m izing " o ff t i m e " ( ti me w h en med ication is n o t effective ) , and trea ting med ication-rela ted com p l ica tions, such as d y s k i nesias, motor fluctua tions, and psyc h i a tric pro b l e m s . 6 None have been shown to a ffect long term fu nction or progression of the d isease, though most do i m p rove q u a l ity of l i fe a n d ADL in the i n teri m . S u rgica l tre a t m e n t for PD is genera l l y cons idered fo r patients who respond to medications bur have i n t o lera ble side e ffects. S u rgic a l options include
C h a pt e r 22 • T h e Pat i e nt w i t h Pa r k i n s o n 's D i s e a s e
327
a b l a tive procedu res ( pa l l id otomy or t h a l a moto m y ) , deep bra i n sti m u l a tion, a n d tissue transpla ntation (e.g., p l uripotent ste m c e l ls ) . " T h e tota l a n n u a l cost for P D i n t h e U n i ted S ta tes i s estima ted t o b e a pproxi
m a te l y $26 b i l l i o n , i n c l u d i n g d i rect and i n d irect costs and lost prod u c t i v i ty. " 1 1
" C l e a r l y, PD p l a ces a m a j o r b u rd e n on both i n d i v i d u a l a n d societal h e a lthcare
resou rces . " 1 2
I t is c l e a r t ha t P a r k i n s o n 's p a t i e n ts a re n o t goin g to be c u red by p h a r m a colog ic o r osteopa t h i c m a n ip u l a ti v e trea t m e n ts at to d a y 's level o f u nd e r s ta n d i n g of t h e d i sease. W h y, therefore, g i v e t h ese tre a t m e n t s a t a l l ? It i s s i m p l y beca u s e t h e q u a l i t y o f l i fe fo r pa tients a n d t h e i r ca r e g i v ers m u s t be c on s i d e red . Wh a t rea s o n s d o i n s u r a n c e p a y ers c o n s i d e r j u s t i fi c a t i o n for c o n t i n u e d r e p e t i ti v e tre a t m e n t ? The red u c t i o n o f costs o f tre a t i n g fa l l s and o t h e r a c c i d e n ts s h o u l d be s u ffic i e n t . W h a t b e n e fi t s d o t h e p a t i e n ts recei ve ? T h e i m p r oved q u a l ity o f l ife for t h e e a r l y a n d i n termed i a te stages o f th e d i sease is u n d e n i a b l e . C a re g i v e rs m a y be g i v e n b a c k , fo r a t i m e , t h e i n d i v i d u a l t a k e n fro m t h e m , a nd o n e c a n n o t p l a c e a p r i c e o n d ecrea s i n g a l o v e d o n e 's s u ffering. I m p ro v e m e n t o f t he s e tre a tm e nts i s t h e la rgest portion of current i n vestiga t i o n s . O s t e o p a t h y h a s c o n tr i b u ted some i n teresting p i l o t research s h o w i n g t r e n d s in i m p ro v i n g overa l l o u tc o m e s , a n d these f i n d i ngs bear further i nvestiga t i o n . Researc h o n m o r e tha n 3 0 0 p h y s i c i a n-p a t i e n t i ntera c t i o n s coveri ng a I -y e a r p e r i o d a n d u s i ng t h e R a n d
36 S h o r t Form ADL s u rvey, t h e GHAA s a t i s fa c t i o n
s u rvey, t h e UPDRS Park i n s o n 's a ssessme n t protocol, i n c o m b i n a t i o n w i t h 3 D ga i t a n a l ys i s , 1 3 h a v e prov i d ed s o m e i n i t i a l evidence t h a t osteop a t h ic m a n i p u l a tive treatment ( i n c o m b i n a t i o n with s t a n d ard d ru g therapy i n te r ve n t i o n ) h a d better q u a l i ty - o f- l i fe mea s u res than d i d s ta n d ard m e d i c i n e s a l one ( a u t h o r 's u n p u b l i s h ed research ) .
Com mon O steo pat h i c Pro b l e m s W i t h a q u i c k l o o k a t t h e c l a s s i c posture o f a p a r k i n s o n i a n ga i t , severa l soma tic d ysfu nctions a re c l e a r l y i d e n t i fied as m a j o r p r o b l e m s . Psoas, h a m s t r i n g , q u a d ra t u s l u m bo r u m , s ternocle i d o ma s t o i d , a n d t h e occ i p i toa t l a n t a l m u s c l e s a r e c o m mo n l y h i t h a rd b y t h e n e u rogen i c d yston i a o f t h e d i sease. Rec i p ro c a l m u sc l e s a tte m p t i ng to co u n te r t h i s i n crease i n tone expend l a rg e a m o u n ts of e n ergy. T h i s fee d - forward fa i l ure o f i m b a lanced reflex a rcs c o n t r i b u te s to t h e p a t h o p h y s iologic p rocess. J o i n t brea k d o w n fro m a s y m m etric t o n e a n d c h ro n i c j o i n t d esta b i l i z a t i o n e n s u e s . A s a res ult, t h e e a r l y - o n s e t osteoarthritis a n d s c o l iosis t h a t a re common e a r l y d e g e n er a t ive c h a nges a ssoc i a ted w i t h this p a t h o p h y s io logy are more e a s i l y u n d erstood . 1 4 The freq uency o f o t h e r m u scu l os k e l e t a l fi nd i ngs, t h o u g h lower i n n u m ber, s t i l l exh i b i t s ign i fi ca n t c o r r e l a t i o n s with t h e viscera l syste m s ' dysfu nctions a nd comor b i d d isease states that a re u s u a ll y presen ted a s seq u e l a e o f PD. S o m a to v i sc e r a l responses m a y p l a y a m u c h l a rger ro l e i n t h e d e v e l op m e n t o f s e q u e l a e , a n d tre n d s i n i n i t i a l observa ti o n a l st u d i es i n d ica te severa l a ssoc i a t i o n s t h a t s h o u l d be i n ve s t i g a t e d fu rther ( a u t h o r 's u np u b l i s h e d researc h ) . Cha nges i n chest wa l l restriction, d i a p h ra g m a tic exc u rs i o n , a n d t h oraco l u m b a r postu ra l re l a t i o n s h i p s fre q u e n t l y preced ed e p i sodes of a va riety of p n e u monias, exace r b a t i o n o f c h ro n ic o bstructive p u l m o n a r y d i se a s e and a s t h m a , and com pla i n ts a bo u t gastroesop h a ge a l refl u x d isease. Desta b i l i z a ti o n of hyperte n s i o n , congestive heart fa i l ure, a nd the i n c i d e nce o f syncope were prece d e d by cha nges i n the kyp hoscoliosis o f t h e upper thora x and cervica l regi o n s . M a j o r fa l l s a ssociated with severe sprains ( a bove grade
3) a n d/or modera te to seve re fractu res were a ssociated
328
Section I I I • C l i n i c a l Co n d i t i o n s
H o e h n a n d Ya h r S ca l e 1
U n i lateral disease
2
B i l a tera l d i sease
3
Post u ra l I n sta b i l i ty, m i l d
4
Postu ra l i n sta b i l i ty, marked
5
No i n dependent wa l k i n g
w ith a cce lerati o n o f t h e degen erati ve process by o n e order of m a g n itude without
65 years o f age with i n iti a l 3 o r h i gh er ( Tab l e 22. 1 ) . A n y process req u ir i n g 6 o r more
recovery to b a se l i nes before i nj u ry in patients over Hoe h n a n d Ya hr sca l es o f
weeks of i m mo b i lization or severe restricti o ns i n acti v i ty e n ded with si m i l a r resu lts ( a ut h o r 's u n p u b l ished rese a rch ) .
Q u a l ity of Life Q u a l ity of l i fe w a s a sig n i fi c a n t a n d re l i a b l e m e a s u re of the se verity of the d isease, but rigorous reviews o f t h e g a it a n a l ysis m a ps, ch arts , a nd
3D v i deo o v e r l a ys pro
v i d e d fa r m o re o bj ecti ve measu res a n d were e x trem e l y p owerfu l tools for d e m o n str a t i n g to the p a t i e nts d u r i ng treatment t h a t they were i m p r o v i n g . This ma d e it possi ble to overcome m a n y psy c h o l og i c a l ba r r iers to i m prov i n g or m a i nta i n i ng q u a lity of l i fe a n d A D L i n the fa ce of the dep ress i o n assoc i a ted with the d i sease . T h i s a lso led to trends of l o w e r d o sing of a nt i d e press a n ts, a h ig h e r l i k e l i h ood of com i n g out o f rec l u s i v e b e h a viors, and a h igher degree of p a rtic ipation i n soc i a l acti vities bot h i n side a n d o u tsid e t h e immed iate fami l y a n d fr i ends. T h ere w a s a lso a higher d egree of p a rtic i p a t i o n i n se l f- h e l p gr o u ps a n d su pport gro u p a ctiv ities. P a t i e nt satisfact i o n levels i n creased si g n i fi c a n t l y over the initia l 1 2 -week period a n d m a i n t a i n e d high scores even a year l a ter ( a u t h o r'S u np u b l ished researc h ) .
Treatm e n t M et h o d s a n d Reas o n i n g Neurologic d isease, P D i n partic u l a r, lends itse lf very well t o a p p l ications of the te nets of oste o pathic med ic i n e . The m ost effective treatments rely o n care fu l ly i ntegrated med ica l and m usc u loskeleta l knowled ge . Treatments fo l low t horo u g h d iagnosis a n d t h e a p p l ication o f a l l a pprop r i ate treatment m od a l ities as so o n a s possibl e, with the goa l of a c h i eving longer retention of qua lity of l i fe a nd ADL. Sta n d a rd osteopath ic str u ct u ra l ex a m inations have been com bined with basic neurologic exa m i n ations, regu l a r genera l physical exa m i n a t i o ns, periodic ga it a n a l yses, a n d regu l a r i nterviews wit h patients and ca regivers to create the fou nd ation of d ecisi o n ma k in g for the use of OMT ( a uthor's u n p u b l ished rese a rch ) . Each treatment begins with a reassessment o f t h e entire patient a t every v isit, m o n itoring c h a n ges in medici nes, fa l ls, progress w ith A D L , exercise progra ms, n utri t i o n a l status, b lood pressu re, and a review o f a ny other act i ve hea lth care issues. The osteo pa thic practitioner exa m i n es gait, and t h e d egree of d ysfu ncti o n is estim ated . A 3D g a it a n a l ysis is c om p l eted in the biomecha nics l a boratory on the i n it i a l v isit, twe lfth visit, a n d then every 3 months. T h i s provides a single sta n d a rd t h a t has a
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h ig h e r degree of p recision a n d i n terexami ner correl a t i ons t h a n goni ometry. C y bex strength te sting for power o u tp u t a nd e n d u ra nce i s o bta i ned on the same sched u l e . T h i s objec t i ve assessment i s compa red t o t h e p h ys i c i a n 's i mpres s i o n b e fore t h e res u l ts of the tests a r e d i sc u ssed d u r i n g per i o d i c q u a l i t y ass urance chart reviews. Then these me a s u re m e n ts a n d ca l c u l a t i o n s extracted from them a re used to d o c u m e n t c o m p a r isons to the basel i n e fu nction o f the p a t i e n t before OMT beg i n s . T h e O MT used w a s pred o m i n a n tl y ( a l p h a betica l l y l isted ) b a l a nced l igamentous ten s i o n , fa ci l i ta ted position a l r e l ease, muscle e n e rgy, m y o fasci a l re lease, a n d osteo p a th.)' i n t h e cra n i a l fi e l d . First ri b restrictions were most o ften trea ted w i t h fac i l i ta ted positi o n a l release, w h i l e other rib restric t i o n s were i n itia l l y treated with b a l a nced l igamento u s te n s i o n fo l lo wed by respi r a tory-assisted m u s c l e e nergy and m yofasc i a l re l ease. Osteo p a t h y i n t h e cra n i a l field w a s a pp l ied w hen cra n i a l , fac i a l , or upper cer vical muscu l a ture d e m o n s trated a s y m metric tone e i ther a n teroposteriorl y or l a terally o r when cra n i o fac i a l a rt i c u l a tions had p a l pa ble asyrrunetric movement pa ttern s . In a d v a nced cra n ia l a p p l ications in w h ic h speec h was a ffected , intra o r a l proced u res were u s u a l l y added to the trea tme n t w hen the p rovider was appro p r i a tely tra i ne d . C h o ices .vere based o n the p a t i e n t's i n i ti a l response to the appl i c a t i o n of a proced ure . If the i n i t i a l exec ution bec a m e d iffi c u l t to a pp l y o r if there seemed to be resista nce to t he a pp l ication in the i n itia l tissue response p h ase as Wi l l i a m Joh nston d e s c ri bes i n his textbook on fu ncti o n a l techn i q u e . I S The proced ure was halted and another tried . T h i s p rocess w a s used a t e a c h b o d y s i te and at e a c h v i s i t . Proce d u res t h a t provided good i n i t i a l tissue respo nses ( ne a r l y i m med i a t e l y decreased TA RT [tissue te x t u re a bnorma l i ty, asym metry o f pos i t i o n , restriction of m o t i o n , tende rness] fi n d ings) te nded to be reused , i ncrea s i n g t h e ease o f trea tment whi l e d ecre a s i n g the time need ed to comp lete trea tment. Sta t i s t i c a l a na l yses of these measu res were used to q u a n t i fy what had been o bserved a n ecd ota l l y. A l l p a t i e n ts trea ted d u r i n g t h a t 1 - ye a r period had a t l e a s t 1 o f 7 5 m e a s u r e m e n ts i m prove s i g n ifica n t l y. M o s t p a tients m a i n t a i n ed i mprove
m e n t i n m o re t h a n ha l f of t h e m e a s u re s . I n a comp a r i s o n o f p a tter n s o f move m e n t t o age-sta n d a r d ized a n d g e n d er-sta n d a rd i z e d c o n t r o l s , a l l p a t i e n ts tre a te d s h i fted th � i r moveme n t pa tterns back toward n o r m a l m o v e m e n t p a tterns, t h o u g h the a m p l i t u d e o f m o v e m e n ts re m a i n e d s o m ew h a t red u c e d . N o n e o f the s o l e l y p h a r m a c o l o g i c a l l y tre a te d p a t i e nts i m proved th e i r p a ttern s o f m o ti o n . Po s t u re i s assessed i n t h e stru c t u r a l exa m i n a t i on , w i t h a d d it i on a l a tt e n t i o n to the l o n g axis t w i s t o ften prese n t i n P D p a tien ts. Sco li o s i s is commo n , as is some of the t ra d i t i o n a l p a rk i n s o n i a n pos t u r i n g s i m i l a r to p s o a s c o n tract u re p o s t u r e . Th i s p o s t u r e w a s nea r l y a l w a y s a s s oc i a ted w i t h severe psoas a n d ster n o c l e i d o m a s t o i d hyperto n i c i ty restr i c ti on s . T h i s a lso i m p roved o n 3 D ga it a na l ys i s i n the p o p u l a t i o n treated w i t h O M T.
Physical Therapy Strength t ra i n i ng , proprioce p t i v e tra i n in g , stretc h i n g , a n d c a r d i o v a sc u l a r e n d u r a n c e tra i n i n g were h e l p fu l a d j u ncts t o t h e progra m . P a t i e n ts w h o w e r e m i ss i n g e v e n o n e o f t h e s e m o d a l i ties h a d p o o r e r o u tcomes th a n t h ose who received the fu l l spectr u m o f tra i n i n g .
Integration of Osteopa thic Diagnosis and Trea tmen t and Pharmacologic Considerations Tacti le co m m u n ic a t i o n is a sta n d a rd p a rt of the i n teraction between the osteo p a t h i c p h ys i c i a n a n d the pa tient. lt i s a method of com m u n ication that o ften exceeds patients' a b i l ity to express t h e severity o f the i r compla i nts, the sites of t h e greatest pro blems,
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a nd their daily di fficu l ty i n j u st sitting o r standing. I n addi tion, pharma cot he r a p y a ffects tissu e textu re a nd postura l tone. These drugs t h a t cha nge postu ral tone, may induce dys k i nesia, shift water content from various compa rtments, and p r o fo u ndly a lter range of motion, gait, and ba la nce. A l l of these changes c a n be percei ved ear l y i n their development b y tra i ned hands far in a d vance of the cha nges that must ta ke place to register o n the various sca les and meas ures customa rily used to fo l low the p rogress of the disease. The medical necessity for repetitive eva luation and m a n agement in t h e ha nds o f a n osteopath i c physician is e m i nently clear i n this l ight. Considerations for Students, Interns, Residen ts, and A ttending Physicians
The MSIII (third-yea r osteopathic med ica l student) level of tra ining is su fficient to have s ig n i ficant i nfluence on this d i sease state. At that level of tra i n ing, the basic s k i l l s req u i red for exec u t i n g si mple y e t s u ffic ient osteopathic m a n i p u lative trea tment i n ter ventions are exactly what is r e qui red . Expe ri e n c e wi th the disease i tself a nd its su b t l e n u a n ces of change require a good dea l more experience i n interp reta tion. O u tcomes in more s k i l led h a nds s howed trends towa rd longer on-per iods between trea tments a nd higher-qu a l i ty movement pa tterns. Earlier d iagnosis and inte rvention p rovide longer q u a l i ty-of- l i fe periods in most diseases, a nd the osteopa t h i c practitioner has skills tha t c a n detect symptoms of the disease e a r l ier via the traditiona l osteo pathic structural exa mination a nd osteopat hic gait a n a l y s i s . Radio logic testing a n d bl ood wor k have been shown to be i nconcl usive in the early stages. i diopa t h i ca l l y trained physicians are not ordinaril y as ski lled with structural diagn ostic methods a s a re osteopathic physicia ns. They are there fore less l i k ely, because they miss this u nder graduate tra i n ing, to d iagnose PD as early a s a n osteopa thic p h ysician does . Trea tments require little time once the in itial treatment series is completed , though t he req u is i te follow-up eva lu ations be fore each treatment can become more time consum ing a s the severity of the disease increases. Tre n d s iden t i fied in t h ese studies w a rra n t fu rther i nvest i ga t i o n , b u t beca use tbe treatment m od a l ities can do n o h a r m , they sho u ld be continued u n t i l fu rt h e r stu d ies i ndicate m o r e precisely w h ic h a re sta tistica l l y stronger a n d u nde r w h a t c i rc u m sta nces t hey a re the preferred trea tme n t m oda l i t y. T h e e ffects on d u ration of p h a r macologic t herapy a nd on dosage of medica t i o n tre nds a re perh aps the most i mporta n t s u bj ects of fu rther i nvestiga ti o n . The c h a nce t h a t OMT m ay a ssist the i ntern a l e nviro n m e n t i n p ro lo n g i ng a pa t i e n t 's a bi l i ty to ta ke a drug a nd to use i t e ffectively a t lower doses h a s p r o fo u nd econo m i c a n d soc i a l ram ifica t i ons . Th e cost of patient c a re co u ld go down in the short term, w h i l e the sa les o f a spec ific a gent might go up or a t least be p r o l o nged befo re into l erances req u i r e c ha nges . Bec a u se " t he goa l of trea tment s h o u l d be to o b ta i n a n optim a l red u c t i o n o f p a r k i n son ism w i t h a m i n i m a l ris k o f l o ng-t e r m s i d e e ffects , " 1 6 osteo p a t h i c i n terventions sho u ld dearl y conti n u e to be a part of the trea tment p rocess . D I SC U S S I O N Tre nds indicated strongly t h a t patients w h o received OMT a veraged fa ster i m pro v e ment, longer retention of qua l ity movement, d ec reased drug use, longer to lerance of t heir medications, a reduction in side effects, l esser deg rees and severi ty o f side effects, and t hey had less fre q u ency a nd severity of addition a l v i scera l d i sease than those who did not. Pa tterns o f movement ba sed on length-ve locity r e l a t io n s h i ps assessed in ga i t ana l ysis returned t o nea r norma l , though t h e amp l itude o f ga i t factors rema i ned sma l ler tha n those of sta ndardized age- a nd gender-matched " norma ls . " Oste op a thic trea tment i n i tia l ly a ppears to have an i m pressive e ffect i n the treatme nt o f pa r k i nson i a n disorders and wa rra n ts furt her i nvestiga tion. Prac t i tioners a t a ll levels of t ra i n i n g
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should be including OMT i n their treatment parad igm a s d eta ils of mechanism of action a nd efficacy stud ies conti nue. Proce d u res Pl ease note: The proce d u res tha t fo l low a re exa m p les of m a n i p u l a tive treatment that you may wish to employ. The actu a l choice of p roced u res used s h o u l d be determi ned by the u ni q u e circ u msta nces of each i n d i v i d u a l p a t i e n t . T h e fo l l o w i n g proced u res a re usefu l when trea ting soma tic d ysfu nction a s re l a ted to the patient w i th PD . A l l trea tment must i nc l u d e c o n t i n u o u s ta c t i l e feed back to mod u l a te the m i n i m u m degree of fo rce req u ired to a c hieve a n e u rom usc u l a r release response ( a cha nge i n TART q u a lities ) . Execu t i o n of t h i s process w i th attention to matching the forces w i t h i n the tissues lets the p a tient's system gra d u a l l y return t o m o r e n o rm a l movement p a tterns . Excessive force consiste n tl y y i e l d s the op posite effect. Increased prec i s i o n y i e l d s i ncreased symmetry o f moti o n . Occipitoatlantal Release
This p roced u re is empl oyed to d ecrease cervica l tissue tension a n d e n h a nce the sym metric ra nge of motion between the base o f the s k u l l a n d t h e cervic a l s p i n e . ( See the p roced u re descr i p t i o n i n C h a pter 8 a n d Fig. 8 . 7. A l so s e e t h e p roced ure descri p t i o n in Cha pter 1 6 a n d Fig. 1 6 . 1 2 . ) Occipitomastoid Decompression
This p roce d u re is e m p loyed to e n h a nce motion of the cra n i a l mecha n i sm at the occipitomastoid s u t u r e . ( See the proced u re d escription i n Cha pter 8 a n d Figure 8 . 8 . ) Cervical (Soft Tissue)
See Figu re 1 0 . 2 . T h i s proced u re i s e m pl oyed t o d ecrease cerv ica l tissue ten s i o n a n d e n h a nce t h e symmetric ra nge of m o t i o n o f t h e cervica l s p i n e . ( F o r d ia g n o s i s , s e e C h a p ter 3 . ) Patient pos i t i o n : s u p i n e . P h y s ic i a n positio n : seated a t the h e a d o f t h e trea tment ta b l e . Pr o ced u re 1.
W i t h both h a n d s , p l a ce t h e p a d s of y o u r f i n g e r s b i l a tera l l y over t h e cerv i c a l
2.
S y m m et r i c a l l y a p p l y a n te r i o r a n d ce p h a l a d p ress u re u nt i l you s e n s e t h e st retc h of t h e
p a rasp i n a l t i ss u es at t h e level of m a x i m a l p a l p a b l e p a ravert e b r a l te n s i o n . cervica l p a ras p i n a l soft tissu e s . A p p l y i n g m o re p ress u re w i l l p rod uce a rt i c u l a r m o ti o n . 3.
H o l d w i t h t h i s d e g ree of a p p l i e d f o rce p o s i t i o n u n t i l t h e t i s s u e s re l a x .
4.
Slowly release t h e h o l d i n g force, exert i n g c a re not t o u n l o a d t h e m u scles too ra p id ly.
5.
T h i s s e q u e n c e s h o u l d be repeated seve r a l t i m es , work i n g up a n d d o w n t h e c e rv i c a l s p i n e , u n t i l t h e d e s i red d ecrease i n p a ras p i n a l te n s i o n i s a c h ieved . As y o u beco m e p rofi c i e n t w i t h t h i s p roced u re, y o u w i l l l e a r n to f o c u s s p e c i f i c a l l y u p o n asy m m e t r i c a reas of paras p i n a l t e n s i o n .
6.
W h e n t h e p roced u re
IS
com p l ete, reassess cervical pa rave rteb r a l soft t i s s u e t e n s i o n
a n d ra n g e of m o t i o n .
Cervical (Muscle Energy) (Fig. 22. 1)
T h i s p roced u re is empl oyed to treat artic u l a r s o m a tic d ys fu nc t i o n of the cerv ica l verte brae, C2 u p o n C3 to C7 u p o n Tl , c a u s e d by a s y m metric a l m u s c l e ten s i o n . ( F o r d i agnosis, s e e Cha pter 3 . )
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Sect i o n
FIG U R E 22. 1 .
I I I • C l i n i ca l Co n d i t i o n s
C e rv i c a l m u s c l e e n e r g y is e m p l oyed to treat a rt i c u l a r s o m a t i c dysf u n ct i o n of the c e rv i ca l v e rte brae, C2 u p o n C3 to C7 u pon T 1 , ca u sed by asym metric m u s c l e te n s i o n .
P a t i e n t p o s ition: s u p i n e . P h y s ic i a n pos i t i o n : sta n d ing o r sea ted a t t h e h e a d o f t h e ta b l e . P r o c e d u re ( E xa m p l e : C4 F l e x e d , Rotat e d Left, S i d e B e n t Left u p o n ( 5 ) 1.
H o l d 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 h a n d s . C o n tact the t r a n sverse p rocess of C4 on the left with the l a t e r a l as pect of the pro x i m a l p h a l a n x of y o u r left i n dex f i n g e r. W i t h t h e f i n g e rt i p s of yo u r r i g h t h a n d , contact t h e a rea l a tera l ly over the t i p o f t h e r i g h t t r a n sverse p rocess o f C 4 .
2.
U s i n g y o u r l eft i n d ex f i n g e r as a f u l c r u m , i n t ro d u ce ext e n s i o n o f t h e ce rvi c a l s p i n e betwee n C 4 a n d C 5 . T h i s exte n s i o n , wh i c h l o ca l i zes fo rces t o t h e verte b ra l level b e i n g t re a t e d , m u st be m a i n t a l Il ed t h ro u g h o u t t h e re m a i n d e r of t h e p roced u re .
3.
W i t h both h a n d s , i n t ro d u ce r i g h t s i d e be n d i n g o f C 4 u p o n C 5 b y h o r i zo n ta l ly t r a n s l a t i n g C 4 to t h e l eft u nt i l yo u feel t e n s i o n accu m u l at i n g between C 4 a n d C 5 a n d t h e s i d e - b e n d i n g b a r r i e r i s reac h e d .
4.
Rotate t h e h e a d a n d n e c k to t h e r i g ht. down to a n d i n c l u d i n g C4, u nti l you feel ten s i o n accu m u l a t i n g betwe en C 4 a n d C 5 and the rota t i o n a l b a r r i e r i s rea c h e d .
5.
M a i n t a i n te n s i o n a g a i nst t h e d ysf u n ct i o n a l b a r r i e r a n d i n st 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 a n d n e c k b a c k to t h e l eft a g a i nst y o u r h o l d i n g fo rce for 3 to 5 seco n d s .
6.
Pa u se f o r 1 t o 2 seco n d s , a n d t h e n s i d e - b e n d a n d rot a te f u rt h e r t o t h e r i g h t to e n g a g e the n ew b a r r i e r.
7.
Repeat steps 5 a n d 6 u n ti I t h e best pos s i b l e i n crease of m o t i o n
8.
W h e n t h e p roced ure i s com p l et e , reassess C 4 u po n C 5 .
IS
o b ta i n e d .
Thoracic and Lumbar Soft Tissue, A rticula tion; Patient Prone T h i s p roced ure i s e m p l o y e d to decrease p a r a v e r te bra l m u s c l e spasm a n d s o ft t i s
s u e te n s i o n of t h e th oracic a n d l u m b a r s p i n e C h a pter 5 a n d F i g u r e
5 .5 . )
.
( Se e t h e p r oce d u re d e scri p t i o n i n
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Thoracic Inlet Myofascial Release
Th i s p roce d u re is e m p l oyed to release restrictions a n d thereby res u l t in s y m m e t r i c movement o f the i n the tra nsverse fasci a l tissues o f t h e th oracic i n l et. It may be p e r fo rmed ei t h e r a s a d i rect or a n i n d irect p rocedure. ( See t he p roced u re descr i p ti o n i n Cha pter 1 9 a n d F i g u re 1 9 . 2 . ) Rib Inhala tion and Exhalation Muscle Energy
This proced ure i s employed to optimize the respiratory motion of i ndivid u a l ribs. You c a n a ssess the motion of a specific rib with the patient sea ted or s u p i ne, by placing one o f your hands posteri orly upon the a ng le o f the r i b to be eva luated, placing the other h a n d a n teriorly upon the costochondral j u nction of the same rib, a n d palpa ting motion as the patient i n ha les and exha les. An i n h a l a tion ri b moves freely d uring i n h a l a tion but stops moving before a d j a cent ribs stop a t the end o f exhala tio n . A s s u c h , a n i n ha l a tion ri b may a ppear t o b e d isplaced, u p in front, a t t h e costochondra l j u nctio n , a n d down i n back at the r i b angle. Conversely, an exhalation rib moves freely d u ring exha l a tion but stops moving before a d j acent ribs stop a t the end of i n halation, a n d i t may a ppea r to be d is p laced, down i n front and u p i n back . If severa l a d j acent r i bs a re perceived to be si mi larly restricted, a single ri b may be responsible. If the gro u p i s i n i n h a l a tion, the most i n ferior rib i n the gro u p may be preventi ng the rest o f the gro u p from moving free l y into ex ha lation. I f the gro u p is i n e x h a l a ti o n , t h e most su perior rib i n t h e gro u p m a y b e respons i b l e . Conseq uent l y, when trea ting a gro u p of d ysfuncti o n a l ribs, the procedu re s h o u l d fi rst be d i rected a t mobi l i z i ng t h e r i b most l i kely t o b e responsi b l e for m a i n ta i n i n g t h e gro u p p a ttern . In any a ttempt to trea t ri b dysfu nction, a n y a nd a l l conco m i ta n t somatic dysfunction o f the thoracic spine s h o u l d be d iagnosed a nd trea ted fi rst. Frequently, m o b i l ization o f thoracic somatic d ys fu ncti on w i l l e l i m i nate any a ssocia ted rib d ysfunctions. The fo l l owi n g proce d u res e m p loy i s o metric muscu la r contraction to m o b i l ize the r i b s . Beca u se d i fferent m uscle groups a re employed to a ffect d i ffere n t r i bs , the tho racic cage i s d i v i d e d i n to u pper, m id d le, a n d l ower regions, each regi o n req u iring a slig h t l y d i ffe re n t p roced u re to ach ieve the desi red e ffect. I N H A LATI O N, E L EVAT E D , F I R ST R I B
The i n ha la t i o n d ysfuncti o n o f the uppermost r i b s , particularly the first ri b, occu rs as l a teral eleva t i o n of the rib, an eleva ted r i b . A fa cil i t a ted positional release proce d u re for a n elevated first rib i s d escribed i n Cha pter 21 and shown in Figure 2 1 . 3 . I N H A LATI O N S E C O N D T O S I XTH R I B S ( M U SC L E E N E RGY) ( F I G . 2 2 . 2 )
P a t i e n t p o s i t i o n : s up i ne . P h y s i c i a n p o s i t i o n : s ta n d i ng a t t h e head of t h e pa tient a n d towa rd the side o f t h e dysfu nctio n a l ri b . Proced u re ( E xa m p l e : I n h a l a t i o n Th i rd R i b o n t h e Left) 1.
Sta n d i n g at the head of the t a b l e , p l a ce the t h e n a r e m i n e n ce of yo u r l eft h a n d
2.
W i t h yo u r r i g h t h a n d , l i ft t h e p a t i e n t 's h e a d a n d n e c k from t h e t a b l e , t h e re b y i n tro
u p o n t h e p a t i e n t 's a nt e r i o r ch est wa l l c o n t a ct i n g t h e dysfu n ct i o n a l t h i rd r i b . d u c i n g f l e x i o n down to and i n c l u d i n g T2 u p o n B . 3.
H a ve t h e p a t i e n t i n h a l e a n d ex h a l e d e e p l y.
4.
As the patient ex h a l es, a p p l y a n i nfe roposte r i o r fo rce to the a nterior asp ect of t h e t h i rd
5.
At the end of ex h a lat i o n , h o l d t h e ri b a g a i nst t h e restrictive barrier, wa it 2 to 3 seco n d s ,
rib with your l eft h a n d to m ove the r i b i nto exh a l at i o n a g a i n st the rest r i ctive barrier. a n d i n struct t h e patient to i n h a l e deep ly a g a i n . The i n s p i ratory effort a g a i nst the h o l d i n g fo rce f ro m you r l eft h a n d p rovides the isomet r i c contracti o n f o r t h e p roced u re
334
Section I I I • C l i n i ca l C o n d i t i o n s
FIGURE 22.2
M u s c l e en ergy f o r a n i n h a l e d t h i rd r i b o n t h e l eft .
6.
R e p e a t s t e ps 4 a n d 5 u n t i l t h e b est possi b l e i n c rease of m o t i o n i s obt a i n e d .
7.
W h e n t h e proce d u re is c o m p l ete, reassess t h e resp i ratory m o t i o n of r i b 3 .
I N H A LAT I O N S E V E NT H T O T E NTH R I B S ( M U S C L E E N E R GY) ( F I G .
22.3)
P a t i e n t position : s u p i n e . Physici a n position: sta n d i ng a t the side o f the p a tient o n the side of the dysfu nctional r i b .
FIGURE 22.3
M u s c l e e n e rg y fo r a n i n h a l ed e i g ht h r i b o n t h e l eft .
C h a pter 22 • The Pat i e n t with P a r k i n s o n 's D i sease
335
Proced u r e ( E xa m p l e : I n h a l at i o n E i g hth R i b o n t h e Left) 1.
Sta n d i n g o n the l eft s i d e of the p at i e n t , u s i n g y o u r l eft h a n d , p a l pate the l a t e r a l c h e s t wa l l at t h e l evel of t h e dysfu n ct i o n a l e i g ht h r i b . G ra s p t h e p a t i e n t 's r i g h t s h o u l d e r w i t h you r r i g h t h a n d a n d s l i d e i t towa rd y o u , i n t ro d u c i n g s i d e be n d i n g o f t h e p a t i e n t 's u p p e r torso t o t h e l eft, u n t i l y o u p a l pate d e c reased ten s i o n at t h e l evel of the dysf u n ct i o n a l r i b . M a i n t a i n t h i s p os i t i o n t h ro u g h o u t the re m a i n d e r of t h e p roced u re .
2.
P l a c e t h e t h e n a r e m i n e n ce o f yo u r l eft h a n d o n t h e l a te r a l a s p ect o f t h e dysf u n c tional eig hth r i b .
3.
H a ve t h e p a t i e n t i n h a l e a n d ex h a l e d e e p l y.
4.
As t h e p a t i e n t ex h a l es , a p p l y a n i n fe ro m e d i a l fo rce w i t h yo u r l eft h a n d to move t h e
5.
At t h e e n d of ex h a l a t i o n , h o l d t h e r i b a g a i nst t h e rest r i ct ive b a r r i e r, w a i t 2 to 3 sec
dysfu n ct i o n a l r i b i n to exh a l a t i o n a g a i nst t h e rest ri ctive b a r r i e r. o n d s , a n d i n st r u ct t h e p a t i e n t to i n h a l e d e e p l y a g a i n . The i n s p i ratory effo rt a g a i n st t h e h o l d i n g fo rce f r o m y o u r l eft h a n d p ro v i d e s t h e i s o m e t r i c co ntract i o n f o r t h e p roced u re .
6.
Repeat steps 4 a n d 5 u n t i l t h e best p o s s i b l e i n c rease o f m o t i o n i s o b ta i n ed .
7.
W h e n t h e p ro c e d u re is co m p l eted , reassess t h e resp i ra t o ry m o t i o n of t h e e i g h t h r i b .
E X H A LATI O N F I RST A N D S E CO N D R I B S ( M U SC L E E N E R G Y) ( F I G . 2 2 .4)
P a t i e n t pos i t i o n : s u p i ne , P h y s icia n p os i t i o n : sta n d i n g at the side o f t h e p a t i e n t on the side o p p os i te the dysfuncti o n a l ri b .
FI G U R E 22,4
M u s c l e e n e rgy f o r a n e x h a l e d seco n d r i b o n t h e l eft .
336
Sect i o n I I I • C l i n i ca l C o n d i t i o n s
P roced u re ( E xa m p l e : Ex h a l at i o n Seco n d R i b o n t h e Left) 1.
H ave the pati e n t rotate the head s l i g h t l y to the r i g h t . f u l l y flex the l eft e l b ow, a n d a b d u ct a n d exte r n a l l y rotate t h e l eft s h o u l d e r, p l a c i n g t h e b a c k of t h e l eft h a n d u p o n t h e f o re h e a d .
2.
W i t h yo u r l eft h a n d , g r a s p t h e p a t i e n t 's l eft w r i st a n d h o l d i t a g a i n st t h e p at i e n t 's f o re h e a d w h i l e m a i n ta i n i n g t h e rotati o n a l p o s i t i o n of t h e h e a d .
3.
R e a c h a c ross t h e p a t i e n t 's c h est a n d s l i d e yo u r r i g h t 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 's u p p e r t o rso so t h a t yo u r f i n g e rs co ntact t h e p oste r i o r a n g l e o f t h e dysf u nc t i o n a l seco n d r i b .
4.
H a ve t h e p a t i e n t i n h a l e d e e p l y a n d atte m pt t o l i ft t h e h e a d f r o m t h e tab l e wh i l e you res i st the effo rt w i t h yo u r l eft h a n d and s i m u l ta n e o u s l y a p p l y c a u d o l a tera l tract i o n to t h e p o st e r i o r a s p ect o f t h e seco n d r i b with yo u r r i g h t h a n d f o r 3 to 5 seco n d s . Rotat i n g t h e r i b a n g l e d ow n w a rd e l o n g a tes t h e levator costa r u m , d i rectly m ov i n g t h e r i b f u rt h e r i n to a n i n h a l a t i o n p o s i t i o n .
5.
H ave t h e p a t i e n t ex h a l e a n d re l a x a s y o u r e l a x yo u r co u n te rforce .
6.
Wa i t 2 to 3 seco n d s a n d re peat ste ps 4 a n d 5 u n t i l t h e best poss i b l e i n c rease of
7.
W h e n t h e p roced u re is c o m p l e t e , reassess t h e res p i ratory m o t i o n of t h e seco n d r i b .
m o t i o n i s o bta i n ed .
E X H A LATI O N T H I R D TO F I FT H R I B S ( M U S C L E E N E R G Y) ( F I G . 2 2 . 5)
Patient p o s i ti o n : su p ine . Physician positio n : sta n d i ng a t the s i d e of t h e p a t i e n t on the s i d e opposi te the d y sfunction a l ri b . Proce d u re ( E xa m p l e : E x h a l at i o n F o u rth R i b o n t h e Left) 1.
T h e p a t i e n t f l exes t h e l eft e l bow a n d a b d u cts a n d exte r n a l l y rotates t h e l eft s h o u l d e r, p l a c i n g t h e l eft h a n d p a l m u p be h i n d t h e h e a d , cra d l i n g t h e occ i p u t .
FIG U R E 22.5
M u sc l e e n e rgy f o r a n e x h a l ed f o u r t h r i b o n t h e l e ft .
C h a pter 22 • T h e Pa t i e nt w i t h Pa r k i n s o n 's D i se a s e
2.
337
W i t h y o u r l eft h a n d , g ra s p the p a t i e n t 's l eft e l b ow, h o l d i n g t h e p a t i e n t 's l eft s h o u l d e r i n t h e exte r n a l l y ro tated a b d u cted p o s i t i o n obta i n e d i n step 1 .
3.
Reach a c ross t h e p a t i e n t 's c h est a n d s l i d e yo u r r i g h t 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 's u p pe r torso so t h a t yo u r f i n g e rs contact t h e p o ste r i o r a n g le of t h e dysf u n c t i o n a l f o u rt h r i b .
4.
H a ve t h e pat i e n t i n ha l e d e e p l y a n d atte m pt to l i ft t h e l eft e l bow w h i l e y o u re s i st t h e effort w i t h y o u r l eft h a n d a n d s i m u lta n e o u s l y a p p l y ca u d o l at e ra l t r a ct i o n to t h e pos te r i o r a s p e ct of t h e fou rth rib w i t h y o u r r i g h t hand for 3 to 5 se co n d s .
5.
H ave t h e p a t i e n t ex h a l e a n d rel a x a s y o u re l a x y o u r cou n t e rfo rces .
6.
Wa i t 2 to 3 seco n d s a n d re peat steps 4 a n d 5 u n t i l t h e best poss i b l e i n c rease of
7.
W h e n t h e p roced u re i s co m p l eted, rea ssess th e res p i ra t o ry m o t i o n o f t h e fo u rt h ri b .
m o t i o n is obta i n e d .
E X H A LAT I O N S I XTH T O T E NTH R I B S ( M U S C L E E N E R GY) ( F I G .
2 2 . 6)
P a t i e n t p o s i t i o n : s u p i n e . P hysici a n p o s i t i o n : s t a n d i n g a t the side of the p a tient on
the side of the dysfu ncti o n a l r i b . Proce d u re ( E xa m p l e : E x h a l a t i o n Seventh R i b o n t h e 1.
Left)
G rasp the patien t's l eft a rm with you r r i g h t h a n d a n d a b d u ct t h e s h o u l d e r 90 d e g rees. M a i n ta i n the a r m i n t h is p o s i t i o n by h o l d i n g it a g a i nst t h e a n te r o l a t e r a l a s p ect of you r r i g h t t h i g h w i t h yo u r right h a n d .
2.
S l i d e yo u r left 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 's torso s o t h a t yo u r f i n g ers c o n t a c t t h e poste r i o r a n g l e o f t h e d y sf u n cti o n a l seve n t h r i b .
3.
H a ve t h e p a t i e n t i n h a l e d e e p l y a n d a tte m pt t o a d d u ct t h e l eft a r m w h i le you re s i st t h e eff o rt w i t h y o u r r i g h t t h i g h a n d s i m u lta n e o u s l y a p p l y ca u d o l a tera l t r a ct i o n to t h e poste r i o r a s p e ct of t h e sev e n t h r i b with your l eft h a n d f o r 3 to 5 seco n d s .
4.
H ave t h e p a t i e n t ex h a l e a n d re l a x a s y o u re l a x yo u r c o u n t e rfo rces .
5.
Wa i t 2 to 3 seco n d s a n d re peat steps 3 a n d 4 u n t i l t h e best possi b l e i n c re a s e of
6.
W h e n t h e p ro ce d u re i s co m p l ete, reassess t h e re s p i ratory m o t i o n o f t h e seve n t h r i b .
mot i o n i s obt a i n e d .
F I G U R E 22.6
M u s c l e e n e rgy f o r a n e x h a l e d
s eve nt h
rib
on
the l eft .
338
Section 1 1 \ • C l i n i ca l Co n d i t i o n s
FIGURE 22.7
I n d i rect b a l a n c i n g o f t h e t h o r a c i c c a g e to o pt i m i ze r a n g e o f m o t i o n of t h e ch est.
Thoracic Cage Balancing (Indirect) (Fig. 22. 7) T h i s proce d u r e i s e m p l o y e d to opti m i ze r a n ge of m o t i o n o f
the c h es t cage. It is
extremely e ffec t i v e in p a ti e n ts w h o se a b i l i ty to c o n tract m us c l e i s severe l y l i m ited beca use o f n e u r o logic hy perto n i c i ty. I n this proce d u re , the right and
left h a lves of
the thoracic cage a re b a l a nced aga i n s t each other. P a t i e n t p o s i t i o n : s u p i ne or pro n e . Physic i a n positi o n : s ta n d i n g on e i ther side of t h e ta b le fac i n g t h e p a tien t's h ea d . Proce d u re 1.
F i r m l y g r a s p t h e p a t i e n t 's t h o r a c i c c a g e w i t h both h a n d s, yo u r f i n g e rs com forta bly s p re a d , so that your t h u m bs a re d i rected ce p h a l a d and yo u r f i n g e rs curl arou n d t h e i r c h est o n e i t h e r s i d e .
2.
S l i g h t l y rotate t h e t h o r a c i c c a g e t o t h e l eft a n d t o t h e r i g h t a bo u t the vert i c a l a x i s
3.
W i t h s i m i l a r force, i n trod u c e l atera l t r a n s l a t i o n o f t h e t h o r a c i c c a g e t o t h e l eft a n d
a n d i d e n t i fy t h e d i rect i o n of l east resi sta n c e . r i g ht, a n d a g a i n i d e n tify t h e d i re ct i o n o f l east res i sta n c e . 4.
I n t ro d u c e a nte roposte r i o r t ra n s l a t i o n o f t h e t h o r a c i c c a g e a n d a g a i n i d e n t ify t h e d i re ct i o n o f l ea st res ista n ce .
5.
Pos i t i o n t h e t h o r a c i c c a g e away f ro m t h e i d e n t i f i e d rota ti o n a l , left. r i g ht, a nterior, a n d poste r i o r ba r r i e rs i n s u c h a way t h a t you t h a t fee l t h e l east a m o u n t of t e n s i o n betwe e n yo u r two h a n d s . T h i s se n s a t i o n i s t h e p o i n t of b a l a n ce ( b a l a n ced l i g a m e n tous t e n s i o n a n d/o r myofas c i a l n e u tra l ) .
6.
H o l d t h e c h est i n t h i s p o s i t i o n of b a l a nce a n d p a t i e n t l y w a i t . After seco n d s t o 1 to
2 m i n utes, yo u w i l l fee l a f u rt h e r re l a xa t i o n of the p at i e n t 's t h o r a c i c c a g e , a pa l pa b l e n e u ro m u sc u l os k ele ta l re l e ase . T h e g o a l of t h e p roce d u re i s a d e c rease i n TA RT
C h a pter 22 • T h e P at i e n t w i t h Pa r k i n so n 's D i s ease
FIG U R E 22.S
7.
339
C r o s s p i s iform (Texas twi st) HVLA to t r e a t T5 f l e x e d , s i d e b e n t l e ft, rotated l eft .
As the release occu rs, m a i n ta i n t h e p a t i e n t 's t h o ra c i c c a g e i n t h e p os i t i o n of b a l a n ce a n d repeat steps 2 to 6 u n t i l t h e m ost sym m etric t h o r a c i c c a g e m o t i o n is obta i n e d .
8.
W h e n t h e p roced u re is co m p l ete, rea ssess t h e m o t i o n of t h e t h o ra c i c c a g e .
Cross Pisiform or "Texas Twist" (HVLA) (Fig. 22.8) T h i s proced u re m a y be e m p l oyed to tre a t type II t h o r a c i c d y s f u n c t i o n from the leve l o f T3 to t h e t h orac o l u m b a r j u nctio n . Bec a u s e there i s a h i gh i n c i d e nce o f osteoporos is a n d verte b r a l c o m press ion
fra ct u re i n the P D patient p o p u l a tion , bone density scre e n i ng may b e con s i d ered a
r e a so n a b l e p reca u t i o n . T here appears to be a h i g he r c o r r e l a t i o n between c a l c i u m l o s s a nd d u ra t i o n of t h e d i sease t h a n the t r a d ition a l age-sev e r i t y rel a ti o n s h i p . Cross pi s i form HVLA i s a s i m p l e proced u re t h a t is easy to accomp l i s h b u t pres e n ts with nota b l e l i m i t a t i o n s . I f sign i fica n t k y p h os i s is present, t h e p a t i e n t will b e u n a ble to l i e prone a s r e q u i red
without p l a c i ng u nd e s i r a b l e stress u po n t h e c e r v i
c o t h o r a c i c j u nction. Bec a u s e t h e p roce d u re comp resses the p a t i e n t's t h o r a c i c cage a ga i nst t h e t r e a t m e n t ta b l e, t he re i s the pos s i b i l i ty o f r i b fra c t u re if excessive fo rce i s used . T h i s proced u r e is effe c t i v e o n l y fo r fl exed d ysfu ncti o n s and conseq u e n t l y c a n p a i n fu l l y aggra v a te a n e x t e n d e d type I I dysfu n c t i o n .
Pa t i e n r po s i t i o n : p ro n e . P h ysici a n positio n : s ta n d i n g o n e i t h e r s i d e o f t h e t a b l e
.
Proce d u re ( E x a m p l e : T5 F l e x e d , S i d e B e n t Left, Rotated Left) 1.
S ta n d i n g o n t h e p a t i e n t 's right s i d e , p l ace t h e hypot h e n a r e m i n e n ce ( p i s i f o r m b o n e ) of yo u r l eft h a n d over t h e l eft t r a n sverse p rocess of T 5 i n s u c h a w a y t h a t you r f i n g e r s a re p o i nted cep h a l a d .
340 2.
Sect i o n I I I • C l i n i ca l Co n d it i o n s P l ace t h e h y p ot h e n a r e m i n en ce ( p i s i form bone) o f yo u r r i g h t h a n d i n contact with t h e r i g h t tra nsverse p ro cess of T6 i n s u c h a w a y t h a t yo u r f i n g e rs a re p o i nted ca u d a l ly
3.
I n t ro d u ce s i d e b e n d i n g to t h e ri g h t by t ra n s l at i n g T5 l a t e ra l l y to t h e l eft T h i s is acco m p l i s h e d by a p p l y i n g a ce p h a l a d and l eft l a te r a l force over t h e l eft t r a n sverse p ro cess of T 5 w i t h yo u r l eft h a n d .
4.
O bta i n rota t i o n a n d exte n s i o n by a p p l y i n g a ve n t r a l fo rce towa rd t h e t a b l e w i t h
5.
W h e n t h e exte n s i o n , s i d e b e n d i n g , a n d rotation barriers have been specifica l l y engaged,
both of yo u r h a n d s . apply the f i n a l co rredive fo rce as a m i n i m a l q u ick h i g h -velocity, l ow-a m p l itude cep h a l a d t h r ust with yo u r l e ft h a n d u po n t h e left tra nsverse p rocess of T 5 , acco m p a n ied by
a
c a u d a d h o l d i n g fo rce with yo u r right h a n d u po n the rig ht t ra n sverse p rocess of T6. 6.
When t h e proced u re i s c o m p l ete, reassess t h e m o t i o n betwe e n T5 and T6 .
Psoas Muscle Energy, Patient Prone
T h i s procedure is employed to stretch preverre b r a l h i p flexors, p a rticu l a rly psoas m a j o r. It i n c re a se s hip exte n s i o n a nd red u ces com pressive fo rces a t the l u m bosacra l j u nc t i o n . (See the procedu re d escripti o n in Cha pter 26 a n d Figure 2 6 . 2 2 . ) Psoas Release (Balanced Ligamen tous Tension) (Fig. 22. 9)
Bec a u se some d i sease i s so severe that p a tients c a n n o t l ie d own, a seated treatm en t protocol i s i n c l u d e d . Patient p os i t i o n : seate d , arms d raped over the p h ysi c i a n s s h o u l d ers. Phys i c i a n posit i o n : sta n d i ng . '
P roced u re 1.
P l ace yo u r t h u m b s a b ove t h e i l i a c c rests i n t h e postero l atera l co m p a rt m e n t a dj a c e n t to t h e q u a d ra t u s l u m bo r u m 's m ost latera l e d g e .
FIGURE 22.9
T h i s p roced u re m a y b e e m p l oy e d to red uce psoas te n s i o n f o r p a t i e nts whose d i sease p rocess i s s o severe that t h ey c a n n o t l i e d o w n .
341
C h a pter 22 • T h e P a t i e n t w i t h P a r k i n s o n 's D i s e a s e 2.
W i t h t h e th u m b p a d s faCi n g m e d i a l l y a n d poste r i o r ly w i t h t h e in ternal e d g e of t h e q u a d ra t u s l u m b o r u m a l o n g t h e p a d s u rface, a l l ow t h e p a t i e n t to l e a n f o rwa rd, flex ing the tru n k , re l a x i n g t h e ab d o m i n a l m u s c l e s , and a l l ow i n g t h e t h u m bs to m ove m o re m e d i a l l y a n d s o m e w h a t ca u d a l l y
3.
R es p i ratory e xc u rs i o n faci l itates t h e p rocess, w i t h re l a x a t i o n o n e x h a l a t i o n .
4.
R e peat t h e p rocess u n t i l t h e t i p of t h e t h u m b c o m e s i n to c o n t a ct w i t h t h e p s oa s .
5.
I n d i rect f i n e-t u n i n g of t h e p o s i t i o n ta k e s p l a c e , a n d p s o a s t o n e i s d e c reased w i t h
6.
Pass ive s i d e b e n d i n g a n d rotat i o n c a n be a d d e d a s t h e patie nt's a r m s a re s u s p e n d e d
2 to 5 e n s u i n g ex ha l a t i o n s . a c ross t h e p h y s i ci a n 's s h o u l d e rs w i t h d i g its i n te r l oc k e d o r i n t e r l a ce d b e h i n d t h e p h ys i c i a n 's neck . B oth s i d es a re treated to restore sym m et ry a n d to n e .
7 . W h e n t h e p rocedu re i s co m p l e te, reassess p s o a s t e n s i o n (h i p exte n s i o n )
Referen ces L We l l s M R , G i a n r i n o to S , D ' Aga te D , et aL Sta n d a rd os teopa t h i c m a n ip u l a ti ve trea t m e n t a c u te l y i m p ro v e s g a i t per fo r m a nce i n p a t i e n t s w i t h P a r k i n s o n 's d is e a s e . J A m O s te o pa t h Assoc 1 9 9 9 ; 9 9 : 92-9 8 .
2 . K a n d e l ER, Sc h wa rtz J H , J e s s e l l TM . P r i n c i p l e s o f N e u r o s c i e n c e . 4 t h e d . New Yor k : McGraw Hi l l , 2000.
3 . S m u t n )' CJ , We l l s W R , Bosa k A . O s te o pa t h i c c o n s id e r a ti o ns i n Park i n s o n 's d i s e a s e .
J
Am
Os te o p a t h Assoc 1 9 9 8 ; 9 8 : 3 8 9-EOA.
4. We l l s M R , McCa r t), CL, S mu tn y CJ , e t aL Osteo p a t h i c ma n i p u l a t i o n in t h e m a n a ge m e n t of P a r k i n so n 's d i s e a s e : pre l i m i n a r y fi n d i n g s .
i ng
it b s t ra c ts j .
J
A m Osreo p a t h Assoc 2 0 0 0 ; 1 00 : 5 2 1 -EOA lmeet
5 . Ri v e r a - M a r t i n e z S , We l l s M R , Ca p o b i a n c o J D . A retrospec t i ve s r u d y o f c ra n i a l stra i n patterns i n p a r i e n ts with i d i o p a r h i c P a r k i n s o n 's d is e a s e . J Am O s t e o p a th Assoc 2 0 0 2 ; 1 0 2 : 4 1 7--4 2 2 . 6 . Le v i n e C B , F a h r b a c h K R , S i de r o w f A D , e t a L D i agnosis a n d Tre a tme n t o f P a r k i n s o n 's D i se a s e : A S y s t e m a tic R e v i e w o f t ft e L i tera t u r e . A g e n c y fo r H e a l thc a r e R e s e a rc h a nd Q u a l i ty p u b l i c a r i o n 0 3 - E0 4 0 . R oc k v i l l e , M D : U S D epa r t ment of Hea l t h a n d Human S e rvices, J u ne 2 0 0 3 . 7. Te t r u d ] \'iI. H i g h l i g h t s o f t h e 8 t h I n te r n a tio n a l C o n g ress of P a r k i n s o n 's D i se a s e a n d 1vl o v e m e n r D i s o r d e rs
( S u n n y va l e ,
Ca l i fo rn i a ; T h e P a r k i n s o n 's
I n s t i t u re ; P o r to l a
Va ll e y,
Ca l i fornia ; D i recto r, M o v e m e n r Diso rders Tre a tment C e n te r ) . R o m e , Jta l y, J u n e 1 3- 1 7 , 2 0 0 4 . 8 . H a u se r R A . C o n ference r e p o r t . H i g h l ig h ts o f t h e 8 th I n te r n a t i o n a l Co ngre s s o f P a r k i n s o n 's D i sease a n d Move m e n t D i so r d e r s ( S u n n y v a l e , Ca l i fo r n i a ; T h e P a r k i nson 's I n s t i t u te ; P o r t o l a Va l le y, C a l i fo r n i a ; D i rector, M o v e m e n t D i s o r d e r s Tre a t m e n r C e n ter ) . Rome, I ra ly, J u n e 1 3- 1 7, 2 0 0 4 . Posted o n M e d s c a p e J u l y 8 , 2 0 0 4 .
J a v o y - Ag i d F, et a l . A re d o p a m i n e rgic n e u ro n s sel ectively v u l nera b l e to Pa rk i n s o n 's d i s e a se ? A d v N e u r o l 1 9 9 3 ; 6 0 : 1 4 8 - 1 6 4 . 1 0 . D e a n e K H O, E l l i s H i l i C, Pl a y ford E D , er a L O c c u pa ri o n a l t ftera p y for P a r k i n s o n 's d i sease. Tft e Coc h ra n e Co l l a b o ra ti o n , Coc ft r a n e R e v A bs t r a c r 2 0 04 . Posted o n M ed s c a p e J u l y ] , 2 0 0 4 ; d a te of m os t rec e n t s u b s ta n t i v e a m e n d m e n t , Fe b r u a ry 2 7 , 2 0 0 1. 1 1 . B e r c h o u R C . Ma x i m i z i ng t h e be n e f i ts o f p h a r m a c o th e ra py i n Pa r k i n s o n 's d i s ea s e . 9 . A g i d Y, R u b e rg M,
P h a r m a c o t h e r a p y 2 0 0 0 ; 2 0 ( 1 Pt 2 ) : 3 35--4 25 [ r ev i e w ] . 1 2 . D o d e l R C , S i n g e r M , K o h n e - Vo l l a n d R, et a L T h e eco n o m i c i m p a c t of P a r k i n so n 's d i s e a s e . P h a r m a c oeco n o m i cs 1 9 9 8 ; 1 4 : 2 99-3 1 2 .
1 3 . Sc a nd a l i s TA , B o s a k A , Be r l i n e r ] C , e r a L R e s ista nce r ra i n i n g a nd g a i t f u n c t i o n i n p a t i e n ts w i t h P a r k i n s o n 's d i se a s e . Am J P h y s Med R eh a b i ! 2 0 0 1 ; 8 0 : 3 8 --4 3 ; q u i z 44-4 6 . 1 4 . D u v o i s i n R C , M a r s d e n CD . N o t e o n t h e sco l i osis o f P a r k i n s o n i s m . J N e u rol Ne u r o s u rg P s y c h i a try 1 9 7 5 ;3 8 : 7 8 7- 7 9 3 . 1 5 . J o h nston \'ill, Fried m a n H D . Fun c t i o n a l Method s : A M a n u a l f o r P a l p a to r y S k i l l D e v e l o p m e n t i n Osteo pa t h ic Exa m i n a tion a n d M a n ipu lation of M o tor F u nct i o n . In d i a n a p o l is, I N : A m e r i ca n Ac a d e m y of O s teo p a t h y, 1 9 9 4 .
1 6 . M i y a sa k i
JM,
M a r t i n W, S u c hower s k y 0 , et 3 1 . Practice p a ra mete r : I n i t i a t i o n o f tre a t m e nt for
A l l e v i d e n c e - b a se d re v i ew. R ep o r t of t h e Q u a l i ry S ra n d a r d s S u bc o m m ittee o f r h e A m e r i c a n A c a d e m y o f N e u r o l ogy. N e u r o l og)' 2 0 0 2 ; 5 8 : 1 1 - 1 7 . P a r k i n s o n 's
disease:
CHAPTER
The Patient with Larson's Syndrome: Functional Vasomotor Hemiparesthesia Syndrome Frank C. Walton, Sr.
INTRODUCTION Norman J. Larson described a c lini ca l presentation of
p a tients with a unila tera l
complex of symptoms and p h ys i cal changes associated with discrete parave r tebral
somatic d ys f un ction
of the ipsil a te r a l upper thoracic area. He went on to describe the response of th ese patients to osteop a t h i c m an ipulat i ve treatment (OMT)
directed to the upper thoracic somatic dysfunction.) Patients with similar clinical findings, somatic correlation, and response to osteopathic manipulative treatment have been observed by other osteopathic clinicians.2-7
CLINICAL PRESENTATION The presen t i n g clinical histo ry
ing one-half of the p a tie n t
'
S
t y pically includes subj ecti ve complaints involv
body, with desc ript ion of senso r y disturbance, dyses
thesia, pain, and physical c h a n ges in periph eral somatic tissues. Some patients
have the sa me clinical com p l a i n ts and findings, but with variations of pattern distributio n of s y mpto ms and findings, as discussed elsewhere in this chapter
.
The sensory disturbance may include numbness,
tingling, ti s s u e
or
limb
heavi n ess inaccurate se ns a ti on of local heat, or inaccurate sens a tion of local cold. ,
Some patients co mp la i n of diminished limb position awareness (proprioception) and disturbed p e rcept i o n of body pan position and motion tracking. 342
Chapter 23 • The Patient with Larso n's S y n dro m e
343
The dysest hesia m a y include the ski n or d e eper tissues, a sensation of crawling, tightness , hyperse nsitiv ity to l ight touch, hypersensitivity to minimal compression or palpation pressure, and a bnormal sensitivity to ha rmless levels of exposure to rad i a nt heat or sunlight. The patient m a y descr i b e a n unpleasant awareness of non spec ific stiffness of the soft tissues of the a ffected area or of remarka ble resistance to comp liance with a ctive or passive mot i o n of joi nts in the affected areas. The pa in compla int commonly includes a burn i ng pain a nd m a y be d escr i bed as noxious dys-ease, a c h e, sharp pain, or dull pain. The pain may be described a s steady, varia ble, o r shooting along typica l n eurotom e pa tterns o r portions o f n erve d istri buti ons. Ho wever, especially if the c o n d ition bec omes well esta b l i shed, the pain may be descri bed in other patterns, such a s affecting the upper extremity from the mid fore arm d ista l l y, including all of the hand a nd fingers (sometimes cli n i cally d escri bed a s glovel ike) or a ll of the lower extremity from just b elow the knee or just a bove the ankle d istally to includ e a ll of the foot a nd toes. The structures d escri bed a s painful may includ e some or a ll of the skin , su bcutane ous fasc i a , m us cle, joint, or b o n e c ompo nents. Pati ents' free h a nd images of symptom patterns a n d d istri but i o n (num b ness, tin gling, cold sensat i o n , hot sensation, a n d v a r i ous qualities of pa in) drawn o n body parts paper ha v e been found to be rema rka bly useful for defi n ing and following subject i ve d escriptions.8 It is remarka b l e how well s u bjective symptom pattern changes (dra wings) can be c orrelated with o bjective f i nd ings of perceived cha nges in the associated upper thora cic somatic dysfunction. Objective physical changes in tissues i n v o lving the a ffected peripheral and extremity a reas include se veral esp e c i a ll y consistent elements. Skin of t h e area of grea test su bjective compla int will show early erythema. The ski n will begin to manifest increase d turgo r or intra cellular swelling, slight initi a lly a n d gre ater w ith time. Typically, no a ctual extracellular edema is prese nt unless later a ssocia ted with toxic cha nges, n ecrotic cha nges, or infection in c ompromised tissue. This tissue turgor can be a pprec i ated by pa l pation of the a ffected skin a nd associated subcu taneous tissue. Longst a n ding peripheral manifestati o ns beg i n to show chronic tissue changes. F i brotic cha nges t h i cken the skin and und erlying tissues, making them h a rder a n d sti l l less compl i a nt to a ctiv e moveme nt a nd pa ssive moveme nt testing. Compromise of mi croc irculation i n the tissues of t h e a ffected area is visi ble i n the skin. Rapid capillary blanching a nd d ela yed refilli ng are e v i d ent. As the c o n d i tion becomes esta blished , espec i a l l y if it becomes chro nic, d iscoloration of the skin (greater i n t h e more distal areas) that ma y suggest sl ight to increased cyanosis d e v elops. In a ra re a n d a typically drama t i c presentati on, some pati ents exhi b i t a remarka ble skin tissue structura l disruption, deteri oration, and e v e n superfi cial ra wness and sloughing that may appea r early or a fter the condit i o n progresses. Clinical experience suggests t h a t the sam e cha nges are occurring in other ti ssues not visible under the ski n . Thermographic studies have bee n used to d o cume nt and e v a luate cha nges in skin and loca l tissue tempera ture a nd circulation i n the par a v erte bral area, trunk, a n d extremities.9 Swe lling of d eeper c o nnectiv e tissues, fascia, a n d muscles develops as the untreated or in effective l y tre ated clinical conditi o n matures. As a conseque n c e of the ceJlula r swelling, c ompl i a nc e of t h e involve d ti ssues d ecreases. The pati e n t recognizes t h e d ecreased co mpli a nce as subject i v e compl a i nts and the clin i cian can a ppre c i a te i t with physic a l examinati on. When the musc les are inv olved , t h e i r girth i niti a lly increases, t h e t i ssue y ield t o pressure decrea ses, v o luntary active movement is compromi sed, and pass i v e quality o f motion a nd range of
344
Section III • Clinical Conditions
motion are diminished. If it is not treated e ffecti vel y, prolonged pathology will be gin to manifest as muscle atrophy and fibrotic scar ring changes. S welling of the connective tissues of joints, ligaments, and tendons begins to cause dimin ished compliance to motion and stretch, re s u lt ing in further reduced active and passive movement.
If the condition remains chronically present, additional trophic changes become evident in the affected tissues. These appear to be associated with inadequate cir culation, ox ygenation, nutrition, and toxin and waste product r e moval The phys .
ical changes in the tissues also sugg est additional changes expla inable by compro mised cell health, resulting from deprivation of ne urotrophic protein substances (discussed later in the chapter). There is a correlati on of objective findings in the tissues and structures where
subjective clinical complaints manifest. Physical exa mination, assessing for tender ness to light and firm palpation, pain manifestations on tissue manipulation and joint motion te sting, and tissue swelling and/or ed e m a offer valuable information. Trad itional testing for confirmation of light touch, pinprick, and two-point dis crimination sensation status are useful. Soft tissue assessm ent of swelling compli ,
ance to compression, and subtle compliance to myofascial g uiding procedures
allows interpretation of the st a tus of the vitality of the tissues.
Distribution Patterns Other Than Full Half of the Body VariatiollS of the clinical presentation may include other distributions of symptoms and objective f indings that may not include one entire side of the body. In any of these variations, however, there typ i cal ly is paravertebral somatic dysfunc tion in t he ipsilateral up p er thoracic region. On e f airly common variation includes only one upper q uad rant of the body, including half of the head, face, neck, and upper torso and inc l uding the i p si lateral upper extremity. Obvious clinical complaints and findings may be limit ed to some or all of the upper extremity, with m uch-red uced symptoms and findings in the remainder of the upper ext r emity o r up p er q ua drant
.
Less
frequently, only the more distal portions of both extremities on half of the body may be affected. The clinica l presentation may include only a lower q uad rant of the body,
including half of the lower torso and the ipsilateral lower extremity. There may be clinical complaints and findings limited to some or all of the lower extremity, with reduced symptoms and findings in the remainder of the lower qua d rant, hip, or lower extremity. Occasionally, manifestations on both sides of the body are observed. The pres entation may involve essentially all of the bod y distal to the cervicothoracic junc tion of the torso. When this is present it is likel y that the predominance of the ,
clinical f indings will be limited to the extremities, with the torso less affected. A pattern affecting onl y bilateral upper extremities does occur A pattern affecting .
only bilateral lower extremities is less common. Not a common presentation but more freq uent with increased severity and dura tion of the condition is that a patient may also complain of head and cranial nerve unilateral sensory ch anges (vision, pupil hearing, tinnitus, taste, smell, and/or face ,
skin sensation), secretory functiona l changes (disturbed lacrimation, disturbed nasal secretion), and/or motor functional changes (dimi n ished paraorbita l and eyelid muscle tone and strength diminished paraoral muscle tone and strength, dimin ,
ished tongue extension strength). When these variations are present, there typically
Chapter 23 • T h e Pat i e n t w i t h Larso n 's S y ndro m e
345
is a distinct find ing of paravertebral somatic d ysfunct i o n in the ipsilateral higher upper t h o racic level. These head and crani al manifestati ons may mimic facial palsy and must be d i fferentiated from shingles and herpes. Somatic Dysfunction of the Upper Thoracic Spine and Upper Ribs Somat i c d ysfunction fi n d i ngs in t h e upper thoracic area are spec ific to this c l i nical conditi o n. Somatic d ysfunct i on a n d paravertebral soft tissue reactivity fin d ings are typically present at T2, T3, or T4 on the s i d e of the peripheral man ifestations. There are essen t ia l l y al ways additional costotransverse soft tissue findings a n d ri b somati c d ysfun ctions assoc iated with the parave rte bral thorac i c f i ndings. Less common are paraverte bral findings at the level of Tl, although these are more l ikely if the peripheral manifestations i n clude t h e head or neck. Somat i c d y sfunct i o n the level of T5, although also less commonly encountered, is most l ikely if the periph eral manifestati ons i n clude only the lower extremity. The parave rte bral soft tissue changes of thoracic somat i c d y sfunct i o n and the rib and costotransv erse fin d i ngs are easily identified, but the soft tissu e find i ngs commo nly are not as i ntense as mi ght seem consistent with the pro n ounced degree o f t h e peripheral p r esentation. Focal pressu re dur i ng palpati o n of t h e dysfuncti onal para v e rte bral and costotransve rse tissues commonly repro duces the patient's pain and other subjecti v e d ysesthesias in the area o f the peri pheral comp l aint. A dramatic confirmation of these upper thoracic somatic dysfunctions and associated rib somat i c dysfunctions' relationships to the peripheral distur banc es is tile consistency, d egree, and rapidity of response of the peripheral disturbances whe n OMT is administered e ffectively to alle v i ate the somatic d ysfunction. Even co n d it i ons that ha ve manifested for extende d periods respon d impressively to OMT, often sho wing d istinct improvement as quickly as immediately after a sin gle treatment. Conti nued i mprov ement of periph eral find i ngs and symptoms can be identified to correlate with the degree of i m prov ement of the somatic dysfunc tion after initial and subsequent OMT. The find i ngs of upper thoracic and upper rib somatic dysfunction may be d e fined using physical examination, allowing interpretatio n of their role in the clinical pres entation and for the appropriate treatment approach needed. Using the mnemonic TART (tenderness, asymmetry, range or quality of m oti on, and tissue texture changes) when descr i bing the paravertebral and costotransverse find ings all ows for an organized method of description for somatic d ysfuncti ons.lo Palpatory tissue assessment and defined moti on testing findings of posterior vertebral, costotrans verse, and rib tissues and structures pro v ide the desc riptions nee d e d to define and name somatic d ysfuncti on. The findings associated w ith the clinical conditi o n described in this chapter commonly include characteristics that are d ifferent from more typical parave rtebral somatic dysfunction. I I Ten d e r n ess (t) as an element of somatic d ysfunction as d e l ineated by palpati on and pressure applie d to tissue is typi cally present within the skin and soft tissues overlying t he posterior t h orac i c skeletal elements lateral to the spinous process and supe rficial to the transverse process. In the presentati on of Larson's syndrome, sig nificant tendern ess may man i fest deeper in the paraverte bral soft tissues than is the case w i th m ore typical somat i c dysfunction. Palpation of the tissues in this p resen tat i on may d eli n eate the area of deep dull ache (as d escribe d by the patient) in deep tissues in the areas of the costotransve rse junctio n and the posteri or rib tuberc l e. Tenderness commonly is remarka ble and may be found as d e ep as the ligame nts of the costotransverse joint capsule.
346
Section III • Clinical Conditions
A symme t ry (a) refers to the descripti on of the tissues and structu res on either side of the mi dline of the involved ve rtebral segments. These findings may be vis ible or palpabl e as the foll owing changes: • Skin: col or, texture , temperature, capillary circulation, congestion , edema,
tur
gor, and tro phic character • Un derly i n g so ft
tissue (including subcuta neous , fa sci a l , muscular, ligamentou s,
te n dinous , ly m phatic , and vascular): f ulln ess , swe lling, congestion , edema, ten
sion, spasm, turgor, and trophic character •
Par a vertebral bony elements: change of pos i tion in relati on to original neutral
n ormal position or to ot her bony elements (see discussion of rotation and side be nding later in the ch ap ter) • Neck, torso, spine, or other structures: lateral curvature, scoliosis , or focal a ngul at
i on
Description of vertebral and p a raverte bral bony asy mmetry includes definition of vertebral positiona l c h a n ges describe d se parately from the description of motion freedom and restr i ction of motion. (See the descr i ptio n of range of motion and
quality of motion.) If there is a significant sustaine d rotated or side-bent position of the involved vertebral segm e nts , there will be an observable d i fference on each side of the midl in e consistent with mechanical positional changes of the vertebral e leme nts. These position changes may in cl ude the following: • P oste r i or positioning of the transverse process on the side of susta i ned rotation,
th u s a more poste rior prominence of this transverse process than of the COll tra la teral tra nsverse process (rota ted posterior dysf u nction ) • A nterior positioning of the transv erse process on t h e side opposite to the sus
tained rotation, thus
a
more anterior ( deeper) position of the transverse process
on the side opposite the rotation (rotated anterior dysfunction) • Ca ud ad positioning of the transverse process and approximation to the trans
verse process of the next lower ve r te bra on the side of sustaine d side bending, thus a crowding approximation of the transverse processes on the side of side bending (side-bent toward dysfu ncti on) • Cephalad positioning of the transverse process and movement away from
the
transverse process of the next lower verte bra on the side opposite the sustain ed side bending , thus a separat i on or widen ing of the space between the transverse processes on the side o p pos i te the side bending (side bent away from dysfunction) . •
Com b i n at ion positioning of the transverse process or processes as determined by sustained rotated and side-bent positional changed elements that may be pro duced by or d uri ng the developmen t o f th e so m a ti c dysfunction, the presence or a bsence of flexed or exten ded position or forces affecting the pattern of com bi
nations of motion and positioning When somatic dysfunction is present at a thoracic verte bral leve l , th ere typicall y is manifest definable altered position and motion within the normal range of motion of the affected vertebra. II The dysfunctional sustained position is poorly yielding to pas sive motion testi n g and may result in loss of motion or significant compromise of quality of motion. The dysfunction a l position is typically sign ificantly distant from the normal neutral point. The dysfunctional pos ition may be a nywhere within the normal range of motion, however, from an extreme to essential ly the normalnelltral position.
There may be
no
ske letal or vertebra I asymmetry. O ther disturbances of ph ysi
cal findings and functional ch an ges may be evident without d isti nct rotated and/or s i de-be nt c hange s , that is, no clearly posterior transverse process on the side of the somatic dysfu nction . This is poss i b le even w ith
a
d is ti nc t alteration of the pattern,
Chapter 23 • T h e Pat i ent with Larso n's Syn d r o m e
347
ra nge, or quality o f rotation and/or o b v i ous abnormality of the so ft tissue fi n d i ngs . Careful attention should be di r e cted to eval u a ting the possible role of a visceroso matic mechanism in the production of the ori ginal somatic dysfunction, its rec ur rence, or its perp e tuation. (See Cha p te r 5.)
Range and Quality of Motion in Vertebral Somatic Dysfunction
R a nge ( r) and quality of motion of the vertebral segments and spinal regions are assessed a n d descri bed in terms of somatic dysfunctions as a part of the physical
ex a mi nati on of the p a r a vertebral are a. R egi ona l motion and individual vertebral segm ental motion should exhibit normal and full range of motion in e a ch of the three primary motions. The three primary motions of the ve r te b r ae include flexion a n d extension (forward and backward ben d ing ) , rota tion, and side ben d i ng . Various motions a n d motion pa tterns of the verte brae commonly include combi natio ns of th ese primary motions. They must be cons i d ered as b oth single and combined motions in descriptions of normal and abnormal motions of th e verte brae. Other lesser motions that may be sign ific ant in d e ter mi ning the character and clinical im por t of s o ma t ic d ysfunctio n are also sometimes d esc r i bed . These lesser motions are not discussed in this chapter but may be r e v ie wed in other writings. Normal range of mot i o n is e xpec ted for each of the specific movements of the v erte bral segments, including symmetric rotation and side b e n di ng . When the range is reduced (or less frequently, increased) toward one or both s i d es, notation
is tak en . An assessment is made to determine whether the cha nge in motion range is r e l a t ed to ana tomic bony or ligamentolls c h ang es or to soft tissue physical and functional changes. Muscular contraction and tension changes a nd effects of nerve input to motor function are assessed. Muscular effects and the effects of other soft tissues may produce alteration of both r ange of motion and quality of motion or only of q u al i ty of moti o n. In the somatic dysfunctions related to Larson's syndrome, the motion change may
be a less co m m on type. The motion may be compromised in sllch a way that the bony element (transverse process, spinous process, fa cets, r i b) position remains near the normal, neutral, resting position, with a definable resistance to movement of the element during active motion effort and passive motion test ing. This distinct loss of range of m oti o n and position held near the neutral position, alone or combined with oth er quality of motion changes, may be a reason that OMT directed to the somatic dysfunctions typically found i n La rson's syndrome are likely to be most effec ti ve if they specifically include emphasis on vertebral-rib element mobilization proced ures,
in particular in cluding high-velocity, low-amplitude (HVLA) procedures. Range and Quality of Motion in Rib Somatic Dysfunction Range of motion, quality of motion, and asymmetry of t he ribs as they relate to th e vertebtal column, to the sternum and costosternal e l eme n ts , to the other ribs, and to the diaphragm a n d abdominal wall are assessed and defined as a part of the
physic a l exa mination of structural a spects of somatic d ysfunctions. The upper five ribs a re i m po rtant in this discussion. Ribs in general terms move with i n spir ation, expiration, an d mechanical movements of the vertebral units and thorax. Ribs exhibit motion patt e rns i n cl u d in g the foll o w i ng : •
Upward and downward moveme n t of their most lateral aspect (sometimes named bucket-handle motion)
•
Upwar d and downward movement of the most anterior aspect (somet im es named pump-handle motion)
348
•
Section III • Clinical Conditions
Twist i ng motion of the head of t h e rib at its attachment to the vertebral b ody about an anteromedial to posterol ateral ax i s
•
Upward and downward mo vement of the poster ior tubercle or an gle of t h e rib
an approx i mately side-to-side horizontal axis modulated by t h e li gamen tous attac h ments to the associated vertebrae and accentuated or di minis h e d by
about
an effect of the movement or restriction of movement of the transv erse process •
of the associated verteb rae Small gl iding anterior or posterior movement in a horizontal plane, as the rib moves with the v erteb ral tran sverse process d urin g s pi ne, trunk, and vertebral rotation Normal motion of the ribs is d i rectly influenced by the other stru ctu ra l elements
ad joining and attached to the rib elements. Rib motion may like w i se d i rec tl y influ ence the motions of the other st ructural el ements.
When somatic dysfunction invclves a rib, there typically is a definable altered position (held in an in hale d , inspired, elevated position or
an
exhal ed, expired,
depressed position ) and al tered motion within the normal range of motion o f the a ffected rib . L3,l4 The dys fun ctional sustained position yields poo rly to passi ve motion testing, with loss of motion and/or significant compromise of quality of motion. The dysfunctional position is typ ically significantly distant from t h e normal n e u tral point; however, the dysfunctional position may be anywhere within the normal range of motion from the extreme to essent iall y the normal neutral position. Alteration of rib motion may refl ect a situ ation similar to that sometimes seen in vertebral motion, in w h ich the rib e lement is held at or near the n or ma l neutral position with definable resistance to movement of the rib d uring active motion effort and/or passive motion testi ng. The range of motion may be minimal in one or more directions. A more detailed d iscussion of rib motion, in pa rti c u la r a d i s cussion of the uniqueness of motion patterns of partic u l ar rib pairs at various levels of the rib cage, can be found in other wr i t i ngs . Quality-of-motion assessment of the vertebra and rib may demonstrate normal, smooth active and passive movement throughout the range of motion, normal to
the structures being assessed . Normal qu ality of motion is exp e cted for eac h of the spe ci fic movements of t he vertebral segments, incl u din g symmetry of rotation and side bending. When the quality is altered on one side or both sides, notation is ta ken. If qua lity of motion is altered, this may offer information useful in desc r ib ing abnormal findings .
The altered quality of motion of the somatic dysfunction can be identified from the following characteristics: (1) It can yield resistance to motion throug hout all or most of the range of motion. (2) It can demonstrate resistance to motion that becomes remarkably g reater as the extreme of normal range is approached. (3) It can demon strate resistance that becomes greater as movement approac h es
a
poi nt well b e fore the
anticipated normal end of t h e range of mot ion. Each of these c h aracter istics offers dif ferent information that is useful for clinical interpretation. In the somatic dysfunction tha t is a part of Larson's syndrome, it is common that a distinct resistance is noted very early as passive motion is attempte d in any direction away form the stati c poi nt.
Tissue Texture Changes Changes in soft t issue texture (t) in t h e paraver tebral and rib areas can be assessed by palpation and other physical examinations that allow gatherin g of information and a mea n s of interpretin g the findings. Soft tissue stat us, including skin, fascia, and
su bcuta n eous, vascular, lymphatic, ligame n tous, tendinous, muscular, periarticular, and periosteal tissues, can be appreciated for acute and chronic c h anges . Changes may re flect soft tissue physical , physiol ogi c, and f unct ional status. Acute tissue
Chapter 23 • T h e Pati ent wit h Larson's Syndro me
349
congestion, swelling, edema, metabolic, and toxic changes may be recognizable: Tension changes of muscular contraction, effects of motor nerve input, effects of sen sory nerve feedback and response, and metabolic status may be identified by palpa
tion. Chronic tissue changes, fibrotic changes, and trophic changes may affect tissue
circulation, compliance, and vitality. Soft tissue changes affect movement of the soft
tissues and associated joints, including quality and range of motion. Consideration
should be directed at an effort to determine whether the paravertebral soft tissue findings (reactivity) have characteristics that strongly suggest an underlying viscero somatic reflex etiology. (See Chapter 5.)
Role of the Sympathetic Nervous System Somatic dysfunction in the upper thoracic segmental levels is observed to have an inte gral role in the clinical condition described here as Larson's syndrome . I One pla u si ble ex pla n atio n of this relationship correlates with the observation that the sympathetic autonomic nervous system demonstrates a remarkable concentration of interactive neurons (intermediolateral cell columns) in the cord levels ofTl to T5.15 This suggests a relationship between normal function of the upper thoracic cord segments and nor Ill al sympathetic effects on the related p er i p hera l tissues and structures. A reasonable
extension of this observation would be that a significant disturbance of function of the upper thoracic cord segments can be expected to contribute to an abnormal func tional state of the associated sympathetic nerves, possibly producing an abnormal sympathetic effect on the related peripheral tissues and structures.
