Core Concepts in Core Concepts in

Osteopathic Manipulative Medicine Osteopathic Manipulative Medicine

& &

The Application To Board Examinations The Application To Board Examinations

Michael P. Rowane, DO, MS, FAAFP, FAAOMichael P. Rowane, DO, MS, FAAFP, FAAOAssociate Clinical Professor of Family Medicine and PsychiatryAssociate Clinical Professor of Family Medicine and Psychiatry

Case Western Reserve University Case Western Reserve University

Director of Medical EducationDirector of Medical Education

University Hospitals Richmond Medical CenterUniversity Hospitals Richmond Medical Center

Director of Osteopathic Medical EducationDirector of Osteopathic Medical Education

University Hospitals Case Medical CenterUniversity Hospitals Case Medical Center

Cleveland Academy of Osteopathic Medicine

D.O.s: Treating Our Family & Yours

6th Annual OMT Seminar: January 24th, 2010

OutlineOutline

�� Review core concepts of OPP/OMM/OMTReview core concepts of OPP/OMM/OMT

�� Discuss general measures to prepare for board questions Discuss general measures to prepare for board questions

involving Osteopathic Principles & Practices [OPP]involving Osteopathic Principles & Practices [OPP]

�� Examine the COMLEX Structural/OPP component to the Examine the COMLEX Structural/OPP component to the

National Board of Osteopathic Medical Examiners [NBOME] National Board of Osteopathic Medical Examiners [NBOME]

�� Present the 10 Basic Body Functions related to Osteopathic Present the 10 Basic Body Functions related to Osteopathic

Manipulative Medicine [OMM]Manipulative Medicine [OMM]

�� Explore the 5 Models involved in using Osteopathic Explore the 5 Models involved in using Osteopathic

Manipulative Treatment [OMT] Manipulative Treatment [OMT]

�� Go over COMLEX practice questions involving OPP/OMM/OMTGo over COMLEX practice questions involving OPP/OMM/OMT

Andrew Taylor Still, MD, DOAndrew Taylor Still, MD, DO

�� Born in 1828Born in 1828

�� Father = Minister & Father = Minister & PhysicianPhysician

�� MD in Kansas City, MoMD in Kansas City, Mo

�� Abolitionists, moved to Abolitionists, moved to Native American Reservation Native American Reservation in Indianain Indiana

�� Kansas LegislatureKansas Legislature

�� Children died of meningitisChildren died of meningitis

�� MECHANICAL AGEMECHANICAL AGE

�� Discovered Osteopathy 1874Discovered Osteopathy 1874

�� American School of American School of Osteopathy in Kirksville 1892Osteopathy in Kirksville 1892

Key ConceptsKey Concepts

Somatic DysfunctionSomatic Dysfunction

�� Definition:Definition:

��pathologic alteration of joint pathologic alteration of joint functionfunction

��mimic or aggravate organic mimic or aggravate organic disease disease

�� involves involves ““TARTTART””�� TTendernessenderness

�� AAsymmetrysymmetry

�� altered altered RRange of motionange of motion

�� TTissue texture abnormalityissue texture abnormality

Barriers To MotionBarriers To Motion

��AnatomicAnatomic

��PhysiologicPhysiologic

��PathologicPathologic

Indications/Contraindications Indications/Contraindications

for Manipulationfor Manipulation

�� IndicationsIndications: alleviate somatic dysfunction: alleviate somatic dysfunction

�� ContraindicationsContraindications::

�� trauma (fractures, lacerations, bleedingtrauma (fractures, lacerations, bleeding

�� pathologic bone disease (pathologic bone disease (lyticlytic / / blasticblastic))

�� poor patient cooperationpoor patient cooperation

�� neurologic symptoms while positioningneurologic symptoms while positioning

�� severe RA, structural defectssevere RA, structural defects

Indications/Contraindications Indications/Contraindications

of Manipulationof ManipulationContraindicationsContraindications

(cont.)(cont.)

