SAAO Convocation - March 14th, 2019Victor Nuño, D.O., C-ONMM, C-IM

Touro University California College of Osteopathic MedicineAssociate Professor, Department of OMM

The ABC’s of Osteopathic Medicine:

How to organize your patient approach

Osteopathic Philosophy

OMT

What makes osteopathic physicians unique?

Most D.O.’s utilize OMT less than 5% of the time?

ONMM & Family Medicine D.O.’s most likely to utilize OMT

Conditions and diagnoses for which osteopathic primary care physicians and specialists use osteopathic manipulative treatmentSM Johnson; ME Kurtz

The Journal of the American Osteopathic Association, October 2002, Vol. 102, 527-540.

How much is OMT being utilized in practice?

● Time● Practice protocol● Training deficiencies● Attitudes● Not sure where to start● Comfort level in application● Patient unfamiliarity

What barriers exist to OMT utilization?

For what type of issue/complain is OMT most often used?

Conditions and diagnoses for which osteopathic primary care physicians and specialists use osteopathic manipulative treatmentSM Johnson; ME Kurtz

The Journal of the American Osteopathic Association, October 2002, Vol. 102, 527-540.

“I don’t know how to treat that”

-Every medical student I ever trained

Solution came from the problem

What’s the issue then?

-Application of principles to novel situations-Think quickly, under pressure-Rely on basic understandings with firm foundational knowledge

Often, you do know the solution already

A framework for:

● Where to look for somatic dysfunction ○ to optimally treat any patient with any condition

● A way to organize treatment ○ based on treatment objective

What are the ABC’s?

AUTONOMICS

BIOMECHANICS

CIRCULATION

SCREENING

The ABC’s are:

Assess and treat areas of autonomic influence

Ex: sinusitis

● Sympathetic: T1-T5● Parasympathetic: OA, AA, C2, cranium

AUTONOMICS

ORGAN SYMPATHETIC PARASYMPATHETIC

Head and Neck T1-T5 Vagus Nerve (also CNIII, VII, IX)

Heart T1-T5 Vagus Nerve

Lung T2-T5 Vagus Nerve

Lower Esophagus / Stomach T5-T10 Vagus Nerve

Liver and Gallbladder T6-T9 Vagus Nerve

Small Intestine T9-T11 Vagus Nerve

Ascending / transverse colon T11-L1 Vagus Nerve

Descending and Sigmoid colon/rectum

L1-L2 S2-S4

Kidney T10-L1 Vagus Nerve

Ovary/Testes T9-T11 S2-S4

Uterus T12-L1 S2-S4

Cervix T10-L2 S2-S4

Autonomic function is essential to physiologic processes

Autonomic dysfunction exacerbates or is contributing factor to ANY medical condition

How does it do this?

Why AUTONOMICS first?

Primary Afferent Nociceptors● Widely distributed throughout tissues of the body● Chemical, thermal, and mechanical (proprioceptors)● Synapse in spinal gray matter

● Increased input of receptors cause upregulation of interneurons

● Upregulation of interneurons, can upregulatesympathetic efferents

Somatic Dysfunction AutonomicNervous System Connection

Pickar, 2002

Most of what we teach/learn

Ex: Low Back Pain

● Hamstring tightness● Pubic tubercle symmetry● Innominate shears● Sacral dysfunctions● Innominate rotations● Innominate flares

● Also, distal connections - cranium, cervical/thoracic spine, upper/lower extremity; tenderpoints

BIOMECHANICS

“how mechanical forces applied during osteopathic manipulative treatment could lead to effects at the cellular level…”

Biotensegrity

Biotensegrity: A Unifying Theory of Biological Architecture With Applications to Osteopathic Practice, Education, and Research—A Review and Analysis. Swanson RL, DO, PhD. JAOA Jan 2013

Biomechanical applications of OMT in ● Asthma● CHF● GERD● UTI

CIRCULATION

Assess and treat areas of arterial, venous, and lymphatic influence

Ex: sinusitis

● Arterial● Venous● Lymphatic

○ Diaphragms - Thoracic Inlet, Thoracoabdominal, pelvic, etc. .

