12_hosptalized_patient_06-07.ppt

8/12/2019 12_hosptalized_patient_06-07.ppt

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CORE OMM Curriculum

for Students, Interns, & Residents 2006

Osteopathic Management ofthe Hospitalized Patient

Part 1 of 2

Developed for OUCOM CORE

by: Craig Warren, D.O.

Edited by: David Eland, D.O.

and theCORE Osteopathic Principles and Practices Committee

Session #12 Series B


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CORE OMM Curriculum


Objectives

Obtaining a pertinent osteopathic history from the patient or

caregiver

Perform a pertinent osteopathic exam under the conditions

of the hospital

Understand the studies necessary to plan OMT

Recognize limitations to the exam

Recognize special situations where OMT will benefit the

patient


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CORE OMM Curriculum


Obtaining the History

The following elements are important not to

neglect when taking the hospital history:

Head Trauma

Motor vehicle accidents

Fractures

Episodes of loss of consciousness

Presence of known short leg Scoliosis

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CORE OMM Curriculum


Obtain the History from

Patient if possible

May be intubated, altered LOC, etc.

Family Members

Nursing Home

Other Caregivers

Always remember the previous Chart


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CORE OMM Curriculum


Data Collection

Before exam inat ion of the patient, review th e fol low ing

in format ion:

1. Any radiographs pertinent to the problem

- Review these yourself. A radiologist usually doesntcomment on bony and fascial abnormalities that are

significant to your OMM plan.

2. Always review the history before exam of the patient.

3. Use the above information to focus the examination of

the patient


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CORE OMM Curriculum


Physical ExaminationProtocol

Based on the Respiratory-Circulatory-Neurologic Model

Major diaphragms of the body

- Bony & Fascial attachments

Rib function

- Fluid movement within the body

- Reflexed mediated by the SNS (chain ganglia)

Paraspinal myofascial elements

- Suboccipital, sacral, thoracolumbar areas


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CORE OMM Curriculum for Students, Interns, & Residents 2006

Physical ExaminationProtocol - continued

If ambulatory, the exam doesnt differ much from the

outpatient exam.

If hospital, a bedside osteopathic evaluation in the supine

position is necessary.


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ASIS CompressionTest

Bilateral compression of

the ASIS:

This test indicates

restrictions in iliosacralmobility that interfere with

sacral and pubic motion,

and pelvic diaphragm

tension.

Foundations for Osteopathic Medicine, 2nd. Edition, p. 424


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Physical ExaminationProtocol

Evaluate and treat the sacrum and lumbar areas from the patients

side.

Patient is usually laying on a draw-sheet & fitted mattress sheet.

Slip hands under the patient, palms up, between the draw-sheet and

the fitted mattress sheet.

The figure in the next slide shows how this can be easily

accomplished.


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A: Loosen draw-sheet from under the

mattress.

B: Roll draw-sheet parallel to the

patient.

C: Place hands between draw-sheet

and mattress to contact lumbar areas.

This approach protects the patients

modesty, and the physician is lesslikely to come in contact with any

discharge, drainage, urine, or feces in

bed.

Physical ExaminationProtocol - continued



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Sacral Motion Restriction

Place the fingertips of one hand

at the inferolateral angle of the

sacrum and fingertips of the other

hand at the ipsilateral sacral base.

Exert alternate pressure in the

anterior direction with the

fingertips, ascertaining the ability

of the sacrum to rock on its

L-shaped articulation.



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Lumbar SpineExamination

Assess tissue texture changes and motion restriction of thelumbar spine.

If patient is not in the immediate postoperative period after abdominal or pelvicsurgery:

Palpate the abdomen for visceral dysfunction

Assess restrictions of thoracoabdominal diaphragm

Place one hand under the patient at T10-L2 area posteriorly.

Other hand anteriorly, just inferior to the xiphoid process

Perform motion testing

The abdominal diaphragm dysfunction is named according to thedirection of preferred fascial movement sensed by theabdominal hand.


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Lower and Upper RibExamination

Assess rib excursion by having the patient breathe

deeply.

Palpate rib cage at the midaxillary line lateral to thesternum (upper ribs).

If chest tube is present or patient on ventilator, follow the

motion present by lightly resting hands on the rib cage.


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Sternal Palpation

Gently rest the palpating

hand on the sternum and

follow its motion, noting anyfascial pulls and any

costosternal articular

restrictions.



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Chapmans Reflex

Perform an anterior screen

of the anterior Chapmans

and Jones points in the

thoracic and abdominal

areas.