The manifestations of upper thoracic somatic dysfunctions and their relation ships to other neurointeractive musculoskeletal and autonomic mechanisms play a ro l e in the v u l n e r a b il i ty to, development of and perpetuation of sympathetically ,
mediated peripheral disturbances. The relationship of p rimary somatic dysfunc tion to the development and accentuation of secondary somatovisceral and reflex peripheral vasomotor disturbances plays a significant role in development of peripheral sympathetic disturbances.16 Original external insult or primary and secondary internal neurologic dysfunction have been demonstrated to contribute to develop m ent of sustained somatic dysfunc tion in the thoracic spinal cord segments that thereafter contribute to the development
of acute and of sustained peripheral vasomotor (sympathetic) disturbances. Other peripheral disturbances are associated with altered nerve stimulation and compromised delivery of neurotrophic proteins and other nerve-transmitted nutritional elements. Osteopathic clinicians and researchers have observed a relationship between upper thoracic spinal cord function or somatic dysfunction and sympathetic function or dysfunction that offers a mechanism to describe a role of the sympathetic nervous system in Larson's s y nd rome •
.
17
This description includes the following:
Spinal cord-level (upper thoracic) somatic dysfunction co n tri buting to distorted functional status of associated sympathetic nervous
•
eleme nts
Distorted input of sympathetic innervation to vascular tissues and to other nerve tissues
•
• •
Altered arterial circulation to l arger peripheral nerves precipitated by distorted sympathetic motor input Altered tissue health of the nerves resulting in distorted nerve impulse transmission Altered target tissue (arteries and other peripheral cells and tissues) response to
nerve impulse input •
Altered trophic status of target tissues (arteries and peripheral cells and tissues) due to lack of neurotrophic substances production, ce n trifug a l movement, and release to tissues
350
Section III • Clinical Conditions
•
Functional d isto r t i on of ne r v e fu n c tion rela ted to com p romised e fficacy in
•
A l tere d tis s u e health o f the nerves resu lting from com prom ised uptake and ret
•
Altered t i s sue heal th of the ne rves r e s u lt i ng in d i s to rted p roduct ion of n euro pep
response to sensory n e u rotransmis s i o n rograd e transfer of nu trie n t and t i s s u e trophic subs tanc es t i d e s and the i r c e n t r i p e tal movement This cascade of effects and e v ents s eem capa b l e of pro d u c i ng the clinical condi t i o n s d i s c u ssed. It remains to be seen whether adequate d ata to resu l t in general accepta n c e of s u ch an explanation can be o b ta i n e d .
Other Clinical Entities Some of the cli nical presentation d iscussed by Larson in his descr i ption of f u nctional vaso motor hemi paresthesia synd rome shares characterist i cs w i th oth e r d esc r i bed con ditions. Specificall y, peripheral causalg ia, reflex sympat h e t i c d ystrophy,
and
Horner's syn drom e can be consid ered. IS Each of these con ditions is attr i b u ted to a distu r bance of funct i o n or anatomic d is r u pt i on of sympathetic nervous e l eme n ts. Non e of t h e se ent i t i e s , as discussed in trad i t i onal me d i cal li terature, ad d ress the potential of spina l cord f u n ctional d i s t urbance as the likely e t i olog y. Correlation has been d rawn by osteopathi c phy s i c ians for a proposed cau sal relationshi p between somatic d ysf u n ction, assoc i a ted d i stur bance of the s y m path etic nervou s s u p ply, an d the symptoms and si gns i n the p e r i pheral somatic s truc t u res.
Osteopathic Manipulative Treatment Effec tive ap plication of
OMT to somatic d ysfunction d e pends u pon accurate d iagnos
tic i nterpretation of the p a ravertebral and rib f i n d ings Treatment must appropriate l y .
ad dress mec hanical, fu nctional, and reflex n eurologic e l ements. Distinct response to i nitial osteopathic manipu lation, as expected, is a confi rmation of accurate diagnosis, correct selection of treatment ap proach, and e ffec tive application of the treatm ent. Of particular note in se l ection of osteopathi c manipulation p roced ures for treat ment of somat i c d y sfunctions as typ i cal ly fou nd in Larson's sy ndro m e is the charac ter of range or qual ity of motion d istu r bances. Distin ct loss of range of motion and position held near the neutra l position alon e or with other qua l ity of motion c hanges may be a reason that OMT directed at the somatic d ysfu nct ions typically fou n d in Larson's synd rome is likely to be mos t effec t i ve if it spec ifically i ncl u d es e mphas is on vertebral and rib elemen t m o b i l i za tion . OMT, par t ic u larl y HVLA and other direct proced u res using low-velocity, h i gh-am pl itude ins istent range-oF-motion forces, also may be needed to facilitate the motion of the d ysfunctional musculoskeletal elements. The patient typicall y reports rap i d reduc tion of symptoms, sometimes
immedi
ate l y after the first effective OMT. Subjective s y m ptoms may remai n abated or may return over a few to seve ral days. Reported i mprovement after one or two treat ments may be as great as complete resolu tion of subjec tive symptoms and may be permanent . It is common that s u bjective symptoms are d ramati ca l l y improved afte r fou r to s i x treatme n ts. T i ss u e p h ysical changes a n d trophic changes in t h e affected per ipheral areas may take su bstanti al l y longer to improve and resolve. This process may be recognizab l e within the first few treatments but may take as long as several mont hs, dep e n d i n g on the d u ration and sever i ty of tissue compromis e . Reassessme n t at 2 t o
3 days after t h e i n i t ial
OMT allows eva l u atio n of the effect
of treatment. Some pati ents have an accentuation of symptom s after treat m e n t, either after an init ial improvement or w i thou t a n y i n i t ial posit i v e response. S u c h accentuation o f symptoms ten d s to be transient, re solv i n g i n 2 4 t o 4 8 h o u rs, a n d
C h a pter 23 • T h e P a t i e n t w i t h La rson's Syndro m e
is n o t typica l afte r su bseq u e n t trea t m e n t s . or
A t 2 to
35 1
3 d a y s a fte r the i ni t i a l t r e a t m e n t
a fter r e g r e s s i o n of a n y s i gn i ficant e x a c e r b a ted s y m p tom s , further O MT can be
done . S y m ptom i mprovement rat h e r than acce n t u a t ion, is t h e e xpected res u l t . A fa i l u re o f s i g n ifi c a n t s u sta i n ed i mprovement a fter initial O MT sho u l d l e a d the
c l i nic i a n to loo k for a nother p r i n c i pa l e t i ology or other u n a d dressed p r i ma ry or sec onda ry e t iol ogies, incl u d i n g med ica l , psycholog i c a l , s o m a t i c , v is cerosoma t i c , struc t u ral, a n d mecha n ic a l c o n d i t ions. O ther med i cal tre a t ment, incl u d i ng prescription a na l gesic , a n t i - i n flamma tory, a nt i biot i c , a n tifu nga l , c a rdia c , ga stro i n testi na l , a n d muscle spasm medica t ions, m a y be necessa ry. P a t i ents respond better i f t h e y a re s u c
cessfu l
i n red uction or e l i m i n a tion o f tob a cco u s a ge and u s e o f caffe ine .
Proce d u res U s i ng O M T i s a m a tter of d osage, a s d i sc u s sed in C h a p t e r 4. T h e fo l l o w i n g p ro ced u r e s are d i rect H VLA proc e d u r e s t h a t La rson com monly u s ed to tre a t u p p e r to mid tho r a c i c som a t i c dysfu n c tion. O nce m a s tere d , they ca n b e q u i ck l y pe rforme d , lend i n g t h e m se lves w e l l t o b u s y c l ini c a l p ra c tice . However, sometimes t h e pa t i e n t Cil n not to l e ra te t h e more a ggressive fo rms o f m a n i p u l a t i o n , a n d p rocedures b a s e d upon i ndi rect p r i nciples, s u c h a s fa c i l i ta te d pos i t iona l re l e a s e or function a l proce dures, il re more a p p rop r i a te . Counte rstra i n , based u pon i n d irect princ i p l es, i s u seful when trea ting the p a t i e n t
w i th
La rso n
s
'
s y nd rome bec a u s e i t is one of t h e f e w forms of manipulation t h a t
specifica l l y a d d resses t h e pa i n compon en t of soma tic dysfu nc tion . Conseq u e ntly, i t may
be e m p loyed a lo n e or i n com b ina tion w i t h d i rect proce d u re s . Cou nterstra i n
proced u res a re u se fu l to a d d ress res i d ua l discomfort tha t occ a s ion a l l y rema i n s after t h e art i c u l a r com po n e n t o f t h e som a t ic d ysfu nction h a s been success fu l l y treated.
The counterstra i n procedures for pos terior ( e le v a ted) and a n te r ior ( d e presse d ) ri b tender poi n ts, d escr i bed l a te r i n t his c h a pte r, a r e partic u l a r l y usefu l . Please note : The proce d u r e s t h a t follow a re examples o f ma n i p u la tive tre a t ment tha t you may wish to e m p loy. The a c t u a l choice of p roce d u re s used s h o u l d b e d e t e r m i n ed by the u n iq u e c i rc u msta nces of e a c h i n d i v i d u a l pa t i ent. Spin ous Process Thrust (HVLA) (Fig.
23. 1)
T h i s p roce d u re i s employed to t re a t u pper thora c i c , Tl upon T2 to T4 upon T5 , type II ve rte b r a l somat i c dys functi o n . ( For d i agnos i s see Cha pter ,
3.)
Patient pos i t i o n : s e a te d . Phys i c i a n pos i tion: s ta n d i ng b e h ind the p a t i e n t . Procedu re ( E xa m p l e : T2 u pon 1 3 , Flex ed, S ide B ent R i g h t , Rotated R i g ht)
1.
P l ace yo u r r i g h t foot u p o n the ta b l e j u st to the r i g h t of the p at i e n t 's p e l v i s .
2.
Rest t h e p a t i e nt's ri g h t a r m u p o n yo u r r i g h t k n e e . Yo u m a y w i s h t o p l a ce a p i l l o w
3.
P l ace yo u r left h a n d u po n t h e p a t i e n t 's l e ft s h o u l d e r w i t h yo u r f i n g e rs d i rected a n te
between t h e p a t i e n t s a x i l l a a n d yo u r k n e e . '
r i o r l y and yo u r th u m b d i recte d m e d i a l ly, c o n t a ct i n g t h e left l ate ra l a s p e ct of the s p i n o u s p rocess of T2 .
4.
H old t h e p a t i e n t 's torso f i r m l y between yo u r l eft h a n d a n d r i g h t k n e e . T h i s w i l l h e l p t o l o ca l i ze f o rces between T 2 a n d T 3 a n d m u st be m a i n t a i n e d t h ro u g h o ut t h e re m a i n d e r o f t h e p roced u re .
5 . I ntrod uce l eft s i d e b e n d i n g betwe e n T 2 a n d T 3 from b e l ow b y l a te r a l l y t ra n s l a t i n g t h e p a t i e n t 's to rso t o t h e ri g h t w i t h yo u r l eft h a n d a n d r i g h t k n ee .
6.
P l ace t h e p a l m o f yo u r r i g h t h a n d , w i t h yo u r f i n g e rs exte n d e d u pw a rd , i n contact with the r i g h t side of t h e p a t i e n t 's n e c k . A l t e r n a tive l y, you m a y wish to p l a ce yo u r r i g h t e l bow u p 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 a n d yo u r r i g h t h a n d o n t o p o f t h e
352
S ecti o n I I I • C l i nical Conditions
FIG U R E 23 . 1
S p i n o u s p rocess t h r u st ( H V LA) for T 2 u p o n n , f l exed, s i d e bent r i g ht, a n d rotated r i g ht .
p a t i e n t 's h e a d , a l l ow i n g yo u r r i g ht f o re a r m t o c o n t a ct t h e r i g h t l a te r a l as pect of t h e i r n e c k . B o t h of t h ese h a n d pos i t i o n s a l l ow you to i n trod u c e fo rces d ow n to T2 u p o n 13 w h i l e s p l i n t i n g the cervi c a l s p i n e .
7.
U s i n g yo u r r i g h t h a n d , i n trod u c e exte n s i o n d o w n t o T 2 u p o n 1 3 by t ra n s l a t i n g the p a t i e n t 's head and n e c k poste r i o r l y. ( F o r exte n d e d dysf u n ct i o n s , fo l l ow t h e same seq u e n ce , but t ra n s l a te the head and n e c k a n t e r i o r l y to i n t rod uce f l e x i o n down to t h e d ysf u n c t i o n a l seg m e n t . )
8 . W i t h yo u r r i g h t h a n d , i n t ro d u ce s i d e b e n d i n g of t h e h e a d a n d n e ck to t h e l eft down to T2 upon 13 .
9 . A g a i n , u s i n g yo u r r i g h t h a n d , I n trod u c e l eft rotat i o n of t h e h e a d a n d n e c k down to T2 u p o n 13 . 1 0 . T h e f i n a l c o r rective fo rce is a H V LA t h r u st tow a rd t h e r i g h t with yo u r l eft t h u m b a g a i n s t t h e l eft s i d e of t h e s p i n o u s p rocess o f T2 , w h i c h i n creases l eft s i d e b e n d i n g , l e f t rota t i o n , a n d exte n s i o n (o r f l ex i o n , s t e p
1 1 .
7)
o f T 2 u p o n 13 .
R e a ssess t h e re l a t i o n s h i p betwe e n T2 a n d n .
Fixed Poin t, Rota tion (HVLA) (Fig.
23.2)
Th is proced u re is employed t o tre a t thoracic (T3 or l o w e r ) type / I s o m a t i c d y sfu nc
tio n . ( Fo r d iagnosis, see p a g e 3 . ) P a t i e n t p o s i t i o n : s e a ted . P h ys i c i a n posi t i o n : s ta n d i n g b e h ind t h e p a t i e m towa r d t h e s i d e o f t h e d ys f u n c t i on .
Chapter 23 • T h e Pat i e n t w i t h La rson's S y n d r o m e
F I G U R E 23.2
353
F i x e d p o i nt, rotat i o n ( H V LA) fo r T5 o n T6, f l e x e d , rotated l eft, s i d e b e n t l eft .
Proced u re ( E xa m p l e : T5 on T6, F lexe d , R otated Left, S i de B e n t Left)
1 .
Flex yo u r l eft h i p a n d k n e e a n d p l a ce yo u r l eft l e g u pon t h e t a b l e so t h a t the f u l l
2.
H ave the pati ent loosely fo l d the arms a c ross the ch est, and with yo u r left a rm rea c h
l e n g t h o f yo u r s h i n i s i n con tact with t h e ta b leto p j u st t o t h e l eft o f t h e p a t i e n t's pelvis u n der the pati ent's left axi l l a , across t h e c h est, a n d u n der the r i g h t ax i l l a so that t h e f i n gers o f you r left h a n d contact t h e patient's r i g h t latera l thorax. F o r fe m a l e patie nts, some practitioners elect to p l ace a sm a l l p i l low between their l eft forea r m and the patient's ch est
3.
W h i l e h o l d i n g t h e p a t i e n t f i r m l y betwe e n yo u r l eft a r m a n d yo u r c h est. i n t ro d u ce exte n s i o n down to a n d i n c l u d i n g T5 on T6 by a p p l y i n g u pwa rd tract i o n w i t h yo u r left a rm . (When t reat i n g a n exte n d e d dysfu n ct i o n , f l ex i o n i s i n t ro d u ced b y fo rwa rd be n d i n g t h e p a t i e n t 's torso d own to a n d i n c l u d i n g T5 on T6 . )
4.
W i t h yo u r r i g h t h a n d , f i r m l y g ra s p t h e s p i n o u s p rocess of T6 betwe e n yo u r t h u m b a n d i n d ex fi n g e r. T h i s i s t h e fixed p o i n t
5.
Use yo u r l e ft a r m t o i n tro d uce s i d e be n d i n g t o t h e r i g h t a n d rota t i o n to t h e r i g h t f r o m a bove down to T5 o n T6 .
6.
A p p l y t h e f i n a l corrective fo rce as a H V LA i n c rease of r i g h t rotation of t h e pat i e n t 's u p p e r to rso with yo u r left a rm a n d h a n d a g a i n st t h e h o l d i n g fo rce of y o u r r i g ht h a n d .
7.
Rea ssess t h e re l a t i o n s h i p between T 5 a n d T6 .
Re verse Rib (HVLA) (Fig. 23.3)
T h i s proce d u re is e m p l oyed to tre a t costo verte b r a l somatic d ysfu n c ti o n t h a t c a n a ffect t h e second, t h i r d , o r fo urth r i bs . The dysfu n c t i on a l r e l a tionsh i p occurs betwee n a t h o racic ve rte bra and the r i b o f the segment b e l ow. Rota t i o n o f the
Section I I I • C l i n i c a l Co n d i t i o n s
3 54
F I G U R E 23.3
R everse r i b ( H V LA) for t r e a t m e n t of d y sf u n ct i o n betw e e n T 1 a n d t h e seco n d r i b o n t h e r i g h t .
ve rte bra c a u ses the i n fe r i or v e r te b r a l h e m i fa c e t to i m p i nge u p o n t h e h e a d o f the r i b . Th i s in t ll rn d r i ves the rib p o s t e r ior, i m p i n g i n g u p o n the costotrans verse a r t i c u l a ti o n a n d c a u s i n g paJpa b J e prominence, t i s s u e text u re c h a nge, a n d te n d e r n ess o v e r the a ngle o f the d y sfu ncti o n a l r i b . T h i s is a secon d a ry d y sfu nc t i o n , the re s u l t o f a pri m a ry t h o r a cic type II verte bra l d ys f u n c t i o n . As s u c h , the prim a ry thoracic dysfunction s h o u l d be trea ted before th i s proce d u re i s e m p l oyed . Pa tient pos i t i o n : sea ted . Physic i a n p o s i t i o n : s t a n d i n g behind t h e pa t i e n t . Proce d u re ( E x a m p l e : Dysf u n ct i o n B et w e e n T 1 a n d t h e Seco n d R i b o n t h e R i g ht) The rib a n g l e is p ro m i n e n t , with tissue text u re cha n g e and resist a n ce to an a ntero i nferior fo rce . 1.
B e g i n by p l a c i n g yo u r left foot u p o n t h e t a b l e J u st to the left of t h e p a t i e n t 's pel v i s .
2.
P l ace t h e pat i e n t 's l e f t a r m o v e r yo u r l eft k n e e . Yo u m a y w i s h to p l a ce a p i l l ow b e twe e n yo u r k n ee a n d t h e p a t i e n t 's a x i l l a .
3 . W i t h yo u r l eft h a n d , reach i n fro n t o f t h e p a t i e n t , g ra s p t h e ri g h t w r i st, a n d p u l l t h e r i g h t a r m a cross t h e l a p to p rotract t h e r i g h t sca p u l a , exposi n g t h e a n g l e of t h e sec o n d ri b . 4.
P l a ce yo u r r i g h t h a n d u p 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
50
t h a t yo u r f i n g e rs a re
d i rected a n teriorly a n d yo u r t h u m b p o i n ts i n f e r i o rly, contact i n g t h e a n g l e of the dys fu n ct i o n a l seco n d r i b . 5 . W ith yo u r r i g h t h a n d a p pl y a n i n fero m e d i a l force, h o l d i n g t h e p a t i e n t 's t o rso fi r m l y betwe e n yo u r r i g h t h a n d a n d l e ft k n e e . T h i s h o l d i n g force m u st be m a i n ta i n e d t h ro u g h o u t t h e re m a i n d e r of t h e p roced u re .
Ch a pter 23 • T h e Pat i e n t w i t h La rso n 's Synd ro m e
355
6 . W i t h yo u r l e f t h a n d , g r a s p t h e l eft s i d e o f t h e p a t i e n t 's h ea d so t h a t yo u r w i d e s p re a d f i n g e rs a re d i rected a n te r i o r l y, co ntact i n g t h e p a t i e n t 's l e f t c h ee k , a n d y o u r t h u m b contacts t h e poste r i o r s k u l l a t o r J ust i n f e r i o r t o t h e exte r n a l o cc i p i ta l p rotu bera n c e .
7.
U s i n g yo u r l eft h a n d , poste r i o r l y tra n s l ate t h e p a t i e n t 's h e a d to stra i g h t e n t h e u p p e r t h o r a c i c a n d c e rv i ca l s p i n e . T h i s s p i n a l posi t i o n i n g m u st be m a i n t a i n e d t h ro u g h o u t t h e re m a i n d e r of t h e p roced u re .
8 . W i t h yo u r l eft h a n d i n t ro d u ce rota t i o n o f t h e h e a d a n d cerv i c a l s p i n e t o t h e l eft u n t i l fo rces a c c u m u l a te at t h e l evel of T 1 .
9 . The f i n a l corrective fo rce is
a
H V LA i n crease i n l eft rotation of t h e p a t i e n t 's h ea d a n d
cervica l s p i n e a g a i nst t h e h o l d i n g force o f yo u r r i g h t t h u m b u p o n t h e secon d r i b a n g l e .
1 0.
Reassess t h e re l a ti o n s h i p betwe e n T 1 a n d t h e seco n d r i b .
Co un terstrain Procedures for Posterior (Ele vated) a n d A n terior (Depressed) Rib Ten der Points
Co u n terstra i n p o i nts a re c o m m o n l y p a i red as poste r i o r a n d a n teri o r p o i n ts . T h i s i s beca u s e t h e y o ften p r e s e n t cli n i ca l l y i n t h i s p a i r e d r e l a t io n s h i p . I f a poste r i o r t e n d er po i n t is i d e n t i fi e d , a s m i g h t be a n ticipa te d over the r i b a n g le i n a pa t i e n t w i t h La rson 's s y n d r o m e , t h e segmenta l l y re l a te d a n te r i o r p o i n t s h o u l d be s o u g h t o u t too. The two p o i n ts s h o u l d t h e n be co m p a re d fo r d egree o f t i s s u e textu re a b n o r m a l i ty
a n d ten d e r n ess, a n d the m o r e s e v e re poi n t s h o u l d be trea ted fi rst. F o l l o w i n g t r e a t m e n t , t h e t r e a t e d po i n t s h o u ld be r e a s sessed , a nd if i t has reso l ve d , t he segmenta l l y
p a i red p o i n t s ho u ld b e reev a l u a ted . I f t h e p a i red po i n t i s a ls o resol ved , the treat me n t proc e d u re i s s u cc es s fu l . If the p a i red p oi n t re m a i n s te n d e r, i t s h o u l d be treat ed. Aga i n , fo l l ow i ng t re a t m e n t , the second point s h o u l d
be reassessed , a n d
if i t h a s
reso lved , t h e segm e n ta ll y p a i red point ( th e fi rst point trea ted ) sho u l d b e reeva l u a t
ed. I f t h e fi rst p o i n t treated re m a i n s reso l ve d , the trea tme n t p roced u re is s u ccessfu l . I f, h o w e v e r, t h e fi rst p o i nt h a s returned , a th i r d segmenta J l y related p o i n t, a n a n te r i o r or p o s t e r i o r t h o ra c i c p o i n t, o r a n a typica l point ( a s d es c r i bed i n v a r i o u s c o u n terstra i n texts ) s h o u l d
be s o u g h t o u t a n d tre a ted . be e n c o u n synd rome ( F i g . 2 3 . 4) a r e d escr i bed h e r e . The
T h e c o u ll te rs t r a i ll p o i n ts a s soci a ted w i th the u pp e r s i x r i b s th a t m a y tered i n t h e p a t i e n t w i t h La rso n 's
poste r i o r ( e l e v a ted ) c o u n te r s tra i n te n d e r p o i n ts are fo u n d b i l a ter a l l y over the p o s
te rio r
rib a ng l e s o f t h e i r respecti ve r i bs . T h e a n ter i o r ( d epressed ) r i b te n d e r p o i nts
a re l oca ted b i l a te r a l l y over the a n te r i o r a spect o f the c h e s t . The te n d e r p o i n t for
ri b i s at i ts cosroste r n a l j u n c t i o n , j u s t i n fer ior to t h e s te r n o c l a v i c u l a r j o i n t . a spect o f t h e seco n d r i b a t t h e m i d cl a v i c u l a r l i n e . T h e ten d e r p o i n t s for t h e t h i rd a n d l o wer r i b s a r e loca ted t h e fi rst
T h e te n d e r po i n t fo r t h e second r i b i s ove r t h e a n te r i o r u p on the r e s p e c t i v e r i b s at the a n teri o r a x i lla r y l i n e .
F I G U R E 23.4
L e ft: Ante r i o r (de p ressed) rib te n d e r p o i nts for r i b s 1 to 6 b i l at e ra l l y over t h e a nt e r i o r a s p ect of t h e c h est. Right: Corres p o n d i n g poste r i o r ( e l evated) cou nte rstra i n te n d e r p o i nts for r i bs 1 to 6, fou n d b i l a tera l l y j u st med i a l to the sca p u l a , ove r t h e poste r i o r rib a n g l e s of t h e i r respective r i b s .
356
Section I I I • C l i n i c a l Co n d i t i o n s
FIGURE 23.5
C o u n t e rstra i n f o r poste r i o r t h i rd r i b t e n d e r p o i n t o n t h e l eft .
Ribs Posterior (Elevated) Tender Points, Patient Seated (Coun terstrain) (Fig. 23. 5)
This p roce d u re i s emp l oyed to red u c e ten d erness a nd p a in a ssociated w it h a co u n ters tra i n te n d e r p o i n t . T h e l oc a tions of t h e respective tend er points a re described p rev io u s l y. The patient m a y be d i a g nosed w h i le sea ted or p r o n e by p a l patio n for
the tissue texture a b n o r m a lity a n d a ssocia ted ten derness i n t h e te nder poin ts. P a t i e n t p o s i t ion: seated on the side of the treatment ta b l e . P h ys i c i a n p o si t i o n :
s t a n d i n g beh ind the p a t i e n t . T h e p hysic i a n monitors t h e te nder point conti n uo u s l y th rougholl t t h e p roced ure,
u sin g l i g h t touch and in term i ttent i n c r ea sed pa l patory p ressure to determine the degree of ti s s u e texture a b no rma l i ry a n d tenderness. As t he patient is pos i t i oned for t he proced u re, the tissue textu re a bnormal iry a nd ten d er n ess a s soc i a ted with the ten der poi n t s hou l d be red uced to no more t h a n 3 0 % of t h a t encou ntered a t t h e o u tset of trea tmen t . This is determ ined by p a lpating the tiss ue text u re a nd a s k i ng the p a ti en t for thei r perception of tenderness to i ncreased palpatory pressure. The d u r ati o n of the proced u r e is c l assi c a l l y 90 secon d s , a l though i f YOLl are ca pa b le of pa l p a t i n g a rel ease,
t his may b e emp loyed as a n i nd ic a t or th a t the trea tment is fi n i shed . Proc ed u re ( E x a m p l e : Poste r i o r Th i rd R i b Te n d e r Po i n t o n t h e Left)
1.
P a l p a t e t h e p oste r i o r t e n d e r p o i n t u p o n t h e a n g l e of t h e th i rd r i b on the l eft w i t h t h e i n d e x f i n g e r o r th u m b o f y o u r l e f t h a n d . T h i s h a n d p l a ce m e n t m u st b e m a i n ta i n e d t h ro u g h o ut 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 associ a ted w i t h t h e t e n d e r p o i n t . By i n creasi n g t h e a m o u n t of d i g i ta l p ressu re a p p l i e d to t h e te n d e r p o i n t , dete r m i n e t h e b a se l i n e seve rity of te n d e r n es s . Ass i g n t h i s level o f t e n d e r n e ss 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 . Te l l t h e p a t i e n t to p l a ce t h e left foot u p o n t h e ta b l e b e n e a t h t h e r i g h t t h i g h . T h e l eft h l p s h o u l d be f u l ly f l e x e d a n d exte r n a l l y rotated w i t h t h e l eft k n e e f l exed . Th e l a t e r a l a s p e c t of t h e l eft t h i g h a n d l e g s h o u l d be i n contact with t h e ta b l et o p .
Chapter 23 • T h e P at i e n t w i t h La rso n 's Sy n d ro m e 4.
357
P l a ce yo u r l eft foot upon t h e table l atera l to t h e p a t i e n t 's l eft h i p .
5 . P l a c e t h e p a t i e n t 's l eft a r m over yo u r l eft t h i g h . P l a c i n g a p i l low betwe e n yo u r t h i g h a n d t h e pat i e n t 's a x i l l a w h i le f l ex i n g t h e pati e n t 's l eft e l bow a n d p l a c i n g t h e fo re a r m u p o n yo u r l eft k n ee wi l l re d u ce p ress u re u p o n t h e b ra c h i a l p l exus a n d re d u ce t h e te n d e ncy to deve l o p p a rest h e s i a s d u ri n g t h e re m a i n d e r of t h e p roced u re
6 . Tra n s l ate t h e p a t i e n t 's u p p e r torso to t h e l eft by s i d e-sh ifti n g yo u r p e l v i s a n d l eft k n e e to the left .
7 . H ave t h e p a t i e n t a l l ow t h e r i g h t a rm t o h a n g over t h e s i d e o f t h e t a b l e b e h i n d them.
8 . W i t h yo u r r i g h t h a n d , g ra s p t h e p a t i e n t 's h e a d a n d i ntro d u c e rota t i o n a n d s i d e b e n d i n g o f t h e c e rv i c a l a n d u p per t h o r a c i c s p i n e to t h e r i g h t . I n t rod uce flex i o n of t h e c e rv i ca l a n d u p p e r t h o ra c i c s p i n e by d ro p p i n g t h e c h i n towa rd t h e c hest . T h e cu m u l at i ve effect of ste ps 3 to 8 s h o u l d be a p rog ress ive re d u ct i o n o f t i s s u e t e n s i o n a n d te n d e r n ess a ssociated w i t h t h e te n d e r po i n t
9 . F u rt h e r m o d ify t h e p a t i e n t 's pos i t i o n , p a rt i c u l a r l y by adj usti n g t h e pos i t i o n s i n tro d u ced i n steps 6 and 8, to obta i n 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 te n d e r n es s re d u ct i o n . It i s g e n e ra l l y f e l t t h a t p a t i e n t - p e rceived t e n d e r n ess s h o u l d be d e c reased to n o m o re than 3 0 % of t h e 1 00 % esta b l is h e d in step 2 .
1 0 . H o l d t h i s positi o n of 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 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 t o t h e or i g i n a l positi o n . I t i s i m p o r t a n t n ot to re m ove y o 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 roce d u re so t h a t you ca n b e c e r t a i n t h e red uct i o n i n t e n d e r n ess post trea t 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
1 1 . Reassess t h e poi nt f o r t e n d e r n ess. Ribs A n terior (Depressed) Tender Poin ts, Patient Sea ted (Coun terstrain) (Fig. 23. 6)
This p roced u re is employed to re d u ce tenderness a nd p a in associate d with a cou n
terstra i n te n d e r p oi n t . The loca tions o f the r e s p ect i ve ten d er poin ts a re descri bed p r e viously. The pa t i e n t m a y be d i agnosed se a ted or s u p i n e by p a l pating for t h e tiss u e textu re a b nor m a l i ty a n d assoc i a ted te n d e r ness i n t h e loca t i o n of t h e t en d e r po i n ts . Patient p o s i t i o n : sea ted on t h e s i d e of t h e trea t m e n t table . P h y sic ian position : s ta n d i ng be h i n d the pa ti ent . T h e p h ysicia n m o n itors t h e tend e r point th ro u g h o u t t h e p roced ure , using light touc h and in ter m i ttent i n c re a sed p a l p a tory pressure to determine degree of t iss u e tex t u re a b no r m a l ity and te n d e r n e s s . As the pati e n t is posi t i o ned for the proce d u re , the tissue textu re a b norma l i ty a nd tend erness associated with t h e tender p o i n t should b e re d u ced to n o m o r e than 3 0 % o f t h a t encountered at t h e o u tset of trea t me nt. Th is is determined by palpating the tissue texture and a s k i ng the p a ti e n t for h i s or her perce ption of tend erness to i ncreased pa l pa to ry press u r e . The d u ra ti o n of the procedure is c l a s s i ca l l y 90 s eco n d s , a l t h o u g h if you are capable of pa lpati n g a release, th i s may be em ployed as an i n d ica tor tha t the treatment is fi n is h e d . P a tient p os it i o n : seated on t h e side of the trea tment ta b l e . P h ys ic ia n position: s t a n d i n g b e h i n d the pa t i en t . Proced u re ( E xa m p l e : A n t e r i o r T h i rd R i b Te n d e r Po i nt on t h e R i g ht)
1 . P a l pate the t e n d e r p o i n t u p o n the t h i rd rib a t the a n t e r i o r a x i l l a ry l i n e on the r i g h t w i t h t h e i n dex f i n g e r o f y o u r r i g h t h a n d . T h i s h a n d p l a c e m e n t m u st be m a i n ta i n e d t h ro u g h o u t t h e p roced u re .
2 . Assess t h e d e g re e 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 asso c i a te d w i t h t h e t e n d e r p o i n t . B y i n c rea s i n g t h e a m o u n t of d i g it a l p ressu re a p p l ied to t h e t e n d e r p o i n t ,
358
Sect i o n III • C l i n i ca l Co n d i t i o n s
FIGURE 23.6
Cou nterst r a i n f o r a n t e r i o r third r i b t e n d e r p o i n t o n t h e right.
d ete r m i n e t h e base l i n e severity of t e n d e r n ess p rese n t . Ass i g n this level of te n d e r n ess a va l u e of 1 00 % a n d i n form the p a t i e n t .
3 . Tel l t h e p a t i e n t t o p l ace t h e l eft foot u po n t h e ta b l e b e n e a t h t h e r i g h t t h i g h . T h e l eft h i p s h o u l d be f u l l y f l exed a n d exte r n a l l y rotated w i t h the l eft k n ee f l exed . The l atera l aspect of the left t h i g h and leg s h o u l d b e i n contact w i t h t h e t a b l e to p .
4. 5.
P l a ce yo u r left foot u p o n t h e t a b l e lateral t o t h e p a t i e n t 's left h i p . P l a ce t h e patient's l eft a rm over yo u r l eft t h i g h . P l a c i n g a p i l l ow between yo u r t h i g h a n d t h e p at i e n t 's a x i l l a w h i l e f l ex i n g t h e p a t i e n t 's l eft e l bow a n d p l a ci n g t h e fore arm u p o n yo u r left k n ee wi l l red uce p ressu re u po n the brac h i a l p l e x u s and red u ce the te n d e n cy t o deve l o p p a rest h e s i a s d u ri n g t h e re m a i n d er of the proce d u re .
6.
Latera l l y t r a n s late t h e p a t i e n t 's u p p e r torso t o t h e l eft by s i d e -s h i ft i n g yo u r pelvis and l eft k n ee to the l eft .
7.
H ave t h e p a t i e n t a l l ow t h e r i g h t a r m to h a n g over t h e s i d e of t h e ta b l e b e h i n d h i m o r h e r.
8 . W i t h yo u r left h a n d , g ra s p t h e pat i e n t 's h e a d a n d i nt rod uce rota t i o n a n d s i d e b e n d i n g of t h e cervica l a n d u p per t h o r a c i c s p i n e to t h e r i g h t . Add i t i o n a l l y, i nt rod uce fl ex ion of the cerv i c a l a n d u p p e r t h o r a c i c s p i n e by d ro p p i n g the c h i n towa rd the chest. The c u m u lative effect of steps 3 to 8 s h o u l d be
a
p ro g ress i ve red uction of tissue
t e n s i o n and te n d e r n ess a ssoci ated with the te n d e r p o i n t .
9.
F u rt h e r m o d i fy the p a t i e n t 's posit i o n , part icu l a rly by adj u d u ce d i n steps 6 a n d 8 , t o obta i n m a x i m u m p a l p a b l e tissu
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Cha pter 23 • The Pat i e n t w i t h La rso n 's S y n d r o m e
red u ct i o n . I t i s g e n e ra l l y t h o u g h t t h a t p a t i e n t - p e rc e i ve d te n d e r n es s s h o u l d be decreased to n o m o re than 30% of t h e o r i g i n a l 1 00 % esta b l i s h e d in step 2 .
1 0 . 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 p a b l e t i s s u e t e n s i o n a n d ten d e r n ess red uct i o n 90 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 t o t h e o r i g i n a l p o s i ti o n . I t i s i m p o rt a 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 ro ce d u re s o t h a t yo u c a n be cert a i n t h a t the re d u c t i o n i n ten d e r n es s post t rea t m e n t occu r red specifica l l y in the o r i g i n a l te n d e r p o i n t . 1 1 .
Reassess t h e poi nt f o r te n d e r n e s s .
Fo r
add itional
m a n i p u l a ti v e
proce d u res
for r i b
soma tic d y s f u n c t i o n , see
Cha p ters 21 and 2 2 .
References 1. L a r so n NJ . F u n c t i o n a l v a s o m o t o r h e m i p a rest h e s ia s y n d r o m e . A c a d e m y o f A p p l i e d O s teo p a t h y 1 9 70 Yea r b o o k . C a r m e l , C A : A c a d e m y of A p p l ie d Osteop a t h y, 1 9 7 0 : 3 9-4 4 . ( Ava i l a b l e t h rough the A me rica n A ca d em y o f O s teo p a t h y, I n d i a n a p ol i s . ) 2 . La rson NJ . A study o f t h e response o f u nc o m p l ica ted pe r i p h e r a l sen sory d i s t u r b a nces t o spe
c i f i c osteopa t h ic m a n i p u l a t ive trea t m e n t . ] A m Osteopath Assoc 1 9 72;72 : 6 2-EO A . 3.
K a p p l er R E . Addendum J u l y 1 970; La rson NJ . F u nctiona l va somotor h e m i p a resthesia syn d rome. Academy of A pp l ied O s teo p a t h y 1 9 70 Yea r b oo k . Ca r m e l , C A : Aca d e my o f Ap p l ied Osteopat hy, 1 9 7 0 : 4 4 . ( Ava i l a ble thro u g h rhe American Aca d e m y of O s teop a th y, Ind i a n a p o l i s . )
4 . Larson NJ , Wa lton M W, K e l s o A F. Effectiveness o f m a n i p u l a t i ve t rea t m e n t fo r pares thesias w i t h p e r i p h e r a l nerve i n v o l vement. J A m Osteop a r h Assoc 1 9 8 0 ; 8 0 : 2 1 6-EO A .
5 . La rso n NJ , Wa l ton MW, H u n t H H , Kelso A F. A d o u bl e - b l i n d c l i n ic a l stu d y o f t h e e ffects o f m a n ip u l a t i v e treatment o f pa t i e n ts w i th pe r i phera l n e rve com p l a i n rs . J A m O s t e o p a t h Assoc 1 9 7 6 ; 76 : 2 0 9 - E O A . 6 . S p r a fk a
SA .
Cl inical
problem solving:
Case six.
I n : Ward R C , e d . Found a t i o n s fo r
Osteo p a t h i c Med i c i n e . 2nd e d . P h i l a d e l p hia : Li p p i n cott Williams & W i l ki n s , 2 00 2 ; 2 6 9 . 7 . La rson NJ . Osteopa t h i c m a n i p u l a t i on fo r s y n d romes o f t h e
b ra c h i a l plex u s . J Am Osteopath
Assoc 1 9 7 2 ; 72 : 3 7 8-3 8 4 . 8 . La rson NJ . A s t u d y o f t h e response o f u ncom p l ica ted p e r i p h e r a l s e n sory d i stu rba nces to s p e
c i fic osteo p a t h ic m a n i p u l a tive trea t m e n t . J A m Osreop a t h Assoc . Sep 1 9 72 ; 72 ( I ) : 62-EOA.
9 . K a p p l e r R E, Kelso AF. T he r m og r a p h ic s t u d i e s of s k i n rem perature i n p a r i e n ts r e c e i v ing osteo pa th ic m a n i p u l a ti ve trea t m e n t for per i p h e r a l n e rv e p r o b l e m s . J A m Osteo p a t h i c A ssoc
1 9 8 4 ; 8 4 : 76-EO A . 1 0 . G l o s s a r y o f osteop a t h i c term i n ology. I n : Wa rd
RC, ed.
Fo u nd a t i ons
fo r
O steo p a thic
Med 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 nc ot f Wi l l i a m s & W i l k i ns 2 0 0 2 ; 1 2 29-1 2 5 3 .
1 1 . Wa lton F e . P a l p a tion a n d moti on tes t i n g i n a c u re a n d c h ro n i c d i s e a s e . O s te o pat h Med 1 9 7 7 ;2 : 8 0-8 3 , 8 6 .
1 2 . Wa lton WJ . Text book o f O st e o p a t hi c D i a gnosis a nd Tec hn i q u e Proced u res . 2 n d e d . C h icago: Ch icago Co l l ege o f O st e o p a t hic Medicine, 1 9 7 0 ; 1 1 4 - 1 1 9 . 1 3 . H r u b y RJ . T h e ri b cage . I n : Wa rd RC, e d . F o u n d a t i o n s fo r Osteo p a 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 : L i p pi ncott Wi lliams & Wi l k i ns 2 0 02 ; 7 1 8-7 2 6 .
1 4 . Wa lton W] . Te xtbook o f Osteopa t h i c D i a gnosi s a n d Tec h n i q u e Proced u re s . 2 n d e d . Ch i c a go : C h icago Co l l ege o f Osteop a t h i c Med i c i n e , 1 9 7 0 ; 3 3 8 . 1 5 . Wi l l a r d
F H . A u to n o m i c nervous syste m . In: Wa rd RC, e d . Founda rions for Osteo p a t h i c
Med i c i n e . 2nd e d . Ph i l a d e l p h i a : Li p p i ncot t Wi l l i a m s & Wi l k i n s , 2 0 0 2 ; 9 0- 1 1 9 . 1 6 . Korr
1 M . The s p i n a l cord a s organ izer o f d isease processes: IV. Axona l tra nsport a nd neurotrop h
ic fu n ct i on in relation to somatic d ysfunction . ] Am Osteo parh A s s oc 1 9 8 1 ; 8 0 : 4 5 1 -4 5 9 . 1 7 . Patterson M M , Wu rster R D . N e u ro p h ys i o l ogic m e c h a n i s m s of i n t e g r a t i o n a n d d i s i n tegra tion .
I n : Ward R C , e d . Fo u nd a tions for O steo p a t h i c M e d ic 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 ncott W i l l i a m s & W i l k ins, 2 002 ; 1 2 0- 1 3 6 .
1 8 . N e l s o n K E . O s teopa t h ic m ed ica l cons i d e ra ti o n s of r e f l ex s y m pa t h e t i c d ys rro p h y . Osteo p a t h i c Assoc 1 9 9 7 ; 97 : 2 8 6-2 8 9 .
J
Am
CHAPTER
24
The Patient with Fibromyalgia/Chronic Fatigue Syndrome Anette K. Schilling Mnabhi [
INTRODUCTION Everyone gets tire d, and e veryo n e has occasional aches and pains. The d ifference for people with chronic fa tig u e syndrome and/or fibromyalgia is that the f a tig ue and the aches and pains d o n o t just go away afte r a few nights of slee p or a break f r o m the u sual a c tivities or even wit h time. T he challenges for i n d ivi d u a ls wit h one of t h ese syndromes are compou nded for several reasons: First, the causes of these syn dro mes are still n o t clear; there is m u ch deb a te as to their etio l ogy a n d patho
physiology. Second, many physicians a nd h ea l th p r ofess i ona l s sti l l do not recognize
these syndromes Third, because of the compl exity of symptoms and u nknown .
ca u s es, research into e ffective treat m ent is challengi n g . Witho u t dia gnosis, little effective trea tment ca n fo l low. Individuals with chro nic fatigue syndrome or fibrom ya lgia have many needs
a nd
often require a var iety of the r a peutic approaches.
It is increasingly a ppa re nt tha t b o th syndromes i nvolve an interaction of dysfunc
tion a cross syste m s , inc l u d ing im m u ne end ocrine ca rd i ovascular d igesti ve, and ,
,
,
a u ton omic nervo u s sys tems . Osteop a t h ic medicine is idea l ly suite d to provide
an
integra ted approach to the soma tic and vi scera l d ysfu nct ion experie nce d by these indiv i d u a l s . Chronic fatig u e syndrome is a serio u s problem a ffecting ma n y indivi d u a l s . I t is e s tim ated that 400,000 to 800,000 A meric a ns o f al l ages, races, socio economic groups, a nd ge n d e rs m a y be affected by this disorder. Chronic fa tigue syndrome is 360
Chapter 24 • The Pat i e nt w i t h Fi bro myalg i a
361
most common in women in their 40s and 50s. Some studies have shown the high est rates are in Latinos and African -A m ericans, followed by w hites and Asians. Similar illnesses have been seen in adolescents and chil d re n, but prevalence data are limited for this population . Interna t i on all y, some societies are just beg inni ng to rec ognize the disorder. The etiology and pathophysiology of ch r on ic fa ti gue syn drome are not know n , but evidence is growing that a neuroendocrine dysfunction casc ading into multiple-system dysfunct ion is a key factor. 1,2 F ibromyalgia is estimated to have a pr ev ale nce of 3. 4% for women and 0.5% for men. While the causes of fibromyalgia a r e still unclear, it appears tha t alter ations in sleep patterns and changes in n e u roe n docri n e transmitters play si gn ifi cant roles.3
THE DIAGNOSTIC PROCESS As a starting point to effective diag nosis and tre a tmen t of chronic fatigue syn drome or fibromyalgia, it is esse n tial to know what symptoms are present and how the con d i ti on s are defined. Both are primarily cl inical diag noses and must be diagnoses of exclusion; both are treated empiric all y, al t h ou gh some small clinical studies have looked at the use of low-dose antidepressants, exercise, and cogni tive therapy. Research into causes and treatments is ongoing, and t h is is a con stantly ev ol vin g field. Chronic fat ig u e sy n d r om e a nd fibro myalgia are separate conditions, yet often i n dividual s in either group will share similar characteristics or exhibit both conditions simultaneously. Treatment i n te r ve ntion s overl ap , so the two condi t io n s are usually treated together. Alth o u gh k n ow n by many names (chronic f atig u e and immune dy sfunction synd rom e, my algic e n ceph alopat hy or encephalomyelitis, postv i r al fatigue, ch ro n ic Epstein-Bar r syndrome, neurasthe nia, fi b ros i tis ), these syndromes are characterized by the foJlowing:4-6 • Headache • Frequent infec t io n s, such as sinus or respiratory in fec tions •
Lymphade n opat h y
• U r i nary bladder infections or candidiasis • Myalgi a and arthral gia • I nability to concentrate, or brai n fog • Exh a ust io n • D iso rd er ed s leep • Bowel disorders • In c r eas ed th irst • Low libido • Low temperatures • Anxiety and depression • Weigh t gain
This constellation of symptoms reflects s i gnificant visceral and somatic dys p hysi cian is well equi p ped to handle.
f un c tion that the osteopathic
Chronic Fatigue Syndrome
Chronic fatigue syndrome is characterized by severe and d ebili ta ti n g fatigu e that has been present for more than 6 mon ths and has associated muscle aches, tender and swollen lymph nodes, chills, art h r algias, sore th roa t, head aches ,
po
ste xertional
malaise, and unrefreshing s l eep . The Centers for Disease Control (CDC) has
362
Section III • Cli n i ca l Co nditions
established that a case of chron ic fatig ue syndrome is defined by the presence of the fo ll o w ing : • Clinically evaluated, u ne xpl a i n e d , persistent, or re laps i n g chron ic f ati gue that
is of new or definite onset (has n ot been l ifelon g); is not the result of o n g oi n g
exertion; is not substantia ll y alleviated b y rest; and results in substant ial r e duct i on in previous levels of occupational, educat i onal , social, or personal activities
• Concurre nce of four or more of the follo wing symptOms, a l l of which must have
persisted or recurred d uring 6 or more consecutive months of i l lness and must not h ave predated the fat i g ue : • Self-reported impairment in short - te r m memory or concent rat i o n severe enoug h to cause substantial reduction in prev i ous levels of occupational, ed u cational, social, or personal activities
Sore throat • Te n de r ce rvical or a x i ll ary l y mph nod es •
Muscle pain Mul tij oint pain without joint swe lli n g or redness • Headaches of a new type , pattern, or severity
•
•
• •
U nrefres h in g sleep Poste xerti on a l malaise lasting more than 24 hours
This research definition excludes many individuals because of its restrictive nat u r e J Fatig ue is co m mon in many illnesses. For this reason, the differential diag nosis includes an extensive list of diseases that must be e x cluded .
Fibromyalgia
Fibromyalgia is characterized by sl eep disturbance; sponta n eous , widespread soft tissue pain ; fatig ue ; and w idespread te n der points . The American College of Rhe u matO l ogy has set the fo l lo win g criteria for a definition of fibromyalgia: • A h i sto ry of widespread pain. T h e patient must have pain or achiness, s tead y or
inte r m itte n t , for at least 3 month s . At times, the pa in must have been present •
On both the right and left sides of the body
•
Both above and below the wa ist
•
Mid b o dy, for example, in the neck, mid c h e st, or mid b a c k , or in the
head • Pain on pr essi ng at least 11 of the 18 spots on the body that are known as ten
der poi n ts (Fig. 24.1).8 • T he presence of anot her c l inical disorder, suc h as arthritis, does not r u l e out a
diagnosis of fibrom ya l g i a . 9
For a tender point t o b e conside r ed posi tive, the s u bject must state that the pal pation was painful; tender is not to be considered painful. The te nder points are p aired and are located as follows: 1 and 2, occ ip ut, bilateral, at the suboccipital muscle insert i ons; 3 and 4, low cervical, bilatera l , at the anterior aspects of the intertransverse spaces at C5 to C7; 5 and 6, trape zi us, bilateral, at the m i dpoi n t of the upper b o rde r; 7 and 8, supraspinatus, b ilate ral, at origins, a bove the scapu l a sp i n e near the medial bord er ; 9 and 10, second rib, bilateral, at the second costochond ral junctions, just l ateral to the junctions on u p pe r sur faces; 11 and 12, lateral e picond yle , bilate r al , 2 em dista l to the epico ndy l e s; 13 and 14, gluteal , bilateral, in upper outer q uad r an t s of buttOcks in ante rior fold
of musc le; 15 and 16, greater trochanter, b ilatera l , po s te ri o r to t h e trochanteric
Chapter 24 • The Patient with Fibromyalgia
FIGURE 24.1
363
Fibromyalgia is suspected if pain can be elicited in 11 of 18 tender point sites with digital palpation using an approximate force of 4 kg.
p romin ence ; 17 and 18, knee, bilateral, at the media l fat pad proximal to the
joint line.g
Disturbance in the neuroendocrine axis is implicated in the etiology of fibromya lgia as well. In sleep studies, patients with fibromyalgia have a distur
bance of the non-REM sleep phase by intrusions of alpha waves, with infrequent progression to stage 3 and stage 4 sleep.lo Several conditi ons besides chronic fatigue syndrome are associated with fi b romy a l gia , including migraine headache, irritable bowel syndrome, and depression. I
I
Diagnosis of either chronic fatigue syndrome or fibromyalgia involves eliciting a detailed history from the patient, a thorough physical e x a mi n ation , and ruling out any underlying conditions that may m i mi c the symptoms of either chronic
fatigue syndrome or fibromyalgia (discussed later in the chapter). Theories, Causes, and Contributing Factors
Although for some time individuals who complained of chronic fatigue synd rom e or fibromyalgia were considered to have an emotional disturbance (and by some practitioners many stilJ are), it is becoming clear that chronic fatigue syndrome and fibromyalgia cannot be understood on the basis of a sing l e dysfunc tio n ; rather, the function of a II essential systems must be considered in an integrated manner.
Evidence exists
for immune,
endocrine,
cardiovascular,
and auto
nomic nervous system dysfunction in patients with chronic fatigue syndrome.
364
Section III • Clinica l Cond itions
In fibromyalgia, in addition, there is evidence of sleep disturbance and neuroen docrine dysfunction. Leaders in the field advocate for multidisciplinary research4 This situation is analogous to having a car with fo u r flat tires and a dead battery.
If you change one tire, you will have one good tire but still three flats and a dead battery. If you change the battery, the car will start, but it will still be a rough ride with flat tires, and yo u will not be able to go very fast. All four tires and the bat tery must be changed for success. In the same way, it is beginning to appear that multiple systems are involved in both chronic fatigue synd rome and fibromyalgia, and successful intervention means treating and supporting multiple systems simultaneously. Regarding the etiology of these disorders, a strong neuroendocrine connection is emerging. In one study, it was found that patients with chronic fatigue syndrome had reduced gray matter volume in the bilateral prefrontal cortex. The volume of reduction in the right prefrontal cortex paralleled the severity of the subject's fatigueY In another study, chronic fatigue syndrome patients were found to have a decreased density of serotonin transporters, indicating an alteration of the sero tonergic system in chronic fatigue syndrome.13 The hypothalamus controls sleep, hormonal patterns, autonomic function, and temperature. Hypothalamic dysfunction is often a common denominator in chronic fatigue syndrome and fibromyalgia.14 Hypothalamic dysfunction may come from mitochondrial dysfunction. How do the mitochondria become dysfunctional? Autonomic dysfunction, various infections, stresses, and hormonal deficiencies can exhaust the mitochondria, leading to mitochondrial dysfunction. That in turn leads to hypothalamic dysfunction, leading further to chronic fatigue, sleep distur bance, and fibromyalgia. In a survey of the literature regarding the biology of chronic fatigue syndrome, Komaroff15 and Komaroff and BuchwaldJ6 summarized the following findings in patients with chronic fatigue syndrome: •
Magnetic resonance imaging has revealed punctate areas of high signal in the white matter.
•
Single photon emission computed tomography signal abnormalities are often found in patients with chronic fatigue syndrome; abnormalities of the sympa thetic and parasympathetic systems that are not explained by depression
or
deconditioning have been revealed through autonomic nervous system testing. •
Hypothalamic and pituitary studies have revealed abnormalities not seen in healthy control subjects; a central down-regulation of the hypothalamic-pituitary adrenal axis is often present, resulting in a mild hypercortisolism.
• •
Disruption of the serotonergic and noradrenergic pathways has been identified. Many chronic fatigue syndrome patients have been found to be in a state of chronic immune activation, with increased numbers of CD8+ cytotoxic T cells with antigenic markers of activation and depressed function of natural killer cells, leading to a hypothesis of reactivation of latent viruses or of chronic low grade viral infection.
•
A novel 37-KDa protein has been found in about 70% of patients with chronic
•
Aberrations in the 2-SA synthetase pathway (that has antiviral roles) have also
fatigue syndrome.
been seen. While these findings have not yet been synthesized into a single t heory that explains the etiology or pathophysiology of chronic fatigue syndrome, there clearly an abundance of evidence pointing to an u nderlyi ng biological process.
lS
Chapter 24 • T h e Pati e nt with F ibro m y al g i a
365
Neurologic and endocrinologic findings in patients with fibromyaJgia include the following: • Elevati on of cerebrospinal fluid substance P levels to three times normal levelsl7 • Low overall production of cortisol and alteration of the hypopituitary-adrenal
a xis 18
• A significant prevalence of neuronally mediated hypotension evidenced by
p rovocation of symptoms during tilt-table testing19
The musculoskeletal system, the neuroendocrine system, and the central nerv ous system, particularly the limbic system, appear to play major roles in t h e patho genesis of fibromyal gia as weJ l.20 (See Chapter 6.) If we consider what is known about nervous system function from a neuroen docrine perspective and from the body's drive to maintain homeostasis, this seem
ingly rand om cascade of symptoms and findings fits together as parts of an inte grated whole. Moreover, these findings are consistent with the consequences of excessive allostatic load or a chronic state of allostasis. Structure and function are interrelated. If function is impaired, structure will ultima tely be i mpaired; if structure is impaired, function ultimately will be affected. Somatic dysfunction is a part of this process. In addition to activating related spinal cord ci rcuits, somatic dysfunction releases humoral factors. Summation of these two events occurs at the level of the brainstem to initiate general arousal and protective endocrine and neural reflexes. In acute situa tions, these responses, which result in a state of allostasis or compensation, are protective; however, chronic exposure to allostasis is pathologic. Allostasis is the response by the neuroendocrine and immune network to stimuli, with a consequent rapid release of chemicals that alter the normal homeostatic pat terns: norepine p hrine, adrenal cortical steroids, and cytokines. Allostasis is dis tinct from h omeostasis, and when prolonged, allostasis produces harmful effects. Chronic somatic or visceral dysfunction can have pathologic conse quences ansing from continuous stimulation of the arousal system . 21 AlJostasis is a defensive state. Long-term activation of the allostatic mechanism or increasing allostatic load leads to extensive wear and tear on the organ systems of the body. Some consequences of prolonged acti vation of the aliostatic system include memory l oss, depression , immunosuppression, and enhanced Th2 cytokine activity, allowing yet more antibody-mediated autoimmune and aller gic types of diseases to be expressed. In the gastrointestinal system and skin, elevated cortisol a n d catecholamines increase the responsiveness of delayed ty pe hypersensitivity reactions, insulin resistance, atherosclerosis, and hyper tensionY The sympathetic nervous system and the hypothalamic-pituitary-adrenal axis are cou p l ed to the arousal system. With increased input to the arousal system, there is a release of catecholamines from the sympathetic nervous system and adrenal corticosteroids from the hypothalamic-pituitary-adrenal axis. Cortisol and norepinephrine work to modify the production of the cytokines from the immune system. The neural, endocrine, and immune systems a l l work together in response to threat to alter homeostasis to the compensatory state of allostasis . If the body is unable to return to homeostasis, whether because of chronic exposure to threat or failure of the neural or humoral pathways, the body exists in a chronic compensatory state. As we know in the case of congestive heart fai lure, the com pensatory mechanisms ultimately create further pathol ogy if h omeostasis is not restored.
366
Section III • Clinical Conditions
How does this relate to chronic fatigue syndrome and fibromyalgia? The consequence of existing in a chronic compensatory state or allostasis reflects many of the problems encountered by the individual with chronic fatigue syn drome or fibromyalgia. If one examines the wide array of symptoms and the biologic findings previously noted, they are clearly indicative of a state of chronic allostasis.
Differential Diagnosis A multitude of conditions can lead to symptoms of long standing chronic fatigue and must be considered in the differential diagnosis and ruled out. In the future, some may even be found to be causative factors. Disorders in all systems can be a factor. The following must be considered (Table 24.1). The differential diagnosis must include careful consideration of infectious, neu roendocrine, psychiatric, neuropsychiatric, hematologic, rheumatologic, cardio vascular, pulmonary, and gastrointestinal disorders. Psychological causes of fatigue also act as triggers of allostasis. Fear, sorrow, guilt, depression, anxiety, anger, resentment, bitterness, frustration, worry, jeal ousy, hatred , and grief all depress bodily functions and can lead to somatic dys function. Negative factors includ e the following: •
Boredom drains energy and is stressful.
•
Compulsions can lead to continuous fatigue.
•
Depression can be the cause of or the result of fatigue.
•
Noise poll ution, including background noise in large cities and constant TV, radio, or music in the workplace or home, can be wearying.
•
Stress-lack of balance in the lifestyle-leads to fatigue as the body is no longer able to react to the stress when the stress-reaction mechanisms become exhausted (excessive allostatic load). Positive emotions, s uch as joy, on the other hand, induce dilation of the capil
laries and arteries, increasing blood supply throughout the body. The eyes brighten, thinking becomes clearer, respirations deepen, heartbeats strengthen, and digestion becomes more efficient. Allergy and Fatigue
Allergens act as stressors , triggering allostasis; energy is depleted with every aller gic reaction. Allergy symptoms can mimic chronic fatigue syndrome and fibromyalgia. Muscle and bone pain, paleness, dark circles under the eyes, irri tability and tension, headaches, stomachaches, and respiratory tract symptoms (repeated colds, asthma, or allergic rhinitis), fatigue, irritability, mental confusion, unhappiness, nervousness, emotional insta bility, and inability to concentra te are characteristic of allergies. Identifying allergens and treating and eliminating the causes can be hel pful. Sources of allergens include foods, the environment, workplace exposure, and household toxins. Common food allergens include milk, kola (includes cola drinks and chocolate, which both contain much caf feine), corn, eggs, and legumes. (The pea family incl udes peanuts, soybeans, and l icorice.) Mature dry peas and beans are more likely to induce reactions than are green or string beans or green peas. People sensitive to legumes are often sensi tive to honey. (In the United States , honey is collected mostly from plants in the legume family.) Other allergen-inducing agents include citrus, apple, tomato,
Chapter 24 • T h e Pati ent with F ibro m yalg ia
367
Causes of longstanding Chronic Fatigue
System Dysfunction Immune
Causative Factors Collagen-vascular
Food allergies
Infectious
Malignancy, cancer
Multiple chemical
Occult infection
Rheumatic fever
Sarcoidosis
Streptococcal infections
Systemic lupus
TuberculosIs
disease
mononucleosis sensitivities
erythematosus Viral diseases Endocrine,
Anemias
Diabetes
Endocrine abnormalities
hematologic
Hyperthyroidism
Hypoglycemia
Hypothyroidism
Menstrual disorders
Obesity
Pregnancy
Asthma
COPD
Emphysema
Hyperventilation,
Sleep apnea
Sickle cell disease Pulmonary
hypoventilation Cardiovascular
Congestive heart failure
Hypertension
Low cardiac output
Gluten intolerance,
Hepatitis
Mitral valve dysfunction Digestive tract,
Chronic constipation
celiac disease
hepatic
Inflammatory bowel
Irritable bowel syndrome
Ulcer disease
Dementia
Insomnia Narcolepsy
disease Neurologic
Amyotrophic lateral sclerosis
Genitourinary
Multiple sclerosis
Myasthenia gravis
Parkinson's disease
Post concussion syndrome
Glomerulonephritis
Lower urinary tract
Menorrhagia
infection Metabolic,
Alcoholism
Caffeine use
Chronic dehydration
Fasting
Hypokalemia
Medications
Severe dietary
Severe dietary
Hypermobility
Osteoarthritis
Rheumatoid arthritis
deficiencies Musculoskeletal Environmental. social
Chemical dependency, drug abuse
nutritional
restrictions
Environmental stress
Inadequate rest
Lack of exercise
Poor ventilation
Recent illness
Recent su rgery
Sick building syndrome
Sleep disturbance
COPD, chronic oiJstructive pulmonary disease.
368
Section III • Cl in i cal Condi tions
grains (wheat is the most allergenic; rye, the least), food additives and spices, and meats. (Pork is a common meat allergen; all other meats and seafood can be also.) Environmental allergies, such as plants, molds, gases, animals and their hair and dander, chemicals, drugs, cosmetics , and synthetic fabrics also must be considered.
Prognosis Little is known about long-term outcomes of chronic fatigue syndrome or fibromyalgia. Most patients seem to improve within 5 years, but most continue to struggle with some symptoms and some degree of impairment on an ongoing basis. In light of understanding the consequences of a chronic compensatory state, unless the body achieves homeostasis, the negative effects of chronic exposure to allosta sis will progress.
Initial Workup The initial workup for patients who complain of fatigue and/or widespread mus culoskeletal pain should include the following: • A detailed history elucidating onset of symptoms and a thorough evaluation for
evidence of underlying conditions or contributing factors • A detailed physical examination, including neurologic and psychologic evalua-
tions and musculoskeletal and structural examinations • Urinalysis •
Complete blood count with leukocyte differential
• Sedimentation rate or C-reactive protein • Alanine amino transferase and aspartate transaminase • Globulin • Alkaline phosphatase • Glucose • Calcium • Phosphorus
• Thyroid function test (thyroid-stimulating hormone, free T4, total T ) • Rheumatoid factor and antinuclear antibodies
If there are indications of nutritional concerns, serum Bt is useful, and if aller 2 gic symptoms are predominant, an immunoglobulin-E may be helpful. Often the history and examination will indicate further tests that may explain the fatigue state, for example a sleep study for suspected sleep apnea. An early morning cor tisol level, hepatitis serology, rapid plasma reagin, Lyme serology, and a tuberculin purified protein derivative with an anergy panel may be indicated if other labora
tory and clinical findings are negative.22
Key symptoms to evaluate on the initial visit include sore throat, painful cervi cal or axijjary lymph nodes, unexplained generalized muscle weakness, prolonged (more than 24 hours) generalized fatigue, generalized headaches, migratory
painful joints without swelling or redness, areas of lost or depressed vision, pho tophobia , forgetfulness, excessive irritability, confusion, difficulty thinking, inabil ity to concentrate, depression, and unrefreshing sleep. It is helpful to have the patients grade the symptoms as mild, moderate, severe, or absent. The chronic fatigue syndrome Diagnostic Decision-Making Model provides a basic guide to working through ti1e diagnostic process7 (Fig. 24.2). For more information or to obtain continuing education credits, please visit www.cfids.orgltreatcfs or phone 1-704-364-0016.
Chapter 24 • The Patient with Fibromyalgia
369
CFS Diagnostic Decision-Making Model Fatigue
Symptom Driven Evaluation:
1. 2. 3.
History & physical findings Exclusionary lab tests Neurological & psychiatric evaluation
Illness Identified
I
Treatment
I
• No Plausible Explanation
l
Chronic Fatigue ;" 6 months
�
Significantly affects daily activities and work
Meets;"
4
of the
Symptom Criteria:
a) postexertional malaise :j: b) unrefreshing sleep c) impaired memory or concentration' d) muscle pain e) multijoint pain t f) new headaches g) tender cervical or axillary lymph nodes h) sore throat§
�
No significant effe ct
�
8
�
I
Chronic Fatigue � 6 months Reevaluate at appropriate intervals; provide appropriate treatment
Less than 4 of 8 symptoms present
Reevaluate at appropriate intervals; provide appropriate treatment
Reevaluate at appropriate intervals; provide appropriate treatment
Key . severe enough to reduce levels of
§
t :t
occupational, social, or personal activities frequent, recurring without joint swelling or redness lasting more than 24 hours
Chronic Fatigue Syndrome
Supported by the Centers for Disease Control and Prevention and the CFIDS Association of America· wvvw.cfids.org/trealcfs
FIGURE 24.2
The chronic fatigue syndrome diagnostic algorithm was designed for the chronic fatigue syndrome Provider Education Project, which is supported by the Centers for Disease Control and Prevention and the Chronic Fatigue and Immune Dysfunction Syndrome Association of America.
THE INTERRELATIONSHIP OF STRUCTURE AND FUNCTION IN CHRONI C FATIGUE SYNDROME AND FIBROMYALGIA In osteopathic practice, the objective is to find the underlying causes of illness and
remove barriers to healing. While there is no clearly defined cause of chronic fatigue syndrome or fibromyalgia, the constellation of symptoms is consistent with a state of chronic allostasis. There is evidence of abnormal neuroendocrine function in chronic fatigue syndrome and fibromyalgia. The physician can use knowledge of
370
Section III • Clinical Conditions
structure and function interrelationships to facilitate homeostasis and eliminate sources of input activating allostasis. The finding of viscerosomatic reflexes on structural examination can offer useful information and direct clinical investi gation. Specific organ systems identified can help the physician evaluate for under lying organic pathology. (See Chapter 5.) Two drives affect the arousal-allostatic mechanism: physical, through somatic dysfunction and visceral dysfunction, and psychological, through emotional and cognitive influences.21 Individuals with chronic fatigue syndrome or fibromyalgia are clearly in a chronic compensatory state, a state of allostasis rather than homeostasis. By addressing somatic, visceral, emotional, and cognitive dysfunction, the physician can help facilitate the patient'S return to a state of homeostasis.
Management Individuals with chronic fatigue syndrome and fibromyalgia often have been strug gling with symptoms for years and require much support from the physician. A willingness to try novel therapies in difficult cases is useful. The goals of treat ment are to alleviate allostatic load, support return to homeostasis, decrease fatigue and pain, and increase daily functional abilities by supporting dysfunctional systems while eliminating identifiable contributing factors. Effective and support ive therapy must be directed toward key areas providing symptomatic treatment and relief. Teitelbaum,5 based on a double-blind study, has published an extensive list of interventions ranging from nutritional supports and herbal interventions to pharmaceutical interventions for each of the systems that may be in dysfunction in chronic fatigue syndrome or fibromyalgia. Emphasized for the beginning of treat ment are five key areas: sleep treatments, pain treatments, hormonal treatments (adrenal, thyroid and sex hormones), nutrition, and infections. Some key interventions for these four areas are summarized in Table 24.2, which provides an excellent resource when seeking options for symptomatic treatment.5 Osteopathic manipulative treatment (OMT) is useful for enhancing immune function and has proved helpful in reducing the intensity and duration of ill nessy-25 Goals of treatment include the following:26 •
Normalizing nerve function, including all cranial and spinal nerves as well as the autonomic nervous system
•
Balancing sympathetic and parasympathetic tone
•
Normalizing function of the cerebrum, thalamus, hypothalamus, and pituitary body
•
Normalizing cerebrospinal fluid fluctuation
•
Releasing membranous tension
•
Modifying gross structural patterns
•
Counteracting stress-producing factors
•
Alleviating pain
•
Improving lymphatic function and improving circulation In this author's experience, patients respond best to gentle indirect OMT pro
cedures, and while they may derive some temporary relief from direct procedures and high-velocity, low-amplitude (HVLA), these approaches often result in a flare of symptoms later in the day that may persist for several days. Myofascial release, gentle muscle energy, facilitated positional release, balanced membranous tension, balanced ligamentous tension, the Fulford percussor, gentle soft tissue, and articu lation are all helpful approaches.
Chapter 24 • The Pat i e nt with Fibr o m yalg i a
371
Selected Treatment I nterventions for Chronic Fatigue Syndrome or Fibromyalgia Sleep Treatments Zolpidem (Am bien) 10 mg 1/2-11/2 at HS; may take an extra 1/2 during the night Trazodone (Desyrel) 50 mg 1/2-6 at HS Revitalizing Sleep Formula (herbal blend by Enzymatic Therapies and PhytoPharmica) 1-4 at HS; can be used during the day for anxiety Tizanidine (Zanaflex) 2-8 mg at HS Clonazepam (Klonopln) 0.5-3 mg at HS; very effective for sleep, restless leg syndrome, pain Doxylamine (Un150m), over-the-counter antihistamine, 25 mg 112-1 tablet Carisoprodol (Soma) 1/2-1 at HS; can be useful if pain is severe Cyclobenzaprine (Flexeril) 10 mg 1/2-2 at HS Zaleplon (Sonata) 10 mg 1 at HS-may repeat during the night if awake before 3 a.m. Melatonin 0.5-1 mg at HS 5-HTP (5-hydroxytryptophan) 200-400 mg at HS; natural stimulator of serotonin Mirtazaplne (Remeron) 15 mg 1-3 tablets at HS Amitriptyline (Elavil) 10 mg 1/2-5 tablets at HS; good for nerve pain and vulvodynia Doxepin (Sinequan) 5-10 mg 1-3 capsules at HS Alprazolam (Xanax) 0.5 mg 1/2-4 tablets at HS
Pain Treatment Glucosamine sulfate 500 mg Li.d. for patients with arthritis Lidocaine 15% in PLO gel; rub on painful areas Lidocaine patch; can be cut to size and left on for 12 hours Methocarbamol (Robaxin) 750 mg 1 or 2 capsules t.i.d.-q.i.d. as needed Tramadol (Ultram) 50 mg 1 or 2 tablets up to q.i d. Metaxalone (Skelaxin) 400 mg 1 or 2 tablets q.i.d. as needed Gabapentin (Neurontin) start with 100-300 mg at HS; may Increase dose as needed to maximum of 3600 mg/day
Hormonal treatments (All dosages adjusted to patient's response) Adrenal Hydrocorttsone (Cortef) 5-mg tablets 1/2-21/2 tablets at breakfast, 1/2-11/2 tablets at lunch, 0-1/2 tablet at 4
PM,
lowest dose that feels best for patient
Panax ginseng 100-200 mg twice a day Increase salt, water, potassium for low blood pressure (12 oz V8 Juice, 1 banana/day)
Thyroid Levothyroxine (Levoxyl or Synthroid) 50 �g-titrate dose as needed Thyroid desiccated (Armour Thyroid) 30 mg (112 grain prior to start of thyroid support Liothyronine (Cytomel pure active T3) 5 �g tablets -
=
30 mg); if taking Cortef, begin Cortef 1-7 days
372
Section III • Clin ical Co nditio n s
TABLE 24.2 (CONT.) Selected Treatment Interventions for Chronic Fatigue Syndrome or Fibromyalgia Nutrition Magnesium glycinate 75 mg/malic acid 300 mg 2 tablets t.i.d. for 8 months then 2 tablets dally (decrease dose if diarrhea occurs) Magnesium malate 100 mg 3 t.i.d. Zinc picolinate or zinc sulphate 25 mg b.l.d. for 6 weeks then stop Vitamin C 500-1000 mg b.i.d. Vitamin B12 1000-15,000 mcg/ml lM 3-5 times a week for up to 10 weeks N-Acetyl-l-cysteine 500-650 mg per day Chromagen FA (R) one tablet daily (for low iron levels) Omega 3 fish oils 1/2-1 tablespoon per day Vitamin E 400 IU per day CalCium 500-1000 mg daily with 400 IU vitamin D B-complex one tablet or capsule daily Complete amino acids, nutrients, vitamins and minerals (Daily Energy Enfusion Powder formulated by Enzymatic Therapies) 1/2-1 scoop daily in morning; take with B-complex Digestive enzymes (Complete Gest Enzymes by Enzymatic Therapies or Similase by PhytoPharmlca) 2 capsules with each meal to help digestion
Antiviral and Antibacterial Treatments Famciclovir (Famvir) 750 mg t.i.d. Amantadine (Symmetrel) 100 mg b.i.d. Ciprofloxacin (Cipro) 750 mg b.i.d. Doxycycline 100 mg b.i.d. Sinusitis nasal sprays, ordered from a compounding pharmacist itraconazole (Sporanox), xylitol, mupirocin (Bactroban), beclomethasone (Beconase), nystatin
HS,
hour of sleep;
1M,
intramuscular; PLO, pluronic lecithin organogel; Ll.d., three times a day; Q.l.d., four times a day;
bid.,
twice
a day. Data from Teitelbaum
J.
From Fatigued to Fantastic. New York Penguin Putnam,
2001
Many patients with chronic fatigue syndrome or fibromyalgia are extremely sensitive; therefore, when beginning osteopathic treatment, care should be taken not to overdose. (See Chapter 4.) Too much treatment will result in an exacerba tion of pain symptoms that may last for days. When in doubt, be conservative and evaluate the patient's response before proceeding with more extensive treatment. Osteopathic treatment of somatic dysfunction can provide the patient with relief of often relentless and intense pain. While the effects may not always be long last ing, OMT is a nonpharmacologic intervention with limited side effects and is often soothing to the patient. Moreover, it has demonstrated immunologic benefits. 2 5 A sequence to consider for the use of OMT when treat ing
a
patient with chronic
fatigue syndrome or fibromyalgia is presented next. (Again, this sequence would be modified by the patient'S condition, individual needs, and structural findings.)
C h a pter 24 • T h e P a t i e nt with F ibromyal g i a
373
I t i s a n ine-step trea tment regi men for a gentle basic treatm ent emp h a siz i ng the
neuroend oc r i ne , m yofasc i a l , and l y m p hatic systems. P a t ient is supi ne. •
Relea se of m yofascia I restrictions of the feet, knees, a n d lower extremities
• Pelvic diaphra gm release • •
Sacrum Rel a x or dome the a bdom ina l diaphragm
• Respiratory d iaph ragm release •
• •
•
Rib bal a n ci n g, ri b ra i s i n g and/or p a raspina l i n h ibition ( T I -U ) ,
Release of thoracic inlet Lymph atic pum p (tho r a c i c or ped al, depending on p a tient'S to lerance and level of p a i n ) CY-4
See ot h e r proced u res described at the end of th is cha pter. Individ u a l structural find i ngs c a n be add ressed on a n ongo ing basis. Foc us
treatme n t on ke y somatic d ysfunctions that will improve and bala nce sympathetic
a n d p a rasy m p a th eti c tone, i mprove lym phatic flow, i mprove circulatio n , a nd i mprove neu roe ndocrine functio n. An important adjunct to ha nds-on treatment is a realistic plan of physi ca l a ctiv
ity for th e patients. Often patients a re too fa t i gued or i n too much p a i n to do a ny
thing , yet decreased activity contributes to t h e cycle of pa i n a nd fa tigu e. Beg i n ning with gen tle stretches t h a t can be done i n bed and brea thing exercises, patients must
be ta ught to tit r a te their a ctivity and incl ude freq uent rest periods; they must lea rn to stop before they begi n to feel tired. As symptoms i mprove, they will be tempt
ed to overd o exercise a nd will consequen tly o ften regress. It is importa n t to teach pati e n ts to sto p ea rly and rest often b u t then to get movi ng again.
Sleep The goal is for the patient to get 7 to 9 ho urs of refresh i n g sleep each night without feel ing h u ng over. Sleep is a n essentia l pa rt of healing. Many of the resto rative p rocesses ta ke place at n i g h t . With out a dequate sleep, it is difficu lt to achieve home
osta s i s . I t is essential to wo r k on esta blishing norma l sleep a rchitecture. Have the patient elim i n ate caffeine and a lcohol, both of which i nterfere with sleep. Instruct the pa tient to get out of bed at the same time ea ch morni ng to promote a hea lthy c i rca dia n rhythm. R e ferral to a sleep specialist m a y be helpful i f there is an underly ing s l eep d isorder. Most s l eeping pills in common use worsen the quality of sleep by increasing the a mount of l ight-stage sleep a nd d ecrea sing the deep stages of sleep. It is importa nt to avoid the use of suc h agents . Some helpful opti ons include zolpidem, za leplon, tra zodone, clona zepa m , d oxyl a m ine , ca risoprodol (for patients in severe pa i n ) , C },c1obenz a p ri ne, mirta zapi ne , a m itriptyline, a nd a l p ra zo l a m P Start with l ow doses. Often a low dose of two agents is more e ffective t h a n a h igh dose of j ust on e. Since resea rch into the p harm acology of these a gents at the applied clinica l level is l i m ited , the physician will have to work on an approach tha t fits t he p atient best and ach ieves the goa l of 7 to 9 ho u rs of refreshing sleep .
Pai n Osteopathic treatment , warm baths, and aceta m inophen a re helpful. Use of opioids
has not been fo und helpful, but in extreme cases of pain, they may be necessa ry. More benefit has been found from the use of a muscle rela x a n t such as cyclobe nzaprine. The causative mecha n ism of p a i n is not fully understood, so interventions a re gea red
3 74
Section I II • C l i n i c a l Co n d i t i o n s
t o s u pport. Biofeed b a c k , tra n sc u ta n e o u s n e u r a l sti m u l a tion, massage, a n d u l t ra sound a r e some of t h e tech n i q u es t h a t i n d i vi d ua l s h a v e fo u n d to be he l p fu l . Pa i n relief at bedtime is i m p o r ta n t to fa c i l i t a te a d e q u a te r e s t a n d slee p .
Neu roend oc rine I m balances Dysa utonomias
a re
sometimes
helped w i t h
i ncre a s e d
fl u i d
and
sa l t inta k e .
Hypoa d re n a l fu n c t i o n h a s been shown to ben efit f r o m low-dose h y d roco rtisone
( 5-25 m g d a i l y up to 24 m O ll th s , then taper d osage as n ecessary) . Fa tigue was improved a n d d i s a b i l i ty was re d u ced w i th o u t sign i fica n t s h o rt-te r m a dverse e ffects or s u pp ress i o n of the hypoth a l a m ic-pi t u i ta r y -a d re n a l a x i s . 28-3 1 T h y r o i d a n d ova r i a n fu nct i o n o ft e n i m p ro v e o nce a d re n a l fu n c t i o ll i s s u pported, b u t a t ti mes, t h e p a t i e n t wil l sti l l be border l i ne or l ow i n t h yroid or o v a r i a n f u n c t i o n a n d requ i re treatment as i n dica ted by the i n d ivid u a l con d i t i o n . Slee p , pain, bra i n fog, a n d energy leve l s h a ve all b e e n fou n d to i m p rove w i t h a d re n a l s u p p o r t .
Infections A n y u n d e r lying infec tio n s s h o u l d be t r e a ted . Ch r o n i c s i n u s i n fecti o n s , funga I s k i n i n fectio n s , v a g i n a l y e a s t infec t i o n s , a n d c h ron ic v i ra l a n d b a c t e r i a l i n fections a l l a c t a s stressors o n t h e s y s t e m . While t h ere i s n o c o n se n s u s a s to t h e best a p p ro a c h t o t re a t these c h ro n i c i n fections, w e d o k n o w t h a t t h e ongo i n g p resence of u n t rea ted infecti o n s a cts as a s t r e s s o r and p u s h es the s y s t e m t o w a r d a l l o s ta s i s a n d a w a y fro m homeosta s i s . A r e v i e w of p a s t tre a t m e n t a ttem pts, c u r r e n t a v a i l a b l e o pt i o ns, a nd a w i l l i ngness to try n e w i n t e r ve n tions w i l l be most h e l p fu l to the p a t i e n t .
N u trition A d e q u a te w a ter i n t a k e a n d good n u trition a re esse n t i a l . A d eq u a te i n ta k e of prote i n , fru i ts, a n d vegeta bles is importa n t t o p r o v i d e t h e esse n t i a l v i ta m i ns , m i nera l s , a n d a mi n o a c i d s needed to repa i r a nd restore b o d y f u n c t i o n s . Cons u lta t i o n wi t h a n u tr i t i o n i s t w i l l b e help fu l i f t h e p h y s i c i a n d e s i re s ass ista nce rega rding n u tri ti o n a l i s s u e s .