● Remember to treat terminal drain first (Thoracic inlet)!

● Under sympathetic control

● Lymphatic flow dramatically increased with thoracic/abdominal pumps

● Osteopathic lymphatic pump techniques enhance immunity

Lymphatics

Lymphatic Pump Treatment Mobilizes Bioactive Lymph That Suppresses Macrophage Activity In VitroRudy Castillo, BS; Artur Schander, MS, DO, PhD; Lisa M. Hodge, PhDJAOA, July 2018, Vol. 118, 455-461.

● LPT significantly increased ○ TDL flow and protein flux in TDL (P<.001)

● LPT significantly decreased ○ NO2−, TNF-α, and IL-10 by macrophages (P<0.01)

Conclusion: The redistribution of protective lymph during LPT may provide scientific rationale for the clinical use of LPT to reduce inflammation and manage edema.

Recent Scholarly Activity

Lymphatic Pump Treatment as an Adjunct to Antibiotics for Pneumonia in a Rat ModelLisa M. Hodge, PhD; Caitlin Creasy, MS; KiahRae, Carter, MS; Ashley Orlowski, BS; Artur Schander, DO, PhD; Hollis H. King, DO, PhDJAOA, May 2015, Vol. 115, 306-316.

● LPT and levofloxacin significantly reduced CFU compared with sham therapy and levofloxacin ○ Decreased bacterial load at 72 and 96 hours after infection (P<0.05)

Conclusion: The results suggest that 3 applications of LPT induces an additional protective mechanism when combined with levofloxacin and support its use as an adjunctive therapy for the management of pneumonia; however, the mechanism responsible for this protection is unclear.

Recent Scholarly Activity

SCREENINGReminder to look at the whole person and treat the whole body

Various methods of screening

○ Zink○ Mitchell Model○ Tenderpoints○ Fascial pull○ Mind, body, spirit

Explored further in lab

Low Back Pain

Asthma

CHF

Urinary Tract Infection

GERD

Application of the ABC’s

*ABC’sof Low Back Pain

*Autonomics:* PANS: S2-S4* SANS: T12-L2

*Biomechanics:*Lumbar spine *Sacrum/pelvis* Thoracic spine* Thoracoabdominal Diaphragm

*Circulation:*Pelvic diaphragm*Thoracoabdominal Diaphragm * Thoracic inlet

*Screen:* Zink Screen* Mind, Body, Spirit Connection* Behavioral Contributions

Sympathetics● T10-L2

○ Mechanical, thermal, and chemical input from ■ Lower extremities, pelvis, sacrum, lumbar, and thoracic spine

○ somato-somatic facilitation● Compromises blood flow to and reduces nutrient/medication delivery to:

○ Muscles, ligaments, bones, synovium, fascia

Parasympathetics■ S2-S4

● Mechanical, vascular, and lymphatic congestion/dysfunction can increased nociceptive input

AUTONOMICS of LBP

BIOMECHANICS of LBPLumbar spine

● Somatic dysfunction can sensitize interneurons leading to facilitation● Muscle may spasm as a (initially) protective mechanism● Strained ligaments● Trauma

Sacrum/Pelvis● Intricately related to low back pain● Trauma

Thoracic spine motion● Group dysfunctions causing lumbar strain● Fascial and muscular connections

Diaphragms● Thoracoabdominal and pelvic diaphragms through direct/indirect connections

Circulation of LBPArterial supply

● Dorsal branches of the embryonic intersegmental somatic arteries

Venous drainage● Vertebral column veins form intricate plexuses along the entire column, external

and internal to the vertebral canal○ no valve, freely anastamose○ communicate with cranial dural venous sinuses○ Transmit pressure

Lymphatic drainage● Deep lymphatic vessels tend to follow the arteries

○ Lateral aortic and retro-aortic nodes● Drain to cisterna chyli and thoracic duct

● Thoracic inlet -> TA diaphragm -> pelvic diaphragm

Screening for LBPZink ScreenConsider places where fluid may become restricted at mechanical diaphragms

