OMM 3 #52
Weds.,12/10/03/ 1PM
Dr. Gamber
Theresa Poth for Will Sawyer
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Pneumonia
The Goals of Therapy
1. To improve lmphatic and venous flow- prevent stasis
2. To improve arterial circulation to carry immune system products to the lungs
3. To ease removal of accumulated bronchial secretions and phlegm
4. To decrease the workload of breathing
Osteopathic manipulation should address these goals to assist the body’s fight against
infection
Our approach to treatment is going to be in three stages:
I. Day 1- pt presents in ER, ICU, doc’s office and is acutely ill
II. Day 3- pt is getting progressively better
III. Day 6- patient is better
Case
CC: 54 year old male presents to ER with productive cough, malaise and progressive
dyspnea and fever for three days. He has had increased stress with job loss 2 weeks
previous, is currently living with family that includes a 3-year-old granddaughter, who is
currently in daycare (she could be bringing home bacteria). Has taken some left over
Ampicillin, unknown strength, from URI illness 2 years ago, took it three times daily for
2 days, no effect.
Patient has now been symptomatic for 5 days.
History
Allergies: NKMA
Meds: Tylenol prn, Vit C, Captopril unknown dose
Medical History: HTN for 3 years, open cholecystectomy, 1984; appendectomy, age 14
Family Medical History: Father deceased age 56 MI (cardiac history), mother alive and
well, 3 siblings, one with DM, HTN, uncle with TB
Social History: Unemployed, Welder ( think fumes, heavy metals, find out respiratory
history), single, no religious affiliation, Tob: 1 ½ daily for 30 years. EtOH: occasional;
denies drug use, no exercise, sedentary, poor to fair diet/nutrition habits
ROS: Dyspepsia, occasional headaches, insomnia. anxiety, PPD 3 years ago was negative
Physical Exam
5’10 190 lbs. T=103 BP-154/92 (), R-26 () , HR 86
General: Alert and orientated to person, place and time in mild distress, dehydrated,
mucous membranes slightly dry, appears nourished and well developed.
Skin: Warm, dry, without lesions or rashes
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Weds, 12/10/03, 1 PM
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HEENT: Exam normal except, right temporal bone internally rotated, tender right
occipitomastoid suture
Neck: No adenopathy, thyroid not enlarged, trachea midline and moveable and no
masses. Tenderness mid-cervical area with C4 RrSr; plus focal tenderness right OA with
OA E SLRR
Chest: Respiratory excursions decreased on the right especially in ribs T4-10, also
elevated left first rib with tenderness located lateral to the sternoclavicular junction.
Lungs: Decreased breath sounds right lower lobe with minimal end inspiratory crackles.
(get CXR)
Heart: Rate and rhythm regular at 86, no abnormal sounds
Abdomen: Scars well healed, consistent with surgical history; diaphragmatic restriction
on right side, bowel sounds within normal limits; abdomen soft, protuberant, no masses,
tenderness, or rebound.
Thoracolumbar: Right rib angles 2-4 posterior, tissue texture changes of bogginess,
tenderness noted. T2 and T3 E RL LL. T10-L2 paraspinal muscle tension increased on
the right.
Lumbosacral: General decreased regional mobility with decreased spring compliance at
the lunbosacral junction in extension.
Springing Technique:
1. Hands on lumbosacral junction
2. Spring lightly forward up the spine
3. If normal springing-no somatic dysfunction-neg test
4. If no springing and tissue is tight-somatic dysfunction-pos test
Rectal exam: Occult blood negative; prostate boggy without nodularity
GU: Benign. No scrotal edema
Extemities: Right scapula myofascial tension, right hip inflare with internally rotated
right hip
Neuro: No significant findings; non-contributory
Goals for OMM
1. Along with hydration, medications and PT modalities (such as respiratory therapy),
OMT treatment is employed.
