Osteopathic Evaluation & Treatment The Patient with Respiratory Dysfunction

1. Osteopathic Evaluation & Treatment The Patient with Respiratory Dysfunction Developed for OUCOM CORE by Craig Warren, D.O. Edited by Clay Walsh, D.O. and the CORE Osteopathic Principles and Practices Committee Session #6 - Series B

2. Objectives • Understand viscerosomatic reflexes as they relate to the respiratory system • Discuss the sympathetic and parasympathetic innervation of the respiratory tract • Properly document somatic dysfunction and OMT in the hospital chart • Demonstrate OMT that may favorably influence the somatic, lymphatic, and autonomic components of respiratory disorders.

3. Find any S/D that may be related to the visceral dysfunction or significantly effect the body in some way as to impede homeostasis Sympathetics Parasympathetics Respiration and Circulation Related structural mechanics Mobility and motility of the viscera Goals of Structural Examination in Visceral Dysfunction

4. Normalize sympathetic tone to that viscera. Normalize parasympathetic tone to that viscera. Improve venous and lymphatic return. Improve the mechanical function of the contiguous structures. Improve the mechanical environment of the viscera for visceral mobility and motility. Remove any structural hindrance to respiration and circulation. Goals of OMT in Visceral Dysfunction

5. Heart & Lungs T1-T5 Autonomics to the Respiratory System

6. Cervical Sympathetic Chain Ganglia are associated with: C2 C6 C7 www.anatomy.tv Cervical Sympathetic Ganglia Superior cervical ganglion Middle cervical ganglion Inferior cervical ganglion

7. Neurolympatic Reflex which results in visceral dysfunction being manifested as a palpable knot in a somatotopic pattern. Used both diagnostically and therapeutically Chapman’s Reflexes:Anterior Reflex Points page 232 of Osteopathic Considerations in Systemic Dysfunction 2nd & 3rd editions by Michael Kuchera, D.O.

8. Chapman’s Reflexes:Posterior Reflex Points page 233 of Osteopathic Considerations in Systemic Dysfunction 2nd 3rd editions by Michael Kuchera, D.O.

9. Lymphatic Return Osteopathic Considerations in Systemic Dysfunction 2nd & 3rd editions by Michael Kuchera, D.O pgs. 39 &40

10. Primary Elastic Recoil Secondary Muscles of Respiration Rectus abdominus Internal Intercostals External Obliques Transversus abdominus Mechanism of Expiration

11. Primary: Diaphragm Attaches to lower 6 ribs Attaches to lumbar vertebra and fascia of psoas major and quadratus L. post Continuous with the pericardial fascia which attaches to T3 and T4 Secondary: External intercostals – lift the rib SCM – lift the sternum Scalenes – lifts ribs 1 &2 Mechanism of Inspiration –Muscular Activity

12. Cervicals C3-C5 (Phrenic Nerve) Sternum T1-12 and Ribs 1-12 (Somatic Nerves and Mechanisms of Respiration) Thoracolumbar Junction (Diaphragm) OPP for the Lower Respiratory Tract Patient Somatic Dysfunction Facilitated Segment Sympathetics Parasympathetics Rib Raising T1-T6 Chapman’s Reflexes OPP for the LRT Patient OA, AA, Cranial Vagus Nerve Lymphatics/Circulation Thoracic Inlet Rib Raising Abdominal/Pelvic Diaphragm Lymphatic Pumps

13. Cervicals C3-C5 (Phrenic Nerve) Sternum T1-12 and Ribs 1-12 (Somatic Nerves and Mechanisms of Respiration) Thoracolumbar Junction (Diaphragm) Medial pterygoids Hyoid Soft Tissues OPP for the Upper Respiratory Tract Patient Somatic Dysfunction Facilitated Segment Sympathetics Parasympathetics OPP for the URT Patient Rib Raising T1-T6 Chapman’s Reflexes C2, C6, C7 OA, AA, Cranial Sphenopalatine Ganglion Lymphatics/Circulation Thoracic Inlet Rib Raising Abdominal/Pelvic Diaphragm Lymphatic Pumps/Effleurage

