12/7/15 1 Ryan A. Seals DO Assistant Professor OMM Year 2 course director An Osteopathic Approach to Low Back Pain Using Still Technique Objectives • Review Osteopathic Philosophy and Principles • Recall the differential diagnosis of low back pain • Discuss how somatic dysfunction influences low back pain • Discuss billing and coding for OMT • Review research supporting OMT Goals • Provide a framework for using OMT to treat low back pain • Give a logical sequence for treating somatic dysfunction associated with low back pain • Introduce Still Techniques for the pelvis, sacrum, and lumbar spine • Give opportunity for hands on practice!
Transcript
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Ryan A. Seals DO Assistant Professor OMM Year 2 course director
An Osteopathic Approach to Low Back Pain Using Still Technique
Objectives
• Review Osteopathic Philosophy and Principles • Recall the differential diagnosis of low back pain • Discuss how somatic dysfunction influences low
back pain • Discuss billing and coding for OMT • Review research supporting OMT
Goals
• Provide a framework for using OMT to treat low back pain
• Give a logical sequence for treating somatic dysfunction associated with low back pain
• Introduce Still Techniques for the pelvis, sacrum, and lumbar spine
• Give opportunity for hands on practice!
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Case
• A 56 year-old male presents to the clinic with lower back pain. The pain started about two weeks ago after he was moving boxes at home. Pain is worse when bending over or trying to lay flat. Denies numbness, tingling, or weakness.
• Exam: Reflexes are 2/4 in lower extremity, strength is 5/5, sensation is normal. Straight leg raise is negative. Bilateral lumbar paraspinal hypertonicity is noted.
Significance of LBP
• Affects 5.6 % of U.S. adults daily. • 18 % of U.S. adults report having LBP in past month. • Lifetime prevalence 60-70%.
Kindkade, Scott, MD, Evaluation and Treatment of Acute Low Back Pain, American Family Physician Vol 75 No 8 April 15, 2007.
Patients Presenting with LBP
• 25 % of patients with LBP seek medical attention. • One of top three reasons to go to FM doctor. • FM doctors see more LBP than any other specialist
and more than Ortho and Neurosurgery combined.
Kindkade, Scott, MD, Evaluation and Treatment of Acute Low Back Pain, American Family Physician Vol 75 No 8 April 15, 2007.
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Red Flags • Spinal Fracture
• Significant trauma • Prolonged glucocorticoid use • Age > 50 yr
• Infection or Cancer • History of cancer • Unexplained weight loss • Immunosuppression • Injection drug use • Nocturnal pain • Age > 50 yr
• Cauda Equina Syndrome • Urinary retention • Overflow incontinence • Fecal incontinence • Bilateral or progressive motor
deficit • Saddle anesthesia
• Spondyloarthritis • Severe morning stiffness • Pain improves with exercise, not
rest • Pain during second half of night • Alternating buttock pain • Age < 40 yr
Less than 5% of low back pain
Kelley's Textbook of Rheumatology , Ninth Edition Gary S. Firestein, et al. Chapter 47 Low Back pain
Differential Diagnosis
• Mechanical 97% • Degenerative Joint Disease 10% • Herniated Nucleus Pulposus 4% • Osteoporotic Compression Fx 4% • Spinal Stenosis 3% • Spondylolisthesis 2% • Majority have no “medical” cause (74%)
• Considered Lumbar sprain/strain
Kindkade, Scott, MD, Evaluation and Treatment of Acute Low Back Pain, American Family Physician Vol 75 No 8 April 15, 2007.
Mechanical Low Back Pain
• Sclerotomal pain • This pain can arise from pathology within the disk, facet
joint, or lumbar paraspinal muscles and ligaments. • Like sciatica, sclerotomal pain is often referred into the
lower extremities, but unlike sciatica, sclerotomal pain is nondermatomal in distribution, it is dull in quality, and the pain usually does not radiate below the knee or have associated paresthesias.
