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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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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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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
1 of 2
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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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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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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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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
Foundations for Osteopathic Medicine, 2nd. Edition, p. 425
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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.
Foundations for Osteopathic Medicine, 2nd. Edition, p. 426
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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.
Foundations for Osteopathic Medicine, 2nd. Edition, p. 426
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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
Foundations for Osteopathic Medicine, 2nd. Edition, p. 426
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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.
Foundations for Osteopathic Medicine, 2nd. Edition, p. 427
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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.
Foundations for Osteopathic Medicine, 2nd. Edition, p. 427
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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.
Foundations for Osteopathic Medicine, 2nd. Edition, p. 427
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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