OSTEOPATHIC APPROACH TO

PATIENT CARE AND WELLNESS

OSTEOPATHIC APPROACH TO

PATIENT CARE AND WELLNESS

SMART LIFE FORUMNOVEMBER 16, 2006

HARRY D FRIEDMAN DO

SMART LIFE FORUMNOVEMBER 16, 2006

HARRY D FRIEDMAN DO

OSTEOPATHIC MEDICINE AS ART, INTEGRATING

OSTEOPATHIC MEDICINE AS ART, INTEGRATING

NATURAL & TECHNOLOGICAL APPROACHES

SCIENTIFIC & INTUITIVE THINKING STRUCTURAL & FUNCTIONAL

THERAPY PATIENT & DISEASE FOCUSED

CARE

NATURAL & TECHNOLOGICAL APPROACHES

SCIENTIFIC & INTUITIVE THINKING STRUCTURAL & FUNCTIONAL

THERAPY PATIENT & DISEASE FOCUSED

CARE

DEFINITION OF OSTEOPATHIC MEDICINE

DEFINITION OF OSTEOPATHIC MEDICINE

“A complete system of medical care with a philosophy that combines the needs of the patient with the current practice of medicine, surgery and obstetrics; that emphasizes the interrelationship between structure and function; and that has an appreciation for the body’s ability to heal itself.”

-A.O.A. House of Delegates

“A complete system of medical care with a philosophy that combines the needs of the patient with the current practice of medicine, surgery and obstetrics; that emphasizes the interrelationship between structure and function; and that has an appreciation for the body’s ability to heal itself.”

-A.O.A. House of Delegates

OSTEOPATHIC PRINCIPLESOSTEOPATHIC PRINCIPLES

THE BODY FUNCTIONS AS A UNIFIED WHOLE WITH AN INHERENT VITALITY THAT IS

SELF-HEALING AND SELF-REGULATING. STRUCTURE & FUNCTION BEING INTERRELATED, ALTERATION OF THE BODY’S STRUCTURAL

FRAMEWORK AND CONNECTIVE TISSUE SYSTEM CAN LEAD TO ILLNESS AND DISEASE, THE

CORRECTION OF WHICH IS PART OF RATIONAL OSTEOPATHIC HEALTHCARE

THE BODY FUNCTIONS AS A UNIFIED WHOLE WITH AN INHERENT VITALITY THAT IS

SELF-HEALING AND SELF-REGULATING. STRUCTURE & FUNCTION BEING INTERRELATED, ALTERATION OF THE BODY’S STRUCTURAL

FRAMEWORK AND CONNECTIVE TISSUE SYSTEM CAN LEAD TO ILLNESS AND DISEASE, THE

CORRECTION OF WHICH IS PART OF RATIONAL OSTEOPATHIC HEALTHCARE

PASSEBECQ (1992)PASSEBECQ (1992)

“TO MAINTAIN A HEALTHY BODY, HOMEOSTASIS MUST BE KEPT CONSTANT…A HEALTHY ORGANIC TERRAIN IS THE BASIS OF HEALTH AND CONVERSLEY DISEASES DEVELOP IN A DEPLETED OR CONGESTED TERRAIN. UPSTREAM OF MOST DISEASES IS AN UNBALANCED TERRAIN.”

“TO MAINTAIN A HEALTHY BODY, HOMEOSTASIS MUST BE KEPT CONSTANT…A HEALTHY ORGANIC TERRAIN IS THE BASIS OF HEALTH AND CONVERSLEY DISEASES DEVELOP IN A DEPLETED OR CONGESTED TERRAIN. UPSTREAM OF MOST DISEASES IS AN UNBALANCED TERRAIN.”

BEING COMPRISED MOSTLY OF FLUID, LIVING TERRAIN IS NOT

STATIC, BUT CONSTANTLY MOVING, LIKE THE EBB AND

FLOW OF THE OCEAN. WHERE THERE IS A LACK OF MOTION, THERE LIES AN UNBALANCED TERRAIN AND THE BEGINNING

OF DISEASE.

