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Osteopathic Manipulative Treatment (OMT) for the OB-GYN PatientMarch 2021 Brown Bag Lecture Kelsie Cabrera, DO, MS, Assistant ProfessorUNMC Dept. of OB-GYN

I have no financial disclosures.

Objectives1. Discuss the philosophy of Osteopathic Manipulative

Treatment (OMT)2. Describe physiological changes in pregnancy that

impact women’s musculoskeletal system3. Articulate how OMT may be used in the OBGYN

clinical setting

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Main Sections• Osteopathic Philosophy• Physiological Changes in Pregnancy• Osteopathy in Pregnancy• Osteopathy in Gynecology• OMT Techniques• Research: OMT in Pregnancy

Osteopathic Philosophy

https://www.kirksvilledailyexpress.com/news/20191104/dr‐at‐still‐‐‐americas‐healthcare‐disruptor‐premieres‐thursday‐in‐kirksville

How It Began• Founder: Andrew Taylor Still, MD, DO (1828-1917)• Convinced patient care was inadequate

• Desired to improve surgery, obstetrics, and general treatment of disease

• Began in-depth study of anatomy, physics, chemistry and biology

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What is Osteopathy?“It is a scientific knowledge of anatomy and physiology in the hands of a person of intelligence and skill, who can apply that knowledge to the use of man when sick or wounded by strains, shocks, falls or mechanical derangement or injury of any kind to the body” - A.T. Still

General Philosophy• The human being is a dynamic unit of function• The body possesses self-regulatory mechanisms that

are self-healing in nature• Structure and function are interrelated at all levels• Rational of treatment is based on these principles

Osteopathic Approaches to Patient Care• Biomechanical model: muscles, spine, posture, motion• Respiratory-Circulatory model: rib cage, diaphragm,

respiration, circulation, venous and lymphatic drainage• Neurological model: head, brain, spinal cord, control,

coordination, sensation• Metabolic-Energy model: internal organs, endocrine

glands, metabolic processes, homeostasis, energy, regulatory processes, digestion, removal of waste

• Behavioral model: patient’s lifestyle, environmental stressors, values and choices

The 5 coordinated body functions

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Somatic Dysfunction• Impaired or altered function of related components of

the somatic (bodywork) system including: the skeletal, arthrodial, and myofascial structures, and their related vascular, lymphatic, and neural elements.

• Diagnosed using “TART”• Tissue texture changes• Asymmetry• Restriction of motion• Tenderness

Physiological changes in pregnancy

https://theexpectingmamasnetwork.com/pregnancy‐memes‐new‐mom‐memes/

Spinal Column• Balance points or fulcrums

• C7-T1, T12-L1, L5-S1• Pelvis tilts forward

• Increased lumbar lordosis as counterbalance• Increased thoracic kyphosis

• Anterior/Posterior curve changes reduce the efficiency of the spinal system

• Shifts stresses from ligamentous and disk-oriented to strenuous muscle-controlled

https://www.physio‐pedia.com/File:Pregnancy.png

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Spinal Column• Distension of abdomen reduces muscular capacity to

counterbalance • SI joints and ligaments become more lax• Pubic symphysis widens

https://www.physio‐pedia.com/File:Pregnancy.png

MusclesIliopsoas• Major contributor in the

column support system• Crosses L5-S1

• Originates at transverse processes of L1-L5, anterolateral surfaces of vertebral bodies T12-L5

• Distributes forces to the sacrum

• Supports viscera and growing uterus

Psoas Syndrome:• Central lower back pain• Flexed forward, list to

one side

MusclesPiriformis Syndrome:• Aching pain in gluteal

region• Aggravated by sitting• Paresthesia down

posterior aspect of thigh

Piriformis• Originates on anterior

surface of sacrum • Inserts on upper aspect

of greater trochanter• Distal and lateral to

lumbosacral junction

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Respiratory • Normal breathing is anatomically dependent on a

level pelvis and straight spine• Thoracic cage is suspended from spine

• Changes in mechanical configuration of thoracic cage• Circumference increases 5-7cm• Subcostal angle widens from 68 to 103 degrees• Diaphragm pushed superiorly 4cm

• Decreased expiratory reserve volume and residual volume

• Increased tidal volume

Neurological • Peripheral nerves susceptible to injury due to

compression, traction and ischemia• Uterus puts pressure on pelvic organs, ligaments,

lumbosacral plexus and lower limb peripheral nerves• Example: lateral femoral cutaneous nerve

compression

Lymphatic• Increase of interstitial fluids

• Increase 6.5L over course of pregnancy• 3.5L from fetus, placenta and amniotic fluid• 3L from maternal blood volume and size of

uterus and breasts• Increased demand to pelvic organs for

metabolic needs of fetus • Increase in estrogen, progesterone and adrenal

hormones• Promotes fluid retention (tissue edema)

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Resulting Symptoms• Low back pain• Thoracic/mid-back pain• Anterior head and neck causing tension headache• Loss of balance• Pain with upright posture• Psoas syndrome• Fatigue• Edema• Neuropathy• Pubic symphysis pain

https://www.boredpanda.com/pregnancy‐memes/?utm_source=google&utm_medium=organic&utm_campaign=organic

Osteopathy in Pregnancy

https://me.me/

Osteopathy in Pregnancy• Enhances homeostasis• Facilitates adaption to structural and hormonal

changes• Alleviates discomfort• Saves patient energy

• Musculoskeletal dysfunction increases demands up to 300%

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Indications• Somatic dysfunction • Scoliosis or structural

condition associated with pregnancy

• Edema or congestion• Other pregnancy-

associated condition amendable to OMT

https://familydoctor.org/back‐pain‐pregnancy/

Contraindications• Premature rupture of

membranes• Premature labor

Absolute

• Undiagnosed vaginal bleeding

• Prolapsed umbilical cord

• Placental abruption• Ectopic pregnancy• Placenta previa• Threatened or

incomplete abortion• Severe pre-

eclampsia/eclampsia

Relative

Osteopathy in Gynecology

https://www.pinterest.com/pin/32017847330101959/

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Osteopathy in Gynecology • May reduce severity of pelvic pain

• Endometriosis

• Assists with PMS symptoms• Headaches

• Bloating/bowel frequency

OMT Techniques

www.webmd.com

Note: Links to videos of techniques are available at the end of this presentation.

