Clinical Integration of OMM

00:01 We're going to take this time to talk about the clinical integration of osteopathic manipulative medicine.

00:06 We're going to talk about some of the theories and how are you going to do it.

00:09 And then we're going to talk about integration of OMM into emergency medicine.

00:15 So, we're going to start with talking about what I do.

00:19 I'm an emergency medicine physician.

00:21 I see patients in acute care setting who had injuries from trauma, severe illness.

00:26 They may have severe pain.

00:28 And when do you start thinking osteopathically versus treating somebody in a basic science manner that may or may not have osteopathic principles involved? Well, osteopathic manipulative treatment may be different than osteopathic manipulative medicine.

00:44 And how you look at people and how you arrive at a diagnosis and decide what to do is going to be different from the manipulative therapy that you can provide as well.

00:55 I also want to go through some of the areas where osteopathic manipulative therapy has been shown to have a clear benefit.

01:04 In looking at osteopathic physicians who identify emergency medicine as their specialty, they asked them if they used OMT, and 55% of those docs said yes, they did.

01:13 With 28% saying they use it every time they're working on a daily or weekly basis. So, OMT is in many of my protocols, particularly chronic pain.

01:24 Nobody who comes to my ER gets a narcotic without having been treated with manipulation first to see if it works.

01:30 They can't be allergic to it.

01:32 And even if they don't want it, it's a way of easing motion enhancing abilities.

01:39 And if they don't want that, then they don't really want the pain addressed.

01:45 The principals of osteopathic manipulative medicine are helpful with thinking about what's going on with a patient.

01:53 When people come to the E.R., they're not thinking mind, body, spirit.

01:56 They're thinking, my elbow hurts.

01:58 They're thinking single issue.

02:00 So, we have to through asking questions, through prodding, through looking at what's going on. Take them past the simple complaint, the single issue towards understanding the bigger picture.

02:13 So, you can do a rapid screening exam of the musculoskeletal system, which is good and may reveal other problems.

02:20 You may talk to them about things that get more information.

02:25 You may identify distant findings that relate to the central core of what's going on.

02:32 So, all of these are part of the osteopathic medicine approach that's helpful in emergency medicine. Well, the majority of people coming to the E.R.

02:40 are looking for treatment of visceral pain, trauma, or a chronic or a chronic or acute issue.

02:48 We will look at whether or not the issues are acute or chronic, whether this is something to be addressed in the emergency room or outside the emergency room.

02:57 Understanding the acuity, understanding the acuteness of a finding versus the chronicity of a finding is very helpful.

03:05 Another concept we look at often is visceral, somatic versus somatic visceral reflexes. Are the findings I'm getting on a musculoskeletal exam due to another problem that's distant from the musculoskeletal exam and unrelated? Or is it all part of the same thing? And when you talk about visceral somatic reflexes, a lot of that is an inflammation coming from the nervous system.

03:30 You'll have a convergence of visceral nociceptors that are coming from the somatic tissue producing a clinical effect.

03:38 This could be referred pain distal to where the issue is.

03:42 It could be segmental facilitation, where the pain occurs easier and is more apparent because those pathways have been worked through before.

03:50 And these are just things to keep in mind when you're treating a patient.

03:55 Spinal cord facilitation is where you reduce the threshold for the firing of an internneuron because it's been worked before, because it's a position of ease, and it may give you an exaggerated, segmental, autonomic response. It may cause fogginess, increase temperature or increase sweating in a particular area.

04:16 So all of those are concepts to focus on.

04:20 In spinal cord facilitation, you may have high paresthesia, increased sensitivity, or you may have referred pain.

04:28 And it may alter the automatic autonomic outflow to the viscera.

04:33 The other thing we look at is not just the musculoskeletal system, but Chapman's points are an area that you can use to see what else you may want to examine.

04:41 One of the big things you see in the emergency room is chest pain.

04:44 And the question is always, is this cardiac or not? We always look at the Framingham risk factors, whether the smoking family history, high cholesterol, hypertension and other issues that may lead you towards worrying about cardiac disease.

04:59 But you can also look at C1, C2.

05:02 You can look at the Chapmans points that may lead you towards a different conclusion. Chapman's points are small ganglia formed contractions that block lymphatic drainage.

05:13 They're present in the musculoskeletal, musculoskeletal system, and they can be palpated to give you more information.

05:22 So the sympathetic nervous system dysfunction and lymphatic pathologies that follow visceral somatic reflexes can lead you towards or away from a specific diagnosis.

05:35 When palpating for Chapman's point, you want to palpate deep to the skin, and it's most often lying in the deep fascia as the place to be looking for Chapman's points.

05:47 They can be found on both the dorsal and ventral aspects of the body.

05:51 And again, these are small, smooth, firm nodules that are 2 to 3 millimeters in diameter, and they are tender to palpation, but they generally don't radiate and they generally localized to that one area.

06:06 The other concept I use a lot is the five treatment models of osteopathic medicine.

06:12 When somebody comes to me, I want to classify their disease.

06:16 Is the difficulty breathing and difficulty catching your breath, is that part of the bio energy model? Is that a respiratory circulatory model or is that a psycho behavioral model? Is it anxiety related? Is it energy related? Is it pulmonary related? Not every wheeze is asthma.

06:35 Sometimes it's anxiety.

06:37 And if I understand that patient's personality and that patient's complaint, it makes it easier for me to focus.

06:45 And I'm not saying to exclusively choose one model.

06:48 An inability to catch your breath could be asthma that started off as anxiety.

06:53 But it doesn't mean that looking at a person has to be an only the restless circulatory model because they got to that point where it eventually affects the lungs.

07:02 It could be that it's anxiety that started in the psycho behavioral model and progressed on to a complaint in the respiratory circular model.

07:10 So looking at the five models is an important way of developing an idea of what's going on with the person.

07:18 The other thing is in the osteopathic world, we look at the lymphatics and the fascia a lot more seriously and a lot more broadly.

07:26 And within this, I will treat facilitated segments that might be blocking lymphatic return.

07:32 I also look at protoplasm and tissue.

07:35 How does the patient look? Do they look strong? Do they look healthy? Do they look beaten up or torn down? All are things that will give you additional information on what's going on with the patient, and it also gives you a place to address an issue.

07:50 Addressing key regions of the lymphatic system that help enhance lymphatic return will give the patient more energy and give them a sense of well-being when they leave.

08:00 So even if you couldn't cure them, and you're giving them more direction to go for care, there are things you can do in the meantime that will enhance their well-being.

08:09 I also want to address any musculoskeletal restrictions, any biomechanical restrictions that affect the person's ability to function.

08:16 Those can contribute to the patient's presentation and are helpful in what we're doing. Decreasing the static load and energy expenditure are also helpful, particularly when it's breathing related.

08:28 With patients in the emergency room.

08:31 It also helps you establish a connection with your patient through talking with them, expanding the history, and showing an understanding and appreciation for what they're going through.