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A Hands-On Introduction to Osteopathic Manipulative Treatment & Acupuncture in a Case of Low Back Pain

Gautam J. Desai, D.O.Physician Educator, Dept of Medical Affairs Associate Professor, Dept of Family Medicine Kansas City University of Medicine &

Biosciences College of Osteopathic Medicine

Mary P. Guerrera, MD,FAAFP, DABMAAssociate Professor, Dept of Family MedicineUniversity of Connecticut School of MedicineW. Joshua Cox, D.O.

Assistant Professor, Dept of Family Medicine

Kansas City University of Medicine & Biosciences College of Osteopathic Medicine

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This presentation was made possible by GrantNumber 5 R25 AT000529-03 from the National Center for Complementary andAlternative Medicine (NCCAM) and the American Student Medical Association Foundation (AMSA Foundation) - itscontents are solely the responsibility of the speakers and do not necessarilyrepresent the official views of the NCCAM, the National Institutes of Health, or AMSA.

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Prevalence of CAM use in the USTindle, Eisenberg, et al. January/February 2005 Alternative Therapies in Health and Medicine – compared CAM usage from 1997-2002

> 1 in 3 U.S. adults (36.5 and 35.0 %, respectively) used at least 1 form of CAM. Over the 5 yrs between the 2 most recent surveys, the total using any CAM stable at 72 million

BUT, changes in the choice of CAM Largest change = 50 % jump in herbal use, 12.1% - 18.6% Yoga increased 40 %, from 3.7 % in 1997 to 5.1 %

Use of CAM therapies such as acupuncture, biofeedback, energy healing, and hypnosis remained essentially unchanged btw 1997 - 2002, whileuse of homeopathy, high-dose vitamins, chiropractic, and massage therapy declined slightly.

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Other Changes

Only 5 % of people who used herbs saw a herbal practitioner in 2002 (vs. 15% in 1997)

More self-treatment, possibly based on advertising

DSHEA

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Medicine in the latter half of the 19th Century

Heroic MedicineEvery effort made to “preserve the life force”Stimulants if the patient drowsyHypnotics if the patient agitated

Effort aimed at “conquering” diseaseEnough force, enough drugs would cast out the demons

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Medicine in the latter half of the 19th Century

The “magic bullet” a drug called “606” (later renamed “salvorsan”) discovered by Paul Erlich in 1910A.T. Still was well trained in these areas and believed they did not work. Searching for a more effective method of healing

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The Still Approach

If drugs didn’t workIf purgatives and cathartics didn’t workWhat would work…

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Osteopathic Approach

“To find health should be the object of the doctor. Anyone can find disease.”

A.T. Still, M.D.,D.O.

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The Four Tenets of Osteopathy1. Person is a unit of body, mind, and spirit.2. The body is capable of self regulation, self

healing, and health maintenance.3. Structure and function are reciprocally

interrelated.4. Rational treatment is based on an

understanding of the basic principles of body unity, self regulation, and the interrelationship of structure and function.

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First School of Osteopathy

October 3, 1892 The American School of Osteopathy (ASO) was chartered

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Evidence for use of OMTAndersson GBJ, Lucente T, Davis A, et al, A Comparison of Osteopathic Spinal Manipulation with Standard Care for Patients with Low Back Pain N Engl J Med.1999;341 (19): 1426-1431

Standard Medical Care (n=72) vs OMT group (n=83)both groups improved during 12 weeks.

no statistically significant difference between the two groups in any of the primary outcome measures.

osteopathic-treatment group required significantly less meds (analgesics, antiinflammatory agents, and muscle relaxants) (P< 0.001) and used less PT (0.2 percent vs. 2.6 percent, P<0.05).

Conclusions OMT and standard medical care have similar clinical results in patients with subacute low back pain. However, use of meds is greater with standard care.

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Practice Patterns Review of 1999 National Ambulatory Medical

Care Survey comparing DO’s v. MD’s when the dx was “musculoskeletal disorder”

Some differences seen in this studyDOs spent more time with patients,DOs provided more manual and complementary therapies. MDs ordered more diagnostic testsMDs prescribed more medications.