Common Types of OMT• Muscle Energy: patient’s muscles are actively used

in a specific direction against a counterforce• Engage barrier, patient resists for 3-5 seconds, both

relax and then further engage barrier. Repeat.

• Soft Tissue/Myofascial Release: direct techniques by engaging a loaded, constant, direction force until tissue releases.

• High Velocity Low Amplitude (HVLA): rapid, therapeutic force of brief duration that engages restrictive barrier to elicit release of restriction. “popping technique”

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Positions• Supine• Lateral recumbent• Seated • Prone

https://www.thoughtco.com/anatomical‐position‐definitions‐illustrations‐4175376

Areas of Focus- OB• Areas of transition- serve as fulcrums

• C7-T1

• T12-L1

• L5-S1

• Iliopsoas muscle• mainstay in column support and crosses L5-S1

• Piriformis muscle • Pelvis/Sacrum/Pubic Symphysis• Mechanics of Pulmonary Respiration

• Helps venous blood return and lymphatic drainage

Areas of Focus- GYN• Dysmenorrhea: Patient may self-treat utilizing knee-

chest position• Helps to decompress pelvis• Increases drainage• Lifts uterus out of the pelvis

• PMS symptoms• Headaches- cervical/suboccipital region • Bloating/bowel frequency- lymphatics

• Pelvic pain• Thoracic and lumbar spine• Sacrum• Pelvic diaphragm relieves pelvic congestion• Trigger points

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Cervical SpineSuboccipital ReleaseParaspinal Muscles

Thoracic/Lumbar SpineParaspinal Muscles

Thoracic CageRib Raising

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PelvisIliopsoas Muscle

PelvisPiriformis

Sacrum– Patient supine, doctor at

side – Patient’s hips and knees

flexed with feet together, knees fall to side

– Doctor contacts sacrum– Sacrum taken to point of

ligamentous balance with respiratory assistance

– Patient holds breath and straightens legs

Frog Leg Sacral Articulation

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Pubic Symphysis

Carpal Tunnel

ExtremitiesEffleurage/Petrissage

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Research: OMT in Pregnancy

Osteopathic Manipulative Treatment of Back Pain and Related Symptoms During Pregnancy

• Randomized trial • Usual obstetrical care (UOBC)• + OMT (UOBC-OMT)• + Sham Ultrasound (UOBC-SUT)

• 30 minute treatment (32, 34, 36, 37, 38 and 39 weeks)• 146 total subjects (49, 49, 48 respectively)• Mean pain levels decreased in the UOBC+OMT group,

remained unchanged in the UOBC+SUT group, and increased in the UOBC only group

American Journal of Obstetrics and Gynecology, January 2010 J. Licciardone, et al

Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects (PROMOTE)

• Randomized Trial• Usual care only• +OMT• +Placebo Ultrasound Treatment (PUT)

• 20 minute treatments started at 30 week gestation (30, 32, 34, 36, 37, 38, 39)

• 400 participants• Slower rate of deterioration of back-specific functioning in

participants receiving an OMT protocol compared with participants receiving UCO. • It also showed that OMT mitigated pain progression compared

with UCO. • No statistically significant difference was found between the

OMT group and the PUT group

JAOA November 2016K. Hensel, et al.

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Conclusion• OMT can be used for various complaints throughout

pregnancy and certain gynecologic conditions• Simple techniques can be taught to family members

for continued relief• Keep in mind relative and absolute contraindications

to OMT in pregnancy

Resources1. Tettambel, M. "Low Back Pain in Pregnancy." Foundations of

Osteopathic Medicine. 3rd ed. Wolters Kluwer.2. DiGiovanna, E. (2005). Gynecologic Considerations. In An

Osteopathic Approach to Diangosis and Treatment (3rd ed., pp. 651-657). Philadelphia: Lippincott WIlliams & Wilkins.

3. Hensel, DO, K., Buchanan, DO, S., Brown, S., Rodriguez, M., & Cruser, D. (2015). Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects: The PROMOTE study. Am J Obstet Gynecol.

4. Hensel, DO, K., Pacchia, C., and Smith, M. Acute improvement in hemodynamic control after osteopathic manipulative treatment in the third trimester of pregnancy, 2013-12-01Z, Volume 21, Issue 6, Pages 618-626

5. Licciardone, DO, J. et al. (2010). Osteopathic Manipulative Treatment of Back Pain and Related Symptoms during Pregnancy: A Randomized Controlled Trial. Am J ObstetGynecol.

6. Cunningham, F. G. (2014). Williams Obstetrics. New York: McgrawHill Medical

Video Resources• Suboccipital Release:

https://www.youtube.com/watch?v=AcnBZsM6qjI• Paraspinal muscles:

https://www.youtube.com/watch?v=yOa9NlIzyCs• Rib Raising: https://www.youtube.com/watch?v=A4lW9K7v5TA• Psoas: https://www.youtube.com/watch?v=4ao-5CibplY• Pubic Symphysis:

https://www.youtube.com/watch?v=ky5GQt5ypE0

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Questions?

https://marsandstarsbaby.com/9‐pregnancy‐memes‐mom‐future‐mom‐can‐totally‐relate/