TenderpointsAnterior lumbar, posterior lumbar, sacrum/pelvic points

Mitchell ModelImproving metabolic efficiency and decreased energy requirements and increases exercise capacity via normalizing proper alignment and function of the sacrum and pelvis

● Dirty Half Dozen (Greenman)o Pubic Shearo Innominate Shearo Leg length discrepancy (sacral base un-leveling)o Backward Sacral Torsiono Muscle Imbalance (lower crossed or psoas syndrome)o Non-neutral lumbar spine Type II somatic dysfunction

Mind, Body, Spirit● Recognize and change potentially destructive habits● SMART goals - exercise example

○ Specific - walk 15 minutes daily○ Measurable - track time ○ Attainable - realistically can walk for 15 minutes, physically able○ Relevant - increasing exercise is a vital part of plan○ Time-sensitive - I will start this program tomorrow

*ABC’sof

Asthma

*Autonomics:* PANS: Vagus* SANS: T2-T6

*Biomechanics:* Ribs* Cervical/Thoracic spine* Sternum/Clavicles* Thoracoabdominal Diaphragm

*Circulation:*Thoracic inlet*Thoracoabdominal Diaphragm

*Screen:* Zink Screen* Mind, Body, Spirit Connection* Behavioral Contributions* Posture

Sympathetics● T2-T6

○ Sympathetic chain ganglia lie anterior to rib heads● Vasoconstriction -> hypoperfusion of alveoli ● Epithelial hyperplasia (increase in Goblet cell, sticky secretions)● Initially, dilation of bronchial tubes, effect eventually wanes

Parasympathetics■ Vagus nerve

● Bronchodilation● Because of congestion/obstruction

● Shallow rapid breathing

AUTONOMICS of Asthma

BIOMECHANICS of AsthmaRib motion

● Often restricted globally● With hyperinflation, may see many inhaled ribs

Thoracic spine motion● Dysfunctions with “sticky” end-feel♦ (Viscero-somatic)

Type 1 vs. type 2 dysfunctions

Thoracicoabdominal diaphragm● May be flattened and needing to be re-domed

Cervical Spine● Especially C3-C5 (Phrenic)● Hypertonic scalene muscles

Sternum motion● Typically motion is very limited

Circulation of AsthmaArterial supply

● Bronchial arteries from systemic circulation

Venous drainage● Considerable variation

Lymphatic drainage● Superficial and deep plexuses

○ Anastomose peripherally and at hilum○ No lymph vessels in alveoli○ Lack of drainage = organ pathology

● Thoracic inlet -> TA diaphragm -> pelvic diaphragm

Screening for AsthmaZink ScreenConsider places where fluid may become restricted at mechanical diaphragms

Chapman’s Points● Anterior

○ 2nd intercostal space -> bronchus○ 3rd intercostal space -> upper lung○ 4th intercostal space -> lower lung

● Posterior○ between SP and TP of T3 posteriorly

Mitchell ModelIpsilateral innominate for unilateral

Mind, Body, SpiritJournaling - 20 minutes daily for 3 daysBreathing Exercises (Buteyko, Yoga, Physical Therapy)Yoga - 14 randomized trials show: ● Improvements in asthma control, quality of life, peak expiratory flow rates, and the ratio of

forced expiratory volume in 1 second compared to psychological interventions.

*ABC’sof

CHF

*Autonomics:* PANS: Vagus* SANS: T1-T6

*Biomechanics:* Ribs* Thoracic spine* Sternum/Clavicles

*Circulation:*Thoracic inlet*Thoracoabdominal Diaphragm *Pelvic diaphragm

*Screen:* Zink Screen* Mind, Body, Spirit Connection* Behavioral Contributions

Sympathetics● T1-T6

○ Right side- SA node, Left side- AV node○ “Increased sympathetic tone increases morbidity following myocardial

infarction, it inhibits the development of collateral circulation, and it can adversely affect the degree of recovery from myocardial injury.”