Psychological Su p port Severa l i n terventions can be h e l p fu l . S t ress m a n a gement, r e l axa t i o n tec h n i q ues, a n d emoti o n a l s u ppOrt a re all i m p o r ta n t p a ns o f trea t m e n t . S o m e c l i n i c a l s t u d ies h a ve fo u n d cogni tive thera p y to be help f u l ; i t s h o u l d , howe ver, b e carried out b y a tra i ned c l i n ic i a n Y Most i m p o r t a n t is the p s y c h o l ogica l s u p po r t prov i d e d by t h e trea t i n g ph y s i c i a n . Li ving w i t h c h ro n i c fa t i g u e s y nd rome o r fi b r o m y a l g i a i s d i ffi c u l t, and many pa tients have been told t h e y a r e c r a z y or that nothing i s wrong with t he m . T h e y need and d eserve the support o f a c o m p a s s i o n a te ph ysic i a n who is wi lling to wo rk with them to find s o l u ti o n s fo r t h e i r s y m pt o m s , even as rese a rch ers a ttem p t t o exp l a i n w h y a n d find sol u ti o n s . I t is i m porta n t t o eva l u a te n e w s y m ptoms o r a n y c h a nges o r d e t e r i o r a t i o n fo r p o s s i bl e o n s e t of o t h e r i l l nesses. W h e n trea ting t h e pa tient, fo c u s on a l l of t h e sym p t o m s , n o t j u st t h e fa tig u e . P rovide s u p p o r t fo r t h e p a t i e n t , fa m i l y, a n d sig n i f ica n t o t h e r s . S y m ptoma t ic trea t m e n t c a n improve the q u a l ity o f l i fe fo r peo p le w i th ch r o n i c fa t i g u e syndrome or fi bro m y a l g i a . 7 Wo r k i n g w i t h t h e s e p a ti e n t s w i l l req u i re a n o n g o i n g s u pp o r t i ve p h y s i ci a n-p atien t re l a t i o n s h i p . W h i l e there i s s t i l [ m u c h to u nd ersta n d a b o u t c h ronic fa t i g u e s y n d rome a n d fi brom y a l g i a , t h e osteopa th i c phys i c i a n h a s t h e o p p o r t u nity t o s u p p o r t t h e p a tien t'S return to homeostasis thro u g h osteop a thic tre a tm e n t, m i tiga ting a n d el i m i n a t i ng soma tic d ys fu n c t i o n as a s t ress or, a n d p r o v i d i ng o n go i n g c l i n i ca l s u pport for the m y r i a d o f s y mptoms a nd comor b i d cond i ti o n s a ffec ting t h ese i n d i v i d u a l s .
C h a pter 24 • T h e P a t i e n t w i t h F i b r o m ya l g i a
37 5
Proce d u res P l e a s e note: T h e p r oc e d u res t h a t fo l l o w a re e x a m p les of m a n i p u l a t i v e trea t m e n t t h a t you m a y w i s h to empl oy. T h e a c t u a l c h oice o f proced u re s used sho u l d b e determ i n e d by t h e u n i q u e c i rc u m s t a n c es o f e a c h i n d i v i d u a l p a t i e n t . T h e fo l l o w i n g is a g e n tl e b a s i c t r e a t m e n t e m p h a s iz i ng t h e n e uroe n d oc r i ne a n d l ym p h a t i c systems. R e l e a s e o f t he thor a c i c inlet ( Se e t h e d e s c ri p t i o n of the p roced u re i n C h a pter 1 9
•
a n d Fig. 1 9 . 2 . )
R i b r a i s i n g ( S ee t h e d e sc r i p t i o n o f the p roced u re i n Ch a p te r 5 a n d Fig. 5 . 6 . )
• •
Para s p i n a l ( T 1 -L2 ) i n h i b i tion i n the s a me positions a s r i b ra i s i ng ( Se e C h a pter 5 . )
•
Re l a x o r d o me the thor acoa bdom i n a l d i a p h r a g m ( S e e the d e s c r i p t i o n o f the proced u re in C hapter 19 a n d Fig. 1 9 . 4 . ) Lym p h a ti c p u mp, t h o ra c i c (See the d es c r i p t i o n o f the proce d u re i n C h a pter 1 6
•
a n d Fig. 1 6 . 1 9 . ) •
Ped a l p u m p ( S ee t h e desc r i p t i o n o f t h e p roced u re i n Ch a p te r 1 0 a nd F i g . 1 0 . 3 . )
•
Trea t t h e p e l v i c d i a p h ra g m ( Se e t h e d e s c r ip t i o n o f t h e p roced u re i n C h a p t e r 9 a n d Figs . 9 . 1 1 a n d 9 . 1 2 . ) CV-4 ( S e e the d e s c r i p t i o n o f t h e proce d u re i n C h a p ter 1 0 a n d F i g . 1 0 . 1 . )
•
For a m ore e x te n s ive trea t m e n t , a d d t h e fo l l owi ng : Re lease o f m y o fa sc i a l restr i c t i o n of t h e f e e t , knees a n d l ower e x trem i t ies ( d i s -
•
c u ssed l a te r i n t h e c h a pte r ) •
S a c r u m ( See t h e descri p t i o n o f t h e proced u re i n C h a p te r 1 2 a n d F i g . 1 2. 5 . )
•
P i r i fo rm i s ( d i s c u s s e d l a t e r ) Psoas ( i f i n d i c a te d ) ( S ee t h e d es c r i ption o f t h e p roce d u re i n Cha pter 9 a n d
•
Fig. 9 . 3 . ) •
Faci l i ta ted p o s i t i o n a l re l e a se o r c o u n te rstra i n fo r thora c i c a n d l u m b a r reg i o n s
•
R i b b a l a ncing ( S e e F i g . 22 . 8 . )
dysfu n c t i o n ( S e e Figs . 1 3 . 2 a n d 1 3 . 4- 1 3 . 6 . ) •
C e r v i c a l s p i ne proced u re s ( S e e Figs . 1 2 . 1 , 1 6 . 6 , a n d 2 5 . 6 . )
•
Occ ipitoa t l a n ta l j o i n t ( See Figs . 1 6 . 1 2 a nd 2 5 . 7 . ) Cra n i u m ( See F i g s . 8 . 5-8 . 9 , 1 4 . 4- 1 4 . 7 , a n d 25 . 8-25 . 1 0 . )
Piriformis Muscle Tender Point (Coun terstrain) (Fig. 24. 3). T h i s proced u re i s e m p l oyed to a l l e v i a te t e n d e rn e s s of the p i r i fo rm i s m u s c l e . Pa t i e n t po s i t i o n : p r o n e . P h y s ic i a n pos i t i o n : s e a te d bes i d e the ta b l e a t t h e l e v e l of the p a t i e n t 's p e l v i s o n t h e s i d e of the dysfu n c t i o n a l p i r i form m u s c l e . P roce d u r e
1.
W i t h t h e i n dex f i n g e r of o n e h a n d , l o cate t h e t e n d e r p o i n t co m m o n l y fo u n d cen t ra l ly with i n t h e body of t h e p i riform i s m u s c l e a p p rox i m a t e l y m i dway between the i n f e ro l atera l a n g l e of t h e s a c r u m and the g re a t e r troc h a n t e r of t h e fe m u r. This h a n d p l a c e m e n t m u st be m a i n ta i n e d t h ro u g h o u t t h e p roced u re .
2.
Assess t h e d e g re e o f t i s s u e text u re a b n o r m a l i ty a n d t e n s i o n associated 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 ta l p ress u re a p p l i e d to t h e te n d e r p o i n t , d ete r m i n e t h e base l i n e sever ity of te n d e r n ess p rese n t . Ass i g n t h i s level of te n d e r n ess a v a l u e o f 1 0 0 % a n d i n f o r m t h e pa t i e n t .
3.
H a ve t h e p a t i e n t s l i d e t h e p e l v i s towa rd y o u s o t h a t t h e h i p o n t h e s i d e o f t h e dys f u n ct i o n a l p i rifo r m i s m u s c l e is a t the e d g e of the treat m e n t t a b l e .
4.
W i t h you 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 a n k l e c l o s e r to y o u , f l e x t h e k n ee , a n d
l o we r it off t h e s i d e o f t h e s i d e o f t h e trea t m e n t t a b l e , f l e x i n g t h e h i p . At t h i s p o i n t ,
376
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P i r i fo r m i s t e n d e r p o i nt, co u n t e rst ra i n , e m p l o y e d to a l l ev i ate t e n d e r n ess of t h e p i r i f o r m m u sc l e .
y o u m a y f i n d i t e a s i est t o s u p p o rt t h e p a t i e n t 's t h i g h b y h o l d i n g t h e i r k n e e between yo u r k n e e s .
5.
F u rt h e r adj ust h i p f l e x i o n a n d exte n s i o n , a b d u ction a n d a d d u ct i o n , a n d inte r n a l a n d exte r n a l rota t i o n by movi ng the p a t i e n t 's k n e e w i t h yo u r k n ees to obta i n m a xi m u m red u ct i o n o f 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. I t i s g e n e ra l l y t h o u g h t that when t h e patient is p roperly positi o n e d , perceived t e n d e r n ess sho u l d be decreased to no m o re than 3 0 % of the 1 00 % esta b l i s h e d i n ste p 2 .
6.
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 c t i o n 90 seco n d s , t h e n s l ow l y ret u r n t h e pat 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 i s i m p o rt a n t not to r e m ove yo u r m o n i t o r i n g fi n g e r d u r i n g the c o u rs e of t h e p roced u re so that you c a n b e c e rta i n t h e red u c t i o n i n te n d e r n ess p o st treatm e n t occu rred s p e c i f i ca l ly in the o r i g i n a l tender p o i n t
7.
Reassess t h e t e n d e r p o i n t f o r res i d u a l t e n d e r n es s .
Hamstring Release (Myofascial Release) (Fig. 24. 4) T hi s procedure is employed to decrease hamstring hype rtonicity. It empl oys the principles of counterstrain to treat d ys fu nction between agonist and antagonist m u scle groups. A specific tender point is not necessarily present. The p hysician loads the antagonist and unloads the agonist. This may be considered a direct myofascial release to the antagonist or an indirect technique to the agonist. Patient position: prone. Physician position : standing at the side of the treatment table on the side of the dysfunctional hamstring muscle or muscles. Proced u re 1.
U s i n g both h a n d s , p a l pate t h e dysfu n c t i o n a l h a mst r i n g m u s c l e to i d e n t i fy i n c reased m u s c u l a r ten s i o n . Keep one h a n d i n c o n t a ct with t h i s a rea t h ro u g h o u t t h e rem a i n d e r o f t h e p ro ce d u re .
Chapter 24 • T h e P a t i e n t w i t h F i b r o m y a l g i a
F I G U R E 24.4
2.
377
H a m st r i n g r e l ease, e m p l oyed t o decease h a m st r i n g h y p e rto n i city.
With your other h a n d , grasp the a n k l e of the dysfu n ct i o n a l lower extrem ity and sl owly flex the p a t i e n t 's knee u n t i l y o u pa l pate decreased ten s i o n in the dysfu n ct i o n a l ha mstri n g m u s c l e . I n t h i s pos i t i o n , t h e p a t i e n t s h o u l d f e e l t e n s i o n i n t h e i r a nt e r i o r t h i g h m u sc u l at u re . T h u s , y o u h a ve u n l oaded the h a mst r i n g (a g o n i st) m u scles a n d l oa d e d the q u a d riceps ( a n ta g o n i st).
3.
It may be necessa ry to i n troduce s m a l l a m o u n ts of i nte r n a l o r exte r n a l rota t i o n of the tibia, o r tra n s l at i o n of t h e ha mstri n g g ro u p m ed i a l ly o r l atera l l y with y o u r m o n i tor ing h a n d u n t i l yo u feel the l e a st a m o u nt of te n s i o n in the h a mstri n g . The p u rpose of the p roced u re is to i d e n tify the p o s i t i o n of g reatest re d u ct i o n of t i s s u e te n s i o n .
4.
H o l d t h e p o s i t i o n a n d wa i t f o r a re l e a se, t h e p e rc e pt i o n of relaxat i o n of te n s i o n , to o c c u r. S l o w l y ret u r n t h e l e g down to t h e ta b l e .
5.
Reassess h a mstr i n g m u scu l a r t e n s i o n a n d te n d e r n e s s .
Knee (Myofascial Release) (Fig. 24. 5) This procedure is employed to a l leviate fa scia l restriction a nd i mp rove k n ee func tion . I t is pa rt icul a rly beneficial for treating tibia l torsion, a dysfunction in which the tibia is interna l l y or externall y rotated relative to the fem u r. This p rocedure may be performed with either direct or indirec t treatment principles. Pat i ent position: supine. Physician position : standing at the side of the treat ment table on the side of the dysf unctional knee. Proce d u re 1.
Sta n d i n g w i t h yo u r we i g h t u p o n o n e l e g , f l ex yo u r oth e r h i p a n d k n e e a n d p l a ce t h a t k n ee u p o n t h e treat m e n t ta b l e w i t h y o u r th i g h b e n e a t h t h e p a t i e n t 's dysfu nc t i o n a l knee, thus i n trod u c i n g s l i g h t f l e x i o n o f t h e p a t i e n t 's knee. Yo u may also acco m p l i s h this b y p l a c i n g a p i l low beneath t h e p a t i e n t 's k n e e .
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F I G U R E 24. S
2.
T h e posit i o n for t h i s p r o ce d u r e may be e m p l oyed to a l l ev i ate fasci a l rest r i c t i o n a n d i m prove k n e e f u n ct i o n a n d to treat dysfu n ct i o n between t h e t i b i a a n d fem u r.
P l a ce o n e of yo u r h a n d s u p o n t h e p a t i e n t 's a n te r i o r t h i g h j u st p roxi m a l to t h e pate l l a a n d yo u r oth e r h a n d u p o n t h e a n t e r i o r t i b i a a t t h e l eve l of t h e t i b i a l t u be ro s i ty.
3.
U s e t h i s h a n d p l a ce m e n t to assess myofa s c i a l t e n s i o n of t h e k n e e by g e n t l y a p p l y i n g a l te r n a t i n g le ft a n d r i g h t l a te r a l tra n s l a t i o n , i n te r n a l a n d exte r n a l rotat i o n , a n d co m p ress i o n a n d d i stract i o n betwe e n t h e t i b i a a n d fem u r. F o r e a c h o f t h ese m o t i o n p a i rs , i d e n tify t h e d i rect i o n s of ease a n d o f rest r i ct i o n .
4.
To p e rform d i rect m yofa sci a l re l e a s e , e n g a g e t h e res t r i c t ive b a r r i e r or b a r r i e rs , mov i n g the t i b i a i n re l a t i o n to the fe m u r in the d i rect i o n of the res t r i c t i o n s of l a tera l tra n s l a t i o n , rotati o n , a n d co m p ress i o n a n d d i s t ra ct i o n . H o l d t h i s p o s i t i o n a n d wa it for a n i n h erent re l e a s e o r softe n i n g of tissue tens i o n .
5.
To p e rform i n d i rect myofa s c i a l re l e a s e , move away from t h e rest r i ctive b a r r i e r o r b a r r i e rs , m ovi n g t h e t i b i a I n re l a t i o n t o t h e fem u r i n t h e d i rect i o n o f ease o f l a tera l t r a n s l a t i o n , rot a t i o n , a n d co m p re s s i o n a n d d i stracti o n . H o l d t h i s p o s i t i o n a n d wait f o r an i n h e r e n t re l e a s e o r softe n i n g of t i s s u e t e n s i o n .
6.
Reassess t h e dysfu n ct i o n a l k n e e .
Tibiofibular Balancing (Indirect) (Fig. 24. 6) P a t i e n t p o s i t i o n : s u p i ne . Physic i a n p o s i t i o n : s tan d i n g a t t h e s i d e of the tre a t m e n t
ta ble
on
the s i d e of t h e dysfu nc t i o nal k n ee.
Proced u re
1.
Sta n d i n g w i t h yo u r w e i g h t u p o n o n e l e g , f l ex you r other h i p a n d k n ee a n d p l a ce that k n e e u p o n t h e t re a t m e n t table with yo u r t h i g h b e n e a t h the p a t i e nt's dysf u n ct i o n a l
379
C h a pter 24 • The Pat i ent w i t h Fibromya l g ia
F I G U R E 24. 6
This procedure i s e m ployed t o treat dysfunction betwe en the t i b i a and fi b u l a .
k n e e , t h u s i n t rod u c i n g s l i g h t f l e x i o n o f t h e p a t i e n t 's k n e e . Yo u m a y a l so a c co m p l i s h t h i s b y p l a c i n g a p i l low b e n e a t h t h e p a t i e n t 's k n e e .
2.
P l ace o n e o f you r h a n d s u p o n t h e p a t i e n t 's a n t e r i o r t i b i a at t h e l e v e l o f t h e t i b i a l t u b e ro s ity w i t h yo u r t h u m b p o s i t i o n e d l a t e r a l l y to m o n i t o r m ot i o n of t h e p roxi m a l f i b u l a . T h i s i s yo u r p a s s i v e , m o n ito r i n g h a n d .
3.
P l a ce yo u r o t h e r h a n d on t h e a n t e r i o r a s p ect of t h e p a t i e n t 's a n k l e i n s u c h
a
man
n e r t h a t yo u c a n g ra s p t h e a n k l e b etwe e n yo u r t h u m b a n d i n d e x f i n g e r. T h i s i s yo u r active h a n d .
4.
Use yo u r a ctive h a n d t o i ntrod uce i n t e r n a l a n d exte r n a l rot a t i o n b etwee n t h e t i b i a a n d t h e f i b u l a a ro u n d the l o n g it u d i n a l axis o f t h e l e g a n d i d e n t i fy t h e d i re ct i o n o f ease a n d of restricti o n . The re lati o n s h i p betwe e n t h e t i b i a a n d fi b u l a i s s u c h t h a t a s yo u i ntro d u ce I n te r n a l rotation of the leg at the d i stal t i b i of i b u l a r a rt i c u l atio n , the l a t e ra l m a l l e o l u s w i l l be d rawn a n terio rly, and s i m u lta n e o u s ly, at the p rox i m a l t i b i o f i b u l a r a rt i c u l a t i o n , the f i b u l a s h o u l d move post e r i o r l y.
5.
C o nverse ly, as you i n trod u ce exte r n a l rotat i o n of the leg at t h e d istal t i b i ofi b u l a r a rt i c u l a t i o n , the l atera l m a l l e o l u s wi l l be p u s h e d poste r i o rly, a n d s i m u l ta n eo u s ly, at t h e p rox i m a l t i b i ofi b u l a r a rtic u l atio n , the fi b u l a s h o u l d m ove a n te r i o rly.
6.
To p e rfo rm i n d i rect myofasc i a l release m ove away from t h e rest rictive b a r r i e r or b a rri ers, movi n g t h e fi b u l a i n re l a t i o n to t h e t i b i a i n t h e d i re c t i o n of ease. H o l d t h i s posi t i o n and wa it for a n i n h e rent re l ease o r softe n i n g of tiss u e t e n s i o n .
7.
Reassess t h e m ot i o n b e twe e n t h e t i b i a a n d f i b u l a .
Plantar Fascial Tender Poin t (Counterstrain) (Fig.
24. 7)
T h i s p r o ce d u re i s e m p l oyed to a l l ev i a te t e n d e r n e s s o f the p l a nta r fa s c i a a t i ts i n ser tion o n the c a l c a n e u s . Pa t i e n t p o s i t i o n :
supine. P h y s ic i a n p o s i ti o n : s e a ted a t the foot o f t h e trea t m e n t
ta b l e . Proce d u re 1.
W i t h t h e i n d e x fi n g e r of o n e h a n d , l o c a t e t h e te n d e r po i n t on t h e i n f e r i o r s u rface of t h e c a l c a n e u s , w h e re t h e p l a n t a r fasc i a i n serts. This h a n d p l a c e m e n t m u st be m a i n ta i n ed t h ro u g h o u t t h e p roced u re .
Section I I I • Cl i n i ca l C o n d i t i o n s
380
F I G U R E 24.7
2.
P l a n t a r f a sc i a l t e n d e r p o i nt, cou nterst ra i n , e m p l oyed to a l l ev i ate t e n d e r n ess of the p l a n t a r fascia at its i n s e rt i o n on the ca l ca n e u s .
Assess t h e d e g ree of t i s s u e textu re a b n o r m a l i ty a n d ten s i o n a s s o c i a t e d w i t h the te n d e r p o i n t By i n cre a s i n g t h e a m o u n t of d i g i ta l p ress u re a p p l i e d t o t h e t e n d e r p o i nt, d et e r m i n e the b a se l i n e seve r i ty of t e n d e r ness . 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 f o r m the p at i e n t .
3.
G ra s p t h e d i st a l p o rt i o n of t h e p a i n f u l foot w i t h y o u r o t h e r h a n d , p l a n t a r flex t h e a n k l e , a n d f l e x t h e toes to o b ta i n m a x i m u m re d u ct i o n o f p a l p a b l e t i s s u e t e n s i o n a n d te n d e r n ess . S u p i n a t i o n o r p ro n a t i o n of t h e f o o t m a y a l so be req u i red to obta i n t h e o pt i m a l p o s i t i o n i n g . It i s g e n e ra l l y t h o u g h t t h at w h e n t h e p a t i e n t i s properly p o s i t i o n e d , p e rce ived t e n d e r n ess s h o u l d b e d ec re a s e d to no m o re than 30% of t h e
1 0 0 % esta b l i s h e d i n ste p 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 p a l p a b l e tiss 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
90 s e co 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 t o t h e o n 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 n o t to r e 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 c o u rse of the p roced u re so y o u c a n b e c e rta i n t h e re d u c t i o n i n t e n d e r n e s s p o st t re at m e n t o c c u r red s p e c i f i c a l l y i n the o r i g i n a l tender p o i n t
5.
R e a ssess p l a n t a r fa s c i a l t e n d e r n e s s a n d t i s s u e text u re .
Refe rences 1. C h ro n iC fa t ig u e s y n d r o m e : D i a g n os i s a n d M a n a ge m e n c . Tr a i n i ng M a n u a l . R e v e d . A col l a b o ra t i v e e ffo r t o f t h e Cen ters for D i s e a se C o n t r o l a nd Prevention a n d t h e CF l D S Assoc i a t i o n o f A m er i c a . A t l a n t a : CFlD S Assoc i a t i o n o f A m e r i ca ; C e n te r s f o r D i sease C o n t rol a n d Preven r i o n , 2 0 0 3 ; 8 . 2 . C ra i g T, I< a k u m a n u
S . C h r o n i c fa t i g ue s y n d r o me : E v a l u a t i o n a n d trea t m e n t . A m F a m
Physician 2002; 6 5 : 1 0 8 3 - 1 0 9 0 , 1 09 5 . 3 . JVlil l e a PJ , H o l l ow a y
R L . Tre a t i ng f i b r o m y a lg i a . A m Fa m P h y s i c i a n 2 0 0 0 ; 6 2 : 1 5 7 5 - 1 5 8 2 ,
1587.
T R , P a p a n i co l a o u D A , A m s tern a m J D , e t a l . I m m u n o lo g i c a s pects o f c h ro n i c fa t i g u e t h e CFlDS Associ a t i o n o f America a nd cos p o n s o re d by the US C e n ters fo r D i sease C o n t r o l a nd Prev e n r i o n a n d t h e N a t i o n a l I n s t i t u tes o f He a l t h . Neu ro i m m u n o m o d u l a t i o n 2 0 0 4 ; 1 1 : 3 5 1 -3 5 7 .
4 . Gerrity
s y n d r o m e . R e p o n o n a Resea r c h S y mposi u m c o n v e n e d b y
Chapter 24 • The Pati e n t w i t h F i b ro m y a l g i a
381
5 . Tei t e l b a u m ] . F r o m F a t i g u e d to F a n ta s t i c . N e w Yo r k : P e n g u i n P u tn a m , 20 0 1 ; ! . 6 . C h ro n i c fa t i g u e s y n d r o m e F a c t S h e e r . N a t io n a l I ns t i t u re of A l l e r g y a nd I n fe c t i o u s D i s eases
We bs i re . L a s t u p d a red May 2 0 0 4 . Ava i la b le at hrtp/w ww. n i a i d h . n l h .gov/fa c t s h e e ts/cfs . h tm . Accessed M a y 4 , 2 0 0 S . 7. C h r o n i c fa t i g u e s y n d rome: D i a g n os i s a n d M a n age m e n t . Tra i n i n g
Ma n u a l . Rev ed . A c o ll a b
o r a r i v e e ffo rt of the Cenrers fo r D i s e d s e Co n t r o l a n d P r e v e m i o n a n d t h e C F l D S Assoc i a ri o n o f A m e rlca , I n c . A t l a n ta , G A : C F I D S A s s oc i a t i o n o f A m e r i c a ; Centers f o r D i se a s e C o n t r o l a n d P r e v e nt i o n , 2 0 0 3 : 1 .
F, S m y te H A , Yu n u s M B , et a l . T h e A m e r i c a n Co l l ege o f R b e u nl a tology 1 9 9 0 C r i te r i a
8 . Wo l fe
fo r the C l a s s i fi ca t i o n o f F i b r om y a l g i a . R e p o r t o f t h e M u l ticen ter C r i te r i a C o m m i t tee. Arthritis R h e u m 1 9 90;3 3 : 1 7 1 .
9 . Wo l fe F, S m y t h e H A , Yu n u s M B,
et
a l . The A m e rica n C o l l ege o f R h e u m a tol ogy 1 9 9 0 C r i r e r i a
f o r t h e C l a s s i ficarion o f F i bromy a l g i a . R e p o r r of t h e M u l t i c e n t e r C r i te r i a C o m m i ttee. A r t h r i t i s R h e u m 1 9 9 0 ; 3 3 : 1 6 0- 1 72 . 1 0 . Lentz
Mj ,
L a n d i s C A , R o t he r m e l j , S h a v e r j L . E ffects o f s e lective s l o w w a v e s l eep d i s r u p t i o n
on m u sc u loskel eta l
pa i n
and
fa t i g u e
in
middle
a ge d
wom e n .
j
R h e u m a to l
1 9 99;26:
1 5 8 6- 1 5 9 2 .
1. 1 . Hudson j l , Golden berg D L , P o p e H G j r, et a 1 . Comorb i d ity o f f i b ro m y a l g i a w i th m e d i c a l and psyc h i a t r i c d i s o r d e r s . 1 2 . Okada
Am J
M e d 1 9 92 ; 9 2 : 3 6 3 -3 6 7 . et
T, Ta na k a M , I< u ra ts u n e H,
a l . Mech a n i s m s u n d e r l y i n g fa t i g u e : A v o x e l - b a s e d mor
p h o m e t r i c study o f c h ro n i c fa t i g u e s y n d ro m e . B M C N e u r o l 2 0 0 4 ; 4 ( l j : 1 4 .
1 3 . Ya m a m o ro S , O u c h i Y, Onoe H , e t a l . R e d u c t i o n o f s e r o to n i n tra n s p o r rers o f pa tie nrs w i t h c h ro n i c fa t i g u e s y n cl r o m e . N e u f o r e p o r t 2 0 04 ; 1 5 : 2 5 7 1 -2 5 7 4 . 1 4 . N a m p i a p d rJ lll P i l D E , S h m e r l i n g R H . A r e v i e w o f fi b ro lll y a i gia . A m j M a n ag Care 2 0 04 ; 1 0 (1 1 Pt 1 ) : 7 9 4 - 8 0 0 . 1 5 . K o m a r o f f A t . T h e b i o l o gy o f c h r o n ic fa tig u e s y n d ro m e . A m j Med 2 0 0 0 ; 1 0 8 : 1 6 9- 1 7 1. 1 6 . K o m a r o f f A L, B u c h w a l d O S . C h r o n i c fa t i g u e s y n d r o m e : An u p d a t e . I n : Cogg i n s C H , H a n cock EW, Levitt J J , e d s . A n n u a l R e v i e w o f Med i c i n e . P a l o A l to , C A : A n n u a l R e v i ews, 1 99 8 ;49: 1 - 1 3 . 1 7 . R u s s e l l Ij , O r r M D , L i r rm a n G , e t
a l . E l e va ted c e r e b ro s p i n a l flu i d l e v e l s o f s u bsta n c e P i n
p a t i ents w i t h the fi b r o m y a l g i a s y n d ro m e . A r t h r i t i s R h e u m 1 9 9 4 ; 3 7 : 1 5 9 3 - 1 6 0 1 . 1 8 . Dern i track M A , Cro fford
LJ . E V i d e n ce
fo r a n d pa r h op h y siolog i c im p l i ca t i o n s o f hypotha l a m ic
p i tu i t a r y -a d re n a l a x i s d ysregu l a t i o n i n fi b r o m y a l g i a and ch ronic fa t i g u e s y n d ro m e . Ann
NY
A c a d Sci 1 9 9 8 ; 8 4 0 : 6 8 4 -6 9 7 . 1 9.
B o u - H o l a i g a h r, Ca lk i n s H , F l y n n j A , e t a l . Provoca t i o n o f h y p o te n s i o n a n d p a i n d u ring
u p r i g h t t i l t ta b l e tes ting in a d u l ts w i th fi b ro m y a l g i a . C l i n Exp R h e u m a r o l 1 9 9 7 ; 1 5 : 2 3 9 -2 4 6 .
2 0 . D e m i tra cJ< M A , D a l e j I< , Stra u s S E , e t a l . E v i dence fo r i m p a ired a c ti v a t i o n o f t h e h y p o t ha la
m i c - p i t u i ta ry - a d re n a l a x i s i n p a t i e n ts w i t h c h r o n i c fa t i g u e s y n d r o m e . j C l i n E n d o c r i n o l Meta b 1 9 9 1 ; 7 3 : 12 2 4- 1 2 3 4 . 2 1 . Wi l l a rd
F H . Noc i ce p t i o n , t h e neu roend o c r i ne i m m u n e s y s t e m , a n d osteopa t h i c m e d ic i n e . I n :
Wa r d R C , ed . Fo u n d a t i o n s fo r Osteo p a rh ic Med 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 ncott Wi l l i a m s & Wi l k i n s, 2 0 0 2 ; 1 3 7- 1 5 6 . 2 2 . J o h n ] F, e d . A Conse ns u s M a n u a l fo r t h e P r i m a ry Ca re a nd Ma n a g em e n t o f c h r o n ic fa t i gu e s y n d rom e . Ac a d e m y of M e d i c i n e o f New Je rsey, U n i v e r s i t y of M e d i c i n e a n d D e n t is r r y o f New j e rsey, and N e w jersey Depa r t m e n t o f Hea l t h a n d Sen ior Services. March 2 0 0 2; 1 1 . 2 3 . W h i t i n g C A . I n ves t i g a t i o n o f t h e
p h a gocy t i c i nd ex . Bu l le t i n 1 . AT S ti l l R e s e a rch I n s t i tu te .
C i n c i n n a t i , O H : M o n fo r d , 1 9 1 0 ; 6 1 -6 3 . 2 4 . S m i th
R I< . O n e h u n d red t h o u s a n d cases o f i n fl u e nz a w i t h a d e a t h ta te o f o ne - fortieth o f t h a t u n d e r c o n ve n t i ona l m e d i ca l trea t m e n t . j Am Osteo p a t h A s soc 1 9 2 0 ;
o ffi c i a l l y repo rted 1 9 : 1 72-1 7 5 . 25. Measel
j W j r.
The e f fect o f t h e l y m p h a t i c p u m p u p o n t h e i m m u n e res p o n se : . I. P r e l i m i na r y
s t u d i e s on t h e a n ti b o d y r e s p o n s e to p n e u m oc occ a l p o l y s a cch a t i d e assa yed by b a c te r i a l a g g l u r i n a ti o n a n d p a ss i v e h e m a ggl u t i n a t i o n . J A m O s te o p a th A s soc 1 9 8 2 ; 8 2 : 2 8 -3 1 . 2 6 . K i n g H H , La y
EM. O s t e op a th y in the cra n i a l fi e l d . I n : Wa rd RC, ed . F o u n da r ions for
Osteopa t h i c IVled i c i n e . 2 n d ed . P h i l a d e l ph i a : Li p p i ncott W i l l i a ms & W i l k i ns, 2 0 0 2 ; 9 8 5 - 1 00 l . 2 7 . Te i te l b a u m ] , Bird
B . Effec t i v e tre a t m e n t o f c h ron i c fa t i g u e s y n d r o m e a nd F M S : A ra n d o m
ized , d o u b l e - b l i n d p l a c e b o contro l l ed s t u d y. j C h r o n i c F a t i g u e S y n d ro m e 20 0 1 ; 8 ( 2 ) .
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Section III • Cl inical Conditi ons
C l e a re
AJ, Hea p E, M a l h i GS, e t a J . Low-dose h y d rocortisone in c h r o n ic fa t i g u e s y n d r o m e : A ra n d o m i sed crossover tria l . La ncet 1 9 9 9 ; 3 5 3 : 4 5 5 -4 5 8 . 2 9 . Tei te l ba u m J , B i r d B . E ffec t i v e t re a tm e n t o f se vere c h r o n i c fa t i g u e : A r e p o r t o f a s e r i e s o f 6 4 p a t i e n t s . J M u s c u l os kel eta l P a i n 1 9 9 5 ; 3 ( 4 ) : 9 1 -1 1 0 . 3 0 . J e ffe r ie s W M . S a fe Uses o f Corti s o l . 2 n d Ed . S p r ingfield , I L: Cha r l es C . T h o m a s, 1. 9 9 6 [ m o n o g ra p h l . 3 1 . J e fferi es WM . Low-dosage g l ucoco rticoid thera p y : An a p pra isal of its s a fe ty a nd mode o f a c t i o n i n c l i n ica l d i s o r d e r s , in c l u d ing rheu m a to i d a rt h r i t i s A rc h l n r e rn Med 1 9 6 7 ; 1 J 9 : 2 65 -2 7 8 . 28.
.
The Patient with Chronic Pain, Headache Thomas M. Richards
INTRODUCTION More than 50 million workdays are lost each year to pain, the second leading cause of medically related work absenteeism. I I n addition to absenteeism, most pain-related lost p r oduct ive time has been shown to occur in the fo rm of reduced p e r fo r man c e while at work.2 In the Un i ted States, the use of com plementary a nd alternative medicines (CAM) are on the rise.] Most p eopJe us e CAM to prevent and/or t re at mu scu loskeletal or other cond itions associated with chronic o r recurring pain. These co n d it ion s afflict one-quarter to one-third o f the adult U.S. popu latio n.4-9 Many forms of chronic pain r es i st conventionaJ medical treatment, so it is not surprising that so many seek alternat ive treatments.IO,11 In 1997 (the most recent y ear for which data are availa ble), it was estimated that betwee n $36 billion and $47 billion was spent by the U.S. p ublic on CAM th era pie s. s Between $12.2 billion and $19.6 b i l l i on was pai d out of pocket for the s ervices of profe s s i o n a l CAM health care provid ers (e . g., chiropractors, acupuncturists, and massage ther apists). This is more t ha n the U.S. p ub l i c paid o u t of pocket for all hospita lizations and about half that paid o ut of p ocke t for all physician s e rvices that same yearY Health plan provid ers repo rt that the cost effect of chronic pain is greater than that for all oth er typicall y diagnosed chronic conditi ons. 1.3 Thus, the costs of a cute and
383
384
Section III • Clinical Conditions
chronic pain to society, through consumption of health care services and lost pro ductivity, are enormous. Emotional costs and suffering are inestimable. The ideal way to treat any malady is to identify and treat the cause. Somatic dysfunction is a frequent primary, secondary, andlor sustaining cause of both acute and chronic pain. Optimum pain management requires the identification and appropriate trea tment of somatic dysfunction. \4-19 Somatic dysfunction is defined as impaired or altered function of related compo nents of the somatic (body fra mework) system: skeletal, arthrodial , and myofascial structures and related vascular, lymphatic, and neural elements.JS,17 It is characterized by palpation of tissue texture abnormality, asymmetry, restriction of motion, and tenderness (the standard osteopathic TART [tissue texture abnormality, asymmetry of position, restriction of motion, tenderness] criteria of somatic dysfunction).2o
Somatic Dysfunction Codes from the International Classification of Diseases, 9th Clinical Modification, 2005 739 Nonallopathic lesions not elsewhere classified Includes segmental and somatic dysfunctions
739.0 Head region Occipltocervical region
739.1 Cervical region Cervicothoracic region
739.2 Thoracic region Thoracolumbar region
739.3 Lumbar region Lumbosacral region
739.4 Sacral region Sacrococcygeal region Sacroiliac region
739.5 Pelvic region Hip region Pubic region
739.6 Lower extremities 739.7 Upper extremities Acromioclavicular region Sternoclavicular region
739.8 Rib cage Costochondral region Costovertebral region Sternochondral region
739.9 Abdomen and other
Chapter 25 • The Patient with Chronic Pain, Headache
385
Somatic dysfunction is treatable using osteopathic manipulative procedures,'9 and diagnoses can be coded in the International Classification of Diseases, Ninth Clinical Modification
(ICO-9CM) controlled vocabularies (Table 25.1).
Almost all physicians who administer osteopathic manipulative treatments (OMT) have treated patients with one procedure and observed "miraculous" cures. 16 This occurs usually when the etiology of the malady is acute somatic dys function, such as an occipitoatlantal dysfunction causing a muscle tension headache21.22 or a sacroiliac dysfunction causing sciatica.23 Likewise, they have seen patients who have a recurrent problem. These patients respond favorably to treatment, but as time passes, the problem returns to its pre rreatment state, only to respond again and again to treatment. Possible causes are inaccurate or incomplete diagnosis or some outside factor. Outside factors include ongoing misuse, as in repetitive use injuries, ongoing nociceptive perception, either central or peripheral, or something as simple as a short lower extremity. There has been much discussion24,25 about prolonged recurrent use of OMT for the same problem. When a patient presents with polyuria, polydipsia, and polypha gia, a blood sugar of 350, and a hemoglobin Al C of 10.2, the prescription might
include dietary control, an exercise program, and a blood sugar-lowering agent. When that patient's blood sugar and hemoglobin
Ale return to normal, the manag
ing physician does not discontinue therapy. Likewise, when a patient's hypertensive blood pressure returns to normal, the phy sician does not discontinue the antihyper tensives. A subset of patients require recurrent OMT to maintain optimal function ality. Patients in this category include some of those with chronic recurrent headaches26.27 or chronic recurrent back pain28 and those with chronic disease states with somatic dysfunction components, such as diabetes, hypertension, and chronic obstructive pulmonary disease,29.3o It is appropriate to evaluate and treat such patients every 3 or 4 weeks to
2 or 3 times per year.
There is no paucity of studies evaluating manual medicine for the treatment of
back pain.28.30--31 Such studies are viewed as comparable to studies evaluating the effi cacy of antibiotics in controlling fever or leukocytosis. OMT is not used to treat back pain; OMT is used to treat somatic dysfunction that may be the cause of back pain.
KINDS OF PAIN To alleviate pain effectively, it is essential to adequately assess its source or sources. Pain falls intO three physiological types, each with differing underlying mecha nisms that can occur independently or in combination.
Nociceptive Pain The nervous system possesses specialized nociceptive pain receptors on the tips of nerve cells that react to extreme temperatures (hot or cold), pressure, and sub stances released by other cells. These nerves can respond to burns, cuts, infections, inflammation, a severe lack of oxygen, or excessive pressure within or stretching of an organ.
Neuropathic Pain When nerves become abnormally active, the sensation of pain can result. This neuropathic pain occurs, for instance, in diabetic neuropathy and in the posther petic neuralgia that accompanies
a
shingles outbreak. Another example is the
386
Section I II • Cli nica l C o n d i t i o n s
pain associated with the phantom limb phenomenon, i n which abnormal ner ve acti vity causes pain to persist long past the time expected for healing of the injury. In other cases, the etiology of the pain can be very difficult to identify and treat. Diagnostic protocols are not standard. Neuropathic, nociceptive, and idiopathic pain may coexist. There is no consensus on the optimal management of neuro pathic pain. Treatment may invol ve drug therapies, in vasi ve therapies (ablati ve surgery, nerve blocks), and alternative therapies.34-37 Psychogenic Pain When no p h ys ical cause of pain can be identified, psychologic causes should be explored.38-40 No ma tter what the cause, the subjecti ve sensation of pain varies with every person and can be influenced by an indi vidual's attention to the pain, cultural learning, the percei ved meaning of the situation, and any number of other psychological variables.41 MODALITIES IN PAIN TREATMENT Numerous modalities, including pharmaceuticals, physical measures, physical therapy modalities, motion therapies, OMT, dietary measures, beha vior modifica tion, and invasi ve procedures, are available to treat pain (Table 25.2). Reflecting this range of options is the fact that com prehensive pain management is evolving as a multidisciplinary team approach. The team may include practition ers from many diverse specialty areas. One such team includes 19 providers from the following areas: primary care, neurology, anesthesiology, pa in management psychology, osteo pathic mani pulati ve medicine, physical therapy, pharmacy, occu pational medicine, and acupuncture. There is also a nurse practitioner, who man ages medications, and appointment coordinators. The team meets formally weekly to discuss selected new an d/or difficult patients. The osteopathic physicians func tion as an intake portal and administer OMT to patients with so matic dysfunction when indicated. The OMT practitioners were selected to serve as the intake portal for a number of reasons. Many chronic pain patients ha ve back pain or headache. Approximately 85% of back pain is idiopathic to the allopathic profession.42 The etiology of pain in many of these patients is somatic dysfunction. Manipulative medicine expertise in evaluating and treating somatic dysfunction that is causing the patient'S pain makes the osteopathic physician a valuable front-end asset to the team. These team members are able to identify and treat pain patients and fre quently can a void the expensi ve workups and interventions, such as invasive injec tion procedures and surgeries. The use o f OMT as an intervention, when effective, is extremely cost effecti ve, eliminating the need for the more invasive procedures. Also, in a subset of patients OM T appears to be synergistic with invasi ve injec tions, such as epidural steroid injection or lysis of epidural adhesions. Some who d id not initia lJy respond to OMT begin to respond after injections. An unantici pated benefit is the realization that a fair number of patients at the pain clinic have pain that is secondary to previously undiagnosed and untreated systemic disease, such as diabetes, thyroid disease, and the like. This benefit is believed to be the consequence o f osteopathic training, whose physicians are instructed in primary care with O MT. After treatment, patients are returned to their primary provider for further evaluation and treatment of their disorders.
Chapter 25 • The Patient with Chroni c Pain, Heada che
387
Modalities in Pain Treatment Pharmacologic Oploid analgesIcs Nonoploid analgesics Nonsteroidal anti-inflammatory drugs Muscle relaxarlts
OMT Dietary measures Improved nutrition Weight loss
Behavior modification
Antiseizure medications
Psychotherapy
Tricyclics
Biofeedback
Serotonin-specific reuptake Inhibitors
Hypnosis
Gabapentin
Invasive procedures
Anxiolytics
Trigger pOint injections
Physical measures
Prolo injections
Heat
Nerve blocks
Ice
Epidural steroids
Traction
Epidural lysis of adhesions
Physical therapy modalities Ultrasound Short -wave diathermy E-stim Transcutaneous electrical nerve stimulation Whirlpool
Facet injections Sympathetic blocks IDET Acupuncture Nucleoplasty Opioid pumps Intrathecal opioids
Motion therapies
Intrathecal baclofen
Stretching exercises
Radio frequency ablation
Strengthening exercises
Implantable cord and nerve stimulators
Yoga
Surgery
Tai chi
Rolfing
Aquatic therapy
Reiki
THE OSTEOPATHIC MODEL The role of osteopathic philosophy and medicine can be illustrated using headache as
a
model. The osteopathic philosophy dictates that osteopathic physicians treat
the whole
person. There are many good references on the treatment of headache.
Only the aspects of evaluation and treatment that are distinctively osteopathic are discllssed here.
Classification of Headaches The International Headache Society has classified headaches into 14 types with
more than 60 subtypes.43-45 Generally, these may be broken down into primary,
388
Section III • Clinical Conditions
International Classification of Headache Disorders (lCHD-2) Primary headaches
1.
Migraine
2.
Tension type
3.
Cluster headache and other trigeminal autonomic cephalalgia
4.
Other primary headaches
Secondary headaches
5.
Headache attributed to head and/or neck trauma
6.
Headache attributed to cranial or cervical vascular disorder
7.
Headache attributed to nonvascular intracranial disorder
8.
Headache attributed to
9.
Headache attributed to infection
a
substance or Its withdrawal
10.
Headache attributed to disorder of homoeostasis
11.
Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures
12.
Headache attributed to psychiatric disorder
Cranial neuralgias, central and primary facial pain, and other headaches
13.
Cranial neuralgias and central causes of facial pain
14.
Other headache, cranial neuralgia, central or primary facial pain
secondary, and other headaches (Table 25.3). The A m er i c a n Academy of Osteopathy i ncludes, in a level II course, training instruction on the osteopathic treatment of headache.46 The following is a d escr i pti on of some proced ures devel oped over the years that have been found to be useful in the manipulative treat ment of muscle tension, migraine, and cl uster headache secondary to somatic dys function and other headaches secondary to visceral disease.
Primary Versus Secondary Causes When diagnosing any headache, one should first d istinguish whether it is p rimary, secondary, or both. Headache with a close temporal rel at i o n to another disorder known to cause headache, a marked w o r se n i n g of a preexisting headache with the onset of the d isorder, good evidence that the d isorder can cause or aggravate tension headache, and improvement or resolution of tension headache after relief from the d isorder may be considered as being seco n da ry Disorders to consid er include head or neck trauma; cranial or cervical vascular d isorders; nonvascular intracranial d isorders; substance use or withdrawal; infection; disorders of home ostasis; d isorders of the cranium, neck, eyes, ears, nose sinuses, teeth, mouth or other facial or cranial structures; an d psy chiatric d isorders. As p a r t of the com plete h istory and physical, it is important to search for and note the red flags (Table 25.4), as OMT to the head and neck is contraind icated in many of these conditions. .
Chapter 25 • The Patient with Chronic Pain, Headache
389
Contraindications to OMT for the Head and Neck
Red Flag
Possible Cause
Diagnostic Test
Sudden-onset headache
Subarachnoid hemorrhage
Neuroimaging
Bleed into a mass or AVM
Lumbar puncture (after
Mass lesion (especially
neuroimaging evaluation)
posterior fossa) Mass lesion
Worsening headache
Neuroimaging
Subdural hematoma Medication overuse Headache with systemic illness (fever, neck stiffness, cutaneous rash)
Meningitis
Neuroimaging
Encephalitis
Lumbar puncture
Lyme disease
Biopsy
Systemic infection
Blood tests
Collagen vascular disease Arteritis Focal neurologic signs or
Mass lesion
Neurolmaging
symptoms other than
AVM
Collagen vascular
typical visual or sensory
Collagen vascular disease
evaluation
aura Papilledema
Mass lesion
Neuroimaging
Pseudotumor
Lumbar puncture (after
Encephalitis
neuroimaging evaluation)
Meningitis Triggered by cough, exertion or Valsalva
Subarachnoid hemorrhage
Neuroimaging
Mass lesion
Consider lumbar puncture
Cortical vein, cranial SinUS
Neuroimaging
maneuver Headache dUfing
thrombosis
pregnancy or postpartum
Carotid dissection Pituitary apoplexy New headache type In a patient with Cancer
Metastasis
Neuroimaging
Lyme disease
Meningoencephalitis
Neuroimagi ng
HIV
Opportunistic infection
Neuroimaging
Tumor
Lumbar puncture
Lumbar puncture Lumbar puncture
AVM,
arteriovenous malformation.
Adapted from Lipton RB, Bigal
ME,
Steiner
TJ,
et
at
Classification of primary headaches. Neurology
2004;63:427-435.
3 90
Section II I • Clinical Conditions
Muscle Tension Headache Tension headaches are the most common type of primary headache, having affected as many as 90% of adults, and they have the highest socioeconomic cost. Tension headaches affect both sides of the head, are typically steady rather than throbbing, and may be triggered in response to stressful events or a hectic day. Previously, this type of headache was considered to be psychogenic, but studies strongly suggest a neurobiological basis, especially for the more severe su btypes. The ICHD-2 (International Classification of Headache Disorders, second edi tion45) has divided this class of headache into infrequent and frequent, episodic, and chronic , with each class subdivided by whetl1er or not they are associated with pericranial tenderness. In the absence of evidence for a known causative disorder, a tension headache
should be considered primary and can be episodic or chronic. Infrequent episodic tension headaches are typically bilateral and last anywhere from 30 minutes to 7 days. To be considered episodic, there should be at least 10 episodes averaging
less than 1 day per month and fewer than 12 days per year. These headaches are of mild to moderate intensity unaccompanied by nausea. The pain is pressing or tightening in quality (not pulsating) and does not worsen with routine physical activity, such as walking or climbing stairs, but photophobia or phonophobia may be present. These headaches may or may not be accompanied by increased peri cranial tenderness on manual palpation. The presence of increased tenderness is the most significant abnormal finding in tension headache. It is detected by small rotating movements and a firm pressure with the second and third finger on the frontal, temporal, masseter, pterygoid, sternocleidomastoid, splenius, and trapez ius muscles. Frequent episodic tension headache is identical to infrequent episodic tension headache, the difference being that at least 10 episodes occur on more than one but fewer than 15 days per month for at least 3 months (at least 12 and fewer than 1 80 days per year). This type of headache frequently coexists with migraine with
out aura. Patients should be taught to differentiate between the two types so as to select
the right
procedure
and to prevent medication overuse headaches.
A diagnostic headache diary is useful in identifying coexisting frequent episodic
tension headaches in migraine patients. Chronic tension headaches gradually evolve from episodic tension headaches. These occur on more than 15 days per month for more than 3 months (more than 1 80 days a year) and are slightly more severe in that they may last hours or be con
tinuous and may be accompanied by photophobia, phonophobia, or mild (not moderate or severe) nausea. Look for somatic dysfunction as part of the comprehensive structur;)l examina tion. Anything from flat feet to occipitoatlantal compression associated with ten sion headache may be the primary etiology of the headache. Look at the occipital and suboccipital areas. The greater occipital nerve traverses the suboccipital trian gle. Increased tension in this group of muscles can compress the nerve, causing severe pain in the distribution of the nerve and exquisite tenderness over the nerve. Typical findings are dysfunction at the occipitoarlantal joint, Cl to C2, and/or C2 to C3. For the patient without contraindications, high-velocity, low-amplitude
(HVLA) treatment is preferred. Generally, HVLA may not be recommended in this area for geriatric patients. The positioning of the patient should not increase the headache or calise neck pain. If it does, select a differenr treatment procedure. Treatment using HVLA is preferred because the relief of pain is usuaUy immediate. Be careful using HVLA to C2, particularly on the left side, on the nauseated
Chapter 25 • The Patient with Chronic Pain, Headache
391
patient. It is possible to make the nausea severe and precipitate vomiting because a branch of the vagus innervates this area. The use of cervical and suboccipital HVLA has recently been controversial. (The
American Osteopathic Association
and
the American
Academy
of
Osteopathy have studied the issue and released a position paper that is included in its entirety in the Appendix.) Sutherland's occipitoatlanral decompression procedure is a cranial procedure that is commonly useful prior to HVLAY Soft tissue treatment to the cervical area along with myofascial release and counterstrain are also useful procedures in this area. Rarely is cervical dysfunction found without related dysfunction in the upper thoracic area. T2 to T4 dysfunctions are common, as the sympathetic nerves to the head and neck originate in the upper thoracic region. The upper four ribs are also commonly involved, with the first and second ribs held in inhalation and the third and forth held in exhalation. Remember that the insertion of the scalenes is on the first and second ribs. It is usually better to treat thoracic dysfunctions prior to treating cervical dysfunctions. Other areas of attention include the thoracolumbar junction, the sacral base, and the feet. During a headache or an initial visit, it is usually not necessary to treat more than the upper thoracic region, the cervicals, and the occipitoatlantal joint. It is very easy to overtreat. Treat other areas on follow-up visits as needed. When recurring dysfunctional patterns in the cervical and thoracic areas are encoun tered, look lower for the primary cause. Remember, the osteopathic physician facilitates healing, but the healing comes from within. Two old adages apply here: "Find it, fix it, and leave it alone," and "Treat what you find, not what you expect to find. " The use of OMT to treat somatic dysfunction associated with tension headache is not to be done to the exclusion of other modalities, such as medications, exercise, and addressing any psychosocial issues. Myofascial release procedures that can be performed at home can be taught to many patients with muscle tension headaches (Fig.
25.1). It is imperative that the procedure be done
exactly as described. It is not recommended that these procedures be taught to the elderly patient or to patients with cerebral or vertebral basilar artery disease or severe cervical joint disease.
Migraine Headache By definition migraine headaches are recurrent and are one-sided, pulsating or throbbing. They produce moderate to severe pain that interferes with or prevents normal activity and that worsens during ordinary daily activities. They are accom panied by nausea or vomiting, photophobia, and phonophobia. Frequently, migraines are foretold by symptoms that include various combinations of fatigue, difficulty in concentration, sensitivity to light or sound, neck stiffness, blurred vision, nausea, yawning, or pallor. These premonitory symptoms generally occur hours to a day or two before a migraine attack. An aura is a complex of neurological symptoms that occurs just before or at the
onset of a migraine headache. The aura may manifest itself as fully reversible visual symptoms, such as flickering lights, spots or lines, or loss of vision, fully
reversible sensory symptoms, such as pins and needles or numbness, or fully reversible dysphasic speech disturbance. These may develop over more than
5 min
utes and may occur in succession, each lasting less than 60 minutes. Migraine headache is categorized as being with or without aura. A genetic form of migraine,
392
Section III • Clinical Conditions
A
FIGURE 25.1
Myofascial release procedures that can be self-administered by the patient at home. These procedures are also used to test for abnormal
muscle contraction associated with chronic headache. (A) The first step consists of simple rotation of the head through its full range. There should be no tilting of the head, and the chin should be kept on the same plane throughout the rotation. (B) The second step consists of plac ing the thumb under the chin and holding the head in full rotation by pressing against the chin with the flexed fingers. Then the chin should be elevated 1 or 2 inches. (C) The third step consists of lateral bending of the fully rotated head and neck. This maneuver should be done slowly and gently and should not cause pain or dizziness; it should be done in the area where the head and neck join, not in the lower or mid portion of the neck. If this maneuver is done correctly, there will be a stretching pulling sensation just below the superior nuchal line. (Reprinted with per mission from Peterson DI. Headache: Modern concepts of diagnosis and management. Primary Care 1984;11 :707-721.)
familial he miplegic migraine, is accompanied by both an aura and motor weak ness. The ICHD-2 id entifies further subtypes of migraine as well. In diagnosing migraine, it is particularly important to rule out other underlying somatic causes, because presenting sy mptoms between primary and secondary migraines may be indistinguishable. A particularly striking example is a report of two patients with identical presentations appearing as migraines. One was second ary to a patent foramen ovale in the heart. The other was assoc iated with increased paravertebral muscle tension of the mid to lower cervical and upper thoracic spine bilaterally and a somatic dysfunction at the atlantoaxial area that was revealed upon .osteopathic examination and almost completely resolved by OMT.48 New oral abortive pharmacotherapeutic agents (triptans) have been successfully used to treat migraine attacks and provide an ad dition to the armamentarium of the osteo pathic physician.49
Chapter 25 • The Patient with Chronic Pain, Headache
Migr a i ne headache is produced by
393
constriction followed by d ilati o n of the
intracrania l vessels. Besides being responsive to dr ugs, such as nitrates and a lpha
blockers, the a r teries are under the control of the sympathetic nervous system. The
headache a ssoc ia ted with cons u m ptio n of ni trog lyce ri n e is in a sense a migraine . The s y m p a thet i c innervation of the blood vessels in t he cranium reache s the ves
sels by way of mult iple g a nglia and the trigeminal ner ve. The tr i gem in a l nerve sup plies thr ee - four t hs of the sensory fibers to the meninges.50 The middle meningeal
artery crosses t h e s phenosq uamo u s articulation and is in approximation to the
sphenosquamous pi vo t. Impaction of the s ph eno s q ua m ous pivot is a fai rly com
in mig r a i ne patients. Any dysfunct i on of the te m po ral bone can result in m ig r a i n e attacks beca use of its rel a tionsh ip w i t h the trige m inal gangl i o n and
mon finding
trigeminal n e r ve . Nausea and vomiting with m igrain e may be due to
vagal
involve
foramen acco mpan ied by tensio n on the dural sleeve. 50 W h en e v a lu ating patients with migraine , pay attention to the cranium, particu
ment at the j ugular
lar ly t h e s pheno basil a r area, the temporal bone, the s phen os q uam o us pivot, and
the j ugu lar foramen. Also look at the subocci p it al area, C2 ( vagus involvement), and the upper thor ac ic spine and associated ribs. The role of the sympath e tic nerv system in many pain states is s up por ted by t h e observation that s ympathec
ous
tomies can atten u ate the anomalous pain states leading to t he d iagnosi s of sympa t h e tica l ly de penden t pain.51-53 Cranial O M T is best l eft to visits between mig r aine attacks, using a pprop ria t e proced u res to free the sp henoba silar a nd the tem po ral re gion s . 5o Treat the cervical dysfu n ctions with indirect proced u re, balanced liga
mentous tension, or very gentle d ir ect myofasc ial release so as not to fu rt he r stim
Any ap prop riate procedure can be used to normalize the fun ction of the upper thoracic and rib dys fu nctio ns . Do not n eg l ect jo n es 's co u nterstrai n
ulate the vagus.
poi nts for the suboccip i ta l area and the inion p o in t. Also, recall t h a t the inion point is frequenrly a maverick, and the position of treatment is just the o ppos i te of
what one would expecr.54 Remember, the last thing pa tie n rs want d u ri ng
a
migrain e attack is someone cran k ing their head around. It is not reco mme n ded that the
HVLA procedure be used for cervical or subocc i p i tal dysfunction during
the acute p hase of a m i graine , as it fre q uen tly aggravates the headache. The use of OMT to treat soma t ic d ysfun ctio n associated with migraine h eadache
is not to the
exclusion of other modalities, such as avoidance of trigge r s , medications, exercise,
and addressing any p syc hosocia l
issues.
Cluster Headache Cluster headaches are grou ped with other trigeminal autonomic ce p halalgias . They are cha ra cter i ze d by severe to very severe unilateral pain in and around one eye. Attacks are brief
(30 min utes to 2 h o u rs ) and happen from once every other
d ay lip to eight times per day in clusters that typica ll y last for a few mon ths . Epi sodic cluster headaches may occur in periods lasting 7 d ays to a year separated
by pain -f ree per i ods lasti n g a mo n t h or longer. Chronic cluster headaches occur for more than a y ear without remission or with remiss i ons last i ng less than a month.
This type of head ac h e is often a cco m p ani ed by tearing and redness of the affec ted eye, a
stuffy nose, or i psila teral forehead or facial sw el lin g . The a ttac k s may be l\tiost patie n ts are restless or
p r ovo k ed by a lcoh o l , histamine, or nitroglycerine.
agitated during an attack bec a use th e pain is so excruciating th a t they are unable
to lie down. Men
are affected six ti mes as fre quen tl y as women.
The findings of so m ati c d y sfunc tion a n d t h e osteo p athic manipulative p roce
dures for cluster headaches are similar to tll O se of mig r a i ne . One add itional pearl:
394
Section III • Cl i n i cal Conditions
In a p atient who reports the se nsation of an ice pick behind the eye and who does not have optic neu r itis , brain tumor, or ot h e r anatomic lesion, look for a C1 to C2 d ysfunction , anterior on the side of the pain . Treat i ng this d ysf u n ct i on can have a dramatic res ponse ( H abe nicht AL. Persona l communication, August 2004). Headache Tertiary to Secondary Somatic Dysfunction Ma n y osteopath ic ph ys i cians who use manipulative p ro ce d ures have seen p a ti ents with headac he whose etiology is somati c dysfunction secondary to organ disease. An e x a m p le of this is the headache associated with gallbladder d is ease , also k nown as a b ilious headache. The physiologic basis for headache seco nd ary to somatic dys function is described here, us ing biliary dys ki nesia as a model. S y m pathet i c afferent
nerves from the bi l i a ry tree re tu r n to the sp i na l cord in the T6 to T9 seg m e n ts . The hyperactivity of the sympathetic afferents causes facil i tation of the T6 to T9 der matome, resulting in increased muscle tone in the muscles innervated by the T6 to T9 somatic afferent nerves, which may resu l t in a type II somatic dys fu n ct i on at that leve1.55,56 The dysf u n ction is us u a l ly T8 extended with side bendi ng and rotation right. T he resu l t frequentl y is increased muscle ten sio n cephalad to the suboccipital area . The parasympathetic efferents and afferents are with the vagus nerve.56 A branch of the vagus is given off at C2. This can lead to increased tension of the muscles of the suboccipital triangle , which can in tu r n cause compression of the ver tebral artery and the greater occipi t al nerve as they pass through the triangle. The result can be both muscle tension and migraine head ach e. Anticholinergic medica tion can be specific for treati ng some muscle tension and migraine headaches u s in g this modeL Treatment of headache in i tiated by visceral pathology begins by treat ing the un de rly ing cause. Then treat the associated somatic dysfunction.
CONCLUSION The overall effects of chronic pa i n on personal and societal health cannot be over stated. A multid isciplinary team a ppro ac h to com prehensive pain m anagem ent is evolv i ng as one of the most cost effective and beneficial means to address chronic pain cases. Osteopath ic phys i cians should play a lead ro l e by f u nction i ng as an intake portal, a d ministe ri ng OMT to patients with somat i c dysfunctions that underlie the cause of pain when indicated , po s s i bly a vo i d i ng costly workups and a l lopat hic interventions. The successful ma ni pu lati v e treatment of major forms of ot h e r wise idiopath ic headache is a case in point. Witl1 the use of complemen tary and alternative medicines on the rise in the United States and the in creasi n g recog nition of the potential benefits of such a ppr o a c h es by the a l lopathic medical estab lishm e nt , osteop a t hic physicians stand in a good p osition to pl ay a vital role in lessening the burden of chronic pain to society. Procedures
Selected Osteopathic Manipulative Procedures Useful in Treating Headache In treating the cer vical spine, it is important to d iagnose and treat the LIpper tho racic reg ion first.
Muscle Energy, Upper Thoracic Spine This procedure is e m plo yed to treat Fryette type II dysfunction, either flexed or extended , in the upper thoracic spine. (For di agnosis , see the p r oced u re in C h a p ter 16 and Figu re 16.1.)
C h a pter 25 • T h e P a t i e n t w i t h C h ro n i c Pa i n , H e a d a c h e
F IG U R E 2 5 . 2
395
K n e e i n t h e b a c k H V LA proced u r e f o r T3 o n T 4 exte n d e d , s i d e b e n t r i g ht,
a n d rotated r i g h t .
Kn ee in the Ba ck, Upper Thoracic Typ e 1/ Extended Dysfunction (HVLA) (Fig. 25. 2) T h i s p roced u re is em p l oyed to trea t ty pe II a rtic u l a r soma tic d ysfu n c t i o n of the t h o r a c i c s p i n e . T h e p a t i e n t position d escr i bed below s p e c i fica l ly a l lows access to the u p per t h o ra c i c r eg i o n . ( For d ia g n o s i s , see Cha pter 3 . ) Patient pos i tio n : sea ted u po n the trea t m e n t ta b l e w i t h the k nees exte n d e d and the legs resting l e n gthwise on the ta b l e . Physici a n p o s i t i o n : sta n d i n g b e h i n d th e pa tient a t the e n d of the ta b l e . In this p o s i ti on, the p a ti e n t c a n comforta bly l e a n b a c k t o bri n g t h e u p per t h oracic spine into contact w i th t h e p hysic i a n 's k ne e , e v e n i f t h e p h y s ic i a n h a s re l a t i v e l y s h o n l e g s . Proced u re ( E x a m p l e : T3 o n T 4 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 ace a p i l l ow or ot h e r s m a l l pad over the re l a t i v e l y poste r i o r r i g h t t r a n sverse p rocess of 13 .
2.
P l ace yo u r r i g h t foot u p o n t h e ta b l e a n d y o u r k n ee f i r m l y a g a i nst t h e p i l l o w o r p a d i n c o n t a ct w i t h t h e r i g h t tra n sverse p rocess of 13 . Yo u r k n e e m u st re m a i n t i g h t l y i n c o n t a c t w i t h 1 3 t h ro u g h o u t t h e re m a i n d e r o f t h e p roced u re
3.
I n st r u ct t h e p a t i e n t to p l a ce t h e h a n d s b e h i n d t h e n e c k a n d to l a ce t h e f i n g e rs t o g e t h er.
4.
W i t h both of yo u r h a n d s , rea c h b e n e a t h t h e p a t i e n t 's a x i l l a e o n e i t h e r s i d e a n d f u l l y exte n d b o t h of yo u r w r i sts s o t h a t y o u r f i n g e rs c a n c o n t a ct t h e d o r s a l (exte n s o r) s u r face of t h e p a t i e n t 's f o re a r m s b i l a t e r a l ly at t h e w r i sts .
5.
I n st r u ct t h e p a t i e n t to b r i n g t h e e l bows t o g et h e r i n fro n t , l a t e ra l l y d i s p l a c i n g t h e sca p u l a e .
6.
I n s t r u ct t h e p a t i e n t t o s l u m p f o rw a rd ; a s s i st by p u s h i n g g e n t l y d o w n w a rd a g a i n st t h e w r i sts w i t h yo u r f i n g e rs a n d p u l l i n g p o s t e r i o r l y a g a i nst t h e a x i l l a e w i t h yo u r forea r m s . T h i s w i l l i n t ro d u ce f l ex i o n o f t h e u p p e r s p i n e d o w n t o a n d i n c l u d i n g
1 3 u p o n T4.
Secti o n III • C l i n i ca l C o n d i t i o n s
396 7.
contact betw e e n yo u r r i g h t k n ee a n d t h e r i g h t t r a n sve rse p rocess of 13 , use both o f yo u r a r m s to tra n s l ate t h e p a t i e n t 's u p p e r torso to t h e r i g h t , t h e re b y i n t r o d u c i n g l eft s i d e b e n d i n g betwee n 13 a n d T4 . B e certa i n to k e e p b ot h o f t h e p a t i e n t 's i s c h i a l t u b e rosit i e s so l i d l y i n contact w i t h t h e ta b l e d u r i n g t h i s M a i n ta i n i n g t h e f i r m
p rocess .
8.
I n tro d u ce l eft ro t at i o n of 13 u po n T4 by p u l l i n g poste ri o r l y w it h yo u r l eft fore a r m a g a i n s t th e pati e n t 's l eft a xi l l a .
9.
B y a p p lyi n g f l exi o n , l e ft s i d e b en d i n g , a n d l eft rota t i o n t h ro u g h t h e p a t i e n t 's pec t o ra l g i rd l e with y o u r fo r e a rm s w h i l e m a i n ta i n i n g f i r m c o n t a ct w i t h yo u r r i g h t k n ee u p o n t h e r i g h t t ra n sverse p rocess of
13 , y o u s h o u l d be a b l e to loca l i ze fo rces to 13
u po n T4 . 1 0 . A p p l y t h e f i n a l c o r rective force as a q u i c k t h r u st d i rected u pwa rd a n d a n te r i o r l y a g a i n st t h e r i g h t t r a n s v e r s e p rocess of
13 w i t h y o u r r i g h t k n e e by a b r u pt l y p l a n t a r a n kle in c o m b i n a t i o n w i t h a s i m u l t a n e o u s s l i g h t i n c rease i n f l e x i o n of t h e p a t i e n t 's to r s o (13 u p o n T4) t h ro u g h yo u r f i n g e rs i n contact w i t h t h e fo r ea r m s 1 1 . R e a ssess t h e m o t i o n between 13 a n d T4 . f l ex i n g you r r i g h t
.
Knee i n the Back, Upper Thoracic Type /I Flexed Dysfunction (HVLA) (Fig. 25.3) This p roced u re i s e m p l o ye d to trea t type II a rt i c u l a r s o m a t i c d ys f u n c t i o n of t h e t h or ac i c s p i n e . The pa ti e n t p o s i t i o n s p e c i fi c a l J y a l l ows a cc e s s to t h e u p per t h o ra c i c region ( Fo r d iag n o s i s , s ee Chapter 3 . ) .
Pa tie n t p o s i tion : s e a t e d u po n the trea tment ta b l e wi th the k nees exte n d e d a n d
the l eg s resting le ng thwi s e o n the ta b l e . Phys i c i a n pos ition : sta n d i n g be h i nd the the p a t ie n t can com fo r ta b l y l e a n b a c k to b r i ng t h e u p p er t h o r a cic s p ine i n to c o n t a c t w i t h the phys i c i a n 's k n e e, e v e n if t h e p h ysician h a s r e l a t i v e ly s h ort legs. p a t i e n t at the e n d o f the tab l e . In t h i s p os i t i o n
FIG U R E 2 5 . 3
,
K n e e i n t h e b a c k H V LA proc e d u r e f o r T 3 o n T 4 f l e x e d , s i d e b e n t r i g h t, and rotated r i g h t .
C h a pter 25 • T h e P at i e n t w i t h C h ro n i c Pa i n , H eadac h e
397
Proce d u re ( E xa m p l e : T 3 o n T 4 F l e x e d , S i d e B e n t R i g ht, a n d Rotated R i g ht)
1.
Place a p i l l o w o r ot h e r s m a l l p a d ove r the l eft t r a n sverse p rocess of T 4.
2.
Place yo u r left foot upon the ta b l e and yo u r knee f i r m l y a g a i n st the p i l l ow o r pad in c o n t a ct with the l eft tra n sve rse process of T4 . Yo u r knee m u st re m a i n t i g h t l y i n c o n t a ct w i t h T 4 t h ro u g h o u t t h e re m a i n d e r o f t h e p ro c e d u re .
3.
I n struct t h e patient t o place t h e h a n d s b e h i n d t h e n e c k a n d t o l a c e t h e fi n g e rs together
4.
W i t h both of yo u r h a n d s , rea c h b e n e a t h the p a t i e n t 's a x i l l a e o n e i t h e r s i d e a n d f u l l y ext e n d b o t h of yo u r wri sts so t h at yo u r f i n g e rs ca n c o n t a ct t h e d o rs a l (ext e n s o r) s u r face of t h e p a t i e n t 's fore a r m s b i l a tera l ly at t h e w r i sts .
5.
I n st r u ct t h e p a t i e n t to b r i n g t h e e l bows t o g et h e r i n fro n t . l atera l l y d i s p l a c i n g t h e s ca p u l a e .
6.
I n struct t h e patient t o re l ax; t h e n p u l l poste riorly a g a i nst t h e a x i l l a e with yo u r forea r m s . T h i s w i l l i ntrod uce exte n s i o n o f t h e u p p e r s p i n e d o w n to a n d i n c l u d i n g T3 u p o n T4 .
7.
M a i n ta i n i n g t h e f i r m c o n t a ct betwe e n yo u r r i g ht k n e e a n d t h e l eft t r a n sv e r s e p rocess of T 4 , u s e both of yo u r a rm s t o tra n s l ate t h e p a t i e n t 's u p p e r torso t o t h e r i g h t , t h e re b y I n t ro d u c i n g l eft s i d e b e n d i n g betwee n T3 a n d T 4 . B e certa i n t o k e e p both of t h e p a t i e n t 's i sc h i a l t u b e ro s i t i e s so l i d l y i n c o n t a ct w i t h t h e ta b l e .
8.
I n trod u c e l eft rota t i o n o f T3 u p o n T4 b y p u l l i n g p o s te r i o r l y w i t h yo u r l eft f o re a r m a g a i nst t h e p a t i e n t 's l eft a x i l l a .
9.
B y a p p l y i n g exte n s i o n , l eft s i d e be n d i n g , a n d l eft rotat i o n t h ro u g h t h e patient's pecto ra l g i rd l e With you r fo rea rms w h i l e m a i nta i n i n g firm contact with yo u r l eft k n e e u p o n t h e left tra n sverse p rocess of T 4 , you s h o u l d be a b l e to local i ze fo rces t o T 3 u p o n T4 .
1 0 . A p p l y t h e f i n a l c o r re ct i ve fo rce as a q u i c k u p wa rd t r a ct i o n w i t h yo u r h a n d s a n d fo rea r m s 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 a g a i nst t h e h o l d i n g force o f yo u r l eft k n ee u p o n t h e l eft t r a n sverse p ro c e s s of T 4 .
11.
Reassess t h e m o t i o n betwee n T 3 a n d T 4 .
Reverse Rib (HVLA) (Fig. 25.4) T h i s proced u r e is e m p loyed to tre a t costovertebr a l s o m a t i c d y s f u n c t i o n t h a t ca n a ffect t h e seco n d , t h i rd , or fo u r th r i b s . T h e d y sfu nctiona l rela tionship occ u r s
FIG U R E 2 5 . 4
Reve rse r i b ( H V LA) p roce d u re f o r treat i n g t h e dysf u n ct i o n a l re l a t i o n s h i p betwee n T 1 a n d t h e seco n d r i b o n t h e r i g h t .
398
Sect i o n III • Cl inic a l Conditions
between a thora c i c verte b r a a n d t h e r i b of t h e segm e n t b e l ow. Rota t i o n of t h e ver h e a d of t h e rib. This i n t u r n d rives t h e rib p o s te r i o r, i m p i n g i n g u p o n the costotr a n s ve r s e a r t ic u l a t i o n a n d causing p a l p a b l e p r o m i n e nce, t i s s u e tex ture c h a ng e , a n d tenderness o v e r t h e a n g le of the d ysfu nc t i o n a l rib. This is a s e c o n d a r y d ys fu nc t i o n , the res u l t of a p r i m a ry t h oracic type II verte bral d ys f u n c ti o n . As s u c h , t h e pr i m ary t horac i c d y sfu n c t i o n s h o u l d b e trea ted b e f o r e t h i s p roced u r e is e m p l oyed . Pa t i e n t p o s i ti o n : sea ted u p o n th e s i d e of t h e t r e a t m e n t ta b l e . P h y s i c i a n p o sit i o n : s t a n d in g b e h i n d t h e p a tie n t . te b ra c a u ses the i n fe r i or h e m i fa c e t to i m p i nge upon the
Proced u re ( E x a m p l e : Dysfunction B etween T 1 a nd the S e cond R i b o n the Right) T h e r i b a n g l e is p ro m i n e n t , wit h t i s s u e text u re c h a n g e a n d resista nce to a n a n teroi nfe r i o r force .
1.
P l a ce yo u r l eft foot u p o n t h e ta b l e j u st to the l e ft of t h e p a t i e n t 's pelv i s .
2.
P l a c e t h e p a t i e nt's l eft a r m over yo u r l eft k n e e . Yo u m a y w i s h t o p l a ce a p i l low
3.
W i t h yo u r left h a n d , re a c h i n front o f t h e p a t i e n t , g r a s p the r i g h t wrist, a n d p u l l the
between you r knee a n d t h e p a t i e nt's ax i l l a . r i g h t a r m a c ross t h e lap to p ro t r a ct the r i g ht sca p u l a , expos i n g t h e a n g l e of t h e sec ond r i b .
4.
P l a ce yo u r r i g h t h a n d u p 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 so t h a t yo u r f i n g e rs a re d i rected a nte r i o r l y a n d you r t h u m b p o i nts i n fe r i o rly, c o n t a ct i n g t h e a n g l e of t h e dys f u n ct i o n a l seco n d r i b .
5.
W i t h yo u r r i g h t h a n d , a p p l y a n i n f e ro m ed i a l f o rce, h o l d i n g t h e p a t i e n t 's torso f i r m l y betwe e n y o u r r i g h t h a n d a n d l eft k n e e . Th i s h o l d i n g fo rce m u s t b e m a i nta i n e d t h ro u g h o u t t h e re m a i n d e r of t h e p roced u re .
6.
W i t h y o u r l eft h a n d , g r a s p t h e left s i d e of t h e p a t i e n t 's h e a d s o t h a t yo u r w i d e s p re a d f i n g e rs a re d i rected a n t e r i o r l y, contact i n g t h e l eft c h ee k , a n d yo u r t h u m b contacts t h e poste r i o r s k u l l a t o r J ust i n f e r i o r t o t h e exte r n a l occi p i tal p rot u b e r a n c e .
7.
U s i n g yo u r l eft h a n d , poste r i o r l y tra n s l ate t h e p a t i e n t 's h e a d to stra i g h t e n t h e u p per thoracic and cerv i ca l s p i n e T h i s s p i n a l p o s i t i o n i n g m u st be m a i n ta i n e d t h ro u g h o ut the re m a i n d e r of t h e p roced u re .
8.
N ext, w i t h yo u r l eft h a n d , i n t rod u ce rota t i o n o f t h e h e a d a n d cervica l s p i n e to t h e l eft u n t i l fo rces a c c u m u l ate at t h e l eve l of T 1 .
9.
T h e f i n a l c o r rective force is a h i g h-v e l o c i ty, low-a m p l it u d e i n crease i n l eft rotat i o n of t h e p a t i e n t 's h e a d a n d cerv i c a l s p i n e a g a i nst t h e h o l d i n g fo rce of y o u r r i g ht t h u m b u po n t h e s e c o n d r i b a n g l e .
1 0.
Reassess t h e m o t i o n between T 1 a n d the seco n d r i b on t h e r i g h t .
Eleva ted Firs t and Second Ribs, Patient Prone (HVLA) (Fig. 25. 5) This proced u r e is e m p l o y e d to treat el e v a t e d fi r s t or seco n d r i bs to restore n o r m a l
res p i ra t o r y excursi o n . A n y v e r te bra l s o m a t i c d y s f u n c t i o n s h o u l d be tr e a te d befo re ri b d y s f u n c t i o n . ( F o r d i a g n o s i s , see C h a p t e r 1 6 . )
P a tient p o s i t i o n : pro n e . T h e c h i n sho u l d b e i n c o n ta c t w i t h t h e t a b l e , a nd the head a nd c e r v ic a l s p i ne s h o u l d be i n t h e m id l i n e , w i t h n o rotation to e i t h e r th e r i g h t or left. P h ys i c i a n p o s i ti o n : s ta n d i n g a t the p a t i e n t 'S h e a d on the s i d e o p p o s i te t h e d y sfunctio n a l r i b . Proc e d u re ( E xa m p l e : E l evated S e cond R i b o n t h e Left)
1.
W i t h yo u r r i g h t h a n d , g ra s p the l e ft s i d e of t h e p a t i e n t 's h e a d a n d i n t ro d u ce s i d e be n d i n g to t h e r i g h t d o w n t o T l u p o n T2 b y m o v i n g t h e p a t i e n t 's h e a d t o t h e
C h a pter 2 5 • T h e Pat i e nt w i t h C h r o n i c Pa i n , H e a d a c h e
399
T h e H V LA p roce d u re to t r e a t a n e l evated s e c o n d r i b o n t h e l eft .
FIGURE 25.5
r i g h t w h i l e k e e p i n g t h e c h i n i n c o n t a ct w i t h t h e ta b l e a n d n o t rota t i n g t h e h e a d o r c e rv i c a l s p i n e . I t i s i m p o rta n t to m a i n ta i n t h i s s i d e b e n d i n g w i t h y o u r r i g h t h a n d a g a i n st t h e p a t i e n t 's h ea d t h ro u g h o u t t h e r e m a i n d e r of t h e p ro c e d u re .
2.
W i t h t h e t h e n a r e m i n e n c e o f yo u r l eft h a n d , c o n t a ct t h e a n g l e o f t h e dysf u n ct i o n a l seco n d r i b a n d a p p ly a c a u d a l a n d s o m ew h a t l a te ra l f o rce .
3.
I n st r u ct t h e p a t i e n t to ta k e a d e e p b rea t h .
4.
A s t h e p a t i e n t beg i n s t o ex h a l e , a p p l y t h e f i n a l corrective f o rce a s a n H V LA t h r ust d ow n w a r d , a n t e r i o r l y a n d l a t e ra l l y t h ro u g h y o u r l eft h a n d a g a i n s t t h e a n g l e of t h e dysf u n ct i o n a l seco n d r i b .
5.
Reassess t h e m o t i o n of t h e seco n d r i b o n t h e l eft.
Posterior Occiput, Muscle Energy T h i s p ro ce d u re i s e mployed to tre a t a r t icular so m a t i c dysf un ction of the occ iput
rel a ti ve to C 1 , the at l as, to e st a blish sy mme t ric mo tion be t we en the occipu t an d t he at l as . ( Fo r di a gnosis , see Ch apte r 3, a nd the des c r ip t io n of the proce dure in Cha pt e r 1 6 a nd Fi gure 1 6 . 1 0 . ) C 1 Posterior (Counterstrain) (Fig. 25. 6) T h i s proce d ure is e mplo yed to re d uce discomfor t associa ted wi th a te nder poin t .
The C 1 po s ter io r o r i n i o n , tend er p o i n t is on e i t h e r side o f the midline ap proxi ma te ly 3 cm i nferio r to the exte r n a l o c ci p i tal p r o t u bera nce, i n i o n , in the mos t med ia l asp ec t of t he inse rtion of t he sp leni us cap i t is onto t h e occ i p u t . T h i s ten d e r p o i n t i s foun d fre q u ently in asso ci a t ion w i t h occipi t a l hea d a ches. This i s a n a typ ,
ica l or ma ver i c k c o u n te r s t r a i n p o i n t .
Pat ie nt po si tio n : s up in e Ph ys i c i a n p o s i ti o n : s e a ted a t t he h e a d o f t h e t r e a t me n t tab le . .
Proce d u re ( E xa m p l e : Poste r i o r C 1 Te n d e r Po i nt Located to t h e Left of t h e M i d l i n e )
1.
C ra d l e t h e poste r i o r a s p ect of t h e p a t i e n t 's h e a d w i t h y o u r l eft h a n d , p l a c i n g t h e t i p y o u r i n d e x f i n g e r i n co n t a ct w i t h t h e p o ste r i o r C 1 t e n d e r p o i n t . Yo u r f i n g e r s h o u l d rem a i n i n c o n t a c t w i t h t h e t e n d e r p o i n t t h ro u g h o u t t h e treat m e n t proced u re .
400
Section I I I • C l i n i ca l Co n d i t i o n s
FIG U R E 25.6
2.
T h e p o s i ti o n fo r c o u nte rst ra i n to t r e a t l eft of t h e m i d l i n e .
a
p o st e r i o r ( 1 t e n d e r p o i n t t o t h e
Pa l pate t h e p o i n t t o esta b l i s h t h e p at i e n t 's awa re n ess o f t h e d e g re e o f te n d e r n e ss p re s e n t a n d a ss i g n a va l u e of 1 0 0 % to the te n d e r n es s .
3.
G ra s p t h e t o p of t h e p a t i e n t 's h e a d w i t h yo u r r i g h t h a n d so t h a t you r p a l m i s i n c o n t a ct w i t h t h e ve rtex of t h e s k u l l a n d yo u r f i n g e rs exte n d a n te r i o r l y toward o r o n to t h e f o re h e a d
4.
A p p l y a ca u d a l l y d i rected fo rce w i t h yo u r r i g h t h a n d , t h e re by i n trod u c i n g exte n s i o n of t h e occ i p u t u p o n t h e a t l a s , u n t i l yo u f e e l decre a s e d te n s i o n i n t h e t i s s u es s u r ro u n d i n g t h e te n d e r p o i nt b e n e a t h yo u r l eft i n d e x f i n g e r. It m a y be n ecess a ry to p o s i t i o n t h e p a t i e n t so t h a t t h e h e a d a n d n e c k a re off t h e h e a d of t h e trea t m e n t t a b l e i n o rd e r t o i nt ro d u ce t h e d e g re e of exte n s i o n n ecessa ry to o b t a i n re l a x a t i o n .
5.