 Sun C, Desai G, Pucci D, Jew S: Management of Musculoskeletal Disorders: Does the

Osteopathic Profession Demonstrate Its Unique and Distinctive Characteristics? Journal of the American Osteopathic Association, April 2004, vol 104, number 4

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Safety of OMT

Adverse events: 1 in 400,000 treatments to 1 in 1 million

Higher incidence of side effects from meds vs OMT

Koss RW, Quality Assurance Monitoring of OMT, JAOA. 1990;90(5):427-434

Fractures

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Overall Absolute OMT Contraindications

Open woundsFever > 102 degrees

avoid lymphatic spread of pathogen

De novo diagnosed carcinomaavoid spreadavoid possible fracture of fragile bone

Osteogenesis imperfecta

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Overall Relative OMT Contraindications

Continuous pain not improving with OMT

think of other etiologies

Systemic signs of illnessfever, weight loss, fatigueloss of strength

Neurological deficits

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Some OMT Types

Soft TissueMuscle EnergyHigh velocity, low amplitudeCounterstrainStill’s technique, MyofascialCraniosacralFacilitated Positional Release, Visceral Techniques

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Potential Causes of Somatic Dysfunction

The ‘OJ’ sprint through the airport with one shoulder bagCramped seatsProlonged immobilization of joints/musclesPre-existing conditions

RA, OA

Being a delivery guy

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TART Findings – Hands On Activity with a Partner (20 min)

Tissue Texture ChangesAsymmetryRestriction of MotionTenderness

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Exploring Acupuncture STFM 40th Annual Spring Conf 27 April 2007

Mary P. Guerrera, MD, FAAFP, DABMAAssociate ProfessorUniv of Connecticut SOMDepartment of Family Medicine

YIN & YANG 20

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AARP & NCCAM: Jan 2007 22

Rakel D. Editor. Inegrative Medicine.Saunders:2003.p 5.

Integrative Medicine~“Integrative Medicine is healing oriented & emphasizes the centrality of the doctor-patient relationship. It focuses on the least invasive, least toxic, & least costly methods to help facilitate health by integrating both allopathic & complementary therapies. These are recommended based on an understanding of the physical, emotional, psychological, & spiritual aspects of the individual.”

Ernst E. Desktop Guide to CAM: An EB approach. 2nd ed. 2006.

Acupuncture: definition

“Insertion of a needle into the skin & underlying tissues in special sites, known as points, for therapeutic or preventive purposes.”

World Health Organization (WHO) Viewpoint on Acupuncture

Inter-regional seminarBeijing (Peking) 1979Participants from 12 countries

Drew up provisional list of diseases that may be treated with acupuncture…

WHO. Viewpoint on Acupuncture. Geneva, Switzerland:WHO,1979.

WHO Viewpoint on Acupuncture:Respiratory TractAcute sinusitisAcute rhinitisCommon coldAcute tonsillitis

Bronchopulmonary DisordersAcute bronchitisBronchial asthma

Disorders of ENTAcute conjunctivitisCentral retinitisMyopia (in children)Cataract (without complications)ToothachePain after tooth extractionGingivitisAcute and chronic pharyngitis

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Gastrointestinal DisordersSpasm of the esophagus and cardiaHiccupsGastroptosisAcute and chronic gastritisGastric hyperacidityChronic duodenal ulcerAcute and chronic colitisAcute bacterial dysenteryConstipationDiarrheaParalytic ileus

Neurologic and Orthopedic DisordersHeadache/MigraineTrigeminal neuralgiaFacial paralysisParalysis post-sz fitPeripheral neuropathyParalysis caused by poliomyelitisMeniere’s syndromeNeurogenic bladder dysfunctionNocturnal enuresisIntercostal neuralgiaPeriarthritis humeroscapularisTennis elbowSciatica, lumbar painRheumatoid arthritis

NIH Consensus statement on acupuncture. JAMA 280:1518-1524,

1998.

