OMT for LBP
Samuel A. Yoakum, DO
Disclosures
none
Outline
Background
Definitions
Diagnosis
Techniques
Billing
Definitions
Manual manipulation/therapy
Hands-on manipulation, mobilization or
massage techniques involving articulations
and/or soft tissue movements in order to
modulate pain, augment range of motion,
facilitate movement, and improve function.
Manual therapy
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Acupressure
Bodywork
Bowen technique
Chiropractic
Craniosacral therapy
Indian head massage
Lomilomi
Manual lymphatic drainage
Massage therapy
Naprapathy
Osteopathic medicine
Physical therapy
Rolfing structural integration
Shiatsu
Thai massage
Tui na
Watsu
Osteopathic Medicine
Definitions:
•Osteopathy = Osteopathic medicine
•Osteopathic manipulative medicine = OMM
•Osteopathic manipulative treatment/techniques = OMT
•Doctor of Osteopathy = DO
According to the World Osteopathic Health Organization, Osteopathy is a
“…system of healthcare which relies on manual contact for diagnosis and
treatment. It respects the relationship of body, mind and spirit in health and
disease; it lays emphasis on the structural and functional integrity of the body
and the body's intrinsic tendency for self-healing.”
Tenets of Osteopathy
● The body is a unit
o Understanding this concept allows the treatment of patients as
a functional whole.
● Structure and Function are interrelated
o Still’s philosophy: “Disease is the result of anatomical
abnormalities followed by physiologic discord”
● The body possesses self-regulatory and self-healing
mechanisms
● Rational treatment is based on applying these principles
Diagnosis
Somatic Dysfunction
● Tissue Texture Changes
o Boggy/edematous, taught/hypertonic “knots”, ropy/fibrosed,
atrophied, rigid, moist, dry
● Asymmetry
o ‘Inspection’
● Restriction of motion = a deeper look at A/PROM
o Named for FREEDOM Of MOTION
o Restricted motion is the BARRIER
● tenderness
o Tenderpoints vs. Triggerpoints
Tissue Texture Changes
● Acute
● Chronic
o Edematous
o Flat
o Erythematous
o Cool
o Boggy
o Leathery, low tone
o Slick, sweaty
o Flaccid, ropy, fibrotic
Asymmetry
● Group curvature
● Single segment disfunction
● Compare Side-to-side
● Mastoid
● Acromion
● Lower ribs
● Iliac crests
● Greater trochanters
● Lateral femoral condyles
● Lateral malleoli
Restriction of motion
● Orthopedic
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Very Loose
● Rheumatologic
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Very Restricted
● Somatic Dysfunction
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Free in one direction + restricted in the other
The Barrier Concept
● BARRIER stops motion
● FREEDOM Of MOTION is opposite the barrier
● Barriers
o Anatomical
o Physiological
o Restrictive
Anatomical & Physiological Barriers
Restrictive Barrier
Osteopathic Manipulative Techniques
● Direct Techniques
o Engage (go into) the dysfunctional barrier
o Goal is moving through the barrier to restore normal motion
● Indirect Techniques
o Disengage (go away from) the barrier
o Using the path of least resistance
● Combined Techniques
o Begin indirect, then go direct
OMT
● Soft tissue mobilization / Articulatory Techniques
o Direct
● Myofascial Release (MFR)
o Direct or Indirect
● Muscle Energy (contract-relax)
o Direct
● Jones Counterstrain & FPR
o Indirect
● High Velocity Low Amplitude (HVLA)
o Direct
● Craniosacral
o Direct or Indirect
Common PT Crossover
● Contract-Relax
o Muscle Energy
● Joint Mobilizations = “Mobs” = direct technique with a
range of force and velocity (Grade I-V)
o Deep articulation
Key: Know What You Are Treating
● Soft tissue – skin, adipose, superficial fascia
● Deep Fascia – layers, lines, planes, strain patterns
● Muscle – follow the fibers
● Joint – vertebral segments, articulations, syndesmoses
High Velocity,
low amplitude
● Confronting restricted motion of segments and
articulations “head on”
● Requires skill for safety and appropriate application
● The barrier is engaged, isolated in multiple planes to
minute specificity
● Final thrust in nearly ALL cases should be quick (high
velocity) but short (low amplitude)
● “shotgun” techniques are discouraged
Soft Tissue Mobilization
● Soft tissue tensions affect function of the soft tissues
and the joints to which they attach.
● Allows treatment to other parts of the body to be more
effective.
● Gently and directly applying pressure as to separate the
origin and insertion of muscle fibers from each other.
● Deep articulation, in contrast, is the repeated
engagement of the barrier or endpoint of joint motion in
order to increase mobility and ROM.
Myofascial Release (MFR)
● MFR is an umbrella term
encompassing several types of
osteopathic manipulative techniques
(OMT) that stretch and release
muscle and fascia restrictions.
● MFR first involves palpating a
restriction in the fascia/soft tissue.
● Direct MFR = practitioner engages
the restrictive barrier and holds until
a release is felt in the tissue.
● Indirect MFR = practitioner moves
the myofascial structures away from
the restrictive barrier.
Counterstrain
Used to treat Tenderpoints
● Tenderpoints are small tense edematous areas of
tenderness typically located near tendon attachments,
ligaments, or in the belly of some muscles.
● Tenderpoints, unlike trigger points, do not radiate pain
when compressed.
Counterstrain
● Jones Counterstrain = passive indirect
technique
o Muscle being treated is positioned at a point of balance or
ease, away from the restrictive barrier.
o “Fold and hold” for 90 sec
● This is a neurosensory approach to the
treatment of tenderpoints.
o Mimicking the original strain position -> reducing
aberrant afferent flow from the muscle spindle ->
relaxes the muscle “spasm” associated with a
tenderpoint
Facilitated Positional Release (FPR)
● Indirect technique
● Place tissue in neutral position to diminish tissue/joint
tension in all planes
● Add activating force (compression or distraction)
● Takes 3-4 seconds to induce a release
● Good for superficial muscles or deep intervertebral
muscles
Muscle Energy
● Muscle energy, also known as “contract-relax,”
is a direct technique used to improve range of
motion.
● This is a form of OMT in which the patient
actively uses his/her muscles against the
practitioner’s resistance.
o Physician engages a barrier and holds
o Patient is instructed to contract the muscle against
your holding force (Activating force)
o Relax
o Engage a new barrier
o Repeat
Still Technique
● A combination of indirect technique, moving to
direct technique following the release
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The patient is completely passive
The lever is placed in a position of ease
Holding force (compression/distraction) is applied
The joint, or body part is then taken through a range of
motion while attempting to hold the activating force as long
as possible
● The range of motion is taken to (and through if reasonably
possible) the barrier
References