Understanding and Treating Chronic Fatigue Syndrome and Fibromyalgia

This article provides an overview of Fibromyalgia and Chronic Fatigue Syndrome, including information about symptoms and homeostasis (self-healing).

"The most commonly accepted definition (devised by the American College of Rheumatology in 1990) is that the person affected needs to show a history of widespread pain (pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist and pain below the waist. In addition there should be pain in the spine or the neck or front of the chest, or thoracic spine or lower back) and pain in 11 of 18 tender point sites on finger pressure."

Basic Symptoms of Fibromyalgia

Multiple tender areas (muscle and joint pain) on the back of the neck, shoulders, sternum, lower back, hip, shin, elbows, knees.
Fatigue
Sleep disturbances
Body aches
Reduced exercise tolerance
Chronic facial muscle pain or aching

"Both Chronic Fatigue Syndrome and Fibromyalgia often seem to begin after an infection or a severe shock (physical or emotional), and the symptoms are very similar. The only obvious difference seems to be that for some people the fatigue element is the most dominant while for others the muscular pain symptoms are greatest. In other words for many people the diagnosis Chronic Fatigue Syndrome and Fibromyalgia are interchangeable terms, although there are certain symptoms (fever, swollen glands for example) which are found in a higher percentage of Chronic Fatigue Syndrome patients than those with Fibromyalgia, which sometimes make such a comparison less precise."


Treatment:

Osteopathic treatment is based on the premise that restricted movement in the spine may lead to reduced function and pain. Spinal adjustment (manipulation) is one form of therapy a chiropractor uses to treat restricted spinal mobility. The goal is to restore spinal movement and, as a result, improve function, decreasing pain. Manipulation does not need to be forceful to be effective. A osteopathic physician may also use soft tissue massage in the treatment of FMS, stretching muscles that are shortened or in spasm.

You may also consider:

Diet And Nutrition

A natural Fibromyalgia Treatment and balanced fibromyalgia nutrition diet can be helpful in counteracting stress, removing toxins from the body, and restoring the natural balance of nutrients. Homeopathy medicine, FIBRO-HELP products, help patients by combatting stress, replacing deficiencies, and supporting the immune system. Patients are recommended to limit the amount of sugar; caffeine; alcohol; and fried, processed, fatty foods consumed. These substances have been shown to irritate muscles and stress the system increasing FM pain. Even for those patients who do not have severe food triggers or allergies, eating a healthier diet can have long-term benefits in the treatment of fibromyalgia. Supplementing the present diet with greater quantities of raw or lightly cooked fruits and vegetables, and substituting meats that are high in fat with fish or lean poultry, are also beneficial practices.

Exercise
Fibromyalgia Exercise is one of the most powerful remedies in the treatment of fibromyalgia. Increasing scientific evidence has shown that exercising for a minimum of 20 minutes per day will help fibromyalgia patients as a natural fibromyalgia treatment. Exercise becomes a key component in healing FM Syndrome patients because a properly designed routine will improve the body tissues, decrease pain, and increase mobility. The fibromyalgia exercise program must be slow and gradual. The goal is to improve overall health while decreasing FM symptoms.

Homeopathy

The word Homeopathy (or Homoeopathy) is derived from the Greek words “homoios”, meaning “like” or “similar”; and “pathos”, meaning “suffering” or ”disease”. Homeopathy is a system of medical therapeutics for treating based on the principle of “similae” or “simile.” “Disease is eliminated through remedies able to produce similar symptoms.” The principle is that certain substances (herbs, minerals, inorganic salts, and other organic materials, etc.) in full strength yield the same symptoms as does a known disease, and that those same substances when "potentised" (or diluted and vigorously agitated) can provide relief of those same symptoms. Titrated dilutions and succussions of a particular substance can often be the means for fibromyalgia treatment. Today, unlike nutritional substances, Homeopathy substances are considered medicines, recognized as powerful entities which allow specific medical claims to be made about them.

Massage Therapy

Massage involves the use of different manipulative techniques to move the body's muscles and soft tissues. Massage Therapy aims to improve circulation in the muscle, increasing the flow of nutrients, eliminating waste products. Massage can relax muscles, improve range of motion in the joints, and increase the production of the body's natural painkillers. It often helps relieve stress and anxiety for those afflicted with the symptoms of pain.

Physiatry

Physicians who specialize in Physical Medicine and Rehabilitation are called Physiatrists. Doctors of Physiatry specialize in the diagnosis and treatment of patients in 3 major areas of medical care: musculoskeletal injuries and pain syndromes, Electrodiagnostic Medicine, and rehabilitation of patients with severe physical impairments.

Physiotherapy

Physical Therapy is a health care profession that helps the patient restore the use of muscles, bones, and the nervous system. The basics of the physical therapy profession include the use of modalities like ice, heat, ultrasound, and electrical stimulation. Therapeutic exercises, therapeutic massage, manual therapy, and hydrotherapy-aquatic therapy are all used for pain relief and fibromyalgia treatment.

