"OMT & Sports Injuries"

Disclosure

• The Presenter Has No Financial Relationships With Commercial Interests That Would Constitute A Conflict Of Interest Concerning This Presentation.

Outline

• Review Of The Basics Including:

1. The Tenets Of Osteopathic Medicine

2. Basic Terminology

3. Basic Documentation

• Discuss The Basic Sciences Of Two Common Sports Related Injuries

• 10 Min Break

• Lab

• Closing Remarks

The Basics

The Basics: The Tenets of Osteopathic Medicine

• The Body Is A Unit; The Person Is A Unit Of Body, Mind, And Spirit.

• The Body Is Capable Of Self-Regulation, Self-Healing, And Health Maintenance.

• Structure And Function Are Reciprocally Interrelated.

• Rational Treatment Is Based Upon An Understanding Of The Basic Principles Of Body Unity, Self-Regulation, And The Interrelationship Of Structure And Function.

The Basics: Terminology

• Somatic Dysfunction: Impaired Or Altered Function Of Related Components Of The Somatic (Body Framework) System Including The Skeletal, Arthrodial, And Myofascial Structures With The Related Vascular, Lymphatic, And Neural Elements.

• Diagnosed By Observing T-A-R-T Or S-T-A-R In Regions During Physical Examination.

–Fred Mitchell Sr

“Not every injury/problem/lesion is necessarily a Somatic Dysfunction; “Implicit in the term

‘somatic dysfunction’ is the notion that manipulation is appropriate, effective, and

sufficient treatment for it.”

The Basics: Terminology

The Basics: Examples

• Applying For Nmm +1 Residency While Still In ACGME Psychiatry Residency: "How Would You Treat Schizophrenia With OMT?"

• While Doing Neurology Rotation In PGY I Year: "How Would Cracking This Person's Neck Help His Migraine?"

• In A Patient's Chart: • Incorrect: ”Piriformis Syndrome Treated With OMT.” • Correct: “Piriformis Tender Point Treated With OMT.

After Treatment, Patient Noticed A Decrease In Sx Of Piriformis Syndrome Suggesting A Link Between The Above-Listed Dysfunction And Patient's Pain.

The Basics: Documentation - 1

The Basics: Documentation - 2

The Basics: Summary

• Omm/Nmm Is A Treatment For Somatic Dysfunction. It Is Used To Facilitate The Body's Intrinsic Ability To Heal Itself.

• There Is Often Overlap Between Somatic Dysfunction And Illness/Injury.

Injury 1: Concussion

Some Physics

What is the expected outcome and why?

Force

Some Physics

Force

Some Physics

The Brainstem Is Relatively Fixed Meaning Shearing Or Tearing Is Possible

Some Physics

• Reticular Formation: Regulation Of Arousal And Of Consciousness • Pons:

1. Base (Upper): Arousal And Modulation Of The The Sleep–Wake Cycle, Pain Sensation

2. Tegmentum (Lower): Nuclei For CN 6 & 7

Concussion Facts - 1

• Professional Football Players Who Have Had Concussions Are 1.5–3 Times More Likely To Develop Depression Than Their Non-Concussed Team Mates.

• Results Of Brain Imaging And Neuropsychiatric Testing In Retired Players Are Similar To Those Of Patients Who Have Had A Traumatic Brain Injury.

• Previously Concussed Brains Show Excess Cerebral Tau Protein And Plaques And Tangles.

Concussion Facts - 2

• Patients Who Have Had A Concussion Are More Likely To Have Additional Concussions.

• Even After A Patient Has Fully Healed, Subsequent Concussions Will Be More Severe Because Of A Cumulative Effect .

• A Concussed Patient Who Receives An Additional Head Injury Within Days Of The First Is Vulnerable To The “Second Impact Syndrome.”

• Destructive And Potentially Fatal Cerebral Edema. • Affects Children And Teenagers More Frequently And More

Severely Than Adults. • Fatal In Almost 50% Of Cases.

Treatment

• Removal From Sports!!

• Brain And Physical Rest With Titration Of Exertion. • Encourage Patient To Have Some Activity As Being

Bed Bound Or Home Bound Can Worsen Sx. • Explain To Patients That Pushing Themselves

Beyond Their Limits Will Worsen Sx.

• Monitor Progress With Concussion Specific Testing Like SCAT-3 Or Concussion Vital Signs.