��Bruits in carotidsBruits in carotids

��Lens implantsLens implants

��HemophiliaHemophilia

��MedicolegalMedicolegal

situationssituations

““Red FlagsRed Flags”” = = RIFTRIFT

��RRadiculopathyadiculopathy

��IInfectionnfection

��FFractureracture

��TTumorumor

Types Of Manipulation:Types Of Manipulation:

Direct/IndirectDirect/Indirect

SOFT TISSUE TECHNIQUESOFT TISSUE TECHNIQUE

DEFINITIONDEFINITION: :

Procedure Procedure

directed toward directed toward

tissues other tissues other

than skeleton than skeleton

while monitoring while monitoring

response and response and

motion changes motion changes

using diagnostic using diagnostic

palpation.palpation.

SOFT TISSUE TECHNIQUE SOFT TISSUE TECHNIQUE

((concon’’tt))

Usually involves Usually involves

lateral lateral

stretching, linear stretching, linear

stretching, deep stretching, deep

pressure, pressure,

traction, and/or traction, and/or

separation of separation of

muscle origin muscle origin

and insertion.and insertion.

MUSCLE ENERGY MUSCLE ENERGY

TECHNIQUETECHNIQUE

DEFINITION: DEFINITION:

A term first suggested by A term first suggested by Fred L. Mitchell, Fred L. Mitchell, SrSr, DO. , DO.

A form of Osteopathic A form of Osteopathic manipulative technique in manipulative technique in which the patient uses their which the patient uses their muscles, on request, from a muscles, on request, from a precisely controlled position, precisely controlled position, in a specific direction, against in a specific direction, against a distinctly executed a distinctly executed operator counterforce.operator counterforce.

HIGH VELOCITYHIGH VELOCITY--LOW AMPLITUDE LOW AMPLITUDE

(THRUST) TECHNIQUE(THRUST) TECHNIQUE

DEFINITION: A DEFINITION: A

type of direct type of direct

technique that technique that

uses high uses high

velocityvelocity--low low

amplitude amplitude

forces.forces.

COUNTERSTRAIN COUNTERSTRAIN

TECHNIQUETECHNIQUE

DEFINITION: DEFINITION:

�� An indirect technique An indirect technique

developed by Lawrence developed by Lawrence

Jones, DO. Jones, DO.

�� The operator moves the The operator moves the

patient or part passively patient or part passively

away from the motion away from the motion

barrier always searching barrier always searching

for the position of for the position of

greatest comfort.greatest comfort.

COUNTERSTRAIN TECHNIQUE COUNTERSTRAIN TECHNIQUE ((concon’’tt))

�� Tender point associated Tender point associated with somatic with somatic dysfunctiondysfunction

�� Patient is held in Patient is held in position of comfort for position of comfort for 90 seconds90 seconds

�� Physician brings patient Physician brings patient back to neutral positionback to neutral position

�� Tender point is Tender point is reassessedreassessed

Jones Jones TenderpointsTenderpoints

OTHER MANIPULATIVE OTHER MANIPULATIVE

TECHNIQUESTECHNIQUES

�� OSTEOPATHY IN THE CRANIAL FIELDOSTEOPATHY IN THE CRANIAL FIELD

�� ARTICULATORY TECHNIQUE (Low ARTICULATORY TECHNIQUE (Low VelocityVelocity--High Amplitude)High Amplitude)

�� BALANCE AND HOLD TECHNIQUEBALANCE AND HOLD TECHNIQUE

�� EXAGGERATION TECHNIQUEEXAGGERATION TECHNIQUE

�� FIXED POINT ROTATION TECHNIQUEFIXED POINT ROTATION TECHNIQUE

�� FUNCTIONAL TECHNIQUEFUNCTIONAL TECHNIQUE

�� GUIDING TECHNIQUEGUIDING TECHNIQUE

�� INHIBITORY PRESSURE TECHNIQUEINHIBITORY PRESSURE TECHNIQUE

�� FACILITATED POSITIONAL RELEASEFACILITATED POSITIONAL RELEASE

OTHER MANIPULATIVE TECHNIQUES OTHER MANIPULATIVE TECHNIQUES ((concon’’tt))

�� MYOFACIAL RELEASE TECHNIQUEMYOFACIAL RELEASE TECHNIQUE

�� RANGE OF MOTION TECHNIQUERANGE OF MOTION TECHNIQUE

�� RESISTIVE DUCTION TECHNIQUE RESISTIVE DUCTION TECHNIQUE �� ((RuddiRuddi Technique)Technique)

