Osteopathic EPEC

1. Osteopathic EPEC Education for Osteopathic Physicians on End-of-Life Care Based on The EPEC Project, created by the American Medical Association and supported by the Robert Wood Johnson Foundation. Adapted by the American Osteopathic Association for educational use. American Osteopathic Association AOA: Treating Our Family and Yours

2. Module 13:Osteopathic ManipulativeTechnique in End-of-Life Care

3. OMT Applications at End of Life • Generalized pain and disability • cancer, metastasis • heart disease,stroke, COPD, neuropathy • neurodegenerative conditions/failure to thrive: e.g., Alzheimer or Vascular Dementia and Parkinson Disease • impair mobility • cause musculoskeletal dysfunction

4. Goal of OMT: Normalization • The body is: • Being assaulted by disease • Suffering medication side effects • Going through a closing down process • The mind • The spirit

5. Depression Anything that can be addressed? Family Issues Relationship resolution Personal Issues Context and meaning of one’s life Personal faith Hope The patient The family Psychosocial and Spiritual Issues Near the End of Life Talking with a non-family member may assist in eliminating past emotional baggage and barriers

6. Compassionate Touch = OMT biomechanically alters physiology Addresses emotions

7. Compassionate Touch = OMT • Compassionate touch has its own healing quality • People’s emotional barriers often soften when compassionate touch is involved • OMT is designed to biomechanically alter physiology

8. MIND / BODY/ SPIRIT • Set goals: curative versus palliative • Body • assaulted by disease • suffering from medical side effects • going through closing down process i.e., end-of-life phase ?

9. Body/mind/spirit approach Principles • Select your goal • Extension of life • Quality of life (Palliation) • Diagnosis: • Cause as little pain as possible • Treatment: • First, do no harm • Treat one problem • Allow the body to adjust

10. OMT Treat one body part Allow body to adjust Re-assess Re-treat

11. Global disease Area of greatest restriction (AGR) Best method when problem is complex, e.g., chronic LBP Best demonstrates OMM Best for hardest cases Local disease Treat the local somatic dysfunction Commonly works! Treatment Type Decisions

12. Two Approaches • Global diagnosis • Sequencing area of treatment by area of greatest restriction (AGR) • Best method when the problem is complex • E.g., chronic low back pain • Best demonstrates osteopathic theory and philosophy • Best for hardest cases • Local diagnosis • Easier method when you know the problem is local • E.g., sprained ankle • Most commonly used • Does not completely demonstrate osteopathic theory and philosophy • Often works

13. Two Approaches • Which to choose? Dependent on: • Time • What the real problem is • Your level of mastery • Where the patient is in the end of life process • Why you need both of these skills • Global probably has the highest success rate • Local approach can be done in less time to address • specific problems

14. Global Approach • Examine the body for the area of greatest restriction (AGR) • Treat the AGR • Reexamine other areas of restriction to see if they have changed (or start the whole process over) • Treat successive areas of greatest restriction (AGRs)

15. Q: Why go global?A: Chasing pain often leads to failure Consider the case of two people carrying a heavy load; one drops most of his load. Which one complains the most? THINK: The painful SI joint is frequently on the side opposite the pain. (Analogy for the classic presentation of sacroiliac joint dysfunction. That is, the side exhibiting most pain is often the side oppositethe dysfunction!)

16. Global Diagnostic Principle • The AGR may be and frequently is in a different body region than the site of the chief complaint. • In those cases, the area of pain is where the body is compensating, not where the problem is originating.

17. The body is a unit… . . . with forces distributed through a tensegrity system

18. Global Treatment Principle • Sequence is vital… • You have the right numbers… • But having the right numbers won’t always open the lock!

19. Distant dysfunction mechanisms manifesting as low back pain • Cranium • Dural attachments • Neck • Fascia and muscle attachments, innervation of superficial low back muscles • Thoracic and ribs • Fascia and muscle attachments, abdominal muscles, diaphragm • Upper extremity • Scapular and latissimus dorsi attachments • Lumbars • Local problem • Pelvis and sacrum • Local problem • Lower extremity • Fascial and muscle attachments to ilia and sacrum

20. Examination for AGR • Based on the third principle of physiologic spinal motion • When motion is induced in one plane, movement in the other two planes is decreased. • We will induce motion in one plane • This will restrict motion into the other two planes • Then we will induce motion into the other two plane • If you induce motion into a second plane, it also restricts motion in the other two planes • This will achieve what is called a physiologic lock. • A normal joint will still have joint play, a small ability to move. • A restricted joint will not have the ability to spring.