Note any specific rib

restrictions so they can be

treated later.


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Place patient in Fowlers

position:

Standing and leaning over the head

of the bed from behind, slide fingersunder draw sheet down to the T12 -

L2 area of the patients back.

Push anteriorly with fingertips of

both hands, assessing the tissue

texture changes then rotatory motionof the paraspinalelements.

Thoracic RegionExamination



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Individual Rib Evaluation andTreatment Position

Place the fingertips of the anterior

hand against the costochondral

junction, and those of the posterior

hand at the rib head of the same rib.

Palpate along the region for tissue

texture changes and somatic

dysfunction in the individual ribs

based on respiratory motion.



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Thoracic Inlet Examination

Assess the suboccipital area for

condylar compression and OA

and AA somatic dysfunction.

Gently cradle the head and

upper cervical area with the

fingertips and hands.



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Cranial Examination &Treatment Position

The cranium is now

palpated for somatic

dysfunction

The cranium can be

evaluated with many hand

positions.



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Neuromusculoskeletal SystemEvaluation- Summary

Sympathetic Nervous System

SD indicated by palpation of the thoracic and upper lumbar area for

viscerosomatic and articular restrictions, and of rib cage for restrictions

affecting the sympathetic chain ganglia.

Parasympathetic Nervous System SD indicated by palpation of the sacral, suboccipital, and cranial areas.

Lymphatic System

SD indicated by assessing the four major diaphragms of the body and rib

motion.

Pelvic diaphragm

Thoracoabdominal diaphragm

Superior thoracic aperture

Tentorium cerebelli


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NeuromusculoskeletalSystemEvaluation- Summary

Visceral Dysfunction

Reflected by positive anterior Chapmans points,

visceral palpation (when possible), and spinal somatic

dysfunction that may be related to facilitated segments.

Structural Components

Asymmetries and abnormalities of the cervical,

thoracic, rib, and pelvic areas affect optimal functioningof the autonomic and lymphatic systems.


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Conclusion

1. Always do a through osteopathic history.

May need to obtain this from others

2. Incorporate the osteopathic exam into the physicalexamination.

3. Develop your own routine and stick with it

4. Ancillary tests such as radiographs, CT scans, etc.,

should be reviewed prior to evaluating the patient.


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Conclusion - continued

Over-treatment: How do I gauge this?

Do the tissues stop responding with a sense of softening

after one or two techniques?

Does the patient start to complain of soreness even withgentle indirect treatment?

Does breathing accelerate?

Do vitals change negatively? Increasing heart rate?

Negative change in blood pressure? Negative pulse

oximetry change?

Etc.


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Summary

Hospitalized patients can derive significant benefit from focusedproblem based OMT.

Work around what the patient can do in the hospital bed.

Evaluation of the four diaphragms and their potential implications

can be simple and straight forward.

Think of:

Fluid movement

Autonomic influences

Pain relief

Gentle treatment that includes continuing evaluation of tissueresponse it most effective.


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References

Balon J, Aker PD, Crowther ER et al. A comparison of active and simulated chiropractic manipulation

as adjunctive treatment for asthma. NEJM 339(15): 1013-1020. 1998

Dickey JL. Postoperative manipulative management of median sternotomy patients. JAOA 89(10):

1309-1322. 1989.

Fryman VM, Carney RE, Springall P. Effect of osteopathic medical management on neurologic

development in children. JAOA 92(6): 729-43. 1992

Henshaw RE. Manipulation and postoperative pulmonary complications. The DO 63: 132-133. 1963.

Hermann EP. Postoperative adynamic ileus: Its prevention and treatment with osteopathicmanipulation. The D.O. 65: 163-164. 1965.

Noll DL, Shores JH, Bryman PN, Masterson EV. Adjunctive osteopathic manipulative treatment in the

elderly hospitalized with pneumonia: A pilot study. JAOA 99(3): 143-152. 1999.

Paul FA, Buser BR. Osteopathic manipulative treatment applications for the emergency department

patient. JAOA 96(7): 403-409. 1996.

Radjewski JM, Lumley MA, Cantieri MS. Effect of osteopathic manipulative treatment on length of

stay for pancreatitis: A randomized pilot study. JAOA 98(5): 264-272. 1998.

Steele KM. Treatment of the Acutely Ill Hospitalized Patient. Foundations for Osteopathic Medicine.

Williams & Wilkins: Baltimore. 1037-1048. 1997

Images were scanned from the second edition of the Foundations for Osteopathic Medicine. Lippincott

Williams & Wilkins: Philadelphia. 2003

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