It a l s o m a y b e n e cessa ry t o i n t ro d u ce s m a l l a m o u nts o f s i d e be n d i n g a n d/o r rot a t i o n of C 1 , m ost ofte n to t h e l eft, u n t i l yo u f e e l f u rt h e r d e c r e a s e d te n s i o n i n t h e t i s s u e b e n ea t h yo u r i n dex f i n g e r. As t i s s u e te n s i o n decreases , if a s k e d , t h e p a t i e n t wi l l re p o rt a p r o p o rt i o n a te decrease o f t e n d e r n es s .
6.
T h e fi n a l p o s it i o n i s t h at i n w h i c h n o m o re t h a n 3 0 % of t h e p at i e n t 's su bjective t e n d e r n ess re m a i n s . T h i s p o s i t i o n s h o u l d b e h e l d u n t i l co m p l ete t i s s u e re l a x at i o n , a re l e a s e , occu rs . T h i s o f t e n req u i res u p to 90 seco n d s a f t e r t h e f i n a l pos i t i o n i s o b ta i n e d .
7.
W h i l e m o n i t o r i n g t h e ten d e r p o i nt, ret u r n t h e pati e n t 's h e a d a n d n e c k t o t h e n e u t r a l rest i n g p o s i t i o n . T h i s p rocess s h o u l d b e d o n e s l owly so t h a t t h e t i s s u e t e n s i o n i n t h e reg i o n of t h e te n d e r p o i n t d o e s n o t retu r n .
8.
Ag a i n , p a l pate t h e te n d e r p o i n t t o d e t e r m i n e w h e t h e r a n y res i d u a l te n d e r n ess rem a i n s .
Sutherland's Occipitoatlantal Decompression (Crania/) (Fig. 25. 7)
Thi s p r o c ed ure is e m p loyed to reduce l ig a mentous a r tic ul a r str ain bet w e e n t h e occi put a n d atla s . Thi s is a dy sf unction in wh i c h t h e con dy l es o f rh e o ccip u t a re a n te r i o r relative to the a tl as . Pat ie nt positio n : supi ne. Physi c i a n pos it ion : s e at ed at t h e he a d o f th e t rea tm e n t ta b l e .
Chapter 25 • The Patient with Chron i c Pa i n, Hea dache
FIG U R E 2 5 . 7
40 1
Suthe r l a n d 's occ i p itoat l a nta l d e co m p ressio n .
P roced u re
1.
P l a ce 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 's h e a d a l o n g t h e l o n g i tu d i n a l a x i s of the p a t i e n t 's body a n d w i t h yo u r f i n g e rs p o i n t i n g ca u d a l l y so t h a t t h e tip of you r m i d d l e f i n g e r c o n t a cts t h e most i n f e r i o r a s p e c t of t h e o cc i p u t i n t h e m i d l i n e
2.
P l a ce t h e o t h e r h a n d l i g h t l y i n c o n t a ct w i t h t h e p at i e n t's f o re h ead t o sta b i l i z e t h e h e a d u p o n t h e p o ste r i o r h a n d .
3.
H a ve t h e p a t i e n t m i n i m a l l y t u c k t h e c h i n , t o i n trod uce occ i p i toa t l a n t a l f l e x i o n w i t h o u t f l e x i n g t h e re m a i n d e r of t h e cervi cal s p i n e . T h i s w i l l b r i n g t h e poste r i o r t u ber cle of t h e a t l a s i n to c o n t a ct w i t h t h e t i p of t h e m i d d l e f i n g e r of t h e hand cra d l i n g t h e p a t i e n t 's h e a d . T h i s p o s i t i o n c a n b e a u g m e n ted b y a p p l y i n g a ca u d a l l y d i rected force, l i g h t l y a p p l i e d w i t h the h a n d in c o n t a ct with the p a t i e n t 's forehea d .
4.
S u p port t h e a t l a s w i t h t h e t i p o f t h e m i d d l e f i n g e r o f yo u r poste r i o r h a n d , t h e re b y a l l ow i n g t h e occi p itoa t l a n t a l l i g a m e nts to reba l a n ce t h e j o i n t a s t h e occi p u t d i se n g a g e s a n d m oves poste r i o r l y u pon t h e a t l a s .
5.
Reassess t h e re l a t i o n s h i p betwe e n t h e o cc i p u t a n d t h e a t l a s .
6.
T h i s proced u re m a y t h e n b e fol l owed w i t h occi p i t a l co n d y l a r d e co m p re ss i o n , a s d i c tated by t h e p a l p a b l e s y m m e t ry of t h e o cc i p u t .
Occipital Condylar Decompression (Crania/) (Fig. 25.8) T h i s p r o c e d u r e s h o u l d be u sed o n ly b y i n d i v i d u a l s e xperience d w i t h c r a n i a l m a n ipu l a ti o n.
T h i s p ro c e d u re is e m p loye d to reduce intra osseous d ysfunct i o n o f tile occ i p u t i n v o lvi n g the s q u a mous, la tera l , and basil a r pa rts of the oc c i p i t a l base. These dysfu nc tions ca n be very c o m p l e x consisting o f compression between the bas i l a r a nd one or bot h latera l pa r ts w i t h a n tero posterior a nd med i o l a tera l deviation of the lateral parts and rota t i o n a l stress upon the s q u a m o u s portion of the occipu t. The proced ure i s c on ducted as a n i n d i rect trea tment method whose goa l is to red uce p a l p a b l e ten s i o n ,
,
asymmetry o f t h e occip u t . T h e exa m p l e provides a ba s i c h a n d p l a c e m e n t a nd t h e a p p roa c h t o a spe c i fi c pa ttern exa m p le . The p r o ce d u re a s e m p loyed c l i n i c a JJ y s h o u l d be d ictated by t h e pattern p a l pa ted in the i n d iv i d u a l patient'S s k u l l .
Section I I I • C l i n i c a l C o n d i t i ons
402
FIGURE 25.8
O cc i p i t a l condy l a r d e compress i o n .
P a t i e n t p o siti o n : s u p i n e . P h y s i c i a n p o s i t i o n : sea ted a t the h e a d of t h e trea t m e n t
ta b l e .
Proced u re ( E xa m p l e : Antero posteri o r Co m p ress i on B etwe e n the R i g ht La tera l and t h e B a s i l a r P a rts of the B a s i occ i p ut)
1. 2.
C ra d l e the p a t i e n t 's occi p u t in b ot h h a n d s . P l a ce yo u r r i g ht 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 's h e a d a l o n g t h e l o n g i tu d i n a l a x i s o f t h e p at i e nt's b o d y w i t h yo u r f i n g e rs p o i n t i n g ca u d a l l y so t h a t t h e t i p o f yo u r m i d d l e f i n g e r c o n ta cts the m o st i n fe r i o r a s p ect of t h e occi put i n the m i d l i n e a n d yo u r i n d ex f i n g e r i s d i rected toward t h e r i g h t o cc i p i tal c o n d y l e .
3.
H a ve t h e p a t i e n t m i n i m a l ly t u c k the c h i n to i n tro d u ce occi p i t o a t l a nta l f l e x i o n w i t h o u t f l ex i n g t h e rema i n d e r of t h e cerv i c a l s p i n e .
4.
U s e t h e t i p o f yo u r ri g h t i n d ex f i n g e r t o h o l d t h e r i g h t l a te r a l p a rt i n p l ac e .
S.
W i t h yo u r l eft h a n d , a p p l y g e n t l e, posterosu p e r i o r tracti o n to t h e l eft s i d e of the s q u a m o u s portion and l eft l ateral p a r t of the occi pita l base.
6.
D i rect t h e h o l d i n g fo rce of your r i g h t i n d ex f i n g e r latera l l y to the p a t i e n t 's r i g h t w h i l e a p p l y i n g a m e d i a l ly d i rected f o rce w i t h yo u r r i g h t m i d d l e f i n g e r.
7.
L i g h t l y a dj u s t t h e t e n s i o n s a p p l i e d with both h a n d s u n t i l you feel t h e occ i p ut
8.
T h e eff i cacy of t h i s p roced u re i s g re a t l y e n h a n ced by work i n g i n syn c h ro n y w i t h t h e
re l e a s e . c ra n i a l rhyth m i c i m p u l s e ( C R I ) .
9.
Reassess t h e o cc i p u t .
Fron tal Lift (Crania/) This p rocedure is employed to trea t s o m a ti c d y s fu n c t i o n of t h e fronta l b o n e . P a t i e n t position: supine . P h y s ic i a n position: a t the h e a d of the t a b l e . D I AG N O S I S N ot e t h e fronta l b o n e . A l t h o u g h t h i s b o n e i s a s i n g l e osseo u s st r u ct u re i n most a d u l ts, it m oves l i ke t h e p a i red bo nes of t h e s k u l l , ref l e ct i n g its o r i g i n as p a i re d b o n e s o n e i t h e r
Chapter 25 • The P a t i ent with C h ronic Pa i n , H eadache
F I G U R E 25.9
403
Fronta l d i a g n o s i s .
s i d e o f t h e meto p i c s u t u re ; f ro n t a l moti o n s h o u l d occ u r i n sy n c h ro n y w i t h t h e b i p h a s i c C R I . T h u s , d u r i n g cr a n i a l f l e x i o n , t h e f r o n t a l b o n e o r b o n e s ext e r n a l l y ro tate, w i d e n i n g l atera l ly, a n d d u r i n g c ra n i a l extensi o n , t h e fro n t a l bon e(s) i n te r n a l ly rotate, n a r row i n g l a t e r a l ly. Dysf u n ct i o n c a n oc c u r i n t h e sym m etry of t h i s m o t i o n f r o m m a n y s o u rces . T h e s e i n c l u d e d u ra l m e m b ra n e te n s i o n , a rti c u l a r o r i n traoss e o u s dysfu n c t i o n a t t h e m etop i c s u t u r e , a n d a rt i c u l a r rest r i ction betwe e n t h e fronta l b o n e a n d a d j a c e n t s t r u ct u res, i n t h i s c a s e p a rt i c u l a r l y t h e g reater w i n g s of t h e s p h e n o i d b o n e a n d t h e p a i re d p a r i eta l b o n e s . D i a g n ostic Procedure ( F i g .
1.
25.9)
P l a ce b o t h h a n d s i n contact w i t h t h e f ro n t a l b o n e s u c h t h a t t h e i n d ex f i n g e rs a re a l i g n e d on e i t h e r s i d e of t h e meto p i c s u t u re a n d t h e oth e r f i n g e rt i p s c o n t a ct t h e b row r i d g es b i l a tera l l y.
2.
Pa l p ate t h e m o t i o n betwe e n t h e l eft a n d r i g h t h a lves of t h e fro n t a l b o n e as y o u 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 I . As t h e h e a d m oves i n t o f l ex io n , t h e frontal bone or bones s h o u l d be felt to f l a tten a n t e r i o r l y and w i d e n l atera l l y i n exte r n a l rotat i o n . As t h e c ra n i a l b a s e m o v e s i n to exte n s i o n , t h e f ro n t a l b o n e o r b o n e s s h o u l d be f e l t t o n a rrow l a t e r a l ly i n i n te r n a l rotati o n .
3.
I d e nt i fy m o t i o n rest r i ct i o n .
Treat m e n t Proced u re
1 .
P l ace y o u r e l bows u po n t h e ta b l e b i l ate r a l l y on e i t h e r s i d e of t h e p a t i e n t 's h e a d a n d i n te r l a ce yo u r fi n g e rs i n front o f t h e p a t i e n t 's f o re h ea d . Yo u r f i n g e r s s h o u l d n o t t o u c h the f ro n t a l b o n e .
2.
C o ntact t h e l a t e ra l a n g l e s of t h e fro n t a l b o n e o r b o n e s b i l at e r a l ly w i t h y o u r hypo t h e n a r e m i n e n c e s .
3.
P a l pate t h e C R I .
4.
A s the h e a d m oves i n to exte n s i o n a n d t h e f ro n t a l b o n e o r b o n e s i n te r n a l l y rotate, fo l l ow w i t h yo u r h a n d s by a p p l y i n g gentle m e d i a l p res s u re w i t h your hypot h e n a r e m i n e n ces a n d by atte m pt i n g t o d r aw y o u r i n t e r l a c e d f i n g e rs a p a rt I n i n te r n a l rota t i o n , y o u w i l l be able to d i se n g a g e the fro n t a l bone f r o m adjacent cra n i a l (not f a c i a l ) s t r u ct u res .
404
Section I I I • Cl inica l Cond i t i ons
FIGURE 25. 1 0
5.
Pa r i eta l l i ft .
D u r i n g exte r n a l rota t i o n , l ift t h e fronta l b o n e
00
b o n e s a n t e r i o r l y u n t i l t h ey a re f e l t
to move f r e e l y i nto exte r n a l rotat i o n .
6.
F o l l o w t h e C R I a n d ret u r n t h e f r o n t a l b o n e o r b o n e s t o the sta rti n g positio n .
7.
R e a ssess f ro n t a l b o n e m oti o n .
Parietal Lift (Crania/) (Fig. 25. 1 0)
pa ri eta l bones. a t the h e a d of the ta b l e .
Th i s proce d u re is used to tre a t s o m a t i c d y s fu nction of t h e P a t i e n t p o s i ti o n : s u p i n e . P h y s ic i a n p o s i ti o n : sea te d Procedu re
D i a g n o s i s of p a r i eta l dysf u n c t i o n i s p e rfo r m e d i n a fa sh i o n s i m i l a r to t h a t of fronta l b o n e d i a g n os i s ( d e s c r i b e d e a r l i e r i n the c h a pte r), w i t h t h e exce p t i o n o f h a n d p l a c e m e n t , w h i c h s h o u l d f o l l o w t h e d e s c r i p t i o n of h a n d p l a ce m e n t i n t h e tre a t m e n t p ro ce d u re h e r e .
1.
P l a ce both h a n d s i n contact w i t h t h e p a r i eta l b o n es so that you r i n dex f i n g ers a re J u st poste r i o r to t h e coro n a l s u t u re a n d a b ove t h e s p h e n o p a r i etal s u t u res, yo u r m i d d l e a n d r i n g f i n g e r s a re s l i g h tly s e p a rated a b ove t h e s q u a m o u s te m p o ro p a r i eta l s u t u res, a n d yo u r l i tt l e f i n g e r s l i e a n te r i o r a n d s u pe r i o r to t h e l a m b d o i d s u t u re . Yo u r w r i sts s h o u l d be l i g htly a p p ro x i m ated , a n d u n l ess yo u r h a n d s a re very s m a l l , yo u r p a l m s w i l l not b e i n c o n t a ct with t h e p a t i e n t 's h ea d .
2.
Pa l p ate t h e m o t i o n betwe e n t h e l eft a n d r i g h t p a r i et a l b o n e a s you p a l pate t h e rate and a m p l i t u d e of t h e i n h e re n t m ot i o n of t h e C R I .
3.
A s t h e c ra n i a l b a s e m oves i n to exte n s i o n a n d the p a r i eta l b o n e s i nter n a l l y rotate, fo l l ow with yo u r h a n d s by a p p l y i n g g e n t l e m e d i a l p ress u re with the pads of yo u r f i n g e rs . I n i n t e r n a l rotati o n , y o u w i l l b e a b l e t o d i s e n g a g e t h e p a r i et a l b o n e s from a d j a c e n t cra n i a l s t r u ct u re s .
4.
D u r i n g exte r n a l rotati o n , d raw t h e p a r i eta l b o n e s s u p e r i o r l y towa rd you u n t i l you feel them m ov i n g free l y i nto exte rn a l rotat i o n . The fo rces a p p l i e d d u ri n g the l i ft m a y b e acce n t u ated t h ro u g h o n e o r m o re o f yo u r f i n g e r contact p o i nts as t h e s e n s a t i o n of m o t i o n rest r i ct i o n d i ctates .
5.
F o l l ow t h e C R I a n d ret u r n t h e p a r ie t a l b o n e s to t h e sta rt i n g p o s i t i o n .
6.
Reassess t h e c ra n i a l m o t i o n o f t h e p a r i e t a l b o n e s .
405
C h a pter 2 5 • T h e Pa t i e nt w i t h C h r o n i c Pa i n , H e a d a c h e
Refe re nces 1 . Fox C D, B e r g e r D , Fine PG, e t al. Pa i n a s s e s s m e n t a nd t r e a t m e n t i n the m a n a ge d ca re e n v i r o n m e n t . A po s i t i o n sta tement from t h e A m eric a n Pa i n S o c i e ty. 2 0 0 0 . Ava i l a b l e a t h ttp:// w w w. a m pa i nsoc . o rg/m a n a ge d c a re/p d f/aps_po s i t i o n . pd f. Accessed A p r i l 1 7, 2 0 0 5 . 2. S t e w a r t W F,
R i c c i J A , C h e e E, et 3 1 . Lost p r o d u c tive t i m e a n d c o s t d u e to c o m m o n p a i n c o n
d i t i o n s i n t h e US w o r k force. J A M A 2 0 0 3 ; 2 9 0 : 2 4 4 3-24 5 4 .
3 . Ba rnes P M , I) owe l l - G r i n e r E, McFa n n K , N a h i n R L . Comp l e m e n t a r y a n d a l te r n a t i v e med i c i n e u s e a m o n g 'l d u l ts : U n ited S t a tes, 2 0 0 2 . C D C A d va n ce D a ta F r o m V i t a l a n d Hea l t h S t a t i s t i c s ; re p o r t n o 3 4 3 . H y a tt s v i l l e , M D : N a t i o n a l C e n te r fo r H e a l t h S ta t i s t i cs . M a y 2 7 , 2004 . 4 . A s t i n J A . W h y p a t i e n ts use a l te r n a ti v e m e d i c i n e :
R es u l ts of a n a t i o n a l s t u d y. J A M A
1 9 9 8 ; 2 7 9 : 1 5 4 8- 1 5 5 3 .
5 . E i s e n b e rg D M , D a v i s R B , E t t n e r S L , et a l . Tre n d s i n a l t e r n a t i v e m ed i c i n e u s e i n t h e U n i ted S t a tes, 1 9 90-] 997: R es u l t s o f a fo l l o w - u p n a t i o n a l s u rvey. J AM A 1 9 9 8 ; 2 8 0 : 1 5 6 9- 1 5 7 5 . 6 . O l d e n d i c k R , Co k e r A L , W i e l a n d D , e t a t . Pop u l a ti o n - ba s e d s u r v e y o f c o m p l e l11en ra r y a nd a l ter n a t i v e m ed i c i n e u s a g e , p a t i e n t s a t i s fa c t i o n , a n d p h y s i c i a n i n vo l v e m e n t . S o u t h C a ro l i n a Corn pi e rne n t a r y iYl e d i c i n e P r o g r a m Base l i n e Resea rch Tea m . S o u t b M e d J 2 0 0 0 ; 9 3 : 3 75-3 8 1 . 7 . P a r a more L e . U s e o f a l te r n a t i v e t h e r a p i e s : Esti m a t e s fro m the 1 99 4 Ro be n Woo d J o h n s o n
Fou n d a t i on N a t i o n a l A c c e s s ro Cue S u r v e y . .I Pain S y rn p r o rn M a n a g 1 9 9 7; 1 3 ( 2 ) : 8 3 -8 9 .
8 . l . i p t o n R B , S t e w a rt W F, D i a m o n d S , e t a l. . P r ev a l e n c e a n d b u r d e n o f m i g ra i n e i n t h e U n i ted S r a tes : Dara fro lll t h e A m e r i c a n M i gra i n e S t u d y I I . H e a d a c h e 2 0 0 1 ;4 1 : 64 6 -6 5 7 . 9 . Ye l i n E, I-l e r r n d o r f A , Tr u p i n L , So n n e bo r n D . A n a t i o n a l s t u d y o f m e d i c a l c a r e expe n d i t u res fo r m u sc u l os k e l eta l c o n d i t i o n s : T h e i mpacr o f h ea l t h i n s u r a nce a n d m a n a ge d care. Arthr i t i s R h e u m 2 0 0 1 ; 4 4 : I 1 6 0-1 1 6 9 . 1 0 . D ey o R A , We i n s r ei n .I N . L o w back p a i n . N Engl J M e d 2 0 0 1 ; 3 4 4 : 3 63-3 7 0 .
1 1 . Tu r k D e . C l i n i c a l e ffec r i v e n ess a n d cosr-e ffectiveness o f t r e a tm e n ts fo r p a t i e n ts w i t h c h ro n i c pa i n . Clin
J Pa i n 2 0 0 1 ; 1 8 : 3 5 5 -3 6 5 .
1 2 . C e n t e r s f o r Med i c a re a n d M e d i c a i d S e r v i ce s . 1 9 9 7 N a r i o n a l H e a l t h Expe n d i t u r e s S u rvey. Ava i l a b l e a t h tt p ://22 2 . c ms . h hs . go v/s ta t i s t i cs/n he/. Accessed A p r i l 1 7 , 2 0 0 5 .
1 3 . Ve r h a a k PF, K e r s s e n s JJ , De k k e r .I , e t a l . Preva l e n c e of c h ron i c be n i g n p a i n d i sord e r a m o n g a d u l rs : A r e v i e w o f t he l i te r a t u r e . Pa i n 1 9 9 8 ; 7 7 : 2 3 1 -2 3 9 . 1 4 . B ra n t i n g h a m .lW. A c r i r i e a l l o o k a t t h e s u b l u x a t i o n h y p o t h e s i s . J M a n ip Phy s i o l T h e r 1 9 8 8 ; 1 l : 1 3 0- 1 3 2 . 1 5 . Va n B u s k i r k R L . Nocice p t i v e reflexes a n d t h e s o m a t i c d y s f u n c ti o n : A m od e l . J A m O s te o p a t h A s s o c 1 9 9 0 ; 9 0 : 7 9 2-8 0 9 . 1 6 . Wa x 0 \11 , A b e n d ]) S , Pea rso n P H . C h e s t pa i n a n d t h e r o l e o f s o m a r i c d y s fu n c t i o n . J Am O s reop a t h A s s oc 1 9 9 7 ; 9 7 : 3 4 7-3 5 2 , 3 5 5 . 1 7 . Wi l l i a m s N . M a n a g i n g b a c k p a i n i n gene r a l p r a c t i c e : Is o s t e o p a thy t h e n e w p a ra d igm ? B r J
Gen P r a c t 1 9 9 7 ; 4 7 : 6 5 3- 6 5 5 . 1 8 . I rv i n
R E. . The o r i g i n a n d re l i e f of c o m m o n pa i n . J B a c k M u sc u l o s k e l e ta l
Reha b i l
1 9 9 8 ; I 1 ( 2 ) : 8 9- 1 3 0 .
1 9 . S u n C , D e s a i GJ , P u c c i D S , J e w S . M u s c u l o s k e l et a l d i so r d e r s : D o e s t h e osteopa r h i c m e d ica l p r o fess i o n d e m o n s t r a te i ts u n i q u e a n d d i st i n c t i v e c h a r a c t e l- i s t i c s ? J A m Osteo p a t h Assoc 2004; 1 0 4 : 1 49-1 5 5 . 2 0 . M c P a rt l a n d
J M , Goo d r i d g e J P. Co u n t e rstra i n d i a g n os t i c s a n d t r a d i t io n a l o s teopa thic e x a m i
n a t i o n o f t h e c e r v i c a l s p i n e com pare d . J Bodywork Movem e n t T h e r a p 1 9 9 7; 1 : 1 7 3 - 1 7 8 .
2 1 . M a k o fs k y H . T h e e f fect o f h e a d p o s r u r e o n m u s c l e c o n t a c t pos i t i o n : T h e s l i d i n g c r a n i u m t h e o r y . C ra n i o 1 9 8 9 ; 7 : 2 8 6-2 9 2 . 2 2 . S t i tze l CJ , M o rn i n gs t a r M W, P a o n e PR o T h e e ffects o f b i t e l i n e d e v i a t i o n o n l a re r a l c e r v ic a l ra d i o g r a p h s w h e n u pp e r c e rv i c a l j o i nt d y s fu n c t i o n e x i s t s :
A p i l o r s t u d y. J Ma nip P h y s i o l Ther
2003;26 ( 7 ) : E 1 7. 2 3 . D i e z F. C h i ro pra c t i c m a n a ge m e n t of p a t i e n ts w i th bi l a t e r a l c o nge n i ta l b i p d i s loca t i o n w i r h c h ro n i c l o w b a c k a n d l eg p a i n . J Ma n i p P h y s i o l T h e r 2 0 0 4 ; 2 7 ( 4 ) : E6 . 2 4 . l .c s h o E P. A n o v e r v i e w o f o s te o p a t h i c m e d i c i n e . A rch F a m Med 1 99 9 ; 8 : 4 7 7-4 8 4 . 2 5 . B l e d s o e B E . T h e e l e p h a nt i n rhe lOom : Does O M T h a ve p r o v ed b e n e fi t ? J A m Oste o p a th A s soc 2 00 4 ; 1 04 : 4 0 5 -4 0 6 .
S e ct i o n I I I • C l i n i ca l Co n d i t i o n s
406
2 6 . Bi o n d i D M . Cervicogen ic headac he : Mec h a n i sms, eva l u a ti o n , a n d treanne n r srra tegie s . J A m
Oste o pa th Assoc 2 0 0 0 ; 1 0 0 ( 9 s u p p l ) : S 7-5 1 4 . DJ . Progressi v e i n h i b i r io n o f neu r o m u scu la r strucru res ( PI NS ) rechmque . .I A m Osreo p a t h Assoc 2 0 0 0 ; 1 0 0 : 2 8 5-2 8 6 , 2 8 9-2 9 8 . 2 8 . Licc i a rd o n e ] C . T h e u n i q u e r o l e o f osteopa t h i c p h ysi c i a n s i n trea ting pa tients w i t h l ow back p a i n . J Am Osteopa th Assoc 2 0 0 4 ; 1 04 ( 1 1 suppl 8 ) : S 1 3 -S I 8 . 2 9 . Sp i ege l A./, C a p o b i a n c o jD, K r u ger A, Sp i n ne r W D . Osteopa t h i c m a n i p u l a tive m e d i c i ne in the trea tm e n t o f h y pe n e n s i o n : An a l te r na r i ve , c o n v e nr i o n a l a p p roa c h . H e a rt D i s
2 7 . Dowl i ng
2 0 0 3 ; 5 : 2 72-2 7 8 .
DG, P h e l e y A M . Use o f osteopa t h i c m a n i p u l a ri v e trea rmen t by O h i o osteopath ic p h y s i c i a n s i n v a r i o u s s p eci a l t i e s . J Am Osteo p a r h A s s o c 2 0 0 3 ; 1 0 3 : 1 6-2 6 . 3 1 . j e r m y n RT. A n o n s u rgica l a p p roach ro l o w b a c k pa i n . J A m Osreop a t h Assoc 2 0 0 1 ; 1 0 1 ( 4 s u p p l p t 2 ) : 5 6 -5 1 1 . 3 2 . B u rron A K , McCl u ne T D , C l a r k e R D , Ma i n CJ . Lo ng-re r m fol l o w - u p o f p a t i e n ts w i t h low back p,1 i n a tten d i n g fo r m a n i p u l a ti ve care: O u tcomes and p r e d i c to r s . M a n i p Ther 30. Spaeth
2 0 0 4 ; 9 ( 1 ) : 3 0-3 5 .
3 3 . McPa rriand j M . Tra vell trigger p o i n t s : Molecular a n d osteopath i c perspectlves. J A m
Osteopath Assoc 2 0 04 ; 1 0 4 : 244-24 9 . 3 4 . H a rden N , C o h e n M . U n m e t needs i n t h e m a n a ge m e n t o f n e u ro p a t h i c p a i n . Nl a n a g 2 0 0 3 ; 2 5 ( 5 s u p p l ) : S 1 2-5 1 7 . 3 5 . C h o n g M S , Bajwa ZH. D i a g n o s i s and rrea tment of n e u ro p a t h i c pa i n .
J Pa i n S y m ptom
J Pa i n S y m ptom
tvl a n a g
2 0 0 3 ; 2 5 ( 5 s u p p l ) : S4-S I 1 . 3 6 . Pasero C . P a t h op h y s i o l o g y o f n e u r o p a r h i c pa i n . P a i n M a n a g N u l'S 2 0 0 4 ;5 ( 4 S u p p l I } : 3- 8 . 3 7 . Nama ka M , G ra m l i c h C R , R u h l e n D , e t a \ . A trea tment a lgorithm f o r n e u ropa t h i c pa i n . C l i n Ther 2 0 0 4 ; 2 6 : 9 5 1 - 9 7 9 . Erra tum i n C l i n T h e r 2 0 0 4 ; 2 6 : 2 1 6 3 . 3 8 . Wa ng SJ , J u a n g K D . Psyc h i a tric c o m o r b i d i t y o f c h ro n i c d a i l y h e a d a c h e : i m pa c t , rrea r m e n t ,
o u tcome, a n d fu t u re s t u d i e s . C u r r Pa i n H e a d a c h e R e p 2 0 0 2 ; 6 : 5 0 5-5 1 0 . 3 9 . Meri k a ngas K R . Assoc i a t i o n between ps)'c h o p a r h o l ogy a n d h e a d a c h e s y n d romes. C u r l' O p i n Ne u ro I 1 9 95 ; 8 : 24 8-25 1 . 4 0 . M e r i k a ngas K R , Stevens DE, A ngst j . P s y c ho p a t h o l o g y a n d hea d a c h e synd romes i n r h e c o m
m u n i ty. H e a d a c h e 1 9 9 4 ; 3 4 ( 8 ) : 5 1 7-5 2 2 . Erra tu m i n Heacl a c h e 1 9 9 5 ; 3 5 ( 1 ) : p rececl i . 4 1. K a t z j , Me l z a c k R . Measurement o f p a i n . S u rg C l i n North A m 1 9 9 9 ; 79 : 2 3 1 -2 5 2 . 4 2 . A b t a h a m I , K i l l a c key-J o n e s B . La c k o f e v i d e nce-based res e a rc h for i d iopath i c l o w b a c k pa i n : T h e i m p o r ta nce o f a specific d ia g n o s i s . A rch I n te r n M e d 2 0 0 2 ; 1 6 2 : 1 4 4 2 - 1 4 4 4 ; d i s c u s s i o n 1 447. 4 3 . Ta y l or F R . D i agnosis a n d c l a ss i fi c a r i o n of h e a d a c h e . P r i m C a r e 2 0 0 4 ; 3 1 : 2 4 3-25 9 . 4 4 . Li pton R I3, Biga l M E , S t e i n e r TJ, cr a t . Cla s s i fication of p r i m a r y h e a d a c h e s . N e u ro l ogy 2 0 04 ; 6 3 : 4 2 7-4 3 5 . 4 5 . Hea d a c h e Class i fi c a t i o n S u bcom m i rree o f t h e I n te rn a tio na l Hea d a c l1c Soci ety. T h e interna
t i o n a l c l a s s i f i c a t i o n of h e a d a c h e d isorders. Cep h a l a l g i a 2 0 0 4 ; 2 4 ( 5 1 ) : 1 - 1 5 1 . 4 6 . A me r i c a n A c a d e m y o f Osteo p a t h y. I ntegrating ma n u a l m e d ic i n e i n to p a t i enr care r h rough
h a n d s - o n workshops, 2 0 0 5 . F l o w chart o f A A O cou rse o ffe r i ngs. Ava i l a ble a t h rrp ://wlVw. a c a d e m y o fo s te o p a r h y. org. A c ce ssed A p r i l 1 7, 2 0 0 5 . 4 7 . S u th e r l a n d W G . Tea c h ings in t h e Science of Osteopa th y. Portla n d , OR: R u d r a , 1 9 9 0; 1 1 2 . 4 8 . G i a t i s IZ, Ga rwood R iVl . Diagnosing m i g r a i nes t h e osreo pa r h i c w a y : Case s t u d i e s overview
ing t h e i m p o r t a n c e o f recogn i z i n g a nd trea r i n g the m u scu loskeleta l compo n e n ts o f m ig r a i n e h e a daches. Osteopa th Fa m P h y s i c i a n N e w s 2 0 0 4 ;4 : ] , 1 0- 1 2 . 4 9 . M u e l l e r L . Tri pta n s h a v e revol u t i o n ized a c u te m i g r a i n e thera p y : T h e osreo p a th i c fa m i l y phys i c i a n 's m igra i n e a r m a m e n ta r i u m h a s grea t l y expa n d e d over the l a s t deca d e . Osteo p a t h F a m P h ysician N e w s 2 0 0 4 ;4 : 1 4 - 1 6 . 5 0 . Mago u n H I . Osteo p a t h y i n r h e Cra nia l Field . 3 rd cd . K i r k s v i l l e, M O : J o u rn a l P r i n t i ng , 1 976;] 84, 2 8 2 . 5 1 . Wa l d m a n S D . I n re r v e nr i o n a l Pa i n JV[a n a gcment. 2 n d cd . N e w York : S a u n d e r s , 2 0 0 1 ; 2 7 .
S 2 . La r s o n N j . F u n c ti o n a l v a s o m o to r h e m i p a r e s r h e s i a s y n d r o m e . A ca d e m )' of A p p l i e d
O s teopathy 1 970 Yea rboo k . Ca r m e l , C A : A c a d e m y o f A p p l i ed O s teo p a t h y, 1 9 7 0 : 3 9-44 . ( A va i l a b le th r o u g h t h e A m erican Aca d e m y of Osteopa thy, I n d i a n a po l is . )
C h a pter 25 • T h e Pat i e n t w i t h C h ro n i c Pa i n , H e a d a c h e 5 3 . N e l s o n K E . O steopa th i c med ica l co n s i d e r a ti o n s of reflex s y m pathetic d y s t r o p h y.
407
) Am
Osteopath Assoc 1 9 9 7; 9 7 : 2 8 6-2 8 9 . 5 4 . Ya tes H A , G l o v e r ) c . C o u n terstra i n : A H a n d bo o k o f O s teo p a t h i c Tec h n i q u e . Tu l s a , O K : Y K n ot, 1 9 9 5 ; 5 2 . 5 5 . K u c h e t a WA , Kuchera ML. Osteop a t h ic
P r i n c i p l e s i n Practi c e . 2 n d ed . Col u m b us, O H :
G reyd e n , 1 9 9 3 ;3 3- 3 4 , 2 2 9 . 5 6 . Wa l ton W) . Textbook of Osteopa t h i c D i a g n o s i s a n d Tec h n i q u e Proced u r e s . 2 n d e d . C h icago: Ch icago Co l l ege o f Osteop a t h i c M e d ic i n e , 1 9 72 ; 1 3 9-1 4 0 .
CHAPTER
26
The Patient with Back Pain: Short Leg Syndrome and Postural Balance Kenneth E. Nelson and Anette K. Schilling Mnabhi
INTRODUCTION Low back pain is very frequently enco u n tered . It affects most individuals at some time du ring the cour se of their l ife. This chapter discusses the mechanics of
unequal leg lengt h and postural balance in t he coronal pl ane . Chapter 27 consid e r s d y sfu nctiona l mec hanics in the sagi ttal plane. This is an artifici al division, and
the material covered in the se two chapters s h ould be considered to gether. A thor
ough und ers tand ing of these mechanics \vill help with di a gn osis and tre a t m en t of a significant number of p atients with low back pa i n and individuals with a my ria d
of other mu s culoskelet a l com p l aints . Because of the phy sic al s tresses th at p ostu ral acco mmodation pla ces upon the pat i ent, t rea tmen t of dysfun ction a l balance mechanics proves to be u s eful adjunctive therap y for most cases of chronic med ical con d i t i o n s th at affect t he am b ulatory patient. Elderly p atie n ts with p ro g ressiv e loss of the a bili ty to perform the activ ities of d ai ly living may regain sign i ficant function when the effects of so matic dy s f un ction are el imi na ted or reduced. Inequality of leg len gt h is extremely common.1.2 Of 105 members of the 1968 to 1971 cl asses of the Chi cago College of Os teopa thic Medicine (CCOM) who had post u ra l rad iogra phs done, 58, or 55%, had an inequality of leg length of one quarter inch or greater. (Serrecchia F, N elson KE. S u rvey : CCOM a lu m n i who had pos tural radiogra phs as freshman medi ca l students. Unpublished d ata, 1994.) Studies of schoo lchildren show that differences in leg le n gth tend to increase as 408
Chapter 26 • The Patient with Back Pain: Short Leg Syndrome
409
children grow.3-S The diagnosis of short leg syndrome is ba sed upon a constella tion of muscu l oskeletal and general body symptoms and upon physical find ings tha t may be confirmed by radiography. It is necessary to recall one's understa n d i n g o f sacropelvic mechan ics,6.7 s ince inequ a li ty o f l e g length i s a common ca u se of pelvic un leveling with re s u l t a nt s acropelvic dysfunc ti on.
THE PRESENTATION OF THE PATIENT Ty pica l pa tients are midd le a ged or older. They commonly pre sen t with a chief com plaint of midline lumbosacral pa i n that is most often d escribed as dull or aching. Frequently, the pain rad i a tes to one buttock, u sually on t h e side of the shor t leg. Patients may also have a my ria d of other pelvic complai n ts a n d myalg i a s anywhere alo ng the spine. Sometimes they complain of a general feeling of fa tigue ( br i nging such t hin g s as a nemi a a n d h y pothy ro i d i s m into your d ifferen tial d iagn osis ) Often, when quesrioned, patients say they awake in the morning with little or no discom fort, but as the day p r ogresses they become m o re a nd more symptoma tic. Sometimes they note thar their sympto ms d evelop at the same time every d a y. -
.
,
An Explanation of the Chief Complaint If an individual has equa l leg length a n d there is
no
prima ry sacropelvic d y sfun ct i o n,
the pelvi s and sacral base should be level. With a level pelvi s, the spine above should be straight ( Fig 26.1). If one leg is short, the stra ight spine m ight be expec ted to tip to the sid e of the short leg (Fig. 26.2). This obviously does not occur. Ra ther, in an at tempt to m a i n ta i n one's center of gravi ty o v er the pelvis, a compensa tory (Type I) curve develops ( F i g 26.3). A single curve (Fig. 26.3A) c a n develop, or ad d i tional .
.
Right
FIGURE 2 6 . 1
Level pelv i s w i th a stra ig ht spi n e above.
410
Section III • Cl inica l Condit i ons
Right
FIGURE 26.2
If one leg is s h ort, t h e straight spine m i g ht be expect ed to t i p to the side of the s h ort leg. T his obv i ou s ly does not occur.
FI G U RE 26.3
In an attempt to maintain one's center of gravity over the un level e d pe lvis, a compensat o ry (type I) curve devel ops. A sin g l e cu rve (A) c a n develop, o r additi ona l c ompensatory curves (B) m a y occur.
Chapter 26 • The Patient with Back Pain: Short Leg Syndrome
411
Left
f F I G URE 26.4
A s h ort l eft leg with a compe n s atory l u mba r cu rve (convex l eft) a nd a d d i tiona l t h o rac i c and cerv i ca l compe n s a tory c u r ves.
compensatory curves (Fig. 26.3B) may occur. The i n dividu al in Figure 26.4 has a shorr left leg with
a com pensatory lumbar curve (convex left ) and add iti onal thoracic and cervical compensatory curves. These curves are not just balance d above the pelvis, they are the result of and are maintained by asymmetric paravertebral muscle
contraction (Fig. 26.5). Under certain circumstances, the sacrum shifts so that it rota tes upon either the le ft or right oblique axis.8 Weight bea ring on one l eg engages t he ipsil a teral ob liqu e axis, with resultant sacral rotation. Side bend i ng of the lumbar s pine also engages the oblique sacra l axis on the side toward w hich the l u m b a r s pine is side bent. Figure 26.6 shows h ow, because of the s hort left leg, th e compensatory lu mba r curve engages the right obliqu e axis. Also, because of the i neq u a l ity of leg length, individuals walk and bea r weight asymmetrical1y. As pat ients walk, they must step up d uring stance p hase upon the l ong leg and step down d u ring stance p ha se on t h e short leg side . This as ymmetr ic workload tends to chronically engage the sacral obliq ue axis on the l o ng leg side . Since sta nding and walking ten d to occur under neutral circumstances, if, as in F igure 26.6, the right o blique axis is ch ron ic a lly engaged, the sacrum is chronically rotated right on the right o b liq ue axis. Lumbosacral mechanics in this c ircu mstance will be a right-on-right forward tor sion. The sacrum, al th o ugh anatomically part of the pelvis, funct ions p hysiologi cally as jf it were parr of the lum bar sp ine . 9 As sLlch, the sa cr um is functionally the
lowest segment in the compensatory lumbar curve. The curve (Type I me ch anics) as a group is side bent right and rotated left. The fifth lu mbar verteb r a , being below the apex, is si d e bent right and rot a t ed left relative to the sacrum. There fore, the left
412
Section III • Clinica l Conditions
Left
FIGURE 26.5
Th e compensatory spi n a l cu rves above an unlevele d pe lvis are not just bal anced above the pe lvis; they are the resu lt of and are maintained by a symm etric paravertebr a l musc l e contraction.
side of the sacral base is relatively anterior to the l eft transverse process of L5. This is right-on-right forward sacral torsion. Sacroiliac mechanics are equally logical. If the sacr um is c h ron ica l ly rot a ted r ight on the r ight oblique a x is, the mechanics fa vo r either an anterior sacrum on the left or a post erior sacrum on the right. That is, because of sacral rotation to the rig ht between the il i a , the sacrum wil l be a nte r i or to the ilium at the sup er io r pol e of the left sacroiliac articulation and p oste ri or to the i l iu m at the inferior pol e of the ri ght sacroi liac articulation. Anterior and poste rio r sacrum are d ysfunctions of arricular motion restriction. So with sacral rotation right on the right oblique a x is, if articu lar motion of l ef t sacroiliac joint is restr icted , it is called an anterior sacrum on the
left. If articu l ar motion of r ight sacroil iac joi n t is restricted , it is called a po st e r io r sacru m on t h e right. With accommodation to a s hort leg m os t common ly there is an anterior sacrum on the short leg side.lO An a n ter io r sacrum is a ss ocia ted with i psi l atera l g l uteal ( glu teus medius) spasm a n d pain. A posterior sacrum is assoc iat ed with ipsilateral piriformis muscle spasm, pai n , and often sciatica. D ysf u n ct i o n al s acro pe l v ic mechanics twist the three bones of the pelvis so that as ym m e t ri c stresses are placed upon the abdominal wall and myofascial tissues of t h e pe lv ic floor, w h i ch may result in sy m p to ms resembling p roc tit is, pro st a titi s, cy stiti s, and/or a m y ri ad of gynecologic prob l e ms. I J The allop at hic d iagnoses lev ator ani s yndrome and p r octalgia f ugax often may b e manifestations of sa c r o p e l vi c d y s fun ction .
413
Chapter 26 • The Patient with Back Pain: Short Leg Syndrome
Left
FIGURE 26.6
A short left leg with a compensatory lumbar curve side bent to the right will cause the sa crum to be chronically rotated right on the right oblique axis.
Musculoskeletal co m pl ain ts above the pelvis result from asymmetric muscle
contraction associated with type I m ech a nic s and the fact that s o ft t i ssu e s 011 the side of the con v e xi ty of
a
type J curve are constant ly being stretched.
Type II mechanics are frequently found at transitional points within the patient's
type I pattern. Typ e I curves are frequently
a sso c i
at ed with increases in the s a gitta l
p l an e ( lor d otic kyphotic) curves. Intersegmental rotational mechan ic s ch an ge at the ,
apex of a type I c ur ve As such, t ype II (flexion m echa n ics) might be expected at the .
level of the spinal segment i mm ediately above the apex of a type I t h o r ac i c curve and
type It (extension m echa n ics) at the level o f the segment i mme d iately above the apex a type I lumbar curve. At the crossove r point between two type I c u r v e s the anteroposterior (AP) curve is flattened, m aki ng these areas more vulnerable to type l[ extension dysfunct i ons in the t h o r ac ic region and to type II flexion dysf unct i on in the lumbar region S p inal facilitation at these levels can affect the pat ien t in m any ways through somatovisceral reflexes. (See Chapter 5.) Rib compla in ts may be pr od u ce d by the side ben ding and rotational mec h an ics of a ty p e I thoracic curve. Frequently, a pa tie nt has dis com fo rt merdy because of
of
,
.
the crowding of th e ribs on the concave side of a thoracic group curve or the approximation of the lower ribs and iliac crest on rhe co nca ve side of a lumbar curve . Costotransverse d ys f u nction s are ofte n found in assoc i at io n with type 11
vertebral dys fu nct i o ns
.
414
Section III • Clinical Conditions
Figure 26.4 shows how the compensatory partern can extend up into the cervi cothoracic and upper cervical reg io n. This can pr od uc e shoulder pain, ce r vical pain, muscle tension c epha lalg i a , and even temporomandibular joint d ys f u n ction. Muscle contraction (white fiber) is fueled by g lycoly sis . Initially, m us c l e contrac tion (r ed fiber) is fueled by efficien t aer o bic gly coly s is , in whic l 1 gl u cose is oxidized complete l y to car b o n dioxide and water; however, when gl u cose is incompl et e ly oxidized, suc h as after prolonged m u sc le contraction when ava ilab l e oxygen is depl eted (the rule of the artery), th e system shifts to an aer o bic glycolysis. Anaerobic glycol ysis resu lts in the productio n of excess r educ i ng e qu i v ale n ts (hyd rogen as r edu ced nicotinamide adenine dinucleotide [NADHJ) and the co n s eq ue n t accumu lation of lactic acid within the m u scl es with resultant myalgia. Asymmetries in pos t ura l mechanics result in stress on the m us c ula t u re, leading to p rol o n ged muscle contraction in the stressed muscle. With this information in mind, one m u s t reconsider the p re se n ta t i on of the patient with short leg syndrome. The chief complaint is most often mid l in e lum bos a cr al p ain that is the r es u lt of altered lumbosacral me cha n i cs. The pain is dull a nd a chi ng , it is a b sen t or less severe ear ly in the morning, when the patient a wa k e n s r e freshed after a night'S s l eep . As the day p r ogresses and the p a tie n t fatigues, t h e p ain develo ps . The a s ymmetr ic mechanics of the compensatory curves and sacroiliac dys fun ct ion determine the pain patte rn . Since younger individuals ha ve high ph y sica l reserve, they t e nd to have a greater tolerance for the stres ses of asym m etr i c p ost u ral mechanics. As p a ti ents age, tolerance decreases until e v e nt u ally s y m p to m s ap pea r. Typica lly this does not occur until after age 35. If a young patien t has what ap p ears to be s h or t leg s yndrome , a th o r ough search should be made for com p l i cati n g factors. If the patient is yo ung e r than 20, a t hor ough search should be made for sign ifi c ant l oca l p at h ology (spinal a nom a l i e s , d iscitis , ost eomyeli ti s ) or distant p a tho l ogy r esu l ting in a v i s c eroso ma tic reflex. Individuals younger than age 20 r a r el y present with short leg syn d ro m e .
THE PHYSICAL EXAMINATION Firs t , conside r t h e a p p aren t l eg len gth and diff er en ti a te between functional
(i.e.,
app ea rs to be) and an atomic ( i.e ., act u al l y is) in equality of leg length. The evalua
tion of leg l e ngth with the p a tien t s u p in e by comparison of the r e l ati v e positio n s m edi al malleoli by itself does n ot ad e q uate l y differentiate between functional and anatomic leg length di screpa n cie s . Causes of f u nctio n a l leg length discrepancy of the
inclu de the fol lowing:
26.7). In a supine p a t ie n t, the p resen c e of lum ba r group curve echa n ics ) wil l ten d to pull the h em i p el vi s on the s i de of the concavity of the curve ce p ha l a d . This will in turn pull the lower e x t r emi t y ceph al a d, cre a ti n g the appearance of (i.e., functional) leg le n g t h i n e quality. Anterior or p osterio r rotation of the ilium (Fig. 26.8) is said to occur as r otat i o n of the ilium about the h yp ot h e tical inferior transverse sacral axis, as p rop os ed s by M itc h ell . Because the hip j oint is ant er io r to the sacroiliac j o i n t , p osterior rotation of the ilium draws the hip j oi nt c eph a l ad (Fig. 26.8A). With the pa t i ent l y ing down, this creates an i psila ter al functional short leg. Conversely, anterior rotation of the il i u m causes the hip j o int to move in a caudal direc tion ( F ig. 26.8C). This, with the patient s u pin e , pr odu ces a ips il ate r al func tional lon g l e g . Some clinicians attempt to measure leg l engt h with a tape measure by deter mi n ing the distance between the m os t inferior aspect of the an te r i or superior iliac Lumbar curve ( F ig .
(type I
m
Chapter 26 • The Patient with Back Pain: Short Leg Synd rome
415
Left
t t _v FIG URE 26.7
With t h e patient s upine, t h e l u mbar gr oup curve (type I mec h a nics) tends t o pu l l the h e m i p e lvis on t h e si d e of the c onc a v i ty of the curve ceph a l ad, c a u sing a f unctional s h ort l eg on t h a t s ide.
spine (ASIS) and the most dista l point on the homola teral med ial malleolus. This is don e with the patient supine, a nd although it ma y s u f fi ce for determin ing orthopedic (mea sured in inches) ana tomic i n eq u a lities of l eg l ength, the inequalities dea l t with when treating anato mic s h ort leg mecha nics are meas ured in increments of one-e ighth i nch or in m i l l i m ete rs. T h e act of placi n g t h e rape measure upon the ASIS o r malleolus h a s a n inherent error potential o f a t l ea s t one-eighth inch, which inva l ida tes t h i s mea surement for a ssessing minor l eg l engt h inequalities. Consider a l so the effect of pelvic dysfunction upon the positio n of t h e ASIS. It can be seen how a posterior ilium will prod uc e a func tional s h or t leg (Fig. 26.8A). As the ilium rota tes posteriorly, however, it dis p l aces the ASIS supe r i o rly This increases rhe distance between t h e ASIS and .
Section III • Clinical Conditions
416
o
t FIGURE
26.8
o
+
A
(A) Posterior rotation of the ilium draws the hip joint cephalad, with a resultant functionally short leg on that side. (8) Relationship between the normally positioned ilium and the lower extremity. (e) Anterior rotation of the ilium displaces the hip joint caudally, with a resultant functionally long leg on that side.
the medial m alleolus, causing the functional short leg to measure lon g . The converse wou ld be true in t he presen ce of an anterior ilium (Fig. 26.8C). These considerations obviously limit the effectiven ess of this procedure for the eval u ation of the majority of patients . Anatomic leg l ength discrepancy is the result of actual inequali ty of the l ength of the legs .' o It ca n result from a ct u a l in equality of the length o f the l ong bones of t h e legs, or it can be the result of asy m metric mechanics of the k n ees, valgus or va r u s deformity, or pronation or s u pination of the ankles and feet. It is apparent how asy m metric valgus or varus of th e knees can unlevel the pelvis. Dysf u nctional mechanics of the ankles and feet are more comp lex. If the foot is pronated, the foot is a b ducted, dorsally flexed, and everted; this leads to internal rotation a nd shor ten ing of the lower extremity. If the foot is supinated, it is adducted, plan tar flexed, and inverted. This leads to external rotation an d lengthenin g of the lower extremity. The most common asymmetric foor position is the pronated foot, often found as compensation on the side of the an a tom i c long leg'2,13 (Fig.
26.9).
After the k nees, ankles, and feet h a ve been evaluated for asy mmetry, anatomic leg length discrepancy is best assessed with the patient s ta n di n g , knees fully extended and bearing weight on both legs e q ua ll y. This uses the f l oor as a fixed reference point. Observation of a co n ste l lation of anatomic landmarks is per for med by co m pari ng them bilatera lIy. These landmarks include the fo l l owing: • P oste r ior superior iliac spines (PSIS), the landmark many clinicians feel is the
best indicator of sacral base p l ane • Sa c ral d imp les • Most lateral aspect of the iliac c rests • Tops of the greater trochanters, the m ost direct indicator of leg length (They a re, however, often obscured by overlying soft tissue a n d fai l to account for inequal ities of femoral neck angles or morphologic asy m metries of the trochanters.) Typically, all of these l a n dmarks are low on the side of the shorr leg.
Chapter 26 • The Patient with Back Pain: Short Leg Syndrome
B Supinated foot
A Pronated foot
Lateral
Medial
FIGURE 26.9
417
Medial
Lateral
(A) A pronated foot
demonstrates ab duction, dorsiflexion, and eversion, resulting in internal rotation and functional shortening of the lower
extremity.
(B) A s u pin ate d
foot demonstrates adduction, plantar flexion,
and inversion, hence internal rotation and functional lengthening of the lower extremity.
The sta n d ing structural examination may be completed by checking for the following: •
Pelvic side shift (d isc u ssed later in the ch ap te r )
• Lateral c u rves : have the patie n t bend forwa r d and ob se r ve fo r a sy m m etri c pa r
ave rt eb ra l pr omin en ce , the re s u l t of the r otation a l component of type I
mechanics • S y m met r y of anatomic landmarks abo v e the pelvis (i.e., sca p ula e , acromion
processes, mastoid processes) •
S y mmet r y of anatomic landmarks of the lower extremity (i.e., p op li tea l creases and medial malleoli) In addition, observe for asymmetry of s k in folds on the torso and the way the
patien t 's garments (e.g., belt line) are positi oned . This complete constellation of observations should give an idea of the pat i ent's neu tral w e igh t bearing pattern. If t his information is a dded to that obtained from the supine e xa m ination, discussed previously, one can d r aw conclusions as to the pres enc e and clinical s i g n if ica n ce of anatomic versus functional leg length m echanics. Now consider p e l vic side shift, or lateral deviation of the pelvis to the ri g h t or left of t h e midline when t h e patient is s t a n din g . It is tested while sta bil i z in g t h e u ppe r t orso b y holding the sh o ulde r with one hand and then pushing m edia ll y over the lateral aspect of t h e opposite h em i pe l vis with the other hand . The test is pos i tive when the pelvis moves freely in one d irection and resists movement in the op pos i te direction. A posi t i v e pelvi c side shift is designated as either l ef t or ri g h t as an i n d ic a ti on of t h e direction of unrestricted pelvic motion. F i gure 26.10 illus tra t es a po s i t ive pe l vic side s hift right. Since pelvic side shift moves the center of t h e p e lv i s away fro m the midline and a per so n will attempt to maintain the center of g r avity io the midline, t h e t o r s o a b o ve the pe l v i s will move in the direction op posite the side shift. Under neutral circumstances t h is results in a co m p en sat o r y lumbar curve (ty pe 1 mec h a n ics ) , convex on the side op p osite the side shift. In Figure 26.10, the r i gh t pelvic side shift is assoc i a ted with a thoracolumbar c ur ve, convex left. The lumbar side
418
Section III • Clinical Conditions
Left
F I G URE 26 . 1 0
Right
Level pe l vis with a s i d e shift t o the r i g ht. PSS, pe l v i c s i d e shift .
bending i s to [he right (the side o f the gro up concavity), which will engage the sacral right ob l iq u e axis. Since co nditi o ns are n e ut r a l , a right-an-right forward tor sion (lumbosacral) results. Because t h e sacrum is rotated right on the right oblique axis, if sacr o i l iac dysfunction is present, o n e would expect to f i n d an anterior
sacrum on the left or a posterior sacrum o n the rig ht in ass oc i ati o n with a pelvic
side shift to t h e right.
Pelvic side s hift may be t he result of conditions affecting the pelvis fr o m bel o w
.
Inequality of leg l engt h is ass o c i a t ed with pelv i c shift to w ard the long leg side.lo The pelvis functions symmetrically most readily when the s a cra l base is level. Shift ing the pelvis toward the long leg side ten d s to level the sacral base (Fig. 26.11). Pelvic sid e shift may be t h e res ult of co nditions affecti n g t h e pelv is from above. Group curve mechanics (type 1 mechanics) may produce a pel vic side shift.
FI G U RE 2 6 . 1 1
Inequa l ity o f l e g l ength affecting t h e pel vis from b e l ow. The effect of l e ve l i n g t h e pelvis is a pe l vic side shift tow a r d the l o n g l e g sid e. PSS, pelv i c s i d e s h ift .
Chapter 26 • The Patient with Back Pain: Short Leg Syndrome
Left
419
Right
PSS FIG URE 26.12
A group curve (type 1 m ec h a n i cs) affect i ng the pelvis from above a n d resu l t i ng in a p e l vic s i d e shift . PSS, pe l v i c s i d e s h ift .
Idiopathic scoliosis co m m on ly presents as a pr imary fixed (i . e. , will no t straighten whe n side bending is in t roduced toward the convex side) thoraci c curve that is convex righ t . There is often a smaller l umbar compensatory c urve, convex left. This latte r curve will shift the pelvis toward the ri g h t (F ig. 26.12). (Scoliosis refer s to latera l curvature of the spine g reater than 10 deg rees . The l ate ral curves associ ated with short- leg mechanics should not be referred to as scolioses or scoliotic unless they exceed 10 de g rees because of the d isqu ie ting effect of these terms upon pa tients . ) The contribution of typ e 1 lum bar mechanics to pelv ic side shift can be read ily seen when a patient has a short leg a nd the entire co m pe nsation occurs between L5 and S1 (Fig. 26.13). Because the spine is s tr a ight , the center of grav ity is centered ove r t he pe l v i s, and th er e fore , no pelvic side sbift results. Under these circumstances, the unequal leg l e n gt h allows the pelvis to ten d to shift tow a r d the long leg s i d e, but the side shift is not maintained du ring normal
weight-bearing activity. Muscle pull mech a nics from above can also produce a pelvic side shift. Th i s occurs in t h e presence of a sym metric spasm of psoas major.14 Spas m of the left
psoas major will produce a side shift to the right in an otherwise level pelvis (Fig. 26.14). Psoas spasm may ov erco m e the compensatory s pina l curve from a short leg, eliminating pel vic side shift (Fig. 26.15), or it may a ugmen t shorr leg mechanics (Fig. 26.16). Before short leg mechanics can be ef fectively d iagnosed or treated, dysfu nction a l muscle pull mechanics must be eliminated. Spasm on the long leg side can negate the com pen satory lumbar curve a nd
pe l v ic side shift. Spasm on the short leg side can augment the compensatory lumbar curve
pelvic side shift.
and
420
Section III • Clinical Conditions
Left
FIGURE 26.13
l
Right
A short leg with all of the spinal compensation between LS and S 1. PSS. pelvic side shih.
Left
Right
PSS FIGURE 26.14
� t
A level pelvis with pelvic side shih to the right as the result of spasm of the leh psoas major muscle. PSS. pelvic side shih.
Chapter 26 • The Patient with Back Pain: Short Leg Syndrome
Left
FI G U RE 26.1 5
One com bined effect o f pso a s spasm a n d u n equa l leg length.
Left
FI G URE 26.1 6
Right
Right
O n e co m bined effect of pso a s spa s m a n d u nequ a l leg l engt h .
421
422
Section III • Clinical Conditions
ASSESSMENT The diagnosis of short leg syndrome is based upon the pain complaint (pattern, quality, and incidence) and the findings of the musculoskeletal examination. The pain complaint associated with short leg syndrome is described previously. It is worthwhile to iterate, however, that short leg syndrome is the result of weight bearing upon essentially normal anatomy (since most individuals have leg length inequality). The patient tends to awaken in the morning pain free , or at least with decreased symptoms.
The pain complaint
increases as the day
progresses.
Complaints associated with anatomic pathology (herniated nucleus pulposus, spondylolisthesis) are affected similarly by rest and weight bearing; however, they tend to become intensely symptomatic after briefer periods of weight bearing. Muscle pull mechanics produce pain patterns similar to short leg mechanics. The incidence of the pain differs. low back pain resulting from psoas spasm is worse after periods of immobility because the offending muscles become set abnor mally short when they are resting. The patient has significant discomfort on first walking in the morning. As the patient moves around and the muscles warm up, the symptoms abate. The musculoskeletal findings typically associated with short leg syndrome are
as follows (Fig. 26.17):
1. Anatomic landmarks (PSIS, iliac crest, greater trochanter) low on short leg
side (example: on left)
2. Pelvic side shift toward long leg side (example: toward the right) 3. Pelvic rotation toward the long leg side due to forward torsion (example: right
on right forward torsion, pelvic rotation right)
Left
FIGURE 26.17
Right
The musculoskeletal findings typically associated with a short left leg. PSS, pelvic side shift.
Chapter 26 • The Patient with Back Pain: Short Leg Syndrome
423
4. Anterior sacrum on short leg side (example: on left) 5. Compensatory spinal curve convex on short leg side (example: convex left)
Postural Radiographs The findings on physical examination may be confirmed by a postural radiographic series. IS, 16 The postural series is the gold standard for determining weight-bearing mechanics. It was developed in Chicago by Hoskins17 and Schwab in the 1920s. The series consists of three films taken with the patient standing: 1. AP pelvis and lumbar spine
2. Lateral pelvis 3. APthoracic spine
When the postural series is properly performed, measurements obtained from it are accurate to within one-eighth of an inch. Measurements typically obtained from the AP pelvis film include the following (Fig. 26.18): Femoral head height discrepancy Sacral base unleveling Pelvic side shift (static deviation of the pelvis from the weight bearing midline, also called the mid-heel line) Iliac crest height discrepancy (occasionally measured)
a Left
FIGURE 26.18
Right
(a) (b and b') Horizontal lines demarcat ing the femoral head heights. (e) Plane of the sacral base. (d and d') Two Marking and interpreting the AP pelvis film of the postural series:
Vertical reference, the mid-heel line.
vertical lines that demarcate the sacral base relative to the position of the
femoral heads. (e and e') Horizontal lines demarcating the amount of sacral base unleveling relative to the position of the femoral heads.
424
Section III • Clinical Conditions
The AP thoracic film gives informa t i on regard ing the ty pe I spinal compensa tory p a ttern. The latera l pelvic film offers information that ca nnot be obtained readily by physical examination. The proced ure for taki ng the postural radiogra phic series has been described elsewhere. IS, 18,19 The films a re viewed with the pa tient's left on the left side of the ra diographic view box (Fig. 26.18), tha t is, as from behind. The AP films i n dica te bala nce mecha n i cs i n the corona l pla n e and are d iscussed here. The i n terpretation of the la teral film is discussed a t length in Cha p ter 27. The first step is to identify a true vertical reference, the mid-heel line (Fig. 26.18, line a). This is often obtained by hanging a radiopaque plumb line between the pa tient and the ra diograph cassette. Once the vertical reference mid-heel line has been identified, femoral head heights, that is, tru e anatomic leg length, sho uld be measured (Fig. 26.18, lines ba n d b)' . femoral hea ds o n e i ther sid e and draw two horizontal Jines, one from the upper most a spect of each femoral hea d, tha t intersect the mid-heel line at 90 degrees a nd to measure the distance between the points where the horizontal femoral head lines intersect the mid-heel line. This establishes the d ifference in ana tomi c leg length. To measure the amount of sacral base unleveling, one must identify a n d mark bila terally symmetric points on the sacral base, like the sacral no tches. These two points establish a line tha t parallels the sacral base (Fig. 26.18, line c). This is the sacral base plane. If the sacral notches cannot be identified, it is necessary to draw a line d own the center of the sacrum connecting the spinous processes and a second line 90 d egrees to the line connecting the sacral spinous processes. This sec ond line a pproxima tes the sacral base plane . The sacral base plane line sho uld extend over the femoral heads bila terally. The next step is to draw two vertical l ines, each 90 d egrees to the femoral hea d lines, directly over the highest point on each femoral head (Fig. 26.18, lines d a nd d') and extend them to transect the sacral base pla ne. From these two p o i n ts of intersection, one can draw two horizontal lines tha t intersect the mid-heel line at 90 d egrees (Fig. 26.18, lines e and e'). The d istance between where these two lines intersect the mid-heel line is the a mount of sacral u nleveling relative to the femoral heads. Leg length inequality a nd short leg syndrome are trea ted by functi onally bal ancing the sacrum. Sacral unleveling, which contributes to sacral dysfu nction, is a d dressed by placing a heel p a d in the pa tient'S shoe. The measurement of sacral unleveling obta ined over the femoral hea d s is proportionate to the inequ ality of leg length. Consequently, it is a better ind i c a t i o n of the size of the therapeutic lift. Up to this point, postural balance has been consid ered i n terms of left-right bi lat eral mecha n i cs. The standing lateral pelvic radiograph gives important d ata about balance mechanics in the sagittal plane. This to pic is covered in d epth in Chapter 27.
Treatment Having ma d e the diagnosis o f ana tomic short leg, the physician formulates a trea t ment plan. The objective is functi onal balance, that is, leveling, of the pati ent'S sacral base, eliminating the propensity for chronic engagement of either the right or left oblique axis. Dysfunction of the knee, ankle, or foot that a ffects the distance between the floor a nd femoral heads d u ring weight bearing sho uld be a d dressed . Knee bracing m a y be a p propria te, as may be the use of laterally wedged ortho tics to a d d ress foot and ankle mecha nics, but these subjects are beyond the scope o f this chapter. If the short leg is, as i s commo nly the case, the result o f u nequal length
Chapter 26 • T h e Pati ent w i t h Back Pai n : S hort Leg Syndrome
42 5
of the long bon es o f the leg, this ma y be ma naged by em ploying lift therapy.2o A sim ple hee l p a d , typically no larger t h a n one- q u a rter of a n inch, is p l a ced - in the pa t ient's shoe on the s ide of the short leg and then adj usted upw ard (or downward) in i ncrements of one-e igh th inch a bout every 2 weeks . As long as the a n terior s a c r u m persists on t he short leg side, the thickness of the heel p a d should continue
to be i ncreased . If sacra l mec h a n i cs invert so that the sacrum becomes anterior on t h e sid e opposite the a n a tomic short leg, an a rtifi cial long leg has been created , a nd the thi c kness of t he heel pad should be reduced to what it was before t he s a cral mec h a n i cs inverted . Heel pads larger tha n three-eighths o f an i nch us u ally a re too th i ck to fit co m forta bly into the patient'S shoe a nd there fore should be a d d ed to the exte r i o r heel o f the shoe . Hee l pads greater t h a n one- h a l f inc h ma y require build i ng u p the sole of the shoe as well as the heel . For olde r patie nts, a ro ugh estimate of how muc h l i ft will u l tima te l y be requ ired can be obtained by dividing the radi ogra ph ica l l y m easured i nequa l ity of s a cral base unleveling in h a l f. The size o f the ini tial heel pad a nd the ra te by which the heel pad thick ness is i n creased a re d eter
m i ned by the f1exib iliry of the pa tient . This ma y be determined by ha ving the patie nt p l a ce t he heel o f t he s horr leg u pon pads of various thic knesses and o bserv i n g t he e ffect upon the pelvic side shift a nd the co m pe nsa tory l u mbar t y pe I curve . The ad u l t posrura l pattern is usually esta blished by the middle of the second decade of life . The longer the leg length ineq u a l i ry has been present, the more fixed the pa tient's accom mod a tion is l ikely to be a nd the more slowly t he lift t herapy sho u l d p rogress. W hen trea ting leg length ineq u a l i ty of recent onset ( i .e . , fra c ture o r hip su rgery), i t is a ppro pri a te to atte mp t to correct t he d i fference immed iately. Pla cing
a
heel pad in a p a tien t 's shoe necessitates t h a t the i n d i vid u al shift t he
p a t tern of a c c o m mod ation a ccording l y. This shift in acco m mod a tion m a y be fa cil i t a ted by s pec i fi c a l ly t rea ting all e xistent so matic dysfu n c tion before init i ating lift t he r a p y or whe n making cha nges in the size of the hee l pad . A d j unctive e xercise should a lso be em ployed . Act i ve stretc hing exercise will i nc rease the patient'S overa l l ra nge o f motion. Passive, lazy -person exerc ises (see C h a p ter 28) m a y be used specifically to stretch the co ncave side of type I accommod a
tive spi nal c u rves. .I n genera l , it is a good princi ple t o sta bil i ze as we ll a s mo bilize.
Most of t hese pa tients have some degree of l u m bosacral instability, a nd actively strengthening t he paravertebra l and abdomin al m uscles is a lways a good idea. Strengthening t he a bdomina l musc u lat ure will tend to decrease the lum bar lordosis, Ferguson's angle, a nd consequently lum bosacral decompensation i n the sagittal plane. The Levitor, an orthotic device, m a y also be used for this pur pose. ( See Cha pter 2 7 . )
CONCLUSION This c h a p ter provides the informa tion necessary to solve p ro b lems of p atients with l a teral l y asymmet r ic postural b a l a n ce problems. The disc ussion is esse ntially lim ite d to the t y p ic a l patte r n of a cco m mod a tion to leg length i ne q u ality. Pa tients m a y p rese nt wit h var i a tions in the a c commodative pattern, and a l though the initiation of l i ft t he r a p y m a y occasiona l l y be trial and error, these principles still a pply. When a patie nt'S chie f com p l aint is l u mbosacra l p a in, the most common etiologies are fu nctio n a l disorders. For young adults, the like ly d iagnosis is psoas spasm . I n middle-aged patients, shorr leg syndrome is encountered wi t h. increasing frequency. The pain co mplaint associated with shorr leg s y n d rome is t he res u lt of weight bearing u po n nor m a l a nato m y. Typ ically, the p a tient wa kes in t h.e morning wit h o u t d isco m fort o r w i t h decreased symp toms. The pa i n gets worse a s t h e d a y p rogresses. Co m p lain ts assoc i a ted with ana tomic patho logy (herniated nucleus p ulposus,
426
Secti o n III • C l inical Conditions
spondylol isth esis ) are affected simi larly by rest and wei ght bearing; howeve r, they tend to become intensely pai n ful a fter brief per iods o f weight bearing. Psoas spasm resu lts in pain similar to short leg mechanics. The i n c idence of the pai n differs. Low back pain resulting from psoas spasm is worse after periods of i m mobility because the offending m uscles become set abnormal l y short when they are resting, and the patient has significant discomfort on first wal k i ng in the morni ng. As the patient moves around and the muscles warm u p , the symptoms decrease. The typ ical patient with acute psoas spasm is a man in his mid 20s with pai n u pon arisi ng. Many give a history of sim i lar episodes in the past that have resolved spontan eousl y. This is also, of course, the presentation of a patient with an k ylosing spondylitis. The incidence of psoas spasm and short leg syndrome is higher than that of anky los ing spondylitis or spondy lol isthesis; however, their potential to resu l t i n lum bosacral pain n ecessitates a compl ete history a n d physical examina t i on . I n case one inadvertentl y misdiagnoses organic pathology as somatic dysfunc t i o n , it is i m p orta nt to recogniz e that organic pathology does not resolve w h en t reated with OMT. Should a patient fa i l to sign ificantly i m p rove after t h ree to five treatments with OMT, one should look a gain for u n d er l ying organic p a tholo g y.
Proced u res Please note: The proced u res that follow are exampl es of manip u lative trea tmen t that you may wish to empl oy. Ti1e actua l choice of proce d u res used s hou ld be determined by the uniq ue circ u mstances of each individ u al patie nt.
Constant Rest Position (Fig. 26. 19) This position, used to relieve acute l ow back pai n , may be e mployed w h i le wait ing for an analgesic to take e ffect. It redu ces st ress on t i1 e back by re moving the weight transm itted through ti1e l u m bar spi n e d u ring weig h t bearing. It redu ces ti1e l u m bar and cervical lordotic c urves and rela xes the parasp i n a l m uscu lature. T h i s position also unloads spastic psoas maj or m usc les, a p prox i mati ng their o r i gin and i nsertion by flexing the hips.
FIG U R E 26. 1 9
Constan t rest pos i t i on used to relieve acute low back pa i n ; it may be employed dur i ng the wait for an ana lg esic to ta ke effect . It reduces stress on t h e back by removi ng the weight transm i tted thro u g h t h e
lumbar spi n e d u ring wei g h t bearin g . It reduces the lum bar and cer v i ca l
lordotic curves a n d relaxes the para s p i n a l musculature. I t also u n l oads spast ic psoas major muscles by approximati ng the origin and i n se rtion .
Chapter 26 • The Pat ient with Back Pa i n : Sho rt Leg Sy ndrome
427
Procedure 1.
T h e p a t i e n t l i es s u p i n e o n a f i r m s u rface w i t h a s m a l l p i l l o w b e n e a t h t h e h e a d a n d
2.
T h e p a t i e n t p l aces t h e feet a n d l e g s u p o n a c h a i r, b e n c h , or s i m i l a r s t r u ct u re, s u c h
n e c k for c o m f o rt . t h a t t h e h i p s a re f l exed t o 9 0 d e g rees o r m o re .
3 . T h i s po s i t i o n m a y be m a i n ta i n ed a s l o n g a s n e cessary.
A nterior Sacrum, Muscle Energy T h i s proced ure is em ployed to introduce motion to a d y s function al sacroi l iac artic ulation (For d iagnosis, see Cha pter 3, and for a d escrip t i o n of this proced u re, see C h a p ter 9 and Figure 9 . 5 . )
Posterior Sacrum, Trunk Rota tion (HVLA) (Fig. 26.20) Th is p rocedu re is em p loyed to treat spec i fic s a c roil i a c a rt i c u l a r dysfu n ction found i n a s sociation with sacra l forward torsion . Considering a pos terior sacrum , the
i n n omina te is anter i or to the sacrum, so t his proced u re moves t h e i l i um poster i or to meet the sac r u m . P a t i e n t pos ition : s u p ine. Physic i a n position : standing a t the level o f the p a t ient'S
pe l vis oppos i te the side of the posterior s a cr u m .
P roced ure ( Example : Posterior Sacrum o n t h e R ig ht) 1.
P u l l the p a t i e n t 's p e l v i s towa rd you s o t h at the left h i p i s a t the e d g e of the ta b l e .
2.
M ove t h e p a t i e n t 's u p p e r torso away from y o u to i n t ro d u ce s i d e be n d i n g t o t h e r i g h t from a b ove down t o t h e s a c r u m betwe e n t h e i l i a . T h e p a t i e n t 's l eft s h o u l d e r s h o u l d be l y i n g i n t h e m i d l i n e o f t h e ta b l e .
3.
M ove t h e p a t i e n t 's feet away f ro m y o u t o i n t ro d u ce s i d e be n d i n g to t h e r i g h t from b e l ow up to t h e sacr u m . Ste p s 1 to 3 com b i n e to i n tro d u ce s a c r a l side b e n d i n g to t h e r i g h t betwe e n t h e i l i a .
4. 5.
I n st r u ct t h e p a t i e n t t o p l ace t h e h a n d s b e h i n d t h e n e c k a n d t o i n t e r l a ce t h e f i n g e rs . R e a c h a c ross t h e p a t i e n t , a n d co m i n g i n f ro m t h e p a t i e n t 's r i g h t , s l i d e yo u r ri g h t h a n d t h ro u g h t h e t r i a n g l e fo r m e d b y t h e p a t i e n t 's r i g h t a r m . I n t h i s p o s i t i o n , yo u r
FI G U RE 2 6 . 20
Tru n k rota t i o n to t r e a t a p o ste r i o r s a c r u m o n t h e r i g h t .
428
Sect i o n III • C l i n ica l C o n d i t i o n s r i g h t h a n d s h o u l d b e d i rected b a c k a t y o u so t h a t i t rests p a l m u p i n c o n ta ct w i t h t h e p a t i e n t 's ste r n u m .
6.
P l a ce yo u r left h a n d o n t h e p at i e n t 's r i g h t A S I S t o h o l d t h e r i g h t S i d e o f t h e p e l v i s a g a i n st t h e t a b l e .
7.
D r a w yo u r r i g h t a r m tONa rd yo u , p u l l i n g t h e p a t i e n t u p o n t o t h e l e ft s h o u l d e r to rotate the t o rso to the l eft . I t i s i m p o rta n t to keep the p a t i e n t 's l eft s h o u l d e r in the c e n t e r of the t a b l e t h ro u g h o u t t h i s p o rt i o n o f the proce d u re to p rod u ce rota t i o n to the l eft co u p l e d with t h e s i d e b e n d i n g to the r i g h t , i n t r o d u ced In ste ps 1 to 3 .
8.
The f i n a l c o r rect i v e f o rce i s s i m u l t a n e o u s rota t i o n f r o m a b ove w i t h yo u r r i g h t a r m a n d a q u i c k t h r u st poste r i o r l y o n t h e r i g h t A S I S , m ov i n g t h e i l i u m poste r i o r l y u p o n t h e sacr u m o n the r i g h t .
9.
R e a ssess r i g h t s a c ro i l i a c m ot i o n .
L umbar Walk-Around (HVLA or Muscle Energy) (Fig. 26. 2 1) This p roced u re is employed to treat lu m ba r a n d low to m i d thoracic type I I somatic d y s fu ncti o n . (For d i a gnosis , see Cha p t e r 3 . ) A s i m i l a r p roced u re is descri bed el se w h e re fo r type I , g ro u p c u rve, d y s fu ncti o n . ( See Chapte r 28 a n d F i g u re 2 8 .4.) P a tient positio n : seated a s t r i d e the e n d of the rrea t m e n t ta b l e w i t h the pe l v i s as c l ose to the edge of t h e ta b l e as poss i b l e a nd th e back towa rd the p h y s i ci a n . Physician posit i o n : sta n d i n g b eh i n d t h e seated p a t i e n t and s l i g h t l y towa r d the s id e o p p o s i te t h e r o t a t i o n of t he d ys f u n c t i o n . Proced u re ( E x a m p l e : L2 u po n L 3 , F l exed, Rotated Right a n d S i d e B e n t R ight) 1.
T h e p a t i e n t is i n st r u cted to c l a s p t h e h a n d s b e h i n d t h e n e c k a n d to a l l ow t h e e l bows to d ro p forwa rd .
FIGURE 26.21
Wa l k - a r o u n d , H V L A or m u sc l e e n ergy, e m ployed t o treat l u m b a r a n d low t o m i d thoracic type I I som a t i c dysf u n ct i o n .
Chapter 26 • The Patie n t with B a c k Pain : Short Leg Syn drome
2.
429
Sta n d i n g b e h i n d a n d s l i g h t l y to t h e l eft of t h e p a t i e n t , rea c h over t h e p a t i e nt's l eft s h o u l d e r and across t h e c h e st a n t e r i o r l y w i t h yo u r l eft a r m . G ra s p t h e l atera l c h est i n fe r i o r to the r i g h t a x i l l a w i t h yo u r l eft h a n d .
3.
Pa l pate t h e i n ters p i n o u s s p a ce b etwee n L 2 a n d L 3 with yo u r r i g h t h a n d .
4.
To I n t ro d u ce exte n s i o n , have t h e p a t i e n t s i t u p s t ra i g h t a s you l i ft t h e torso w i t h you r l eft a r m u n t i l yo u p a l pate a p p roxi m a t i o n o f t h e s p i n o u s p rocesses of L2 a n d L3 . Yo u m a y w i s h t o p l a ce a s m a l l p i l low between yo u r l eft forea r m a n d t h e pati e n t 's a n te r i o r ch est wa l l . To i n trod uce f l ex i o n , w h e n t reat i n g a n exten s i o n d ys f u n ct i o n , i n st r u ct t h e p a t i e n t t o s l u m p fo rwa rd u n t i l you p a l pate g a p p i n g between t h e s p i n o u s p rocesses of L2 and L3 .
5.
Mo ve yo u r r i g h t h a n d so t h a t yo u r p rox i m a l p a l m is i n contact w i t h t h e poste r i o r r i g h t t ra n sverse p rocess of L2 a n d t u c k yo u r r i g h t e l bow i n to yo u r to rso J u st m e d i a l t o yo u r r i g h t A S I S .
6.
I n t rod u ce l eft s i d e b e n d i n g between L2 a n d L 3 b y l a t e ra l l y t r a n s l at i n g t h e pat i e n t 's torso to t h e r i g h t a n d by a p p l yi ng p ress u re w i t h yo u r l eft a x i l l a a g a i n s t t h e left s h o u l d e r w h i l e l ifti ng t h e r i g h t s h o u l d e r w i t h yo u r l eft h a n d .
7.
Keep t h e p a t i e n t 's i s c h i a l t u b e ro s i t i e s f i r m l y u p on t h e t a b l e .
8.
I n t ro d u ce rota t i o n o f t h e p a t i e n t 's torso to t h e l eft w i t h yo u r l eft a r m a n d h a n d I n co m b i n a t i o n w i t h p re ss u re t h ro u g h yo u r r i g h t h a n d u n t i l t h e b a r r i e r i s e n g a g e d . A p p l y t h e fo rce t h ro u g h yo u r r i g h t h a n d by movi n g yo u r e n t i re b o d y a g a i n st yo u r r i g h t e l b ow, w h i c h i s f i r m l y fi x e d a g a i n st yo u r r i g h t AS I S .
9.
A p p l y a f i n a l H V LA force th ro u g h yo u r r i g h t a r m b y wa l k i n g (sh i ft i n g yo u r torso to the r i g h t ) f a rt h e r a ro u n d the e n d of t h e ta b l e to t h e r i g h t .
1 0 . T h i s p ro ce d u re m a y b e m o d if i e d to a m u sc l e en e r g y p roce d u re by i n st r u ct i n g t h e p a t i e n t t o t u r n to t h e r i g h t a g a i n st yo u r h o l d i n g fo rce for 3 to 5 seco n d s to treat rotat i o n or to r a i s e the l eft s h o u l d e r to treat s i d e b e n d i n g .
11.
Pause fo r 1 t o 2 seco n d s , a n d then rotate the patient's torso f u rther t o t h e left o r depress the patient's left s h o u l d e r a n d l i ft t h e r i g h t s h o u l d e r t o e n g a g e t h e n ew ba rrier.
12.
Repeat st eps 1 0 a n d 1 1 u n t i l t h e best poss i b l e i n crease of m o t i o n is o b ta i n ed .
1 3.
Reassess m o t i o n between L 2 a n d L3 .
Psoas Spasm (Muscle Energy) (Fig. 26.22) This p r oced u r e i s e m p l oyed fo r i s o m e t r i c stretch of dys f u n c t i ona l ly tig h t h i p flex ors, pa rticu l a r l y psoas ma j o r. It may a l so be em p l oyed to treat a p o s teri orly d is placed i l i u m . P a t i e n t p o s i t i o n : p ro n e . Phys ic i a n positi o n : sta nd i ng o n the side o f the tight psoas m u sc l e . Proced ure ( E x a m ple : Tig ht Right Psoa s M aj or) 1. 2.
W i t h yo u r left h a n d , g rasp t h e p a t i e n t 's r i g h t t h i g h prox i m a l to t h e k n e e . Place y o u r r i g h t h a n d on t h e p a t i e nt's l u m bosacra l j u nction a n d h o l d t h e pelvis f i r m l y a g a i nst t h e ta b l e .
3.