21. Problem-based Local Approach Based on the knowledge that certain problems have local solutions • You can always go back to the global approach • Weakness: forming the habit of relying only on the local approach • The local approach is more reductionist, and therefore doesn’t always treat the cause of the problem

22. Local approach • Focused exam on a problem region and it’s autonomic connections • Analyze: • is there a biomechanical problem? • is there a problem with fluid flow? • are there autonomic imbalances that you can treat to improve the patient’s condition? • Choose: • a model of diagnosis and treatment to treat, depending on the condition of the patient • Counterstrain - Still • MFR - Muscle Energy • HVLA

23. Model of Dx and Tx • Depends upon the patient! • Options for frail and/or elderly: • Counterstrain • Myofascial release technique (MFR) • Craniosacral technique (Still) • Muscle energy technique • requires patient effort • High velocity low intensity - HVLA • VERY cautiously, rarely best

24. Pain Dyspnea, secretions Disorders of the CNS Gastrointestinal symptoms Fluid retention Disorders of skin and mucous membranes Common problemsat the End of Life

25. Dyspnea • Thoracic-sympathetic connection: improve cardio-vascular and respiratory systems • Upper thoracics normalization: indirect MFR • Musculoskeletal system • Coughing, loss of muscle mass • Rib dysfunction • Mechanical structures • Diaphragm

26. Dyspnea Treatment • Cervical treatment • OA decompression • C 3/4/5: Phrenic nerve • OA, AA: Vagus • Rib dysfunction • Diaphragm • Doming it • Indirect treatment • Thoracic sympathetic connection

27. Dyspnea • Autonomics • Cervical Treatment: OA decompression • C 3/4/5 – phrenic nerve • OA, AA – vagus nerve • Ligamentum nuchae – MFR • Suboccipital release: slight compression/traction; let gravity do the work • CV- VI: “reset” button for autonomics

28. Ligamentum Nuchae Regional Technique A useful technique for balancing more than two segments, or to address the general connective tissue for the posterior neck. • Sit at the head of your supine patient. • Cradle the patient’s occiput in the palm of one hand. • Use your other hand to grasp the posterior neck. Your thenar/hypothenar eminences are on one side, your fingerpads at the contralateral articular pillars. • Use motion testing to determine and place the patient in the position of ease, as determined by decreased tissue tension, for the connective tissue: F/E, S, and R

29. Ligamentum Nuchae Regional Technique • You may use the following activating forces: • Respiratory cooperation • Release enhancing maneuvers • Slight compression, traction, or torque • Follow the changing tissue tension in the direction of its relaxation, taking the tissue toward the decreased tension. • When the tissue stops relaxing, slowly return the patient to neutral • Retest for resolution of TART criteria for somatic dysfunction.

30. Ligamentum Nuchae

31. Suboccipital Release • Sit at the head of your supine patient • Place your finger pads against the inferior occiput so that your fingertips are approximately at the atlas. • Your palms are underneath the occiput, but it is initially suspended above them. • Allow the weight of the patient’s head to create the release • Enhance the release with use of traction, compression, or by initiating micro-motion and following the progressive tissue relaxation as it occurs • The occiput gently settles into your palms as the release occurs. • Retest the area for TART resolution.

32. C3-7 Segmental Technique • Sit at the head of your supine patient. • Diagnose the key dysfunction (e.g., C4 ESRRR). • Contact the articular pillars of the dysfunctional segment with the pads of your long fingers. • Induce F/E, then S, then R to match the direction in which the vertebra is already drawn by the tissue (go indirect). Use translation to achieve sidebending. • To enhance the release, you may use activating forces. • Continue until the desired tissue response is obtained, then slowly return to neutral • Retest for TART resolution.

33. C3-7 Segmental Technique

34. Segmental Release

35. Gastrointestinal problems • N/V, diarrhea, ileus cause autonomic effects; attempt to “damp down” • General Treatment • upper thoracics • vagus nerve (OA, AA) • T 5-9 • Diarrhea and constipation • Thoracic and lumbar – sympathetics • Sacral – autonomics • Abdominal treatment • Nausea caused by CMTRZ will require meds

36. Gastrointestinal Problems Treatments • Occipitomastoid decompression • Vagus Nerve OA, AA • Thoracic and Lumbar sympathetic connections • Sacral autonomic connections • Abdominal treatment • Inhibition • Facilitation

37. General Autonomic Reset • CV IV • Lumbosacral decompression

38. Extremities • Evaluation of limitation of motion • Flexion • Extension • Adduction • Abduction • Rotation • Shoulders: bursitis, adhesive capsulitis, or disuse syndromes.

39. Edema fluid • Lymphatic Pump • Can be done easily at the bedside • Mobilization of the patient • To the extent possible • May actually help reduce overall pain

40. Additional Principles • Give patients hope • But not false promises • Help them to have a sense of at least some control over their pain • If you’re using the global osteopathic approach: • Explain to patients why you may not treat the area of greatest complaint • Do at least something with the area of greatest complaint • A number of patients do not wish to take more medicine, but they do want to feel better • Some have difficulty tolerating medication • You may have to talk them into more medication

41. The Last Days: The Actively Dying Patient • Pain is addressed by medication • Some pain is poorly addressed by medication • Rib pain with inspiration • General autonomic treatment