• Most radiant pain is sclerotomal
Kelley's Textbook of Rheumatology , Ninth Edition Gary S. Firestein, et al. Chapter 47 Low Back pain
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Referred Pain Differentiation
DERMATOMAL FACET SACROILIAC GLUTEUS MINIMUS PIRIFORMIS Differential diagnosis for referred pain to the posterior buttock, thigh, calf, and ankle. A) dermatome referred pain from irritation of the S1 nerve root B) sclerotomal referred pain from irritation of the L4-5 facet joint and/or capsule C) sclerotomal referred pain from the sacroiliac joint and/or sacroiliac ligaments; D) myotomal referred pain from the gluteus minimus muscle 1) posteriorly, and 2) anteriorly; E) myotomal referred pain from the piriformis muscle in full-blown piriformis syndrome. (A, B, and C taken from Mooney V, Saal J, Saal J. Evaluation and treatment of low back pain. Clinical Symposia 1996: 48(4); pages 4 and 11. D and E taken from Travell J, Simons D. Trigger
Point Flip Charts, Lippincott Williams & Wilkins 1996.)
How do you approach this patient? • Look for red flags
• Imaging • Not in the absence of red flags or trauma
• NSAIDs, Muscle Relaxer, Opiods • All “weak” recommendations
• Encourage patient to stay active • Avoid bed rest
“Dirty Half-Dozen” Failed Back Syndrome (Greenman) 1. Non-neutral lumbar somatic dysfunction 2. Pubic shear 3. Posterior sacral base or backward sacral torsion 4. Innominate shear 5. Short leg and pelvic tilt syndrome 6. Muscular imbalance of the trunk and lower
extremity (including psoas syndrome)
A study of 183 patients with disabling low back pain with an average of 30.7 months From Greenman PE Syndromes of the Lumbar Spine, Pelvis, and Sacrum Physical Medicine and Rehabilitation Clinics of North America
Volume 7 Number 4 November 1996 pp. 773-785.
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Osteopathic Approach to LBP
• Diagnose and treat dysfunctions in the pelvis, sacrum, lumbars, and lower extremities.
• This will give you good results • Is there a more efficient way??
Dr. Stiles believes that finding the Area of Greatest Restriction (AGR) or the Key Lesion to be the single most crucial issue for obtaining clinical results with OMT.
Never Chase Pain!!! • Pain is the biggest Liar
• Stepping on a cats tail
• Often, the AGR/Key Lesion is in an area totally uninvolved in the Chief Complaint and pain associated is secondary to compensation.
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Tensegrity Structure
• Act as anti-gravity system • Struts or rods = Bones • Wires or tension lines = muscles,
tendons, fascia • Change in one part affects others
Tensegrity “Floating Compression”
Example of Tensegrity on the “Mall” Washington, D.C.
• LIPLSIP • Lower Extremity • Innominate shears • Pubic shears • Lumbar (non-compensated L5) • Sacrum • Ilia Rotations and flares • Psoas (some people would treat this first with lower
extremity)
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You are likely out of sequence if. . .
• Only the area treated improves • Or doesn’t improve with appropriate technique
• The diagnostic patterns don’t match the book • E.g. sacral diagnosis doesn’t fit
• Same somatic dysfunctions keep recurring
Pubic axis
STA
MTA
ROA
ITA
LOA
Ant/post axis
Thoughts on treatment
• If treating a major restriction, then at least 20% of the other dysfunctions should improve
• You can often do a full treatment by treating 2-4 body regions
• Goal is to remove restrictions so that the body can heal itself
• Not treat every area that hurts
Summary
• Screen spine to find AGR • If AGR is in lumbosacral area then:
• Diagnose and treat the pubic and innominate shears • If still restrictions, then diagnose and treat lumbar spine • If still restrictions, then diagnose and treat sacrum • If still restrictions, then diagnose and treat ilia rotations
• Always rescreen spine for AGR after each treatment performed and find the next AGR for treatment
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PRACTICE FINDING AGR AND FIND LUMBAR, SACRUM,
AND PELVIC DIAGNOSIS
Dr. Still • Did not write down many techniques • In Osteopathy, Research & Practice, Dr. Still
recorded twenty-four vague descriptions of techniques he used to treat specific musculoskeletal dysfunctions.
• Still’s Students (one was Dr. Hazzard), also described a few techniques
• Dr. Van Buskirk looked at the techniques described, analyzed the neurophysiology and then applied that physiology to develop techniques for the rest of the body.