● Can lead to ○ Coronary vasospam○ Increased heart rate○ Atrial fibrillation○ Vasocontriction

Parasympathetics● Vagus

○ Slow heart rate○ Constrict coronary arteries

AUTONOMICS of CHF

BIOMECHANICS of CHFRib/Diaphragm motion

● Improves respiratory effort● Improves diaphragm movement for respiration and fluid movement

Thoracic spine motion● Improves respiratory effort● Improves viscerosomatics

Sternum motion● Improves respiratory effort

Intrathoracic Fascia• Improve motion of heart

Circulation of CHFArterial supply

● Coronary arteries

Venous drainage● Pericardial and myocardial veins

○ Drain to coronary sinus

Lymphatic drainage● Subendocardial, myocardial, and subepicardial plexuses

○ Drain to right and left lymphatic ducts○ Cardiac lymphatic dysfunction important etiology in cardiac disease

Caution: take care to not overload the heart if in severe heart failure

Thoracic inlet -> TA diaphragm -> pelvic diaphragm

Screening for CHFZink ScreenConsider places where fluid may become restricted at mechanical diaphragms

Chapman’s Points2nd intercostal space anteriorly, between SP and TP of T3 posteriorly

Mitchell ModelImproving metabolic efficiency and decreased energy requirements and increases exercise capacity via normalizing proper alignment and function of the sacrum and pelvis

Upper Crossed PostureInhibited or facilitated muscles could be upregulating sympathetic innervation to the heart

Mind, Body, SpiritSignificant cardiac effects from anger, stress, anxiety, lonelinessMore MI’s in am, Monday’s, winterReligious involvement has less cardiovascular disease and cardiovascular mortality

*ABC’sof

UTI

*Autonomics:* PANS: S2-S4* SANS: T10-L2

*Biomechanics:* Bladder* Sacrum/Pelvis* Thoracic/Lumbar Spine

*Circulation:*Thoracic inlet*Thoracoabdominal diaphragm *Pelvic diaphragm

*Screen:* Zink Screen* Mind, Body, Spirit Connection* Behavioral Contributions* Posture

Sympathetics● T10-L1

○ Lowest thoracic and first Lumbar splanchnic nerves● Vasoconstriction of afferent arterioles, decreased GFR, decreased urine volume,

decreases ureteral peristaltic waves (can cause ureteral spasm)

Parasympathetics● Kidney

○ Vagus● Proximal ureter

○ Vagus● Distal ureter

○ S2-S4 via pelvic splanchnics● Bladder

○ S2-S4 via pelvic splanchnics

● Effect is unclear (counterbalance sympathetics?)

AUTONOMICS of UTI

BIOMECHANICS of UTIKidney motion

● <1cm with respiration● Motion not uniform, why?

Iliolumbar ligament● Postural decompensation can cause masquerading pain

Diaphragm motion● Dyssynchronous motion increases intrapelvic pressure, urinary reflux● Pelvic floor tension can lead to dysuria/polyuria

Pelvis● Pubic symphysis tension or pubovesicular ligament dysfucntion ->

○ Dyuria/polyuria

Circulation of UTIArterial supply

● Renal arteries○ Branch directly from aorta

Venous drainage● Renal veins

Lymphatic drainage● Renal lymphatic vessels

○ Coalesce at hilum drain to thoracic duct○ Vessels can dilate 300% to protect renal capsule and parenchyma

● Synchronous motion of ○ thoracoabdominal diaphragm and thoracic inlet is vital to drainage

● Thoracic inlet -> TA diaphragm -> pelvic diaphragm

Screening for UTIZink ScreenConsider places where fluid may become restricted at mechanical diaphragms

Chapman’s Points● Anterior

○ Kidney■ 1 in lateral and 1 in superior to umbilicus bilaterally

○ Bladder■ Inverted triangle around umbilicus

● Posterior○ Kidney

■ Intertransverse space between T12 and L1 (bt TP and SP)○ Bladder

■ Upper edge of the transverse process of L2

Mitchell ModelIn addition to pubic tubercles, other pelvic dysfunctions may be contributing to symptoms

Mind, Body, SpiritBehaviors thought to increase risk of UTI

● intercourse, tight clothing, holding urine, irritants (douch, soaps, etc.)Biofeedback decreases incidence of recurrent UTI’s

