Utilizing Conservative Treatment
Options in the Management of
Neuromusculoskeletal Disorders
George Pasquarello, DO, FAAO
East Greenwich Spine & Sport
East Greenwich, RI
Objectives
Understand multiple conservative
treatment options for various pain
conditions.
Identify appropriate patients for referral
to specialty care.
Explain the Osteopathic approach to
evaluation and management of patients
with neuromusculoskeletal disorders
Osteopathic Medicine
History
A.T. Still, M.D.
• Dissatisfied with the practice of medicine in the
1800’s
• “Cure” was often worse than “illness”
• Medicine is “disease based” not “health based”
• Still loses three children to meningitis
• Osteopathic concept is created based on concepts of
promoting wellness and supporting the body’s
inherent ability to heal itself
• Not accepted by the medical community
• Still founds the Osteopathic profession in 1874
Osteopathic Principles
• The body is a unit
• The body has self-healing and selfregulating mechanisms
• Structure and function are interrelated
• Rational treatment is based on these
principles
Osteopathic Manipulative
Medicine
A system of medical care with a
philosophy that combines the needs of
the patient with current practice of
medicine, surgery and obstetrics, and
emphasis on the interrelationships
between structure and function, and an
appreciation of the body’s ability to heal
itself.
Osteopathic Manipulative
Treatment
The therapeutic application of manually
guided forces by a physician to improve
physiologic function and/or support
homeostasis.
Somatic Dysfunction
Impaired or altered function of related
components of the somatic system:
skeletal, arthroidial, and myofascial
structures, and related vascular,
lymphatic and neural elements.
Somatic Dysfunction
Parameters
• The position of a body part as
determined by palpation and referenced
to its adjacent defined structure.
• The directions in which motion is freer.
• The directions in which motion is
restricted.
Types of Somatic Dysfunction
• Acute – tenderness, edema,
inflammation
• Chronic – fibrosis, contracture,
parasthesias
• Secondary – subsequent to other
etiologies
Pathophysiologic Models
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Biomechanical
Respiratory/Circulatory
Neurological
Behavioral/Psychological
Bioenergy
Structural Exam
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Gait evaluation
Postural evaluation
Regional exam
Segmental exam
Static palpation
Dynamic palpation/motion testing
Why Use OMT?
• Musculoskeletal pain
• Decrease impact of structural
dysfunction on body systems
• Improve respiratory mechanics
• Improve venous and lymphatic drainage
• Support homeostasis
• Optimize function
Technique Types
• Active – patient voluntarily performs a
physician directed motion.
• Passive – patient refrains from voluntary
muscle contraction.
• Direct – engages the restrictive barrier and
then carries dysfunctional component into the
restrictive barrier.
• Indirect – disengages the restrictive barrier
and moves the dysfunctional component
away from the restrictive barrier until tissue
tension is equal in all planes.
Techniques
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Thrust Technique ( HVLA )
Articulatory ( LVHA )
Counterstrain
Muscle Energy
Myofascial Release
Facilitated Positional Release
Lymphatic Technique
Soft Tissue Treatment
Visceral Manipulation
Factors Affecting
Choice of Technique
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Physician’s skills
Patient preference
Risk factors/comorbidities
Acute vs Chronic problem
Patient’s ability to cooperate
– Direct vs Indirect technique
• Type of somatic dysfunction
– Soft vs hard end-feel
Adjunctive Treatments
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Exercise
Postural re-education
Counseling
Medications
Injection techniques
Surgery
Injections:
Prolotherapy and
Platelet Rich Plasma
Definitions
• Prolotherapy stimulates healing of injured
ligaments, tendons and joints by injecting
irritant solutions to encourage repair of
damaged tissue.
• Platelet Rich Plasma facilitates healing of
injured ligaments, tendons and joints by
separating and concentrating the healing
components in the patient’s own blood and
injecting the solution (PRP) into the injured
area.
History
• Hippocrates described insertion of
searing needles into the anterior
capsule of the shoulder in javelin
throwers.
• 1837 – Valpeau described the use of
scar formation for hernia repair.
“Sclerosis”
• 1937 – Earl Gedney, D.O. injects
ligaments of hypermobile SI joints.
“Sclerotherapy”
History
• 1954- Kingsley studied the effects of
Platelet Rich Plasma on clotting
• 1970-80s- Significant research on platelet
function and development of mechanisms
to separate and concentrate platelets
• 1987- PRP used during cardiac bypass to
limit intra-operative bleeding.
• 2000- PRP used in dental and ENT surgery
• 2003- PRP use in orthopedic surgery and
sports medicine
Wound Healing
Wound Healing has distinct
phases that overlap in time.