Evidence Based Medicine (EBM) & Acupuncture

NIH Consensus Development Panel 1997:Scientists, Researchers, Practitioners.Effective Tx: nausea due to surgical anesthesia & cancer chemotx, & post-op dental pain.Useful adjunct/acceptable alternative: Addiction, Stroke rehab, OA, HA, LBP, tennis elbow, menstrual cramps, carpal tunnel, fibromyalgia.

NIH Consensus statement on acupuncture.JAMA 280:1518-

1524,1998.

‘There is sufficient evidence of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value.’

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Of note~

Since the 1997 NIH Consensus Panel on Acupuncture there have been >100+ Randomized Controlled Trials.

Ernst E. Editor. The Desktop Guide to CAM: an evidence-based

approach. 2nd ed Mosby 2006, p 295.

Results of Systematic Reviews:

Positive Inconclusive Negative

Chronic back painDental painFibromyalgiaGI endoscopyIdiopathic HAPost-op N & VOocyte retrval pn OA knee

Addictions Lat Elbow pnAsthma Myofascial pn Bell’s palsy Neck painCancer pain OADepression 1 dysmennrhFacial pain SciaticaInduc labor Surgical pain Inflam Rhem ds StrokeInsomnia TinnitusLabor pain TMJ dysfunc

RASmokingWt loss

Ernst E. Desktop Guide to CAM: An EB approach. 2ed. 2006, p.294.

“Because of numerous methodological & other problems, the current evidence allows ample room for interpretations.”

After Vickers 1998. Berman B. EMB & Medical Acupuncture in the 21st

Century. Amer Acad Med Acup Symp. April 24-27,2003.

Results of Controlled Clinical Trials of Acup by Country of Research:

Favoring Acupuncture

Country Total trials

Number %

USA 47 25 53

China 36 36 100

Sweden 27 16 59

UK 20 12 60

Demark 16 8 50

Germany 16 10 63

Canada 11 3 27

Russia 11 10 91

Berman B. EBM & Medical Acupuncture in the 21st Century.

Amer Acad Med Acup Symp. April 24-27,2003.

Why so many Inconclusive Results?

Poor methodological qualitySmall trials w/insufficient power Large number of drop outsImproper blinding doubts about reliabilityInadequate tx

Berman B. EBM & Medical Acupuncture in the 21st Century.

Amer Acad Med Acup Symp. April 24-27,2003.

Why Acupuncture Efficacy RCTs may not capture real-life effectiveness:

Acupuncture studies do not always resemble clinical practice:

Contextualized tx approachIndividualized tx approach

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Is Acupuncture Safe? A Systematic Review of Case Reports.

Lixing Lao, PhD, LAc. et al.Altern Ther Health Med 2003:9(1):72-83.Searched 9 data-bases from 1965-1999 for all first-hand case reports of complications & adverse effects in English lang.Two reviewers.202 incidents identified in 98 relevant papers reported from 22 countries.

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Lixing Lao et al. cont…

Results: Complications included infections (hepatitis) & organ, tissue & nerve injury. Adverse effects included cutaneous disorders, hypotension, fainting & vomiting. Trend toward fewer reported serious complication after 1988.

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Lixing Lao et al. cont…

Conclusions:“Declines in adverse reports may suggest that recent practices, such as clean needle techniques & more rigorous acupuncturist training requirements, have reduced the risks associated with the procedure. Therefore, acupuncture performed by trained practitioners using clean needle techniques is a generally safe procedure.”

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?Safety~ 2 Prospective Studies in UK:

MacPherson H, et al. The York acupuncture safety study: prospective survey of 34,000 treatments by traditional acupuncturists. BMJ. 2001;323:486-7.

White A, et al. Adverse events following acupuncture: prospective survey of 32,000 consultations w/doctors & physiotherapists. BMJ. 2001;323:485-6.

Both studies found no serious events in 66,000 consultations.

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?Safety ~ Systematic review of 9 prospective studies:

Ernst E, et al. Prospective studies of the safety of acupuncture: a systematic review. Am J Med. 2001;110:481-5.

Almost 250,000 txs.Most serious adverse effects: 2 cases of pneumothorax, 2 cases of a broken needle.

