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OSTEOPATHIC APPROACH TO
PATIENT CARE AND WELLNESS
OSTEOPATHIC APPROACH TO
PATIENT CARE AND WELLNESS
SMART LIFE FORUMNOVEMBER 16, 2006
HARRY D FRIEDMAN DO
SMART LIFE FORUMNOVEMBER 16, 2006
HARRY D FRIEDMAN DO
OSTEOPATHIC MEDICINE AS ART, INTEGRATING
OSTEOPATHIC MEDICINE AS ART, INTEGRATING
NATURAL & TECHNOLOGICAL APPROACHES
SCIENTIFIC & INTUITIVE THINKING STRUCTURAL & FUNCTIONAL
THERAPY PATIENT & DISEASE FOCUSED
CARE
NATURAL & TECHNOLOGICAL APPROACHES
SCIENTIFIC & INTUITIVE THINKING STRUCTURAL & FUNCTIONAL
THERAPY PATIENT & DISEASE FOCUSED
CARE
DEFINITION OF OSTEOPATHIC MEDICINE
DEFINITION OF OSTEOPATHIC MEDICINE
“A complete system of medical care with a philosophy that combines the needs of the patient with the current practice of medicine, surgery and obstetrics; that emphasizes the interrelationship between structure and function; and that has an appreciation for the body’s ability to heal itself.”
-A.O.A. House of Delegates
“A complete system of medical care with a philosophy that combines the needs of the patient with the current practice of medicine, surgery and obstetrics; that emphasizes the interrelationship between structure and function; and that has an appreciation for the body’s ability to heal itself.”
-A.O.A. House of Delegates
OSTEOPATHIC PRINCIPLESOSTEOPATHIC PRINCIPLES
THE BODY FUNCTIONS AS A UNIFIED WHOLE WITH AN INHERENT VITALITY THAT IS
SELF-HEALING AND SELF-REGULATING. STRUCTURE & FUNCTION BEING INTERRELATED, ALTERATION OF THE BODY’S STRUCTURAL
FRAMEWORK AND CONNECTIVE TISSUE SYSTEM CAN LEAD TO ILLNESS AND DISEASE, THE
CORRECTION OF WHICH IS PART OF RATIONAL OSTEOPATHIC HEALTHCARE
THE BODY FUNCTIONS AS A UNIFIED WHOLE WITH AN INHERENT VITALITY THAT IS
SELF-HEALING AND SELF-REGULATING. STRUCTURE & FUNCTION BEING INTERRELATED, ALTERATION OF THE BODY’S STRUCTURAL
FRAMEWORK AND CONNECTIVE TISSUE SYSTEM CAN LEAD TO ILLNESS AND DISEASE, THE
CORRECTION OF WHICH IS PART OF RATIONAL OSTEOPATHIC HEALTHCARE
PASSEBECQ (1992)PASSEBECQ (1992)
“TO MAINTAIN A HEALTHY BODY, HOMEOSTASIS MUST BE KEPT CONSTANT…A HEALTHY ORGANIC TERRAIN IS THE BASIS OF HEALTH AND CONVERSLEY DISEASES DEVELOP IN A DEPLETED OR CONGESTED TERRAIN. UPSTREAM OF MOST DISEASES IS AN UNBALANCED TERRAIN.”
“TO MAINTAIN A HEALTHY BODY, HOMEOSTASIS MUST BE KEPT CONSTANT…A HEALTHY ORGANIC TERRAIN IS THE BASIS OF HEALTH AND CONVERSLEY DISEASES DEVELOP IN A DEPLETED OR CONGESTED TERRAIN. UPSTREAM OF MOST DISEASES IS AN UNBALANCED TERRAIN.”
BEING COMPRISED MOSTLY OF FLUID, LIVING TERRAIN IS NOT
STATIC, BUT CONSTANTLY MOVING, LIKE THE EBB AND
FLOW OF THE OCEAN. WHERE THERE IS A LACK OF MOTION, THERE LIES AN UNBALANCED TERRAIN AND THE BEGINNING
OF DISEASE.