BEING COMPRISED MOSTLY OF FLUID, LIVING TERRAIN IS NOT

STATIC, BUT CONSTANTLY MOVING, LIKE THE EBB AND

FLOW OF THE OCEAN. WHERE THERE IS A LACK OF MOTION, THERE LIES AN UNBALANCED TERRAIN AND THE BEGINNING

OF DISEASE.

INTERRELATIONSHIP AND INTERDEPENDENCE OF STRUCTURE-FUNCTION

INTERRELATIONSHIP AND INTERDEPENDENCE OF STRUCTURE-FUNCTION

“DISEASE IS THE RESULT OF ANATOMICAL ABNORMALITIES

FOLLOWED BY PHYSIOLOGIC DISCORD”

“THE RULE OF THE ARTERY IS SUPREME”

-A.T. STILL MD

“DISEASE IS THE RESULT OF ANATOMICAL ABNORMALITIES

FOLLOWED BY PHYSIOLOGIC DISCORD”

“THE RULE OF THE ARTERY IS SUPREME”

-A.T. STILL MD

OPTIMAL MULTISYSTEM FUNCTION REQUIRES

OPTIMAL MULTISYSTEM FUNCTION REQUIRES

UNIMPEDED DELIVERY OF BLOOD AND DISPOSAL OF WASTE PRODUCTS

CENTRAL AND AUTONOMIC NERVOUS SYSTEM BALANCE

MOTOR SYSTEM COORDINATION UNITY OF THE WHOLE THAT ENHANCES

THE FUNCTION OF EACH PART

UNIMPEDED DELIVERY OF BLOOD AND DISPOSAL OF WASTE PRODUCTS

CENTRAL AND AUTONOMIC NERVOUS SYSTEM BALANCE

MOTOR SYSTEM COORDINATION UNITY OF THE WHOLE THAT ENHANCES

THE FUNCTION OF EACH PART

THE WHOLE IS GREATER THAN THE SUM OF ITS

PARTS

THE WHOLE IS GREATER THAN THE SUM OF ITS

PARTS

OSTEOPATHIC MANIPULATIVE APPROACHES CAN ALTERNATELY EVALUATE THE FUNCTION OF THE WHOLE OR ITS COMPONENT PARTS AND PROVIDE TREATMENT THAT ENHANCES EACH

OSTEOPATHIC MANIPULATIVE APPROACHES CAN ALTERNATELY EVALUATE THE FUNCTION OF THE WHOLE OR ITS COMPONENT PARTS AND PROVIDE TREATMENT THAT ENHANCES EACH

OSTEOPATHIC MANIPULATIVE

TREATMENT (OMT)

OSTEOPATHIC MANIPULATIVE

TREATMENT (OMT)

THE THERAPEUTIC APPLICATION OF MANUALLY GUIDED FORCES BY AN OSTEOPATHIC PHYSICIAN TO IMPROVE PHYSIOLOGIC FUNCTION AND/OR SUPPORT HOMEOSTASIS THAT HAS BECOME ALTERED BY SOMATIC DYSFUNCTION

THE THERAPEUTIC APPLICATION OF MANUALLY GUIDED FORCES BY AN OSTEOPATHIC PHYSICIAN TO IMPROVE PHYSIOLOGIC FUNCTION AND/OR SUPPORT HOMEOSTASIS THAT HAS BECOME ALTERED BY SOMATIC DYSFUNCTION

SOMATIC DYSFUNCTIONSOMATIC DYSFUNCTION

“IMPAIRED OR ALTERED FUNCTION OF RELATED COMPONENTS OF THE SOMATIC (BODY FRAMEWORK) SYSTEM: SKELETAL, ARTHROIDIAL AND MYOFASCIAL STRUCTURES AND RELATED VASCULAR, LYMPHATIC AND NEURAL ELEMENTS.”