Non-acupoint stimulation (control = c) compared with visual (a) & acupoint (b) stimulation.

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Wu et al. (NeuroImage, 2002)

1st study to report direct brain-acupoint correlation using electroacupuncture

advantage of objective settings of stimulation Used two acupoints of therapeutic effect for eye disease (GB37) & ear disease (GB 43).

General Considerations - LBP

# 2 reason for OV in USmajority do not require surgical interventionmassive financial burden

cost of treatmentexpense of lost worklegal costs (workman's comp, disability, personal injury)

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Case Intro

David D., a 45 y.o. father of 2 children (ages 3 and 5), works as a delivery man

Presents with constant back pain of moderate – severe intensity, isolated to the lower lumbar spine. Also, c/o tight muscles in same region.

He usually does ok until he has a heavy load day, or works overtime, which seems to cause a flare in back pain.

No ‘red flags’ for LBP

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Soft Tissue Technique – Dr. Cox

A direct technique (engages a restrictive barrier) which involves stretching, deep pressure, traction, and/or separation of muscle origin and insertion while monitoring tissue response.Lumbar Soft tissue – objective is to relax the paravertebral musclesRepeat until desired effect

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Lumbar Soft Tissue TechniqueProne traction

Stand at side of table, place cephalad hand over base of sacrum with fingers pointing toward feet, place other hand on the paravertebral muscles with fingers pointing toward head. Exert separating tractional force in directions fingers are pointing. Intermittent or sustained inhibition

Prone pressure with counter leverageStand at side of table, contact pt’s opposite side, grasp musculature with cephalad hand, apply anterior and lateral force. Contact ASIS with caudad hand and apply upward force. Use kneading or deep inhibitory pressure

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Myofascial Release (MFR)Designed to stretch and release restriction of fascia and muscleGoals

Assess and modify maladaptive patternsSearch out tight and loose “end-feels”• Dynamic barriers

– Soft tissue/bony impediment to inherent motion

• Static barriers– Soft tissue, bony impediment to passive motion

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Myofascial Release

Treatment goalsRelease tensionRestore 3 dimensional patterns to functional symmetry

Direct and indirect treatments

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Myofascial Release

Direct treatmentsDefine areas of tightness by holding tissue firmly into barrier of restrictionWait for tissue release (tissue creep)Art lies in being able to follow tissue response as release begins

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Myofascial Release

Indirect treatmentsMove the tissue in 3 dimensions away from restrictive barrierSubtle release of tissueArt lies in being able to keep the tissues in a “loose” fashion while the body “unwinds”

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Myofascial Release

Post treatment discomfort (rare)Temporary increase of pain on 1st or 2nd treatmentAnalogous to post exercise soreness • Lupus and fibromyalgia patients can have

repeated flare-ups

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MFR

Place hands on lumbar paravertebral muscles and move in all planes, assessing the motionDirect

take fascia where it does not want to go, and wait a few seconds.

Indirecttake fascia where it likes to go, wait few

seconds, and then move back to neutral as tissue relaxes

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Muscle Energy

A form of OMT wherein pt’s ms. are actively used, in a specific direction and against specific counterforce from a specific positionA direct technique (engages the restrictive barrier and then carries the dysfunctional component into the restrictive barrier)

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Basics

Using pt’s “muscle energy” as activating forceDr. counteracts pt’s forceIsometric = no mvmt in active phase

ms are same lengthachieve relaxation after contraction of ms

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Utility

Mobilize joints where mvmt is restrictedStretch tight muscles and fasciaImprove local circulationBalance neuromuscular relationships to alter muscle tone

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Advantages

Safer than HVLAgentle techniquebetter for elderlyalso for those with osteoporosis/risks thereof

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Contraindications

Open woundsBroken bonesUncooperative patientsUnresponsive patientsSevere pain

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Goals of ME

Strengthen weaker side of asymm.Decrease hypertonicityLengthen muscle fibersReduce restriction of motionAlter related resp. and circ. fxnMake the patient feel better