BEING COMPRISED MOSTLY OF FLUID, LIVING TERRAIN IS NOT
STATIC, BUT CONSTANTLY MOVING, LIKE THE EBB AND
FLOW OF THE OCEAN. WHERE THERE IS A LACK OF MOTION, THERE LIES AN UNBALANCED TERRAIN AND THE BEGINNING
OF DISEASE.
INTERRELATIONSHIP AND INTERDEPENDENCE OF STRUCTURE-FUNCTION
INTERRELATIONSHIP AND INTERDEPENDENCE OF STRUCTURE-FUNCTION
“DISEASE IS THE RESULT OF ANATOMICAL ABNORMALITIES
FOLLOWED BY PHYSIOLOGIC DISCORD”
“THE RULE OF THE ARTERY IS SUPREME”
-A.T. STILL MD
“DISEASE IS THE RESULT OF ANATOMICAL ABNORMALITIES
FOLLOWED BY PHYSIOLOGIC DISCORD”
“THE RULE OF THE ARTERY IS SUPREME”
-A.T. STILL MD
OPTIMAL MULTISYSTEM FUNCTION REQUIRES
OPTIMAL MULTISYSTEM FUNCTION REQUIRES
UNIMPEDED DELIVERY OF BLOOD AND DISPOSAL OF WASTE PRODUCTS
CENTRAL AND AUTONOMIC NERVOUS SYSTEM BALANCE
MOTOR SYSTEM COORDINATION UNITY OF THE WHOLE THAT ENHANCES
THE FUNCTION OF EACH PART
UNIMPEDED DELIVERY OF BLOOD AND DISPOSAL OF WASTE PRODUCTS
CENTRAL AND AUTONOMIC NERVOUS SYSTEM BALANCE
MOTOR SYSTEM COORDINATION UNITY OF THE WHOLE THAT ENHANCES
THE FUNCTION OF EACH PART
THE WHOLE IS GREATER THAN THE SUM OF ITS
PARTS
THE WHOLE IS GREATER THAN THE SUM OF ITS
PARTS
OSTEOPATHIC MANIPULATIVE APPROACHES CAN ALTERNATELY EVALUATE THE FUNCTION OF THE WHOLE OR ITS COMPONENT PARTS AND PROVIDE TREATMENT THAT ENHANCES EACH
OSTEOPATHIC MANIPULATIVE APPROACHES CAN ALTERNATELY EVALUATE THE FUNCTION OF THE WHOLE OR ITS COMPONENT PARTS AND PROVIDE TREATMENT THAT ENHANCES EACH
OSTEOPATHIC MANIPULATIVE
TREATMENT (OMT)
OSTEOPATHIC MANIPULATIVE
TREATMENT (OMT)
THE THERAPEUTIC APPLICATION OF MANUALLY GUIDED FORCES BY AN OSTEOPATHIC PHYSICIAN TO IMPROVE PHYSIOLOGIC FUNCTION AND/OR SUPPORT HOMEOSTASIS THAT HAS BECOME ALTERED BY SOMATIC DYSFUNCTION
THE THERAPEUTIC APPLICATION OF MANUALLY GUIDED FORCES BY AN OSTEOPATHIC PHYSICIAN TO IMPROVE PHYSIOLOGIC FUNCTION AND/OR SUPPORT HOMEOSTASIS THAT HAS BECOME ALTERED BY SOMATIC DYSFUNCTION
SOMATIC DYSFUNCTIONSOMATIC DYSFUNCTION
“IMPAIRED OR ALTERED FUNCTION OF RELATED COMPONENTS OF THE SOMATIC (BODY FRAMEWORK) SYSTEM: SKELETAL, ARTHROIDIAL AND MYOFASCIAL STRUCTURES AND RELATED VASCULAR, LYMPHATIC AND NEURAL ELEMENTS.”