Self Care

Self Care is critical in the treatment of Fibromyalgia Syndrome. Some important tips for self care:

• Reduce Stress - Avoid or limit overexertion and emotional stress. Allow time to relax daily practicing stress reduction techniques such as deep-breathing exercises or meditation for FMS treatment. Sleep - Fatigue is one of the major symptoms of FM, getting enough sleep is essential. In addition to allotting enough time for sleep, get into a routine of sleeping and waking up at the same hour each day. Take short naps to restore energy in the body. Fibromyalgia Exercise - Regular exercise will help improve chronic pain symptoms. Stretching, optimum posture techniques, and relaxation practices are also helpful.

• Pacing - Keep a balance on daily activities. If too much is done on a good day, take time off the following day, and rest to avoid bad days.

• Nutrition and Healthy Lifestyle - Eat a balanced diet, limit caffeine and alcohol intake, get plenty of rest, exercise regularly, and do a leisure activity which is enjoyable and fulfilling as a complete FIBRO treatment.

Osteopathic manual medicine technique: Strain /Counterstrain Technique Development

"If You listen to the body it will tell you all you need to know!"
L. H. Jones D.O.


Strain Counterstrain is an Osteopathic manual medicine technique. It emphasizes correction of abnormal neuromuscular reflexes rather than simply addressing painful, postural or structural problems. Counterstrain recognizes that these structural, postural and painful problems are a result of the abnormal reflexes. Until these abnormal neuromuscular reflexes are addressed significant healing is difficult.

Dr. L.H. Jones initially discovered Strain Counterstrain accidentally while trying to achieve a successful treatment of a patient suffering from psoasitis. He was able to help this patient by simply applying a position of comfort for a short period of time while the patient remained passive.

It was approximately 2 years later that a second experience with this new technique helped him to understand the meaning of tender points. These are extremely useful findings in somatic dysfunctions.

Tenderpoints are manifestations of somatic dysfunction much as are the other TART changes. TART changes are seen as tissue Texture changes, Asymmetry, altered Range of motion, and Tenderness. The tenderpoint is a discrete pea sized area of tenderness that is uniquely a part of a somatic dysfunction. Each tenderpoint is a manifestation of a specific abnormal reflex that allows the practitioner to fashion a specific treatment for each patient.

Dr. Jones developed a whole system based on understanding the tenderpoint. It is a unique finding with Strain/Counterstrain that the tenderpoint is found in the shortened muscle group, not in the muscle groups that most commonly present with pain. The treatment is achieved by placing a mild over stretching on the painful muscle thereby shortening the truly dysfunctional muscle group allowing for a reset of this abnormal reflex to a normal level.

For more information see Jones Strain/CounterStrain, by L.H. Jones DO, Randall Kusonose PT, and Edward K. Goering DO.
Published by Jones Strain/Counterstrain Inc.

Dr. Jones worked within the osteopathic and physical therapy profession to develop a coherent method to teach and standardize Strain/Counterstrain techniques. Strain/Counterstrain is considered one of the primary osteopathic manual medicine techniques and as such is taught in all the osteopathic schools worldwide. The American Academy of Osteopathy and the Jones Institute offer courses throughout the United States for qualified health care professionals. Please see course page for more information.

You were wondering ...What is the difference between a D.O. and an M.D.?

You were wondering ...


What is the difference between a D.O. and an M.D.?

It's more than just a bunch of letters. Doctors of osteopathy, better known as D.O.s, are licensed physicians just like their M.D. -- medical doctor or allopathic -- colleagues. The difference lies in their approach. Osteopathic medicine focuses on treating the patient as a whole, rather than focusing on just one part of the body.

Like an M.D., an osteopathic doctor attends four years of medical school and can practice in any specialty. But an osteopath also spends an additional 300 to 500 hours in the study of the body's musculoskeletal system and hands-on manipulative medicine.

Manipulation is a hands-on treatment that is done to make sure the body is moving freely. The motion is done to ensure the body's healing systems aren't being hindered in any way. It's based on the theory that the body's systems are interconnected.

Osteopathy dates back to 1874, when Dr. Andrew Taylor Still, an M.D., became frustrated with the medical practice. He believed the human body possessed the ability to heal itself. So he developed the manipulative techniques.

Common Shoulder Dysfunctions

Posterior shoulder musculature (rotator cuff). Anterior shoulder musculature. Notice the intimate relationship between the scapula and the rib cage. If the ribs and spine suffer from neuromuscular dysfunction, there is no way that the shoulder joint can’t be affected.