-ICD-9 DIAGNOSTIC CODEBOOK (739.0 -.9)

“IMPAIRED OR ALTERED FUNCTION OF RELATED COMPONENTS OF THE SOMATIC (BODY FRAMEWORK) SYSTEM: SKELETAL, ARTHROIDIAL AND MYOFASCIAL STRUCTURES AND RELATED VASCULAR, LYMPHATIC AND NEURAL ELEMENTS.”

-ICD-9 DIAGNOSTIC CODEBOOK (739.0 -.9)

THE HUNT FOR SOMATIC DYSFUNCTION

THINK A.R.T.

THE HUNT FOR SOMATIC DYSFUNCTION

THINK A.R.T.

A FOR ASYMMETRY OBSERVE OR PALPATE “UNEVENNESS”

R FOR RESTRICTION OF MOTION PALPATE FOR EARLY “ENDFEEL”

T FOR TISSUE QUALITY ALTERATIONS PALPATE TEXTURE, TEMP, MOISTURE,

TENDERNESS

A FOR ASYMMETRY OBSERVE OR PALPATE “UNEVENNESS”

R FOR RESTRICTION OF MOTION PALPATE FOR EARLY “ENDFEEL”

T FOR TISSUE QUALITY ALTERATIONS PALPATE TEXTURE, TEMP, MOISTURE,

TENDERNESS

BERNIE SEIGAL, PEACE, LOVE AND HEALING 1989 (#1NY TIMES BEST

SELLER)

BERNIE SEIGAL, PEACE, LOVE AND HEALING 1989 (#1NY TIMES BEST

SELLER)

“THE OSTEOPATHIC STUDENTS HAVE BEEN TAUGHT ABOUT TOUCHING AND MANIPULATING THE BODY, AND WHEN THEY’RE IN MY OFFICE AND A PATIENT WHO HAS SOME PAIN COMES IN, THEY KNOW HOW TO USE MANIPULATION AND MASSAGE TO HELP RELIEVE THAT PAIN. THE MEDICAL STUDENT IS MORE PRONE TO PRESCRIBE A PILL. WE NEED TO TEACH MEDICAL STUDENTS HOW TO TOUCH PEOPLE.”

“THE OSTEOPATHIC STUDENTS HAVE BEEN TAUGHT ABOUT TOUCHING AND MANIPULATING THE BODY, AND WHEN THEY’RE IN MY OFFICE AND A PATIENT WHO HAS SOME PAIN COMES IN, THEY KNOW HOW TO USE MANIPULATION AND MASSAGE TO HELP RELIEVE THAT PAIN. THE MEDICAL STUDENT IS MORE PRONE TO PRESCRIBE A PILL. WE NEED TO TEACH MEDICAL STUDENTS HOW TO TOUCH PEOPLE.”

ANDREW WEIL MD. SPONTANEOUS HEALING 1995 (#1 NYTIMES BEST SELLER)

ANDREW WEIL MD. SPONTANEOUS HEALING 1995 (#1 NYTIMES BEST SELLER)

“I FREQUENTLY REFER PATIENTS TO DO’S FOR OMT AND OFTEN ENCOURAGE MEDICAL STUDENTS TO LEARN THE TECHNIQUE, BECAUSE I HAVE FOUND IT TO BE SAFE AND HIGHLY EFFECTIVE.)

“I FREQUENTLY REFER PATIENTS TO DO’S FOR OMT AND OFTEN ENCOURAGE MEDICAL STUDENTS TO LEARN THE TECHNIQUE, BECAUSE I HAVE FOUND IT TO BE SAFE AND HIGHLY EFFECTIVE.)