2. Normalize autonomic tone-Rib raising(you do this in all 3 stages); treat the OA
somatic dysfunction
3. Improve thoracic cage compliance: thoracic myofascial
release (pp. 786-787); “rib raising” by gentle paraspinal
inhibition in acute phase; after acute phase may use more
direct method (950-951), mild springing, gentle direct
method manipulation
4. Enhance lymphatic return to the heart
5. Reduce contributions to the facilitated cord segment and
thereby reduce sympathicotonia (hypersympathetic tone) to
the lungs (T1 down to lumbar junction)
6. Maximize efficiency of the diaphragm-cervical spinesuboccipital inhibition (pp.781-782) and relieve any mid-cervical
somatic dysfunction; thoracolumbar soft tissue release; redome
OMM 3 #52
Weds, 12/10/03, 1 PM
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the diaphragm (diaphragmatic release)-indirect method (pp.952953), CV4
7.Treat secondary effects: If the above steps are under control,
attention can be focused on secondary effects: i.e., lumbopelvic
somatic dysfunction, scapular somatic dysfunction
8. The following is arranged as a possible progression of treatment,
but each patient must be individually evaluated and treated as
indicated by symptoms and severity of the disease. In all
diseases, the treatment of areas that are involved with
sympathicotonia is probably the first place to start.
Goals for OMM
a. Rib raising or paraspinal inhibition
b.Thoracic inlet and diaphragm release (dome the abdominal
diaphragm)-done to balance parasympathetics
c. Cervical soft tissue followed by muscle energy and
indirect fascial release
d.Counterstrain to first rib (First rib is commonly elevated in pneumonia pt)
1. Put thumbs on superior portion of shoulder region and palpate first ribs on
both sides
2. Treat elevated rib by doing Jones Strain-Counterstrain
3. Contact elevated first rib with thumb and lift head
4. Either fold head into first rib or away from it
5. Carry into flexion/extension, rotation/sidebending until you feel 50% better
6. Then confirm with patient that it is 50% better
7. Hold for 90s
8. Recheck
e. Thoracic, pectoral traction, pedal pump
-Supine--direct method-respiratory force (pectoralis lift) (4933.11F)
Diagnosis: Lymphatic congestion
1. Physician places his/her hand over the pectoralis muscles
and grasps their inferior margins (anterior axillary folds)
between his/her fingers and palms (This may be tender, warn pt)
2. Physician leans backwards and pulls the pectoralis muscles
superiorly and medially putting superior and anterior
tension on its muscular attachments to the sternum and
costal cartilages of ribs 2-6 and sometimes 7 to enhance
inhalation
3. Patient is instructed, “Breathe in and out very deeply.” The
physician holds continued pectoral traction throughout
repeated respiratory cycles (average is about 2 minutes)
4. Recheck lymphatic status
f. Muscle energy to upper thoracic area
g. Dome abdominal diaphragm
h. Myofascial unwinding of bilateral upper extremities,
scapular myofascial release
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- Lateral recumbent--indirect method-respiratory force (scapulothoracic)
(4923.11A)
Diagnosis: Scapular fascial dysfunction
1. Physician’s caudad hand reaches under the patient’s arm
and grasps the inferior angle of the scapula. The physician’s
other hand grasps the superior margin of the scapula
2. Physician carries the scapula superiorly or inferiorly,
medially or laterally and into internal or external rotation
until all three motions are at the point of balanced
ligamentous tension
3. The respiratory phases are tested and the patient is
instructed to hold his/her breath as long as possible in the
phase that provides the best ligamentous balance
4. Recheck
i. L-S spine indirect or direct (i.e., muscle energy)
j. Cranial indirect treatment to improve temporal bones
mobility, occipito-mastoid suture v-spread and condylar
decompression for normalization of vagal function.
Venous sinus drainage and CV-IV technique
k. Specific Skills to Master-(Chapters and page numbers
refer to Foundations of Osteopathic Medicine, 1997,
First Edition.)