�� SPENCER TECHNIQUE SPENCER TECHNIQUE

�� SPRINGING TECHNIQUE SPRINGING TECHNIQUE (Low Velocity(Low Velocity--Moderate Moderate Amplitude)Amplitude)

�� TRACTION TECHNIQUETRACTION TECHNIQUE

�� PROGRESSIVE INHIBITION OF PROGRESSIVE INHIBITION OF NEUROMUSCULAR STRUCTURES NEUROMUSCULAR STRUCTURES (PINS)(PINS)

�� STILLSTILL’’S TECHNIQUES TECHNIQUE

BOTTOM LINEBOTTOM LINE

�� THERE ARE THERE ARE

MULTIPLE MULTIPLE

MANIPULATIVE MANIPULATIVE

MODALITIESMODALITIES

�� DIFFERENT DIFFERENT

CONDITIONS CONDITIONS

RESPOND TO RESPOND TO

DIFFERENT DIFFERENT

MODALITIESMODALITIES

REFLEX ARCSREFLEX ARCS

�� VISCEROVISCERO--SOMATIC REFLEXSOMATIC REFLEX

�� MI & arm painMI & arm pain

�� SOMATOSOMATO--VISCERAL REFLEXVISCERAL REFLEX

�� Fracture & vomiting Fracture & vomiting

�� SOMATOSOMATO--SOMATIC REFLEXSOMATIC REFLEX

�� Tooth painTooth pain

�� VISCEROVISCERO--VISCERAL REFLEXVISCERAL REFLEX

�� MI & vomitingMI & vomiting

REFLEX ARCSREFLEX ARCSYou must know all You must know all viserovisero--somatic somatic

relationships to specific body systems relationships to specific body systems

& disease states& disease states

OMM Board PreparationOMM Board Preparation

�� GoalGoal:: To prepare the physician learner to To prepare the physician learner to successfully understand OMM/OMT questions on successfully understand OMM/OMT questions on Complex/Specialty Board examinations.Complex/Specialty Board examinations.

�� ObjectivesObjectives::�� To discuss salient topics that one must know to pass To discuss salient topics that one must know to pass the OMM/OMT questions on Complex/Specialty Board the OMM/OMT questions on Complex/Specialty Board examinations. examinations.

�� To review and discuss specific OMM/OMT questions To review and discuss specific OMM/OMT questions that one may encounter on Complex/Specialty Board that one may encounter on Complex/Specialty Board examinations. examinations.

�� Recommended strategy to prepare for doing well on Recommended strategy to prepare for doing well on OMM/OMT section of the Complex/Specialty Board OMM/OMT section of the Complex/Specialty Board examinations. examinations.

COMLEX Structural/OPP componentCOMLEX Structural/OPP component

�� Integrated within the fabric of the entire Integrated within the fabric of the entire examinationexamination

�� Osteopathic Principles and Practices [OPP]Osteopathic Principles and Practices [OPP]�� NOT only applicable to musculoskeletal problemsNOT only applicable to musculoskeletal problems

�� Applicable to Applicable to ““human problemshuman problems””�� All Body systemsAll Body systems

�� Various symptomsVarious symptoms

�� 1515--20% of the exam is OPP20% of the exam is OPP--relatedrelated�� This does not include OPP distractors throughout the This does not include OPP distractors throughout the examination. examination.

OsteopathicallyOsteopathically--Oriented Oriented

Question!Question!

�� A DO view of the patient:A DO view of the patient:

�� A whole person of integrated body, mind & spiritA whole person of integrated body, mind & spirit

�� Interactive and adapting to the environment as well as Interactive and adapting to the environment as well as

internal stressorsinternal stressors

�� Struggling to maintain the highest health status Struggling to maintain the highest health status

obtainable [usually] having functional problems interobtainable [usually] having functional problems inter--

related with structural problems for which the patient is related with structural problems for which the patient is

trying to compensate.trying to compensate.

�� Having selfHaving self--healing and selfhealing and self--regulating capacities.regulating capacities.