-ICD-9 DIAGNOSTIC CODEBOOK (739.0 -.9)
“IMPAIRED OR ALTERED FUNCTION OF RELATED COMPONENTS OF THE SOMATIC (BODY FRAMEWORK) SYSTEM: SKELETAL, ARTHROIDIAL AND MYOFASCIAL STRUCTURES AND RELATED VASCULAR, LYMPHATIC AND NEURAL ELEMENTS.”
-ICD-9 DIAGNOSTIC CODEBOOK (739.0 -.9)
THE HUNT FOR SOMATIC DYSFUNCTION
THINK A.R.T.
THE HUNT FOR SOMATIC DYSFUNCTION
THINK A.R.T.
A FOR ASYMMETRY OBSERVE OR PALPATE “UNEVENNESS”
R FOR RESTRICTION OF MOTION PALPATE FOR EARLY “ENDFEEL”
T FOR TISSUE QUALITY ALTERATIONS PALPATE TEXTURE, TEMP, MOISTURE,
TENDERNESS
A FOR ASYMMETRY OBSERVE OR PALPATE “UNEVENNESS”
R FOR RESTRICTION OF MOTION PALPATE FOR EARLY “ENDFEEL”
T FOR TISSUE QUALITY ALTERATIONS PALPATE TEXTURE, TEMP, MOISTURE,
TENDERNESS
BERNIE SEIGAL, PEACE, LOVE AND HEALING 1989 (#1NY TIMES BEST
SELLER)
BERNIE SEIGAL, PEACE, LOVE AND HEALING 1989 (#1NY TIMES BEST
SELLER)
“THE OSTEOPATHIC STUDENTS HAVE BEEN TAUGHT ABOUT TOUCHING AND MANIPULATING THE BODY, AND WHEN THEY’RE IN MY OFFICE AND A PATIENT WHO HAS SOME PAIN COMES IN, THEY KNOW HOW TO USE MANIPULATION AND MASSAGE TO HELP RELIEVE THAT PAIN. THE MEDICAL STUDENT IS MORE PRONE TO PRESCRIBE A PILL. WE NEED TO TEACH MEDICAL STUDENTS HOW TO TOUCH PEOPLE.”
“THE OSTEOPATHIC STUDENTS HAVE BEEN TAUGHT ABOUT TOUCHING AND MANIPULATING THE BODY, AND WHEN THEY’RE IN MY OFFICE AND A PATIENT WHO HAS SOME PAIN COMES IN, THEY KNOW HOW TO USE MANIPULATION AND MASSAGE TO HELP RELIEVE THAT PAIN. THE MEDICAL STUDENT IS MORE PRONE TO PRESCRIBE A PILL. WE NEED TO TEACH MEDICAL STUDENTS HOW TO TOUCH PEOPLE.”
ANDREW WEIL MD. SPONTANEOUS HEALING 1995 (#1 NYTIMES BEST SELLER)
ANDREW WEIL MD. SPONTANEOUS HEALING 1995 (#1 NYTIMES BEST SELLER)
“I FREQUENTLY REFER PATIENTS TO DO’S FOR OMT AND OFTEN ENCOURAGE MEDICAL STUDENTS TO LEARN THE TECHNIQUE, BECAUSE I HAVE FOUND IT TO BE SAFE AND HIGHLY EFFECTIVE.)
“I FREQUENTLY REFER PATIENTS TO DO’S FOR OMT AND OFTEN ENCOURAGE MEDICAL STUDENTS TO LEARN THE TECHNIQUE, BECAUSE I HAVE FOUND IT TO BE SAFE AND HIGHLY EFFECTIVE.)