14. Remember a Rule of 3’s Any physician, any patient, any setting 3 Minutes 3 Area 3 Techniques Integrate OPP Into Your Standard Medical Care

15. Patients with S/D at C3-C4 Greater incidence of post-operative pulmonary complications 109 patients undergoing upper abdominal surgery Patients had S/D at C3-C4 OMT vs Sham-OMT randomization Sham-OMT had 16 times the incidence of post-operative complications OPP Research Henshaw. The D.O. September 1963, pages 132-133

16. Henshaw’s Study • Association of C3-C5 S/D with Post-operative Complications

17. Surgical Populations with Pre-op C3-C5 Somatic Dysfunction Henshaw’s Study 109 Cases OMT Prior to Surgery Sham -OMT Prior to Surgery 3 / 5 Cases 29/34 Cases 5.3 % 85.3 % Post-op Pulmonary Complication Post-op Pulmonary Complication

18. 58 elderly patients (>60 yrs) hospitalized with CAP Two treatment groups All received standard medical care Experimental group – OMT for 10 -15 minutes BID Control group – Sham OMT for 10-15 minutes BID OPP Research: Pneumonia Noll DR, Sholes JH, Gamber RG, Slocum PC. The efficacy of adjunctive OMT in the elderly hospitalized with pneumonia. JAOA 98(7):389. 1998

19. Noll et al Research: Pneumonia Conclusions: Adjunctive OMT reduces significantly the duration of IV antibiotics and the length of hospital stay of the elderly patient with community acquired pneumonia

20. Lower Respiratory Tract Osteopathic Manipulative Treatment

21. Patient: seated, supine or reclining position Physician: Hand position Anterior hand at sternomanubrial junction Posterior hand spans T2-T5 Action: Slight AP Compression Engage indirect barrier (ease) Superior/Inferior Shear Right/Left Lateral Shear Clockwise/CCW Torque Reaction: Hold with constant force or constant stretch until the tissues release (increased motion or decreased resistance to your force) Goal: Normalize sympathetics and improve the mechanics of respiration General MFR of Thoracic Cage

22. Patient: Supine Physician: Seated at patient’s head; hands under thorax with fingers contacting the TP of the vertebra to be treated Action: Fingers will push on TP to engage the direct or indirect barrier Anterior to rotate Cephalad to flex Caudal to extend CW or CCW torque to SB Release: Hold at direct or indirect barrier with constant force until stretch stops or hold with constant stretch until the force becomes constant. Goal: Mobilize thoracic vertebral segment, normalizing sympathetics and improving the mechanics of respiration MFR: Thoracic Vertebra

23. Patient: Seated Physician: Stands in front of patient; Hands at the rib angles Action: Pull the patient towards you extending the thoracic spine and “raising” the ribs. Reposition hands segmentally up the spine and repeat Release: Increased motion of thoracic spine and ribs Goal: Normalize sympathetics and improve the mechanics of respiration Rib Raising: Normalizing Sympathetics

24. Patient: Supine Physician: Seated at patient’s side. Both hands under thorax (palms up) with fingers perpendicular to the table and pushing up on the angles of the ribs Action: Using wrist and forearm as a fulcrum, cyclically lift up on the ribs so as to lift the thorax on that side. Hold for 3-5 seconds and let back down. Repeat for 30 seconds on each side. Release: Increased motion of thoracic spine and ribs Goal: Normalize sympathetics and improve the mechanics of respiration Rib Raising: Supine Position

25. Patient: Supine or Reclining Physician: Seated at the head of the table, hold the occiput in your palms, curling your fingers up to meet the O/A junction. Action: Flex your wrists so that the weight of the head rests on your fingertips. Release: Muscles and fascia will relax with time. Goal: Normalize parasympathetics via Vagus Nerve Suboccipital Release: Normalizing Parasympathetics