Contraindicatons and caution regarding treatment.
1. No forceful direct method treatments
2. Do not overtreat and tire the patient
-Observe your patient and see how your treatment is affecting them, if it is too
much or too little
3. Do not use treatment positions of the patient that
restrict respiratory efforts
4. If pleurisy is present, do not aggravate it and cause
increased pain by treating over it
SAMPLE OF TREATMENT PROTOCOL FOR PNEUMONIA:
Manipulative treatment in the hospitalized patient with pneumonia is suggested at least
daily and ideally, three times a day. Charts and suggestions are only guides and it is the
physician’s examination of each patient that makes the final determination of the
systems that should be supported and the areas that require manipulative treatment.
STAGE I: Moderate distress, febrile, non-productive cough,
usually mildly to moderately dehydrated, exhibiting some degree of electrolyte
imbalance. Usually presenting to ER, ICU or doc’s office
A. Rib raising to point of tissue release in the paravertebral area on each side. Begin with
the area of greatest involvement. In lobar pneumonia this would correspond with the rib
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in direct continuity with the lobar region of involvement. With bronchial pneumonia the
entire rib cage region from T1 through 12 is often involved.
B. Bilateral soft tissue myofascial release of the thoracic inlet fascias and similar
treatment to the upper thoracic subscapular muscular and fascial tensions.
C. Bilateral inhibition of paravertebral muscles in the occipitoatlantal area and down at
least to C5.
D. Bilateral occipital pressures towards cranial extersion (CV4) if able to provide this
treatment properly, is useful especially if temperatures are 101-103 °.
STAGE II: Diminished distress, lysis of fever, early productive cough, restoration of
fluids and electrolyte balance. This usually correlates to 2 days after pt presents
A. Bilateral soft tissue myofascial release of subscapular
muscles and fascia, rib raising by inhibition of paravertebral
muscles to point of tissue effect. Address treatment
especially to tissues which are most significantly effected as
determined by palpation
B. Bilateral soft tissue myofascial release treatment to anterior
cervical fascias.
C. Bilateral soft tissue myofascial release treatment of the
intercostal muscles and fascias.
D. Specific mobilization of C7 to T4. Region involved in respiratory problems
E. Gentle inhibition of the superior cervical segment. Extend
this treatment down to C5.
A. Supine--direct method-kneading or stretching (4921.11A)
Diagnosis: Anterior cervical fascial dysfunction
First remember to do soft tissue and kneading on posterior cervical fascia then treat
anterior
1. Physician grasps the patient’s head with one hand and contacts the side of the patient’s
neck under the angle of the jaw with the pads of the fingers of the other hand
2. Physician curls his/her fingertips into the skin and deep fascia just anterior to the
sternocleidomastoid muscle hooking them behind the anterior cervical muscles if the
technique is being used to knead the muscles. If the intent is to stretch the anterior
cervical fascia, the fingertips are superficial to the muscles and only the deep fascia is
drawn anteromedially. This technique can also stretch the muscles and fascia of the
larynx and may prepare the patient for the hyoid technique (4921.21A)
3. Physician rolls the head in a rhythmic, rocking motion
offering counterforce to the kneading and/or stretching
fingers. The physician repositions his/her fingers more
inferiorly so that the treatment can be applied to the
entire side of the neck
4. Physician then steps around the table and the anterior
fascial treatment is repeated on the other side
5. Kneading and/or stretching is continued until maximal
tissue response is obtained
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Weds, 12/10/03, 1 PM
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6. Recheck
STAGE III: Convalescent, afebrile, productive cough, restoration of fluid and
electrolytes balance has been accomplished.
A. Rib raising each thoracic paravertebral area until tissue
effect is palpable.
B. Lymphatic pump either by bilateral pedal pressure or
thoracic pump.
C. Specific mobilization of segmental vertebral somatic
dysfunction as indicated.