HISTORY OF MANUAL MEDICINE
HISTORY OF MANUAL MEDICINE
2700 BC CHINESE 400 BC HIPPOCRATES 100 BC GALEN, “THE PRINCE OF PHYSICIANS”
19TH CENTURY BONESETTERS 19TH CENTURY STILL, PALMER 20TH CENTURY MENNELL, CYRIAX 20TH CENTURY SUTHERLAND, BARRAL
2700 BC CHINESE 400 BC HIPPOCRATES 100 BC GALEN, “THE PRINCE OF PHYSICIANS”
19TH CENTURY BONESETTERS 19TH CENTURY STILL, PALMER 20TH CENTURY MENNELL, CYRIAX 20TH CENTURY SUTHERLAND, BARRAL
TRACTION AND THRUSTTRACTION AND THRUSTHippocrates Method of Spinal ManipulationHippocrates Method of Spinal Manipulation
Traction and ThrustTraction and Thrust
Woodblock Print by Galen, 400 A.D.
ATATDr. A.T. StillDr. A.T. Still(1828-1917)(1828-1917)Founder ofFounder ofOsteopathyOsteopathy
ANDREW TAYLOR STILL, MD
ANDREW TAYLOR STILL, MD
1854 LICENSED AS MD, SERVED IN CIVIL WAR 1864 3 FAMILY MEMBERS DIE OF MENINGITIS,
RENOUNCES MEDICINE, TAKES UP STUDY OF STRUCTURE-FUNCTION/UNITY OF THE BODY
1874 PRINCIPLES OF OSTEOPATHY UNVEILED 1892 AMERICAN SCHOOL OF OSTEOPATHY
OPENS
1854 LICENSED AS MD, SERVED IN CIVIL WAR 1864 3 FAMILY MEMBERS DIE OF MENINGITIS,
RENOUNCES MEDICINE, TAKES UP STUDY OF STRUCTURE-FUNCTION/UNITY OF THE BODY
1874 PRINCIPLES OF OSTEOPATHY UNVEILED 1892 AMERICAN SCHOOL OF OSTEOPATHY
OPENS
DO SCHOOLSDO SCHOOLS
28
Osteopathic Medical Colleges
HOW DOES MANIPULATION WORK?
HOW DOES MANIPULATION WORK?PATHOPHYSIOLOGIC MODELS
FACET DYSFUNCTION
NOCICEPTION (PAIN) MECHANORECEPTION (PRESSURE)
PROPRIOCEPTION (POSITION)
PATHOPHYSIOLOGIC MODELS
FACET DYSFUNCTION
NOCICEPTION (PAIN) MECHANORECEPTION (PRESSURE)
PROPRIOCEPTION (POSITION)
REFERRED PAINREFERRED PAINReferred Pain of CervicalReferred Pain of Cervical
Zygapophyseal Joint OriginZygapophyseal Joint Origin
NOCICEPTORSNOCICEPTORSSpinal and Para spinal Nociceptors,Spinal and Para spinal Nociceptors,Proprioceptors, MechanoreceptorsProprioceptors, Mechanoreceptors
HOW DOES MANIPULATION WORK?
HOW DOES MANIPULATION WORK? PATHOPHYSIOLOGIC MODELS
NEURAL FACILITATION
ALTERED REFLEXES CAUSING HYPERACTIVE OR INHIBITED
RESPONSES TO STIMULI OR STRESS
PATHOPHYSIOLOGIC MODELS
NEURAL FACILITATION
ALTERED REFLEXES CAUSING HYPERACTIVE OR INHIBITED
RESPONSES TO STIMULI OR STRESS
SPINAL REFLEXESSPINAL REFLEXESSpinal Reflexes
PainPosition
Blood and lymph vessels
Skin
Joints
Muscles
Viscera
NEURAL FACILITATIONNEURAL FACILITATION
VISCERAL (ORGAN) STRESS AND DISEASE ARE REFLECTED IN THE TISSUES SURROUNDING THE SPINAL LEVELS WHICH INNERVATE IT
ESOPHAGUS T 2-3 STOMACH T 5-6 HEART T 2-6 GALLBLADER T8-9 KIDNEY T9-11
VISCERAL (ORGAN) STRESS AND DISEASE ARE REFLECTED IN THE TISSUES SURROUNDING THE SPINAL LEVELS WHICH INNERVATE IT
ESOPHAGUS T 2-3 STOMACH T 5-6 HEART T 2-6 GALLBLADER T8-9 KIDNEY T9-11
HOW DOES MANIPULATION WORK?