L i ft t h e r i g h t t h i g h f r o m t h e t a b l e , exte n d i n g t h e r i g h t h i p u n t i l t h e dysfu n ct i o n a l b a r r i e r I S e n g a g e d . A t t h i s p o i n t . y o u m a y w i s h t o p l a ce y o u r l eft k n e e betwee n t h e ta b l etop a n d t h e p a t i e n t 's t h i g h t o f a c i l itate h o l d i n g t h e t h i g h o ff t h e ta b l e .
4.
M a i n ta i n t h i s p o s i t i o n a n d i n st r u ct t h e p a t i e n t t o g e n t l y p u s h t h e r i g h t k n e e b a c k toward t h e t a b l e i n to yo u r l eft h a n d for 3 to 5 seco n d s .
5.
I n s truct t h e p a t i e n t t o re l a x a n d p a u se f o r 1 t o 2 seco n d s .
6.
Lift t h e r i g h t t h i g h , f u rt h e r exte n d i n g t h e r i g h t h i p t o e n g a g e t h e n ew ba r r i er.
7.
Repeat ste ps 4 to 6 u n t i l t h e d e s i re d i n crease of h i p exte n s i o n is obta i n ed .
8.
Reassess e a s e of exte n s i o n of t h e h i p a s a n i n d icator of p s o a s te n s i o n .
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Sect ion III • Clinica l Con d itions
FIGURE 26.22
P s o a s m us c l e e n e rg y e m p l oyed for i s o m e t r i c stretc h i n g of dysf u n ct i o n a l l y t i g h t h i p f l e x o rs, p a rt i c u l a r l y p s o a s m a j o r. It m a y a l so be e m p l oy e d to t r e a t a poste r i o r l y d i s p l a c e d i l i u m .
Psoas Stretch Exercises
The fol low ing exerc i ses m a y be employed to s t retc h tight i l io p soa s m u sc le s to sta b i lize the low b a c k and m a i n ta in the therapeutic effects o b t a i ned w i t h OMT.
PSOAS ST R ETC H , STA N D I N G ( E X E R CI S E ) (F I G . 2 6 . 2 3 ) This exercise is employed to s tretc h hip flexors, pa rticu larly psoa s m a jor. I t accom
p l ishes this in t wo way s : I t p h ysica l l y stretches the muscles by i ncre a sing the d i sta n ce between the origins a n d insertions, a n d it re flexively ind uces re l a x ation t h ro u gh reciproca l i n h i b i t io n , by a ctive l y contracti ng hip extensors . T h i s p roced u re i s p a rt ic u l a rl y usefu l in that once the pa tient m a s te rs i t, i t can be performed essenti a l ly a ny w here. This is a p revent ive p roce d u r e , and the patien t w ho is p rone to recu rrent e p i sodes of psoas spasm sho u l d be encou r a ged to s t retch dai ly. P a tient p o s it io n : standing.
Proced ure 1.
T h e p a t i e n t sta n d s a p p ro x i m a t e l y 1 to 2 feet away faci n g a wa l l or o t h e r so l i d
2.
T h e p a t i e n t p l a ces t h e p a l m s u p o n t h e wa l l a t s h o u l d e r h e i g h t a n d keep t h e m t h e re
struct u re . th ro u g h o u t t h e exe rc ise to m a i n t a i n b a l a n c e .
Chapter 26 • T h e Patient with Back Pain: S hort Leg S ynd rome
FIGURE
26.23
43 1
Pso a s st retch, sta n d i n g , to st retch h i p f l e x ors, p a rt i c u l a r l y psoas m a j o r.
3.
T h e patient sta n d s e rect w i t h the k n e e s l o c k e d i n f u l l exte n s i o n t h ro u g h o u t t h e
4.
T h e p a t i e n t t i g h t e n s t h e l u m b a r pa raverte b r a l m u s c u l a t u re a n d b u tt o c k s .
exercise .
5.
T h e p a t i e n t p l a c es t h e we i g h t u p o n o n e l e g a n d exte n d s t h e o t h e r h i p , l i ft i n g t h e foot f ro m t h e f l o o r a n d b r i n g i n g t h e e n t i re l ow e r e x t re m i ty, w i t h t h e k n e e s t ra i g h t , b e h i n d . T h e d e g re e of h i p e x t e n s i o n , 1 0 to 2 0 d e g re e s f r o m t h e v e r t i ca l , i s n ot a s i m p o rt a n t a s i s k e e p i n g a s t ra i g h t b a c k a n d k n e e w h i l e m a i n ta i n i n g l u m b a r pa r a v e r t e b r a l a n d g l u t e a l t e n s i o n a n d t a k i n g t h e h i p i n to t h e f u l l est p o s s i b l e exte n s i o n .
6 . T h e p a t i e n t swi tches t h e wei g h t to t h e ot h e r l e g a n d re peats step 5 . 7.
Th i s p roce d u re m ay b e re peated 5 t o 1 0 t i m es o n a s i d e , accord i n g t o to l e ra n ce , a n d s h o u l d be p e rfo r m e d
a
m i n i m u m of t w i c e d a i l y, b efo re ret i r i n g at n i g h t a n d
u p o n a r i s i n g i n t h e m o r n i n g . I t ca n b e p e rfo r m e d a s m a ny t i mes a d a y as n ecess a ry a n d is a p p ro p r i a te before a n d after p ro l o n g e d p e r i o d s of s i tti n g . P a t i e n t s w h o s i t for l o n g p e r i o d s o r w h o a s s u m e c h ro n i c p o s i t i o n s t h a t i n vo lve l u m b a r f l ex io n , l i ke a u t o m otive m e c h a n i cs w h o h a ve to b e n d over c o n t i n u o u s l y, s h o u l d be e n co u ra g e d to stretch freq u e n tl y.
43 2
Sect i o n III • Clini cal Conditions
F I G U R E 26.24
P r o n e psoas stretch to s tr e t ch h i p fl exo rs, particularly psoas maj or, w h i l e st r e n gthe n i n g t h e antag o n ists, the erector s p i n a e m u s c l e s .
P S O A S ST R ET C H , P R O N E ( E X E R C I S E ) ( F I G . 2 6 . 24)
Th i s exercise is e m p l o yed to stre tc h hip flexors, p a r t i c u l a r l y psoas major. It acco m p l i s hes th i s i n t w o w a y s : I t p h y s i c al l y s tretches t h e m u scles b y inc rea s i n g t h e d is tance between the origins and i n s e r ti o n s , a n d i t re flexive l y in d u ces relaxation t h ro u gh re c i p roc a l i n h i b i ti on by ac tive l y c ontr a c t i n g h i p a n d l u m b a r e xte nsors . The p roce d u r e consists of repetit ive c on tra c t i on of the l u m bar para verte b r a l mu sculature a n d t h e hip extensors. Each r e p e t i t i o n h a s 3 steps a n d eac h ste p ra kes a bo u t 5 s econd s , for a total of 1 5 secon d s per repeti tion. Having t he pa tient cou nt to 5 out loud d u r i n g e a c h s tep prevents the Vals a lva m a n e u v e r a n d red uces stress upon the a b d o m i na l w a l l . T h e s e q u e n c e typica lly begins with 10 repe t i t i ons . T h i s p r oc e d u r e does more t o strengthe n the p a raverte bra l muscu lature t h a n d oes t h e st a n d i n g psoas stretch. P a tien t posi tion : prone . P roce d u re 1.
The p a t i e n t s l owly l i fts o n e t h i g h from t h e f l o o r or treat m e n t ta b l e by exten d i n g the
2.
The p a t i e n t h o l d s t h i s p os i t i o n of h i p ext e n s i o n for a 5 co u n t
hip wh i l e kee p i n g t h e knee stra i g h t f o r a 5 c o u n t
3.
T h e p a t i e n t s l owly ret u r n s t h e t h i g h to the f l o o r f o r a 5 co u n t
4.
T h e p a t i e nt re peats steps 1 t o 3 w i t h t h e o t h e r leg . T h i s p roce d u re may be repeated 5 to 1 0 t i m es o n
a
s i d e , a ccord i n g to p a t i e n t toler
a n ce , and m a y be p e rfo r m e d a m i n i m u m of twice d a i l y i n ste a d of t h e sta n d i n g stretch p roced u re , befo re ret i r i n g at n i g h t a n d u p o n a r i s i n g in t h e m o r n i n g .
ADDITI O NA L PROCE D U R E S •
•
•
•
D r y l a n d s w i m t o s tr en gt he n p a r a v erte b r a l m u sc u l a ture ( See t h e d esc r i p t i o n of -
the p roced u re i n C h a pter 27 and Fig. 27. 1 7.) Back h ype rextens ions t o stre n g t h e n p a ra verte br a l m u scula t u re (See t he des c r i p tion of t he p roce d u re in C h apter 28 a n d Fig. 2 8 . 5 . ) Torso c u rl s to s t re n g t h e n a bd o m i n a l m u s c u l a tu r e ( See the d esc r i p t i o n of the p r o ced u re i n C hap t e r 2 8 a n d Fig. 28.6.) Reverse torso c u r l s to st r en g t h e n a bdom inal m u sculat u re ( See the d es c r i p ti o n of t h e proced u re in C h a pte r 28 a n d Fig . 2 8 . 7. )
Refe re n ces 1. Bailey HW, Bec k w i t h C G . S h o r t leg and s p i n a l a n o m a l i e s . J A m Osteopa t h Assoc 1 9 3 7 ; 3 6 : 3 1 9-3 2 7 . R e p r i nted i n A m e r i c a n Aca d e m y of O s t e o p a t h y 1 9 8 3 Yea r b o o k . I n d i a na po l i s : A me r i c a n Ac a d e m y o f O s te op a t h y, 1 9 8 3 ; 6 3 -70 .
43 3
Chapter 26 • The Patient with Back Pain: Short Leg Syndrome 2. S ch w a b WA . Pri nc i pl es of m a n i p u l a t i ve trea tment:
I I I . T he l o w back p r o b l e m . J A m
Os te o p a th Assoc 1 9 3 2 . R e p r i n ted i n : Ac a d e m )' o f A p p l i e d O ste o p a th y ] 9 6 5 Yea r b o o k . Vo l . 2 . I n d i a na p o l i s : A m e r i c a n A c a d e m y o f Os t eo pa th )', 1 9 6 5 ; 2 : 3 0-3 8 .
3 . Pea r s o n W M e t a l . A p r o g res s i ve structu ra l s t u d y o f s c h o o l c h i l d re n . ] A m O s te o p a th Assoc. 1 95 1 ;5 ] : 1 55-1 67. 4 . K l e i n K K . A s tu d y o f the progres s i o n o f la te ra l p e l v i c a s y m m etry i n 5 8 5 e l e me n ta ry, j u n i o r a n d h igh sc h o o l boys. A M Correct Ther ] 1 9 6 9 ; 2 3 : 1 7 1 - 1 73 .
5 . K l e i n K K , R ed l e r I , L o w m a n CL. A s y m metries o f t h e grow t h i n the pel vis a n d l e gs o f c h i l d re n : A c l i n i ca l sta tistica l s t u d y 1 9 64-1 9 6 7 . J A m O s te o p a t h A s soc 1 9 6 8 ; 6 8 : 1 5 3 - ] 5 6 . 6 . H e i n k i n g K P, K a p p l e r R E . Pelvis a n d s a c r u m . I n : Wa rd R C , e d . F o u n d a ti o n s fo r O s te o p a 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 n c o tt Wi l l ia m s & Wi l k i n s, 2 0 0 2 ; 762-7 8 3 .
7 . N e l s o n K E . The sa c r u m : A b o n e o f c o n ten t i o n . AAO ] 1 99 7 ; 7 ( 4 ) : ] 7-24 . 8 . M i tc h e ll
FL S r. Sr r u c t u ra l p e l v ic f u n c t i o n . I n : A c a d e my of A p p l i e d O s te o p a th y 1 9 6 5
Yea tbook . Vo l . 2 . I n d ia n a p o l i s : Ame ri ca n Aca d e m y o f O ste o p a t h y, 1 9 6 5 ; 2 : 1 7 8 - 1 9 9 .
9 . Fryette H H .
Pr i n c i p l es
o f O ste o p a th i c Te c h n i c .
I n d ia n a po l i s :
A me r i c a n
Ac a d e m y o f
Osteo p a t h y, 1 9 5 4 ; 1 9 8 0 ; 3 0 . 1 0 . Ka p p l e r R E . P o s t u r a l b a l a nc e a n d motion pa tte r n s . ] Am Os te o pa t h A ssoc 1 9 8 2 ; 8 1 : 5 9 8 -6 0 6 . R e p r i n ted i n : A m e r i c a n A c a d e m y o f O s t e o p a th y 1 9 8 3 Yea rb oo k . I n d i a na polis: A m e r i c a n A c a d e m y of O s te o p a th y, 1 9 8 3 ;6-1 2 .
1 1 . J u ngma n n Ivl. A b d o m i n o pe l v i c p a i n c a u s e d
b y g ra v i ta ti o n a l stra i n . S o u t h western Med
1 9 6 1 ; 4 2 : 5 0 1 -5 0 8 . 1 2 . D o n a te l l i R . T h e B i o m e c h a n i c s o f t h e F o o t a n d A n k l e . 2 n d ed . P h i l a d el p h i a : D a v is, 1 9 9 6 ; 5 5-5 9 . 1 3 . P o p e R E . The C o m m o n Compen s a t o r y P a t te r n : Its O r i g i n a n d R e l a t i o n s h i p to t h e Pos t u ra l Model . A A O
J o u rn a l
2 0 0 3 ; 1 3 ( 4 ) : 1 9 -4 0 .
'1 4 . K a p p l e r RE. R o l e o f ps o a s m ec h a n is m i n l o w b a c k c o m p l a i n ts . J A m O sr e o p a th Assoc 1 9 73 ; 72 : 7 9 4 - 8 0 1 . 1 5 . D e n s l o w J S , Chace J A , G u re ns o h n OR, K u mm M G . M eth od s i n ta k i n g a n d i n te rp r et i n g
w e i g h t-bea r i ng rad i og ra p h fi l m s .
J Am
Os te o pa t h Assoc 1 9 5 5 ; 5 4 : 6 6 3-670. R e p r i n ted i n
A m e r ica n Aca d e m y o f Os te o p a th y 1 9 8 3 Yea rboo k . I n d i a n a p o l is : A meri c a n A ca d e m y o f
Os te o pa t h y , 1 9 8 3 ; 1 4 4 - ] 5 'J .
1 6 . Wi l l m a n M K . R a d i o g ra p h i c tec h n i c a l a s pects of the p o stura l s tu d y. J Am O ste o p a th Assoc 1 9 7 7 ; 7 6 : 7 3 9- 74 4 .
R ep r i n te d
in
A m e r i ca n
Academy
of Oste o p a t h ),
] 983
Ye a r b o o k .
I n d i a n a p o l i s : Am e r i c a n Ac a d e m y o f O s te o pa t h y, 1 9 8 3 ; 1 4 0- 1 4 3 .
1 7 . H o s k i n s E R . D ete r m i n i n g u n e q u a l l eg l e n g th us ing sta n d i ng ra d i o grap h s . J A m O s t e o p a th Assoc.
1 933-1 9 3 4 .
Re p ri n te d
in
A m erica n
A ca d em y o f Oste o pa t h y
1 983
Yea r b o o k .
I n d i a n a p o l i s : A m e r i c a n A c a d e m y o f Os te o pa t hy, 1 9 8 3 ; 1 54-1 5 5 .
1 8 . Be i l k e M . Roe n tgenologica l s p i na l a n a l y s i s a n d t h e tech n i c for raking s ta n d i n g r a d i o g r a p h p l a te s . J Am O s t e o p a t h A s s o c 1 9 3 6 ; 3 5 : 4 1 4 -4 1 8 .
1 9 . K u c h e r a M L , K u c h e ra WA . Rad iogra p h i c a s pects o f t h e p o s t u ra l s t u d y. I n : Wa r d R C , e d .
Fou n d a tions fo r Os te o pa t h ic Med i c i n e . 2 n d ed . P h i l a delp h i a : L i p p i ncott Wi l l i a ms & W i l k i n s ,
2 0 0 2 ; 5 9 1 -6 0 2 . 2 0 . H e i l i g D . P ri n c i p l e s of l i ft t h e r a py. J A m Os teo p a t h Assoc 1 9 78 ; 7 7 : 4 6 6-4 7 2 . Reprinted i n
A m erican Aca d em y o f Os teo pa th y ] 9 8 3 Yea rboo k . I nd i a n a p o l i s : A m e r ica n Ac a d em y o f Osteopa t h y, 1 9 8 3 : 1 1 3- 1 1 8 .
The Patient with Back Pain: Postural Decompensation in the Sagittal Plane !\Iils A. Olson [
INTRODUCTION Chapter 26 discusses leg length discrepancies and their relation to back pain. This chapter deals with an additional type of postural decompensation and its association with back pain. This syndrome is referred to as sagittal plane decom pensation. This chapter describes how postural decline and gravitational strain contribute to chronic back pain and reviews some therapies that are useful in treat ing this problem. In postural health, the center of gravity in an erect person follows a line that extends from the external auditory canal down through the head of the humerus, the center of the body of the third lumbar vertebra, the greater trochanter, the lat eral condyle of the knee, and the lateral malleolus.l This weight-bearing line allows the weight and forces of the body to rest upon structures that are designed to sup port that weight (Fig. 27.1). In sagittal plane decompensation, these weight-bearing areas do not support the
body as they should. Gravity exerts forces on areas not meant to be support struc tures. This causes the body to compensate in an attempt to maintain that proper structural alignment. This stress causes tension on ligaments and strain on muscles. As ligaments stretch in response to the abnormal weight bearing and the compen satory reaction, muscles must work overtime to maintain posture, actually attempt ing to provide structural integrity that was originally expected of ligaments. 434
Chapter 27 • The Patient with Back Pain: Postural Decompensation
435
F
FIGURE 27.1
Least stressful postural alignment of body in relation to the gravitational line. (A) External auditory canal. (B) Head of the humerus. (C) Center of the body of L3. (D) Greater trochanter. (E) Lateral condyle of the knee. (F) Lateral malleolus.
This lead s to comm on l y found somatic dysfunctions and pain, which can become chronic. If t h e abn ormal weight bearing is not addressed, commonly used therapies to relieve pain may not pr odu ce the desired long-term effect. As part of the standing structural portion of the physical examination, the patient should be observed for increase or decrease of the anterior and posterior spinal curves. The postural al ignmen t of the superficial anatomic lan dmarks of the line of gravity (Fig. 27.1) should also be noted. If indicated, these ph ysical findings may be further evaluated using the lateral standing exposure of the postural series of radiographs. (See Chapter 26.)
THE LATERAL RADIOGRAPH The spatial relationships of the pelvis to the sacrum and lumbar spine can be ana lyzed in a lateral pelvic radiograph. To establish a line of reference in the radi ograph, one must use a radiopaque wire plumb line suspended behind the standing
436
Section III • Clinical Conditions
patient during fi lming . This reference line should merely be somewhere near the
ce nter of the spinal column; it is unimportant if it is slightly off cente r. This line is
usef u l for making s ure that drawn lines are truly vertical or horizontal.
The Pelvic Index A vert i c a l line is drawn from the anterior tip of the sacrum inferiorly, paralleling t he
gravitational line, and is labeled Y. A horizontal line i s drawn posterioriy from the an terior edge of the pubic bone until it i n ter sec ts with line Y. This line is labeled X. The pelvic index is found by divi di ng X by Y (Fig. 27.2).
The spatial relationships of the pelvis to the sacr u m and lumbar spine change
considerably with age It is th ought that this change is
a f fe cted by gravitational pul1.2 If one studies th e anatomic relationships of the spine to the pe l vis in youth, ad ulthood, and old age, the c h a ng e s become quite obvious. In the adult, a pelVIC .
PI=XN cu C ..Q
E
::J a. cu ::J Cco a. 0 "C co 0::
FIGURE 27.2
r 1
......
N 0
y
The pelvic index (PI) determined from a lateral radiograph and measured in reference to anatomic points of the pelvis and sacrum in relation to the gravitational plumb line. (Reprinted with permission from Gallant RA, ed. The Jungmann Concept and Techniques of Anti-Gravity Leverage: A Clinical Handbook. 2nd ed. Rangeley, ME: Institute for Gravitational Strain Pathology, 1992.)
Chapter 27 • The Patient with Back Pain: Postural Decompensation
437
48" Woman aged 79 Index 0.98 FIGURE 27.3
Typical change in the pelvic index with age. (Reprinted with permission from Schubert EV. Roentgenuntersuchungen des knoechernen Beckens im Profilbild: Exakte Messung der Beckenneigung beim Lebenden [Radiographic investigation of the pelvic bones in sagittal view: Precise measurement of the pelvic inclination in living personsJ. Zentralbl GynakoI1929;17:1064.
index of about 0.5 is considered reasonable for good structural health. In youth, the pelvic index is less than 0.5, and in older age, it is more than 0.5 (Fig. 27.3).
This age-related shift in pelvic index is not necessarily accompanied by sagittal decompensation and low back pain. A high pelvic index relative to any given age,
however, can be associated with either chronic back pain or vertebral dislocation (Fig. 27.4).
The Spinal Center of Gravity Weight bearing of the spine as it relates to the base of the sacrum contributes to sagittal decompensation. In health, the center of the third lumbar vertebra is con sidered the spi nal center of gravity. A line drawn inferiorly from the center of L3 and parallel to the vertical line of reference should end within the anterior third of the base of the
sacrum.
Displacement of this weight-bearing line anterior (most
commonly encountered) or posterior to the anterior third of the sacral base can cause muscular anclligamentolls strain and shear stress (Fig. 27.5).
Ferguson's Sacral Angle The third parameter one must evaluate is the sacral angle. This angle is deter mined by radiography, as in the last example. The plumb line again is a useful
tool for making accurate lines and measurements. A line is drawn across the base of the sacrum and extended past the plumb line several inches. Another line is drawn horizontally at a 90-degree angle from the pl u mb line and extends to the line th a t was drawn across the base of the sacrum. That intersecting angle is measured (Fig. 27.6). fn the adult, this angle is normally between 34 and 44 degrees.
438
Section III • Clinical Conditions 1.20r------, 1.10 1.00 0.90 0.80 E
Ol
'iii
.r:
'5
0.60
x
0.50
� oS (.) "> 'iii
.. -
=
0,70
�
.r:
, � ........ ", ... -----Chronic low back pain ..... .. .. n 81 .... ..... ..... ..... ..... No low back pain n 68 =
0.40
[l.
0.30 0.20 0.10
10
20
30
40
50
60
70
80
Increasing age (years) -----FIGURE 27.4
Pelvic index in relation to age in normal individuals and in patients with chronic low back pain or vertebral dislocation (spondylolisthesis). (Reprinted with permission from Gallant RA, ed. The Jungmann Concept and Techniques of Anti-Gravity Leverage: A Clinical Handbook. 2nd ed. Rangeley, ME: Institute for Gravitational Strain Pathology, 1992.)
Gravitational Pull. Sagittal Plane Decompensation and How it Produces Pain When any or all three of these measu r eme n ts of postural health are abnormal, the
result is increased stress on the ligame n ts and muscles that are attempting to com pen sa t e for t h is a bnormal i ty. If the s pi n al center of g rav i ty is a nte rio r to the sacral promontory, for e x ampl e, the lumbar m u scl es are exposed to chronic increased
tone as they attempt to pull the torso back toward balance. This attempt at com pensation is so m ewh at like the cervical s p in e's compensator)' ac t i on to k eep the
eyes level in the p rese n ce of scoliosis.
Nonsurgical Treatment of Sagittal Plane Decompensation Multiple modalities aimed at relieving p ai n and improving function , including exer cises, osteopathic manipulation, proliferative therapy, ph y sic al therapy, orthotic
Chapter 27 • The Patient with Back Pain: Postural Decompensation
FIGURE 27.5
439
The third lumbar vertebra spinal center of g r avity. Here the L3 weight bearing line falls anterior to the sacral base, causing shear stress, espe cially in the posterior elements, the erector spinae muscles, and liga men tous tissues. (Reprinted with permission from Kuchera ML. Gravitational stress, musculo-ligamentous strain, and postural alignment. Spine: State of the Art Reviews 1995;9:463-490.)
FIGURE 27.6
Determination of the sacral angle (angle B) in relation to the ideal gravity line. (Reprinted with permission from Gallant RA, ed. The Jungmann Concept and Techniques of Anti-Gravity Leverage: A Clinical Handbook. 2nd ed. Rangeley, ME: Institute for Gravitational Strain Pathology, 1992.)
440
Section III • Clinical Conditions
devices, and when appropriate, medications, sllch as nonsteroidal anti-inflammatory agents and sometimes even opioids, may be llsed in treatment of this syndrome. The primary exercises used should strengthen the lumbar and abdominal musculature. These include torso curls, reverse torso curls, and the pelvic tilt. The pelvic tilt may be employed to alter tbe relationship between the lumbar spine and the pelvis. It is performed lying supine on a firm surhce. In this position the patient forces the lumbar spine to flatten against the firm surface. This repeti tive series of exercises is usually done twice a day. Once the patient has mastered this maneuver and has begun to strengthen the lumbar musculature, adding bilat eral straight leg raising while maintaining the flattened lumbar spine will further improve muscular strengtb in the lumbar region. However, during straight leg raises, it is i mportant that the patient lift tbe feet no more than 6 to 8 inches to prevent activation of the psoas muscle during exercise. The torso curls and reverse torso curls will primarily improve the a bdominal musculature that secondarily assists the lumbar muscles. Osteopathic manipulation is useful in treating this syndrome. It is not impor tant which modalities are used as long as the goa I is to increase function by improving motion, reducing spasm, and relieving pain. Whether high-velocity, low-amplitude, muscle energy, functional technique, counterstrain, or soft tissue release is chosen is not important. The goal remains the same. Orthotic devices are continually being developed for use in adjusting spinal mis alignments. One such orthotic is the Levitor (U.S. Patent No.4, 275, 718). In con trast to the full-torso Milwaukee brace or the shorter thoracolumbosacral orthoses (e.g., Boston, Miami, Wilmington, and Rosen berger orthoses) used to treat scolio sis and associated lordosis and kyphosis, the Levitor is a much less cumbersome device designed specifically to correct sagittal plane decompensation.
USE OF THE LEVITOR ORTHOTIC IN THE TREATMENT OF SAGIT TAL PLA NE DECOMPENSATION A Brief History of the Levitor Orthotic
Martin Jungmann was a physician in Vienna in the 1930s. He conducted extensive studies on chronic back pain and the effects of gravitational pull on posture and how that related to chronic back pain.2 He developed tbe concept of the Levitor orthotic , which changes the postural alignment of the spine as it relates to the sacrum and pelvis, thus relieving pain. In 1939, he moved to New York City, where he continued his research and in 1957 established the Institute for Gravit;'Hional Strain Pathology. As he taught his theories and lectured to interested physicians, he formed
a
particular relationship with the osteopathic community because its
practitioners seemed particularly receptive to his concepts and theories. J ungmann died in 1973. Today training in the clinical use of tbis orthotic is continued in Kirksville College of Osteopathic Medicine in Kirksville, Missouri, and is available through regional Levitor centers throughout the United States and overseas.
Description T he Levitor orthotic is a dynamic brace. It applies various amounts of pressure and may be adjusted using a scale specifically devised to measure the pounds of pressure produced. It changes weight bearing and the effects of gravity upon the spine. It is not a static brace like traditional lumbosacral supports that are made with Velcro, straps, and staves. It is made of aluminum and is custom formed to
Chapter 27 • The Patient with Back Pain: Postural Decompensation
FIGURE 27.7
441
The pelvic lever action of the Levitor orthotic. (Reprinted with permission from Kuchera ML. Postural considerations in the sagittal plane. In: Ward Re, ed. Foundations for Osteopathic Medicine. Baltimore: Williams &
Wilkins,
1997;999-1014.)
each patient. It must be partially fabricated in the physician's office. Semi-firm pads are attached to the front and back of the device. These pads, when properly fitted, rest against the patient over the pu bic symphysis and the sacrum (Fig. 27.7). It is necessary to measure the anteroposterior diameter of the orthotic while it is being worn by using a caliper similar to the obstetric calipers that were used in the past to determine maternal pelvic dimensions ( Fig 27.8). The caliper is placed .
upon the front and rear pad of the orthotic and a measurement is taken. The orthotic is then placed on the special scale that measures t h e amount of pressure exerted on the pelvis by the orthotic. The orthotic must be stretched over the scale to the exact measurement that was taken while the device was on the patient. Th ese pressures are manipulated by bending the metal with a set of specif ically designed tools (Fig. 27.9). When propedy fitted, the Levitor will produce a pressure in the sagittal plane of 6.5 to 7.5 pounds.
At first, the orthotic will have to be adjusted fairly often, sometimes every 4 or 5 days, to maintain that pressure. As it exerts pressure, the sagittal plane usually
narrows, sometimes by several centimeters. This causes the orthotic to produce less pressure and become less effective and necessitates readjustment. The 6.5 to 7.5 pounds of pressure is required to change the pelvic index, center of weight bear ing, and sacral angle. Less pressure is not effective. More pressure produces dis
comfort not usually tolerated by patients and increases the risk of pressure ulcers w her e
the pads touch the body. Eventually, adjustments are needed only every few
months, and sometimes the patient can go as long as 6 months between adjust ments. Once presc r i bed the orthotic must be worn at all times while the patient is ,
up and around (Figs. 27.10 and 27.11). It is taken off only to lie down, bathe, swim, and sometimes to sit. The more the device is removed while the patient is
442
Section III • Clinical Conditions A
B
FIGURE 27.8
(A) Caliper used to measure the anteroposterior measurement of the Levitor orthotic. (B) Proper position on the patient.
A
B
FIGURE 27.9
Pressure adjustment of the Levitor orthotic.
Chapter 27 • The Patient with Back Pain: Postural Decompensation
443
Too high
Too low
Correct
FIGURE 27 .10
Proper placement of the Levitor orthotic.
upright, the more gravitational forces will tend to return the anatomy to its previ ous decompensated position. Choosing a Candidate for This Treatment
Because of the required commitment to use the orthotic continuall y, candidates must be chosen carefully, or the physician's time and the patients' money will be wasted,
and the patients will be unhappy. Typical patients are middle aged or older and have
FIGURE 27.11
Properly adjusted Levitor orthotic.
444
Section III • Clinical Conditions
had chronic back pa i n that may o r may nor include radicular pain . Many have had several treatments with differen t modalities-physical therapy, medicinal i nterven tion osteo pathic manipulative t herapy (OMT), trigger point injection s , or epi d ura l
,
injecti ons-without success. For success with the L evitor, the pain must be signifi c ant enough for the patient to be committed to wear ing the orthotic continually
while awake. This is not to say that it would not work on lesser pain; it is just this aut h or s experience that '
if the pain is not significant, the patient will abandon the
device after a few m o nth s . Further, the sacroiliac joint must be mobile enoug h to move under the p r essure p rod u ced by the Levitor. Previous surgery does not preclude can didacy. This device has been used successfully even by peo ple who have had lum bar fusion or lum bosacral fusion , both bone graft and intern a l hardware fixation. It worked in those patien t s because the sacroiliac j oi nt was mobile enough to respond. Patients who
have symptomat ic ist h m ic spo n d y l ol ist h es is are good treatment can be r elieved with the use of the Levitor.3
candidates. Pain from this diso rder
Further stud y is needed to dete rm i n e whether use of the Levito r will prevent pro gression of spon d y l olisthesis. The Levitor shifts the weight-bearing fo rces poste r ior l um bosac ral str uctures, th ere b y
from the removing tissue strain.4 If s pon dy l olis
thesis is found i n cid entall y, however, the patient may not have the pain pattern necess ary to impel commitment to use the device. About 5% of the populat ion is
these individuals are Ot her investigators have c o n cl u ded that sagittal plane d ecompen sation is implicated in s po n dy l oly sis and spondylolisthesis.s.9 They use a different method of measurement, spinal inci d ence to d efine s ag i ttal plane d ecompensa ti o n, th ought to have spond y lo li sthesis, and p erhaps on l y half of
sy m ptomati c. 5
-
7
,
but it is a similar concept.
The Levitor is n ot a substitute for appropriate surgical intervention when war ra n ted, such as in a significa nt ly sym ptom atic herniated lumbar disc or severe spinal stenosis. The Levitor may be used in patients who have chronic pain from pos t
l a minectom y sy ndrome . This author has, however, found that t hese patie n ts, while receiv ing a degree of relief, frequently do not get th e desi red satisfactory results.
When the ty pical pa tient has presented, one must obtain the radiographs, or dy n amic films, disc u ssed earlier in the chapter. The patient may then be deemed an appropria te candidate if so m e or all of the ra diogr a phic abnormalities of sagittal pl ane decom p e n sation are found. In this author's experience, the two most impor tant fi n d ings are passing of the wei g h t- be a ring line anterior to the sacral promon tory and a pelvic index of 1.0 or greater.
As with any modality, the end results vary Some patients who are idea l candi .
dates do
n ot
res pond well at all, while some with
m a r gina l
qualifications do
very
well. It is d i fficult to determine who will or will not res pond well. Since these patients have had pain for some time and have had tions before , many
m u lti p le
are wil ling to try this t herapy As .
a
unsuccessful interven
general [ule, the more of
the criteria they meet, the more likely to respo n d favora bl y they are.
Manipulation and the Levitor The Levitor is o n l y one option in the treatment of ce rtain chronic back problems. It is a part of gene r al structural care. It is not a replacem e n t for
OMT. OMT
sbould be an integ r al part of the care of pat ie nts with ch r onic low back pain. The exact
m od a lity
is not as important as is a pl an to maintain mobility and relieve
spasm and liga m en tous strain. So whether one chooses h igh-vel oci ty, low-ampli tude, muscle energy, soft tissue, counterstrain, functional technique, or
any o th e r
manipulative modal ity is not importa nt. What is important is ma i n ta i n i ng mobil ity. There fo r e no specific category of ,
nection with the Levitor ortho ti c.
m a n i pula tion
will be rec om m e n ded in con
Chapter 27 • The Patient with Back Pain: Pos t u r a l Decompensation
445
Case Presentations Case 1 This patient was 55 years old when she presented with chronic back pain. She had a lumbar laminectomy 5 years earlier, followed by a lumbosacral fusion
1 year prior to her initial visit. The fusion was accomplished using plates and screws and included the sacrum and the bottom three lumbar vertebral bodies.
A year post fusion, she had only a little relief and complained of muscle spasm and pains to the point of nausea. She had received chiropractic treatment and had gone through two courses of physical therapy and used a TENS unit (tran scutaneous electrical nerve stimulator). She had worn a 1-inch lift in her right shoe since a short leg was diagnosed after a motor vehicle accident when she was 25 years old. She had multiple compensatory somatic dysfunctions of the thoracic and cervical spine. Dynamic films revealed a sacral angle of 67 degrees, pelvic index of 1.1, and a weight-bearing line 6.6 cm anterior to sacral promon tory (Fig. 27.12). She was fitted with the Levitor orthotic and was followed for several years. She had the Levitor adjusted periodically and received OMT in the form of myofascial procedures to the lumbar area and a combination of muscle energy, soft tissue, and high-velocity procedures to the thoracic and cervical areas. Within a year of initiation of treatment, she had marked improvement of her symptoms. She carried her body more upright and had subjective relief of pain approaching 80%. Interestingly, she had been bothered by shortness of breath, which also resolved with the treatment, probably from the reduction in compensatory response in the thoracic spine and rib cage caused by the previ ous imbalance and decompensation. She specifically noted that if she failed to wear the Levitor for any length of time, her symptoms would begin to resur face. The Levitor worked in this woman in spite of her lumbosacral fusion because her sacroiliac joints were still mobile.
Case 2 This patient was 40 years old when she was first seen. She feared that she was "heading down the same path" as her mother. They both had spondylolisthesis of L5 on 51. Her mother had gone through a spinal fusion but was still in pain and was having significant difficulties with activities of daily living. If the patient was invited to a social event, to guarantee that she would have a chair through out the evening, she and her husband would go early or not go at all. She would not get out of the chair for the entire evening for fear that someone else would take it. Dynamic films revealed a leg length discrepancy of just 8 mm, low on the left. Her weight bearing was 4.2 cm anterior to the lip of the sacrum. The pelvic index was 1.2, and her sacral angle was 72 degrees (Fig. 27.13). She was given a one-eighth-inch (3 mm) lift to wear in her left shoe and was fitted for a Levitor. She also received manipulative treatments. She contin ues to wear the Levitor more than 10 years after the treatment was initiated. She has minimal pain in spite of the fact that she is an active professional who must spend much of her day working on her feet.
446
Section III • Clinical Conditions
FIGURE 27.12
Dynamic film of a 55-year-old woman, 5 years post laminectomy and 1 year post lumbosacral fusion. Sacral angle, 67 degrees; pelvic index, 1.1; weight-bearing line, 6.6 cm anterior to the sacral promontory.
1 FIGURE 27.13
Dynamic film of
a
40-year-old woman with spondylolisthesis of L5 on S 1.
Sacral angle, 72 degrees; pelvic index, 1.2; weight-bearing line, 4.2 em anterior to the sacral promontory.
Chapter 27 • The Patient with Back Pain: Postural Decompensation
447
S UMMARY When treating musculoskeletal p a in due to postural decompensation, one must recognize the significance of dysfunctional mechanics in the sagittal plane. Several modalities are useful in treating t his decompensation, and these modalities are often used together to improve function by reducing strain and muscle spasms and thereby reducing pain. The Levitor orthotic is one of these useful modalities in the treatment of selected individuals. It requires a commitment on behalf of the patient to wear the device routinely and to come in for timely follow-up and readjustment. It is useful when other modalities, such as physical therapy, manipulation, or sur gery, have failed to produce long-lasting results. It does not replace manipulation in these patients, and ongoing evaluation and proper use of OMT can lead to sig nificant improvement in the patient's quality of life.
Procedures Please note: The procedures that follow are examples of manipulative treatment that you may wish to employ. The actual choice of procedures used should be determined by the unique circumstances of each individual patient.
Lumbosacral Release (Direct Myofascial Release) (Fig. 27.14) This procedure is employed sequentially to diagnose and then to treat muscular and fascial tension in the area of the lumbosacral junction. Patient position: prone. Physician position: at either side of t h e treatment table. Procedure Place one hand upon the patient's sacrum with the most proximal po rtion of your palm at the level
of the lumbosacral junction and with your fingers pointing toward
the patient's coccyx.
2.
Place your other hand upon the patient's lumbar spine with your fingers extending up over the thoracolumbar spine and paravertebral muscles.
3.
Apply gentle traction to load the muscles and fascia of the lumbosacral junction by pulling cephalad with your thoracolumbar hand and pushing caudad with your
FIGURE 27.14
Direct myofascial release sequentially employed to diagnose and then to treat muscular and fascial tension in the area of the lumbosacral junction.
448
Section III • Clinical Conditions sacral hand. Use enough pressure to create tension in the soft tissue but stop short of force that will move the sacrum between the ilia.
4.
Use your hands alternately now to assess soft tissue tension and with incrementally more force articular compliance.
5.
Hold with your sacral hand, and with your thoracolumbar hand actively test motion by introducing lateral translation left and right as well as clockwise and counter clockwise twisting. Observe directions of tension and ease.
6.
Hold with your thoracolumbar hand, and with your sacral hand, actively test lateral translation left and right, sacral flexion and extension, and rotation right and left, on both the right and left oblique axes. Observe directions of tension and ease.
7.
Move both hands in the combined directions of tissue tension, hold and wait for a release, the perception of relaxation of tension in tissues between your hands.
8.
Reassess the lumbosacral junction and repeat steps 3 to 7 again as necessary to obtain the optimal effect
Pelvic Tilt (Exercise) (Fig. 27.15) This exercise is employed to strengthen abdominal and lu m ba r paravertebral mus culature and to decrease vertical strain upon the lumbosacral junction by decreas
ing the lumber lordosis, shifting the cente r of the body of L3 posteriorly, and decreasing the sacral angle.
The pat ie n t lies supine or stands with the back against a wall. It may be easier then demonstrate the p roc e d u re standing. Ultimately, it is desirable that pa t i e nts learn
to demonstrate pelvic tilt to the patient supine on the treatment table and to stand and walk with some degree of pelvic tilt.
Procedure
1.
Have the patient lie supine upon the treatment table with the hips and knees flexed and the feet flat upon the tabletop.
2.
The patient places the hands upon the lower abdomen so as to monitor rectus abdominus contraction.
3.
The patient tightens the buttocks and contracts the anterior abdominal muscles, to push the lumbar spine flat against the tabletop. You may wish to place your hand, palm up, beneath the low back to monitor the process and give feedback.
4.
The patient holds the contraction for 30 seconds and repeats the process as tolerated.
FIGURE 27.15
Pelvic tilt to strengthen abdominal and lumbar paravertebral muscula ture and to decrease vertical strain upon the lumbosacral junction by decreasing lumbar lordosis, shifting the center of the body of L3 posteri orly, and decreasing the sacral angle.
Chapter 27 • The Patient with Back Pain: Postural Decompensation S.
449
When the patient understands the procedure, have him or her stand with back to wall. Place your hand between the back and the wall and have the patient repeat steps 3 and 4.
6.
Instruct the patient to stand and walk while maintaining this posture.
Psoas and Quadriceps Stretch Kneeling (Exercise) (Fig. 27.16) This exercise is employed to stretch hip flexors, particularly psoas major. It accom plishes th is in two ways: it physically stretches the muscles by increasing the distance
between the origins and insertions, and it reflexively induces relaxation through reciprocal inhibition by actively contracting hip extensors. Although psoas spasm often occurs as a primary dysfunction, it is also encountered as a s plinting mecha nism to sta bilize an unstable lumbosacral junction. Procedure (Example: Tight Left Hip Flexors)
1.
The patient kneels upon the left knee with the left hip in slight internal rotation. The right hip and knee should be flexed to 90 degrees, and the right foot is flat on the floor, approximately 18 inches in front of the left knee. The patient may wish to hold onto a chair or some other stable object With the right hand to maintain bal ance during the procedure.
2.
The patient keeps the back straight to tighten the abdominal muscles and buttocks and to perform a pelvic tilt as described earlier in the chapter. The patient maintains this posture throughout the remainder of the procedure
3.
The patient places the left hand upon the left buttock to monitor and maintain gluteal tension.
4.
The patient flexes the right knee, pulling the pelvis forward and extending the left hip until tension is felt in the left hip and thigh.
S.
The patient maintains this position for a minimum of 30 seconds and repeats as tol erated.
6.
The procedure should be repeated on the other side.
FIGURE 27.16
Kneeling psoas and quadriceps stretch to stretch hip flexors.
Section III • Clinical Conditions
450
FIGURE 27.17
Dry-land swim to strengthen weak paravertebral musculature.
Psoas, Indirect Release This p r oced ure is employed to reflexively reduce hypert on icit y of the psoas major muscle (See the proced u re d esc ribed in C h ap ter 9 and Fig. .
9.3)
Dry-Land Swim (Exercise) (Fig. 27.17) This exercise may be employed to strengthen weak paravertebral musculature. It consists of repetitive contraction of the pa r ave rteb r al musculature. Each repetition has three steps and each step takes about 5 seconds, for a total of 15 seconds per repetition. Having the patient count to 5 out loud during each step prevents Valsalva and
reduces
intra-abdominal stress upon the abdominal wall. The
sequence ty pically is i n i ti a t ed with five repetitions on each side. The number of repetitions may be increased as back s t rength i m proves. The patient lies prone upon a firm surface with the legs straight and the shoul ders and elbows fully extended so that the arms pro j ect above the head along the longitudinal axis of the bod y . During the entire exercise, the patient must keep the neck flexed by h old ing the chin against the upper chest to prevent hyperextension strain of the mid to low cervical and upper thoracic regions. Procedure 1.
The patient flexes the neck, bringing the chin to the chest (this should be main tained throughout the exercise) and alternately lifts the right arm and left leg slowly from the floor for a 5 count.
2.
The patient holds this position for a 5 count.
3.
The patient slowly returns the right arm and left leg to the floor for a 5 count.
4.
Alternating, the patient repeats steps 1 to 3 with the left arm and right leg
ADDITIONAL EXERCISES THAT MAY PROVE USEFUL •
Back extension exercises (See the description of the pr o ce d ure in Ch a pte r and Fig.
28 and Fig. 28.6.) 28 and
•
Torso curls (See the d escriptio n of the p roced u re in Chapter
•
Reverse torso curls (See the description of the proced u re i n C h apter Fig.
28
28.5.)
28.7.)
References 1. Kuchera ML G ravi ta ti o na l stress, musculo-ligamenwus strain, a nd postural alignment. Spine: State of the Art Rev iew s 1995;9:463-490. 2. J u n gman n M. Backaches, Postural Decline, Aging and Gravity-Strain. Revised ed. Rangeley, ME: Institute for Gravitational Strain Pathology, 1988. 3. Kuchera ML. Gravitational strain pathophysiology. In: Vleeming A, M o one y V, Dorman T, Snijders Cj, eds. Second Interdisciplinary World Congress on Low Back Pain: The Integrated
C h a pter 27 • The Pa t i e nt w i t h B a c k P a i n : Post u r a l D e co m p e n sat i o n F u n c t i o n of the L u m b a r S p i n e a n d S ac ro i l i a c J o i n t .
45 1
Parts 1 a n d 2 . R o tte rd a m : ECO,
1 9 9 5 ; 6 5 9 -6 9 3 . 4 . K u c h e ra M L , J u ngm a n n M . I n c l u s io n o f L ev iro r o r rhoric dev ice i n t h e m a n a g e me n t o f refrac rive l o w b a c k p a i n .
J Am
Osteop a th Assoc 1 9 8 6 ; 8 6 : 6 7 3-6 7 4 .
5 . K u c h e ra ML. P ost u ra l c o n s i d e r a t i o n s i n r h e sa g i t ta l p l a n e . T n : Wa r d R C , e d . F o u n d a t i o n s fo r Osreo p a r h i c M e d i c i n e . B a l t i m o re : Wi l l i a m s & W i l k i n s , 1 9 9 7 ; 9 9 9- 1 0 1 4 .
6 . D i G i ov a n n a E L , K u ch e ra M L , G r ee n m a n PE. Effi c a c y a n d c o m p l i c a t i o n s . I n : Wa rd R C , ed . Fou n d a ti o n s fo r Osteopa t h i c Med i c i ne. Ba l t i mo r e : Wi l l i a m s & Wi l ki n s , 1 9 9 7; 1 0 1 5-1 0 2 3 . 7 . Wi l l m a n M K , K u c h e r a M L, K u c h e ra WA . R a d i o g ra p h i c tech nica l a s pects o f r h e p o s t u r a l s t u d y. I n : Wa rd R C , ed . Fo u n d a t i o n s fo r O s teop a r h ic Me d ic i ne . Ba l t i m o re : W i l l i a m s & Wi l k i n s , 1 9 9 7 ; 1 0 2 5 - 1 0 3 4 . 8 . H u a n g R P, Bo h l m a n HH, Th o m p so n G H , Poe-Koc h e r t C . P r e d i c t i v e va llie o f pelvic i n c i dence in p rog re s s i o n of s p o n d y l o l i s t h e s i s . S p i n e 2 0 0 3 ; 2 8 : 2 3 8 1 -2 3 8 5 . 9 . H a n son D S , B r i d we l l K H , R h e e J M , Le n k e L G . Corre l a t i o n o f p e l v ic i n c i d e n c e w i t h lo\\, - a n d h igh -gr a d e i s t h m ic s p o n d y l o l i s t h e s i s . S p i n e 2 0 0 2 ; 2 7 : 2 02 6 -2 0 2 9 . 1 0 . Ga l l a n t R A , e d . T h e J u ng m a n n Concept a n d Techni q u e s o f A n t i - G r a v i ty Leverage: A C l i n i c a l H a n d boo k . 2 n d ed . R a n g e l ey, ME: I n s t i t u te for G r a v i ta r i o n a l S t r a i n P a t h o logy, 1 9 9 2 .
The Patient with Scoliosis Kenneth E. Nelson
INTRODUCTION Scoliosis is def i ned as a rotational deformity of the spine, best observed on forward
b e n ding and as sociated with a p ersistent lateral curvature of the spine measuring greater than 10 d egrees on weight-bearing rad iography.' T h e diag nosis of sco l iosi s is ba sed upo n a corrsteJiation of h isto ry and physical findings that must be confirmed radiographically. The r ad i ogra p hs must be taken with the patient sta n di n g The spina I l a te r a I curvature in question must exceed 10 degrees as measured by the Fe r guso n 2 or Cobb3 methods (Fig. 28.1). The diagnosis of scoliosis must not be made lightly. The term scoliosis has a prej u di cial connotation implying a d efor m ing disease of th e spine. Either the noun (sco liosis) or the ad j ective (scoliotic) can be very frightening to patients or t he parents. Recording the d iag n osis code for scoliosis (lCD-9CM 737.30, idiopathic scol i osis 4) permanently links t h is d i agnos i s with the patient in the co m p ute r database of the health h isto ry Alternatively, the term lateral curve or spinal curue may be used when discussing the su bj ect with th e patien t A d i a gnosis such as myositis (ICD-9CM, 729.14) may be e m pl oyed if the patient is beirrg treated for associated myal gia This doe s not imply that the d ia gn osis should be withheld when appro priate . Rather, one must be ful l y aware of the power to affect pa t ie n ts lives in area s outside of m e d ici n e One must perf o r m one's d ut ies as a physician appropri ately but with vig i l a nce and r e sp e ct for one's i n flu ence on patients. ,
.
.
.
.
'
.
452
Chapter 28 • The Patient with Scoliosis
FIGURE 28.1
Methods for measuring the angles of spinal curves.
(A)
453
Cobb's method
(preferred): Place lines parallel with the upper end plate of the upper vertebra and the lower end plate of the lower vertebra of the curve. Extend these lines and measure the angle of intersection. Because in small curves this intersection may not occur within the limits of the radiograph, the same angle can be obtained by measuring the angle formed by the intersection of lines drawn perpendicular to the end plate lines. (B) Ferguson's method: Place central points in the apical vertebrae of the curvature and in the vertebrae that define the highest and lowest margins of the curve. Connect them with two lines forming an angle. This is the angle of the curve; it is measured as the divergence from 180 degrees.
The treatment of uncomplicated scoliosis is a life-long intervention. This type
of conrinuity of care requires the special skill offered by osteopathic medicine. It is not the purpose of osteopathic medicine to cure the scoliosis. The osteopathic physician treats the patient. The physician, however, must pay special attention to the scoliosis, addressing how it affects the functional status of the otherwise he81thy individual. The physician must consider the effect of the scoliosis upon the patient's activities of daily living, upon cardiovascular and pulmonary systems, upon pregnancy, and upon rhe chronic conditions of aging. The treatmenr protocol outlined in this coapter is intended both to mobilize and
to stabilize the spine. This may initially seem to be paradoxic. It is directed at selec tively addressing the spinal motion restriction that results from somatic dysfunction woile srrengtoening muscles that stabilize the spine to eliminate spinal instability.
ETIOLOGIES OF SCOLIOSIS Inequaliry of leg length with resultant pelvic unleveling is present in most adults.
(See Chapter 26.) This condition is by far the most commonly encountered etiology of spinal type I group curve mechanics. The amount of pelvic unleveling necessary to produce a compensatory curve large enough (more than 10 degrees) to qualify as scoliosis, however, is rare. The most commonly encountered scoliosis is idiopathic. The etiology of idiopath
ic scoliosis is, as the name implies, unknown. Most persons (80%) with idiopathic scoliosis are female. Idiopathic scoliosis demonstrates high incidence in some fami lies, suggesting a generic origin. It is probably a sex-linked trait. The gene is thought to be on rhe X chromosome. As such, it can be transmitted from
a
mother to both
454
Section III • Clinical Conditions
sons and daughters. It can be transmitted from a father only to his daughters. The trait demonstrates incomplete penetrance and may not manifest in every generation. It is variably expressive. A mother with severe scoliosis may have a daughter with mild scoliosis. If one parent has scoliosis, even if it is not manifest, the chance that their child will have scoliosis is approximately 33%. The most commonly encountered scoliotic spinal pattern (90%) is a thoracic curvature convex on the right. 5 It begins developing in early adolescence, often in association with the prepuberty growth spurt. Infantile scoliosis, a non-weight-bearing spinal curvature that becomes appar ent between birth and age 3, is generally considered to be the result of molding due to intrauterine position. Arbuckle,6 Magoun/ and SergueefS suggest that an intraosseous occipital dysfunction is responsible for this condition. The occiput is formed from seven growth centers, five cartilaginous and two membranous. The occipital condyles are at the point of conjuncture between the three anterior carti laginous centers. (See Chapter 8.) Asymmetric compression of these condylar parts wiH result in the occiput resting asymmetrically upon the atlas. Asymmetry of the occiput upon the atlas produces a compensatory scoliosis from above downward. Scoliosis may result from congenital malformation of verte b r al segments, wedg ing, hemiverrebra formation, or failure of segmentation. These malformations, of course, cannot be treated with osteopathic manipulative treatment (OMT); how ever, the logic of mobilization and stabilization, described later, apply to the com pensatory mechanics that the anomalies produce. Myopathic scoliosis can result from asymmetric muscular strength seen in
con
ditions like muscular dystrophy. Neuropathic (paralytic) causes of scoliosis include poliomyelitis, cerebral palsy, and spinal tumors. Von Recklinghausen's neurofibromatosis is
an
autosomal dominant genetic dis
ease that is associated with scoliosis in approximately 40% of cases. This is due to developmental failure of the spine. It can produce severe deformity quite rapidly during periods of growth. These patients also demonstrate the following: •
Neurofibromatous tumors, essentially 100%, a minimum of 2, as a diagnostic criterion, which may affect skin, peripheral nerves, blood vessels, and the gas troin testina I tract
•
Areas of cutaneous hyper pigmentation spots, called cafe au-Iait, almost 100%
•
Hamartomas of the iris, called Lisch nodules, 90%
•
Optic glioma, 15% Impaired integrity of connective tissue can result in spinal instability and scol
iosis. Marfan's syndrome is such
a
congenital condition. Patients with Marfan's
syndrome demonstrate cardiac valvular disease (mitral and aortic regurgitation), aortic aneurysm, dislocation of the optic lenses, and high arched palate. They are tall, with elongated extremities. Ligamentous laxity results in hypermobility, spinal instability, and scoliosis. Other congenital connective tissue diseases that can result in scoliosis include various types of dwarfism. Juvenile rheumatoid arthritis is an acquired connective tissue disease. These patients occasionally develop scoliosis.
Physical Examination Idiopathic scoliosis begins insidiously and can progress to a catastrophic degree. Although it may be difficult for the untrained observer to recognize the anatomic
Chapter 28 • The Patient with Scoliosis
455
asymmetry of the ea rly stages of scoliosis, the trained examiner can readily identify scoliosis by recogn izing asymmetry of normally symmetric a n atomy. The structura l examination is an integra l component of the osteopa thic physica l examina tion. It should be per formed with a p prop riate modifica tions on every patient from neonate to geriatric, a nd scoliosis screening shoul d be part of the health mainte nance p rogram in a l l school systems. Scoliosis is p athologica l Fryette type I (group or neutral) spina l mechanics. The scoliosis screening exa mination is the same as the osteopa thic structura l exa mina tion with emphasis upon the identification of this type I spinal mecha nics. It is per formed by sta nding behind the individua l. The first step is to observe the positi on of bil aterally sym metric structures: mastoid processes, a cromion processes, scapu lae, iliac crests, sacral sulcae, and greater trochanters. Next is the test for pelvic side shift. Type I mechanics and consequently the severity of scoliosis a re specifica l ly identified by ha ving the pa tient forward bend. The physic i a n should look for the a symmetric paravertebral prominence, which results from the rotational compo nent of spina l group curves. At the thoracic level, it is termed an osseous gibbosity because of the rotation of the ribs; at the lumba r level, it is a muscular gibbosity. It is important to observe standing posture l a tera lly for a bnorma l mechanics of the kyphotic a nd lordotic spinal curves. Spina l a nteroposterior mechanics increase in the presence of type I curves. Significant findings should be further delineated by regional and segmental diagnosis. Physica l findings consistent with scoliosis should then be confirmed a nd quantified radiographically. Spinal Mechanics of Scoliosis and Somatic Dysfunction
In type I spina l mechanics, the involved group of vertebrae demonstr ates a coup led rel ationship between side bending and rotation. Under neutral circumstances (a bsence of s p i n a l flexion or extension engaging the zygapophysea l a rticula tions), when side-bending forces are a pplied to a group of typical vertebrae, the entire group rotates towa rd the side of the produced con vexity. Side bending and rot a tion of the ent i re group are coup led i n opposite directions. Because scoliosis is a rotationa l deformity, it is n a med a ccording to the direc tion of the rotation (the side of the con vexity of t h e curve). Therefore, a curve tha t is side-bent left (concave left, con vex right) a nd rotated right is described as right scoliosis. Type II (not neutra l) somatic dysfunction is found at the tra nsitiona l points of group mechanics. The v ertebrae of maximum rotation, where rotational mechan ics change direction, is called the apex of the curve. The conjuncture of two curves, where side-bending mechanics change, is ca lled the crossover point. Anterior and posterior spinal mech anics a r e affected by type I mechanics. The presence of a group curve increases the existing spinal kyphosis or l ordosis. Therefore, a thoracic type I curve will demonstrate increased kyphosis, a nd a lum bar curve will demonstrate increased lordosis. At a crossover point, the existing anteroposterior curve is decreased. Fryette9 noted tha t type II dysfunction most commonly occurs when force decreases the existing anteroposterior curve. The preexisting anteroposterior flat tening at the crossover point between two type I curves ma kes this a rea most vul nerable for the development of type II dysfunctions. The rotation a l relationship between individua l segments changes between the apex of a group curve and the segment immediately above it. That is, a lthough the entire curve is side bent and rotated in opposite directions relative to the anatomic position, when the mechanics between individua l segments of the curve a re considered, this
456
S ection III • Clinical Conditions
*
FIGURE 28.2
Coupled side bending and rotation in a type I spinal curve. The entire
curve is side bent to the left and rotated to the right relative to the
anatomic position. The apex is rotated maximally to the right. Therefore, relative to segment B, the apical segment is side bent to the left and
rotated to the right, and relative to the apical segment, segment A is side bent to the left but also rotated to the left.
relationship changes . At the apex of the curve and below, if a vertebral segment is con sidered relative to the vertebral segment immediately below it, side bend ing and rota
tion occur in op posite directions. Above the apex, however, if a segment is considered
relative to the segment below it, side bending and rotation occur in the same direction (Fig. 28.2). For
this reason, the upper half of a group curve behaves as a series of type
II d ysfunctions. Because a group cur v e produces an increase in the normal anteropos
terior curve, resultant
type If dysfunctions tend to be fl exed in the thoracic region and
extended in the lumbar region. Pain Associated with Scoliosis
As idiopathic scoliosi s is developing, the sp i ne is lateraUy unstable. The vertebral
segments of s uch a fu nctional curve maintain unrestricted motion, although there is asymmetric position . There is rarely pain . Con sequently, the lateral instability
shifts the positions of the anatomic and physiologic barriers of vertebra l motion. No restrictive (dys f unctional) barriers are present, however. This is why idiopathic scoliosis is usually
first recognized by someone other than the patient. The lateral
insta bility can allow the developing scoliosis to progress fairly ra pidly over
a
few
months, making this time insidiousl y dan gerous .
Scoliotic c u rves that will not straighte n wh en side - bending forces are applied
are called structural (fixed) curves. Scoliotic curves that do straig h ten w hen side
bending forces are appl ied are non str uctu ral or functional curves. Typica l ly, the curve becomes structural in late adolescence. Because of a young adult's ability to compensate (tolerance), there is usually no pain. Pain complaints more often begin to manifest as the adult with scoliosis reach es middle age. Co mmonly, areas of chronically restricted m o tio n are not painful.
Chapter 28 • The Patient with Scoliosis
457
P a i n tends to d e v el op in the segments a djace n t to the restricted area. These segments must compensa te for the restricted motion of their n e i gh b ors. T h e mechan ic a l stress of th is compe nsa t i o n produces pain. These compensatory areas are common l y fo u n d at the crosso ver poi n ts a bo v e a n d below the st r u ct u ral curve. The fla ttenin g o f the a n teroposterior curv e a t the crossover p o i n t a l l ows the devel opment o f ty pe II
mechanics tha t oppose t h e a nteroposterio r curve of t h e regio n, tha t is , extension
a crosso v er poin t in the thora cic region a n d flex ion ty pe II d ysfunc tio n found in the lum ba r regi on. The presence of an extension dysfun ction within a k ypho t ic c u rv e (or fl exion within l ord osis) results i n the oppo
type II d y sfunction, ofte n fou n d a t
,
,
sition of fle x i o n a n d exte nsion weig h t- bea ring forces i n adjace nt segments. The res u l ti ng mec h a nica l stress, a ugme n ted by the increased motion necessary to com pensate fo r the adjacent structural curve, is particularly p a in fu l
.
Diagnostic Testing
Further e v a lua tio n of the spine is d o n e r adiographica l l y A sco l i osis series is t h e .
a ppropri a te ra d i ographic ev a l ua ti on. T h e r a d iog raphs a re taken wit h t h e pa tie n t
standing. The exposure should include the entire s pine a nd pel vis. Three such
exposures a r e ta k e n . The fi rst is take n w ith t he p a tien t sta nd ing normally, wit h w e i ght equally d is tri buted upon both lower extremities. This film is used to measure the spinal curves, a n d if p r o p e rl y ta k e n , it can be used to m e a sure p e lvic un l evelin g and l e g l e n g t h . (Se e C h a pter
26.) The second
and third exposures are
ta ken while the p a tie n t b e n d s th e torso to the left and rig h t . These films are use d to d iffere n t ia te structural (fixe d ) curves from nonstructural (functional) curves. A fo ur th r a d i ograph, often of the ha n d, is taken to eva luate t h e status of e piph y seal fusio n in a d o lesc e n ts. T h e evolv ing sc o l iosis tends to sta bil ize with the ces sa tion of bone growth. One add i t ion al ra diogra p h is necessary to fu l l y e v a l u a te the we i g h t- bearing mech a n ics of a p a t i ent with sc o l iosis. A stand ing l a teral l um
bosa cral spine fi l m is re qu ire d for measurement of the sacral a n gle a n d pelvic
index. This last
film is i nclud ed in t h e postural series.IO,ll (Se e Cha p t e r 27.) and the film to d e termine e p i ph y se a l sta tus are
However, tne s ide-ben d ing films
not part of the postural series a n d should be employed for i n iti a l e v a luation of scoliosis. As such, a combin a t i o n of the scoliosis series and postural series is appro p ria t e . Treatment Protocol
T h e tre a tme n t of a pat i e n t with scolios is is directed a t maintaining fun ction and preve n ting seq uela e. The i n itia l i d e n t i fi ca tion of a spinal curve of
20 d egrees or
greater is indication for refer r a l to a consul tant wno speci fica ll y treats scoliosis. Underlying ca uses, if id e n tifia ble, should be addressed. Tre a t m e n t p rotocols for rare conditions like Marfan's syndrome sh ould be i n i t i a ted. It is h ere tha t the recog nition of unequa l leg leng t h (sta tic scoli osis) a nd chronic occu p a t io nal pos ture (habit scoliosis) can be useful In most cases of i diop a tnic scoliosis, leg l engtn .
has no r e l a tions h ip to tne scolio t ic pat tern. Occa sion a l l y t ne p elvic unleveling ,
assoc i a ted with short leg is consisten t with the spin a l sco lio tic p a t ter n . These patients may be nefi t from lift
therapy. Rarely an indiv idu a l has scoliosis because
of accommodation to unequal leg length. These patients can be "cured" w i th lift th er apy. (See Chapter
26.)
Occupa tio n a l postur a l stresses may contribute to discomfort. Haird resse rs and violi nists a dopt c h ro n i c positio ns t h a t in d u ce a spinal curvature in a n otherwise normal back. Where change of occupation is unrea l ist ic, ind ividualized stretch ing
and stren gth eni n g exercises can be prescribed.
458
Section III • Cl i nical Conditions
Infantile scoliosis can be trea ted with cranial manipulation. The o ccipu t should be exa mined with attention to the c o nd yl a r
p a rts . Spheno basil ar s y nchond r os i s d y sfunct i o n and the rem a ining cranial patte rn should be id enti f ied. The to tal b o dy pattern, with p arti cula r attention to the c ervic oth oracic r eg i o n, sacrum and pelvis, should be defined. Identified d y sfu nc tio nal and acc o mmodative pa tterns can be treated, frequently with p rofo u nd results. (See Cha pter 8.) The treatment o f ad o les c ent idio pathic scoliosis has two prongs, mobilization and stabilization. It is necessary tha t the pati e n t devel o p p r o p r io c e p ti on, body awareness of g oo d posture, and at the same time work in bui l d i n g self-esteem. The pr oto c o l must be i nd i vidualized to the req u iremen ts of the s p ecific p atient. Patients must become ac t ively involved in development of their pr o to col. This ensures tha t
they will continue (and continually adjust) the treatment th rou g h o u t life. This is particularly di fficu l t with adolescents, yet they are the individuals who will benefit
the m ost fro m treatme nt . M o b i l izatio n and
c ontin u e d m o bility are a s igni fica n t
part of trea tment. the spinal curves. Passive str etching- lazy person-exercises are appr o priate (Fig . 28.3). The patient is instructed to lie o n the side so that the convex side of the curve being trea ted is d o wn . A firm but co mpli ant roll approximately 6 i nc he s in d i a m ete r is p l a ced beneath th e patient at the level of t h e apex of the curve. This pass i v e exer cise must be timed carefully to avoid pai nfu l ove r d os i n g. I nitia l ly, 1 or 2 minutes daily is s u fficie n t . This can be increased g r a d ual ly to 5 or more minutes daily, acco r d ing to t o lera n ce . Active stre tch i ng exercises should also be done. Patients should participate in the selection of exercise type. The exercise must be bilate r al , but again, st r etchi n g o f the co ncav ity of the curve or c urv es is the focus o f t he ac tiv ity. The mobiliza tio n of sp ecifi c areas of somatic dysfunction with OMT should be done judici o u sly. Gentle direct st re tch i ng , art i culati o n, muscle energy, and direct and indirect m yofascial pr o cedu r es are m ost app r o p r iate. It may seem i n appropr i a te to mo b ilize a potentially unstable condition. In fact, it is, unless stabilization exercises are a major part of the treatment protocol. Here M o bil iza tion procedures are directed at stretching the concave side of
again, it is impor tant t o en c o u r age t he p atient t o pa rtici pate in the se l ect i o n and deve lo p m e n t of the exercise progra m . Pr edo m inantly asymmetric exercise, such as t ennis, is contra i n dicated . The exercise should be bilateral, but pou ndi ng weigh t
b ear i ng exercises, such as jogging, should also be disc o uraged . Swimming, bei ng b o th s ymm etri c a n d n o n-weigh t b ear i n g, is an example of an ideal ch oic e . The pr ogram should pay part i cular a ttention to strengthening core muscula ture (i.e., a bdomina l and p arave r teb ra l muscles) a long with development and implementa t i o n of both mobilization a nd stabilization exercises. Consultation with a physical the ra pist can be benefic i a l.
FIGURE 28.3
Lazy person exercise. The patient lies on the side with the convexity of the scoliotic curve down upon a firm roll 5 to 6 inches in diameter. This is a passive form of exercise employed to stretch the concave side of the curve.
Chapter 28 • The Patient with Scoliosis
459
Progress should be monitored closely. Reg ularly checking heig ht is an ea sy way for patients to monitor themselves at home. Any decrea se in h eight should be con sidered to b e increase of the scoliotic curve. Follow i ng the initial v isit, the pat i ent
should be seen
in the office at 2 -w ee k
intervals once or twice to ensure efficacy of the exercise program and mon itor progress Follow u p visits may be extended to a bout one a month for the fi rst .
-
6 months and every 3 to
6 months th erea ft er
.
For o ffice documentation, the use of a Polaroid or d ig it al camera to take serial
photog raphs of the patient is worthwhile. Patients should stand with their back toward the camera, idea ll y against a wall marked in such a way that cha ng es in height are a ppa rent . The phot o should be taken with the camera alway s in the sa me pos iti o n A tripod is usef ul for this purpose. The neutral sta ndin g ra diog raph of the scoliosis series should be repeated for comparison if there is any indication of increase of the scoliosis as demonstrated by two or mor e consecutive decreases .
in h eig ht. Radiographs can be re p ea ted a nnua lly until it is apparent that the curve has sta bil ized. Prog ressi on of the curve necessitates referral to a spine surg eon for possi ble b racing or surgi cal stabilization.
Ad u lt pati ents with idiopathic scoliosis typica lly seek medical he l p in middle
age, when their a b ili ty to functionally compensate for their asymmetric weight bearin g pattern d eclines a nd they beg in having persistent pa in described earliel; is typically in functiona l
.
The pain, as
areas t hat are under stress because they
compensate for adj acent areas of restricted motion.
The t herapeut i c approach is, as for the adolescent pat ient a combination of ,
mobilization and stabilization. The mo bi lizati on component for the adult scoliotic is stressed more t han for the adolescent. The adult patient w ill ty pi cally tolerate more aggressive forms of OMT well. The focus of t reatment is the maintenance of funct ion a l a rticular mobility. With sensitivity to tolerance, the primary area of restricted motion (th e structural primary curve) should be t reat ed with the inten tion of maintaining intervertebral range of motion. Stretching
the concavity of the
primary curve and g entle mobil ization of compensatory secondary (nonstructural, nonfunctional) curves and crossover points should be done in clo se association
with stabiJization exercises. As the scoliotic spine ages, the effects of t he thoracic
curve affect mobility of the
th oracic cage and con seq uently ca rdiac a nd pulmona ry physiolog y. The mainte nance of mobil ity of the ribs is
an
important thera peutic g oal for the care of any
one with scoliosis. It becomes ultim at ely important for the geriatric patient.
and the existence of unequal leg leng th are rarely consistent with one another
As mentioned earlier, the mechanics of the scoliotic cur ves pelvic unleveling from Inequality of leg
.
length is present in most adults. The mech a nica l interface between
the scoliosis a nd short leg m ec h an ics is commonly found at the lumbosacral junc
tion. This stress result s in an increased incidence of lumbosacral deg enerative disc
disease, arthri t ic chang e an d radicu lo p athy Heel p a ds may be used empir ica i J y to ,
.
the side of the long leg. The use of lift therapy under these circumstances is d i recte d at reduction of weight-bearing stress. The effect of the use of a lift upon the lumbosacral con sequences of scoliosis must be w ei ghe d against its effect upon sacropel vic mechan reduce lumbosacral stress. Occasionally, the lift must be placed on
ics. The goal is to reduce lumbosacral stress
while ma in ta ining comfort.
More Aggressive Therapies
Failure to prevent progression of the s pi n a l curvature is indication for m ore aggressive therapies. This is why
it is important to monitor the patient's progress
460
Section III • Clinical Conditions
closely until the c u rve or curves are stable. The u se of bra ces that st i m ul a te a ctive co re m u sc l e contraction (Milwaukee brace) is a considera tion
under these
circ u msta nces . S u rgic a l intervention for s p i n a l fusion and i mp l a ntati on of m e tal (as i n the Cot rel-Du bou sset p roc e d ure) pa raspi nal rods is ind icated where b rac ing fa ils to
arrest curve progression. It is also ind i cate d if the c u rve remains unstable a n d the brace ca n not be discontinued. Other indications for surgery include progressive loss of pulmonary fun ction, pa i n, and severe cosmetic issues. Long- Term Consequences of Scoliosis
The a symmet ric weigh t bea ring stresses of sco l i osis have l ong term consequences. -
-
Forces t r a n s m itte d t hro u gh bone m o d ify osteocla stic a nd osteoblastic act i v ity in such a way that the architecture of the bone adjusts to the stress ( Wo lff s law). The shape of the venebrae a nd ribs change, which changes the neutral posi ti o n of the '
axial skeleton witho ut necessarily re sulti ng in the establishment of
a
dysfunctional
bar rier. It is circumsta nces like these that i n val id a te t h e use of positional a sym me try alone in the diagnosis of somatic dysfunction.
These a symm e tr i c pos iti o n a l mechanics facilitate the development of so m ati c
dy sfu n ct ion The y a Iso have a d d i tio n a l mechanical i mplica tio ns .
.
Idiopa thi c sc oli osis typi cally is stable d ur ing a d ult life. Pregnancy, however, can
pose significant prob l ems. Mechanic a l asymmetry of the l u m bar spine an d pelvis
can great ly affect the bi rth process. For ma n a gement of preg n a nt patients, the m a i n tena nce o f spinal st a bi li ty as descri bed ea rlier is a prime ob jec t iv e Here, as .
w h en managing the a d o lescen t with sco l i osis, vigi l ance for progression of sp in a l
curves is import a n t; however, radiographic st udies are inappropriate for pregnant women. The staniS o f the curves must be determined by physical find in gs Serial .
pho tos may a l so be used.
CONCLUSION The therapeutic goals for tr ea t i n g a p at i ent with scoliosis are the
same as those for
treating any ot h er p at ient with a chronic disorder. They are to empower the patient to deal eff ectivel y with a lifelon g c ondit i o n , to maintain opt ima l function and
pre
vent progression of the co nd ition, and not necessarily to decrease the degree of the
spin al curvature. Any reduction in c u r vatu re, a l t h o ugh d esira bl e should be con ,
sidered as fortuitous se conda ry ga i n. An effective protocol begil1s with s pe cific identific a t i o n of the body mechanics of the individual patient, w i th recognition of the spinal level of crossover p oint s between group curves and the level and side of the apices of c urves. Standing postural radiographs a re useful for this purpose. 10.11 Patients sho u l d be a ppri sed of these mec h a n i cs since a person a l understanding of thei r postural asymmetries will assist grea t ly in the develop ment of a treatment
of their spinal a pi ces a n d crossover point s. The individualized t h er a peu t i c protoco l wi l l include b o t h mobilization a nd sta bilization. Mobilization may be accomp l i shed wi th stretching e xerc is e s and OMT. Any manip u l a tive p roced u res m a y be a ppro pr i a t e, although aggressive m o bil i z a protocoL Often i t is desirable to provi d e patien ts with a drawing
tion should not b e employed i n younger patients before their curves have stabi lized . The choice of OMT to be e mp loye d is d icta ted by the criteria discussed in Chapter 4. Stabilization i s accomplished w i th strengthening e xerci ses, and its impo rtance cannot be overemphasized. The following are examples of mobi liza t ion pro ced u re s and stabilization exercises.
Chapter 28 • T h e Patient with Sco l i osis
461
Procedures Please note: The procedures that follow are exa mp les of manipulative treatment that you may wi s h to employ. The actual choice of procedures used should be determined by the unique circumstances of each individual patient. Lazy Person Exercise (Mobilization) (See Fig.
28.3)
This is a passive exercise. Its purpose is to stretch the contracted soft tissues on the concave side of a type I group curve. Certain precautions that must be taken for this exercise. Because scoliosis is a potentially unstable condition and it is the pur pose of this exercise to stretch soft tissue, it is probably not appropriate to begin this activity until after the curve has become fixed. Consequently, this exercise is appropriate for adults and can be considered as an activity to help maintain mobil ity as opposed to something to reverse the curve. Fur t her, because this is a passive activity, dosage (duration of time spent doing the exercise) is often deceptively short. Spending more time than tolerated may not prove to be harmful to an indi vidual with a fixed curve, but it can be very uncomfortable. Patient position: lyi n g on the side with the convexity of the curve down. Procedu re
1.
A firm yet pliable roll should be constructed. A tightly rolled bed sheet is about the correct consistency. Rolled newspaper wrapped In a terry cloth towel is also func tional. The roll should be 5 or 6 inches in diameter.
2.
The patient lies on a firm surface on the side with the convexity of the curve down and with the roll its long axis oriented anteroposterior to the patient, beneath the patient at the level of the apex of the curve.
3. 4.
The patient lies on the roll initially for no longer than 1 minute. The time spent on the roll may be increased gradually in 30-second increments according to tolerance. The maximum time that the patient need spend doing the exercise is probably 3 to 5 minutes.
5.
The procedure can be repeated daily.
Group Curve Mobilization (Articulation, HVLA, or Muscle Energy) (Fig.
28.4)
T h is procedure is employed to enhance spi na l motion and to keep a type 1 group curve flexible. It is useful for curves with apices from the mid thoracic region through
lumbar spine. Because of the way spinal rotation is addressed, the entire curve may be treated in a single procedure. (For diagnosis, see the discussion earlier in this chapter and also Chapter 3.)
the
Patient position: seated astride the end of the table with the back toward the end. Physician pOS i t ion : sta ndi ng behind the patient on the concave side of the curve. Proced u re (Exampl e: Convex Rig h t, T h o racic Type I Gro u p Cu rve, T4 to wit h t h e Apex at
T12,
T8)
1.
Instruct the patient to clasp the hands behind the neck.
2.
Standing behind and to the left of the patient, place your left arm in front of the patient's chest so that your left shoulder is beneath the patient's left axilla and your hand is grasping the right shoulder.
3.
Place the heel of your right hand upon the apex (T8) of the curve on the side of the convexity (right).
4.
Side-bend the patient's spine to the right. The correct placement of your right arm in step 2 will allow you to do this easily by lifting the patient's left axilla with your shoulder while depressing the right shoulder with your left hand.
462
S ection II I • Cli n i ca l Cond i t ions
F I G U R E 28.4
G rou p curve, a rt i c ulat i on or H V L A t o enhance spi nal motion t o keep
a type I gro u p curve flexible . I t i s u sef u l for c u rves w i t h ap i ces from the m i d t horac i c reg ion t h rough the l u m bar sp i n e .
5.
H o l d t h e p a t i e n t i n this fas h i o n t h ro u g h o u t the re m a i n d e r of t h e p roced u re With t h i s position t h e cu rve h a s b e e n stra i g htened with u pwa rd t racti o n , the lower end of t h e c u rve i s held by t h e p a t i e n t 's p e l v i s , and the u pp e r e n d i s i m m o b i l i zed by you r h o l d o n the pati e n t 's p e ctora l g i rd l e . 6 . To a d d ress t h e rotati o n a l c o m p o n e n t o f t h e c u rve, p ress yo u r r i g ht h a n d u p o n the a p ex (T8 r i g ht) w h i l e m a i nta i n i n g t h e h o l d i n g force u p o n t h e u p per e n d of the cu rve as d e s c r i b e d in steps 4 a n d 5 . 7 . T h e s p i n a l s e g m e n ts o f t h e c u rve m a y n ow b e a rti c u l ated b y re peate d l y a p p l y i n g t h e rotat i o n a l fo rce w i t h y o u r r i g h t h a n d a g a i nst t h e h o l d i n g force of y o u r l eft a r m . O r yo u m a y w i s h to a p p l y a fi n a l H V LA th rust to t h e a pex w i t h t h e h e e l of y o u r r i g h t h a n d a g a i nst t h e hol d i n g force of y o u r l eft a r m . 8 . Reassess f o r sym m etry o f s p i n a l motion . .
,
A LT E R N AT I V E P R O C E D U R E S
T h i s p roced u re m a y b e m o d i f i e d a s a m u s c l e e n e rgy p r o ced u re a s fo l l ows 1.
To correct the s i d e - b e n d i n g c o m p o n e n t , m a i n ta i n the p a t i e n t a n d p h ys i c i a n p o s i t i o n s described ea r l i e r. H ave t h e p a t i e n t a ctive l y t ry to s i d e - b e n d t h e u p per t o r s o t o t h e l e ft f o r 3 to 5 seco n d s a g a i nst y o u r h o l d i n g forc e . The pat i ent may d o t h i s b y l ifti n g t h e r i g h t s h o u l d e r a g a i n st yo u r l eft h a n d , o r b r i n g i n g t h e left axi l l a down a g a i nst yo u r l eft s h o u l d e r. R e l a x for 1 to 2 seco n d s , and then e n g a g e the n ew bar rier by l i ft i n g the l eft s hou l d e r with yo u r l eft u p pe r a r m . Repeat t h i s p roced u re t h ree to five t i m e s .
Chapter 28 • T h e Pat i e nt w i t h S co l i os i s
FIGURE 28.5
2.
463
B a c k extensio n e x e r c i s e to stre n g t h e n we a k pa rave rt e b ra l m u s c u l a t u r e .
To correct t h e rotational component, have t h e patie nt actively t ry t o rotate t h e up per torso to the r i g ht for 3 to 5 seconds against y o u r h olding force. Relax f o r
1 t o 2 seconds, and t h e n engage t h e n e w b arr i er b y inc reas ing t h e force ap plied t o t h e apical vertebral segment w i t h your rig h t h and while continuing the h olding fo rce from ab ove with your left arm . R e peat this procedure t h ree to five tim es. Back Extension Exercises (Stabilization) (Fig.
28. 5)
T h ese exe rci ses m a y be emp l oy ed to strengt h e n weak para v e rtebr al m u sc u l a t u re .
They cons i st o f repetitive contraction of t he pa r a v erte bral musc u l ature . Each rep e t i t i o n h a s th ree ste ps; each s t ep t a k es a bo u t 5 seconds, for a tota l of 15 seconds per repeti t i o n . Having the pa t i e nt c o u n t to 5 out loud d u r i ng each ste p prevents the Va l sa lva m a n e uve r and reduces i ntra - a bdomin a l stress upon the a bdomi n a l
wa l l. T h e s e q u e n c e t yp ic a l l y i s initiated w i t h 1 0 r epeti tions. T h e num ber of repe
titions may be i ncrea sed as ba c k streng t h i m p r oves .
The pat i e n t l i es p rone u pon a fi r m sur face with the legs fu l l y exte n de d . If toler
a ted , the p a t i e n t m a y e m p l oy an k l e weights or hook the a n k les b e neath a p i e ce of fu rn i t u re to sta bilize the torso from below. When first perform i ng this exercise, the pati e n t shou ld p l ace th e a r m s at the sides w ith the elbows ful ly extended and the
h a n d s pal m u p . As the patient becomes accustomed to the exe rcise, he or she m a y wish t o l a c e t h e fi nge r s togeth e r be h i n d t h e neck a n d the reby inc r eas e t h e work load on the ba ck m usc l e s . Dur ing the e n t i r e e x e r c is e , the pa t i ent must keep the nec k f l exed by hol ding the c h in aga i n st the upper ch est to p r e v e nt hyperextension s t ra i n of the mid to l ow ce rvica l a n d upper thora cic reg i o n s . Proce d u re
1.
T h e patient flexes t h e neck, bring ing t h e ch in to t h e ch est (th is s h o uld be maIn tained throu g h o ut the exercise), and slowly lifts the h ead and u p p er torso off t h e floor for a 5 count .
