OMT Considerations in
Disabled Patients
Bethany Powers, D.O.
VCOM CC OMM Department Chair
Disclosures
• I have no personal, ethical, or financial conflicts of interest or disclosures.
...My son is adorable
General Considerations in Disabled Patients
• First and foremost- ASK THE PATIENT!
• They have been living with everything, they may already know the best way to
accomplish what you are trying to do.
• Don’t be shy about addressing any limitations, your goal is to help
them feel better. You need the information to do the best job
possible.
• Know your functional anatomy!
Sensory Specific Considerations
• Blindness
• Work on very clear verbal descriptions of motions.
• Helpful to know if patient has ever had vision.
• Deafness
• Find a way to communicate with patient when your hands are full.
• Preassigned instructions related to taps
• Using a 3rd person in the room to translate verbal instructions
Cognitive Disabilities
• Range from mild to profound
• Take the time to ensure that the patient understands who you are and
what you are planning to do to the best of their ability.
• Ask family members/caregivers about the patient’s understanding and
reactions to touch.
• Be aware that patients may have unexpected or violent reactions.
• Weigh potential risks vs. benefits of treatment
• Sometimes helpful to ‘treat’ family member/caregiver first.
• Can be incredibly rewarding patients!
Motor Disabilities
• Paralysis
• Spastic vs. Flaccid
• Complete vs partial
• Amputations
• Traumatic?
• Other causes
• Weakness
• Chronic pain
• Neurological disorders
• Is the patient able to transfer to the table easily?
• Will they need to be treated in their wheelchair?
Lets Review Some Spinal Cord Injuries
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Anterior cord syndrome
Brown-Sequard syndrome
Central cord syndrome
Cauda equina syndrome
Complete transection of the cord
Anterior Cord Syndrome
Interruption of the anterior spinal artery.
http://www.frca.co.uk/article.aspx?articleid=100360
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Loss of motor function
Loss of pain sensation
Loss of temperature sensation
Maintain fine touch
Maintain vibration
Maintain proprioception
May also have autonomic dysfunction
http://www.spoke.com/topics/anterior-cord-syndrome50a4490e3ae4b2145b000a8f
http://emedicine.medscape.com/article/321907-overview
Brown-Sequard Syndrome
Hemisection of the spinal cord.
Quizlet.com
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Loss of ipsilateral motor
Loss of ipsilateral proprioception
Loss of ipsilateral vibration
Loss of contralateral pain sensation
Loss of contralateral temperature sensation
Partial loss of bilateral light touch
http://emedicine.medscape.com/article/321907-overview
Central Cord Syndrome
Most common cervical cord injury.
More common over 50yo.
Spondylosis significant risk factor.
Quizlet.com
1. Loss of motor function in arms/hands (maybe legs)
2. Loss of sensation in arms/hands (maybe legs)
3. Partial loss of pain, temperature, proprioception, and light touch
below lesion
4. Neck pain common
5. Urinary retention common
http://emedicine.medscape.com/article/321907-overview
Cauda Equina Syndrome
Disc herniation. Trauma. Tumors. Inflammatory diseases.
Surgical Emergency!!!
https://www.quora.com/What-causes-pain-from-the-sacrum-down-both-legs
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Lumbar pain typically first symptom
Loss of lower extremity motor control
Gait difficulty
Loss of perianal sensation
Fecal incontinence
Urinary incontinence
Sexual impotence
https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-neoplastic-epidural-spinal-cord-compression-including-cauda-equinasyndrome?source=search_result&search=cauda%20equina%20syndrome&selectedTitle=1~86#H3
Complete Spinal Cord Transection
Complete spinal cord transection---Transverse Myelopathy
 Sensory disturbance
All sensory modalities include soft touch, position sense, vibration,
temperature and pain are impaired below the level of the lesion
 Motor disturbance
paraplegia ( loss of lower limb motor function) or tetraplegia ( Loss of motor
function in all four extremities) occurs below the level of the lesion due to
interruption of the descending cortical spinal tract
 Automatic disturbance
Urinary and rectal sphincter dysfunction with incontinence may occur with
transverse myelopathy.
Common Considerations in Above
• Autonomic Dysregulation
• Sounds like a job for OMM!
• Fascial Tightness and Spasticity
• Sounds like a job for OMM!
• Edema due to venous pooling
• Sounds like a job for OMM!
Remember: Motor control and pain may not be present in the same location
Autonomic Dysregulation
• Rib Raising
• Suboccipital Release
• Sacral Rocking
How do we do these seated?