HOW DOES MANIPULATION WORK?
PATHOPHYSIOLOGIC MODELS
MOTOR SYSTEM DYSFUNCTION
MUSCLE TENSION AND LENGTH ALTERED BY POSTURAL STRESS, INJURY OR ALARM
OVER AND UNDER STIMULATED MUSCLES AND THEIR ASSOCIATED BODY-WIDE COMPENSATIONS CAUSE DISTURBANCES IN POSTURE, MOTION, AND COORDINATION
PATHOPHYSIOLOGIC MODELS
MOTOR SYSTEM DYSFUNCTION
MUSCLE TENSION AND LENGTH ALTERED BY POSTURAL STRESS, INJURY OR ALARM
OVER AND UNDER STIMULATED MUSCLES AND THEIR ASSOCIATED BODY-WIDE COMPENSATIONS CAUSE DISTURBANCES IN POSTURE, MOTION, AND COORDINATION
MUSCLE SPINDLEMUSCLE SPINDLEMuscle innervation
GOALS OF OSTEOPATHIC TREATMENT
GOALS OF OSTEOPATHIC TREATMENT
RESTORE MIDLINE FUNCTION AND MOBILITY OF ALL TISSUES
IMPROVE POSTURE AND BODY MOVEMENT MOBILIZE FLUIDS TO AND FROM ALL
TISSUES BALANCE CNS/ANS REFLEXES (CALM
DOWN HYPERACTIVE NERVES) ENHANCE HEALING AND HOMEOSTASIS
RESTORE MIDLINE FUNCTION AND MOBILITY OF ALL TISSUES
IMPROVE POSTURE AND BODY MOVEMENT MOBILIZE FLUIDS TO AND FROM ALL
TISSUES BALANCE CNS/ANS REFLEXES (CALM
DOWN HYPERACTIVE NERVES) ENHANCE HEALING AND HOMEOSTASIS
MOTION
RESPIRATION
METABOLISM
BEHAVIOR
CIRCULATION
NEURAL INTEGRATION
MOTION
RESPIRATION
METABOLISM
BEHAVIOR
CIRCULATION
NEURAL INTEGRATION
CORRECTIVE FORCES CAN BE DIRECT OR INDIRECT
CORRECTIVE FORCES CAN BE DIRECT OR INDIRECT
DIERCT TECHNIQUES ENGAGE AND OVERCOME TISSUE RESTRICTION
INDIRECT TECHNIQUES DIS-ENGAGE AND RELEASE TISSUE RESTRICTION WITH AFFERENT REDUCTION
BOTH STIMULATE THE PATIENT’S INHERENT RESTORATIVE CAPACITY BY ACTIVATING DYNAMIC MIDLINE FUNCTION
DIERCT TECHNIQUES ENGAGE AND OVERCOME TISSUE RESTRICTION
INDIRECT TECHNIQUES DIS-ENGAGE AND RELEASE TISSUE RESTRICTION WITH AFFERENT REDUCTION
BOTH STIMULATE THE PATIENT’S INHERENT RESTORATIVE CAPACITY BY ACTIVATING DYNAMIC MIDLINE FUNCTION
DOES IT WORKDOES IT WORKDoes this stuff work?
AHCPR no. 95-0642 says YES!¥ Agency for Health Care, Policy & Research
Guidelines, 1994:
¥ For back pain under 3 monthsĞ ANALGESICS
Ğ ALTERATION OF ACTIVITY
Ğ Spinal Manipulation
REVIEW OF LITREVIEW OF LIT
Systematic Review ofRandomized Controlled Trials:
Treatment of Acute and ChronicNonspecific Low Back Pain
van Tulder, Koes, Bouter in SPINE, Vol. 22, 1997
¥Strong evidence was also found forthe effectiveness of spinalmanipulation, back schools andexercise therapy for chronic low backpain, especially for short term effects.