2.
T h e patient h o lds this p osition for a 5 co unt.
3.
T h e patient sl owly retur n s t h e up per to rso to t h e floor for a 5 count .
Torso Curls Exercises (Stabilization) (Fig.
28. 6)
These exercises may be e m p l oy ed to strengthen '..ve a k core m uscu l atu r e , p a rticul a rl y t h e u p per rectu s a bd o m i n is. Torso cur l s consist o f re p e t i t ive contraction o f the m u sc u l a t u re of the a nter i or abdomina l w a l l . E ac h re p etition h as t h ree steps; each
s te p ta kes a bo u t 5 seco n d s , for a total of 15 seconds per repet i t i on . H a v i ng the p a r i e n t co u nt to 5 our l oud d u r i n g each step p revents the Va l sa l v a ma neuver and
r ed uces int ra-abdominal s tr es s u pon the abdo m i n a l w a l l . The se q u ence typ i c a l l y i s T h e num be r o f re pe t i t ions m ay be i n c r eased a s a bdomi na I st r e n gt h i mp rove s . i n i t i a ted w i t h 10 r e p et i ti on s .
464
Sect i o n I I I • Cli nical Conditions
FIG U R E 28.6
Torso curl t o st rengthen wea k core musculature, particularly t h e upper rect us abdomin i s .
T h e p a t i e n t Jies s u p i n e o n a fi r m s u r fa c e w i t h t h e h i ps and k n ees fl exed and the
fee t f l a t o n t h e floor. The patient p l aces the fin ge r s upon the u p p e r a bd o m e n to m o n i to r m u sc u l a r c o n t r a c t i o n and keeps the a b d o m i n a l m us c l e s tig h t
d u ri n g the func
e n t ire exerc i s e . T h e p a t i e n t s h o u l d be c a u t i o n e d to k e e p t h e t h o r a c o l u m b a r tion i n contact w i th the floor to a v o i d c o n tr a c ti n g p s o a s m a j o r
.
P rocedu re
1 . T h e p a t i e n t f l exes t h e n e c k , b ri n g i n g t h e c h i n to the c h est (th i s s h o u l d be m a i n ta i n e d t h ro u g h o ut t h e exercise), a n d s l owly l ifts t h e h e a d a n d u p p e r torso off the floor for a 5 co u n t . 2 . T h e patient h o l d s t h i s p o s i t i o n for a 5 c o u n t . 3 . T h e p a t i e n t s l owly ret u r n s t h e u p pe r to rso to t h e f l o o r for a 5 c o u n t . Reverse Torso Curls Exercises (Stabilization) (Fig.
28. 7)
These exercises m a y be empl oyed to stre n g t h e n wea k core m u sc u l a t u re
,
p a r t ic u l a r l y
the l o w e r rec t u s a b d o m i n is. Reve rse torso c u r l s c o n si s t of repe t i rive c o n t r a c t i o n o f
t h e m u sc u l a t u re o f th e a n t e r i o r a b d o m i n a l w a l l . E a c h reperi r i o n h a s t h r e e step s ;
e a c h step t a k e s a bo u t 5 s e c o n d s , fo r a tota l o f 1 5 s e c o n d s per repeti t i o n . H a v i ng
t h e p a t i e n t co u n t to 5 o u t l o u d d u ring e a c h s te p p revents the Va l s a l v a m a n e u v e r
a n d r ed uces i n t r a - a b d o m i n a l s t r e s s u p o n t h e a b d o m i n a l w a l l . The
seq uence typi
c a l l y i s i n i ti a ted w i t h 5 r e p e t i t io n s . T h e n u m b e r o f r e p e t i t i o n s m a y b e increased a s a b d o m i n a l stre n g t h i m p r o v es . T h i s i s
a
d i ffi c u l t e x e rcise t o
m a s r er.
firm s u rfa ce w i t h t h e h i p s a n d k nees f l e x e d u p o n t h e a b d o m e n a n d w i t h t h e a rms resti ng a t e i t h e r s i d e fo r e a r m s p r o n a te d , p a l ms T h e p a t i e n t l i es s u p i n e on a ,
,
d o w n . T h e p a t i e n t k e e p s t h e a b d o m i n a l m u s c le s t ig h t d u r i n g t h e e n t i re e x e r c i s e . P rocedu re
1 . S l owly l ift th e b u ttocks u n t i l t h e e n t i re l u m b a r s p i n e is off t h e f l o o r for a 5 co u nt . The p a t i e n t h o l d s t h i s posit i o n fo r a 5 cou n t . 3 . The p a t i e n t s l owly ret u r n s the h i p s to t h e f l o o r f o r a 5 cou nt, ta k i n g ca re n o t t o drop the h i ps to t h e floor q u i c kly. 2.
C h a pter 28 • T h e Pat i e nt w i t h Sco l i o s i s
F I G U R E 28. 7
465
R e v e rs e t o r s o c u r l to stre n g t h e n w e a k core m u sc u l at u re, p a rt i c u l a r l y t h e l o w e r rect u s a b d o m i nis.
Refe re nces 1. Keim
H,
Hensi nger
Spi na l
R.
d e fo r m i t i e s :
S co l i o s i s
and
k y phosis.
Clin
Symp
1 9 8 9 ;4 1 ( 4 ) : 3 -3 2 . 2 . F e rgu so n
AB.
O rt h o p a ed i c
Roen tgen
S u rg e r y
d i a gn os i s i n
I n s t r u ctio n a l
t h e ex t re m i t ies a n d s p i n e . A m e r ica n A c a de m y A n n A r bor, 1"11 : J W E d w a r d s
Cou rse Lec t u res .
,
1 9 4 8 ; 2 : 2 1 4-224 . 3 . Co b b J R . O u t l i n e fo r the s tu dy of sco l iosis. A m e r ican A c a d e m y of O rt h o p a e d i c S u rge ry I n s t r u c t i o n a l Cou rse Lectu res . A n n A r bor, M I : J W Ed wa rds, 1 9 4 8 ; 5 : 2 6 1 -2 7 5 .
4 . I C D - 9 C M I n te r n a t i o n a l C l a s s i fica t i o n of D i s ease, 9th R e v i si o n , C l i n i c a l Mo d i fica t i on . 5 t h e d . S a l t La k e C i t y : M e d icode, 1 9 9 9 . 5 . R e a m y BY, S l a k ey J B . A d o lesce n t i d i o p a th ic scol i o s i s : Rev i e w a n d cu rre n t co nc e p ts . Am F a m P h y s i c i a n 20 0 1 ; 6 4 : 1 1 1 - 1 1 6 .
6 . A r b uck le B E . The se l e c ted w r i t i ngs o f B e r y l E . A r b u c k l e . C h a p te r 2 2 . I n d i a napo l i s : A me r i c a n A ca de m y of Osteo p a t h y. 1 9 7 7 . 7 . M a g o u n H I . O s teo p a t hy i n t h e Cra n i a l F i e l d . 3 r d e d . K i rks v i l l e , M O : Jo u r n a l P r i n t i n g , 1 9 7 6 ; 1 4 3 , 2 3 5 , 2 9 1 -2 9 2 . 8 . Sergu eef N. L e B . A . B A d u c ra n i e n , S p e k ed . P a r i s , 1 9 8 6 . 9 . F r y e tte H H . P r i nc i p les o f O s teo p a t h i c Tec h n i c . C a r me l , C A : Aca dem y o f A p p l ied O s teo pa t h y, 1 9 54;24 . 1 0 . W i l l m a n M K . R a d iog r a p hic tech n i ca l a s pects of the p ost u ra l s t u d y J Am Osteo path Assoc .
1 9 7 7 ; 7 6 : 7 3 9 -74 4 .
R e p r i n te d
in
1983
Ye a r boo k
.
I nd i a n a p o l i s :
A me r ic a n
A ca d e m y
of
O s teopa t h y, 1 9 8 3 ; 1 4 0- 1 4 3 .
1 1 . K u c h e r a M L , Kuchera WA . R a d i ogra p h i c a s pects o f r h e postu ra l s t u d y. I n : Wa rd R C , e d . Fo u n d a rions for O s teo pa th i c 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 : L i p p i ncotr W i l l i a m s & W i l k i n s , 2 0 0 2 ; 5 9 ] -6 0 2 .
IV'
SECTION
Practice Issues
The Office Dean Raffaelli [
INTRODUCTION Contrary to popular belief, a new office can be very straightforward to set up, needing only six mod est rooms and totaling appro x imate l y 800 to 1000 square feet: a waiting room, a hallway, two examination or osteopathic manipu lative treatment ( OMT ) rooms, one p rocedure room, a bathroom, and a storage closer. I will begin by describing each room as the p a tients
will see them, going over fur
niture and equipment needed for a bare-bones but efficient operation that can be set up for a reasonable amount of money a nd some sweat equity. T he waiting room is the first room most patients encounter. It need not be large; about 150 square feet should suffice. Two to four chairs; a small table for a cou ple of m aga z ines or better y et, health in for m ation ; a desk for the phone and appointment book; and two fi v e drawer file cabinets are all that is required. This -
room contains the front desk ( receptionist s area). '
The m os t important concern at the front desk is managing app oint m ents It is .
important not to skimp on the appointment book. It should be as big as will fit on the desk. A p hysic ian s practice requires a lot of space to record all of the informa '
tion needed and to make changes. Of course, a computer equ ipped with a qua li ty office management program can facilitate e fficie ncy The basics are the same for .
either an e l ectronic or a paper office system.
466
C h a pter 29 • The Office
467
The physician must decide how long office visits will be and whether to incor porate OMT and procedures into regular office hours or to assign these activities to different days. Obviously, it is necessary first to define office hours: which times to see patients for general concerns and which hours to set aside, if desired, for doing OMT and other procedures. The length of office visits can evolve over time. To start, IS-minute visits work fine and allow enough flexibility to add new patients without special scheduling. At 10 minutes per patient, it is important to allow two slots for each new patient . New patients are the lifeblood of any practice and should not be frustrated in obtaining prompt appointments. This is the twenty-first century, and computers can take the place of most of the paper functions in the office. However, it may be wise not to make a large outlay of capital for practice management software until the practice has been operating for a while and the practitioner's needs are clearly defined. If all goes well, the practitioner can automate quickly and efficiently. The next area the patient encounters is the hallway. Probably the only things vis ible should be a scale with a height measure, possibly a wall phone, and chart con tainers on the examination room doors. In this author's office, colored plastic flags denote which room to enter, but this is hardly necessary in a small space with two or three rooms. If the practitioner is caring for infants, an infant scale is necessary. This author's office plan assumes that there will be two examination and OMT rooms and one procedure room. Room sizing is an art, but examination rooms used for OMT have to be bigger than the size needed for other primary care prac tice because of the necessity of moving a bo u t the patient on all sides. Approximately 8 by 10 feet for the examination rooms and 10 by 10 feet for the procedure room should be large enough. Many practitioners mix and match these rooms to suit their particular style of practice. The location of a practice often defines its needs. A practice in the outer collar counties of a large city may serve primarily children and their pregnant mothers. A practice in a central urban area may be full of 20 year olds and older, with an emphasis on sport injuries and sexually transmitted diseases. A practice near an industrial site is likely to deal with workers compensation cases. Depending on the scenario, it may be necessary to emphasize one use over another. The examination room should have the following attributes: good lighting; an examination and OMT table; adjustable stool on rollers; blood pressure cuff; mir ror; writing surface; storage cabinet; oto-ophthalmoscope; clothes rack or hooks; a hard, easily cleaned tile floor; and if there is room, a chair. A sink is nice b u t not necessary and can be replaced by a soapless hand cleaner. Lighting usually is not easily changed without spending a lot of money that could be put to better use elsewhere. A solution to poor lighting is to supplement it with floor lamps; a lamp with an adjustable neck is helpful. The examination tables can be simple or complex, hence cheap or expensive. The table should do double d uty serving for both physical examination an d OMT. Most osteopathic physicians were trained on sturdy flattop tables, which at the right height work just fine. These are inexpensive and will last an entire career. One of the benefits of OMT is that it is a procedure and can be billed as such. It requires no more equipment than is found in the examination room plus the physician'S two hands. Tables to consider have a slot for the patient'S face and a place on either side for the patient'S arms to lie comfortably. This author purcha sed such a table for approximately $400 in 2002, and prices have not significantly changed over the ,
468
Section IV • Practice Issues
past few years. Tables at this price level usually require some simple
a
s sembly but
are adjustable for the practitioner's height and ordi narily are quite durable. A common mistake when one is setting up the exami nat ion room is not to con sider the needed space surrounding the treatment table. A d equ a te space for the physician is essential for efficiency and for comfortably perfor m i ng manipulation.
Having too little space is like playing pool with no room to swing the cue stick. Being cramped increases fatigue, chips away at efficiency, opens the door to work related injuries, and event u ally cuts down on use of OMT simply because of t h e hassle factor. A good rule of thumb is to be able to scoot around the table on the stool without running into any obstruction. Most practitioners acqu ir e a b lood pressure cuff and an oto-ophthalmoscope while they are students. Initially, these can be used instead of new ones for each room. One ca veat is the need for
a
fu ll size range, from child to a d u lt XXL, of
blood pre s sure c uffs .
If patients are to disrobe, they need a place to hang their clothes. Coat racks and hooks on the wall with several hangers will suffice. A mirror allows p a ti en ts to repair their appearance after a disheveling procedure. A su rfa ce to write or type on-or both-is essential. For a small room, a shelf that folds flat against the wall when not in use can be helpful, but a small table will suffice. Most of the office furniture can be obt a ined at stores that offer simple Scandinavian-style pieces with clean lines that are durabIe and reas ona bly priced. Patients requiring procedures sLlch as Pap smears (the Papanicolaou test), pelv ic examinations, de r mato logic car e, physical therapy modalities , flexible sigmoi doscopy, and blood draws need a separate room with more specialized equipment. It is i mportant to define c a reful ly the type of services the practice will offer. Such pro cedures provide services to your patient on site and provide another revenue stream, but they must be balanced against increased equipment and malpractice cost. Procedure room equipment inclu des everyth ing from a sharps container to a table designed for gynecologica l procedures . Most family practices do Pap and pelvic exami nations on a regular basis. The necessary equ i pm ent includes gowns of va r ious sizes, a selection of stainless steel specula (or d isposa ble plastic specul a ) , microscope slides, cover slips, potassi um h ydroxide (KOH) and saline solutio n s , and a brig h t fl oor l a mp . Use of steel specula will save the cost of d ispos a b les but necessitat e an autoclave or other sterilizer.
A m ic r oscope is requ i red for the practitioner who will read slides. This is defi nitely a device to buy used if a t all possible . Very goo d used scopes can be found for reasona ble p rices , a l th o u g h they may need
a
l it tle cleaning.
Other devices i nclude electrocautery for dermatologic proced ures, electrotherapy
an d ultrasound to help with the treatment of acute and chroni c musculoskeletal disorders, and poss i bly a scope for performing col on cancer sc r een i n g s igmoi doscopy. Another flat table is necessary so patients can lie comfortable while ha v i ng therapy applied. Two other areas that are often overlooked are a separate stor age space and the b a throom . A lockable supply room is helpful for all of the disposables, me d ication samples, linens, forms and everything else that needs a home if space is av a il ab l e. If not, lockable cabinets in ea ch room will su ffice .
The bathroom can be a real b u dget buster if the office space does not already meet the codes for access i b il ity. A priority while shoppi ng for an office is to find a space aheady modified to the proper standards. A renter should come to
an
a rrangem e n t with the owners for making the n ecess a ry modifications before sign ing the lease.
469
Chapter 29 • The Office
a lot of cash ..Most o ffic es need two p ho n e fax ma chin e and a cop i e r. Fax and copier combinations are reasonably priced, and for phones, wireless handsets or h ea d s ets negate the need for running wires throughout the office. Answering mac hin es can re p la ce answering services; however, because most p h y s i cians need to be reachable, an answering service may prove to be an inescapable cost. Finally, is a pri v ate office necessary? Pro b a b ly not. Diplomas and ce rtif i cates can hang in the tre at m en t rooms for t he patients to see. Charts can be do n e pro m pt l y in t h e room with the patient. Phone inquiries can be ha n d led as th e y come in. Each day's pape r wor k should be done before the ph y sic i a n leaves th e office because there will just be more to do the next day.
Telecommunications can ear up
lines,
a
,
CONCLUSION This chapter provi des the basics of what it takes to se t up an office. Wi t h a bare bones ap pro a c h it is nor an insurmountable or prohibitively expensive t ask Each ,
.
l o ca li t y has different requirements, sllch as handicap access and zoning restric tions. It is i m p orta n t to know these matters d uring the search for space. The l e ss the space m ust be altered, t he more resources available for self p ro m ot ion loan repayments, and a kitty for the first few months before the check s ,
for all that excellent care start to roll in.
CHAPTER
30
Progress Notes and Coding Douglas J. Jorgensen, Raymond T. Jorgensen, and Kenneth E. Nelson
This chapter provides guidelines, recommendations, and interpretations that are to be used as a guide for implementation in practice. The actual implementation and interpre tation of these guidelines and recommendations for coding and documentation are at the sole discretion of the provider and staff. Therefore, the provider and staff accept sole responsibility for these deCisions and any repercussions. Neither the authors, Jorgensen Consulting, nor Priority Management Group accept any liability in this regard
INTRODUCTION The medical record is longitudinal documentation of an individual's health care. It contains various pieces of information germane to the patient'S health history and current medical problems. From pharmaceutical lists to demographic information, much can be gleaned from an individual's medical record. The bulk of the medical record consists of the encounters between patient and provider, or progress notes. The progress note documents a single encounter, a snapshot in time, between the physician and the patient. Prio·r to the 1 970s, progress notes were recorded according to the style of the individual attending physician. More individuals became concomitantly involved
470
Chapter 30 • P rog ress N otes and Coding
471
in the care of the patient as postd octoral education and su bspec ialty med ic ine grew in pro m i nence. To facilitate com m u n i cati on, it became apparent t hat a u niversal format for record ing p rogress notes had to be adopted . The m ost commonly employed sequence was h i story (su bjective i n fo rmati o n ) , physical exami n ation ( o bjective i n formati o n ) , d iagnosis (assess ment ) , a n d med ical dec i sion mak i ng ( plan fo r treatment ) . Law rence L. Weed of the Un i versity of I l l i n o i s at C h i cago proposed t hat this sequence be ad opted and coi ned the acronym S O AP note . 1 The physic ian-patient enco u nter consi sts basically o f t h e evaluat i on ( SO A ) and management (P) of the patient. The criteria fo r the vari ous ty pes and levels of eval uation and management (E&M) have been d efined and assigned identi fying a l p hanumeric codes k nown as current proced ural ter minology ( CPT)2 c o d e s . The CPT codes are s u p ported or justified by d i agnosis codes, o r ICD codes . The ICD stand s for Internat i o n a l Clas s ifi cation of D i sease, a n d the 9th C l i nical Mod i ficat i on is in use; hence the abb reviation ICD-9CM. The ICD-9CM and CPT codes m u st correlate ap propriately. Certa i n ICD-9CM c odes ( e.g., chest pai n, ankle pain ) j ustify certain CPT codes (e.g., electrocard i ogram o r ankle rad i ographs, respective l y ) . To ju stify an elec trocard i ograph i c stu d y with ankle pai n instead o f chest pain w o u l d make little to no sense. Thus, the codes ass igned for diagnos is (IC D-9CM c o d e ) and intervention ( CPT code) are cri tical to a clear understand ing of what ( CPT code) occ u r red at the enc o u n ter and why (ICD-9CM code) it was necessary.
CURRENT PROCEDURAL TERMINOLOGY CPT codes descri be what clin ical ser v i ces a patien t receives from a med ical p r o vider. CPT is a c o m ponent of the natio nal Hea l th Care Fi nancing Ad m inistration's ( HCFA) nomenc lature, HCPCS ( pronounced hickpicks, HCFA's common proced u re coding system ) , and is owned and copyrighted by the American Medical Ass ociation (AMA). A new copy of this text s h o u l d be p u r c hased and commo n l y used codes rev iewed annually for c hanges, updates, o r dele tions. Implementation-or when the codes go i nto effect and must be used for correct coding and proper reimb u rsement to occu r-as of 2005 begins annually o n January 1 . Therefore, the l ate s u m m er o r early fal l i s a g o o d time t o rev iew the codes one uses to make ce rtain no c hanges have been made. One c o m m o n a l ity o f the CPT codes among most p h y s i c ians and m i d level prov i d ers is the use of E&M codes. Eac h E&M code depicts the type of v i s i t that occurred, denotes a p lace of service, and us ual l y i d enti fies the level of servi ce p r o v ided. For the p u rposes of t his chapter, the E&M services provide d are i npatient or outpatient and w i l l typically be new ( 9920 1 -99205 or 992 21-992 2 3 ) , consu l tative visits (99241-99245, 9925 1 -99255, or 99271-99275), o r esta b l i s hed patient enco unters (99212-99215 or 99231-9923 3 ). Inpatient or outpatient encounters are c lassified as being fac ility or nonfacility v i sits, respectivel y. The p h ysician-patient encounter may a l so inc l u d e p roced ures, such as osteo pathic man ipulati ve treatment ( OMT) , repair of a laceration, cryosurgery, or flex ible sigmoid oscopy. Such procedures are con s idered to be ad d itional to the E&M and are assigned s pecific CPT codes . The CPT codes are used to record the extent of the encounter for bil ling pu r poses and s h o u l d desc r i be as speci fical l y as possible w hat occu rred at the v i s i t. There are oth e r types of E&M codes and vis its, both faci l ity and n o n fac ility, that this chapter d oes not address. This chapter's foc u s is on the c o m m o n E&M codes u sed with osteo pathic mani p u lation codes (98925-98929). These additi onal
Section IV • Practice I ssues
472
categories covering patient care rendered from newborn care to nursing facility services, can be found in the E&M chapter of CPT. Again, CPT is what was done, and the ICD-9CM is why it was done.
ICD-9CM ICD-9CM coding is responsible for conveying medical necessity, or the reason for the patient's encounter with the health care provider.3 Medical necessity is a feder ally defined term. ,. For this chapter's purposes, medical necessity is established in the notes by a complaint or reason for the visit (e.g., back pain, paresthesia, migraines), and the balance of the history and examination result in exact diag noses (e.g., L4 radiculopathy) or symptoms (e.g., paresthesias) to justify CPT codes, such as magnetic resonance imaging (MRI) to look for a cause of the L4 radiculopathy or perhaps OMT (CPT codes 98925-98929) to treat the complaint. Providers often get focused on diagnoses when symptoms alone can create medical necessity to justify a test, imaging study, or even a procedure, such as a colonoscopy for hematochezia. Alphanumeric identification of what the physician does and why expedites translation to insurers so that they understand what is going on with the patient, or beneficiary, without having to read the note. In theory, this also expedites care and reimbursement. Coding E r rors and F ra ud
In learning and performing this documentation, one wants to be as accurate as pos sible to avoid misrepresenting what occurred at the visit. To do so haphazardly could result in poor reimbursement or even penal action for not following the federal doc umentation guidelines. To do so habitually could constitute fraud, and the federal government can prosecute for fraud without proving intent. The government simply has prove that it occurred, and the physician's notes are evidence enough.4 Therefore, it is important to learn the proper techniques to document and code correctly to be optimally reimbursed and out of harm's way in the event of an audit. This said, most providers are thought to be following the guidelines, and even when mistakes are encountered, they are not typically labeled as fraud. If one makes an earnest effort to learn the federal documentation guidelines, keeps up to date with the CPT and ICD-9CM changes, and codes and bills only for services provided and documented, one will in all likelihood not have penal action in one's future. (Gerold KB. Program Integrity Update. Lecture delivered at the National Heritage Insurance Company's Carrier Advisory Committee Meeting, Waltham, MA, November 5, 2001.) At this writing, federal, state, and private payer entities are still actively seeking out fraud and abuse in health care, and one must remain ever vigilant. The private payers (e.g., Blue Cross, Cigna, Aetna), except where company memoranda deviate, follow the federal documentation guidelines in determining the levels of CPT coding. The E&M and OMT codes are outlined in this chapter to allow for correct documentation and coding. At the risk of being redundant, however, it is the responsibility of the provider, not the billing staff, medical assistant, nurse , or office manager, to make certain the correct codes are assigned for ICD-9CM and CPT to represent what occurred at each encounter.
*
Medical
necessity is defined as a service rhar is injury or to improve rhe functioning
illness or
reasonable and of
a
necessary for the diagnosis
malformed body member.
and treatment of
C h a pter 30 • Progress Notes and Coding
473
Evaluation and Management
Per CPT defini t i o n, each level of E&M is defined in terms of seven components . T h e t h r ee k ey components in determinin g the levels of most E&M visit levels a re h isto r y (S), examination (0), and medical decision m a k in g (A and Pl. There are three contri b u tory com ponents : the nature of the presenting problem, counselin g , and coo r d i n ation of c are .2 A four t h component that is somet im es used is time. Time is used o nly if more t h an 5 0% of the visit encompassed co u nseling and coor dination of care for the patient's c om p la i nts or medica l co n d i tions . The nature of the pres ent i ng problem is some ti m es used in defending why a certain code was pick ed , b u t because of its s u b j ective nature, it is not recommended to j ustify a code . Only the three key components ( his t ory, examination, and medical decision making) are outlined in this cha p ter, as they are the keys to co r rect E&M cod i ng . Before get ti n g to these, s ome rules and definitions must be addressed. New patients are those who have no t received face-to-face service by a provider of the same s pec i a l ty within a group pr actice d u ring the preceding 3 years . s This is important for determin i ng who is considered new and who is cons i dered an estab l i s hed patient . The fa ce-to- face service is a recent change, as it negates telep hon e calls and other services that do not constitute an inpa t i ent or outpati ent E&M visit. The same-group portion of the new patient rule r efers to provi ders who sh are a federal tax identification numbe r. The same-specialty issue is based u pon national boards; this means that in a prima ry ca re practice, an internist could tec h nical ly see a fam i l y p h ys i cian's pat i ent, and because they have different board certifications, the internist could charge the patient as a new patient. M an y groups choose not to do this as a cost-sav ing m easu re to their patients, but this is a business decision for the practice. Two more rules must be ex p l ai n ed : the t h ree-of-three and two-of-three rules. Understanding these rules and the definitio n of a new patient are critically impor tant for underst a nd i n g how E&M codes are chosen. The assignment of three n u meric values (e.g., 2, 3, 4 or 2, 2, 3) indicates the sco r i ng for the level of (1) the h is tory, (2) the p h ysica l examination, and (3) medical dec i sio n ma k ing . They will delineate how one identifies the proper E&M codes for both new and established patients . The three-oF-three rule, for th e purpose of this chapter, applies to new patients and co n s u lts . Simply state d , it say s go to the lowest number. That is, given t h ree num b ers, 2, 3, and 4, the three-of-three rule says pick the number 2, for it is the lowest of the three. If the numbers were 2, 2, and 3, the t h r ee - of - three rule says go to the lowest number, so 2 is the n umber again . The two-of-th ree ru le says go to the middle number-not the number in the cen ter of the string in your records but t he number in t h e midd Ie of the counti ng range-such th at 3, 2, 4, u si n g the two-oF-three rule, makes 3 the correct answer because 3 is the middle number (falls between 2 and 4 in count i n g ) . Given the examp l e of 2, 2, a nd 3 the t w o- of- three rule would pick 2. In t hi s case, the middle and the lowest n u mbe r are 2.
HISTORY The his tory has four major ca tegories: chi e f com p laint (CC), h i story of present illness (HPI), past family, medical, an d soc i a l h istory (PFSH), and the review of sys t em s (ROS). The CC c r e a tes medical necessity by giving you a reason for the v is i t. Without it , the visit might not be reimbursed because there would be no docu men ted cause for the visit. The HPJ descr i bes the chief complaint or complaints, and the PFSH
474
Section IV • Practice Iss ues
and ROS are i m po r tant to evaluate pertinent positive or negative f i n d ings that w i ll h el p in E&M. If the CC is pai n , the HPI can be broken d o w n into the follow ing elemen ts: Locat i o n ( where is the pain) Quali ty ( type o f pai n: sharp, burning, lancing) Severity ( scale of 1 to 10 ) Duration ( how l o n g has t he problem persisted ) Timing ( time o f day or f requency) Context ( what the patient did to ca u se pro blem or was doing when problem occu rred ) Modifying factors ( what made the pro blem better, worse, and so on) Associated s ign s and symptoms O ne scores this as Brief o r Extended d epend ing upon how many of the elements are p resent in the HPJ. A brief HPI has one to th ree elements, w hereas an Extended HPJ has four or more. The score is c u m u lati ve, so if the patient has more than one complaint, two eleme n ts about each pro blem are accepta b le to ach ieve an extend ed HPJ. This i s a typical h i story o ne m ight encounter that cons ists of more than fo u r elemen ts: 36 yo WDWNWHF c/o back pai n . Mid back X 24 hours . Tylen o l helped . Worse today. Sneezed a n d it h u r t her. N o W/A, NSD , BBI. T h i s is the type of history y o u might find in a chart , b u t the acro n y m s may or may not be fam i l iar. It descri bes a patient who is a 36-year-o l d wel l - d evel oped , wel l-n o u r i shed, well-hyd rated female with a complaint of back pai n in the mid bac k , presen t for 24 h o urs, relieved by Tylen o l , wo rse today, and aggravated by sneezing. She denies weakness or atrophy, neurosen sory deficits, and bowel or b lad d er incontinence. If one u ses ac ronyms that are not stan dard ( even if one t h i nks they are, an au ditor m ig h t not understand t hem ) , keep an acronym list so it can be used as a key to in terpret the no tes . Wou l d t h i s l is t of acrony ms be consid ered asso c iated signs and sympto m s or a rev iew o f systems? The differen t i a t i on between the two is cons idered in the next sectio n . The ROS is a n extremely i m portant component of the history that often is not given proper credit in documentation. It is necessary to inc l ude a l l pertinent positives and negatives in the appropriate systems . There are up to 14 systems to be reviewed. For new patients, it may ma ke sense to rev iew all of them to d etermine a compre hensi ve picture of the patient'S pro blem or pro b l ems. For esta blis hed patients seen in follow- up, however, it is necessary o n ly to review the germane systems. Here are the ROS body areas and organ systems ( BNOS) as d efined by Med icare: 1. Consti tutional 2. Eyes ( Head , eyes, ears, nose, and throat s h o u ld be del i neated into each body area o r organ system . ) 3 . Ears , nose, m o u th, and th roat ( See c o mment i n i tem 2 . ) 4. Card iovascular 5. Respiratory 6. Gastro i n testinal 7. Genitourinaf)T 8. Muscu loskeletal 9. Integu mentary 10. Neu rolog ical 11. Psych iatric 12. End ocrine 13 . Hematolog ic, l ymphatic 14. Allergic, i m m unologic
Cha pter 30 • Progress Notes and Coding
475
There a re three ROS lev e l s depe n d e n t on BAlOS revi ewed: Pertinent: 1 BA /O S Exte nded: 2-9 BA/OS Complete: 10+ BA/OS Under the HPJ, it is advisa ble to avo i d using the a ssocia ted signs or sympto m s , as most pati e n ts give m o r e tha n e n o u g h his tOry t o achieve four elements in the HPI. Thu s, one can put in the ROS the bala nce of the positive and negative ques tio ns emp l oyed to na rrow the diagnostic focus to receive a ppropr i a te and l eg i t i ma te c r e d i t fo r obta i ning a n d evalua ting thi s informa t i o n . The PFSH is ra ther straigh tforwa r d a n d ca n even be referenced in n otes once i t i s part o f the permanent m edica l record . Simply l i s t releva n t p a s t medica l h i s tory (PMH) with dia betes, hypertens i o n, asthma, and so on as it perta i n s to the patient. If the info rma tion is noncontrib u to ry, but one still w a n ts credit fo r a sking, s i m p ly document PMH: NC. Not documenting leaves the a ssumption tha t the question was not a sked, so the practitioner rece i ves no credit i n terms of scoring the his to ry section of the vis i t . The social his tOry a n d fami l y h i story are treated just l ike the PMH; list wha t is germane, a n d if it is not, list NC. The PFSH score is based upo n how m any of these q u estions were a sked a n d d ocumented . Only one from any o f the three (family, medical, o r s ocia l ) need be present for a pertinen t PFSH score and two for a complete score i n an esta blis hed pa t i e nt. In a new p a t i e n t, three of these must be covered to get a complete score . The med ica l assista n t or n u rse ca n ta ke a n d d ocu ment the h i s tOry for e very vis i t, or a form tha t the p a tie nt fil l s o u t before the vis i t m a y be e mployed . To d o thi s , da te a n d i n i t i a l t h e form a t least se m i a n nually and i n i t i a l a nd d a te a ny new informa tion tha t m i ght be acqui red during subseq u ent visits. If y ou wish to refer ence a d ocument to get credit for it in the h i story, doc u m e n t the d a te a nd what specifically you a re refe renci ng, such as "For the b a l a nce of PFSH, ple ase see H&P from 6/25104." The last step in the histOry is sco ring it. Ta ble 30.1 outl ines t h a t process usi n g the three-of-three r u l e . The n umbers i n parentheses a r e the scores a ssociated with the different history levels a n d used to calcula te the E&M cod es. If the ROS is n o t clearly designa ted in t h e progress n o t e , the re ma y be n o cred i t fo r i t . Therefore, rega r d l ess of the length or exten t of t h e history, it ca n n o t be d e s i g n a ted a s a n yt h i n g otl1e r than a l ev e l 1 p ro b l e m-focused histOry.t S i m ilar l y, t o achi eve a comprehen sive hi stOry (4) you must include 10 of the 14 systems in the ROS. Witho u t a com plete ROS on new patients o r con s u lts, level 4 or 5 ca n n o t be ach i e ved, n o r ca n higher tha n a level 1 initial hos p i ta l vis i t be achie ved. This is a good time to review the example, resta ted here, la be l ing the d ifferent COI11ponents. It is apparen t that a detailed history was achieved w i th little effort and a s m a l l b ut relevant a m o unt of d ocumentation: 36 yo WDWNWHF cia back pa i n . Mid back X 24 hours. Ty l e no l helped . Worse today. Sneezed and a fterwards it hurt her. ROS: No WIA, NSD, BBI PMH: A l lergic rhinitis SociallFMH: NC
IThe 1995 and lefr
federal documentation guidelines defined only problem-focused and comprehensive examinarions
rhe
expanded-problem-focused (EPF) and d e t a i l ed examinations open ro inrerpretation regarding
rhe number or
BAlOS.
Thus, by convention, rhe
2-4
and 5-7 designarions
for EPF
and derailed, respectively
are national, commonly understood and accepted standards, since problem focused is :sBAJOS and compre
hensive is
·-8
BA/OS.
476
Section IV • Practice Issues
Billing and Coding History Type and Level
(1)
HPI
ROS
PFSH None
Brief
None
Brief
Problem Pert inent
None
Deta iled (3)
Extended
Extended
Pertinent
Comprehensive (4)
Extended
Complete
Compl ete
Pro b l em focused
Expanded problem focused
(2)
1995 and 1997 fed eral documentation guidelines.
Adapted with
Physician's Guide to Billing and Coding. Columbus,
OH:
permission 2004
from Jorgensen DJ, Jorgensen
RT
A
Greyden,
From the scori ng ta ble (Ta ble 30,1), it is apparent tha t this brief descript ion i s a d e tailed h i story. The o nly thing keeping i t from being a comprehensive his tory is the ROS , as i t needs 10 ROS to get to this leve l. A lthough the pro v i d er did not think the socia l or fa m i l y histories were rele v a n t, rather than just not docume n t ing i t, h e or she w rote NC (noncontr i b u tory), T h is makes it part of the n o te and proves tha t it was a s ke d , not forgotten or omitted. T he above are designa ted the S u bjective portion of t h e SOAP note. Physical Examination
The physic a l examination is the Objective portion of the SOAP n ote. There are two sets o f guid elines rega rding documenta tion o f the p hysica l examination, a nd either may be u sed, T h e c h oice even varies from p a tie n t contact to patient contact. It is the a uthors' recomme n d a tio n t h a t t h e 1 9 9 5 sys tem be preferent i a l ly u sed for most specialties, a s it is more forgi v i ng.+ To compa re a n d contrast the two systems, go to the Med icare Web site ( hrrp://cms .hhs,gov/ ),6 The physica l examination itself is d efined in terms of the number of body a reas a n d/or organ systems exa mined. These must be germane to the com pla int. Whe n a phys icia n is try i n g t o esta b l is h a diag n osis or find the eti ology of a n ew patient'S compla i n t, it is likely that a multi system exa mina tion will be performed. In mos t ca ses, this will include a tho rough osteopa thic m u sculos keletal structural examina tion, There are 10 body area s (BA) a n d 11 orga n sys tems (OS ) listed n ext. T h e exami nation m a y incl ude both body are a s a n d organ system s, but cred it cannot be o bta ined for red u n dant examinati on. The CPT recognizes 10 b o d y are a s: 1. H e a d (incl u d i ng the face ) 2. Neck 3. C h e st (including brea sts a nd axillae) 4. A bd omen 5. Gen ita l i a , gro i n , and b u ttocks I[n April 1998, there was a "fly-in" meeting in Chicago, due to unrest by the
stringent natute of the
1997
At thar m ee ti n g , the 1997 eirher the 1995 or 1997 guidelines.
guidelines.
physician community
at the
system was indefinitely suspended, ICJ"ing
Howeve� an ourcome is t ha t if you u,c rhe 1995 system and rry (0 use the complete single system examination ro :l chieve :l comprehcllsive examin;lIiol1 score, you must defer to rhe 1997 guidelines definition of what rhat single system exarninarion ShOltlc1 he. Prior TO 1997, rhe federal government allowed providers to determine what constirllted a complctL' s i l !g lc s)':--tl'1n examinarion. but now rh�t the more strier 1997 exisrs) we arc urged to default to irs rules for rhis portiun of the 1995 examinarion. providers with a choice to use
C h a pter 30 • Progress Notes and Cod i n g
477
6 . Ba c k 7-1 0 . Ea c h o f t h e fo u r e x t r e m i ti e s ( fo u r sepa rate bod y a r e a s ) The CPT recog n i zes ele v e n o r g a n s y ste m s : 1. 2. 3. 4.
5. 6. 7. 8. 9. 1 0.
E y es Ea rs, nose, m o u t h , a n d t h r oa t Ca rd iovasc u l a r R es p i ra to r y Gastroi n testi na l Ge n i to u ri n a ry M u s c u l o s k e l eta l Skin
N e u r o l og i c P s y c h i a tr i c 1 1 . H e m a t o l o g i c , l y m p h a ti c , a n d immunologic Us i n g t hese bod y a re a s a nd o rga n system d es i g n a t i o n s , t h e 1 99 5 s c o r i n g is a s
fo l lows : Pro b le m foc used
:::: 1 BA/O S
E x p a n d e d pro b l e m focused
2-4 BAlO S
Detai l e d Com p r e h e n si ve
5 - 7 BA/O S 2: 8 BA/O S o r 1 com p lete s i n g le s y st e m i c
As ca n b e see n , t h e l e v e l s of the H i story a n d E x a mination u s e i d e ntica l termi n o l ogy a nd a re based o n a four-tiered system w i t h the same point a ssignment. Med ica l Dec i s i o n M a k i n g d oes n o t use t h i s s a me t e rmi n o l o g y but ins tead uses desc r i p tors as to the c o m p l e x i t y of the Med ica l D ecis i o n Ma king provi d e d . Go i n g b a c k to t h e exa m p l e for mid b a c k p a i n , the fo l l o w i ng p h y s i c a l examina tion d oc u m e n ta t i o n w o u l d be s u ff i c i e n t , using the 1 9 9 5 fed e ral g u i d e l i nes, for a d e ta i led e x a m i n a t i o n : PE: WDWNW H F i n m i l d
d i s tr ess on exa m i n a t i o n
E y es : PER R LA w/EO M I ENT: Nega t i ve
MS: M i d tho racic tra pez i u s a n d iliocosta l i s st rain . P a i n w i th m i d t h o r a c ic exten sion a p p ro x i m a te l y T8 N e u ro : No neu rosensory d e fic i ts n o re d . No r e p r o d u c i b l e pain with s p i na l c o m p r ess I O n S k i n : No ecc h y moses n ote d o v e r s i te of p a i n T6 -7NRRSL w i t h r i b s 6-8 locked i n i n h a l a t i o n T8 FRSR T9- 1 0N R R S L T l I -L2NR LSR
Key : PE, physical exam i n a t i o n ; WDWNWHF, we l l -developed, w e l l - n o u r i s h e d , wel l - h yd ra ted fe m a le; PER R L A , p u pi l s e q u a l , ro u nd, a nd re ac ti v e t o light and
a ccomm odatio n ; E O M I , extra-ocu l a r m u s c l es i n t a c t ; ENT, e a r s , n ose, and t h r o a t; MS, m u sc u l oske l eta l; NR RSL, n e u t r a l , rotated r i g h t , s i de bent left; NRLSR, n e u rra l , rorated l efr , s i d e b e n t r i g h t . Th is exa m p l e h a s s i x a re a s o r s y s te m s e x a m i ned a n d d o c u m e n t s we l l t h e areas o f s o m a t i c dy s fu n c ti o n ( th ora x [rCD -9CM d es i g n a t i o n , 73 9 . 2 ] , r i b s [73 9 . 8 ] , a nd l u m ba r [ 73 9 . 3 ] ) t h a t wi l l l i k e l y be a d d r e s s e d with OMT a ndlor other med ical m a n age m e n t.
478
Sect i o n I V • Pract i ce Issues
M e d i ca l Deci s i o n M a k i n g T h e M e d i c a l Decis i on Ma k i n g por r i o n o f t he E & M i n v o l ves a review o f t h e a ssess
ment a n d pla n , t he A a n d P of t h e S O A P n o t e . At fi rs t g la n ce th is sec t i o n , as com p a red to the h i s t or y o r p hys i c a l exa m i n a ti o n , is the most d a u n t i n g . H o we ve r i n d a i l y p ra c t i ce, t h e pr a c ti t i o n e r develops more o f a gesta l t m o d e fo r Med i c a l Decis i o n Ma k i n g T h is t a k e s p r a c ti c e a n d ex p e r i e nce b u t c o u p l ed w i t h q u a r te r l y a u dits to d eter m i n e whether the c o d i n g t h a t is b e i n g s u b m itted i s accura te, it is n o t d i ffi c u l t to le a r n this ski l l . The a s s e ss m e n t is the res u l t o f the H i s tory a n d Physica l Examina tion, w i t h a ta lly of t h e n u m be r o f d i a g n o ses or u n d i a g nosed i s s u e s ( s y mp to m s ) a n d w i th c l a rifi c a t i o n reg a r d i n g t he i r s t a t u s , s u c h a s new vers us esta b l i s hed o r ch ron ic a n d sta ble, improved, o r worse n i ng . 2,l The Pl an ( P o f SOAP) i s t he recom mended cou rse a nd type or ty p e s o f tr e a t m e n t associa ted w i t h e a c h ite m i n t h e assess ment. T h e re are fo u r l e v e l s o f Me d i c a l D ec i s i o n Ma k i ng : ,
.
,
1 . S t r a ightfo r w a r d
2 . Low c o m p l e x i t y 3 . M o d e r a te c o m p l ex i t y 4. C o m pre hensive D e ter m i n i ng t h e fi n a l level of Med i c a l Dec i sion Ma king i s d o n e b y sc o r i n g t h re e i n d e p en d e n t a r e a s of t h e assess m e n t a n d pl a n :
1 . T h e n u m be r o f d i ag nos e s o r ma n age m e n t o p t i o n s 2. T h e a m o u n t or co m p lex i ty o f the d a ta 3 . T h e d e gre e of r i s k o f comp l i ca t i ons, m o r b i d i t y a n d /o r mo r t a l i t y ,
Number of Diagnoses and Management Options (Table
30.2)
Ta ble 3 0 . 2 a l l ows o n e to ta l ly the n u mber of d i a gnose s ; wh ether the diagnosis, pr o b lem, o r symptom is new or ch ron i c ; a n d w hether it is i m p r ov e d sta ble, or worse n i ng .
,
D i a g n o s i s o r D i a g n oses a n d M a n a g e m e n t Options N u m be r (X) of
Pos s i b l e
Pro b l e m Categ o r i e s
Pro b l e m s
Poi nts
Self-li m ited, minor
(Max
=
2)
(M ax
=
1)
Established problem; stable or Improved; resolving or resolved; wel l controlled Esta blished problem; i n adequately controlled or worsening New problem; no additional worku p N e w problem; additional wor k u p planned
2 4 Total
Federal E&M documentation guidelines.
Score
Chapter 30 • P r o g ress N otes a n d C o d i n g
479
Straightfo rward pro b l em s a re j u st t h a t; they require n o a d d i ti o n a l work u p . H o w e v e r, a q u e s t i o n a b l e d eep te n d on reflex a t L 4 c o u l d warra nt a n MRI, a nd i f t h e p r o b lem i s new, t h e M R I i s the a d d i ti o n a l w o r k u p n o t e d i n t h e ta b l e . T h e m a x i m u m score poss i b l e fo r t h i s ta b l e is 4 , s o ev e n i f o n e e xceeds t h i s n u m ber w i t h d i agnoses, p ro b l ems, a c u ity, a n d s o o n , i t i s n o t p o s s i b l e to g e t extra cred i t i n t h e fin a l m e d i c a l d e c i s i o n m a king ta b l e . I n t h e co lu m n h e a d e d N u m ber ( X ) o f P r o b l e m s , t h e M a x 2 a n d Max 1 sta tements a pp ly o n l y to t h e l i ne i te m to t h e l e ft, n o t up or d o w n th e c o l u m n . For e x a m p le, a p a t i e n t p rese n t i n g with two o r more new pro bl e m s t h a t w i l l not req u i re a n y d ia g n ostic s t u d i es receives a ma x i m u m o f t h ree p o i n ts . This i s beca u s e t h e m a xi m u m cre d it fo r t h i s l i n e is t h r e e poi nts, a s t h e d i rective is Max l. The fo l l ow i n g e x a m p les m o re c l ea r l y d e m o nstrate the u se o f Ta b l e 3 0 . 2 : =
=
=
1 . A patient p rese n ts w i t h a n e x a ce r b a t i o n o f c h ro n ic o bs t r u c t i v e p u lm o n a r y d i s
e a s e ( C O PD ) a nd a n a x i l l a ry m a s s that i s d iscovered d u ri n g the exami n a t i o n . T h i s p a tien t rece i ves t w o p o i n ts for t h e C O P D a s a n esta b l ished pro b l e m ; w o rsen i ng, a nd a n a d d i t i o n a l fo u r p o i nts for t h e a x i l l a ry m a ss a s a new p r o b l e m ; a d d i ti o n a l w o rk u p p l a n n e d . T h e tota l fo r t h i s e n c ou n te r w o u l d be s i x . T h e m a x i m u m req u ired fo r a n y o f t h e m e d i c a l decision - m a k i ng ta b l e s i s fo u r, bec a u s e fo u r p o ints eq u a ls t h e h ighest of t h e fo u r poss i b l e leve l s . 2 . A p a t i e n t prese n ts w i t h a n k l e s pra i n a n d a lso menti o n s h a ving c o n t a c t d e r m a t i t i s t h a t d e ve l o ped o v e r t h e wee k e n d a fter w o r k i n t h e gard e n . Ass u m i n g n o d i a g n o s tic proced u re s fo r e i th e r, b o t h i s s ues fa ll u n d e r the ca tegory o f new p r o b l e m , n o workup p l a n ne d . This c a tegory a ffor d s t h ree po i n ts per issue b u t h a s a m a x i m u m c r e d i t p e r pa t i e nt e n co u n ter o f o n l y o n e new pro b le m . T h e r e fore, w h i le o n e m a y b e te m p te d to s h o w a tota l of s i x p o i nts for t h i s e n c o u n te r, ( th re e p o i n ts fo r t h e s p ra i n p l u s a n a d d i ti o n a l t h ree p o i nts f o r d e r m a t i t i s ) , cred i t is a ffo rded fo r o n l y o n e o f the two i ss u e s , t h a t i s , a m a x i m u m o f th ree po i n ts for th i s e x a m p l e . Aga i n , ca tegory poi n ts a re tota led w i t h a m a x i m u m score o f fo u r p o i n t s . Once t h e m a x i m u m of fo u r total p o i n ts h a s been a c h i e v e d , t h ere is n o need to conti n u e a d d i n g p o i nts. A m o u n t or Complexity of Data
Ta b l e 3 0 . 3 a l l oc a tes p o i n ts fo r o r d e r i n g o r reviewing l a boratory tests, r e v i e w in g d a t a , d e c i d i n g t o o b ta i n o l d records , or even d i s c u s s i n g res u l ts with a n o t h e r d oc tor. P o i n ts c a n n o t be o b tained b y b o t h o r d e r i n g a n d rev i e w i ng tests o n t h e s a me d a te o f service for t h e s a m e a p p o i n tm e n t . O n a given d ate, cred i t is g i ve n fo r one o r t h e o t h e r. Fu rther, no a d d i tio n a l cred i t i s given for orderi ng more t h a n one d i ag nostic proced u re from t he same CPT c h a pter in t h e r a d i o logy ( i . e . , 70,000 ra nge ) , c l i n ic a l l a bora tory ( i . e . , 8 0 , 0 0 0 ra nge) o r med i c i n e ( i . e . , 9 0 , 0 0 0 ra nge) sec t i o n s . However, i f tests a re o r d e red o r reviewed f r o m d i ffer e n t secti o n s o r a test i s o r d e re d a n d d i s c u ssed w i t h a n other p r o v i d e r i n cons u l ta t i o n a bo u t t h e p a t i e n t , t h e p o i n ts a re c u m u l a ti v e . The Ty pe o f D a ta co l u m n d e te r m i n e s w h a t d a ta a re b e i n g reviewed o r ordered a s well a s s o u rces of i n fo rma t i o n . Most o f t h e credit fo r this ta b l e i s a ffo rded from the P l a n e l e m e nt of the SOAP note. O c c a s i on a lly, these d a ta may be i n t h e s u bjec t i v e portion or i n a refe renced n o te . Here i t is i m p orta n t to be fa m i l i a r with w h a t tests a r e c o m m o n l y o rdered a n d from w h ich sectio n they a r e t a k e n s o tha t p o ints can be a p p ro p r i a te l y a l loca ted . The n u meric c l a s s i fi c a t i o n s h o u l d make th i s a s i m p l e exerc i s e . T h e d e c i s i o n to o bt a i n medical record s or to o bt a i n a med ica l
480
Section IV • Pra ct i ce I s s u es
Amou nt and /or Complexity of Data to be Rev iewed A m o unt of Data to be Revi ewed or Com p l exity Type of Data
I n d i cate Cred i t (Xl
Poss i b l e Poi nts
Score
Review and/or order tests in
C PT 8XXXX (cl i n ical la boratory tests) Review and/or order tests In C PT 7XXXX (radio logy) Review and/or order tests in C PT 9XXXX (medi cine section)
Discuss test res u l ts with performing doctor
1
Independent review of image, tracing,
2
or specimen Decision to o b tain old records a n d/or obtain h istory from oth ers Review and s u m marize old records, and/or
2
o btarn h istory Total
federal E&M documentation g u idelines.
hisrory from othe rs s imply sho uld be d oc u m ented a s fro m who m the records were o bta i n ed and/or who was spoken with to get the hisrory . Fa m i l y cou nts, even a w i fe or h u s b a n d or a si b l ing or chi ld . " Re view a n d sum m a r i ze med ical reco rd s " req u ires a written d o c u m e n t t h a t the p h y sicia n o r someone e l s e p u t toge t h e r, b u t i t co u ld even be the pa tie nt's exist i n g medica l record tha t was c redited a fter ha v i n g b e e n s u m ma r ized . Th i s s o u rce need n o t come f r o m outs i d e the practice. Risk
Ta b le 3 0 . 4 represents the Level of Ris k rhar is assu med w h e n trea ting and ca r i n g f o r a patient. There a re fo u r Levels of Risk: m i n i ma l , low, m o d e ra te , a n d h ig h , a g a i n scored 1 t o 4 . T h e re a r e three disti nct ca tego ries: Presenting Prob lems ( level of a c uity ) , Diagnostic Proce d u res (ty pe o f tests tha t m i ghr be ordered or per fo rmed ) , and M a n ageme n t Options (e .g., trearments o r proced u res ) . So m e a spects o f thi s ta ble m a k e l i ttle t o n o sense. The m os t o b v i o u s i s t h e fo urth c o l u m n (Manage m e n t O p t i o n s ) i n t h e s e c t i o n o n mod e r a te ris k , t h e thi rd item. Presc riptio n d rug m a n a ge m e n t is n o t n ecessa r i l y prescr i b i ng a med ica t i o n b u t perh a ps consid ering it or d iscussi ng i t w i t h t h e patient. The fed e ra l docume n ta t i on gui d e lines con s i d er t h e fou rth i t e m , thera peutic n u c lear medic ine, ro b e ana l ogo u s i n terms o f complexi ty. However co nfu s i ng t h i s t a ble i s , i t i s t h e s y s t em with which the p h ys i c i a n has to work. T his is the th i rd and fina l tab le to review before c a l cul a t i n g the Med ical Decisio n M a king rora l a n d a d d ing ir ro the H i sto ry a nd P h y s ical Exam i na t i o n to d e re rmine the £&M cod e .
48 1
C h a pter 30 • Progress Notes and Cod ing
R isk of Com plications a nd /or Morbidity or Mortality; Also R i s k o f Malpractice H i g h est Leve l in Any Catego ry Is the Level of Risk Category Two
Category Th ree
Category One
D i agnostic Proced u re(s)
M anagement
Level of Risk
Presenting P ro b l e m
Ord e red
Options Sel ected
M i n imal ( 1 )
One sell-limited or minor
Laboratory test req u i ring
Rest
pro b l em, e , g , cold, insect bite,
venip unct ure
t inea corpori s C hest radiography
Gargles
ECG, E E G
Elastic bandages
U r i n a lysi s
S u p erfi c i a l d ressings
U l trasound, e g , echocardiography KOH prep Low (2)
Two or more se l l - l i m i ted or minor problems
Physi ologic tests not under stress, e g ,
Over-th e-cou n ter drugs
p u l m o nary function tests One stable, chroni c I l lness, e , g "
Imaging study (not
M i n or s urg ery with
we l l contro l l ed hypertens i o n ,
ca rdiovascular) w i t h
no identified risk
non-insulin dependent d i a betes,
cont rast, e , g " ba rium
factors
cataract, BPH
enema
Acute uncompl ica ted i l lness o r inJ u ry, e g , cystitis, a l le r g i c
Su perficial needle
Physical th erapy
biopsies
r h i n itis, simple sprain C l i n i ca l la bora tory testi n g req u i ring a rterial
Occupat iona l t h erapy
p u nct u re Skin b iopsy
IV f l u i d s without
Phys iolog ic testing und e r
M ino r surgery w i t h
addit ives Modera te
(3)
One or more chro n i c i l lnesses with mild exacerbatio n ,
stress, e . g " cardiac stress
id ent ilied risk
progression, or side effects
test, fetal contra ction
factors
of treatment
stress test
Two or more sta b l e c h ronic i l lnesses
D i a g nostic endoscopy with no identified risk factors
E l ective major s u rg e ry (open, percutaneous, or endoscopic) with no i d e n t if ied risk I actors
Undiagnosed new problem wi t h unce rta in prognos is,
Deep needle or incis ional b iopsy
Prescri ption drug mana g ement
e g , lump in breast
(continued)
482
Section I V • P r a ct i ce I ss u es
TA B L E
3 0 . 4 ( C O NT. )
R i s k of Co m p l icat i o n s a n d / o r M o r b i d ity o r M o rta l i ty; Also R i s k o f M a l p ractice H i g hest level i n Any Category I s the leve l of Risk Category Two leve l of Risk
Category Three
Category O n e
Diag nostic Proced u re(s)
M a nagement
P resenti n g Problem
O rdered
Options Sel ected
Acute i l l n ess with syste mic symptoms, e g , pyel oneph ritis, pneumonitis, colitis
Ca rdiovascular i m a g i ng study wi th con trast, n o Identified risk factors, e g , arteriogram, cardiac catheterization
Therapeutic n uclear medicine
Acute com p l i cated inJ U ry, e g , head i nj U ry with brief loss of consciousness
Obtai n f l u i d from body cavity, e g , l u m b a r punct u re, thoracentesis, cu ldocentesis
IV fluid with
additives
C losed treatment of fractu re or dislocation without manipulation H i g h (4)
One o r more chronic i l l nesses with severe exace rbatio n , prog ression, or side effects or treatment
Cardiovascu lar imag i n g s t u d y with contrast with identified risk factors
Card iac Acute or c h ron ic i l l ness o r I n j u ry that th reatens l ife or bodily electro physiologic tests function, e g , multiple trauma, Diag nostic endoscopy acute myoca rd i a l infarction, with identified p u l monary embolus, severe risk factors respiratory distress, progressive severe rheumatoid a rth ritis, psychiatric Illness with possibility of threat to self or others, peritonitis, acute ren a l fail ure An abrupt change I n neurologic status, e . g . , seizure, transient ischemic attack, wea kness, sen sory loss
Discography
E l ective major su rgery (ope n, percutaneous or endoscopic) wi t h identified risk fadors E m erge ncy major surgery (open, percutaneous, or endoscopic) Parenteral controlled su bstances
Drug therapy requiring intensive monitoring or toxicity Decision not to res uscitate or to deescalate care because of poor prognosIs
Federal E&tv1 documentation g u idel i nes
Chapter 30 • P r o g r e s s N otes a n d C o d i n g
483
Ta b l e 30.4 is scored b y p i c k i n g the single highest item in any of the th ree cate gories: Presenting Problem, D iagnostic Proced u res Ord ered , or M a nagemen t ·O ption. That highest i tem i s the th i rd Medica l Decision Making score. The best reco m m e n d a tion fo r i n d i v i d u a l practitio n e rs is to deve l o p c l i n ica l v i g n e ttes tha t work fo r t h e i r p ractice. Aga i n , co n s i s tent u s a ge by c l i n i c i a n s is essen t i a l to e n s u re acc u r a te cod i n g a n d to m i n i m ize risk associa ted with a n a u d i t . A wri tten policy i s strongly reco m m e n d e d . Ta ble 3 0 . 4 is ta k e n d i rect l y fro m t h e 1 9 9 5 g u i d el i n e s . Ta b l es 3 0 . 2 a n d 3 0 . 3 were j oi n t ly d e v e l oped b y the Ce n te r fo r Med ica re Stand a r d s ( CMS ) a nd t h e Ma r s h field C l i n i c . A l t h o u g h Ta b l e s 3 0 . 2 a n d 3 0 . 3 a r e not i n t h e 1 9 9 5 g u i d e l ines, they were d i stri b u ted to a l l Med icare c a r r iers by CMS fo r use a n d im p l e m e n ta t i o n o f t h e 1 9 9 5 g u i d e l i nes. Fol l o w i n g Ta b l e 30.5 by the book each and every v i s i t i s impractica l . O n e h a s to l o o k a t the Assess m e n t ( d i a g n o s i s o r d i a g noses; A o f S O A P ) a n d a d d t h e m up with the d i a g n o s i s ta b l e; l o o k a t the s tu d i e s , la b o r a tory fi n d i ngs, and med ica l reco rd review, and a d d t h o s e p o ints u p on t h a t ta b l e ; a n d then go to t h e ta b l e of r i s k to d e te r m i n e which s i ngle e l e m e n t i s the h ighest level of ris k a n d a s s i gn a p o i n t f r o m t h e r e . E a c h ta b l e w i l l be ta ll i e d 1 t o 4 . T h e n t a k e t h e m i d d le n u m be r ( two o f-t hree r u l e ) , and that is t h e Medical D e c i s i o n M a k i ng score, a s Ta b le 3 0 . 5 shows. A l th o u g h i t i s co n fu s i n g a t fi rst, w i t h practice o n e w i l l beg i n to see tre n d s in o n e 's med i c a l d e c i s i o n m a k i ng. Practice w i l l a llow a m o re gesta l t-d rive n p r a g m a t i c use o f t h i s ta b l e , fo r to use i t every t i m e one sees p a tients i s a n e a r i m possi b i l i ty. I d e n tify i n g t h e Eva l u at i o n a n d M a n a g e m e n t S e rvice
E&M serv i ces a re specifica ll y identi fied u s i ng fi ve-d igit nu meric d escriptors. To d ete r mine the i d e n t i fy i ng number, the ph y sic i a n must decide upon the genera l cat ego ry or type of visit ( o u tpat i ent vers u s i n patient, esta blished o r fo l l ow- u p v i s i t, new visit or co nsu lt) . Next t h e phys ician decides upon the leve l of service that was provided by a d d i ng up the H isto ry p o i n ts, P hysica l Exa m i n a tion points, and Med ica l Decision Ma k i ng points , and a p p l y i n g the two-of- t h ree or three-of- t h ree rules a s the partic u l a r code category d icta tes. Time, a s a l located per code b y CPT, c a n b e used o n l y t o j u sti fy a pa rticu.l a r code when counse l ing or coord i nation of care constituted more tha n 5 0 %
Med i ca l Dec i s i o n M a k i n g Sco r i n g S u m m a ry Medical Decision M a k i n g Dete r m i n ation (2 of 3) Decision M a k i n g
Stra ig htfo rwa rd
low
M oderate
High
1 . N u m ber of diag nosis, management options
M i n imal ( 1 )
Limited (2)
M u lt i p l e (3)
Extensive (4+)
2 . Amount o f data to be rev i ewe d
M i n i m a l , none ( 1 )
Lim ited (2)
M u l tip l e (3)
Extensive (4+)
1 Table of risk
Minimal ( 1 )
Low (2)
Moderate (3)
High (4)
484
Section IV • P r a ct i ce I s s u e s
of t h e fa ce-to-face contact i n the physicia n-pa tien t enco u n ter. I n s u c h a n i nstance, t i me may be considered the contro ll i ng fa ctor to q u a l ify fo r a p a rt i c u l a r l e v e l o f E & M serv ice. I n t h i s i n s ta nce, Ti me s up e r s i d es the t h ree key c o m p o n e n t s . C o m p a red to t h e 1 9 9 7 system, t h e 1 9 9 5 system will at t imes
l l o w fo r a n d
a
a p p e a r t o j u s t i fy ove rcod ing o f a seem i n g l y r o u ti n e vis i t . Th e H i story a n d E x a m i n a
ti o n sect i o n s revea l e d t h a t b y stic k i ng t o t h e r u le s , b y a n d l a r g e t h e p r a c t i c i ng p h y s i c i a n c a n sta y sa fe i n a n a u d i t The gre a test reason fo r the crea t i o n of the 1 9 9 7 s ys .
t e m w a s to r e m o v e t h e a m b i g u ity a n d a b i l i t y to ove rcode t h a t t h e 1 9 9 5 s y s t e m a fford ed a p r a c t i t i o n e r for r o u t i n e pa t i e n t e n c o u n ters . U n fo r tu n a tely, t h e 1 9 9 7 s y s t e m w e n t t o o fa r a n d m a d e i t too d i ffi c u l t to a c h i e v e l e g i t i m a te codes w i t h i ts oner
o u s b u l leted e xa m ina tion s . The 1 9 9 7 s y s te m does, however,
a l low a
s pec i a l is t t o
a c h ieve a h i g h e r- l e vel e xa min a t i o n e v e n t h o u g h o n l y o n e or two bod y syste m s a re
exa m i ned . If o n e l e a rns from one s p ra c t i ce w h a t t h e ty p ica l codes a re, a n d i f t h e '
v i s i t i s m ore c o m p l e x t h a n u s u a l , o ne c a n d oc u m e n t a s i s a p p ro p r i a t e, a n d pa y i n g
p a rt i c u l a r a tte n ti o n to t h e t h ree key co m p o n e n ts c o d e t h e v i s i t as a l l o wed . It i s ,
i m p orta n t n o t t o u n d ercod e o u t o f fea r o f a u d i ts o r pena lties b u t e q u a l l y i m p o r ta n t t o a v o i d o v e r co d i n g j us t beca use the ru l e s a re k n o w n a n d e n o u g h h i s t o r y o r ex a m i n a t i o n c a n b e a d d e d t o t u r n an u nco mp l ic a t e d ot i t i s med ia
i n to
a
9 9 2 1 4 . Cri tics o f
t h e 1 9 9 5 s y ste m a rg u e t h a t i t a ll ow s , i f n o t j u st i fi e s , s u c h cod ing, b u t p r a g m a t i c a l l y, a n o ffice v i s i t for a n u nc o mp l ic a te d e a r i n fec t i o n i s l ik e l y a 9 9 2 1 3 u n l es s o t h e r fa ctors c o m pl i c a te m a tters. T h e b e s t a d v i c e i s t o d oc u m e n t w b a t i s fo u n d a n d code the vis i t a c cord i ng l y, k e e p i n g in m i n d t h e level o f i n te n s i ty a nd acu i t y. Levels and Codes
With t hese r u l es a n d ta b les a l re a d y pr e s e nte d , the fo l l o w i n g ta bles pro v i d e the fou n d a t i o n fo r d e t e rm i n i ng the c o d e selection b a sed u po n the type o f v i s i t a n d t h e d oc u menta tion o f t he History, Physic a l Exa m i n a ti o n , a n d Med ica l Dec i s i o n J\/I a k in g . I f
t i m e i s used a n d O MT i s d o n e a t t h a t v i s i t, t h e t i m e do i n g t h e O M T d oes n o t c o u n t toward the time for the v i s i t . Ma n y prov iders ta l k w i t h pa tie n ts a b o u t va r i o u s issues during OMT, but t h is d oes not c o u n t tow a rd the 50% ru l e , beca u se t h e p h y s i c i a n is a l re a d y being r e i m b u rsed for the ti me fo r doing tbe OMT I n m os t instances, p rope r
d o c u men tation of t h e H i story, P hysica l Exa m i n a ti o n , a n d Med ica l D ec i s i o n M a k i n g
w i ll m a ke the use of t i m e as the p r i n c ip a l d o c u m e n ta t i o n q u i te u nnecessa ry. As o n e b ecomes sk i l led i n d o c u mentation meth o d o l ogy, one d oc u m e nts what i s needed for tbe med i c a l record , and i t w i l l g e l fluid l y with w h a t i s needed fo r c od i n g a s wel l . New Pa tient Codes
(9920 1 -99205)
These c o d e s are u s e d for pa ti e n ts w h o meet t h e new-pa t i e n t d e fi n i t i o n * a n d
a re s e e n
i n a n o u t p a t i e n t sett i n g . Pati e n ts in the e m e rgency d ep a rtme n t o r i n the h o s p i t a l fo r
o bserv a t i o n h a ve o u t p a t i e n t sta r u s , a nd t h e r e fo re o u tp a tien t codes m a y be u s e d i n ,
those setti ngs a s w el l . T h e scope o f t h i s c h a p ter does n o t a l l o w fo r fu r t h e r d i scu s s i o n . T h u s tbe r e a d e r i s re fer r ed to C PT or o n e o f t h e re fere nced texts fo r further info r ma t io n . These codes a re u s e d once, a n d v i s its a fter the f i r st o n e , a ss u m i n g i t is l e s s tha n 3 years, a re t ypi c a l l y b i l led in t h e esta b l i s h ed pa t i e n t v i s i t code set ( 9 9 2 J 2-9 9 2 1 5 ) . Ta b l e
3 0 . 6 o u t l i n e s the H i s t o ry,
Exa min a t i o n ,
a nd
Medica l
Decis i o n M a k i ng fo r t h e n e w p a ti e n t c o d e s . These, l i k e Co n s ul t cod es, req u i l"e t h e -
t h ree o f th r ee r u l e ( g o t o t h e l o west n u m ber) w h e n d e termi n i n g the co d e s . -
-
'Parient 1 \ 0 [ seen
hsr rh ree
by
yea rs.
<1
provider o f t h e same spec i .1 l i ry with i n
<1
group p racricc (sinSk E I NfTAX I . D . ) d ur lll g rhe
C h a pte r 30 • P rog ress N ot e s a n d Cod i n g
,
•
,.-
- y�•
TA B L E
485
•��
3 0 . §';'�
New Pat i e n t V isits a n d C o n s u ltat i o n : Th ree-of-T h re e R u l e O u tpatient
New
Consult
Patient
H i story
Physical
Medical Deci sion
Exa m i n ation
Making
9924 1
992 0 1
Problem focused
Problem focused
Straightforward
99242
99202
Expanded problem focused
Expanded problem focused
Straightiorward
99243
99203
Detai led
Detai led
Low complexity
99244
99204
Comprehensive
Comprehensive
Moderate complexity
99245
99205
Compre h ensive
C o m p re h ensive
H i g h complexity
Adarted with permission from
OH
G reyden,
2004 .
Jorgensen
DJ. Jorgensen
RT A Physician's
G u ide to B i l l ing and
C o din g . Colu mbus,
Consultations
Con s u lt codes a l so req uire the t h ree-of- t h ree r u le ( l owest n u m be r ) , whether t h e y a re i n pa t i e n t ( 9 9 2 5 1 - 9 9 2 5 5 ) or o u tpatient ( 9 9 24 1 -9 9 2 4 5 ) , fa c i l i ty or n o n fa c i l ity, res pecti v e l y. C a r e m a y be i n i t i a ted a t the t i m e of c o n s u l ta t i o n . 7 A w r itten req uest o r at l e a s t a speci fied req u e s t or referra l fro m t h e referring provi d e r is req u i red . For a n i n pa tient, a written order i n the chart is needed (a v e r b a l order by a n u rs e is accepta b l e ) before the p a ti e nt can be s ee n . For a n o u tp a t i e n t , a fter the co n s u l tati o n , a l etter ( n o t j u s t a ca r bon copy o f t h e con s u l ta ti o n n o te ) m u s t b e sent to the referr i n g provider. It can be a fo r m l etter t h a n k ing the p r o v ider fo r the re q ue s t a n d s a y i n g that a copy of the cons u l ta ti o n note w i l l fol low, b u t i t m u s t be a letter. Some p rov i d e rs prefer to d ictate the entire v i s i t i n l etter fo rma t for t h e r e fe r r i ng provider. Either method is fi n e a s l o n g a s a letter i s sent. Con s u l t s c a n be d o ne w i t h i n the s a m e office a n d w i t h i n t h e s a m e s p ec i a l ty, b u t t h e referra l a n d l e t t e r r u les sti l l a p p l y. S o m e p r i v a te i n s u rers have spec i fic r u l es rega rd i ng w h o can or ca n n o t d o c o ns u l ts , b u t m o s t a l l ow a n y provider w h o is q u a l i fied to d o con s u ltative work . Once a consu l t has been done, the s u bseq u e n t v i s i ts use t he esta b l ished patient codes for o u tpa tients ( 9 9 2 1 2-9 9 2 1 5 ) and use hospita l care codes ( 9 92 3 1 -9 9 23 3 ) for i n patients. The o n l y t i me to u s e another co n s u l t code i s i f t h e p a t i e n t presents with a new and u n re l a ted pro b l e m , a n d a n other re ferr a l a n d eva l u a t i o n have been requ ested . If t h i s i s done in the i n pa t i e n t fa c i lity setting, u se the fol l ow - u p co n s u l t codes ( 9 9 2 6 1-9 9 2 6 3 ) n oted la ter i n t h e c h a pter. Do not use fol l ow- u p c o n s u l t c o d e s f o r rou t i ne fo l l o w - u p from a n i n i t i a l consu l t ; these a re o n l y fo r a new p r o b lem t h a t the cons u lt a n t h a s been requ ested t o e v a l u a te a nd poss i b l y tre a t . S e e Ta b l es 3 0 . 7 t o 3 0 . 9 . Established Patient Office Visits
(992 1 1-992 1 5)
Esta bl i s h ed patient v i s i t codes a re the m o s t c o m m o n l y u sed E &M cod es. These codes fo l l ow the two-of-three rule . Provid ers s h o u l d use codes 9 9 2 1 2 to 9 9 2 1 5 , a s 9 9 2 1 1 i s typ ica l ly a l l oc a ted to n u r s i n g s t a ff. They are used a fter consults o r new p a t i e n t v i s i ts for fol l ow - u p visits. Ta b le 3 0 . 1 0 shows t he a lgorithm to dete r m i n e the code selecti o n .
Section IV • P r a ct i ce I s s u e s
486
I nitial Hospital (Facility) Con sult Codes: Th ree-of-Three Rule Phys ical
M edical Decision
H i story
Exam i n ation
Making
992 5 1
Prob l e m focused
Prob lem focused
Stra i g h tforward
20
99252
Expanded
Expanded
Stra i g h tforwa rd
40
99253
De t a i led
Detailed
Low co m p lex i ty
55
99254
C o m p rehensive
C o m p r ehe n sive
Moderate co mplexity
80
99255
C o m p rehensive
C o m p rehensive
H i g h complexity
1 10
I n it i a l I n patient Consult
problem focused
Time
problem focused
Adapted with permission from Jorgensen DJ, Jorgensen RT A Physicia n 's Guide to Bil ling and Coding. Columbus,
OH
Greyden,
2004 .
Subsequent Hos pital C a re Codes : Two-of-Th ree Rule Physical
Medical Decision
H i story
Exami n ation
Making
Pro b l e m -focused
Problem focused
S t ra i g h tforward,
Su bseq uent Hospital Care
9923 1
Expanded prob l em
-
focused interval D e ta i l ed i nterva l
99233
15
low compl exity
i n t e rval
99232
Time
E xp anded
Moderate co m p l ex i ty
25
H i g h co m p lexity
35
prob l e m focused De t a i l e d
Adapted with perm ission from Jorgensen DJ, Jorgensen RT A Physician's Guide to Bil ling and Coding. Colum bus,
OH
G reyden,
2004.
Follow-up I n patient Con s u lts : Two-of-Three Rule Phys ical
Med ical Decision
H i story
Exam ination
Maki n g
Prob l e m -foc used
Problem focused
S t ra i g h tforward low
Fol l ow-up I n patient Consult
992 6 1
i n t e rva l Expanded
99262
prob l e m focused D e t a i l e d i nterva l
99263
Time ,
Expanded p ro b l e m focused Deta i l ed
Moderate comp lexity
20
H i g h complexity
30
Adapted with permission from Jorgensen DJ, Jorgensen RT A PhYS ician's Guide to Billing and Coding. Columbus,
OH
Greyden,
2004.
10
complex i ty
C h a pter 30 • Progress Notes a n d Codi n g
487
Established Patient Office Visits: Two-of-Th ree R ule
Code
H i story
Physical
M e d i cal Decision
E xam ination
M ak ing
Time
992 1 1
Physi c i a n not req u i red
Stra i g h tforward
5
992 1 2
Problem focused
Problem focused
Stra i g h tfo rwa rd
10
992 1 3
Expanded
Expanded
Low com p l ex i ty
15
prob lem focused
prob l e m focused
992 1 4
Deta i led
Detailed
Moderate complexity
25
992 1 5
C o m prehensive
C o m prehen sive
H i g h complexity
40
Adapted with permission OH Greyden, 2004 .
from Jorgensen DJ, Jorgensen Rl A Physician's G Uide to Billing
and Coding.
C o l u mbus,
U se of O MT
OMT i s d e fi ned in CPT a s "a fo r m o f m a n u a l tre a t m e n t a p p l i e d by a p h y s i c i an to e l im i n a te o r a l l ev i a te somatic d ysfu ncti o n a n d re l a ted d isorders . " The d octor of osteo p a t h y has been tra i ned to d i a g n ose somatic d y sfu n c t i o n and use OMT. O MT is a thera peutic proced u re . A n y proce d u re performed u po n a patient m u s t be recorded i n the progress note. In the SOA P n ote fo rma t, therape u tic proced ures a re record ed i n t h e P, o r Pl a n , port i o n o f the n o te . I n t h e sta nd ard osteop a thic med ica l record , deve l oped by the Lo u i sa B u rn s Osteop a t h ic Resea rc h Com m i ttee o f the A m e r i ca n Academy o f Osteo p a t h y, a specific a rea h a s been a l located for record i n g both somatic d y s fu n ction a n d i ts tre a t m e n t w i t h O MT. ( Se e C h a p ter 3 1 . ) O nce the p h y sician has e x a m i n e d the p a t i e n t a n d d e c i d e d upon a d ia gnosis a n d pl a n fo r trea tment, an E & M code is id e n ti fi a b l e . Thi s c o d e m u s t be recorded i n assoc i a t i o n w i t h a l l a ppropri a te d i a gnoses . D i agn oses s u c h a s soma tic dysfunc tion are i d e n t i fied n u m e r i cally. I CD - 9 CM i s the reference in which accepted d i a g n o s i s codes a re to b e fo u nd . A d i agn ostic code for s o m a tic d ysfunc tio n , 7 3 9 , i s l isted i n I C D - 9 C M . It i s s u b d i vi d e d accord i n g to the a n a to m i c reg i o n w h e re soma t ic d ys fu nction is d i ag nosed a s fo l l ows: 73 9 . 0, 73 9 . 1 , 73 9 . 2, 739.3, 73 9 . 4 , 739.5, 739.6, 73 9 . 7, 739.8,
som a t i c somatic somatic somatic soma tic soma tic somatic soma tic somatic 7 3 9 . 9 , so m a tic
d ysfunction d ys f u n c t i o n d ysfunction d y s fu nction d ysfu nction d ysfu nction dysfunction d y s fu nction d ysfunction d ysfu n c t i o n
cra n i a l cervica l t h o ra c i c l u m ba r sacru m/pe lvis i l i u m/pe l vi s lower extre m i ty ( o n e or both ) uppe r extre m i ty ( o n e or both ) r i bs ( a n y or a l l ) a bd o m e n/otherS
As a proced u re , OMT i s c a r r i ed out in a d d ition to E & M . A fee for service m a y t h e re fore b e s u b m i tted fo r O MT i n a d d i t i o n t o t h e fee s u b m i tted fo r E & M . U n d e r th ese c i rc u m stances, a 2 5 - mod i fi e r ( - 2 5 ) m u s t fol l ow the a ppro pria re E & M c o d e .
488
Sect i o n IV • P ractice I s s u e s
T h u s , t h e E&M code f o r a n esta b l i s hed p a t i e n t l e v e l I I v i s i t i n wh ich O MT h a s been performed i s 9 9 2 1 2-25. The 25-modifier i s a sign ifica ntly a n d sepa r a te l y i d e n t i fi a b l e service i n a d d i t i o n t o E & M . A 25-mod i fier i s u sed t o o bta i n reim b u rsement for a n E&M serv ice by t h e s a m e p rovi d er on the s a me d a y a s a n o t h e r s e r v i c e or a proced u re w he n a n E&M c o m p o n e n t is s igni fica n t l y a n d sepa rare l y i d e n tifia b l e fro m the other serv ice o r proced ure I t i n d icates tha t a n a d d i ti o n a l pro ced u re code i s bei n g s u b m i tted in a ssoci a rion with the p r i m a r y E&M c o d e . The d i agnosis l ea d i n g to the d ec i sio n to p rovide OMT can be the sa me a s the one used fo r the E&M, a nd the AMA, i n a l etter to the A m erica n O s teopa t h i c A ssoc i a t i o n ( A O A ) l ega l d e p a r t m e n t , has u p he l d t h a t O MT d oes not i nc l u d e a n y E & M serv ice ( l etter fro m Sherry L . S m i th, comm ittee secreta ry, AMA S peci a l ty Soc iety RVS Upd a te C o m m ittee, to Yo l a nd a L. Doss, R H I A , a s s i sta n t d i rector o f cod i n g a nd reim b u rsem e n t , AOA, M a r c h 1 0 , 2003 ) . T h is m e a n s t h a t O MT a nd E & M a re n o t b u n dl e d , a nd i f b o t h se rvices w e re p ro v i ded a nd t h e d o c u m e n ta t i o n s u pports i t , both s h o u ld b e bi ll ed a n d re i m b u rsed . The 25-mod i fi e r d oes not s p e c i fically i n d i ca te t h a t OMT w a s d o n e , a s it c a n be u sed w i t h a ny n u m b e r o f other proced ures (e.g., flex i b l e sigmo i d oscopy, cryother a p y, s k i n biops i es ) . I t is s i mply a means to i n fo r m the i n s u re r th a t this i s nor a stra ightforw a rd office or h o s p ita l v i s i t a n d t he p h y s i c i a n s u bm it t ing the b i l l w a n ts a n d expects to be p a id for both serv ices . .
OMT CPT Codes
A series of five - d i g i t codes ( 9 8 9 2 5-9 8 9 2 9 ) are used to i d e n t i fy OMT. T h es e codes i n d ica te the n u m ber of separa te body regi ons i n wh ich s o m a t i c d ys fu n c t i o n h a s been d ia gnosed and O MT h a s been used . They d o not i n d icate the type of OMT tha t h a s been used. 9 8 9 25: 9 8 926: 9 8 927: 98928: 98929:
1 or 3 or 5 or 7 or 9 or
2 body regions 4 body reg i o n s 6 b o d y reg i o n s 8 body regions 10 body regions2
Ea ch OMT CPT code can be used once p e r visit. If 7 o r 8 a reas were trea red , the code is 9 8 9 2 8 . I f 9 areas were treated, the code is 9 8 92 9 . U s i n g m U l ti p le OM T CPT codes per v i s i t is fra u d u le n t a n d m i srepresents w h a t occ u r red ar t h e v i s i t . I t i s a l so n o t accepta b le t o u s e the term therapy i n the p rogress note or a n y other com m u nica tions fo r cran i a l oste o p a t h y or any other ry pe of O MT. The T in O M T sta n d s for trea tment. To use the word th erapy m i s r ep r es e n ts w ha t h a s been d o n e fo r t h e patient, a n d i t c o n fuses t h e i s s u e for i n s u rers, s o m e o f w h o m do n o t re i m b u rse for c r a niosacra l thera py b u t d o p a y f o r os t eo p a t h y i n r h e c ra n i a l fi e l d o r other cran i a l osteopathic proced ures. S e m a n tics a r e i m p o r ta n t , a n d lea r n i n g t h e proper ter m i no logy a n d u s i ng it i s pa ra m o u n t . W h e n a n O M T p roced u re c o d e i s s u b m i tted , the number of 7 3 9 d i a g n o s i s codes s u b m i tted m u s t s u bsta n t i a te t h a t proced u r e c o d e . Th at is, i f 9 8 9 2 6 is s u b m i tted , i nd icating t h e treatment o f t h ree o r f o u r r egions i t m u st be accom p a n i e d b y a t least three sep a r a te 73 9 d i a g n o s i s codes, i n d i c a ting t h a t s o m a t i c d ysfu nc t i o n w a s d i agnosed i n a t least th ree se p a r a te bod y regi o n s . It is not a p p ropri a te to u se p hysica l therapy codes to charge for O MT. P hysica l the rapy i s j u st t h a t-t h era py. P h y s ic i a n s , p h y s i c i a n a s s i sta nts, and nurse practitioners pe rfo r m p r oced u r e s a n d s pecific a l l y d o not d o t h erapy i n ter m s o f m a n i p u l a t i ve med ici n e . Therefore, d o n o t a l l ow O MT t o be a l l ocated i n th i s re a l m , a s i t is n o t co r rect cod i n g ,
.