�� Functioning better when there is normal inherent Functioning better when there is normal inherent

motion of the musculoskeletal and connective tissue motion of the musculoskeletal and connective tissue

structurestructure

10 Basic Body Functions10 Basic Body Functions

1.1. Posture and Body MovementPosture and Body Movement

2.2. CirculationCirculation

3.3. Pulmonary RespirationPulmonary Respiration

4.4. Digestive, Absorption and Digestive, Absorption and

EliminationElimination

5.5. Metabolism and Energy BalanceMetabolism and Energy Balance

10 Basic Body Functions 10 Basic Body Functions

[[concon’’tt]]

6.6. Regulation of Fluid and Electrolyte Regulation of Fluid and Electrolyte

BalanceBalance

7.7. Protective mechanismsProtective mechanisms

8.8. Sensory SystemsSensory Systems

9.9. ReproductionReproduction

10.10. Consciousness and BehaviorConsciousness and Behavior

5 Models: Using OMT5 Models: Using OMT

�� Structural Model Structural Model

�� Posture & Body MovementPosture & Body Movement

�� RespiratoryRespiratory--Circulatory ModelCirculatory Model

�� Metabolic ModelMetabolic Model

�� Neurologic Model Neurologic Model

�� Sensory & ProtectiveSensory & Protective

�� Behavioral Model Behavioral Model

�� Reproduction, Consciousness and BehaviorReproduction, Consciousness and Behavior

When reading questions, keep When reading questions, keep

in mind the different models in mind the different models

that questions are based on.that questions are based on.

Structural Model Structural Model

[Posture & Body Movement][Posture & Body Movement]

�� Biomechanical adjustmentBiomechanical adjustment

�� Mobilization of JointsMobilization of Joints

�� Remove restrictive forces & enhanceRemove restrictive forces & enhance

�� Myofascial connective tissueMyofascial connective tissue

�� Bony & soft tissuesBony & soft tissues

Structural Model Structural Model

[Posture & Body Movement][Posture & Body Movement]

�� OMT ModalitiesOMT Modalities

�� HVHV--LALA

�� Muscle EnergyMuscle Energy

�� CounterstrainCounterstrain

�� Myofascial ReleaseMyofascial Release

�� LigamentousLigamentous

ArticularArticular

TechniquesTechniques

�� Functional Functional

TechniquesTechniques

RespiratoryRespiratory--Circulatory Circulatory

ModelModel

�� Goal: Improve all diaphragm restrictors in the Goal: Improve all diaphragm restrictors in the

bodybody

�� Diaphragms Diaphragms

�� ““Transverse restrictorsTransverse restrictors”” of motionof motion

�� Venous drainageVenous drainage

�� Lymphatic drainageLymphatic drainage

�� CSFCSF

Diaphragms: Diaphragms:

““ConceptionalConceptional DiaphragmsDiaphragms””

�� Plantar fasciaPlantar fascia

�� Knee [Knee [poplitealpopliteal fascia & fascia & cruciatecruciate]]

�� PelvicPelvic

�� Respiratory/TRespiratory/T--L DiaphragmL Diaphragm

�� Thoracic Outlet [Thoracic Outlet [cervicothoraciccervicothoracic]]

�� SuboccipitalSuboccipital triangletriangle

�� TentoriumTentorium CerebelliCerebelli

�� Diaphragm Diaphragm SellaeSellae

RespiratoryRespiratory--Circulatory Circulatory

ModelModel

�� OMT ModalitiesOMT Modalities

�� Osteopathy in the Osteopathy in the

crainalcrainal fieldfield

�� Myofascial ReleaseMyofascial Release

�� LigamentousLigamentous

ArticularArticular

TechniquesTechniques

�� Lymphatic pump Lymphatic pump

techniquestechniques

Metabolic ModelMetabolic Model

�� Enhance selfEnhance self--regulatory & selfregulatory & self--healing healing

mechanismsmechanisms

�� Enhance energy conservationEnhance energy conservation

�� Balance the body economyBalance the body economy

�� Energy expenditureEnergy expenditure

�� Energy exchangeEnergy exchange

�� Foster Immune enhancementFoster Immune enhancement

�� Foster endocrine organ function Foster endocrine organ function

enhancementenhancement

Metabolic ModelMetabolic Model

•• OMT ModalitiesOMT Modalities•• Lymphatic pump Lymphatic pump

techniquestechniques

•• Other Other

osteopathically osteopathically

oriented oriented

management management

considerations:considerations:•• Nutritional Nutritional

counselingcounseling

•• DietDiet

•• ExerciseExercise

NeurologicNeurologic Model Model

[Sensory & Protective][Sensory & Protective]