HISTORY OF MANUAL MEDICINE

HISTORY OF MANUAL MEDICINE

2700 BC CHINESE 400 BC HIPPOCRATES 100 BC GALEN, “THE PRINCE OF PHYSICIANS”

19TH CENTURY BONESETTERS 19TH CENTURY STILL, PALMER 20TH CENTURY MENNELL, CYRIAX 20TH CENTURY SUTHERLAND, BARRAL

2700 BC CHINESE 400 BC HIPPOCRATES 100 BC GALEN, “THE PRINCE OF PHYSICIANS”

19TH CENTURY BONESETTERS 19TH CENTURY STILL, PALMER 20TH CENTURY MENNELL, CYRIAX 20TH CENTURY SUTHERLAND, BARRAL

TRACTION AND THRUSTTRACTION AND THRUSTHippocrates Method of Spinal ManipulationHippocrates Method of Spinal Manipulation

Traction and ThrustTraction and Thrust

Woodblock Print by Galen, 400 A.D.

ATATDr. A.T. StillDr. A.T. Still(1828-1917)(1828-1917)Founder ofFounder ofOsteopathyOsteopathy

ANDREW TAYLOR STILL, MD

ANDREW TAYLOR STILL, MD

1854 LICENSED AS MD, SERVED IN CIVIL WAR 1864 3 FAMILY MEMBERS DIE OF MENINGITIS,

RENOUNCES MEDICINE, TAKES UP STUDY OF STRUCTURE-FUNCTION/UNITY OF THE BODY

1874 PRINCIPLES OF OSTEOPATHY UNVEILED 1892 AMERICAN SCHOOL OF OSTEOPATHY

OPENS

1854 LICENSED AS MD, SERVED IN CIVIL WAR 1864 3 FAMILY MEMBERS DIE OF MENINGITIS,

RENOUNCES MEDICINE, TAKES UP STUDY OF STRUCTURE-FUNCTION/UNITY OF THE BODY

1874 PRINCIPLES OF OSTEOPATHY UNVEILED 1892 AMERICAN SCHOOL OF OSTEOPATHY

OPENS

DO SCHOOLSDO SCHOOLS

28

Osteopathic Medical Colleges

HOW DOES MANIPULATION WORK?

HOW DOES MANIPULATION WORK?PATHOPHYSIOLOGIC MODELS

FACET DYSFUNCTION

NOCICEPTION (PAIN) MECHANORECEPTION (PRESSURE)

PROPRIOCEPTION (POSITION)

PATHOPHYSIOLOGIC MODELS

FACET DYSFUNCTION

NOCICEPTION (PAIN) MECHANORECEPTION (PRESSURE)

PROPRIOCEPTION (POSITION)

REFERRED PAINREFERRED PAINReferred Pain of CervicalReferred Pain of Cervical

Zygapophyseal Joint OriginZygapophyseal Joint Origin

NOCICEPTORSNOCICEPTORSSpinal and Para spinal Nociceptors,Spinal and Para spinal Nociceptors,Proprioceptors, MechanoreceptorsProprioceptors, Mechanoreceptors

HOW DOES MANIPULATION WORK?

HOW DOES MANIPULATION WORK? PATHOPHYSIOLOGIC MODELS

NEURAL FACILITATION

ALTERED REFLEXES CAUSING HYPERACTIVE OR INHIBITED

RESPONSES TO STIMULI OR STRESS

PATHOPHYSIOLOGIC MODELS

NEURAL FACILITATION

ALTERED REFLEXES CAUSING HYPERACTIVE OR INHIBITED

RESPONSES TO STIMULI OR STRESS

SPINAL REFLEXESSPINAL REFLEXESSpinal Reflexes

PainPosition

Blood and lymph vessels

Skin

Joints

Muscles

Viscera

NEURAL FACILITATIONNEURAL FACILITATION

VISCERAL (ORGAN) STRESS AND DISEASE ARE REFLECTED IN THE TISSUES SURROUNDING THE SPINAL LEVELS WHICH INNERVATE IT

ESOPHAGUS T 2-3 STOMACH T 5-6 HEART T 2-6 GALLBLADER T8-9 KIDNEY T9-11

VISCERAL (ORGAN) STRESS AND DISEASE ARE REFLECTED IN THE TISSUES SURROUNDING THE SPINAL LEVELS WHICH INNERVATE IT

ESOPHAGUS T 2-3 STOMACH T 5-6 HEART T 2-6 GALLBLADER T8-9 KIDNEY T9-11

HOW DOES MANIPULATION WORK?