*ABC’sof GERD

*Autonomics:* PANS: Vagus- OA-C2* SANS: T5-T9

*Biomechanics:* Stomach * Esophagus* Thoracoabdominal Diaphragm (LES, Right crus of the diaphragm)

* Lumbar spine (crura attach here)* Hiatal Hernia

*Circulation:* Diaphragm* Thoracic inlet

*Screen:* Zink Screen* Mind, Body, Spirit Connection* Behavioral Contributions

Sympathetics● T5-T12

○ Via greater and lesser splanchnic nerve, celiac plexus● Decreases mucosal defenses against digestive acids via vasocontriction● Nociceptive signals are conveyed by sympathetic & vagal afferents

○ Mechanosensory signalling

Parasympathetics● Vagus nerve

○ Left = greater curvature○ Right = lesser curvature

● Increases secretion of glands

AUTONOMICS of GERD

BIOMECHANICS of GERD

Stomach/Esophagus● Exhaled (superior)♦ pulls cardiac portion of stomach through sphincter -> hiatal hernia

Thoracoabdominal diaphragm● Crura intricately related to esophagus

Thoracic spine motion● Restriction can be “sticky” in quality suggesting viscero-somatic reflex

Lumbar spine motion• Crural attachment, anchor

Circulation of GERDArterial supply

● Left gastric artery branches, thoracic aorta○ Branch directly from aorta

Venous drainage● Left gastric, short gastric, azygous/hemiazygous● GE junction -> anastomosis of portosystemic systems

Lymphatic drainage● Small channels into cisterna chyli, between right crus and aorta● Cisterna chyli drains to thoracic duct

● Thoracic inlet -> TA diaphragm -> pelvic diaphragm

Screening for GERDZink ScreenConsider places where fluid may become restricted at mechanical diaphragms

Chapman’s Points● Anterior

○ Esophagus■ Intercostal space between 2nd and 3rd ribs, close to sternum

○ Stomach (acidity)■ 5th intercostal space (bt 5th and 6th rib)

● Posterior○ Esophagus

■ T2 -> midway between SP and TP○ Stomach (acidity)

■ Intertransverse space between T5-T6 -> midway between SP and TP

Mind, Body, Spirit● Lifestyle modifications like quitting smoking and losing weight (if overweight/obese)● Avoid foods that relax LES

○ Alcohol, chocolate, coffee, cow’s milk, fat, orange juice, spicy foods, tea, tomato juice● Avoid large meals or meals too close to bedtime● Increase HOB by 4-6 inches (under bed, not pillows)● Exercise -> weight loss, but also direct effects improving digestion

● Mnemonic trigger to help think of OMT○ Where to treat○ Why to treat○ By what mechanism

● Overlap treatments

○ Often treating 1-2 dysfunction can satisfy all ABC’s

● Examples○ Thoracic inlet○ Rib raising○ Suboccipital release○ Pelvic (Mitchell Model)

Summary

OMT for ALL(Allostatic Load Lowering)

Pilot/feasibility study● 2 MSMHS students (high stress)● 11 biomarkers before and after● 3 OMT sessions 2 weeks apart (utilizing ABCs as Protocol)● Biomarkers tested

○ Anthropometric: BMI, waist-to-hip, diastolic/systolic blood pressure○ Trier Inventory for the Assessment of Chronic Stress ○ Blood: HDL, HS-CRP, HgA1C, DHEA ○ Urine: Cortisol, Dopamine, Norepinephrine, Epinephrine

Juster et al 2010.

OMT for ALL Data

AL Biomarker High Risk Cutoff Value OO1 OO2

Pre-intervention Post-intervention Pre-intervention Post-intervention

HDL ≥ 40 mg/ dL 1 0 0 0

DHEA ≥ 15.8 µg/g Cr for premenopausal women, ≥ 15.8 µg/g Cr for men

0 0 0 0

hsCRP < 3 mg/L 0 0 1 1

HbA1c < 6% 0 0 0 0

Diastolic BP < 80 mmHg 0 0 1 0

Systolic BP < 130 mmHg 0 0 1 0

BMI ≤ 18.5 for men, ≤ 24.9 for women 1 1 0 0

Waist to hip ratio 0.94 0 0 0 0

Cortisol < 29.5 µg/g Cr (1st A.M.), 68.9 µg/g Cr (2nd

A.M.),19.2 µg/g Cr (evening), 8.4 µg/g Cr (night)