Seated Autonomics
Suboccipital Release
Rib Raising
Sacral Rocking
Seated Sacral Treatment
• Grasp just behind the patient’s knees,
engaging fascia in popliteal fossa
• Create anterior traction on fascia, you can
feel the pull into their SI joints.
• If patient able to lean, they may lean to
engage each plane, hold until fascial
release is felt.
• Provider may also ‘rock’ the sacrum by
increasing and decreasing amount of
traction on the fascia.
Lymphatic Congestion
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Thoracic Inlet
Respiratory Diaphragm
Pelvic Diaphragm
Popliteal Fossa
Lymphatic Pump
https://www.shutterstock.com/search/edema
Thoracic Inlet Direct Myofascial Release
Nicholas & Nicholas, Atlas of Osteopathic Techniques. 3rd ed. Ch 16.
1. Patient is supine with the arm abducted to
approximately 90 degrees.
2. Physician places the index and third finger pads of the
cephalad hand over the area of the thoracic inlet to
palpate the fascial tone at the insertion of the first rib
at the manubrium and the supraclavicular fascia.
3. Physician gently moves the patient's arm through a
series of motions to vector a line of tension toward the
thoracic inlet. (When successful, the physician will
palpate the tension at that site.)
4. Physician waits for a release & continues until there is
no further improvement in the restrictive barrier. (Deep
inhalation or other release-enhancing mechanisms can
be helpful, as can a vibratory motion produced through
the upper extremity with the wrist-controlling hand.)
(Fig. 16.29)
(arrows, Fig. 16.32)
Thoracoabdominal Diaphragm
• D.O. grasps lateral sides of rib cage with palms and
fingers spread apart.
• Observe respiration to determine which hemidiaphragm is restricted.
• Carry rib cage into L or R rotation into barrier to point of
maximum ligamentous tension, not causing discomfort
to your patient. Then add components of R or L
sidebending to the barrier as well as flexion/extension
until all planes are localized at the restrictive barrier.
• Have patient take some deep breaths. D.O. resists
the inhalation effort on the side with the best
motion, forcing the restricted side to move.
• Repeat several cycles.
• Reassess
Redoming the Diaphragm
• Provider behind the patient, hold patient just below
the ribs.
• Gently scoop fingers under rib cage and lift to engage
the respiratory diaphragm.
• Pt slumps forward.
• Resist motion as patient inhales, take up slack with
exhalation.
• Repeat for 3-5 cycles.
• Recheck.
https://www.acofp.org/ACOFPIMIS/Acofporg/PDFs/ACOFP17/handouts/FRIDAY/Fri_pm_200_Heinking,%20Kurt_OMT%
20Evidence%20Based%20Medicine.pdf
Hip and Pelvic Floor Fascia Seated
• Still-MFR type technique
• Create traction or compression into
the hip.
• Initially internally rotate and flex hip
• Maintain traction/compression
• Externally rotate and abduct hip
• Return to seated position
• Recheck fascial pulls
Popliteal Fossa Release
• Grasp popliteal fossa with both hands
using fingerpads.
• Motion test for fascial restrictions.
• Perform direct or indirect myofascial
release.
• Recheck.
https://www.kenhub.com/en/library/anatomy/popliteal-fossa
Lymphatic Pumps
• Pedal Pump
• Thoracic Pump
Questions?
Now Time to Really Learn
See if you can diagnose and treat any concerns your partner might have.
We will come around to help you with positioning strategies.
References
Unless otherwise noted on the slide, all pictures and information comes from the following sources:
• Chila, A.G. Foundations of Osteopathic Medicine. 3rd Edition. 2011.
• DiGiovanna, Eileen; Schiowitz, Stanley; Dowling, Dennis An Osteopathic
Approach to Diagnosis and Treatment – 3rd Ed. Lippincott, 2005
• Gilroy, Anne M, et al. Atlas of Anatomy – 2nd Ed. Thieme, 2009.
• Greenman, Philip E. Principles of Manual Medicine. Baltimore: Williams &
Wilkins, 1989.
• Kimberly, Paul. Outline of Osteopathic Manipulative Procedures. 2008.
• Nicholas, Nicholas S., B.S., D.O., F.A.A.O. Atlas of Osteopathic Techniques.
Philadelphia: Philadelphia College of Osteopathic Medicine, 1974.
• Savarese, R.G. OMT Review. 3rd Edition. 2003.
• Umberger, Daniel, D.O. Teaching Material Library.
• Williams, Stuart, D.O. Teaching Material Library.