Inflammation Phase
Macrophages control wound healing
-Phagocytosis
-Enzymes
Collagenase
Elastase
Granulation Phase
Fibroblasts differentiate to proto-myofibroblasts
which
pull the wound together
Remodeling Phase
Remodeling Phase
Remodeling Phase
structure
Remodeling Phase
• Final repair is not distinguishable
from the original tissue by any
analytical means.
• There is no scar tissue.
• This process gives animals the
resources to repair minor injuries in
such away that they will have lost no
capability to survive.
Remodeling Phase
• To complete healing of ligament and
tendons, movement and loading of
the tissue is critical to a good
outcome.
• There is period of vulnerability when
the curve of wound healing is plotted
against pain and ligament strength.
• The period of vulnerability is
proportional to original severity of
injury and expected demand.
Remodeling Phase
Chronic Enthesis Injuries
• Consequence of chronic stress at
enthesis is tissue micro trauma with
altered or incomplete tissue repair.
• Orderly phased wound repair is
absent or aborted in these areas of
micro trauma because of hypoxia.
• This is enthesopathy or tendinosis.
Enthesopathy & Tendinosis
Ligament and tendon changes include
Enthesopathy & Tendinosis
• Enthesis is the most richly
innervated region of a
ligament or tendon.
• C and A pain fibers have
naked terminals.
Impact of NSAIDs and
Corticosteroids: Incomplete wound
healing
Wound Healing References
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Banks, A.R., “A Rationale for Prolotherapy”, J. Orthopedic Medicine 13 (3),
54-9 (1991)
Benjamin M, Evans EJ, Copp L. The histology of tendon attachments to
bone in man. Journal of Anatomy 149:89-100, 1986.
Clark RAF, Henson PM (eds). The molecular and cellular biology of wound
repair 2nd ed, Plenum Press, New York, 1996.
Hargreaves KM. Mechanisms of pain sensation resulting from inflammation.
In Sports Induced Inflammation, ed. Leadbetter WB, Buckwalter JA, Gordon
SL. Am Ass Orthopedic Surg. Park Ridge IL, 1990.)
Mauch C. Hatamochi A, Scharffetter K, Krieg T. Regulation of collagen
synthesis in fibroblasts within a three-dimensional collagen gel. Exp Cell
Res 178:493-530, 1988.
Saklatvala J. Glucocorticoids: do we know how thy work? Arthritis Res
4:146-150, 2002.
Simon AM, Manigrasso MB, O’Connor JP. Cyclo-oxygenase 2 function is
essential for bone fracture healing. J Bone Mineral Res 17:963-977, 2002.
Tomasek JJ, et al. Myofibroblast and mechanoregulation of connective
tissue remodeling. Nat Review Molecular Cell Biology 3, 349-363, 2002.
Causes of Ligament Laxity
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Incomplete wound healing
Recurrent trauma (overuse injuries)
Overwhelming tissue trauma
Hormonal deficiencies: thyroid,
estrogen, testosterone or hGh
• Nutritional deficiencies
Overlap of Ligament Laxity and
Tendinosis
Tendon and
ligament
instability is not
a local
phenomena.
Response to ligament laxity
• Muscles try to support joints
• Increased work load causes early
fatigue
• Persistent muscle firing and fatigue
causes atrophy
• Inability to compensate causes chronic
fatigue and pain
Signs of Ligament Laxity
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Pain – local/referred
Joint hypermobility
Spasm of associated muscles
Trigger points in associated muscles
Weakness/atrophy of associated
muscles
• Somatic dysfunction
• Morning stiffness (it’s not arthritis!)
Prolotherapy
• Inject injured ligaments or tendons
• Encourage activity to stress the lines of
force through the tissue
• Avoid NSAIDs for 4 days pre and post
injection
• Analgesics for pain (usually narcotics
for the first three to five days)
• 3-6 sessions are typical at 3-4 week
intervals
• Appropriate rehabilitation
Rehabilitation
• Throughout injection sessions, treat
underlying somatic dysfunction.
• Add stretching, strengthening and
proprioceptive retraining.
• Postural retraining and behavior
modification for recurrent injury.
• EMG biofeedback may be useful in old
injuries.
Common Problems
Responding to Prolotherapy
• Joint instability: Ankle, knee, hip,
sacroiliac, shoulder, wrist and digits
• “Fibromyalgia”, i.e. tendonosis
• Spinal pain due to tendonosis or ligament
laxity
• Persistent post MVA pain, occipital
headaches
• Piriformis syndrome
Platelet Rich Plasma
• Concentrated autologous blood
products injected into an injured
enthesis to stimulate the wound repair
process.
• Similar principle as prolotherapy.
• Advantage: use of autologous blood
products.
• Disadvantage: additional equipment and
time needed for solution prep.
Platelet Rich Plasma Prep
Platelet Rich Plasma Injection
Injections:
Epidural Steroid Injections,
Facet Injection and
Radiofrequency Ablation
Radiofrequency Ablation