In-patient OMMBrian Loveless, DO

Associate Professor, Vice-Chair Department of NMM/OMM, WUHS/COMP

AAO Convocation 2019

DisclosureI have no actual or potential conflict of interest in relation to this program/presentation.

Objectives

Review

Review current research into inpatient care models

Explore

Explore a process for quickly acquiring relevant examination findings

Incorporate

Incorporate those findings into an evidence-based treatment plan•Integrating osteopathic philosophy

“To find health should be the object of the doctor. Anyone can find disease” Philosophy

Are we doing OMM in the hospital?Carruzzo (2013)

◦ 37 Swiss hospitals surveyed◦ 19 hospitals reported offering at least one CAM◦ Most frequent was acupuncture, followed by manual therapies, osteopathy,

and aromatherapy◦ This is a 54% increase in ~10 years

Rhon (2018)◦ Military hospital, 7566 patients with spine or shoulder conditions in 2009◦ Tracked manipualtive treatment by DO, DC, PT◦ 26.6% received manipulative treatment at least once, average of 3.3 visits per

patient◦ Thoracic complaints most likely (50.8%), shoulder complaints least likely

(24.2%)◦ 29% of the manipulation was by DO

Are we doing OMM in the hospital?Aveni (2016)◦ Swiss hospital, staff surveyed to assess attitudes toward

complementary medicine for chronic pain◦ 96.6% in favor of CM (hypnosis, osteopathy, acupuncture)◦ Over half (58.3%) had never referred for CM, 84.3% felt the lacked

the knowledge to inform their patients about CM

Smith-Kelly (2016)◦ 474 employees at an American hospital in Oregon◦ Housed AOA residencies in FM, IM, Orthopedics, General Surgery, and

Psychiatry◦ 25.7% reported that they were not at all knowledgeable about OMM◦ This group inclouded RN, CNA, NP, PA and "Other" (clerical, therapy,

technicians)

Osteopathic Recognition213 programs as of February 2019

No specific requirement for inpatient OMM but many programs have inpatient rounds

◦ Who is leading those?

Should we be doing OMM in the hospital?Baltazar (2013) - Postoperative ileus

Cerritelli (2013) - NICU

Crow (2009) - Postoperative ileus

Fleming (2015) - Postoperative ileus

Hastings (2016) - Postpartum

Noll (2010) - Pneumonia

Pizzolorusso (2014) - Preterm infants

Probst (2016) - Postop bowel

Racca (2017) - Postop sternotomy

Swender (2014) - Cystic fibrosis

Should we be doing OMM in the hospital?Bagagiolo (2016)◦ "The available studies in neonatal settings provide evidence that

OMT is effective in reducing the hospital length of stay of the treated infants, therefore, (sic) suggesting that robust cost-effectiveness analyses should be including in the future clinical trial's design to establish new possible OMT_shared strategies within the health care services provided to newborns."

How do we do OMM in the hospital?

Review of Hospital Exam

OA/AA

Cervical TART changes

T1/supraclavicular fossa/1st rib/clavicle

Thoracic TART changes

Ribs

T12

Lumbar TART changes

L5

SI/ASIS/Pelvis

OMMBiomechanical Neurological

Behavioral

Respiratory/Circulatory

Metabolic

ABCs of OMT•Autonomics

•Biomechanics

•Circulation

•screening

Comparison of ApproachesExam Noll Radjeski Clark MOPSE Swender

OA/AACondylar Decomp

Condylar Decomp Subbocc ihn Decomp

Cervical ST ST/HVLA ST

T1 MFR 1st rib CS MFR MFR

ThoracicParaspinal Inhibition ST/ CS ST

Rib Rib Raising Ant CS Rib Raising Rib Raising Rib Raising

T12Doming Diaphragm

Doming Diaphragm

Doming Diaphragm

Lumbar ST/CS

L5 CS LS decompPelvis IS mob

LymphaticLymphatic Pump

Pectoral Traction

Lymphatic Pump Pedal/Thoracic Thoracic Pump

Other Sternal MFR SBS Decomp

Using Osteopathic PrincipleslApplication of osteopathic principles, not techniques

lInfluencing physiology using the musculoskeletal system as a handle

lNeed to get away from the disease model of care

lTreat the patient, not the disease

Proposed “Framework”lSacral/Pelvic balance

lL/S decompression

lLumbar treatment

lT/L junction

lThoracic diaphragm

lThoracic treatment

lRibs

lScapulae

lThoracic inlet

lFirst rib

lCervical treatment

lOA/AA

lLymphatic pump

ContraindicationslPatient refusallNo supervisionlCancer?lInfections?lFractures?lHeart Failure?

COPD and OMTl“Immediate Effects of Osteopathic Manipulative Treatment in Elderly

Patients With Chronic Obstructive Pulmonary Disease” Noll, et al May 2008

lWorsening of air trapping following a session of OMT

l“The immediate effect of individual manipulation techniques on pulmonary

function measures in persons with chronic obstructive pulmonary disease”

Noll, et al Oct. 2009

lUse of thoracic pump with activation increases post treatment residual volume

Dosing of OMTlNot longer than the patient can tolerate

lMake an initial treatment as focused and brief as necessarylRe-assess to evaluate the patient's responselFurther treatments longer or shorter as appropriate

lTypical treatment lasts

Frequency of OMTlNo more frequent than the patient can handlelTypically treat daily

lSicker patients may benefit from shorter, more frequent treatmentslAs the patient improves may increase time between treatments

Informed Consentl Nature of the procedure

l Reasonable alternatives to the proposed intervention

l Explanation of

lRisks

lBenefits

lUncertainties

l Assessment of understanding

l Acceptance of intervention

“I have no desire to be a cat, who walks so lightly that it never creates a disturbance. I want to be

myself, not ‘them,’ not ‘you,’ not ‘Washington,’ but just myself; well plowed and cultivated”

Autobiography

References1. LBORC A. Inpatient Osteopathic SOAP Note Form. In.