HOW DOES MANIPULATION WORK?

PATHOPHYSIOLOGIC MODELS

MOTOR SYSTEM DYSFUNCTION

MUSCLE TENSION AND LENGTH ALTERED BY POSTURAL STRESS, INJURY OR ALARM

OVER AND UNDER STIMULATED MUSCLES AND THEIR ASSOCIATED BODY-WIDE COMPENSATIONS CAUSE DISTURBANCES IN POSTURE, MOTION, AND COORDINATION

PATHOPHYSIOLOGIC MODELS

MOTOR SYSTEM DYSFUNCTION

MUSCLE TENSION AND LENGTH ALTERED BY POSTURAL STRESS, INJURY OR ALARM

OVER AND UNDER STIMULATED MUSCLES AND THEIR ASSOCIATED BODY-WIDE COMPENSATIONS CAUSE DISTURBANCES IN POSTURE, MOTION, AND COORDINATION

MUSCLE SPINDLEMUSCLE SPINDLEMuscle innervation

GOALS OF OSTEOPATHIC TREATMENT

GOALS OF OSTEOPATHIC TREATMENT

RESTORE MIDLINE FUNCTION AND MOBILITY OF ALL TISSUES

IMPROVE POSTURE AND BODY MOVEMENT MOBILIZE FLUIDS TO AND FROM ALL

TISSUES BALANCE CNS/ANS REFLEXES (CALM

DOWN HYPERACTIVE NERVES) ENHANCE HEALING AND HOMEOSTASIS

RESTORE MIDLINE FUNCTION AND MOBILITY OF ALL TISSUES

IMPROVE POSTURE AND BODY MOVEMENT MOBILIZE FLUIDS TO AND FROM ALL

TISSUES BALANCE CNS/ANS REFLEXES (CALM

DOWN HYPERACTIVE NERVES) ENHANCE HEALING AND HOMEOSTASIS

MOTION

RESPIRATION

METABOLISM

BEHAVIOR

CIRCULATION

NEURAL INTEGRATION

MOTION

RESPIRATION

METABOLISM

BEHAVIOR

CIRCULATION

NEURAL INTEGRATION

CORRECTIVE FORCES CAN BE DIRECT OR INDIRECT

CORRECTIVE FORCES CAN BE DIRECT OR INDIRECT

DIERCT TECHNIQUES ENGAGE AND OVERCOME TISSUE RESTRICTION

INDIRECT TECHNIQUES DIS-ENGAGE AND RELEASE TISSUE RESTRICTION WITH AFFERENT REDUCTION

BOTH STIMULATE THE PATIENT’S INHERENT RESTORATIVE CAPACITY BY ACTIVATING DYNAMIC MIDLINE FUNCTION

DIERCT TECHNIQUES ENGAGE AND OVERCOME TISSUE RESTRICTION

INDIRECT TECHNIQUES DIS-ENGAGE AND RELEASE TISSUE RESTRICTION WITH AFFERENT REDUCTION

BOTH STIMULATE THE PATIENT’S INHERENT RESTORATIVE CAPACITY BY ACTIVATING DYNAMIC MIDLINE FUNCTION

DOES IT WORKDOES IT WORKDoes this stuff work?

AHCPR no. 95-0642 says YES!¥ Agency for Health Care, Policy & Research

Guidelines, 1994:

¥ For back pain under 3 monthsĞ ANALGESICS

Ğ ALTERATION OF ACTIVITY

Ğ Spinal Manipulation

REVIEW OF LITREVIEW OF LIT

Systematic Review ofRandomized Controlled Trials:

Treatment of Acute and ChronicNonspecific Low Back Pain

van Tulder, Koes, Bouter in SPINE, Vol. 22, 1997

¥Strong evidence was also found forthe effectiveness of spinalmanipulation, back schools andexercise therapy for chronic low backpain, especially for short term effects.