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Technique SimplifiedPosition body part at point of initial resistanceAs pt. moving part away from restriction, dr. providing equal counterforce to achieve isometric state, while monitoring pt to ensure proper positionHold for about 5 seconds, and both pt and dr relax simultaneously (repeat 3-5 times or until no new barriers)Recheck motion

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Muscle Energy Treatment

Restriction of hip flexion (from tight extensors)

Fully flex the hip while pt supineAsk the patient to gently extend leg while the doc resists motion for 3-5 secondsDuring relaxation, move further into barrier and then repeat the process until no new barriers are reached

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Still Technique

A specific, non-repetitive articulatory method that is indirect then direct, and is attributed to A.T. StillCan be used to treat regional and segmental dysfunctionTypically a supine treatment, but if concept is applied, it can be performed from nearly any position to adapt to a specific patient

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Still Technique

SimplificationPlace dysfunctional area where it wants to go (indirect). Add a compressive or traction force and articulate it to where it doesn’t want to go, thus engaging the restrictive barrier (direct). Remove force and place pt back in neutral position. Reassess

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Lumbar Still TechniqueFor regional dysfunction (group curve):

Pt supine, stand on side of concavity (side of side bending component). Contact pt’s lumbar transverse process with cephalad index finger, supporting the muscles with palm, this is the monitoring hand. Grasp pt’s knee on same side with caudad hand and flex knee and hip until motion/relaxation felt at monitoring hand or approx 90 degThen move monitoring hand to knee, and caudad hand to leg around ankle. Induce internal rotation (pull lower leg lateral) and adduction by pushing knee medially. This sidebends toward concavity and rotates away - indirect (induces tissue relaxation)Press down with 5 # pressure on knee toward the table in direction where monitoring hand had been. Maintaining compression, carry knee through neutral and then abduction and external rotation in articulatory manner. Pt’s leg brought back to extended, neutral supine position. Reassess.

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Acupuncture Demo

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CAM Resources for Educators

www.amsa.org/humed/CAM/resources.cfm

1. Stress Reduction, Relaxation, and Wellness: A Didactic and Experiential Workshop

2. Introduction to Evidence-Based Complementary & Alternative Medicine

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Core Curriculum CAM Integration in 10 categories:

1. Nutrition and Lifestyle: Diet, Exercise, Sleep and Stress Management

2. Mind-Body Medicines 3. Alternative Systems of Medical Thought:

Traditional Chinese Medicine, Kampo, Tibetan Medicine and Acupuncture

4. Alternative Systems of Medical Thought: Yoga, Ayurveda, Native American and Yoruba Based Medicines

5. Alternative Systems of Medical Thought: Homeopathy and Flower Essences

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Core Curriculum CAM Integration in 10 categories:

6. Bioenergetic Medicines 7. Pharmacologic/Biologically Based:

Herbal Medicines 8. Pharmacologic/Biologically Based:

Nutrition, Dietary Supplements & Vitamins

9. Manipulative Therapies: Chiropractic and Osteopathy

10.Manipulative Therapies: Therapeutic Massage

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EDCAM SiteD. CAM Clinical Interviewing: CAM History

Taking, Holistic Interviewing, Patient-Centered Interviewing and Cultural Competency

E. Integrative Medicine Field Study: CAM Research, Literature Search, Community Service Project and CAM Mentorship

F. U.S. and International CAM Electives: Clinical or Exploratory

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EDCAM Site

STUDENT WELLNESS MODULE•Healing the Healer https://www.amsa.org/healingthehealer/ 

EVALUATION TOOLS•Pilot School Student Survey  

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OTHER EDUCATION RESOURCES

Consortium of Academic Health Centers for Integrative Medicine, Curriculum in Integrative Medicine: A Guide for Medical Educators

http://www.imconsortium.org/html/education.php

The George Washington Institute for Spirituality and Health http://www.gwish.org/index.htm

University of Arizona Program in Integrative Medicine http://www.integrativemedicine.arizona.edu/

American Osteopathic Association http://history.aoa-net.org/Osteopathy/osteopathy.htm