26. Patient: Supine or reclining position Physician: Hands under the neck with pads of middle fingers in contact with the posterior surface of the lateral pillars Action: Lift head to flex or extend the segment and use pads of fingers on lateral pillars to side bend and rotate the segment Engage the indirect barrier Flex/Extension Side bending Rotation Release: Hold at the indirect barrier with either constant force or constant stretch until the tissues release (increased motion or decreased resistance to your stretch) Goal: Reduce any irritation to Vagus Nerve, Phrenic nerve or Cervical Chain Ganglia and improve the mechanics of respiration MFR of Cervical Spine

27. Patient: Supine, seated or reclining position Physician: Hands encircle the thoracic inlet Action: Engage indirect barrier (ease) Side bending Clockwise/CCW rotation Release: Hold at the indirect barrier with either constant force or constant stretch until the tissues release (increased motion or decreased resistance to your stretch) Goal: Improve the mechanics of respiration and remove restrictions to lymphatic flow Thoracic Inlet Release

28. Patient: Supine or reclining position Physician: Anterior hand is just inferior to xiphoid; Posterior hand at thoracolumbar junction Action: Slight A/P Compression Engage Indirect Barrier (ease) Clockwise/CCW Rotation Release: Hold with constant force or constant stretch until the tissues release (increased motion or decreased resistance to your stretch) Goal: Improve the mechanics of respiration and remove restriction to lymphatic flow. MFR: Abdominal Diaphragm

29. Patient: Supine or reclining position Physician: Anterior hand is just superior to pubes; Posterior hand under the sacrum Action: Slight A/P Compression Engage Indirect Barrier (ease) Clockwise/CCW Rotation Release: Hold with constant force or constant stretch until the tissues release (increased motion or decreased resistance to your stretch) Goal: Improve the mechanics of respiration and remove restriction to lymphatic flow. MFR: Pelvic Diaphragm

30. Patient: Supine Physician: Stands at patient’s head; Palmar surface of hands on upper Chest with thumbs on the sternum and fingers in axilla. Action: Have patient take deep breaths. Resist the chest expansion in inhalation and compress the chest during exhalation. Repeat 3-4 cycles. On last cycle quickly slide hands off the chest at the peak of inhalation causing a “gasp” Goal: Improve the mechanics of respiration and remove restriction to lymphatic flow. Lymphatic Pump:Chest Compression

31. Patient: Supine Physician: Standing at patient’s feet; Palms on ball of foot Action: Rhythmic Flexion (or extension) at ankles. Effective rhythm causes a rhythmic “sloshing” of the belly. Goal: Mobilize lymphatic fluid from the lower extremities and lower trunk into central circulation Pedal Lymphatic Pump

32. Patient: Supine Physician: Standing at patient’s head Action: Hands grasp the pectoralis muscles at the axillary fold and lean back putting a stretch on the muscles. Have patient take deep breaths. On inhalation pull on the muscles and with exhalation hold the tension. Repeat 3-4 cycles Goal: Stretch and release the pectoralis muscles facilitating lymphatic flow back to central circulation Pectoral Traction for Lymphatic Drainage

33. Upper Respiratory Tract Osteopathic Manipulative Treatment

34. Transverse Sinus Straight Sinus Superior Sagittal Sinus Metopic Suture Venous Sinus Drainage

35. Patient: Supine with effected ear up Physician: Standing at the patient’s head Action: One hand stabilizes the head at the frontal bone while the other grasps the angle of the mandible on the effected side. Rhythmically draw the mandible anteriorly and release. Repeat for 1 minute Goal: Facilitate eustachian tube drainage and aeration of middle ear Galbreath Mandibular Drainage Technique (Eustachian tube dysfunction & Otitis Media)

36. Patient: Supine Physician: Standing at patient’s head with gloved hand. Slide fifth finger posteriorly past the last upper molar letting the tip of the finger go medial and superior into the Sp-Pal fossa where you contact the SPG (will be very tender) Action: Push on SPG for 3 seconds and release. Repeat 3 times Goal: Stimulate the parasympathetic output to the URT Sphenopalatine Ganglion Stimulation(Used for any URI)

37. The End QUESTIONS ?