489
Cha pter 30 • P r o g ress N otes a n d Cod i n g
CONCLUSION The pra ctice of med i ci n e at t h e o u tset of the twe n ty f irst cen t u ry ha s beco m e extreme l y co m p l e x . T h e p r og r ess nare i s a n i m porta nt compone n t of c o n tempo rary medica l p ractice. The c o m p l e x i ty o f c o n t e m porary m e d i c a l pract i ce r e q u i r es practi ti oners to a d h ere to a strict protocol for w r i t i n g pro gr ess n otes for medicole gal and reim b u rseme n t p u r p oses The p r o g r es s note is t h e reco rd that a l l ows conti n u i ty o f care. S u bspeci a l ty m e d ica l prac tice w i t h a ssoci a ted d i a g n ostic a n d t h e r a pe u t i c a dva nces has created a n e n v i ro n m e n t w h e r e i n pat i e n ts a r e reg u l a rl y cared for by m o r e tha n one p hysici a n . [ n a c a d e mi c med i c i n e , t h e p resence o f s t u d e n ts a n d res i d e n ts prod u ces a d d ition a l leve l s o f com plex ity. To mai n ta i n conti n u i t y a m o ng a l l o f t h e p a rticipa nts, i t i s i m p e l" a t i v e t o com m u n ic a te c l e a r l y. To ensu re o p t i m a l patient c a re , a l l p h y s i ci a ns m llst fo l l ow t h e s a m e r u l e s . I n the p a st, p a tients perso n a l l y pa id the phy sic i a n fo r th e i r h e a l t h ca r e They w e re d i rectl y a w a re o f w h a t had be e n d one and co n se q u e n t l y could j u dge whether the fee for se rv ice was appropriate. T h i r d par ty reimbursement fo r phys i cian services has cha nged that re l a t i o n s h i p The third pa rty c a n n Ot have d i r e c t k n o w ledge of w h a t occu rs between the p a t i e n t and p h y s ic i a n . The m e d i c a l record therefore s e rves a s d oc u m e n ta t i o n o f the extent of se r vice rend ered . The p ro g r e s s n o te j usti fies the d o l l a r a mo u n t re q u ested for E&M se r v i ces a n d i n d ica tes whether o r not d i a g nost i c a n d t h erapeutic proced u res are rei m b u rs a b l e . If th a t documentation does not j u s t i fy what is c h a rged be p r epared to repay the re i m b u rse m e n t poss i bl y w i th pe n a l ti e s , i n the e v e n t o f a n a u di t . It m a y s e e m c r a s s t o d iscuss m o n ey when ta l k i n g a b out the c a r e of p a t i e n t s . M e d i c i n e , however, i s a b u s i ness It i s a b u s i ness o f c a ri n g f o r people, b u t a b u s i n e s s noneth e l ess. Docto rs c a n n o t ca re fo r t h e i r p a t i e n ts i f t h e y c a n n o t a fford to keep the office o p e n . Wo r se yet, pa tients may fi nd thei r trust in thei r p hys i c i a n s h a k e n i f thei r p h ysic i a n is a c cu sed of fra u d u l e n t activ ity. H a v i n g spen t m a n y y e a rs lea rn ing me d i c i ne p h ysici a ns m u s t a l so l e a r n the req u i rements of correct m e d i c a l record kee pi ng, a co n t i n u a l l y evol v i n g a rea o f i n forma tion that is p a r t o f thei r c o n ti n u i n g e d uca tio n . -
.
.
-
.
,
,
.
,
References 1. S l e s z y n s k i SL, G lonek T, K u chera WA . Sta n d a rd ized m ed i ca l record: A new o u r p a t i e n t osteo p a t h i c S O A P fo r m : Va l i d a t ion o f a s t a n d a r d i zed o ffice form aga i n st p h y s ic i a n 's p rogr e ss n o t e s . J A m Osteo p a t h Assoc 1 9 9 9 ; 1 0 : 5 1 6-5 2 9 . 2 . C u r r e n t P roced u r a l Te r m i n o logy ( CPT) 2004 . C h icago : A merica n Med i c a l Association, 20 0 3 . 3 . J o rge n s e n DJ , J o r g e n s e n RT. A Physi cia n 's G u i d e to B i l l i ng a n d Cod i n g . Co l u m b u s , O H : G r e y d e n , 2004 . 4. S ecti o n 1 1 2 8 A o f S S A , H I PA A of 1 9 9 6 , P u b l i c L a w 1 04-9 l . 5 . Med ica re C u r i e r Ma n u a l 1 5 502. Pa ragra p h A . 6 . Cen rers fo r M e d i c a r e a n d Med ica i d S e r v ices . D o c u m e n ta t i o n G u i d e l i n e s : Ev a l u a t i o n a n d Ma n a g e m e n t S e r v i c e s . Av a i l a b le a t h t t p ://w w w. c m s . h h s . gov/med lea rn/e m d o c . a s p . L a s t m o d i fied O c to b e r 7, 2004 . Ac ce s s e d Fe bruary 2 2 , 2005 . 7. M e d i c a re C a r r i e r M a n u a l 1 5 5 0 6 . Paragraph B . 8 . I n t e r n a t i o n a l C l a s s i fi c a t i o n o f D i seases, 9 t h R e v i S i o n : Cl i ni c a l M od i fica ti o n . 5 t h e d . Sa l t L a k e C i ty : M e d i c o d e , 1 9 9 9 .
CHAPTER
31
The Standardized Medical Record Sandra L. Sleszynski and Thomas Glonek
INTRODU CTIO N On January 12 to 14, 1996, in a small c onferen c e room at the H a mi l t o n Inn O' Ha r e in C hicago, a group of 14 in d iv i du a l s m e t for a co n cen trated
weekend to d isc u ss the realm of m e d i cal record standard izati on. ,. The American Aca d em y of Osteopathy (AAO) Lo uisa B urns Osteopathic Research Committee (LBORC) of the American Osteopathic Association (AOA) and guests, u n d er t h e lead e r ship of San d ra Sleszynski a n d fun d e d by the AAO, gat her e d to d eve l o p an instru m e nt that could be used efficiently and effectively for s p ec ifi c ost e o p athi c clinicaJ, ed ucat i onal, and research p u rp o ses . This new progress n o te w ou l d fol Jow th e SOAP format (subjective, objective, assessment, plan), b e simple, guide in c o d ing for reimbursement, allow t rac king for ed u catio n , and facilitate research data c o llect io n with little effort. Out of this p rivate g r o u p of clinicians, educators, an d researchers, the single-page Outpatient Osteopathic SOAP Note Form was create d . I
"'Invitees included 38 doctors
listed in
490
acknowledgment. I
of osteopathy
and doctots
of philosophy
and 2 administrative
staff. (Committee
Chapter 31
• The Standardized Medical Record
491
SOAP NOTES AND CURRENT PROCEDURAL TERMINOLOGY CODING GUIDELINES: 1995 OR 19977
Coding for reimbursement and the ease of coding are key issues in any clinical practice. The current 199511997 Medicare documentation guideline ruling2 is problematic,J,4 particularly if one's intention is to standardize and simplify medical reporting, which is what SOAP notes and electronic medical records are supposed to be all about. Needless to say, it is impossible to create a one-size-fits-all report ing instrument in an atmosphere of federal and medical community squabbling and indecision. Nevertheless, it is important to try since regulatory issues continu ally evolve and inaction invites Chaos. At the time the first SOAP note form was being created, the 1997 CPT coding guidelines were in force. Since this new set of guidelines also was compatible with the use of standardized forms and electronic medical records, it was decided to meet the new guidelines and create the SOAP notes consistent with the 1997 reporting system. For once, it was thought, we were ahead of the game. How foolish. The medical community howled! Not only were the new guidelines more com plicated, demanding still more documentation per patient visit, they were more restrictive, resulting in undercoding and decreased practice revenues. The federal government reconsidered. In an April 1998 fly-in-to-the-AMA in Chicago, the 1997 system was indefinitely suspended, making it one option and the 1995 system another.2.4 This is still the case. Most nonmedical personnel, such as lawyers and consultants, of course, prefer the 1997 system, as it requires counting bullets, and one doesn't need to know much about medicine. The 1997 guidelines also facilitate the development and use of electronic medical records. It is thought by many, however, tnat tne 1995 sys tem far outweigns the 1997 system in simplicity of implementation in the clinic. 3 This system is familiar to clinicians and more protective of the practice in the event of a state, federal, or penal audit or any other payment review process. Meanwhile, back at SOAP note headquarters (spread all over the country but linked via the Internet) and on the heels of this switch to the dual-reporting system, SOAP notes were being designed, content was being decided, and validation pro grams were being written and carried out. It was decided to continue following the 1997 guidelines, since they were in force at the time, and the intent of the SOAP note instrument was creation of consistent documentation for care of the patient and ease of review and data collection (patient, educational tracking, and research informa tion). Moreover, the history and the medical decision-making sections of progress notes wer e virtually identical for the 1995 and 1997 guidelines, so one need only know the physical examination differences to implement either one of them. The osteopathic manipulative treatment (OMT) tables in the SOAP notes were designed to facilitate this. During this time, the LBORC was aware of the brewing discontent within the medical practice community but reasoned that increased restrictions, the need for increased documentation, and standardization were inevitable. It was then and still is believed that compatibility with the 1997 system was the safe option and that with time reporting would drift in the direction of more and more rigorous doc umentation and standardization in the medical record. Some practitioners use the 1997 system in practice but request that the 1995 system be used in the event of an audit. This provides more than ample documen tation. The downside is that physicians can find themselves not billing at legitimate higher-level codes, because the 1997 system disallows some coding.2,4 In either case, physicians are well known to down-code levels of service and not sufficiently document the care they give. The SOAP notes provide tools to help remedy these
492
Section IV • Practice Issues
inherent traits of physicians. On the upside, because of their design, use of SOAP notes has done the following: •
Made practice more efficient by requiring less thinking about what is included in the note and making it easier to find the diagnosis, the treatments prescribed, the techniques that are working, the procedures that were done, and the degree of patient compliance, with follow-up appointments to improve care and to justify
• • • •
coding choices Made it obvious how many and which regions of the body were treated Reduced the incidence of failure to reimbursement due to unclear notes Decreased confusion as to whether the patient was improving Yielded payment when charges look suspicious, such as with Medicare, pro longed visits, counseling visits, and any time there are higher charges than appear warranted from the diagnoses or procedure codes listed on the insurance form
RAISONS D'ETRE Have you ever wondered why osteopathic medicine exists and persists? To retain
its professiona I identity, osteopathic medicine must address concerns critical to the future of the profession. It must provide information on concepts that are central
to treatment and on how the disturbances it professes to treat, almost uniquely in the health care field, are distributed among the population. In this regard, the most characteristic component is "the role of palpatory diagnosis and manipulative treatment in osteopathic teaching and practice. "5 Third-party payers are demanding that medical practices be evidenced based. This poses a particular dilemma for osteopathic medicine because the multiple variables encountered in holistic medical practice necessitate that one deal with large and diverse volumes of information, a good portion of which is difficult to quantify. There have been many clinical reports of the efficacy of osteopathic evaluation and manipulative treatment in the management of a host of diseases and disorders of structure and function. The corresponding basic science data involving human subjects that support the clinical studies, however, are relatively few, primarily because of a lack of appropriate investigative technologies. The scientific solution to these deficiencies and the key to professional survival for osteopathic manipu lative medicine lie in the generation of clinical outcomes data on a national scale. Implicit in this statement are the requirements for standardized nomenclature and a standardized method of reporting, involving trained investigators. T he development of a vehicle for the establishment of an accessible database of clinical information would greatly facilitate and accelerate osteopathic outcomes research. Consider, for example, the Danish "Better Health for Mother and Child" cohort study. The goal of this national outcomes program is the creation of a data bank that generations of investigators can mine and/or use as a starting point for studies on the effects of medical treatmenr.6 In contrast to pure outcomes studies, however, Americans prefer to design their studies to answer specific questions or to conduct long-term follow-ups. The goals of the osteopathic SOAP note program incorporate both outcomes and clinical tri als philosophies: to begin the creation of an osteopathic medical databank for research mining, as in the Danish program, but also to conform to the American model and answer specific clinical questions using the mined data. Once created, the database itself will facilitate the training of family medicine residents by pro viding hard data for both retrospective and prospective resident research papers.
Chapter 31
• The Standardized Medical Record
493
With the growing call for outcomes-based research / ·8 there is an increasingly urgent need for a standardized format for reporting the incidence, severity, treat ment, and outcomes related to family practice and particularly musculoskeletal somatic dysfunction. If osteopathic medicine is to continue in the increasingly competitive arena of health care provision , it must provide information on the concepts that are central to its treatment and how the disturbances it professes to treat, almost uniquely in the health care field, are distributed among the popula tion. Moreover, to be reimbursed by third-party payers, physicians must document all aspects of evaluation and management (E&M). The level of complexity of
E&M determines the level of reimbursement. If interaction with a patient is highly complex but the physician fails to document that level of complexity, the physician will be reimbursed only for what was documented rather than what was actually done in the clinic. One of the persistent problems that has faced osteopathic medicine, however, is the lack of reliable and easy-to-use methods for recording clinical findings and treatments in a format that is usable for subsequent data collection. This has been in part responsible for the lack of a referable database from the practitioners of the profession on the general parameters of osteopathic family practice; on the preva lence, frequency, and severity of somatic dysfunction in various classes of patients, and on the effects of treatment. There have been attempts to present
a
standard
ized format for such examinations.9 In addition, standardization for research pro
tocols has been discussed in various forums. 10-18 Most of these attempts, however, have been to provide complete guides to the documentation of osteopathic diag nosis and somatic dysfunction and may be too cumbersome for outcomes research involving large groups of participating family physicians. A standardized medical record nevertheless is essential for documentation of
osteopathic practice. Standardization will provide an efficient profession-wide national database of outcomes information that will find use in documenting the efficacy of osteopathic medical practice for the public as well as for medical, legal, insurance, and other third parties. It will also facilitate postdoctoral education in family medicine by providing the data required for resident tracking.
PAPER SOAP NOTES Only through valid and consistent documentation can osteopathic physicians hope to obtain the outcomes information needed for providing quality patient care, full reimbursement, and quality postdoctoral education programs. The establishment of a common record-keeping system for osteopathic physicians was suggested more than 20 years ago.19 More recent studies have recommended tne develop ment of such a system in hospitals, based on evidence that there was a lack of osteopathic evaluation on inpatients in osteopathic hospitals along with incorrect recording of findings when such evaluations were performed.20 Tne original SOAP note was developed by Weed.21-24 SOAP notes essentially cover the range of the physician's activity during an encounter with a patient. (A further development of the SOAP note is the problem-oriented note based on the patient's chief com plaint.) The presentation of a SOAP note can vary significantly from a series of check boxes to a full narrative. A SOAP note form pioneered by the LBORC was developed specifically for osteopathic medicine (Fig. 31.1). The original form, named the Outpatient Osteopathic SOAP Note Form, has been in use in physicians' offices nationwide since 1998. This form has been formally validated against physi cians' progress notes through a grant from the AOA.'
Section IV • Practice Iss u es
494
Outpatient Health Summal'Y
Paumt', Narnt Daft. of BiJ'th M MarUaJ S(g,tll.S! SlcnHlcanf Otbui: Re1i ....on:
EmploJinent Tobacco
Social Hirtory: Faml1y HIstory: CPT'
S
Sex
Date
W
D
ET OH
DNRS'ahU": Re-.ru,citate1 Nt..YI of Kin: Occupadon
Drlln
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No
I
F
I
Qualifications:
Educatioo
Se.xl-b:
OtlIU':
SlbUn"
M
Start Date
Phone: Nlunbtn:
Updal�; Home Work Yes
Past Medical Hi"!)1.0ry Medic.;ationi
Problun J Dig,Vlosh
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Hl"..aItb MiIlIntenRDce
Datu
Dltft
Pm Surllical History Type
Conllut_atlU
PAP �mew"
Mammouam Urinal 'ill HemoccuU Ch.oIwu61
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hldldbYIV1lnlfromu. BIl,renofRdweh .))()� ArntI'£.lDArtdtroyofo.t.opllby o.s� 10 OOOrdlhloll 'WIth tI. Ecubb.Jhtcl Ou.!ptJ'lCrtlCMIfOp"tllX SOAP liolt Fono RKollllIllldl l dby Mltl1Q� ,--,,lI0II o(CoDtp.ofo.llop11".JI: !'4dionl
FIGURE 31.1
The Outpatient Osteopathic SOAP Note Form series. (A) Page 1, outpatient health summary.
The two-page revised version of this form (Fig. 31.2) is secured by copyright and is being distributed to interested physicians and schools through the A merican College of Osteopathic Family Physicians (ACOFP)25 as well as t he AAO.25 (The more cO'mprehensive four-page version of this note also is available (Fig. 3 1.1). This SOAP note was the first step in provi di n g standardized documentation for osteopathic family practice. Sufficient data have been co l l e cted since its creation
that the form is now ready to be used for outcomes research.
Chapter 31
• The Standardized Medical Record
W8Y. SOAP versJon 5 091102b
Outpatient Osteopathic SOAP Note History Form P:atiml', N:U1U _________
HlSTOR': (Sec:
S
Outplltient H":!Ilth
DOlte______
Surom�ry Form for details
Patient's Pain AJHI.log Scale:
0
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A,<___
,,(history)
done
NQPAIN
WQRSTPOSSIBLE PAIN
cc
Hi!itory orPrese-nt IUneu Location
OR
Quality
or
Severity
Status
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of<:.3 chronic
ill
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Timing
Con/ext Modiryina:
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Duration
�
495
faclors
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encoullter.)
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Gastrointestinal
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P:lst Medical, F�Uy. SOrlallDIWI1'
0
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done
r1!III
Allergies:
V
Medications:
o
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Family histo.,.
c)vergJJ Hh'fory
Averace or HPIt ROS
FIGURE 31.1
or
PFSH.:
IT (l.lHtl)
0 m(l.IIIJ"I.IROI)
I Slinlllure or
o IV (h 1G1.:H MS.l W$H)
exammer.
(8) Page 2, history. (Continued)
CLINICAL OUTCOMES AND EVIDENCE-BASED MEDICINE
Clinical outcomes have become an important buzzword in the lexicon of managed care. Outcomes are measured to predict the course of an ill ness and to analyze the effects of various treatment options. Outcomes data can be divided into three groups: input (stratification of patients based on diagnosis), intervention (treat ment options), and outcomes (results of treatment on the course of the process).26 Measuring outcomes has been facilitated by the addition of symptom data (chief
496
Section IV • Practice Issues
Outpatient Osteopathic SOAP Note Exam Form Q 0 Not done *
P"tiwt'l Namt ______ __ not, Vilal Sism (1 of7) WI. --;;R,"g. ---=- Pt.. position
Sex:
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"
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0
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0
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0
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0
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a
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IV
o No SD or background (BO) levels 2 = ObvioUi TART (esp. Rand n. +/. Ilymptoms 1== M(lrc than BO levels, minor TART 3 = Key 1(s:i(\II�, symptom.'ltic, R and T st:<md out Scvu1ty SOnt;ltic Dyrfuncd.on u,d Othtr S 'Ituru MS fSNS/PNS IL\"M.I CV I RESP.I OliFAS. I ctc. 0 , , 3 0 0 0 0
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(e) Page 3, physical examination. (Continued)
complaint, or the problem24), as well as functional assessments, such as the Rand
SF-36.27 Analysis of outcomes and incorporation into the clinical setting leads to the practice of evidence-based medicine. Over the past several years, there has been an increasing emphasis on outcome measures in the practice of medicine. Medical outcomes research investigates how a process used in providing health care services affects the outcome of the patient'S dis ease or health status. This type of research does not look at mechanisms or causes of the change in outcome, but only the end result of the procedure. Outcomes can include physical data, treatment results, practice encounter characteristics, types and
• Th e Sta ndard i z ed M edica l Record
Cha pter 31
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(D) Page 4, assessment, treatment plan, and determination of E&M level.
frequency of proced ures used, fr e q ue n c y of disease , psychological d a ta satisfaction a c o m b in a tio n of these facto rs. As managed care o rganizations and government age n cies increasingly rely o n c l in ical o u tco mes meas u rements fo r d evel opment o f clin ical p ractice guide l i nes, increasing demands will be pla c e d upon physician s to co n form to these gu ideli nes in thei r practices.n,29 It has bee n suggested that a central resource, such as a pro fessi onal organizat ion, be used to d evel o p practice guid elines, with p ract i tione rs within that orga n ization co ntributing to their develo pme n t.3o By participating in with t r e a tm e nt , quality of life and fu nction, health c a re costs, o r
,
Section IV • Practice Issues
498
Outpatient Osteopathic SOAP Note--Follow-up Form PaticnC.'i Name
�
__________
Agc ___
·ViwlSiglls(Jo(7)
Resp. _
Pulse
Patient's Pain Analog Scale:
Reg.
im!g.
o
Wl.
Dille
____
lit.
Sex:
Male
_____
PI. position (or recording DP Sl.ilndmg___ Silting___
Nol Jon(!
Female
Otliccoi
Lying___
For office IISC only:
Tcmp. _ __
W01�ST roSSIDLF.I'I\IN
\'0 PATN
CC: HPI: (T .ocalioll, Quality, Stverit;.-, Dumlion, Timing. COllh!X!, Modifying (actors, Associ'lll.xi Signs alld S�) PFSA: ROS: (Coustilmiol1.11, Eyes, EarsINosclMollth/Throat. Cardiovll5Culnr, Rcspirnlol)'. Gl, GU, MUSt:Hloske1clal. Inh,!gumentary, Nl.!uroiogiC-.'l), PsychiaLric. Endocrine, HL,natologklLymphulk, Al1t:rgicIl11111l111101ogic)
l�'wl: 111"1
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FIGURE 31.2
The Outpatient Osteopathic SOAP Note, Fol l ow-up Form. (A) Page 1, space allocated for demographics, vital signs, and narratives of the subjective and objective portions of the note. (Continued)
this process, not only d o clinicians become de facro researchers, but the)' also of ne cess ity devel o p lifelong learning skills (and help control their own destiny). The creation of outcomes-based clinical practice guidelines for osteopa t hic medicine will not only have the effect of standardizing osteopa thic medical care on a national basis but will also sign ifi cant ly streamline the process of professional edu cational assessment. Curricula in undergraduate and gr adu a te programs will c hange to more accuratel), reflect the practice of medicine, that is, an integrated, problem-oriented approac h .
Chapter 3 1 • The Standardized Medical Record
wok SOAP Follo.... . llp \'/Jrllon 2:0J !403b
O u t p a t i en t Osteo p a t h i c S O A P N o t e- Fo l low- u p F o r m l-'aLil.:IU ' $ N lIlllL'
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( 8 ) Pa g e 2, a r e a s designa ted to record the diag nostics and tre a tm e nt of somatic dysfu nction, a ssessm ent, treatme n t plan, a nd dete r m i nati on of E & M l evel.
In the present med ical environme n t , it is esse n t i al that the medical professions be able to conduct outcomes research , To enable med i c a l professions to investigate and va l i d a te the i r treatment, diagnostic, and prevention modalities, methods of clinical data col lection in practi ce- based settings must be developed and validated , This process has begun using the Outpatient Osteopathic SOAP Note Form ro col l ect and report incidences o f d i f ferent disease e ntities within a famil y practice. 3 1
500
Sect i o n IV • Pract i c e I s s u e s
P R E A M B LE T O AN E LE CTRONIC M E DICAL R E CORD : T H E VAL I DAT E D SOAP NOT E FO R M
The l o n g-term goal o f L B O R C's progress n o te wor k , d e fined a t the i nau gural mee t i n g in 1 9 9 6 , has been t h e c reation of an electronic ve rsion o f the O utpatient Osteopathic S O AP Note Form for use by all family pra ctitione rs, American Acad emy of Family Physicians ( AA F P ) as we l l as A C O FP. Since that meeti ng, the fede ral gove r n m e n t has man d ate d that within a d ecade near l y a l l A m e r i ca ns must have an e lectronic med ical record . Recognizin g t he impend i n g c h ange , t h e L B O R C , i n a sso ciati o n w i th I n s titu tional Co m p u ting at Des Moines University u n d e r t h e leadersh ip of B rya n La rse n , set o u t to create an o n l ine versio n of the osteo pat hic SOAP n o te fo rm. Named e S O A P, this p r o totypical o n l i n e d ata co llection for m incorpo rates an attract ive We b in t e r face t hat resem b l e s the paper SOAP note fo rm b u t e xists o n th e Wor l d Wide We b . The system a l lows users to log on to a We b site and have a b lan k S O A P note that can be completed wit h d eid entified p a t i e n t d a ta. T h i s el ectronic n o te is avai lab l e fo r use by i n te rested investigators. l2t The original p u rpose of deve l o p i n g e S O A P was to al low the creation o f a natio nal osteopathic data base t hat co u l d p rovid e i n fo r mation on p r a ctice pat terns and efficacy of the diagnostic and the rapeutic measures e m p loyed by physicians practicing manual m e d icine . The current d esign, however i s much m o re flexib le, i n that ad d i tional m o d u l es may be i n corporated as needed fo r specifi c p rojects o r applications. 32:j: This fl exibility permits t h e capabilities of e S O A P to b e en hanced . From the research perspective, the cu rrent system has s u ccessfu l l y co m p l eted beta test trials and i s consid e red sci e n tifical ly val i d ated . 3 6 Beca use t h e p u rpose o f e S O A P was primari l y research, n ot med ial record kee p ing, i t was deci ded to e lim i nate private health informatio n ( PHI) fro m t h e database , s i n ce the i n cl usion of PHI w o u l d n ecessitate specific au thorization from each patient represented in this d atabase . The Health I n s u rance Portability and Acco u n tabi l ity A ct ( H I PAA ) req u i res that speci fic authorization to use PHI for research must be o btained from research participants . Because i t was n o t certain that s uch authorization wou ld be col l ected in every i nstance, the database was con str u cted w i t h o u t t h e inclusion o f PHI. eSOAP retai ns u t i l ity fo r p racticing p h ys i cians a s a chart n o t e , since the physician can , upon co m pletion o f the reco r d , p rin t it and affi x the p a tie nt's i d e n ti fying in formation to it fo r i nclusion in the ch art. W h i le the We b- based eSOAP was functional and attractive, its one key d raw back was that physician s cou l d not read i ly co m p lete the eSOAP wh i l e see i ng patients , since d ata input req u ired being onlin e . Th us, for most p racti ces, a separate session to input data wo u l d be needed . It was concl u d e d t hat t h i s wou l d red uce p a r ticipati on, a conside ration that s u ggested a new version o f eSOAP was needed . In view of t h e forego i ng, L B O R CIIT ( De s Moines) began development of a stand -alone perso n a l co m p u te r ( P C ) version o f the e S O AP. This has been i m ple m e nted on a tab l et com p uter that can be used in t b e e xam i nation room during an o ffice v isit. The inte r face for this stan d -a l o n e e S O AP prod u ct has been redesigned so that m a n y p u l l -d own m e n u s and check boxes a re e m p loyed to keep the use r from h aving t o scro l l d ow n l o n g pages o f informatio n . T h e record can con ta i n PHI, since t h e reco r d \-v i l l reside o n the ph ysician 's com p uter. A hard co py can be printed to go i nto the patien t 's permane n t reco r d . The inaugural d e m o nstrat i o n of
t Ern a i l : brya n . l a rsen@d m u , ed u .
l Em a i l :
tg l o n e k @rcn.com. P a s t
Dean of u n i v e rsity ch a i r, UIORC.
resea rch ,
Des Moines
U n i v e r s i ry
Osteopa r h i c
Medical
Ce n rer.
C h a pter 3 1
• T h e Sta n d a rd i z ed M e d i ca l R e c o rd
50 1
" S ta nd - a l o n e e S O A P " h a s been a n n o u n ced fo r the Fa l l 2 0 0 6 A O A C o n v e n ti o n i n L a s Vega s , N e v a d a . In t h e c o u rse o f develo p m e n t o f t h e sta n d - a l o n e eSO AP, i t bec a m e a p p a r e n t th a t t h i s i n s t r u m e n t cou l d b e used t o d oc u ment items needed fo r t h e A O Ns Clinica l Assess m e n t Progra m ( C A P ) . As
a
res u lt, a d di t i o n a l fi e l d s have been i n corporated
i n to t h e la test v e rs i o n o f the s ta nd - a l o n e eSOAP that w i l l s u pport CAP. As develop m e n t c o nti n u es, i t w i l l he poss i b le to add i ncrea s i n g levels o f fu nctiona l i ty a s fu t u re v e rsi ons of eSOAP a re d e v e l oped . U l t i m a te l y,
an
i n terfa ce w i l l be a va i l a b l e for the
stand-alone eSOAP t h a t w i l l a llow u p l oa d o f d e id e nt i fied d a ta to the n a t i o n a l osteo pa t h ic d a ta base for m a j o r i n ter i n s ti t u t i o n a l s t u d i e s of e ffica c y and practice patte r n s . W i t h i n t h e c l i n i c , p h y s i c i a n s c a n u s e c o mp u te r progress n otes l i n k e d to d ec i s i o n s u pp o r t s ystems to mo d i fy t h e i r p r a c t i c e p a tterns i n respo nse to a q u i c k l y c h a ng ing e n v i r o n m e n t . 1 U 4 Th i r d - p a rry p a yers a c t u a l l y pre fe r el ectro n i c recor d s o v e r h a n d w r i tte n n o tes or e v e n pa per S O A P notes. Keeping el ectronic med i c a l record s ( E M R s ) is n e a r ly e ffo r t l e s s . T h e y tend to be c o m plete, provid i n g t h o r o u g h d oc u m e n ta t i o n fo r t h e med i c a l practice wi th few e r re s u b m i s s i on s , l e s s h a ss l e , a n d grea ter re i m b u rse m e n t : t h e perfect remed y for r i s i n g p ra c t i c e c o s t s . O n e o f t h e p r i nc i p a l a d v a n ta ges o f u s i n g m u ltisite c o m p ut e r p a t i e n t record s i s t h e c a p a b i l i t y o f record i ng l a rge q u a ntities of d a ta w i t h i n a centr a l reposi tory o v e r a re l a t i v e l y s h o r t t i me. W i t h H I PA A -c o m p l i a n t o v e r s i ght, t h e s e d a ta m a y b e a n a I yzed i n c I i n i c a l resea rc h s t u d i e s , v a s t ! y i ncrea s i ng effi c i e n c y o v er c o n v e n t i o n a I
( a n a l og ) m e t h o d s . T h e a d v a n t ages to osteopa t l1 i c p o s tgra d u a te t r a i n i n g i ns t i t u t i o ns a n d fa m i l y m e d ic i ne res i d e n c y progra m s a re en o r m o u s . St u d i es a l re a d y co m pl eted ha ve shown s u bsta ntial economic a d v a n ta ges. A s
a
gro u p , no ma tte r w h ether paper n o tes or e lectro n i c med i a , fa m i l y p h ys i c i a ns ha bitu a l l y u nd e rcode. I n one s m a l l s t u d y ca rr i ed out in 2002,
a
p r i v a te physici a n switched
practice record i n g to use o f the S O A P notes, and the esti m a ted ye a r l y revenue i n c rease a m o unted to $ 1 2,000. The incre ased reve nue was d u e p r i m a r i l y to a SO 'Yo increase in the use of level 3 codes over leve l 2 (Ta ble 3 1 . 1 ) . Ad d computer a i d s a nd rem inders to this m i x to fa c i l ita te acc u ra te cod i ng, a n d re i m b urse m e n t can o n l y go u p . I n a d d i t i o n to prov i d i n g econ o m ic a d v a n tages, in t h e c o n text o f o u tcomes
resea r c h , EMRs p ro v i d e
a
fo r m id a b l e d a ta -h a n d l i n g i n s tru m e n t . It is expected th a t
E sti mated Ye a r l y Rev e n u e I n crease Fo l l owi ng U s e of t h e S O A P N ote Form i n a Pri vate Fa m i ly P ractice Ave r a g e
Yea r ly Breakdown
Code Level
Usage
(%)
January 2002 (%)
Usage
February 2002a U s a g e (%)
70
63
38
3
25
33
50
4
4
3
11
5 Est i m ated yearly i n c r ea se in reve nue: 'New SOAP note form.
$ 1 2,000-1 4,000
502
Section IV • Pract i ce I s s u e s
t h e u s e o f c o m p u ter rec o r d s w i l l gre a t l y fa ci l i ta te t h e a v a i l a b i l i ty o f l a rge a mo u n ts of sta n d a r d ized , c e n tr a l ized d a ta , a d d re s s i n g the need for o u tcomes rese a rc h m ore e ffi c i e n tl y w h i l e effec t i v e l y pro d u c i ng v a l id a te d practice g u i d e l i nes for osteo p a t h i c fa m i l y practice.
T h e Pa p e r S O A P Note F o r m s The o r i g i n a l SOAP n o te for m, the O u tp a t i e n t Osteo p a t h i c S O A P Note Form, was crea ted and v a l i d a ted w i th the i n te n t th a t t h e note w o u ld be a s fo l l o w s : 1 . A standa rd ized record i n g i n strume n t 2 . Used by physici a n s world w i d e 3 . E a s y to u s e a s we l l a s u sefu l i n t h e cl i n i c a l setti n g
3 . U s e d t o s t a n d ard ize e d u c a t io n a n d t h e t r a c k i n g of tra i n i n g ; for d i ffere n t rese a r c h top i c s
5 . A b l e to be mod i fi e d
6 . C a p a b l e o f c o l l e c t i n g re l ia b l e rese a rc h d a ta q u i c k l y To d a te , t h e S O AP notes a re sta n d a r d i ze d , u s e d by p h ys i c i a n s w o r l d w i d e , a n d
h a v e bee n s h o w n t o be e a s y to use a n d u sefu l i n t h e c li n i ca l setting . Rece n t retro spec t i v e s t u d ies have s h o w n t h e note's a b i l i ty to c o l lect re l ia b l e research d a ta q u ickly on many topics a nd to track t h e tra i n i ng o f resi d e n ts . 35,]6 Imagine trying to get 14 oste o p a t h i c p h y s i c i a n s to agree o n the p e r fect n o te fo r everyon e . D iffi c u l t ? I n d eed yes. I m possi ble ? We l l , n o t rea l l y. To fa c i l i ta te conse n
s u s prior to t h e a c t u a l crea tion o f t h e S O A P note, th ree b r o a d a re a s o f n e e d were iden ti fied : c I i n ical practice, ed u c a t i o o , and resea rc h . •
Pro fess i o n a l a n d c l i ni c a l oeed s i n v o l v e prov i d i ng i m proved q u a l i t y p a t i e n t ca re, d e v e l o p i n g pra c t ice g u i d e l i n e s a n d pro v i d i n g j u s t i fica t i o n for re i m b u rseme n t i n ,
a n e a s y - t o - use eifi c i e n t fo r m a t . •
Ed u ca t i o n a l n e e d s i n vo l ve tra c k i n g c a p tu red e x p e r ie nces, e n s u r i n g t h a t d is t i n c t i vely osteo p a t h ic ed u c a tiona l requ irements f o r a cc re d i t a t i o n a n d gr a d u a t i o n a r e m e t , a n d provi d i n g a tra i n i ng t o o l fo r d oc u m e n t a t i o n and cod i n g
•
.
Rese a r c h ne e d s i n v o l v e g a t h e r i n g la rge a m o u n ts o f q u a l i ty resea rc h d a ta i n a sta n d a rd ized for m a t by physic i a n s worl d w i d e u s i n g va l i d a ted i n s t r u m e n ts, w i t h a fra m e w o r k e a s i ly m o d i fi e d fo r a v a rie ty o f topics a n d types of rese a rc h designs ( e . g . , retrospec t i v e , prospective ) .
Advantages o f U s i n g the O u tpati e nt Osteo pat h i c SOAP Note Forms Why use a fo r m r a t h e r t h a n s c r i b b l i n g on a b l a n k piece of pa p e r ? A fo r m is s i m p l e r a n d fa ster t o u s e , sta n d a rd i zed , a n d i t p r o v i d e s u n a m b i g u o u s h a rd c o p y p roo f of w h a t w a s d on e . F u r t h er, i t sa ves the practice a gre a t d ea l of m o n e y t h ro u g h c o d iog re m i n d ers a n d by prov i d i n g p r o p e r, e a s i ly reviewed d oc u m e n ta t i o n . O u tl i ned next a re other a d v a n ta ges.
Educa tional Adva n tages •
Provides tr a c k i ng of p a t i e n t encou nters for p h ys i c i a n s , students, i n terns, a n d res i d e n ts , inc l u d i n g d ia g n oses, treatments, a n d proced ure s . Pa t i e n t e n co u n ters usi ng the S O A P n o te for m s a r e b e i n g a n a l yzed fo r e d u ca t i o n a l tra c k i ng pu rposes . J 5 The use of t h e s e fo rms i n tra i n i ng i ns t i t u ti o n s w i l l i m prove q u a l i ty by c l a r i fy i n g t h e a cc r ed i ta t ion and gra d u a ti o n p rocess.
Chapte r 31
• T h e Sta n d a rd i z ed M e d i c a l Record
503
•
Documents w h ether competency req uirements a re bei ng met. The series i s rec ommended for use by Americ a n Association of Colleges of OsteDpa thic
•
Provides training and reminders with regard to documentation. Studen ts, interns, and residents who have used the initial SOAP note form found it easy to use and
•
Provides tra ining i n coding. Phys i c i a n s i n tra ining who ha ve used the form i n
Medic ine ( A ACOM ) .
helpful in reminding them of items they were forgetting during patient encounters . 1 t h e past now request to use it because o f its tra i n i n g va lue. •
Reminds the aut hor th at there may be a musc u l os keleta l component to consider.
•
Provides for a u n i form education a l tra cking in fra structure.
Research Advantages • •
Fac i l i tates retros pective c ha rt rev iew36 Faci l i tates outcomes research 3 1 , 3 5 , 3 6
•
Ada pts ea s i ly for use in prospective studies
•
Accepts addition al study-spec i fic modu les a s req u ired
•
A l l ows data to be arc h i ved in a n a tionw ide d a ta ba se for access by i n vestigators addres s i n g other research question s . Such an a rchive a l s o may provide the n a t ura l history of a disea se or a ssist in finding anomalous regional hea l th pattern s useful in fig hting the war on b i oterrorism.
•
Provides
•
Has been va lida ted in publis hed studies funded by the AOA i ,35-37
a
un i form researc h i n frastructure a mong cooperating grou ps
Pro fession Advantages •
Un i form notes m a k e auditing and peer rev iew easier on the revi ewer.
•
C l ear coding j usti fication promotes reimbursement.
•
The conden sed note format promotes doc umen ting more of what occurred dur
•
It mi nim izes lack of reimbursement or c l a i m rej ection due to u n c lear n otes .
•
It yields payme nt when charges look suspic ious for d i a gnoses used, suc h a s with
•
It renders obvious how many and what body regions a re treated.
ing the patient encounter, l eadin g to higher coding levels.
Medicare, prol onged visits, and counsel ing. •
It eases credentia l ing of hos pita l s , schools, and progr a m s , especia lly w i th regard to the musculoskeletal c omponen t .
•
I t provides trac k i n g o f patient en counters for i mproved c l i n ical pra ctice.
•
CME credit is a va i l a ble for training i n th e use of the form .
•
A va riety of forms are a va i l able for speci fic k in ds of patient vi sits .
•
It is time effic ient.
•
It a ll ow s for less th i n king about reporting for m at, hence more thi n k i ng abo u t
t h e patien t . Patient A dvan tages •
Promotes easy trac king of p a t i ents' p rogress overa l l and progress w i th respect to pain management through the pain a n a l og scale
•
Fa c i l i tates c l i n ic a l guidel ine development
•
Identifies fi n d ings that a re out of the ordina ry to prompt early intervention
•
Fa cil ita tes q u a l ity assura nce by peer revi ew
•
M a k es items in the n ote, suc h as diagnoses, trea tment, and procedures, easy to
•
Aids i n iden tifi c a tion of procedu res that are help ing o r n o t helping t h e patient
find from visit to v i s i t and th at s hou ld be conti nued or disconti n ued
Sect i o n IV • Practice I ss u e s
504
T h e S O A P n o t e fo rms a re effective d a t a -g a t hering i n s t r u m e n ts fo r a nswering o u tcomes q u e s t i o n s fa c i ng osteo p a t h ic med icine tod a y. I n p u b l ished o u tcomes a n a lyses,3 1 ,35,36 q u e s t i o n s were a n swered based o n freq u e n c ies, averages, corre l a t i o n s , a n d c o m p a r i s o n s . A l l q u estions a s k e d co u l d be a ns w e red u s ing d a ta from the S O A P n o te fo r m s . For exa m p l e , the severity o f s o m a tic d y sfu nction, the n u m b e r o f regi o n s trea ted w i t h O MT, proced u res u s e d , a n d responses t o trea t m e n t c o u l d a l l be e x p l o r e d . Q u e s t i o n s on a verages, such a s age, d u r a tion o f visit, a nd fo l l ow- u p t i m e , were a n swered . Q u e s t i o n s on correlations between d i sease e n t ities and spec i fi c OMT proced u res u sed and between severity o f som a t i c d ys f u n c t i o n a n d O MT tre a t m e n t response were a n swered . Q u e s t i o n s on d i fferen ces a m ong d octors, such a s the top fo u r d ia g n oses o f each
a tte n d i n g p h y s i c i a n , were
a d dresse d . In a d d i t i o n to answe r i ng t h ese k i n d s of o u tcomes q u estions, the S O A P n o tes p r o v i d e d t h e fo l l ow ing fu n c t i o n s : postd octora l a n d p red octo r a l t r a ck i n g , a d d i t i on a l o u tcomes research i nto t h e efficacy of osteopa t h i c in terv e n tion , medica l science rese a rc h , a u to n o m i c c o r re l a t i o n with d i s e a s e en t i ti e s , d o c u m e n t a t i o n o n t h e n a t u ra l h i story o f m u scu loske l e t a l d y s f u n c t i o n , a n d
bi l l ing i n fo r m a t i o n .
F u r t h e r, t h e d a ta p e r m itted i n te r n a l comp a r i s o n s a m o ng osteopa thic p h y s ic i a n s .
The Forms Gen eral
B a s i c informa tion nee d ed for e d u c a tiona I a n d research p u r poses for tra c k i n g a n d d a t a ga t h e r i ng a s d e t e r m i ned by LBORC a n d c o n firmed b y a retrospec t i ve stu d y3 6 i n c l u d es the fo l l o wing: 1. First and l a s t n a m e and d a te o f v i s i t o n eac h p a ge 2. Age 3 . P a t i e n t 's p a i n a n a l og sca l e 4 . C h i e f c om p l a i n t 5 . M u s c u l o s k e l e ta l ta b l e ( s ) to incl u d e e ither chec k i n g a b o x t h a t sta tes " a l l n o t
d o n e " o r some c o m b i n a tion of methods u s e d fo r exa m i n a tion or exa m i na t i o n m e t h o d u s e d ( ti s s u e texture c h a nge, asymmetry, ra nge o f m o t i o n , a nd ten d er ness [TART] ) , severity of som a t i c dysfu n c t i o n , description o f s o m a t i c d ys fu n c tion fi n d i ngs, whe t h e r OMT wa s performed, what OMT proced ures were used , a n d respon se to tre a t m e n t 6 . P h y s ic i a n 's e v a l u a ti o n of t h e p a t i e n t p r i o r to treatment ( fi rst v i s i t o r reso lved
or i m proved or u n c h a nged or wo rse ) 7. Prior i t i zed d i agnoses, written o u t a n d r C D - 9 CM-coded 8. M i n u tes spen t w i t h the p a t i e n t 9 . Follow- u p rec o m m e n d ed i n n u m be r o f d a y s , week s , m o n t h s , years o r a s
needed 1 0 . N u m be r o f a re a s o n which OMT w a s pe r formed 11 . O ther proced u res p e r formed , i n c l u d i ng C u rrent Proced u r a l
Ter m i n o l o gy
( CPT ) code and written d e s c r i p t i o n 1 2 . E & M cod e 1 3 . Sig n a tures of exa m i ne r a n d tra n scri b e r ( i f o n e is used ) at t h e bottom of e a c h
p a ge T h i s b a s ic i n forma t i o n i nc l u d e s on Iy i n fo r m a t i o n perti n e n t to the chief com p l a i n t a n d excl u d e s the com p lete genera l h i story, s u c h a s the past med ica.1 h i story, hea l t h m a i n tena nce i n fo r m a t i o n , a n d other d a ta t h a t are not needed for every fo l l ow up vis i t .
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Th ree vers i o n s of the SOAP n ote fo r m a re recommended for u s e a nd can be d ownloa d ed from t h e ACOFP and AAO We b site s : 25 1 . O u tp a t i e n t Osteop a t h i c SOAP Note Form
( 1 9 9 8 ) , o n e page
2 . O u tp a t i e n t Osteop a t h i c SOAP Note-Fo l l o w - u p Form ( revised
2 0 0 2 ) , two pages ( Fig. 3 1 . 2 ) 3 . O u tp a t i e n t Osteop a t h i c S O A P N o t e F o r m Series ( re v i sed 2002 ) , th ree or fo u r pages ( Fi g . 3 1 . 1 ) Specialty Forms Developed fro m the Origina l SOAP Note Forms
1 . O u t p a t i e n t Osteo path ic Single Orga n System Muscu loskeleta l Form Series 2. O u t p a t i e n t O s teopa t h i c Cra n i a l SOAP Note Fo r m §
3. Osteopa t h i c M u s c u l osk e le t a l Exam i n a ti o n o f the Hos p i ta l ized Patient, a o n e
page i n patient form for o n ly t h e exa m i n a ti o n porri on of a p a t i e n t e n co u n ter '· * A l l of the S O A P notes d e v e l o ped since 1 9 9 6 a re recom m e n d e d for use by t h e A O A , A A C O M , ACO FP, a n d A A O . The orig i n a l o n e -p a ge n o t e , O u tp a ti e n t Osteopa t h i c S O A P Note For m , w a s v a l i d a ted i n 1 99 7 , with t h e copyri g h t secured i n 1 9 9 8 and the v a l i d a t i o n study p u b l i s h e d i n 1 9 9 9 . A l t hough i t w a s a d eq u a te a t t h e ti me, 2 years l a ter a revision p rocess bega n . This exp a n d e d t h e form t o two p a ges a nd beca me the O u tp a t i e n t Osteo p a th i c S O A P Note Follow- u p Form, copy righ t sec u red in 2002. Through interaction a n d fee d b a c k from the osteop a t h i c comm u n i ty, i t was dete r m i n ed t h a t severa l n o tes w e r e needed . A n i n i t i a l - v i s i t for m w a s d eemed necessa ry, a n d t h e for m was fu r t h er expa nded to become t he fou r page O u t p a ti e n t O s teopa t h i c SOAP Note Form Series . The Outpatient Osteopathic SOAP Note Form Series is i ntended for use in p r i m a r y ca re p ractice and m a nipu l a ti ve med icine spec i a l ty practices o t h e r t h a n osteopa t h i c practices. The O u tpatient Osteopathic Single Organ System Musculoskeleta l Form Series ( S O S ) was va l id a ted in 2 0 0 4 . 3 1 This series i s intended fo r use in osteop a t h i c ma n i p u l a t i v e med i c i n e spec i a l ty pra ctices o r w h e never a comp lete m u sc u l os k e l et a l e xa m i n a ti o n i s need e d , such a s d u r i n g a n i n i t i a l h istory a n d p h ysica l . T h e m a i n d i f fe rence between the S O A P note series a n d the SOS is t h e exa mina tion fo r m . I n the SOS, the exa m i na t ion fo r m is d e ta i l e d to i nc l u d e i te m s needed for a compre h e n sive exa m i n a t i o n fo r c o d i n g . In a d d i tion, i t s u ggests i t e m s t h a t the physician m a y want t o t r a c k or t h a t a re u s e fu l i n osteop a t h i c trea tme n t . T h e O u t p a t i e n t Osteopa th i c C ra n i a l S O A P N o t e F o r m D i s des igned s pec i fica l ly fo r os teo p a t h i c p h ys i cia ns who primari l y u s e c r a n i a l osteopa thy or fo r p a t i e nts w h o h a v e a h e a d d i sorder or dysfu nc t i o n . A l l of t h e s e for m s c a n be u sed together o r s e p a r a te l y i n a n o u t p a ti e n t o ffice i n a n y m a n n e r t h e practitioner c h ooses. F o r exa mp le, o n a n initi a l vis i t o n e c o u l d u s e th e O u tp a t i e n t Osteopa t h i c S O A P N o t e Form Series. At t h e f i r s t v is i t , t h e physi cian fi nds tha t the patient h a s low back p a i n, a n d o n a ret u r n v i sit, a c o m p lete m u sc u l oskeletal e x a m i n a t i o n i s g i ve n . For this rer u m v i s it, one co u l d u s e the O u tp a t i e n t Osteop a t h i c S i ngl e Organ System Muscu l os k e leta l Form Series. For s u bs e q u e n t fo l l o w - u p v i s i ts for OMT, the O u t p a t i e n t Oste o p a th i c S O A P Note-Fo l l o w- u p Form w i l l w o r k we l l fo r record i n g t h e encounters . A l l of these fo rms co n ta i n the basic i nfor m a t i o n needed fo r c l i n i c a l , ed u c a t i onal, and research p u rpose s . The origi na l O u tp a t i e n t Osteopa t h i c SOAP Note Form was designed so
SSpearheaded by L B O R C m e m be r
Mills. Michael K uchera.
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Section IV • Pract i ce I s s u e s
506
t h a t physicia n s c o u l d m a k e u p their own e x p a nd e d vers i o n s fo r c l i n i ca l or research p urposes so a s l o n g a s they conta i ne d t h e basic re q u i re d i n fo r m a t i o n and a p p e a red i n the same ge nera l form a t o f the origi n a l note. The basic i n for m a t i o n a nd fo r m a t t i n g a r e i m p o rta n t for ease of d a ta extractio n . In
1998,
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Muscu loskel eta l
Exa m i n a tion-Hos p i t a l F o r m a n d I n s tr u c t i o n Ma n u a l w a s deve l o p e d . S h o r t l y therea fte r, the A O A H o u s e o f Delegates reco m m e n d e d t he form fo r u s e b y osteopathic s tu d e n ts a n d r es i d e n ts i n t h e hosp i ta l s e tti n g . 3 8 T h e p r i n c i p l e s a n d b a s i c i n fo r m a t i o n o f t h e O u t p a t i e n t Osteopa thic S O A P Note F o r m were p u t t o yet a n o ther u s e . T h e s a l i e n t fea ture o f a l l of t hese forms i s t h e u n i q u e l y osteopa t h i c m u sc u l os k e le tal ta b l e . Th is t a b l e i n c l udes TART for regi o n s examined, presence and severity of s o m a tic d ysfu n c t i on, a n d somet i mes, depend i n g o n the fo rm, whether O MT was done, what m od a l ities were u s e d , and what t h e response to trea tme n t was. The Forms: Detail
T h e o r igi na l O u tp a t ie n t Osteopathic S O A P N o te For m , n o w o bsolete, was
a
one
page n o t e . I t w a s the s i mplest p a p e r version and was e a s y to li se i n c l i n i ca l prac tice but was l i m ited i n t h e a mo u n t o f s p ace a v a i l a b l e fo r cha rting. I t w a s designed for u se i n the ou tpa tient setti ng, u s u a l J y fo r a fo l l o w - u p o r re t u r n v i s i t . From the research p e rspective, i t a l re a d y h a s been applied s u ccessfu lly to o u tcomes resea rc h in fa m i l y practice . 3 l However, it collected m i n i m a l d a t a a n d w a s ve r y d e ficient i n g a i n ing u sefu l i n for m a t i o n a bo u t d i agnoses. I t a l so h a s been u s e d fo r e d u c a tio n a l tra c k i n g . l ,3 l The revised O u tp a t i e n t O s t e o p a thic S O A P No te-Fo l l o w - u p Form , t h e p re ferred e s t a b l i s h e d - p a t i e n t n o te fo r priva te practice, is a tw o-page note25 ( F ig. 3 1. 2 ) . T h i s form is a n expa n d e d version o f the origi n a l S O AP note fo rm tha t p rov i d es a d d i tion a l space for h a n dwritten n o tes in t h e s u bjective a n d o b j ec t i v e sec t i o n s a n d a more structured a n d d e t a i l e d w a y of l isti ng d i a g n o s i s . In a d d i t i o n , t h e re
IS
consid
era b l y g r e a t e r d e t a i l w i t h r e g a r d t o cod i ng, p a r t i cu l a r l y i n t h e s u bj ective, a ssess m e n t, a n d p l a n secti o n s of the form . When copied fro n t to back, the fo rm may be p l a c e d on a s i ngle sheet o f p a p er, m a k i n g it e a s i e r to m a n i p u la te d u ring the p a t i e n t enco u n ter w h i l e red uci ng p a g e s i n t h e patien t'S c h a r t , t w o fe a t u res t h a t a r e rea d i l y a pprecia ted i n b u s y practices . The revised O u tp a t i e n t Osteop a t h ic S O AP Note F o r m Series, the p re ferred n o te for a new p a t i e n t v i s i t a n d p h ys i ci a n s i n train i n g , is a three- to fo u r- p a ge note25 (Fig. 3 1 . 1 ) . This s e r i e s i n c l u d e s an o u tpatient hea l t h s u m m a r y ( fi l l ed i n most ly d u r i n g the first v i s i t ) a n d th ree pages for t h e p rogress note, t h e history fo rm, e xa m i n a t i o n fo r m , a n d a s sessment a n d p l a n fo rm. I t co n ta i n s more i n fo r m a t i o n b u t i s s t i l l s i m p l e a n d e a s y t o u s e once o n e i s fa m i l i a r w i t h i ts form a t . I t h a s m o re room to write s u b j ective and o bj e c t i v e fin d i n gs and an i ncrease in cod i n g tra i n i n g i n for m a t i o n . Beca use of this it i s d esigned fo r u s e in t h e o u t p a t i e n t setti ng, u s u a l J y fo r a n e w p a t i e n t . With more cod ing g u i d e l i n e s i nc l u d e d , this is the i d e a l note fo r p h ys ici a ns i n tra i n i ng to u s e w i th n e w - p a t i en t a nd fo l l ow- u p visits . From t h e e d u c a t i o n a l track i ng a nd resea rch perspectives, these n o tes a re c o n s i d e red equa l l y competent, a s they b o t h c o n t a i n t h e essen t i a l i n fo rm a t i o n d e emed necessa ry by the LBORC. T h e S O S form is a three- t o fo u r-page note ( w i t h s u m mary page ) d esigned t o c o m p lement the SOAP n ote for m . 25•37,39 I t s u s e a t the i n it i a l v i s i t a l lows t h e other SOAP note fo rms to be used most effectively as fo l low- up fo r m s . In a d d i tion to the
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i nfo rmation i n the muscu loskeletal ta b l e , the SOS for m includes such i tems a s gait a n d station, spina l curves, exa m i n a ti o n positi o n s , leg l engths, leve l ness o f l a nd ma rk s , reflexes, and motor eva l u a tion t h a t i s required i n a comprehen sive exa m i n a t i o n of the muscu loskeleta l syste m . O t h e r areas o f the for m incl u d e the gen e ra l a ppea rance, ca rd i ovasc u l a r, l y m p h a tic, skin a n d n e u r o l ogi c/psyc h i a tric examinations. These s pe c i fic a reas were i n c l u d ed fo r cod i n g p u r poses and are l isted in box form for ea s y u s e . The SOS form is s t ructured so t h a t if a l l a r e a s a nd boxes a re fil led, the p h ysic i a n wi l l have met a l l cod i ng criteria for re i m b u rsem e n t for a level 5 c o m preh e n s i v e exam i n a tion a s s e t forth b y the May 1 99 7 Hea l t h Ca re Fina ncing A d m i n istra tion . T h e O u tpa t i e n t Osteopa t h ic Cra n i a l S O A P Note Form is a specia l ty for m for u s e w i t h o u t p a ti e nts w h o h a v e sign i fica n t cra n i a l dysfuncti o n . It s i mp l i fies d o c u mentat i o n of c ra n i a l fi nd ings a n d the res u l ts of trea t m e n t . 2 5 T h e Osteo p a t h ic M u scu los ke leta l Exa m i n a t i o n of the H o s p ita l ized P a t i e n t is the i n p a t i e n t fo rm reco m m e n d ed by th e A O A for the stan d a r d i zed hos p i ta l struc t u r a l e x a m i n a t ion in a l l osteop a thic hosp i t a l s . 2 5 ,38 It is a o n e - page form with a n o p ti o n a l w o r k s h e e t t h a t h a s m a ny o f t h e fea t u re s o f t h e SOAP note series form , most no ta b l y t h e p resence o f th e muscu l o s k e l etal s o m a t i c d y s fu nction ta b l e . T h i s fo rm i s l i m ited i n th a t i t contains the e xa m i n a ti o n p o r t i o n b u t n o h i story, assess ment, p l a n , o r trea t m e n t g i ven d u ring a p a t i e n t enco u nter. Outp a tient Os teopa thic SOAP Note Form Series: Form Pages
Of t h e t h ree S O A P n o te fo rms a v a il a b l e , t h i s v e r s i o n i s t h e m o s t co m p re h e n s i ve . I t i n c l u d e s t h e O u tp a t i e n t Hea l t h S u mm a ry F o r m , t h e O u tpa t i en t O s teo p a th i c S O A P N o te H i s to r y F o r m ( pa ge 1 o f 3 ) , t h e O u t p a t i e n t O s teopa t h i c S O AP Note Ex a m i n a t i o n F o r m ( p a ge 2 o f 3 ) , a n d t h e O u tp a t i e n t O s t e o pa t hic A s se s s m e n t a n d P l a n F o r m ( pa g e 3 of 3 ) ( Fi g . 3 1 . 1 , A-D ) . O n t h e s e fo r m s , bo l d b l a c k boxes a re p r o v i ded fo r m a n y o f the e n t r i e s t h a t i n d i c a te t h e d a t a c r i t i c a l t o resea r c h a n d re q u i r e d to be fil led in. Th e fo r m a t o f these fo r m s w a s d e s i g n e d so t h a t d a ta cou l d ea s i l y be c o l lected a n d a n a l y zed by c o m p u te r a nd s o t h a t a d d i t i ons t o t h e fo rm c o u l d be m a d e wi t h o u t d i s r u p t i o n o f b a s i c d a ta g a t h e r i ng . A l l d e fi n i ti o n s a re o b ta i n e d fr om t h e s ta n d a rd C P T a n d I C D - 9 C M b o o k s a n d t h e G l o s s a ry of O s te o p a t h i c Term i n o l ogy. 4 0 This va l i d , sta n da r d i ze d , a n d easy-to-use fo rm i s our best recom m e n d a ti o n fo r resea rch a nd tra ining i n osteop a t h i c med ic i n e . O u tp a t i e n t H e a l t h S u mm a r y i s t h e fro n t left- h a n d p a ge o f a two-sec t i o n ch art system or rhe fro n t page of a one-section chart (Fig. 3 1 . 1 A ) . T h is page i s reviewed a t eac h patient v i s i t, a n d all sect ions a re kept c u rre n t . It i s d i vided i n to six sec t i o n s : l . I d e n t i fica tion a nd d i spositio n 1 1 . S oc i a l a n d fa m i l y h i s tory
I I I . P a s t med i ca l h i story I V. Hea l t h m a i n te n a n c e
V. Past s u r g i c a I h i s t o ry
V1 . Con s u l ta n ts
At each p a t i e n t v i s i t , t h i s sec t i o n provi d e s r a p i d retrieva l of past med ic a l , s u rgi ca l , s oc i a l , fa m i l y, a l l e rgy and med i c a ti o n h i s tory and a l i s t of co n s u l ta n ts, r o u t i n e scree n i ng d a tes, a n d i m m u n i za ti o n s . Th i s form a l so c o n t a i n s ge nera l d e mogra phic i n fo r m a t i o n , i nc l u d i n g d a te o f b i rth , sex, m a r i t a l sta tu s , s ign i fica n t o t hers, re li g i o n , d a te and u pd a te s , p h o n e n u m bers, d o- n o t - re s u scita te s ta t u s , a nd whom a n d h o w t o ca l l i n c a se of a n e m ergen c y. ,
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Sect i o n IV • Practice I s s u e s
The o u t p a t i e n t history fo r m , p a g e 1 of 3 , p r o v i d e s t h e s u b j ec t i ve por t i o n o f a SOAP n o te fo r an o u t p a t i e n t v i s i t ( F i g . 3 1 . 1 B ) . It is d iv i d e d i n to t w o sec t i o n s : 1 . P a t i ent's n a m e , date, a g e , p a i n a n a l og sca l e , a n d c h i e f co m p l a i n t I I . H i s tory o f p rese n t i l lness, review o f s y s t e m s , a n d p a s t m e d i c a l , fa m i l y, a n d
s oc i a l h i s to r y T h e seco n d sec t i o n i s d e s i g n e d t o m a k e the cOll n t i n g o f e l e m ents e a s y fo r b i l l ing p u rposes. O nce i te m s i n e a c h s e c t i o n a re co u n te d , the p h y s i c i a n ca n c h oose r h e a pp r o p r i a te leve l o f c o d i n g s im p l y b y l o o k i ng to t h e l e ft of e a c h secti o n . A t t h e bot t o m o f the page, the three sections a b ove a re c o l l a ted to c o m p u t e a fi n a l h i s t o r y level to b e used o n t h e l a s t p a g e to d e te r m i n e t h e E & M s e r v ice c o d e . O u tp a t i e n t O s teop a t h i c S O AP N o t e Ex a m Fo r m , p a g e 2 o f 3 , p r o v i d es s p a c e for t h e o bj ective, or p h y s ic a l exa m i n a ti o n , fi n d i n gs secti o n o f t h e S O AP n o t e ( F i g . 3 1.1 C) . It is d i v i d e d i n to fo u r sec t i o n s : I . T h e p a t i e n t 'S n a m e , d a te , s e x , a n d v i t a l s ig n s I I . O b j ec t i ve secti o n ( c on t i n u e d ) I l l . H o r i z o n ta l planes a n d l e v e l of gene ra l m u l t i s y s t e m exa m i n a ti o n IV. M usc u l oskele t a I ta ble
Phys ica l fi nd i n gs fo r any a re a s or s y s tems o f the genera l m u l t isys tem e xa m i n a t i o n a re rec o r d e d i n t h e o bj e cti v e sec t i o n . A d i a g ra m i s u s e d o n th i s p a g e to i n d i ca te leve l n ess o f l a n d m a r ks . T h e d i a g r a m i s p laced for r h e con v e n ie n c e o f t h e reco r d e r a nd can b e u s e d i n a ny w a y t h e recorder w i s h es . It is n o t esse n t i a l t o c o l l e e r b a seli ne re s e a r c h d a ta . Sta rred a r e a s o n th i s page a re fo r c o d i n g a s s i s ta nce . K e y p o i nts to r e me m b e r a re t h a t e a c h e x tremity i s c o u nted i n d i v id u a l l y fo r ele m e n ts in t h e e xa m i n a tion section but a r e g ro u p e d in t h e trea t m e n t sec t i o n and th a t t h e s p i n e ( th o r a c i c , ri b s , l u m b a r, s a cr u mJpe l v i s , p e l visli n n o m . , a b d .lo t h e r ) i s g ro u ped i n t h e e x a m i n a t i o n sec t i o n b u t c o u n ted sepa ra te l y i n t h e t re a tm e nt sec t i o n . Each TA RT criterion for each e x a m i n a ti o n region is c o u n ted as one e l e m e n t . A n exa m i n a t i o n c o n d ucted i n the u s u a l o s teopa t h i c mann e r w o u l d t h e n p r o v i d e fo u r e l e m e n ts p e r s pe c i fi e d re g i o n . T h e a l l o w ed regio ns-( 1 ) h e a d , face, a n d n ec k ;
( 2 ) s p i n e ; ( 3 ) r i g fl t u p p er e x t remity; ( 4 ) l e ft u p p er extrem i ty ; ( 5 ) r ig h t l o w e r e x tre m i t y ; ( 6 ) l e ft l o w e r e x t r e m i ty-are gro u ped a nd sta r re d o n t h e fo r m fo r e a s y rem e m bra n c e . A c o d i n g gu i d e f o r t h e fi n a l exa m i n a ti o n l e v e l i s pres e n t o n t h e fo r m . T h e fi na l exa m i n a t i o n c o d e c a n t h e n be tra ns fe rred t o t h e t h i rd p a ge fo r c o m p u t i n g t h e fi n a l l e v e l of t h e E & M service c o d e fo r the v i s i t . O u t pa t i e n t Osteopa t h i c S O A P Note Assess m e n t a n d P l a n Form, p a ge 3 o f 3 , i s d i v i d ed in to s i x s e c t i o n s beg i n n i ng w i t h the a s sess m e n t se cti o n o f t h e S O A P n o te ( F ig. 3 1 . 1 D ) . I . Pa t i e n t 's n a m e a n d d a te I I . D i a g n o s i s a n d e v a l ua ti o n p r i o r to t r e a t m e n t
I I I . P l a n : som a t i c d ys f u n c t i o n regio n , O M T d o ne , t r e a tm e n t m e t h o d ( s ) used , a n d response t o O MT I V. O t h e r t re a tme n t m e t h o d s used V. Cod i n g V I . M i n u te s s pe n t w i t h t h e pa tient, fo l l o w - u p , u n i ts , O M T pe rfo r m e d a s a b ove
( n u m be r of a re a s ) , o t h e r proced ures perfo r m e d , a n d E&M codes The newest fo rms provide fo r priori t i z a t i o n o f d i a g n oses a n d space fo r b o t h w r i tt e n d i agn oses a n d their associa ted I C D - 9 CM codes. Space i s pro v i d ed fo r o t h e r t re a t m e n t meth o d s , s u c h a s m e d i c a m e n t s , exerc i s e , n u t r i t i o n , p h y s ica l t h e ra p y, a n d
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• T h e Standardized M ed i c a l R e c o rd
509
a ny th ing el se that a phys i c i a n m i ght o r d e r. The cod i ng sect i o n i ncl u d es n i teri a for both cod i ng by com ponents and cod ing by tim e , w h ichever the p h ys i c i a n ma y n eed fo r a pa rticu l a r v i s i t . Area s w he re OMT c a n be perfo r m e d inc l u d e h e a d and fa ce, nec k , t h o r a c i c , r i bs , l u m ba r, sacru m , pel v is, a bd o m e n/other, upper extremity, a n d lower ex trem i t y. T h i s p a ge a lso i n c l u d e s t h e ta b l e for fi guring t h e fin a l l e v e l o f serv i ce E & lvl code, the aggrega te o f each fin a l level o f service for the h i sto r y, exa min a t i o n , a nd med ica l dec i s i o n m a k i n g . A l l o t h e r v e r s i o n s o f the S O A P for m s a r e v a r i a tions o n these form s . T h e y a l l h a ve t h e basic esse n tia l i n fo r m a t i o n for research a n d trac k i n g p u rposes b u t h a v e m o r e o r l e s s in fo r m a ti o n i n speci fic a re a s .
U s a g e G u i d es, M ate ria ls, a n d Cou rses Ava i l a b l e P u b l i s h ed a n d b o u n d u s a ge g u i d es ( s ec u red b y c o p y ri g h t ) fo r th ree o f t h e S O AP notes, each o f w h i c h conta i ns b l a n k fu l l - p a ge copies of the forms, m a y be o b ta ined in 11 a rd c o p y versions, w i t h o u t c h a rge, fro m the Ameri c a n A c a d e my of Osteopathy ( 3 5 0 0 De Pauw B l v d . , S u i te 1 0 8 0 , In d i a n a po l i s , I N 4 6 2 3 6- 1 1 3 6 ) . The forms are titled O u tp a t i e n t Osteo p a t h i c S O A P Note Form S e r i e s , O u tp a t i e n t Osteopa thic SOAP Note Follo w-Up Form, a n d O u t p a ti e n t O s te o p a t h i c S i n g l e O rgan System M u sc u l os k e l et a l Form Series. I n a d d i ti o n , e a c h for m , i n c l ud i ng t h e O u t p a ti e n t Osteopa t h i c C ra n i a l S O A P N o t e F o r m , m a y be d o w n l oa d ed fro m th e A A O 's We b si te25 or the We b s i te o f the ACOFP. 2s T h e Osteop a t h ic M u s c u loskele t a l Ex a mi n a ti o n o f the Hospita l i zed Patient is a v a i l a b l e t h ro u g h the We b s i te o f t h e A C O F P.25 An i n s t r u cto r's kit fo r tra i n i n g u sers to be cenified ( for q u a lity a ss u ra nce ) a l s o i s a v a i l a b l e u p on request from t h e LBORC c h a i r. t t Partic i p a n t k i ts i d e ntical to t h a t u s ed i n t h e c o n v e n t i o n s ' certi fic a t i o n cou rse a r e a va i l a b l e t h ro u g h the A A O . T h e tra i n i n g k i t c o n ta i n s t h e fo l l ow i n g mod u l e s :
of t h e O ut p a t i e n t O s teo p a t h ic S i n g l e Orga n System ( S O S ) a nd S OA P N o t e F o r m S e r i e s P h y s i ci a n De mogra p h ic/Pa rticip a t i o n Form Tra i n i ng o u tl i nes fo r the O u t p a t i e n t Osteopa t h i c S O S M u sc u l oske leta l Exa m Form Series a n d O u tp a tient Osteopa t h i c S O A P N o te Form Series C u r re n t a p p l i c a t i o n s Tra i n ing o b j ectives fo r t h e O u tp a t i e n t Osteopa t h ic SOS a nd S O A P N o t e Forms U s a ge gu i d es, w i t h b l a n k fo rms, fo r the O u tp a t i e n t O s teopa th i c SOAP Note Form Series, the S O A P Note Form ( s h o rt fo r m ) , the Fo l l ow-up Form , a nd t h e SOS M u s c u l os k e l e t a l F o r m Ser ies D o c u m e n t a t i o n g u i d e l ines a n d cod i ng, i n c l u d i ng E&M c o d ing and d oc u m e n t a t i o n g u i d e l i nes, 1 9 9 5 , 1 9 9 7 Ad d itiona l d a ta s u rvey tools ( R a n d 3 6 -Item Hea l t h S u rvey 1 . 0 [SF3 6 ] , R a n d Hea l t h Sciences Progra m; Muscu l o s k e l e ta l O u tco mes D a t a Eva l u a ti o n a nd Ma nagement System; Consumer Satisfaction S u rvey, 2 n d edition, GHAAlDavjes & Wa re; S peci a l ized Osteopa t h i c Questionna i re, LBORC, A O A for Osteopa t h ic Ma n i pu lative Med i c i n e Patient Sati sfaction ) Ce rti fica t i o n process, i n c l u d ing i n s tr u c t i ons, case stud ies, a nd b l a n k fo rms
1 . P a rti c i pa nt L i s t F o r m for ceni fica t i o n 2.
3. 4. 5.
6.
7.
8.
9.
" ConraC[ rhe L B O R C ch a i r, now M i c h a e l A. Se ffi nge r, Depa r t m e n t of O S l l'o p J t h i c IVb n i p u l ,l ti v e Med i c i n e , Col kge o f OSleoparh i c Medicine o f rhe P a c i fic, We,rern U n i versity o f Hc<, l r h Sciences, 3 0 9 E a s t Seco n d Srrler, i'o m o ll ;l , C A 9 1 766· [ 8 5 4 .
510
Section I V • P ract ice I ss u es
1 0 . A CD-ROM co n ta i n i n g a PowerPo i nt tu toria l on the use of the n o tes 1 1 . A DVD a u d i o t u t o r i a l on the use o f the n o tes CON C L U DI N G R E MAR KS
S O A P n o te i n s t ru m e nts are a set of too l s for d o c u m e n ting a l l a s pects of t h e c l i n i c a l practice o f osteopa th i c med i c i n e , partic u l a rl y tbose t h a t a d d ress efficacy i n t h e rea l m of m u s c u l o s k e leta l d ia g n o s i s an d trea t m e n t . T h e imp o r t a nce o f this c a n n o t be oversta ted, beca u se it is t h e d i a gnosis a nd trea t m e n t o f somatic d y s fu n c t i on t h a t to a great extent d i stingu i s h o s teopa t h i c med i c i n e from a l l other m e d ica l p r o fe s s i o n s . W hen fi rst s e e n , S O A P n o t e i n s t r u m e n ts prese n t a d a u n t i n g o bstacle. L ike i ncome tax fo rms, they are horri ble, ugly th i n gs. These a u t hors, h o wever, a re not going to a p ologize for them beca use these notes or somet h i ng very m u c h l i k e them w i l l soon be h e re for every overworked p ra c t i c i n g physician to co m p lete. B u t r e a l l y, h onora b l e c o l l e a gues-c ome on. A d a pt. Let y o u ng postdoctoral stu d e n ts lead t h e wa y. Let t he stu d e n ts teac h the tea c h e r s ! They a r e the new century's experts at fil ling o u t forms a n d comp u ter d a ta entry sheets, a n d they c a n d e m o n s t r a te t h a t i t 's not so b a d . I t is n o t necessary to fi l l o u t the whole fo rm, o n l y w h a t h a s b e e n d o ne. Within a b r i e f t i m e , a fter t he p h y s ic i a n is accus tomed to the posi tions of items on the form, the forms actu a l ly will fa c i l i ta te a n orga n i zed a p p roach to clin ica l practice . Th i s a pproach w i l l b e consistent a m o n g otherwise i n d e pe n d e n t fa m i l y practitioners, a n d this con sistency w i l l defe a t m u c h o f t h e c ha o s i n da i l y practice and i n osteopathic resea rch. Indepen d e n t fam i l y pra c t i t i o ners m a y not wish to s u b m i t the mselves to practic ing i n s u c h a regi mente d fa s h i o n , but i n p o i n t o f fa ct, t h i rd - p a rty payers a l re a d y req u i re them to d o so to g e t p a i d . Certa i n a s pects a r e common to a n y v a r i e ty o f t h e practice o f fa mi l y med ici n e . Anatomy i s c o m m o n . T h e p h ysical exa m i n a t i o n i s commo n . These a re fa i rl y easy to deal with in a s t a n d ard i zed progress note. Ot her aspects a r e a j u m b l e o f con sta n tl y c h a ng i n g i tems t h a t conti n u a l l y must be sorted o u t : med icaments, the for m u l a r y, l a bora tory tests, c o d i ng, a n d psych osoci a l i s s u e s ( h o me l i fe, c u l ture, poverty, level of ed ucation, com p li ance, s upport sy stems ) . These a re d i ffic u lt some s a y i m possi bl e-to d e a l w i t h . Nevertheless, the p ressure to y i e l d to s ta n d a rd i z a t i o n w i l l cont i n u a l l y m o u n t . The o n ly practical co urse o f a c r i o n i s for a l l to pa rticipate. J u m p i n , give it a good try, a n d w a tch the money, q u a l i ty tra i n i ng , a n d resea rch e v i d e nce fly. AC KNOW L E DG M E I\lTS
We t h a n k the S O A P Co m m i ttee of 0 1 - 1 2- 9 6 , Sandra L. Sleszyns k i , D O , C h a i r m a n ; J a ne Carreiro, D O ; Th o m a s Glonek, PhD ; Re becca Ha rris, D O ; W i l l i a m J o h nston, DO; R o bert K a p p ler, D O , FA A O ; A l bert K e lso, P h D ' Michael K u c h era, DO, FA A O ; K i m S i n g Lo, D O ; Kenneth Nelson, D O , FA A O , FA COFP; Ly n n Newl u n ; S tep h e n Noone, CAE; M i c h a e l P a tterso n , P h D ; Davi d Yens, PhD .
Refere nces J . Sleszynski SL, G l o n e k T, K u ch era WA . Sta n d a r d i ze d m e d i c a l reco r d : A new o l l t p a [ i e n t osteo
pathic SOAP fo r m : Va l i d a t i o n o f a s t a n d a rd ized o ffice fo r m a g a i ns t p h y s i c i a n 's p rogress
note s . J A m O s te o p a t h A ssoc 1 9 9 9 ; 1 0 : 5 1 6-5 2 9 .
C h a pter 3 1
51 1
• T h e Sta n d a rd i z e d M e d i ca l Record
2 . D r a ft E & M d oc u m e n t a t i o n g u id e l i n e s . Cen ters for Med ica re a n d Med ica i d Services. A v a i l a b l e a t fm p ://c m s . h h s . gov. June 2000. Accessed February 2 3 , 2 0 0 5 .
DJ .
3 . J orge nsen
How to exa m i n e t h e e xa m ina t i o n a n d d e c i d e on m e d i c a l d ec i s i on m a k i ng .
2003 . A m e r i c a n C o l l ege o f Osteo p a t h i c F am i l y P h y s i c i a n s we b pu b l i c a t i o n . Av a i l a b l e a t h t t p ://w w w. a c o fp . o rglm e m ber_p u b l i c a t i o n s/exami n a t i o n . h t m . Accessed Febru a ry 2 3 , 2005 . 4 . Jorgensen DJ , Jorge nsen RT. A P h y s i c i a n 's G u id e to B i l l i n g a nd C o d i n g . M a n c h ester, M E : A u t h o r s , 2004 : 6 1 -6 5 . ( Av a i l a b l e th rough A m e r i c a n Acad e m y of Osteopa t h y, Ind i a n a p o l i s . )
5 . G e v i t z N . 'Pa ra l l e l a n d d i s t i nc t i v e ' : t h e p ll i loso p h i c p a t h w a y fo r reform in oste o p a t h i c m e d ica l ed u c a t i o n . J A m Osteo p a t h Assoc 1 9 9 4 ; 9 4 : 3 2 8 - 3 3 2 [rev iew] . 6. F r a n k L. E p i d e m i o l ogy. The e p i d e m i o l o gist's d ream: D e n m a r k . Scie nce 2 0 0 3 ; 3 0 1 ( 5 6 3 0 ) : 1 6 3-EO A . 7 . Korr
1 M . O s t e o p a t h i c res e a rc h : T h e n e e d e d p a ra d igm s h i ft . J A m Osteopa t h Assoc
1 9 9 1 ;9 J : 1 6 1 - J 6 8 .
8 . R o ss- Lee B , We iser M A . Hea l t h c a r e reg u l a t i o n , p a s t , p resent a nd fu t u r e . J A m O s t e o p a t h Assoc 1 9 9 4 ; 9 4 : 74-7 8 . 9 . Seffinger M A , F r i e d m a n H D , J o h n ston W L . Sta n d a rd i z a t i o n of t h e hospita l record for osteo p a t h i c s t r u c t u r a l e xa m i na t i o n : Record i n g o f m u sc u loskeleta l fi n d i ngs and somatic dysfunc tion d ia g n o s i s . J Am Osteopath Assoc 1 9 9 5 ; 9 5 : 9 0-9 6 . 1 0 . C h i l a A G . A s pects o f osteop a t h ic c l i n i c a l resea rc h . Oste o p a t h A n n 1 9 8 3 ; 1 1 : 2 9 2-29 3 .
1 1 . C h i la A G . Rese a r c h i n man i p u l a t ive t h e ra py. O steo p a t h A n n 1 9 8 3 ; 1 1 : 294-295 . 1 2 . Wa rd R C . Resea rc h i n osteo p a th ic practice: M a n y d i lemmas a n d s o m e opportu n i ti e s . Osteo p a t h A n n 1 9 8 3 ; 1 1 : 2 9 6-2 9 9 .
13 . I'a rterson M M . Osteo p a t h ic resea r c h : W i t h e r or w h i t he r ? Osteo p a t h i c A nn 1 9 8 3 ; 1 1 : 3 00-3 0 5 . 1 4 . H a r a b l JH. Research a n d practice: A c o m m o n g r o u n d . Osteopath A n n 1 9 8 3 ; 1 1 : 3 06-3 0 7 . 1 5 . C h i l a A G . S o m a tic dysfuncti on a s t h e i n d e p e n d e n t v a r i a b l e i n c l i n i c a l research . Osteopath
Ann 1 9 8 3 ; 1 1 : 3 0 8 -3 1 1 . 1 6 . M e a s e l JW J r. A t e a m a p p roach to c l i n i c a l resea rc h . Osteo p a t h A n n 1 9 8 3 ; 1 1 : 3 1 2-3 1 4 . 1 7 . S i nc l a ir Rj . C o n d u c t i ng resea rch w i t h
an
osteopa t h i c p h y s i c i a n : Prob lems a n d poss i b l e so l u -
t i o n s . Osteopath A n n 1 9 8 3 ; 1 1 : 3 1 5-3 1 7 . 1 8 . U p ledger J E . Cra n i os a c r a l fu n c t i o n i n bra i n d y s fu n c t i o n . Osteopath A n n 1 9 8 3 ; 1 1 : 3 1 8 -3 2 4 . 1 9 . K e l s o A I': Reco rds t o a s s i s t osteo p a t h ic p h ys i c i a n s . J Am Osteop a t h Assoc . 1 9 75 ; 7 4 : 75 1 - 75 4 . 2 0 . F r i ed m a n
HD,
J o h nston W L , K e l so AF, Schwartz FN. Effects o f a n e d u c a t i o n a l i n te r v e n t i o n
on q u a l i t y a n d fr eq u e n c y o f osteopa t h ic s t r u c t u r a l d oc u m e n t a t i o n o n hosp i ta l a d m i t t i n g exa m i n a t i o n . J A m Osteopa t h i c A ssoc 1 9 9 0 ; 9 0 : 8 4 0 - EO A . 2 1 . Weed LL. M e d i c a l records, p a t i e n t c a r e , a n d med ical e d u c a t i o n . I r J M e d Sci 1 9 6 4 ; 1 7 : 2 7 1 -2 8 2 . 2 2 . Weed L L . Med ica l reco rds t h a t guide a n d teach . N E n g l J M e d 1 9 6 8 ; 2 7 8 : 5 9 3 - 6 0 0 , 6 5 2-65 7 . 2 3 . Wee d L L . Med ica l Rec o r d s , Med ica l E d u c a t i o n , a n d P a t i e n t C a r e . C l e v e l a n d , O H : Case Western Reserve U n i v e rsity, 1 9 6 9 . 2 4 . Weed L L . I m p l e m e n t i n g t h e P r o b l e m - O r i e n ted Medica l Rec o rd . 2 n d e d . Seattle: Medica l C o m p u te r Services, 1 9 7 6 . 2 5 . S O A P Note a v a i l a bi l i t y expa n d s . A m e r i c a n A c a d e m y o f O s te o p a t h y. M a y 200 4 ; 9 : E O A . Av a i l a b l e
as a
. p d f fi le o n d ow n l o a d f r o m h tr p :llwww. a c a d emyofosteopa t h y. org or contact
the A m e r i c a n Aca d e m y o f Osteopathy, 3500 DePa u w B o u l ev a rd , S u ite 1 0 8 0 , I n d i a n a p o l i s , I N 46236- 1 1 36 ;
Te l .