NEJM ARTNEJM ART

22

Clinical Outcomes Trial

Andersson GB, Lucente T, Davis AM, KapplerRE, Lipton JA, Leurgans S.

A Comparison of osteopathic spinalmanipulation with standard care for patientswith low back pain.

N Engl. J Med, 1999 Nov 4; 341 (19): 1426-31.

RESULTSRESULTS

MD: Standard Care - MD: Standard Care -Manipulation; Manipulation; DO: Standard CareDO: Standard Care

+ Manipulation+ Manipulation

Man.+PT+Meds

N 83

NSAIDS 24%

M. Relax. 6%

Pt 0.2%

PT+Meds

72

54%

25%

2.6%

WC COST ANALYSISWC COST ANALYSISWorkerÕs Compensation Average Cost

of Treatment for LBP (AOA data)

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

Colorado, 1993 Florida, 1988

Non-surgical MD

Chiropractor

Surgical MD

DO

EBM DATAEBM DATAEBM Osteopathic ManipulativeEBM Osteopathic Manipulative

MedicineMedicine

Benefit > Risk for:

Acute, subacute andchronic mechanical lowback and neck pain

Cervicogenic headaches

Knee Osteoarthritis

Prenatal OB

Pediatric NeurologicDevelopment

Can reduce: Pain Medication use PT utilization Hospital days Disability and Impairment Work days lost from

nonspecific or mechanicallow back pain

PRE-POST MFRPRE-POST MFR

49

Pre-post Myofascial ManipulativeRelease of Wrist MRI

(Sucher 1993)

Pre-Manipulation0.84 x 1.72 cm

Post-Manipulation0.96 x 1.9 cm

FRYMANNFRYMANNViola M. Frymann, DO, FAAO

Neurologic Developmental Delayin Children

¥ 18 m.o.-12 y.o. children w/ & w/out neuraldevelopmental delay given 6-12 treatments

¥ Statistically significant improvement in neurologicaldevelopment profile after OMT course of treatment

¥ See JAOA 92(6): 729-744, June 1992

¥ Those with medical problems improved less

¥ Osteopathic Center for Children - San Diego, CA

THE BODY IS ESSENTIALLY A FLUID CONTAINER, ITS

STRUCTURE DETERMINES THE PROPER PLACEMENT AND

COORDINATED FUNCTION OF EVERY TISSUE. WHEN

STRUCTURE AND FUNCTION ARE IMPAIRED, HOMEOSTASIS

FALTERS.

THE BODY IS ESSENTIALLY A FLUID CONTAINER, ITS

STRUCTURE DETERMINES THE PROPER PLACEMENT AND

COORDINATED FUNCTION OF EVERY TISSUE. WHEN

STRUCTURE AND FUNCTION ARE IMPAIRED, HOMEOSTASIS

FALTERS.

OSTEOPATHIC MANIPULATIVE MEDICINE ENHANCES THE BODY’S STRUCTURE AND

FUNCTION, IMPROVING FLUID MOBILITY AND HOMEOSTASIS, IMPARTING HEALTH TO EVERY

TISSUE

OSTEOPATHIC MANIPULATIVE MEDICINE ENHANCES THE BODY’S STRUCTURE AND

FUNCTION, IMPROVING FLUID MOBILITY AND HOMEOSTASIS, IMPARTING HEALTH TO EVERY

TISSUE

LINKSLINKS

WWW.DRAGONFLYVILLAGE.COM/OSTEOPATHY

WWW.SFIMMS.COM WWW.ACADEMYOFOSTEOPATHY.ORG WWW.OSTEOHOME.COM WWW.OSTEOPATHIC.ORG WWW.DO-ONLINE.ORG WWW.AACOM.ORG

WWW.DRAGONFLYVILLAGE.COM/OSTEOPATHY

WWW.SFIMMS.COM WWW.ACADEMYOFOSTEOPATHY.ORG WWW.OSTEOHOME.COM WWW.OSTEOPATHIC.ORG WWW.DO-ONLINE.ORG WWW.AACOM.ORG