�� Goals:Goals:

�� Attain autonomic balanceAttain autonomic balance

�� Address neural reflex activityAddress neural reflex activity

�� Remove facilitated segmentsRemove facilitated segments

�� Decrease afferent nerve signalsDecrease afferent nerve signals

�� Achieve pain reliefAchieve pain relief

NeurologicNeurologic Model Model

[Sensory & Protective][Sensory & Protective]

�� OMT Modalities :OMT Modalities :

�� CounterstrainCounterstrain

�� ChapmanChapman’’s Reflex s Reflex

pointspoints

Behavioral Model Behavioral Model [[Reproduction, Consciousness and Reproduction, Consciousness and

BehaviorBehavior]]

�� Goal:Goal:

�� Improve the biological, psychological, Improve the biological, psychological,

and social functional component of the and social functional component of the

health spectrum.health spectrum.

�� Emotional balancingEmotional balancing

�� Compensatory mechanismsCompensatory mechanisms

�� Other items to considerOther items to consider

�� Reproductive processesReproductive processes

�� Behavioral adaptation/changeBehavioral adaptation/change

When reading questions, keep When reading questions, keep

in mind the different models in mind the different models

that questions are based on.that questions are based on.

Practice QuestionsPractice Questions

1.1. A female at 34 weeksA female at 34 weeks’’ gestation presents with gestation presents with

difficulty breathing while in the supine difficulty breathing while in the supine

position.position. Her lungs are clear to auscultation.Her lungs are clear to auscultation. All All

other tests appear normal.other tests appear normal. In order to release In order to release

her diaphragmatic pressure, the most appropriate her diaphragmatic pressure, the most appropriate

management is to:management is to:

A.A. decrease her blood volume by initiating the use of decrease her blood volume by initiating the use of furosemidefurosemide

B.B. induce her labor with artificial rupture of the membranes induce her labor with artificial rupture of the membranes

C.C. place the patient in the place the patient in the TrendelenburgTrendelenburg position position

D. release her diaphragm using D. release her diaphragm using myofascialmyofascial release technique release technique

E.E. treat C6treat C6--C7 to affect the C7 to affect the phrenicphrenic nervenerve

1.1. A female at 34 weeksA female at 34 weeks’’ gestation presents with gestation presents with

difficulty breathing while in the supine difficulty breathing while in the supine

position.position. Her lungs are clear to auscultation.Her lungs are clear to auscultation. All All

other tests appear normal.other tests appear normal. In order to release her In order to release her

diaphragmatic pressure, the most appropriate diaphragmatic pressure, the most appropriate

management is to:management is to:A.A. decrease her blood volume by initiating the use of decrease her blood volume by initiating the use of

furosemidefurosemide

B.B. induce her labor with artificial rupture of the membranes induce her labor with artificial rupture of the membranes

C.C. place the patient in the place the patient in the TrendelenburgTrendelenburg position position

D. release her diaphragm using D. release her diaphragm using myofascialmyofascial release techniquerelease technique

E.E. treat C6treat C6--C7 to affect the C7 to affect the phrenicphrenic nerve nerve

2.2. In a 22In a 22--yearyear--old patient with asthma, old patient with asthma,

osteopathic manipulative treatment intended to osteopathic manipulative treatment intended to

increase sympathetic stimulation to the lungs increase sympathetic stimulation to the lungs

would be directed to which of the following areas?would be directed to which of the following areas?

A.A. T1T1--T5 T5

B.B. T3T3--T9 T9

C.C. lumbar sympathetic plexus lumbar sympathetic plexus

D.D. suboccipitalsuboccipital area area

E.E. superior cervical ganglion superior cervical ganglion

2.2. In a 22In a 22--yearyear--old patient with asthma, old patient with asthma,

osteopathic manipulative treatment intended to osteopathic manipulative treatment intended to

increase sympathetic stimulation to the lungs increase sympathetic stimulation to the lungs

would be directed to which of the following would be directed to which of the following

areas?areas?A.A. T1T1--T5 T5

B.B. T3T3--T9 T9

C.C. lumbar sympathetic plexus lumbar sympathetic plexus

D.D. suboccipitalsuboccipital area area

E.E. superior cervical ganglionsuperior cervical ganglion

3a.3a. A 53A 53--yearyear--old male presents to the office old male presents to the office