(317)
879-1 8 8 1 .
A l so
a v a i l a ble
through
the
A C O FP
web
site,
h r tp ://w w w . a c o fp . o rg.
26 . Do l i n RH. O u tc o m e a n a l y s i s : Cons i dera t ions for an elect r o n i c hea l t h record . M D C o m p u t J a n-Fe b 1 9 9 7; 1 4 ( 1 ) : 5 0-5 6 [rev iew] . 2 7 . Wa re S, S h e r bo u n i e C. The M O S 36 Item Short Form Hea l th S u rvey ( S F3 6 ) : I. Conceptu a l fra m e w o r k a n d i te m s e l e c t i o n . M e d C a re 1 9 9 2 ; 3 0 : 4 73-4 8 3 . 2 8 . Ca r rey R M, Enge l h a r d C L . A c a d e m i c me d ic i n e meets m a n a ged care: A h i g h i m pact c o l .l i s i o n . A c a d e m i c Med 1 9 9 6 ; 7 1 : 8 3 9 - 8 4 5 . 2 9 . McCormick K A , C u m m i n gs M A , Kovner C. The role of t h e Agency for Hea l t h Care Policy and Res ea rch i n i m p ro v i n g o u tcomes o f h e a l t h c a r e . N u r s C l i n North A m 1 9 9 7 ; 3 2 : 5 2 1 -5 4 2 . 3 0 . O w e n s D K . U s e o f med ica l i n fo r m a tics t o i m p l e m e n t a n d develop c l i n i c a l practice g u i d e l i n e s . W .I Med 1 9 9 8 ; 1 6 8 : 1 6 6 -1 75 .
Sect i o n I V • Practice I ss u e s
512
3 1 . Ne l son K E , G J o n e k T. C o m p u ter/o utcom e s : H a rdcopy S O A P N o te p re l i m i n a r y repo r t : Fa m i l y physici a n . F a m Phys i c i a n 1 9 9 9 ; 3 ( 8 ) : 8- 1 0 . 3 2 . h t t p ://w ww. red-c . d Ol u . ed u . Users m u s t be certified a n d a u thor ized .
3 3 . Evidence- B a sed Med i c i n e Wo r k g rou p . Evid ence-based m e d i c i n e : A new
a pp roa c h
to te a c h i n g
t h e practice o f m e d i c i n e . J A M A 1 9 9 2 ; 2 6 8 : 2 4 2 0-24 2 5 . 3 4 . M i c h a u d G C , M c G o w a n S L , Va n D e r J a gt R H , e t a l . T h e i n t rod uc ti o n o f e v i d e nce-based med i c i n e a s a compo n e n t o f d a i l y p r a c tice. B u l l Med Libr A ssoc 1 9 9 6 ; 8 4 : 4 7 8 -4 8 1 . 3 5 . L i c c i a r d o n e ] C , Ne lson KE, G l o n e k T, e t a l. Osteo pa t h ic m a n i p u l a t i v e r re a t m e n t o f s o m a t i c d y s funct i o n a m o ng p a t i e n ts i n t h e fa m i l y c l i n i c setting: A tetros p ective a n a lysis. J A m Osteo p a t h Assoc 2 0 0 5 ; 1 05 ( 1 2 ) : 5 3 7- 5 4 4 .
3 6 . Sleszynski S L , G l onek T. O u t p a t i e n t Osteopathic S O A P N o te Fo r m : P re l i m i n a r y res u l ts i n osteopathic o u tcomes- based rese a rc h . J A m Osteopa t h Assoc 2 0 0 5 ; 1 0 5 : 1 8 1 - 2 0 5 . 3 7 . S l eszy n s k i
SL, G l o n e k T, K u c h e r a WA .
O u t p a t i e n t Oste op a t h i c S i ngle O rg a n System
M u s c u loske l e t a l E x a m i n a ti o n Form Series: Va l i d a t i o n of the O u tpatient O steo p a t h i c SOS M u scu l os k e l eta l Exa m ination F o r m , a new s t a n d a rd ized med i c a l record . J A m Osteopa th Assoc 200 4 ; 1 0 4 : 4 2 3 -4 3 8 . 3 8 . Et t l i nger H . Tre a t m e n t o f the a c u t e l y i l l hos p i ta l ized p a t i e n t . I n : Wa rd R C , ed . Fou n d a t i o n s fo r
O s t e o p a thic
M e d ic i n e .
2nd
ed .
P h i l a d e l p h ia :
L i p p i ncott
Williams
& W i l k i n s,
2002 ; 1 1 1 5- 1 1 4 2 . 3 9 . Sleszy nsk i
SL,
G l o n e k T, K u c h er a
WA .
O u t p a t i e n t O s te opa t h i c S i ngle Orga n
System
M u s c u l os k e l e ta l Exa m i na t i o n Form : Tra i n i n g and certi fica tion. J A m O s te o p a th Assoc 2004 ; 1 04 : 76-8 1 . 4 0 . ECOP. G l ossary of osteop a t h i c ter m i n o l ogy. I n : Wa rd R C , e d . Fou n d a r ions fo r Osteopa t h i c
Med i c i n e . 2 n d e d . P h i l a de l p h i a : Li p p i ncott Wi l l i a m s & W i l k i n s , 2002 ; 1 229- 1 2 5 3 .
APPENDIX
American Osteopathic Association Position Paper on Osteopathic Manip u lati ve Treatment of the Cervical Spine Adopted by AOA House of Delegates, July 17, 2004* [
]
BACKGROUND AND STATEMENT OF ISSUE There has recently been an increasing concern about the safety of cervical spine manipulation. Specifically, this concern has centered on devastating negative out comes such as stroke. This paper will present the evidence behind the benefit of cervical spine manipulation, explore the potential harm and make a recommenda tion about its use.
BENEFIT Spinal manipulation has been reviewed in meta-analysis published as early as 1992, showing a clear benefit for low back pain.1 There is less available informa
tion in the literature about manipulation in regards to neck pain and headache, but the evidence does show benefit.2-6 There have been at least 12 randomized con trolled trials of manipulative treatment of neck pain. Some of the benefits shown include relief of acute neck pain, reduction in neck pain as measured by validated instruments in sub-acute and chronic neck pain compared with muscle relaxants or usual medical care. There is also short-term relief from tension-type headaches.7 'From American
Osteopathic Association position paper on osteopathic manipulative treatment of the cervical AOA House of Delegates, July 17, 2004. AAO Newsletter 2004 (August): 15-17.
spine, Adopted by
513
514
Manipulation headache and is commonly used medications for headache and first line prophylactic migraine.8 randomized controlled tflals showed that there was a statistically significant reduction in neck pain using a visual analogue scale.9 HARM
Since 1925, there have been approximately 275 cases of adverse events reported with cervical spine manipulation. 10-13 It has been suggested by some that there is an under-reporting of adverse events.IO A conservative estimate of the number of cerbe as high year is approximately vical spine Canada .14,!5 The estimated as 193 million following Ina11lJluiation ranges from J csnmated risk of major lion manipulations. spine manipulation 10 million manipulatJoth. cases of have involved "Thrust" Amplitude" treatment. II Many cases do not distinguish the type of manipulative treatment provided. However, the risk of a ver tebrobasilar accident (VBA) occurring spontaneously is nearly twice the risk of a VBA resulting from cervical spine manipulation.7 This includes cases of ischemic stroke and vertebral artery dissection. A concern has been raised by a recent report that VBA following cervical spine manipulation is unpredictable.1O This report is biased because all of the cases were involved in litigation. The nature of litigation can lead to inaccurate reporting by patient or provider. However, it did conclude that VBA following cervical spine manipulation is "idiosyncratic and rare." Further review of this onset of that 25% of the cases neck pain often associated new and unusual symptoms contrast to a dissection in another recent cerv ical spine this concern cause cerVlpreexisting cervical disc describes complicuions radiculopathy, myelopathy, compression by a larcr;d hcrniation.12 The authors concluded that the incidence of these types ot complications could be lessened by rigorous adherence to published exclusion criteria for cervical spine manipulation.!2 The current literature does not clearly distinguish the type of provider (i.e., MD, DO, DC , or PT) or manipulative treatment (manipulation vs mobilization) provided in cases associated with VBA. This information may help to understand the mechanism of injury leading to VBA, as there are differences in edu cation and practice among the various professions that utilize this type of treatment. COMPARISON
ALTERNATIVE TREATMENTS
neck pain. commonly prescribed NSAIDs a Approximately GI bleeds Americans use NSAIDs I 1 he United without prior symptotns. related to and 2,500 will cause 12,000 emergency Kingdom has complications.22 The tract comdeaths per plications in the US is estimated at $3.9 billion, with up to 103,000 hospitalizations and at least 16,500 deaths per year.2J.24,J2 This makes GI toxicity from NSAIDs the 15th most common cause of death in the United States.J2 Epidural steroid injection is a popular treatment for neck pain . Common risks include subdural injection,
515
Position Paper on OMT
occurs in -1% mtrJvascular injection.35 procedures.35 I injection occurs in of procedures. Intravascular injection is the most significant risk and occurs in -2% of procedures
intratheca
and -8% of procedures in pregnant patients.31 Cervical epidural abscess is rare, but has been reported in the literature.36
PROVOCATIVE TESTS in animals and
Provocative tests such as the DeKline test have been I ike it were found to
humans.
risk of injuring the
reproducibill1)
RISK 000 cases of stroke.
VBA accounlS Approximately
with VBA die as a
functionaL recovery.
II
Ie
rare event. have a good
most common risk factors for VEA are migraine,
hypertension, oral contraceptive use and smoking.31 Elevated homocysteine levels, which have been implicated in cardiovascular disease, may be a risk factor for VBA.34 A study done in 1999 reviewing 367 cases of VBA reported from 1966-1993 showed 115 cases related to cervical spine manipulation; 167 were spontaneous, 58 from trivial trauma and 37 from major traumaJJ Complications from cervical spine manipulation most often occur in patients who have had prior manipulation uneventfully and without obvious risk factors for VBA.7 "Most vertebrobasilar either sponl:1 neck, such sneezing, be the prim:!ry
d
occur in the absencc trivial trauma or common
manipulation, n1mements of the
the driveway, painting exercises." 10 In some the dissection, but an
dental evel p[()posed that thrust techni of hyperextension. and traction of the upper wtll place the patient at greatest risk ot injuring the vertebral artery. In a retrospective review of 64 medical legal cases, information on the type of manipulation was available in 39 (61%) of the cases. 51 % involved rotation, with the remaining 49% represent ing a variety of positions including lateral flexion, traction and isolated cases of non-force or neutral position thrusts. Only 15% reported any form of extension.21
CONCLUSION Osteopathic
trl'lnment of the cervical comparison to other common Cl1Itcomes, trainees shoule:
information
2dvlSI:d of the potential risks.
to distinguish and to deterrnllle
not limited
Itude treatment, is effectile
to High V,:oc tively safe. very smal
associated with manipu
provider type
of the relationship between
of manipulative treatment and VBA. Therefore, it is the position of the American Osteopathic Association that all modalities of osteopathic manipulative treatment of the cervical spine, including High Velocity/Low Amplitude, shouJd continue to be taught at all levels of education, and that osteopathic physicians should continue to offer this form of treatment to their patients.
516
References 1. Shekelle,
of [nterna I
'pinal manipulation for low
Medicine 1992;117(7):590-598. 2. Koe" BW, Bouter, LM, et al. The effectiveness of manual therapy, physiotherapy, and tre:1t
menr by the gcneral practitioner for nonspecific back and nec k complaints, a randollHl.cd clln·
lui trial. Spine 1992;17(1):28-35. 3. Kocs, B, Bouter, L, et al. Randol1l1Sed clinical trial of m;lI1ipularive therapy and phy"othera py for persistent back and neck com pla i nr s : resulrs of one year follow up. BMJ 1992;.lO4: 601-605. 4. Koes
IW/, Bouter Uv!
van Marmercn H, cr al. A ra n d o mized clinical tri;]1 of l11anu;ll rherr'!))'
for persi.erenr neck and back complaints: slIh-grllllp 'lnc1vs's .1nd rel;lt!()[l-
and
J Manipulative Physio Ther ! 5.
rion on J Manipulativc
mohiliza
'11('rion in the cervical spine'
rolled trial.
15:570-575.
6. Jensen 01<
v/lrh rhe lise of
An open study COlllpal
cold pack·;
I-'dsrrraumaric headache.
7. Hurwirz II
Cervical ::, pill c.
ling K. The immediare dfe'l
1250.
H, iVlecku WC, er 31. Me·. lii'uL'II"" sYSlematiL reVieW of the literature. Spine 1;)%,21(15);1
8. ISronforr G, Assendelfr WJ, Evans R, H"ds M, Bourer. Efficacy of spinal manipuhtion for
chronic headache: a systematic review. J of Manip & Physio Ther 2001 ;27(7):457 -466. 9. Cross AR, Aker PO, Goldsmith CH, Peloso P. ConServJfLVe management of mechanical neck
disorders. A systematic overview and meta-analYSIS. Online J Curr Clin Trials. 1 ' 9%; 200 201. 10. Haldeman S, Kohlbeck FJ and McGregor ,'v!. Unpredictability of cerebrov;lsclI!8,· ischemia
associated with cervical spine manipulation: A review of 64 cases afrer cerviC
11. Assende!f·
Imd Knipschild PG. CompIILcIW'Il'. 01 rhe literarure.
12.
manipularion
J
IJlclnipularion:
Fam Pracr 1996,
lon'ecek FJ, Boxell CM, et .1i
(.rvicdl spine
retrospective study in a singk
N( :r.)surg Focus
13(6),200.1..
13. Vick DA. ature fr01l1 I
R. The safety of manipuiJtl\( to 1
14. Haldeman
P,
II
of rhe liter�
1996;96(2):113-115.
cervical
M, Papadopoulos C. Anu
manipulation. The chiropractic experience. CMAJ 2001;165:905-906. 15. Hurwir z EL, Coulter [0, Adams AH, Cenovese BJ, Shckelle PG. Use of chiropractic services
from 1985 rhrough 1991 in the Unired Sures and Canada. Am
J
Pu bl ic Health 1998;88:
771-776. 16. Jenson cr al. Complications of cervical manipularion, General Forensic Science 1987;32(4): 1089-1094. 17. Koss RW. Quality assurance monitoring of osteopathi.c manipulative rreatmcnr. JAOA 1990;90(5):427-433.
18.
cLlnr,crous is manipulation to
report and
1985;2:1-4. 1.I:curr.�llce of cerebral vasculal
19.
practice.
AH, et al. The appropr::Hnness 111 m;w'p"I.Hloll and mobi-
20.
lization 01 , 21. Halderna"
m3nipulatl.(
::,I"ra Monica CA, Rand, ] 'vlceregor. Srroke, cerebral
c· rvical spine
• .J 2002;249:1098-1104.
22. Blower AI, Brooks A, Fenn CG et at. Emergency AdrnJsslons tor Upper GastrointestinJI
Disca'sc and Their Relation to NSAJI)s Use. AI'11131'E. Pharmacology Ther, 1997; 11:283-291. 23. Fnc.s
IF,
Miller SR, Spirz PW, Williams CA, Hubert HB, Bloch DA. TowMd an epidel11lology
of gasrwpathy associ,lted with nonsteroidal anti-inflal11marory drug use. Gastroenterology. 1989;%:647-655.
Index
Page numbers followed by f denote figures; those followed by t de n o te tables
A
American Association of Colleges of Osteoparhic
Absenteeism, work-related, 383
American
Abuse abused psychiatric patients, 84
associated with chronic pelvic pain, 108 Acidosis, in sk in, 62 Acromioclavicular dysfunction, 228-230, 229f ACTH recep tors, 59
Activities of daily living (ADL), Parkinson's disease and, 324, 327, 328 Acute ankle spr a in, 144-145, 144t Acute otitis m e dia, 198
(ACOFP), 494, 500 American College of Rheumatology (ACR), 362 American Medical Association
(AMA),
471
American Osteopathic Association (AOA) Clinical Assessment Prog r am , 501
development of SOAP note forms, 10,490, 493 Found4tions for Osteopathic Medicine, 197
OMT codes, 488 Osteopathic
M anipula t ive
Treatment of
the
American School of Osteopathy, 139
Acute phase response, 59 Acute primaty som atic dysfunction, 36 Acute somatic dysfuncrion, 13
TMJ
503
College of Osteopathic Family Physicians
Cervical Spine (posirion paper), 391, 513-515
Acute pancreatitis, 296-298
Acute
Medicine (AACOM),
pain, 213
Acute viscerosomaric reflex a c ri vi ry, 36 Adet, Robert, 57 Adrenal glands, viscerosomatic reflexes from, 46 Affective disorders, 76
Amitriptyline, 213,373 Anandamide, 61,
61f,
64-65
Ancient brain, 60 Ankle sprains, 144-145, 144r Antagonistic team, and patient empowerment, 4 Anterior innominate
dysfuncrion,
muscJe energy
procedure, 120, 121, 12]f, 154-155 Anterior knee pain, 145, 153-154, 154f
Afferent neLlrons, 33
Anterior lateral malleolus, muscle energy procedure,
Aggressive conserv a ti sm , 148 Aging (see also Geriatric patient) congestive heart failure and, 284 AIDS, treatment of neuro-AIDS, 58 Alexander technique, 213 Allergy, and fatigue, 366, 368 ALLHAT srudy (Antihypertensive and Lipid Lowering Treatme nt to Prevent Heart Attack Trial), 267 Allopathic medicine
151-152,lS2f Anterior lumbar tender poinrs, 188f, 193-194, 193f Anterior neck sofr tissue, lymphatic proce dures, 239-240, 24 If,
322
Anterior occiput, muscle energy procedure, 235-236, 235f Anterior and posterior innominate, muscle energy proced ure, 1161, 120-122, 12lf Anterior sacrum leg pull, HVLA p rocedure,
focus of, 7
118-119,118f
patient empowerment and allopathic physicians,
Anterior sacrum, muscle energy procedure,
somatic dysfuncrion in, 8
Anrerior rhoracic render poinrs Tl-6 and T7-12,
1,3
117-118, 117f, 427
Allostasis fibromyalgia/chronic fatigue syndrome and, 365,366
,
187-190, 188f
Antiviral/antibacterial trearmeors, for fibromyalgial
Alprazolam, 373
chronic fatigue syndrome and, 372r, 374
Altern ative medical therapy use of complementary
procedure
Prevellt Heart Attack Trial, 267
pain behavior and, 63
OMT as, 284
couorersrrain
Antihypertensive and Lipid Lowering Treatment ro
and,
An xiety disorders, 76 383, 394
American Academy of Family Physicians (AAFP), 500 A merican Academy of O steo p ath y (AAO) on ce rvi cal manipulation, 66, 271,391 development of SOAP not e forms, 10, 490,494 Louisa Burns Osteopathic Research Committee (LBORC), 487, 490, 491,493,500,504,506 osteopathic trearment of headache, 388 A merican Academy of Pediatrics (AAP), 92
Anxiety and tension, reduction 0(, 81 AP c ur ve s , observation for, 17 Arbuckle,
B. E.,
454
Ar thrit is fibromyalgia and, 362 rheumaroid, 164, 454
Articul ar dysfu n ction, 8
motion test for sacroiliac, 23-24, 23f restriction of motion in, 14 vertebral, 8-9
Index Diagn ns \ ;\
368, 369£
inrerrel3flor �'!l,r'
diagn o !;':,\
369f
\68,
diffcn.:nrl,li
function
EVA
403f
fronto
in,
o ccipita l condy lar decompression p roce d ure ,
369-370, 371r-372t, 372-375
401--402,4021
procedures, 375-380, 376f, 377f, 378f, 379f, 3S0f
pro cedur e , 404, 404f
Ch r oni c hypoventilation, 281
pa r iera l l i fr
Chl"Onlc otitis media,
Su t h e rl a nd 's occipiroarlantal decompresSion
J 99
Chronic pain, 383-385, 384t (see
al so Headaches)
modalirres in pain treatment,386, 387t
Chr o ni c p el vic pain, 106-108, 109,110 Chr onic s o matic
d y s fun cri o n, 13
Chronic spin a l pClin,osteoparhic ma n ipularion for, 57 Chronic thyroiditis, 309
proce dure , 391,400--401,40 I f n·1J and, 213, 214 Cranlol rhythmic imp u lse , 89, 130, 279 Cranial so mat i c dysfunction, 89
Cross pi sifo r m (Texas twist) HVLA, 339-340 ,
Current
Chronic T\I! Chronic Cleveland
501
pr o c edu ral
o Dalrympk
pllllljl, 136,1361,303
)IOP Hypertension),
DASH Clusrer
De a t h
Cobb, J. R.
De ep - b rcCl r h : np,
Codeine , 213
Co ding (see Progress n o res
{j)1
dISease, 20S, 210 Deming, W. Ed w ards, 4 Den slow, John S ted m an , 34
and c o di ng )
Colic, 95 COll1plementary and alternative med i c i n es (CAM),
383,
1
Degenerative lomt
Cogwh e el rigidiry, 326
394
Compression of CV-4 ( c ra nia l )
339f
terminology (CPT) c o des,
47
36
Internal
521
procedure, 132-133,
132f, 289
Dema I disorders
dental p r o cedu re s and TMJ, 210 p e d iat ri c, 95-96 D ermato l o gic system, th )' r o i d disease and, 315 Dermaromes, 8
Berti's, 50 Co n geniral rorricoJiis, 93 Co mpres s ion resc,
D iagn o sing s omaric
C ongestiv e
284-285
dysfunct i on, 12-13, 28 di a gn o s i s , 13-14, 28
c hronic
obes iry
.�81-282
17, 18f
287f, 289f
procedu(c�, pulm ona r )
17
so m a ci c ..:1y sfu rn:::rionj
procedures,
two chambered pump, 282 ConlulH rest
pos irion , 426--427, 426f
254f
constipared c hi ld, 95
pec mra l rracrion ro en h a nc e morion of rhe\
Consultcttions, 485, 486t, 487t
136-137,137f
Contributory somatic dysfunction, 30
rib raising and motion of thoracoabdominal
Cotrel-Dubousset procedure, 460
diaphragm , 130 d i a phra g m release pr o cedu re,
Counterstrain pro cedur es
rhoracoabdomin a l
for biceps, long head, 157-158, 15?f
J ones
lJ
d ia p h ragm atic release procedures, 253-254,
Constipat i on, 292
C1 postrr;nr
H
D i a p h ra gm
�99-100, 4001
p ir i fo r m
94-95
Digestive
plantar
Do pam lne
for planru
DO).},lamine,
D ry-l a n d
for p ost er im
3551
187,288-289,289£
Diastok Diet (sel:
190f, ] 91f,
CPT (cu rrent 471-472,488 ,491-492
E
99, 100f
E&M ( eva l u a ti o n and
Cra ni a l m e m brano u s r e lease pro cedu r e,
compression of CV-4,132-133, 132f
cranial
vault hold f o r sp h eno - occipi tal synchon
d rosis torsion procedure, 203-204,203f
m an a ge ment )
codes,
471--472,473,478,485,487--488,49.1
Cranial osteopathy, 62 -6 3 , 64
Ear (see also Oti tis media)
pediatric ear conditions, 95 thyroid disease, 3 10-3 1 1
in
Index srrengrhening
Glureal
exercise, 179
GDitor, 308, 309, 110,
11
523
fixed point, rotation, 352-353, 353f group curve mobilization, 461--463,462f
I
Gordon, Thornas, 4
Greves' disease, 307, 308, 310,
knee in the back, 395-397, 3951, 3%f
315
Larson's
s y ndro m e
and, 347
Group curve mobilization procedure, 461--463, 462f
leg pull for anterior sactum, 118-119, 118f
Group dysfunctions, 8
leg pull for posterior sacrum, 119, 119f
Gut feelings, 60
lumbar walk-around, 428--429, 428f
G ynecologic patients, with pelvic pain, 106-107
for muscle (ension headaches, 390-391 patient supine thoracic HVLA for flexed or
H
exrended rhoracicsomaric dysfunction,
301-302, 30 If
Helbit scoliosis, 457
posterior s a crum , trunk roration, 427--428,
Hale, Stephen, 262
reverse rib, 353-355,354(, 397-398, 397f
H3nlsrring releJse, myofasci<11 reJe;!se procedures,
spinous process thrust, 351-352, 352f
152-153, 153f, 376-377,377£
terminal patient and, l84
Hamstring strains, H5-146, 152-153, 153f
upper thoracic type
Hashimoro's thyroiditis, 308, 309, 314
Hazzard, Charles, 244
H.,
Head,
Hypertension, 262-263 evaluation, 263-264
classification of, 387-388, 388t
osteopathic approach, 267-268
cluster, 393-394
osteopathic approach to treatment of, 264-265,
headrlche re rtia r y ro secondary somatic
265t,266t-267t, 267
dysfuncrion, 394
osteopathic manipulation, 270-271
migraine, 39l-393
muscie tension, 390-391, 393f prim;ny vs. secondary C;JllSes, 388,
procedu tes, 271-275, 273f,274f
research bac k g ro u nd, 268-270, 270t
389r
Hyperthyroidism, 308-309, 314
procedures, 394--404, 395f, 396£, 397f, 399f, 400f,40
I f,
Hypothalamic dysfunction, 3 6 4
402f, 403f, 404f
Hypothytoidism, 307, 310
syndrome and, 211
ene
Health
Financing Administration
(HCFA),
Insutance Portability and Accountability Act
HC<1rt,
viscerosornaric reflexes from, 41
musculoskeletal system and, 313
neurologic system and, 314
(HIPAA), 500,501
Heel p"ds, 165,425,459
Heel
the face in, 310
471
Health
Heel
pain,
ptimary, 307 secondary, 307-308 Hypovenrilation
147-148
ch ronic, 281
spur syndrome, 147-148
Hematological system, thyroid disease and, 315
Herbs,
for
317-319, 317(, 318f
Hyperprolactinemia, 307
37
Hea,hchcs
TMJ
II HVLA,
Hyperalgesia, 59, 60
TMJ s yndro m e,
21.1
Hertzberg, Frederick, 3 H igh - veloci ty, low-amplitude procedmes (see HVLA
Ihigh-velocity, 10w-omplirudeJ procedures)
obesity h)'povenrilation syndrome, 281-282
Hysteria, 76
I Jarrogenic cervical fracrures, 65-66
Hill-Sachs deformity, 147
ICD-9CM,
Hip disorders, pedi,tric, 93-94
Idiopathic stoliosis, 419, 452, 453--454, 456, 458,
HIV/AIDS, treatment of "euro-AIDS, 58
Hoehn "nel
Yahr scale, 328, 328t
[Illillune
holistic logic/view, 7,7[, 57, 73-74, 18l-182 spinal somatic dysfuncrion anel, 8-9
H. v.,
57
Hurmonal rrearlllellrs, for fibromy;:lIgia/chronic fatigue
s y nd ro me,
tibiofibular, 378-379, 379f
Indirect hamstting telease, Illyo(asci al release
R., 423
I-IVLA (high-velocity, low-amplitude) procedures,
9,
28,163
Jcrominclavicular, amerior
'1IH.1
posrerior
anrerior, 2.1.1-234, 233f
avoidance wirh migraine headache, 393
avoidance
cnnc;)1
wirh
psychiJrric parienrs, 80
posterior, 231-232, 231 f
cross pisiform
(Tex"s
tWISt), 339-340,339f
epig;),ttic thrust, 156-t57, 156f firS[
and s e c o nd
procedure,152-153,153f Indirect knee release, myofascial release procedure,
clavicle, 228-230, 229f
atlas
immunosuppression, 57
Impingement syndrome, 146-14 7 Indirect ba I" nci ng th or acic cage, 338-339, 338f
Horner's syndrome, .350
E.
system (see also Psychoneuroimmunology)
thyroid disease and, 314-315
cervical, 186,230-231, 23H, 322
371t
Hormone receprors, SH-59 Hoskins,
459,460 Ilium, (Otation of the, 414,416f
Holism
Hoover,
35, 384t, 385, 452, 471,472, 4 8 7
ribs J-[VL,\, 226-228, 226f,
227!,321-322, 398-3�9, 399f
153-154,154f Inditect psoas re le a s e procedure, 115-116,
115f indirect wound/SCM release procedure, 137 Infantile scoliosis, 93, 454,458 Infecrion." (see also Lower respiratory tracr infec rionj Upper respitatory infection)
fibromyalgia/chronic fatigue syndrome and, 372t, 374 Influenza epidemic, 1918,221,243,245
524
Index
Inhibitory manipulative rrearmeru, 47
Lateral curves
Inhibitor), pressure procedures, 50-51, 132, 187
113-114,
sacrum,
as alternate term for scoliosis, 453
observ,Hion for, 17
1131
spinal, 162,452, 453f
Inrernal derangemenr lID) injury, 208, 210
International Classification of D iseases
,
Ninth
Lateral recumbent position, p
Clinical Modification (ICD-9CM), 35, 384r,
I
Lateral recumbent rrl';1tlllcnr of
385, 452,471, 472, 487
Lareral tender poinrs
(ICHD-2), 390, 392
rhe
LP5L render
poinr, 195-196
Inrernarional Classilicarion 01 Headache Disorders International Headache Socier)', 387-388. 388r
for
lareral L.3, L4,
UP5L,195
Intraoperative surgical patients, 129
Layer palpation, 18-19,49
Ipsilateral reflex response, 39
Lazy person exercise, 458, 4581, 461
Irritation producing spinal facilitation, 8-9
Leader-follower ream, and parienr empowerment, 4
Ischial ruberosit)' spread myolascial release proce
Leg length inequ
dure, 123-124, 123£
Short
leg
syndrome and postural h3lancel
Isometric exercises, 166
scoliosis
and
unequal leg lengrh, 459
l.eg pull
cervical isometrics, 166, 177-178,1771 simple cervical isometrics, 176-177
for
anterior sacrum, HVLA procedure,
for
posterior sacrum, HVLA procedure, 119, 119f
118-119, 118f
J
Leukopenia, 308
Jaw lock corrections, 216-217, 216f
Levitor ortLoric, 161,425,440-441,4421,
Johnston, William L., 248, 269, 271-272 loint National Commission 011 the
.
443-445, 443f, 446f
Prevention,
Detection, Evaluation and Treatment of
Hypertension UNC 7), 263, 264, 267, 269
L. H., ISS
jones,
Levodopa, 325, 326 Lifestyle modifications, for
hypnlCllsiol1,
265,271 Lift rhwlpy Iheel pads), 165,425,457,459
jones tender point, 147
Listening, to patients, J-2
juvenile rheumatoid arthritis, 454
Lirtlejohn,
J.
Marrin, 73-74
Liver, viscerosomaric reflexes
from,
44
LoclIs caeruleus-norepinephrine axis, 60
K
Lordosis, 440, 455
Kidney, viscerosomaric reflexes from, 44-45
Louis3 Burns Osteopathic Research Committee
Knee
(AAO), 487, 490,491, 493, 500,504, 506
anterior knee paio, 145 indirecr myolascial release procedure, 153-154,
1541 knee
in
procedures, 395-397,
377-378,378f Komaroff, A. L.,
M.,
Kuchera, w.,
treatmenr
34
Luciani,
L.,
of,
248-259,250f, 251 f, 252f, 2541
41
Lumbar counrerst""in procedur es , 187, 1881', 1901
245, 248
245,
trJU in(cctioll)
<1lso Upper respirator)
case studies, 254-259 pneumonia, 244-247
364
Kubler-Ross, Elisabeth, 182
M.,
Lower resrirJtory tracr infection, 243-244, 2S9-260
(SCI..'
3951,3961 myofascial release procedures, 153-154, 154f,
Kuchera,
Lower respiratory tract,
Irom,41-42
HVLA
rhe back
Korr, Irvin
)'Cfi C\l'S, 4.3 viscerosomatic rcflcxt.'''
Lower g
anrerior lumbar tender poi",s, 188f, 193-194, 193f
248
posrenor lumbar render poinrs. 190i.
Kyphosis, 93, 440, 455
Lumbar curve, 414, 4151
L
Lumbar paravertebral muscles
Latsen, Bryan, 500
Lumbar spine
194--195,
175f soft tissue pr(]ce�ure,
L.umbar dysluncrion, Still technique. 174-175,
Larson, Norman
J.)
53f,114-115,
41, 342
sacral torsions, 1
distriburion patterns, 344-345 procedures, 351-359, 352f, 353f, 3541,
355£,
3561, 358f range and quality of motion in rib somaric dys function, 347-348
and
quality of motion in verrebral somatic
dysfunction, 347
somatic dysfunction of rne upper rhoracic and upperribs, 345-347
forlumb;u
region,
51-52,531 L.umbar walk-around,
HVL.A
or Illuscle energy
procedure, 428-429, 4281 Lumbopelvic release procedure,
98,
981
Lumbosacral release, direct 1l1YOL1SciJI relc:lse procedure, 447-448, 447f anterior Ol'ck sofr rissue, 239-240, 241.1,
349-350
Late postoperative surgical patients,
J
L.ymphatic procedure,
role of the sympathetic nervous system,
tissue texture changes, 348-349
1
stimulatory procedure
OMT,350-351
range
1141, 1.14-135
eX;':lIl1inJrion of the, 22
Larson's syndrome, 342-344
spine
322
Iympharic pump oscillarory modificarion) 2261, 288 lymphatic pump procedure, 221,251-252
13"1
194f
thoracic Iympharic pump, 240-242, 2411 I.ymphatic s),srel11, thyroid disc·.I,,·
'Ind, J I S
I n dex
M McConllel!, CJ!
McC Jrcgnr,
I
Philif'<,
Douglas,
1
posterior ""h)ml"dtc Jysiunctlon, 11M, 120, 121
3
posterior occiput, 234-235, 234f, .199 PSO'5, 116, 1161,340
MlPJlrhnd, J ohn, 61 Ivlagoun, H. 1., 454
Ma/.:.ing
428f
) ! J ,)
piriforrn
525
the Patient Your Partner
(Gordon and
(,dwards),4
pso"s spas m, 429, 430f
rib inhalation and exha lat i on , 333-n7, 3 34f, 33Sf, 336£, 337f
�'1anl1il1o, l R., 269
,Vlortan's syndrome, 454, 457 Moslnw, Abraham, 3 Mt'cILlllic-1l som,Hie d ysfu n ction , 14 , 4 7 J))tx.:h;mic-Jl i)( ,.1;'''(:1 erion,
symphysis pub is superior
or
inferior
shear,
122-123,122f
upper thoracic spine, 224-225,225f, 394-395 48
\Iuscle tension headaches, 390-391, 3931 160-161
36
MtehC111lCoi ;lnlOunr d!
cOllsul[;)[i(Hh, Ji;lgnosb :"\11l1
47St
levels
Jlilrienr and,
Musculc< ;kC1ct';d j\dlpJlOl"
an,.!
for
new pa rient codes, 484, 485r OMT CPT codes,
for pancreatitis, 296-297
488
M useul<>skeletal system
risk, 4XO, 4 8 1t-4 82 r , 483 , 48 3t
lise 01
.\lcdic:11
OMT, 4R7-488 records (see Progress
SOAP 110re forms)
notes
dys tu nction of, 7,291
3TlJ
coding;
(In[lrh�'rojd.
:vI vofascia I release pro cedure s hamstring release, 376-377,
308
blood pressure, 2A5. 266r-2(,7r, 21>7,268
sleep ing
TMJ Metrics, 2
cion,
,\1idcervic:d ((
377f
'51-1 \d, 154f
indirccr
24, i23f
i47f 128
\»1,392f
Middle C
Miller,
C
2361, 322, 331
I
, '86f, 319, 332
thor2«i'�'
Miller, \V
Myopar],',
MilwJuke.:
Misu:1ble
,ynJ[,()l11t, 208,
Indirect hamstring release, 152-153, 153f
ischial
1.3
for
(MPD)
209-210,211
\lcull'ere, 476, 483, 491 l\tlcdic(lriolls
thyroid disease and, 313
Myo la scial pain dysf uncrion
m;ll
Mirc h ell , f L, 141,414
\liroehol1drial dysfunction, 364
);lohilizatlOn
Nlyotolnc\, Myxedema, 307, 311,315
N
e,xt.:rcises.
grollp elil'yt mobilizarion, 461-463, 4f>2f
\rasal congestion, 220-221
laz)' person exercise, 458, 4S8f, 46J
:\ationallnstiture for Mental Health, 58
Morgan, j, p" 270
:\eck, in he ad ach e diagnosis, 388, 389t
Morphine, 61
i'v1otion restricrion
Oi'vtT
and resf()I"3rion
!':"omtal somaric dysfunction, 88
of
Neopla:-.i;l\ visceral\ 35 movement, 2S
348
Neuro-AIDS, 58
["I I' () my a Igialchronic
Neuroe:rl<jC)Cl
365,374
blig\lC:
Neurohol rn(
and, 313-3 J 4 Neurop,-n i;;(...
120,121, J21t, ! '.. !
�nrerior (kLipUt, 2jj-2J6, 2.J5f
IS2r
and posterior inn ominate, 11(-1f,120--122\ 121f 8"r(rlor sacrum, 117-118, 1171, 427 Allferior
arias rosrerior, 232-233, 232f
c e r vica l , 331-332, 332(
group curve mohilization, 4 6 1 -4 63 , 462f
Neurof'c)\r, Jc"<, New pJcic'
)i
Nighr
ulviT and, Nitroglycerine, 393
Nitric ()XIOe,
60-62, 6lf, 64-h5
!':ociceptive pain, 385
�oclal points, in neuropeptide receptor disrriburion,58
!':ull, D,
R"
245
Nonc8fdiac congestive heart failure , 281
I n d ex
526
fo r g a s t r o intes ti n a l p r o h l e m s , 2 9 2 , 2 9 4 , 295-2 9 6 ,
N o r t r i p ty l i ne, 2 1 3
3 0 0- 3 0 3 , 3 0 J (
Nose
1 6 1 , 1 6 2 , 1 6 3 , 1 64 ,
1 6 5 , 1 70- 1 7 9, l 7 2 f, 1 73 f, 1 74 f, 1 75 f,
in t h y r o i d d i s e a s e, 3 1 0-3 1 1
1 7M, J 77 f
v i s c e r o s o m a t i c r e f l e x e s f r o m r h e , 4 0 --4 1
fo r h e a d a c h es, 3 9 4--4 0 4 , 3 9 5 1, 3 9 M, .1 9 7 f, 3 9 9 f,
Nurrition
DASH
I hO,
getiarric p a t i c n t e n d ,
p e d i a t r i c n a s a l d y s fu n c t i o n , 95
4 0 0 f, 4 0 1 f, 4 0 2 f, 4 0 3 1 , 4 0 4 f
( D ietary App roaches ro 5rop Hy pertens i o n ) ,
f o r h y p e r te n s i v e p a t i e n t, 2 7 0-2 7 5 ,
265 for f i b r o m y a l g ia/c h r o n i c fa t i g u e s y n d ro m e ,
2 73 f,
274 f
(o r L a r s o n 's s ), IJ d ro m e , 3 4 5 , 3 4 7, 3 .\ 0-3 5 9 , .1 5 2 f,
3 5 3 f, 3 5 4 f, 3 5 5 f, .1 5 6 1, .l 1 8 f
3 72t, 3 74
for l o w e r resp i rJ tory r r a L [ i n fec t i o n , 2 4 8-2 5 9 ,
gas(fo i n testi n � 1 d y s fu n c r i o n a n d , 2 9 2
2 5 0 (,
fot g e r i a r r i c p a r i c n ts , 1 6 0 , 1 6 8 - 1 70, 1 6 9 t
2 S H,
2 5 2 f, 2 5 4 f
i n m e d i ca l d e c i s i o n m a k i flg, 4 8 7--4 8 8 n i tr i c o x i d e a n d , 6 0 - 6 2 , 6 1
o
OMT
O b e s i ty, 1 6 9
CPT
f , 64-65
codes, 4 8 8
OMT prescri p t i o n , 2 7-.1 1
O b e s i r y h y povent i l a t i o ll s y n d to m e , 2 8 1 -2 8 2
fo r o t i tis med i ,l , 1 9 9-2 0 6 , 20 I f, 2 0 2 1 , 2 0 3 f,
O bs t e t r i c p a t i e n t s
205f, 206f
s o m a t i c d y s fu n c t i o n d U r i n g preg n a n cy, 1 0 8 - 1 0 9
fo r p e n c r e a t i t i s , 2 9 7-2 9 8
s t r u c t u r a l cxa m i n e r i o n o f, 1 1 2- 1 1 3
fo r P a r k i n so n 's
Occi p i r a l c o nd y l a r d ec o m pres s i o n p roced u re ,
4 0 1 --4 0 2 , 4 02 f
3 3 0 , 3 3 1 -3 4 1 ,
.H Of
p a t i e n t to l e r a n c e , 2 9
Occi p i t a l r e l e a s e p r o ce d u r e , I 0 1 , 1 0 I f
ped i a " i c p a t i e nt a n d , 8 7 , 8 9 , 9 0 , 9 1 , 9 3 , 9 5 ,
Occipito a r i a nr a l deco m p re s s i o n p roced u re ,
97-1 0 3 , 9 8 f,
S u r h e r l a n d 's, 3 9 1 , 4 00-4 0 1 , 4 0 l f
9 9 f,
1 00 1, 1 0 i f, 1 02 f
fo r p n e u Tll o n i a p a t i e n t, 2 4 5 , 2 4 8 - 2 5 9 ,
Occi p i r o a r l a n t a l , m y o fa s c i a l r e l e a s e p roced u re ,
2 3 6 -2 3 7 , 2 3 6 (, 3 2 2 , 3 3 1 Occ i p i t o m a s w i d decom p ress i o n ,
d i sease, 3 2 5 , .1 2 9 ,
.1 3 2 f, 3 3 4 f, 3 3 5 (, 3 3 6 £, 3 3 7 f, 3 3 8 f, 3 3 9 f ,
25
I f,
2 5 0 f,
2 5 2 f, 2 5 4 (
fo r p o st u r a l d e c o m pe n s a t i o n , 4 4 0 , 4 4 7--4 5 0 ,
33 I
4 4 7 f, 4 4 8 f, 4 4 9 (, 4 S 0 f
Occ i p i ro m a sr o i d r e i e a s e p roced u re , I 0 1 , 1 02 f, W 3
p r e s c r i p t i o n for, 2 7-3 1
Occ i p u r
p s yc h l 3 " i c pa t i e n t a n d ro l e
a n te r i o r occ i p u r m u s c l e e n e rgy p roced u re ,
2 3 5 -2 3 6 , 2 3 5 t
o f,
7 5 , 7 9-8 3
ps ycho n e u r oi m m ll n o l ogy a n d , 5 6- 5 7 , 6 3 - 6 6 r e b O l m d rea c t i o n s to, 1 64
in
a t b i rth, 8 8 , 8 9 £
record i n g
a n d i n fa n ti l e s co l i o s i s , 4 5 4
fo r sco l i o s i s , 4 5 8 , 4 6 1 -4 6 4 , 4 6 2 f, 4 6 3 f, 4 6 4 f, 4 (, 5 (
p o s [e r i o r occ i p u t m u scle e n e rgy p r o c e d u re,
fo r s h o rt l e g s y n d r o me , 4 2 6 --4 .1 2 , 4 2 6 f, 4 27 f ,
2 3 4- 2 3 5 , 2 3 4 f, Occ l u s a l s p l i n t s , 2
J.1
399
t h e p rogress n O t e , 3 1
4 2 8 f, 4 30f, 4 3 1 f, 4 3 2 f s u rg i c a l p e t i e n t
O ff i c e , the, p h ys i c i a n 's p rac t i c e , 4 6 6 --4 6 9
a nd,
1 2 8 , 1 3 1 , 1 3 2- 1 3 7 , 1 3 2 f ,
1 3 3 f, 1 3 M, 1 3 7 f
O p i o i d rece p w r s , 5 7- 5 8 , 6 1 , 1 2 9
term i n a l p a t i e n t a n d , 1 8 2 , 1 8 4 , 1 8 5 , 1 8 6- 1 9 6 ,
O t ga n i c p a t h o l ogy, 1 2 , 1 3
1 8 8 f, 1 9 O f, 1 9 J f,
O r t h o t i c d e v i c e s , 4 2 4 --4 2 5 , 4 4 0 , 4 6 0
1 93 f,
1 94 f
fo r thyro i d d isease, 3 1 5-3 1 6 , 3 1 7-3 22, .1 1 7f,
Lev i to r o r r h o t i c , 1 6 1 , 4 2 5 , 4 4 0--4 4 1 , 4 4 2 f,
4 4 3 -4 4 5 , 4 4 3 f, 4 4 6 f
3 1 S f, 3 2 0 f r i m e for, 6 5
O s c i l l a to r y r e l e a s e p ro c e d u re s
for
ce r v i c a l a r r i c u l a t o r y r e l e J s e \ 2 5 3
Oste o p a t h i c d i s t i n cti veness, 6-7,
d ys fu n c t i o n , 2 1 2-2 1 3 , 2 1 4-2 1 7 ,
2 1 5 f, 2 1 6 f
l y m p h a t i c p u m p osci l l a to r y m o d i fi c a t i o n , 2 2 6 f , 2 8 8 O s te o a r t h r i t i s , 1 6 4 , 1 6 9 , 3 2 7
TMJ
trecH i n g the p a t i e n t , 1 2 , 1 1 ,
1 5,
2 8 - 2 9 , 1 6 .1
trea t m e n t r e s p o n s e , 2 9-30
tre a t m e n t o f tr3 U n1 <1 p �H i e n rs l 30-.1 1
9-1 0
h o l i s t i c l og i c , 7, 7 f
fo r u p p e r respira rory i n fecti o n , 2 1 9 , 22 2-24 2 , ·
f,
p r i n c i p l e s o f o s t eo p a r h i c m e d i c i n e , 6-7
225 f, 2 2 6 £, 22 7(, 2 2 9 f, 2 3 0 £, 2 3 1
s p i n 8 1 s o m a tic d y s f u n c r i o n , 8-9
2 3 4 f, 2 3 5 (, 2 3 6 f, 2 3 7 f, 2 3 8 f, 2 3 9 f, 2 4 0 f, 24 1
s t r ucru r e , fu n c t i o n , and d y s fu n c t i o n ,
8
Osteopa t h i c m a n i pu l a t i v e tre, r m e n t ( O lvI T ) , 1
A O A's
p o s it i o n p a p e r on cer v i c a l s p i n e , 5 0 -5 1 5
a t h l et i c pa tie n t
and,
1 4 3 , 1 4 5 , 1 4 7, 1 4 8- 1 5 1 ,
1 5 2 - 1 5 8 , 1 5 2 f, 1 5 3 f, 1 5 4 f, 1 5 5 f, 1 5 6 f , 1 5 7 f
for v i scero s o m a t i c re tl e x t s , 3 3 , 4 9 , 5 1 -5 4 , 5 3 !, 5 4 £, 8 0 " h l e t i c p e t i e n t a n d , 1 3 9, 1 5 1 h y p e r te n s i v e p a t i e n t a n d ) 2 6 7
[ n t e rn e t- m ed i a te d d e re b" s e fo r, I ()
f o r c h ro n i c pa i n , 3 8 5 , 3 8 6 , 3 8 7r
th e o f f i c e , 4 6 6-4 6 9
c o n d i tions that have shown positive responses ra J 6 5
a n d p a i n t r ( ;] t m c m , 3 8 6
c o n g e s t i ve h e a r t f. i l lI te , 2 8 3 , 2 8 4 - 2 8 9 , 2 8 5 f,
2 8 6 f, 2 8 7 f, 2 8 9 f d ia g n o s i s for, 1 2 , 2 8 fe m a l e p a t i e ; " J n d , 1 0 6 ,
for
p a t i e n t em powe r m e n t a n d } 1 -3 ped i a tric p a t i e n t a n d , 90-9 1
1 09, J
1 2- 1 2 5 ,
I l3 f,
p h y s i c i a n - pa t i e n t re l a t i o n s h i p ,
1 1 4 f, 11 5 f, 1 1 6 f, 1 1 7 f, 1 1 8 f, 1I 9 f, 1 20f,
psych o n e u ro i m m u n o l ogy � n d , s u r g i c o l p a t i e n t a n d , 1 29
3 7 2 , 3 7 5-3 8 0 , 3 7 6 f, 3 7 7f, 3 7 8 f, 3 7 9 f, } 8 0 f
8 3-84,
1 70
p s yc h i a t r i c p a t i e n t a n d , 7 5 , 77-7 8 , 7 9 , 8 2-X.'
1 2 l f, l 2 2 f, 1 2 3 f, 1 2 4 t f i b r o m ), a l g i alc h to n i c fa t i g u e s y n d rome, 3 70 ,
5 2 f,
Osteo p a t h i c p h y s i c i ::U1 S
fo t c h o l ecysti t i s , 3 0 0
fo r
2 32f, 2 3 3 f,
term i n a l p a t i e n t
a nd ,
1 83
a n d tre J. t m c n t of sco l i o s i s , 4 .5 3
Sfi
f
I n dex Osteopa t h y i n t h e c u n i " 1 field (OCf) (see Cra n i a l
Osteopo rosis, 1 64 , 1 8 4 Otitis media,
p h YS I c a l t h e r a py, 3 2 9
3 3 2 1, 3 3 4 f , 3 3 5 I , 3 3 6 f, 3 3 7f, 3 3 8 f, 3 3 9 1, 3 4 0 1 q u a l i t y 01 l i le , 3 2 8 proced u re s , 3 3 1 - 3 4 1 ,
osteopa t h y )
t 9 7- 1 9R
trea t m e n t m e t h o d s a n d r e a so n i ng , 3 2 8 - 3 2 9
a n a t o m y a n d p h y " o l ogy, 1 9 8 o s t e o p a t h I c t re a t m e n t p a r a d i g m , 1 9 9-20 1
Pare l l a r d i sorders, ped i a tric, 9 4
p a t h o p h Y S I o logy, 1 9 8 - 1 9 9 , 1 9 9 f
P a te l l a r t r a c k i n g a b n o rm a l i ty, 1 4 5
p roced ures, 20()-2 0 6 , 2 0 l f, 2 0 2 £, 2 0 3 f, 2 0 5 f, 2 0 6 £
P a te l l o le m o r a l F a i n s y n d ro m e , 1 4 5 P a ti e n t
O n a w a A n k le R u l e s , 1 4 1 , 1
Om p a r i e n r
Osteopa th i c
( see
rn_ o d t' l s , pJrienr e mpowerme n r a n d ,
1
Patient
7
Patient
S O A P n o te fo t ms ,
P a tiellt
C) v a r ies, v i sceroso m a r i c
ath letic
Overa n x i o u s d i s o r d e r, 7 6
fem a l " g e ri a t r i c p a t i e n t a t t h e e n d of l i fe , 1 8 1 - 1 9 6 Pa i n (sec a l s o H e a d a c h e s ; S h o rr l e g s y n d ro m e a n d
p e d i a t r i c p a t i e n t , 8 7- 1 0 3
p os t u ra l b ;t\ a llcc; Tem p o r o m a n d i b u l a r j o i n t
p s y c h i a t r i c p a tient, 7 3 - 8 5
ITMJ I d y s f u nc t i o n )
s u rgica l p a t i e n r , 1 27-1 3 7
c h o l ec y s t i t i s , 2 9 8
Pa t i e n t p r o n e p os i t i o n , s o ft t i s s u e r a n ge o f m o t i o n
c h ro n IC, 3 8 3-, 8 5 , 3 8 4 r
p r oced u re, 52-53, 5 4 £
d e c o m p e n s a t i o n a n d p a i n p r o d u c t io n , 4 3 8
P a r i e n t ro l e r a n c e , 2 9
h e e l , 1 4 7- 1 4 8
motion o f the
k i n d s of, 3 8 5-3 8 6
: ; 7, 1 3 7 £
a rs o n 's s y n d r o m e , 3 4 1
,' )(: ( W S c a r i n at u m , 93
Pectus
'Tl o d a l i ri e s i n p a i n ( r e a m�cnf,
rump) proced u re, 1 3 fl ,
P ed a l
" u s c u l o sk e l e t a l , 1 6 2 n e u r o pa t h i c , 3 8 5-3 8 6
Ped i a fi"
nociceprive, 3 8 5
d e o r, ' :
d i a g n osIS a n d t r e a t m e n t o f, 9 0- 9 1 , 9 6- 1 0 3 , 9 8 £,
osreo(1a t h i c m.:m i p u l a r i o n for c h r o n IC sp maJ P,1 I n , 5 7
9 9 f, 1 00 1, 1 0 l f, 1 0 2 f
p a i n he h a v i o r J n d J l l os r 3 s i s , 6 3
d i s o rders o f t h e d igestive tracr, 9 4 - 9 5
pa n c rea t i t i s , 2 Y ()
d i s o rders o f weig h t- b e a r i ng m e c h a n i c s , 9 3 -9 4
pe l v i c p a i n i n gy necologic p a r ie n t s , 1 0 6-1 0 8 ,
d ysfunction of r h e s k u l l a n d a x i a l s k eleron, 92-9 3 ,
1 09, 1 1 0
92f
posto p e r a t i v e p a i n contro l , 1 29-1 3 0
ped i a t r i c s o m a t i c d y s f u n c t i o n , 8 8- 8 9 , 8 9 £
psychoge m c , 3 8 6
Pelvic
refe r re d , 3 3 , 3 7
Pelvic
" o l i o s i s , 456-4 5 7
4 ,1 6f, 4 3 7f, 4 3 8 1 p a r i e n t s , 1 06- 1 0 8 ,
LIO
1 4 , 28
,md t e n d e r n es s i n r i ssu( ocr m i n a l p a r i e n r a n d
v is ce r a l
4 1 7-4 1 9 , 4 1 8 f 4 1 9 f, ,
p a i n , 1 83 - 1 8 4 l'ra n s m i ss i o n , 7 5
rest, ! -' , j
r r e a r m e n r for f i b r o m Y J. ! g i a ic h ro n i c
syn-
d r o m e , 3 7 1 t , 3 7 3-3 7 4
1 66 ,
Pelvic
148 449, 448f
Pe l v i s , e xa m i n a ti o n o f t h e , 2 3 - 2 6 , 2 3 f, 2 4 f, 2 5 f
u pper rcs p i r a r o r y t r a e r , 2 1 8
Peppin, J . E, 3
P a l pa t i o n
Pept i d e
o f o l d e r i n d I v i d u a l s , 1 6 2-1 6 3
T
( D A PTA ), 5 8
Per i p h e r a l a ffe r e n t n o c i c e ptors I rA""s ) , 5 9 , 6 0
i n s o m a f i c d ys f u n c t i o n d ia g n o s i s , 1 3
Peri p h e r a l c a u s a l g i a , 3 5 0
for t i s s u e tex t u re a b n o rm a l i ry, 1 3 , 1 8- 1 9 , 4 9
Person a l i t y d i s o r d e r s , 7 4 , 7 6 , 2 0 9
o f v i sccroso m a ric reflexes, 3 5 , 3 6 , 4 9
P e r r , C a n d a c e , 57-5 8
Philos,}f.'ley
Pa ncre a s , v i sc e r o s om a r i c P a ll c r e a ti t i s , 2 9 6-2 9 8
252
P"raspin a l m u s c l e release P " ra s p i n a l m u s c l e s t retc h , procedure, 2 5 1 , 2.5
FJ r a s p i n a l
Principles of i S t i l l ) , 2 6 2 -2 6 3
1i
v iscerosom a r i c
diagnosing
P:l r a s y m p a r h er i c i n ne r v a r ! o n ,
p rogress
res p i ratory t r a c t , 2 2 1 , 2 2 2
fo r sco l i o s i s, 4 5 4 -4 5 5
P a r a s y m p a t h e t i c \risceros o m a r i c reflexes, 3 8 ,
3 9 1-4 01, 2 9 3 , 2 9 5 , 2 9 6-2 9 7 P a r a v e n c b r a I v i sceroso m a t i c r e fl e xe s , 3 9 t-4 0 t
fo r s h o rt l e g s y n d r o m e , 4 1 4 -4 J 9, 4 1 5 f, 4 1 6 f, 4 1 7 f, 4 1 8 f, 4 1 9 f, 4 2 0 f, 4 2 l f fo r TMJ s y n d ro m e , 2 1 1 -2 J 2
P a n c t a l l i ft p roce d u re , 4 0 4 , 4 0 4 f
P h y s i c a l t h e r a p y, for Pa rk i ns o n 's d i s e a s e , 3 2 9
P a r k i n s o n 's d is e a s e , 3 2 4-3 2 7
P h y s i ci a n -c e n te r e d m o d e ls , p a t i e n c e m po w e r m e n t
c o m m o n osteo p a t h i c p r o b l e m s , 3 2 7- 3 2 8
; 2 9 -3 3 0
and, 2 model, 62
2.1) )-20 3 , 2 0 2 f
Index
528
P iriform muscle, m el' '-- ! L
d i a gn o s i s , 2 8 response, 2 9
1 1 9- 1 20, 1 2" ! proce -
P i r i fo r m m uscle re :;j(" d u re, 375-3 7 6 , 3 76 £ P i t u i t a r y d y s fu nc t i o n , 6 2
t rea ti n g t h e trea t m e n r
t r a u ma p a t i e nt s , 3 0-3 1
P R I CEM m n e m o n i c , 1 4 8
Pi tu i t a r y h y pe r t h y ro i d i s m , 3 0 9
a thletic p a t i e n t
Prima r y ca re p h y s i c i a n s ,
P i t u i t a r y m y x ede m a , 3 0 7
P l ag i oc e p ha l y, 92, 92f
Prlm"ry hypothyroidism,
P l a n t a r fa sci a l rcn d e r p o i n t , cOll nrersrra i n proce
P r i m a r y ri b d y s f u n c t i o n , 1 5
d u re, 3 79-1 8 0 , 3 8 0 1
d i a gn o S i S of, 2 8
P l a n r a r (asc i i r i s ( c o u n rerstra i n ) , H e i n k i n g proce
rre a t m e n t of, 3 0 v i sceroso m a tic r e f l e x e s a n d , 3 6
d u re , 1 5 5 - 1 5 6 , 1 5 5 £
P r i m a r y sp i n a l
Pneu m o n i a , 2 4 3 , biomechanical
P r o g re s s no t es bil l i n g a n d
i m p a c t o n eva l u cJi t �\"
p,1 t im t, 247
co d i n g e r r o r s c u r r e n t p r o Cc, 1 1 1 LJ 1
n e u ror e fl ex i ve i I'' ' o s t e op a t h i c c o r n
evaluation and
o u tcome s r u ci ies,
h i s r ory, 4 7 3 I C D - 9 C M , 4 ')
v a sc u l a r i n ter a c t i o n ,;,
P o l y pe pt i d e s , vaso.)uivc i mcsri n •.i l , 6 0 - 6 2 , 6 1 £
4 8 1 t--4 8 2 t , 4 8 .3--4 8 5 , 4 8 3 r, 4 8 5 r , 4 8 6t,
P os te r i o r C h ;:j r ma n 's reflexes, f r o m o t i t i s m e d i a )
1 99 1, 200-201
Pos terior i n nom i n a te d y s f u n c r i on , m u sc l e e n e rg y
p roced u r e , 1 1 6 1, 1 20 , 1 2 1
4 8 7--4 8 8 , 4 8 7 t
p h y s ic a l c xa m i o o ti o n , 4 76--4 77 rec o td l n g O M T, 3 1
P ["og rc')s i v e
Posterior l u m ba r tender poi n ts , 1 90f, 1 94-1 9 5 , 1 94 f
Po s te nor occipll(, m u sc l e e n e rgy p ro ced u r e ,
resistance
e x e rc i s e s � 1 6 6
P , o n J tcd foo t , 4 1 6 , 4 1 7 f Prone e x a m i n a t i o n , 1 4 2 Pr o p tos i s , 3 1 0
2 3 4-2 3 5 , 2 3 4 f, 3 9 9 Po s t e ri o r s a c r u m
P rostarc1 v i sc c roso m a t i c re f l e x e s fro m , 4 5--4 6
leg p u l l , HVLA trunk ror a t i o n ) }
Psoa s 427f
Posre r i o r t h o r a c ic
1 1
m u sc l e e n e rgy
'"1 0 ,
4 29 , 4 3 0 i
s t r a i n pr oc ed l
1 1, 4 26 ,
psoas spa s m ,
Postopera t i v e sllrg i c (l i
BO
Posttra u m a ti c Stre:;"
Postu r a l deco m pe ll \ ,-l l lnn Il'1
429, 430f 149, 4 49f
stretch e x e r c i s e s ) Psoas r e l e a s e
4 3 4 --4 3 5 , 4 3 \ J .
b a l a nced
case p re s e n t a t i o n s ,
3 S f,
la t e r a l ra d i o g r a p h ,
4 3 91, 4 4 0
proce d u r e s , 4 4 7--4 5 0 , 4 4 7r, 4 4 8 f, 4 4 9 £, 4 5 0 f Le vi r o r o r t h o tic, 4 4 0--4 4 1 , 4 4 2 1, 4 4 3 --4 4 5 ,
4 4 3 £, 4 4 6 f
Poseurr (see a l so S hort l e g sy n d r om e a n d p ost u r a l balance)
I igc mlCl"HUUS
3 4 0 -3 4 1 . i nd i rect p roC{" d ! l !T , 1 1
Psyc h utric
c o n d i t i o n , t h y ro i d d i sease a n d , 3 1 4
Ps y c h i a t r i c p a t i e n t , 73-75, B 4 - 8 5 p i tf a l l s , p r a t fa l ls ,
and
p re ca u t i o ns , 8 3- 8 4
postt r a u m a t i c s t ress d i s o rder, 76-1 8 , 8 0
psychod y n a m ics o f so m a t i c d y s fu n c t i o n , n-7Y role of O MT, 7 5 , 79-83 t he s o m a t i z i n g p a t i e n t , 74 , 75-7 6 , 80-8 1 , B3
a g i n g a n d p o s t u r a l ba l a nce, 1 6 1
b o d y posrures o f p s y ch ia tr i c p a t i e n t , 7 9
Ps y c h i c o r i g l l1 o f disease,
oc c u p a t i o na l p o s t ur a l stresses, 4 5 7
po s t u ra l i n s t a b i l i t y
P ot t en ge r,
-4 7 8 [ , 4 8 0r,
m ed i c a l d e c i SIOn llu k i n g ,
Postc holec y s tecrom y s y n d ro m e , 2 9 2
postura l reflexes
1 1J7 , 2 1 9
P r i v a te h e a l t h
contemporary
01
307
P r i m a ry :;oma t i c d y s f u n c t i on ) 1 3 } H S
P l a n t a r fa s c i it i s, 1 4 7-1 4 8
use
a nd , 1 3 9,
1 40
i n P � r k i m: on 's It U Il I
rl !S�;1Sf\ 3 2 6
F. M., 3 Practice of Au/onon,' \',
57
P s y c h o ge n i c , .3 8 6
246
P s y c h o l ogi c a l
i'c d i a r r ic) 96
P r a c t i c e issues t h e o ff i c e , 4 6 6 -4 (, "
. 6 3-66
p rogress n otes a nd
P rega b a l i n ( Ly r ic a i.
1.1
Pr eg n a n c y
scoliosis a n d , 4 60
s o m " i c d y s f u n c t i o n d u ring , 1 0 8- 1 0 9
st r u c r u ra l e�a m i n a r i on of pregn a n t pa t ie n t , 1 1 2- 1 1 3
P re o p era ti v e su rg i c a l pa tien ts, 1 2 7- 1 29 P r escr i pr i o n , OMT d e fi n ed , 2 7
6 0-62, 6 l f P s y c h o p h y s i o l ogic d i sorders, 74-7.5 Ps y c h o s o m J r i c
d c l i n c d , 74 p a r h w a y s , 7 .5
Psychosri 1l1 u l a m s , 1 8 3
529
I ndex " p h:nnp a l a r i n e ga n -
S Sac ra l Sacral rorSlons, 1 1 1
P u l m o n a r y a rter i a l h y pe r t e n s i o n ( PA H ) , 3 1 2 P u l m o n a r y ci rcu l a t i o n , 2 8 1
Sac r o p e l v i c s o m a t i c d y s function, 1 0 7, 1 1 0- 1 1 2
ped Ia t r i c , 96
Sacrum
t h y tOld d i s e a s e a n d , 3 1 2
morion,
23-24, 2 3 f
S a c ro i l i a c s o m a r i c d ysfunc t i o n , 1 0 7-1 0 8 , 1 1 1
P u l m o n a r y d i so r d e rs
Pump-handle
Sacro i l i a c articu l a r d ysfunc t i o n , m o r i o n rest fOf,
HVLA
a n terior s a c r u m l e g p u l l ,
347
proced u re ,
1 1 8- 1 1 9 , 1 I 8 f
Py o g e n i c t h y ro i d itis, 3 0 9 , 3 1 0
a nt e ri o r saC f u m , m u scl e e n e rgy p roce d u re,
Q
1 1 7- 1 1 8 , 1 1 7f, 4 2 7 1 24 - 1 2 5 , 1 2 4 f
d ia g n o s is
Q u a d ricep,
eXami na tion fa c i l i ra t cd
Qua l i ty of
2 4 f, 2 5 f 1 7 5- 1 76 , 1 76 f I l J-1 1 4 , I 1 3 f
i nhibit
R
p roced u r e , 1 1 9,
posterl(;1 11
Ra nge a nd
ro t J r l O n ,
ra nge o f
i n r i b S O t T) : l f ] Z s a c ropel v i ,
in verrebr: d
R e b o u n d rea w o n s to O M f, 1 6 4 Rcd
refl e x ,
Sagi tta l p l a n e dtw m pc n , a r i ofl
i,ec
HVLA
proce-
1 07 , 1 1 0- 1 1 1
Post ura l deco m
pe ns a t i o n i n the s a g i t t a l p la ne )
36, 49
R e fe r red p a i n , 3 3 , 3 7
Sca p u l o t ho racic, m yofa sc i a l r e l ea s e p r oc e d u r e ,
R m il , Wi l he l m , 7 7
S c a r r e l e a s e , i n d i rect p roced u re , 1 3 7
Re f l e x s y m pa t h e t i c d y s t ro p h y, 3 5 0
2 8 7-2 8 8 , 2 8 7 f
Re l a x a t i o n response, 6 1
Sc h i z o p h r e n i c p a t i e n t s , 4, 76
Repos i t i o n i n g a p p l i a nces ( s p l i n ts ) , 2 1 4
Schneider, C a r l
Repres s i o n , 77, 8 3
Sclerotomes, 8
R e p r o d u c r i ve orga n s , v i scerosom a t i c r e f l e xes from ,
Sco l i o s i s , 4 1 9, 4 5 2-4 5 3 , 4 5 3 £, 4 6 0
4 5-4 6
I die xes from
R e s pi r a ron
E.,
4
d i a gn os t i c test i ng, 4 5 7 e r i o l og\c',
R e st
c o n s ra n r
, 426f
R e s r i n g r r e nloe
Reverse
rib,
1 5 .1-.;; 5 , 3 5 4 f,
.1 9 7· R e v e rse
ro[<;o
proced u re s , s p i na l
R h e u m a W h :i d r t h r i llS ,
trea t m e n t p rotoc o l , 4 5 7-4 5 9 , 4 5 8 f
R i b ld a n c i n g p roced u re , 1 3 5
R i b d i ag n o s i s a n d t r e a t me n t , u p p e r, 2 2 5 -2 2 8 , 2 26£, 2 2 7 f, 3 1 9-3 2 2 , 3 2 0 f, 3 3 3
R i b d y s fu n ct i o n ,
a nd ,
4 5 5-4 5 6 , 4 5 6 f
I tlvc n i l e , 4 5 4
"1 5
2 2 6 (, 22 7f, 3 2 1 -3 2 2 , 3 9 8- 3 9 9 , 3 9 9 f
R i b i n h a l a ti o n a n d e x h a l a t i o n , m u s c l e e n e rgy for, 3 3 3 - 3 3 7 , 3 3 4 f, 3 3 5 f, 3 3 6 f, 3 3 7 f
r i b ra i s i n g , 2 4 9-250 S e a ted e x a m i n a t i o n , 1 4 1 - 1 4 2
Seated f l e x i o n test, 2 5 - 2 6 , 2 5 f
S e co n d a ry hypothy r o i d i s m , 3 0 7-3 0 8
S e c o n d ::1rY 5 0 m :l t i c d y_� fu n c r i o n , 1 .1
R i b ra i s i n g , 1 8 7
Segmemai
fOf c o n gc:,ri vc
o f cen ;ved.i
d u ri n g 24 9-2 , I ,
Seared rib a r t i c u l a t i o n , 2 5 0- 2 5 1
R i b , firsr a n d second r i b HVLA procedure, 226-2 2 8 ,
fo r l o w e r
S c r e e n , sca n , segmenta l d i a gno s i s , 2 4 8
2 74-2 75 , 2 7 4 f
S e rg u e e :·j -34 8 somaric
273-274, 2 7 4 f
245 ,
> 4 5 -3 4 7
R i b ren cI e r poi n ts , c o u n re r s r r a i n proce d u res, 355 -3 5 9 , 3 5 5 f, 3 5 6 £, 3 5 8 f
refl exes from, 4 5 (SARS), 243
Severe
S h o r r l eb
b a l a nc e , 1 6 2 , 1 65 ,
4 0 8 -4 0 9 , 4 25-426 assess m e n t , 4 2 2-42 5 , 4 2 2 f, 4 2 3 f
R I C EM mn e m o n ic , 1 46 , 1 4 8
p h y s ic a l e xa m i na t i o n , 4 1 4-4 1 9 , 4 1 5 f, 4 1 6 f, 4 1 7 f,
R o t a t i o n a nd r i b r a i s i n g , 2 5 0-2 5 1 , 2 5 0 f
prese n t a t i o n o f the p a t i e n t, 4 0 9 , 4 0 9 f, 4 1 Of,
R i ed e l 's r h y r o i d i tis , 3 1 4-3 1 5
R o r a r o r c u ff ten d o n i t i s , 1 4 6-] 4 7
4 1 8 f, 4 1 9 f, 4 2 0 f, 4 2 J f 4 1 1 -4 1 4 , 4 1 1 1, 4 1 2 f, 4 1 3 f
I n d ex
530
r e s p i r,Hory i n fection
4 3 0 f,
dlOracic s p i n e a n d
147 S i c k ness beha v I o r, 5 9 , 6 3
v I sce roso m a tic re fl e x es a n d , 3 6 - 3 7
S I de - be n d i n g forces, 8 , 1 4 - 1 5 , 9 3
So m a t i z i ng pa t i c n rs , 7 4 , 7 5 - 7 6 , 80-8 1 , 8 3
S i m p l e c a l f s r ren gt h e n i ng e x e rC I S e , 1 78
So ma t oe m ot io n a l , 77-78
S i m p le cervical i sometrIcs exerc i s e , 1 76- 1 7 7
Soma toform d i sorders, 76
S k i n d r a � , 4 9- 5 0
Soma topsyc h o l o g i c p a t h w a y s , 75
Skin
r ef l ex es ,
62
14,
I
refl e xes, 9) 1 :; ,
' , c a r r fa i l ure a n d , t h e g..1 s r roimesrin a i tL1C[j 3 7 1 t, 3 73
gy neco logIC p r o b le ms and, 1 0 6- 1 0 /
S l es z), n s k i , S a n d ra , 4 9 0
h y perte n s i o n a n d , 2 6 8
S mit h,
fro m p n e u m o n i a p a t i e n t , 2 4 6
R. K . , 2 4 5
S O A P n o te forms, ost e o p a t h i c , 1 0 , 4 92-4 9 3
th y ro i d d isease a nd , 3 0 6
a d v a n rages o f u s i n g , 5 0 2-5 0 4
from u p p e r r e s p i r a to r y tract, 22 1 , 2 2 2
b a s k i n fo C 1 n , n r n n , 5 0 4 - 5 0 5
Cl' 1
reflexes a n J , U
36�37
S p h e n o ' o(z.: i p l r a l s y nc h o n d r o :, ; -:; , t tl
4 9 1 -4 ') 2
No t e
s om a t i c
d ys i u nc r i o n , 8 8 s y n c h o n d ro<3
(SOAP, 5 0 0-5 0 1
na n i a i
v a u i r h o l d fo r, 203-2 0 4 , 2 0 3 i
S p h e n o ba s i l a r release p roce d u re , 9 9- 1 00 , l O O f
fo rm deta i l s , 5 0 6-5 0 7
S p h e n o b as i l a r s y n c h o n d rosis, in pe d i a tri c s o m
fo rm p a ges, 5 0 7-50 9 t h e fo rms, 5 0 4-5 0 9
dysfunction, 88, 9 6
pa per S O A P n o t e s , 4 93 -4 9 4 , 4 9 4 f-4 9 7 f, 4 9 5 f,
S pb e n o p a l a t i n e gangl i o n p roced u r e , 2 0 6 , 2 0 M
33 a n d cod i n g "
in
I,
478,
I,
o f gra v i ty, 4 r
452, 453f ll s i n g , 5 0 1 , 5 0
sLoholi( ( U l v e s , 4 5 6
s p ec i a l ty f o r m s d evelo ped from t h e o r i g i n a l
ty p e
for m s , 5 0 5-5 0 6
I
a n d t y pe I I , 4 0 9 , 4 1 0 f, 4 1 1 , 4 1 2 f, 4 1 3 ,
4 5 5 -4 5 6 , 4 5 6 f
s ta n d i n g srru c t u r a l e xa m i n a t i on f r o m , 1 7, 1 8 1
S p i n a l f u s i on , 4 6 0
th r ee versions o f, 5 0 5
Sp i n a l s o m a t i c d y sf u nc t i o n
m a te r i a l s , a n d
USJ!��L
8. v �! i l a h l e ,
1
8-9
SOA P
1 0,
objective, a s s (:ssmc:) L
model for, 2 8 2 r:nu:=nrs a n d ,
") j ,
Soft
l'U:i:;U\.: p r o .:.:cJu res 2 3 9-2 4 0 , 2 4 1 f, 3 2 2 1 86, 230, 2R5, 331 1 1
l u m h :'\ �
3 5 1 -3 5 2 , 3 5 2 f S p l e e n , v isceroso m a ti c r e flexes f ro m , 44
c e r v i c a l s o fr t i s s u e/a r t i c u l a t i o n , 1 3 3-1 3 4 , 1 3 3 1, l u m b;) f P il. LJ. 'Ii C rre b r a l m uscles)
1 3 0-- t� 1
Sp i no u s process th rll s t , HVLA proced u re,
a n re r i o r neck sofr tissue, ly m p h a ti c p roc e d u res ,
fm
413
40 9 , 4 1 0 f, ,\ l I ,
teVised io nns, 5 0 6-5 0 7
S p l ints, occ l usa l , 2 1 3 Spon d y l o l i s t h e s i s , 4 4 4
t 5,
1 14- 1 35
Spo n d v l o l yscs; 4 4 4
Sports
139
t i s s u e a rt i c u l a t i o n , C X i C Il 'i ! o n e x e r c i s e s , 4 f) \
tension h e a daches,
ra nge or m u D O Il pro c e d u res, 3 l f, ') S f, 5 1 5 4 , 5 2f )
5 3 f, 5 4 f
rever,;:,": iur::iO curl exercise, '1 6 4 , 4 6 i 1 torso c u r l exercise, 4 6 3 --4 6 4 , 4 6 4 f
thoracic, p a t i e n t o n s I d e , 5 1 - 5 2 , 5 2 f, 1 3 4 , 3 0 0 thor a ci c s o ft t i s s u e a rt i c u l a t i o n , 5 1 -5 2 , 5 2 1, 2 8 8 ,
Standa r d i zed me d i ca l record, 4 9 0 , 4 9 2-4 9 3 , 5 1 0 c l i n i c a l o u tcomes a n d e v i d e n ce - b a se d med i c i n e ,
3 00 , 3 3 2
4 95-4 9 9 4 9 5 f, 4 9 9 f
notes, 4 9 3-49 4 ,
"omaric
and
CPT c o d i n g
4 9 1 -4 9 2 1 0, 50 lt
SOAP Note Form,
StJ n d i ng d e i i r:tJ, 1 2- 1 3
IIc,ion
tes t , 2 4 f, 25
Sr�1 n d i n g .:i t r u cru r a l exa m i na tio n , 1 7,
in fem a l e pa t i e n ts , 1 0 7- 1 0 8
S ta r l i n g ,
ge r i a t ric m u s c u l o s k e l er a l f u n c t i o n a n d , 1 6 0- 1 7 1
S t a t i c sco l i os i s , 4 5 7
I S!, 1 4 1
E. H . , 1 84
m e c h a n ical e ffect/i m pa c t o f , 4 8 , 2 2 0-22 2
S t i l e s , Edwa r d , 2 4 5
O M T for, 1 2 , 1 3 , 1 5 , 2 7- 3 1
S t i l l , A n d re w Ta y l o r, 2 7 , 5 6 , 5 7 , 1 3 9 , 1 84, 2 2 1 ,
262-2 6 3 , 3 1
89 f
01, 78-79
5
Ss"
1 72f, 1 73 f 1 75! 4 , 1 74 1
I n d ex
532
T h y r o i d maligna n cy, 3 J
6 hormone
Th y r o i d -st i m u l a ti n g
(TS H ) , 3 0 5 , 3 0 6 ,
3 0 7-3 0 8 , 3 0 9 , 3 1 5
Va lgus and varus p r o b le m s p e d i a t r i c , 9 4
T h y r o i d i t i s , 3 0 8 , 3 0 9 , 3 1 4-3 1 5
Va n B u s k i r k , R .
T h y ro r o x i c o s i s , 3 0 8 T h y rorrop i n - re l easing h o r m o n e ( T R H I , 3 0 5 , 3 0 7 Ti biofi b u l a r b a l a ncing, i n d i recr procedll tc, 3 7 8-379, 379f
61
o f v i sceroso m a tic refl exes, 3 9 , 4 9 TMJ Associ a t i o n , 2 1 4
proce d u re , 2 0 2-203 , 2 0 2 f
Tra n s a b d o m i n a l s t i m u la t i o n , 1 8 7, 3 0 2 - 3 0 3 Tra n s ference, i n p h y s i c i a n - p a t i e n t rel a t i o n s h i p , 8 3-84
J 30,
Tra u be - H e r i n g - M a y e r osc i l l a r i o n , 62,
1 6 8 , 279
Tra u m a , PTSD a n d , 77, 78
., " d , 1 3 , 3 3 -3 5 ,
V i scera l p a i n , rerrn i ne l p a r i e n t
1 8 3- 1 8 4
Visee rosoma r i c reflexes,
4 H -4 9 , 5 7 , 1 64
f r o m the g a s r r o i nres r i n " l nact, 42-4 4 , 2 9 2-2 9 5 , 2 9 6-2 9 7 , 2 9 9 , 3 0 0
12 ;'1 11(1 [ h r n a r .
gy neco l og i c p r o b l e m s a n d , 1 0 6 , 1 from t h e hea d , eyes, e a r s , n o s e ,
fro m
4 0-4 1
rhe h e M r , 4 1
h y pe r te n s i o n a n d , 2 6 8
Tra u m a p a r i e n ts , OMT for, 3 0 -3 1
loca t i o n o f , 3 7-3 9 , 3 9r-4 0 t
Tra v e l l trigger po i n r s , 6 2
from t h e l o w e r re s p i ratory r r ;:t ( f . 4 1 -4 2
Tra z o d o n e , 3 7 3
antidepressa nts,
V i ra l t h y roi d i ti s , 3 1 4 V i scera l n eo p l a s i a , 3 5
(rom the endocrine g l a n d s , 46
Tort i c o l l i s , 9 2 - 9 3
pinna
2 (1 8
d i ag n o s i s o f , 3 5 -3 7 , 3 7 (, 4 9- 5 0
Torso c u r l e x e rc i s e s , 4 63 -4 6 4 , 4 6 4 f, 4 6 5 f
213
Trige m i n a l n e r v e p roce d u re o f
OMT o f, 3 3 , 4 9 ,
Ba i l e y
,
2 3 7-240,
Tri p t . n s , 3 9 2 Two-c h a m bered p u m p ( hea n l ,
SO
from the p a ncre"s, l i ver, ga l l b l ., d J e r,
and
,plecn, 4 4
(rom p n e u m u n i a p a t i e n t , 2 4 6
2 3 7 f, 2 3 8 f
f r o m [he reprod u c t i v e o rga n s , 4 5 -4 (;
282
from s u rge r y a (rer a th l e t i c i n j u r y, 1 5 0 surgical pari e n t a n d , 1 2 8-1 29,
Two-of-three r u l e , 4 7 3 , 4 8 6t, 4 8 7 t
Ty pe I a n d type I I s o m a t i c d y s fu n c t i o n , 1 4 - 1 5
a n d type 11 s p i n a l c u r v e s , 4 0 9 , 4 1 0 f, 4 1 1 ,
4 1 3 , 4 1 7, 4 1 8 , 4 5 5 -4 5 6 , 4 5 6 f
1 3 1 , 1 3 2- 1 .1 7 ,
1 .l 2 (, 1 3 3 f, 1 3 6 f, 1 3 7f
in te r m i n a l p a t i e n t s , 1
R3 of, 1 4 , 2 8 - 2 9 " p per r e s p i r a ror y r r a e r ,
treatment from
2 1 8- 2 1 9 , 2 2 .1
fr0111 t h e u r i n a ry t r a c t , 4 4 -4 5
u
Visc e r o s o Jn Cl t i c a n d s o m a r o v i �ct' r 3 1 r e f l e x e s , 3 3- 3 4
Upper g a s t r o i n res r i n J I v i sceroso m a t i c r e f l e x e s , 4 2 U p p e r resp i r a tory i n fecti o n , 2 1 8-2 1 9 ( see a l s o Lower res p i ratory tracr in fe c r i o n ) mec h a n i c a l i m pact o f s o m a t i c d y s funct i o n , 220-22 1 n e u ro l og;c impact of soma ric d y s fu n c t i o n , 22 1-222
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