• MMSE Not Appropriate

• Reassure

Injury 2: The Unhappy Triad

The Unhappy Triad

Mechanism Of Injury - 1

ACL

Force

Mechanism of Injury - 2

• When The Heel Is Planted In The Ground And The Knee Twisted, The Medially Directed Force Causes A Gapping Of The Medial Compartment Ultimately Causing Tearing Of:

• Acl Resulting In A Positive Anterior Draw And Lachman Test

• Mcl Resulting In A Positive Valgus Stress Test • Medial Meniscus Resulting In A Positive

Mcmurray Test

Treatmement

• R-I-C-E At First

• Surgery For ACL And Meniscus If Necessary

• PRP Beneficial

Lab Session

PINS - 1

• Examine For S-T-A-R (Sensitivity, Tissue Texture Changes, Asymmetry, Restriction Of Motion)

• Use Patient’s Complaint As Guide

• A “Primary Sensitive” Point Is Located. If A Significant One Is Not Found, Then The Physician Widens The Search To Contiguous Areas.

• Another Point, Designated As The “Endpoint” Is Located Distal Or Proximal To The Primary Point. If The Primary Point Is At The Origin Of A Muscle, The Endpoint May Be At The Insertion

PINS - 2

• The Physician Establishes A Muscular, Fascial, And/Or Neurological Pathway Between The Primary Sensitive Point And The Endpoint. The Primary-To-Endpoint Line May Be Curved, Straight, Or Zigzag. The Direction Of Treatment May Be From Distal To Proximal, Or Proximal To Distal.

• Both The Primary Point And The Endpoint Are Pressed Simultaneously Using A Few Ounces Of Pressure By A Finger Pad On Each Hand.

PINS - 3

• The Physician Should Also Determine The Soft Tissue Response To Pressure.

• After A Change In S-T-A-R Is Observed, Another Finger Is Used To Locate A “Secondary Point.” If The Index Finger Is On The Primary Point, Then The Middle Finger Can Be Used To Palpate An Arc To Look For A Secondary Point. The Patient Is Asked To Compare The Initial Primary Point To The Secondary Point.

• Note: The Endpoint Finger Never Changes!

PINS - 4

• If The Secondary Point Is More Sensitive Than The Primary Point, It Becomes The New Primary Point.

• If The Secondary Point And Primary Point Are Equally Sensitive, Maintain Inhibition Of The Primary Point Until Another Change Is Felt And Look For Secondary Point Again.

• If There Is No Secondary Point Found, Maintain Inhibition Of The Primary Point Until Another Change Is Felt And Look For Secondary Point Again.

• Repeat Until Primary Point And End Point Are Approx 2 Cm Apart.

• Re-Evaluate Patient.

Directing The Tide - 1

• Used To Alter The Pattern, Rate, Direction, And Amplitude Of CSF Fluctuation.

• Used To Improve Motion At Cranial Articulations

• Remove Restrictions On The Mechanism

Directing The Tide - 2

• Cradle Patient’s Head Crossing Fingers Beneath Neck, Mcp At Mastoid Processes, Thenar Eminences At Mastoid Portions.

• Observe

• Roll Hands, “Wait For Water In Glass To Be Completely Emptied”

• Roll Hands In Opposite Direction, “Wait For Water In Glass To Be Completely Emptied”

• When The Fluid Begins To Move On Its Own, Switch From Directing To Catching, Continue Until A Still Point Is Reached

• Wait For PRM To Establish New Pattern

• Leave It Alone

Directing The Tide - 3

• Contraindications Include Recent Skull Fracture, Acute Hemorrhage, Elevated ICP, Cerebral Edema

Compression Of The Fourth Ventricle

• Fingers Overlapped Under Patient’s Neck

• Thenar Eminences Of Both Hands Under Supraocciput At Lateral Angle

• Make Sure Contacts Are Not On Temporal Bones Or Above Nuchal Line On Occipital Scam

• Once Contact Established, Bring Thinner Eminences Together Until You Feel A Change

• Hold Until Still Point

• Procedure Is Finished When Patient Has Deep Inspiration, Pinker Cheeks, Forehead Moisture, Recognition Of Improved Physiology

Torque Unwinding

Fibular Head Dysfunction

• A Posterior Fibular Head Somatic Dysfunction Is Defined As Increased Posterior With Decreased Anterior Slide; Often Accompanied By Foot Inversion, Forefoot Adduction, And Lower Leg Internal Rotation.

• Increased Anterior Slide With Decreased Posterior Slide Signifies Anterior Slide Dysfunction; Accompanied By Foot Eversion, Forefoot Abduction, And Lower Leg External Rotation

Muscle Energy For Posterior Fibular Head

• Flex Knee And Hip To 90 Degrees Each.