1 2 3 2

Norepinephrine < 22 µg/g Cr (1st A.M.), 38.2 µg/g Cr (2nd

A.M.), 42.9 µg/g Cr (evening), 38.8 µg/g Cr (night)

2 1 2 3

Epinephrine < 1.5 µg/g Cr (1st A.M) ,6.1 µg/g Cr(2nd

A.M.), 8.1 µg/g Cr( evening), 4.2 µg/g Cr (night)

2 0 1 1

AL Score 7 4 9 7

OMT for ALL Data

Specific techniques addressing the ABC’s of

Low Back Pain

Asthma

CHF

Urinary Tract Infection

GERD

Lab

Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 41st edition. Susan Standring. Elsevier, 2016.-Chapters on lumbar spine, lungs, heart, kidney, stomach, and esophagus

Integrative Medicine, 4th edition. David Rakel. Elsevier, 2018.Chapters on Low back pain, asthma, heart failure, UTI, and GERD

Smyth J.M., Stone A.A., Hurewitz A., and Kaell A.: Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis. JAMA 1999; 281: pp. 1304-1309

Cowie R., Conely D., Underwood M., et al: A randomized controlled trial of buteyko technique as an adjunct to conventional management of asthma. Respir Med 2008; 102: pp. 726-732

References

Systemic Considerations in Somatic Dysfunction, 2nd edition. Kuchera & Kuchera. Greyden Press 1994. KUB pgs 124-128.

An Endocrine Interpretation of Chapman’s Reflexes. Charles Owens, D.O. American Academy of Osteopathy. 2002

Radiat Oncol. 2013; 8: 248.Published online 2013 Oct 26. doi: 10.1186/1748-717X-8-248PMCID: PMC3829388PMID: 24160868An analysis of respiratory induced kidney motion on four-dimensional computed tomography and its implications for stereotactic kidney radiotherapyShankar Siva,corresponding author#1,2,6 Daniel Pham,#3 Suki Gill,1 Mathias Bressel,4 Kim Dang,3 Thomas Devereux,3 Tomas Kron,2,5 and Farshad Foroudi1,2

References

Goyal R.K.: Diseases of the esophagus. In Kasper D.L., Braunwald E., and Fauci A.S. (eds): Harrison’s principles of internal medicine, ed 16. New York: McGraw-Hill, 2004.

Hershcovici T., and Fass R.: Gastro-oesophageal reflux disease: beyond proton pump inhibitor therapy. Drugs 2011 Dec 24; 71: pp. 2381-2389

Yarnell E.: Naturopathic gastroenterology. Sisters, OR: Naturopathic Medical Press, 2000.

Eherer A.: Management of gastroesophageal reflux disease: lifestyle modification and alternative approaches. Dig Dis 2014; 32: pp. 149-151

Djärv T., Wikman A., Nordenstedt H., et al: Physical activity, obesity and gastroesophageal reflux disease in the general population. World J Gastroenterol 2012; 18: pp. 3710-3714

References

Minardi D., d’Anzeo G., Parri G., et al: The role of uroflowmetry biofeedback and biofeedback training of the pelvic floor muscles in the treatment of recurrent urinary tract infections in women with dysfunctional voiding: a randomized controlled prospective study. Urology 2010; 75: pp. 1299-1304

Neuhuber WL, Raab M, Berthoud HR, et al: Innervation of the mammalian esophagus. Adv Anat Embryol Cell Biol 2006; 185: pp. 1-73

Festi D., Scaioli E., Baldi F., et al: Body weight, lifestyle, dietary habits and gastroesophageal reflux disease. World J Gastroenterol 2009; 15: pp. 1690-1701

Kahrilas P.J.: Gastroesophageal reflux disease. N Engl J Med 2008; 359: pp. 1700-1707

Yarnell E.: Naturopathic gastroenterology. Sisters, OR: Naturopathic Medical Press, 2000.

References