with severe numbness and tingling down the with severe numbness and tingling down the

lateral aspect of the left arm to the thumb and lateral aspect of the left arm to the thumb and

the upper back.the upper back. This began insidiously one This began insidiously one

month ago, and no trauma is recalled. The month ago, and no trauma is recalled. The

most likely diagnosismost likely diagnosis isis

A.A. anterior disk anterior disk herniationherniation

B.B. brachial brachial plexopathyplexopathy

C.C. foraminalforaminal encroachment from osteoarthritis encroachment from osteoarthritis

D.D. posterior cervical muscle strain posterior cervical muscle strain

E.E. spinal cord tumorspinal cord tumor

Question 1 of 2 in setQuestion 1 of 2 in set

3a.3a. A 53A 53--yearyear--old male presents to the office old male presents to the office

with severe numbness and tingling down the with severe numbness and tingling down the

lateral aspect of the left arm to the thumb and the lateral aspect of the left arm to the thumb and the

upper back.upper back. This began insidiously one month This began insidiously one month

ago, and no trauma is recalled. The most likely ago, and no trauma is recalled. The most likely

diagnosisdiagnosis isis

A.A. anterior disk anterior disk herniationherniation

B.B. brachial brachial plexopathyplexopathy

C.C. foraminalforaminal encroachment from osteoarthritisencroachment from osteoarthritis

D.D. posterior cervical muscle strain posterior cervical muscle strain

E.E. spinal cord tumorspinal cord tumor

Question 1 of 2 in setQuestion 1 of 2 in set

3b.3b. The nerve root most likely The nerve root most likely

involved in this presentation isinvolved in this presentation is

A.A. C4 C4

B.B. C5 C5

C.C. C6 C6

D.D. C7 C7

E.E. C8 C8

Question 2 of 2 in setQuestion 2 of 2 in set

“…“…severe numbness and tingling down the severe numbness and tingling down the

lateral aspectlateral aspect of the left arm to the of the left arm to the thumb and thumb and

the upper backthe upper back..””

3b.3b. The nerve root most The nerve root most

likely involved in this likely involved in this

presentation ispresentation is

A.A. C4 C4

B.B. C5 C5

C.C. C6C6

D.D. C7 C7

E.E. C8 C8

Question 2 of 2 in setQuestion 2 of 2 in set

4. 4. A patient presents with A patient presents with

vertigo.vertigo. Dysfunction of which of the following Dysfunction of which of the following

cranial bones is most likely involved?cranial bones is most likely involved?

A.A. ethmoidethmoid

B.B. maxilla maxilla

C.C. parietal parietal

D.D. sphenoid sphenoid

E.E. temporaltemporal

Inner Ear & Temporal BoneInner Ear & Temporal Bone

4. 4. A patient presents with A patient presents with

vertigo.vertigo. Dysfunction of which of the Dysfunction of which of the

following cranial bones is most likely following cranial bones is most likely

involved?involved?

A.A. ethmoidethmoid

B.B. maxilla maxilla

C.C. parietal parietal

D.D. sphenoid sphenoid

E.E. temporaltemporal

SummarySummary

�� Reviewed core concepts of OPP/OMM/OMT Discussed general Reviewed core concepts of OPP/OMM/OMT Discussed general measures to prepare for board questions involving Osteopathic measures to prepare for board questions involving Osteopathic Principles & Practices [OPP]Principles & Practices [OPP]

�� Examined the COMLEX Structural/OPP component to the Examined the COMLEX Structural/OPP component to the National Board of Osteopathic Medical Examiners [NBOME] National Board of Osteopathic Medical Examiners [NBOME]

�� Presented the 10 Basic Body Functions related to Osteopathic Presented the 10 Basic Body Functions related to Osteopathic Manipulative Medicine [OMM]Manipulative Medicine [OMM]

�� Explored the 5 Models involved in using Osteopathic Explored the 5 Models involved in using Osteopathic Manipulative Treatment [OMT] Manipulative Treatment [OMT]

�� WentWent over COMLEX practice questions involving over COMLEX practice questions involving OPP/OMM/OMTOPP/OMM/OMT