• The Physician Stabilizes The Patient’s Bent Knee And Holds The Fibular Head Between Thumb And Index Finger With One Hand And Holds The Foot With The Other.

• The Physician Engages The Barrier By Everting And Dorsiflexing The Patient’s Foot And Externally Rotating The Lower Leg.

• The Patient Will Push Toward The Fibular Head Freedom By Pushing His Foot Medially Against Isometric Resistance For 3 To 5 Seconds.

• The Patient Is Instructed To Relax For 3 To 5 Seconds, And Then The Physician Repositions The Patient Into The New Barriers.

• The Procedure Is Repeated Until Normal Range Of Motion Is Accomplished Or Approximated.

Muscle Energy For Anterior Fibular Head Dysfunction

• Flex Knee And Hip To 90 Degrees Each.

• The Physician Stabilizes The Patient’s Bent Knee And Holds The Fibular Head Between Thumb And Index Finger With One Hand And Holds The Foot With The Other.

• The Physician Engages The Barrier By Inverting The Patient’s Foot And Internally Rotating The Lower Leg.

• The Patient Will Push Toward The Fibular Head Freedom By Pushing His Foot Laterally Against Isometric Resistance For 3 To 5 Seconds.

• The Patient Is Instructed To Relax For 3 To 5 Seconds, And Then The Physician Repositions The Patient Into The New Barriers.

• The Procedure Is Repeated Until Normal Range Of Motion Is Accomplished Or Approximated.

Summary

Osteopathy Is Not Just High Velocity...

Summary

• The Body Is An Interconnected Unit.

• Somatic Dysfunction Is Effectively Treated By Omt

• Correcting Somatic Dysfunction Can Greatly Improve Symptoms The Patient Has As The Result Of Traumatic Injury Such As Injury To The Head Or Knee

REFERENCES• CDC.Heads Up Animation Of A Concussion Video. Retrieved From Http://Www.Cdc.Gov/Headsup/Basics/Concussion_Whatis.Html

• CDC.Heads Up Video: What Is A Concussion. Retrieved From Http://Www.Cdc.Gov/Headsup/Basics/Concussion_Symptoms.Html

• Digiovanna, E. L. (2004). Chapter 4: Somatic Dysfunction. An Osteopathic Approach To Diagnosis And Treatment, 3Rd Edition (3Rd Ed., Pp. 16-24) Lippincott Williams & Wilkins.

• Dowling, D. J. (2004). Chapter 23: Inhibition And Progressive Inhibition Of Neuromusculoskeletal Structures (Pins) Techniques. An Osteopathic Approach To Diagnosis And Treatment (3Rd Ed., Pp. 118-123) Lippincott Williams & Wilkins.

• Dowling, D. J. (2004). Chapter 31: Pins Techniques For The Cervical Spine. An Osteopathic Approach To Diagnosis And Treatment, 3Rd Edition (3Rd Ed., Pp. 158) Lippincott Williams & Wilkins.

• Dowling, D. J. (2014). Chapter 97: Muscle Energy Of The Lower Extremity . An Osteopathic Approach To Diagnosis And Treatment (3Rd Ed., Pp. 509-511) Lippincott Williams & Wilkins.

• Feibish, G. (2006). The Knee Joint: Anatomy, Physiology And Examination.

• Kaufman, D. M., & Milstein, M. J. (2013). Chapter 22: Traumatic Brain Injuries, Minor Head Trauma. Kaufman’s Clinical Neurology For Psychiatrists (7Th Ed., Pp. 532-535) Saunders, Elsevier Inc.

• Ropper, A. H., Samuels, M. A., & Klein, J. P. (2014). Chapter 35. Craniocerebral Trauma. Adams & Victor's Principles Of Neurology (10Th Ed. ). New York, Ny: The Mcgraw-Hill Companies.

• Sleszynsk, S. L., Glonek, T., Zanetti, C. A., Ching, L. M., Dudley, G. J., Lund, G. C., . . . Cole, D. Outpatient Osteopathic Single Organ System Musculoskeletal Form Series Usage Guide Retrieved From Http://Files.Academyofosteopathy.Org/Lborc/Soapnotes/Soapnotessosms-Usageguide.Pdf

• Split-Shift.Jpj. Retrieved From Http://Www.Kimberlydurban.Com/Blog/Wp-Content/Uploads/2011/03/Split-Shift.Jpg

• Burruano, M. P.Management And Fluctuation Of Csf. Unpublished Manuscript.