Video
Still Technique- Steps • Evaluate the affected tissue and place it in its position of ease • Introduce a force vector (compression or traction) to the affected tissue from another
part of the body. This should be less than 5 pounds. • While maintaining this force vector, move the tissues from the position of ease
toward and through the position of the restriction in a smooth motion. • As the tissue moves through its restriction, a “bump” and/or “click” may be felt or
heard (although neither is necessary for correction of the dysfunction). • Do not take the tissue too far into (or past) the barrier as this can be uncomfortable for
the patient and can be irritating to the tissues • You want to “nudge” the barrier and be very localized with your force.
• The compression is released and the region is passively returned to neutral • Retest
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Application • The combination of physiological effects means the Still
technique works well at an articular level, but also at fascial and muscular levels.
• It can be used for articular, muscular, tendonous, ligamentous and soft tissue injuries.
• This technique requires specific articulatory diagnosis which is no different than other OMM techniques.
• Depending on the type of injury, either traction or compression may work better.
• Just as with any OMT technique, we use our monitoring palpation to guide us through the treatment.
More About The Force Vector
• Vector goes from your operating hand, in a straight line, to your palpating finger on the dysfunctional tissue.
• Vector is not necessarily axial • The minimal amount of compression or
traction you can feel at the dysfunctional tissue is all you need.
• Excessive force will tend to lock the tissues and the treatment will cause discomfort.
• The more precise the vector is aimed at the dysfunction, the less force is needed and the greater chance for success you will have.
Palpation Exercise
• Partner up • Patient seated and physician standing in front
• Palpate the posterior aspect of rib one with one hand • Contact the elbow with the other hand • Move the elbow until you feel motion at the rib • Add force vector • Recheck motion
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Diagnosis
• Superior Innominate Shear • All landmarks are superior on one side of the pelvis
compared to the other • ASIS, PSIS, Ischial tuberosity, pubic ramus
• Pubic Shear • Pubic rami are asymmetrical • Other findings are inconsistent
• Use standing flexion test to determine side of dysfunction
Pubic axis
Treatment Approach
• Superior Innominate Shears • Patient supine • Physician contacts ankle and externally rotates the hip • Add traction and internally rotate the hip • Treat upper and lower poles of SI joint for full resolution
• Pubic Shears • Patient supine with knees bent • Contact knees and add compression toward pubic bone • While maintaining compression, move legs laterally in abduction • At about 60 degrees have patient straighten their legs
Sacral Diagnosis (simplified!)
• Unilateral Sacrum • Seated flexion test and posterior ILA on SAME side
• Diagonal Sacrum • Seated flexion test and posterior ILA on Opposite sides
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Treatment Approach • Unilateral Sacrum
• Patient supine • Physician stands on side opposite of dysfunctional sacrum • Opposite leg is flexed to 90 degrees and abducted • Compression is added to side of dysfunctional sacrum • Knee is moved across midline and then inferiorly
• Diagonal Sacrum • Patient supine with knees and hips bent • Knees and thighs are aligned with axis of sacral diagnosis • Add compression through the knees to the sacrum • Side bend legs to involve opposite sacral axis, then extend legs
Still- Summary
• Still technique is an indirect to direct, non-repetitive, articular technique using a force vector as an activating force.
• Based on sound physiology. • Like all OMM techniques, Still technique uses different combinations
of our physiological tools. • It is effective. • It is gentle and can be repeated if needed. • It is efficient both in diagnostic protocol and treatment time so it is
easily used in clinical practice.
Volume 341:1426-1431 November 4, 1999 Number 19
Results: The osteopathic-treatment group required significantly less medication (analgesics, antiinflammatory agents, and muscle relaxants) (P< 0.001) and used less physical therapy (0.2 percent vs. 2.6 percent,
• Licciardone, JC, et. al. Annals of Family Medicine. 11:2. March/April 2013.
• According to the study, OMT was not only more effective than ultrasound for treating low back pain, but its use also allowed participants to cut down on the amount of medication they took to treat their lower back pain throughout the 12-week study.
• Nearly two-thirds of the individuals who received OMT had a 30 percent reduction in their pain level, and half of those patients had a 50 percent reduction in their pain level, the study showed.
• Plan • Osteopathic Manipulation to 3-4 regions (98926) • Educated patient on proper lifting • Stretches and back exercises given- encouraged gentle activity • Consider Heat, NSAID and/or muscle relaxant • RTC in 1-2 weeks if not improved