2. Aveni E, Bauer B, Ramelet AS, et al. The Attitudes of Physicians, Nurses, Physical Therapists, and Midwives Toward Complementary Medicine for Chronic Pain: A Survey at an Academic Hospital. Explore (NY). 2016;12(5):341-346.

3. Bagagiolo D, Didio A, Sbarbaro M, Priolo CG, Borro T, Farina D. Osteopathic Manipulative Treatment in Pediatric and Neonatal Patients and Disorders: Clinical Considerations and Updated Review of the Existing Literature. Am J Perinatol. 2016;33(11):1050-1054.

4. Baltazar GA, Betler MP, Akella K, Khatri R, Asaro R, Chendrasekhar A. Effect of osteopathic manipulative treatment on incidence of postoperative ileus and hospital length of stay in general surgical patients. J Am Osteopath Assoc. 2013;113(3):204-209.

5. Carruzzo P, Graz B, Rodondi PY, Michaud PA. Offer and use of complementary and alternative medicine in hospitals of the French-speaking part of Switzerland. Swiss Med Wkly. 2013;143:w13756.

6. Cerritelli F, Pizzolorusso G, Renzetti C, et al. Effectiveness of osteopathic manipulative treatment in neonatal intensive care units: protocol for a multicentre randomised clinical trial. BMJ Open. 2013;3(2).

7. Clark RC, McCombs TM. Post operative osteopathic manipulative protocol for delivery by students in an allopathic environment. The AAO Journal. 2006;16(2):19-21.

References (cont.)8. Crow WT, Gorodinsky L. Does osteopathic manipulative treatment (OMT) improves outcomes in patients who develop postoperative ileus: A retrospective chart review. International Journal of Osteopathic Medicine. 2009;12(1):32-37.

9. Fleming RK, Snider KT, Blanke KJ, Johnson JC. The effect of osteopathic manipulative treatment on length of stay in posterolateral postthoracotomy patients: A retrospective case note study. International Journal of Osteopathic Medicine. 2015;18(2):88-96.

10. Hastings V, McCallister AM, Curtis SA, Valant RJ, Yao S. Efficacy of Osteopathic Manipulative Treatment for Management of Postpartum Pain. J Am Osteopath Assoc. 2016;116(8):502-509.

11. Noll DR, Degenhardt BF, Johnson JC, Burt SA. Immediate effects of osteopathic manipulative treatment in elderly patients with chronic obstructive pulmonary disease. J Am Osteopath Assoc. 2008;108(5):251-259.

12. Noll DR, Degenhardt BF, Morley TF, et al. Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial. Osteopath Med Prim Care. 2010;4:2.

13. Noll DR, Johnson JC, Baer RW, Snider EJ. The immediate effect of individual manipulation techniques on pulmonary function measures in persons with chronic obstructive pulmonary disease. Osteopath Med Prim Care. 2009;3:9.

14. Nuno V, Pena NJ, Hughes TNF, Cuny LAM, Pierce-Talsma SL. Teaching Osteopathic Principles and Practices: Easy as ABCs. The AAO Journal. 2018;28(2):34-38.

References (cont.)15. Pizzolorusso G, Cerritelli F, Accorsi A, et al. The Effect of Optimally Timed Osteopathic Manipulative Treatment on Length of Hospital Stay in Moderate and Late Preterm Infants: Results from a RCT. EvidBased Complement Alternat Med. 2014;2014:243539.

16. Probst P, Buchler E, Doerr-Harim C, et al. Randomised controlled pilot trial on feasibility, safety and effectiveness of osteopathic MANipulative treatment following major abdominal surgery (OMANT pilot trial). International Journal of Osteopathic Medicine. 2016;20:31-40.

17. Racca V, Bordoni B, Castiglioni P, Modica M, Ferratini M. Osteopathic Manipulative Treatment Improves Heart Surgery Outcomes: A Randomized Controlled Trial. Annals of Thoracic Surgery. 2017;104(1):145-152.

18. Radjieski JM, Lumley MA, Cantieri MS. Effect of osteopathic manipulative treatment of length of stay for pancreatitis: a randomized pilot study. J Am Osteopath Assoc. 1998;98(5):264-272.

19. Rhon D, Greenlee T, Fritz J. Utilization of Manipulative Treatment for Spine and Shoulder Conditions Between Different Medical Providers in a Large Military Hospital. Archives of Physical Medicine and Rehabilitation. 2018;99(1):72-81.

20. Smith-Kelly JB, Cardenas A. Assessment of Hospital Staff's Knowledge of Osteopathic Manipulative Medicine: A Survey-Based Study. J Am Osteopath Assoc. 2016;116(12):764-769.

21. Swender DA, Thompson G, Schneider K, McCoy K, Patel A. Osteopathic manipulative treatment for inpatients with pulmonary exacerbations of cystic fibrosis: effects on spirometry findings and patient assessments of breathing, anxiety, and pain. J Am Osteopath Assoc. 2014;114(6):450-458.