NEJM ARTNEJM ART
22
Clinical Outcomes Trial
Andersson GB, Lucente T, Davis AM, KapplerRE, Lipton JA, Leurgans S.
A Comparison of osteopathic spinalmanipulation with standard care for patientswith low back pain.
N Engl. J Med, 1999 Nov 4; 341 (19): 1426-31.
RESULTSRESULTS
MD: Standard Care - MD: Standard Care -Manipulation; Manipulation; DO: Standard CareDO: Standard Care
+ Manipulation+ Manipulation
Man.+PT+Meds
N 83
NSAIDS 24%
M. Relax. 6%
Pt 0.2%
PT+Meds
72
54%
25%
2.6%
WC COST ANALYSISWC COST ANALYSISWorkerÕs Compensation Average Cost
of Treatment for LBP (AOA data)
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
Colorado, 1993 Florida, 1988
Non-surgical MD
Chiropractor
Surgical MD
DO
EBM DATAEBM DATAEBM Osteopathic ManipulativeEBM Osteopathic Manipulative
MedicineMedicine
Benefit > Risk for:
Acute, subacute andchronic mechanical lowback and neck pain
Cervicogenic headaches
Knee Osteoarthritis
Prenatal OB
Pediatric NeurologicDevelopment
Can reduce: Pain Medication use PT utilization Hospital days Disability and Impairment Work days lost from
nonspecific or mechanicallow back pain
PRE-POST MFRPRE-POST MFR
49
Pre-post Myofascial ManipulativeRelease of Wrist MRI
(Sucher 1993)
Pre-Manipulation0.84 x 1.72 cm
Post-Manipulation0.96 x 1.9 cm
FRYMANNFRYMANNViola M. Frymann, DO, FAAO
Neurologic Developmental Delayin Children
¥ 18 m.o.-12 y.o. children w/ & w/out neuraldevelopmental delay given 6-12 treatments
¥ Statistically significant improvement in neurologicaldevelopment profile after OMT course of treatment
¥ See JAOA 92(6): 729-744, June 1992
¥ Those with medical problems improved less
¥ Osteopathic Center for Children - San Diego, CA
THE BODY IS ESSENTIALLY A FLUID CONTAINER, ITS
STRUCTURE DETERMINES THE PROPER PLACEMENT AND
COORDINATED FUNCTION OF EVERY TISSUE. WHEN
STRUCTURE AND FUNCTION ARE IMPAIRED, HOMEOSTASIS
FALTERS.
THE BODY IS ESSENTIALLY A FLUID CONTAINER, ITS
STRUCTURE DETERMINES THE PROPER PLACEMENT AND
COORDINATED FUNCTION OF EVERY TISSUE. WHEN
STRUCTURE AND FUNCTION ARE IMPAIRED, HOMEOSTASIS
FALTERS.
OSTEOPATHIC MANIPULATIVE MEDICINE ENHANCES THE BODY’S STRUCTURE AND
FUNCTION, IMPROVING FLUID MOBILITY AND HOMEOSTASIS, IMPARTING HEALTH TO EVERY
TISSUE
OSTEOPATHIC MANIPULATIVE MEDICINE ENHANCES THE BODY’S STRUCTURE AND
FUNCTION, IMPROVING FLUID MOBILITY AND HOMEOSTASIS, IMPARTING HEALTH TO EVERY
TISSUE
LINKSLINKS
WWW.DRAGONFLYVILLAGE.COM/OSTEOPATHY
WWW.SFIMMS.COM WWW.ACADEMYOFOSTEOPATHY.ORG WWW.OSTEOHOME.COM WWW.OSTEOPATHIC.ORG WWW.DO-ONLINE.ORG WWW.AACOM.ORG
WWW.DRAGONFLYVILLAGE.COM/OSTEOPATHY
WWW.SFIMMS.COM WWW.ACADEMYOFOSTEOPATHY.ORG WWW.OSTEOHOME.COM WWW.OSTEOPATHIC.ORG WWW.DO-ONLINE.ORG WWW.AACOM.ORG