Shoulder problems are interesting and one of my favorite regions of the body to treat. One of the things that many health care providers fail to realize is the underlying cause of the degenerative processes that lead to eventual tissue failure. There is no reason that computer use would cause any more detrimental force than any other activity, on the contrary I would say just the opposite. Now if this is the primary activity of the involved shoulder then we have other considerations, such as progressive weakening, adaptive shortening of contractile tissues and an increase in fibrosis changes at the cellular level. All of these things can happen from disuse and misuse, or as a result of neuromuscular dysfunction. I find that the majority of people who suffer from a torn rotator cuff, tendonitis or other chronic irritations of this incredible joint have the latter, neuromuscular dysfunction (NMD). So what is NMD? It is a reflexive disorder of the body's built in soft tissue and joint injury defense system. In the shoulder is it most often present as upper thoracic spine dysfunction and associated costal cage dysfunction (ribs). This may sound strange, especially if you are like most people and tend to think of problems and the pain one feels as the same thing. In reality, the pain is usually not the problem, only a symptom of the dysfunction. The ribs, especially the top 5 are crucial to the functional integrity of the scapulothoracic joint (articulation of the scapulae and posterior costal cage). In most cases of shoulder NMD the contour of the ribs is uneven. A single rib or two that become elevated (posterior aspect of rib) and/or depressed (anterior aspect) can result in structural compensation of the entire shoulder girdle. The shoulder girdle is comprised of all of the 4 joints in the shoulder and all of the scapular and glenohumeral (true shoulder joint of upper arm and shoulder blade) musculature. When this happens there is a marked increase in the demands (load) placed on the muscles of the rotator cuff, especially the supraspinatus muscle. The rib dysfunction essentially causes a migration of the shoulder blade towards the front of the body and tilts the shoulder blade up and forward. This causes a marked increase in the stretch applied to the shoulder muscles in the back and a marked shortening of the shoulder muscles in the front. This looks like your typical poor, slouched posture, but has nothing to do with ones conscious ability to affect posture; it has everything to do with the bodies' reflexive protective spasm response to inappropriate nerve signals from our muscle and connective tissues. In some cases, the spine will not be bent forward; it will actually be in an extreme upright position. This is equally troublesome because it interferes with the mechanics of the scapulae and ribs by causing the same type of disturbance in the costo-vertebral joints (place where the rib attaches to the spine) found in the forward bent spine.

Strain and Counterstrain

Strain and Counterstrain was developed by Lawrence Jones, D.O. It has been used for over fifty years to improve range of motion and flexibility in athletes and other patients. Over the last 30 years, Strain and Counterstrain has been proven successful on all patient populations, including orthopedic, neurologic, geriatric, and pediatric. Strain and Counterstrain Technique eliminates protective muscle spasm in skeletal muscles. It is common knowledge that a skeletal muscle like the biceps muscle can go into protective muscle spasm. What is less widely known is protective muscle spasm of smooth muscle. Smooth muscle lines all the vessels in our body. When smooth muscle goes into spasm, it causes the vessels in our body to become rigid and inflexible. This affects blood pressure and overall circulation. In turn, this affects range of motion and joint mobility of neighboring joints because the body tries to protect the compromised vessel.

How it works – The basics of physiology

Muscle origin and insertion

All muscles have a starting point on a bone (origin) and an ending point on a bone (insertion). Muscles are attached to the bone by a tendon. Think of a chicken drumstick. When you pull the meat away from the bone, it is adhered at the end by a clear or whitish tough cord. This is the tendon. A therapist can move a muscle into a lengthened position (stretch) or shortened position by knowing the origin and insertion of that particular muscle. By moving the bones, muscles can be put into a fully lengthened position, a shortened position or anywhere in between.

Sensory Input and Motor Output

All muscles communicate to the spinal cord and brain (central nervous system) via sensory nerves and receptors located in the tendon. These receptors called golgi tendon organs and muscle spindle fibers, relay information about the length of the muscles and how fast and in what direction the muscle is moving the bones and joints. They also communicate what state of contraction the muscle is in at rest (muscle tone). This is a part of our sensory feedback system which the nervous system uses to decide how to instruct the muscle what to do next (motor output). Our sensory system is highly sophisticated and sensitive. It provides our nervous system with the information to make rapid decisions to plot a course of action based on the desired activity of the brain while also avoiding injury.

Muscle Tone

Our central nervous system supplies a certain amount of constant output to each of our muscles. This is called the muscles’ tone. Without any input the muscle is flaccid (abnormal state) as seen in a stroke. With too much output a muscle is spastic and can make lengthening movement of a muscle nearly impossible. In between flaccid and spastic is a resting state for normal that varies with the individual.

Muscle tone continuum

l_______l______l_______l_________l______l________l________l

FLACCID RELAXED NORMAL TENSE SPASM SPASTIC
(ABNORMAL) (ABNORMAL)

Muscle spasm – A vicious cycle.

A protective mechanism of the body based on these principles is called a muscle spasm. When the body perceives danger to a joint, the nervous system instructs the muscle to contract strongly to prevent movement that may cause damage. The muscle can stay in this state for a few minutes or a few days. It can become chronic and then this mechanism rarely serves to help or protect the body any longer and can become detrimental.

A vicious cycle is developed with pain, muscle guarding and muscle spasm.

A muscle in spasm is constantly sending signals to the nervous system, much like listening to music that is too loud. The nervous system reacts by sending strong signals right back. This is how a muscle can get into a vicious circle with the nervous system.

How it works – the technique

• The therapist identifies the muscle in spasm.
• The muscle can be in visible or palpable spasm or can be identified by “tender points”. The therapist positions the body so the muscle is in a shortened position and holds the position for at least 90 seconds. At times, the position is held greater that 5 minutes waiting for changes in muscle and fascia (tissues surrounding muscles and organs. More about this will be explained in future articles.)
• The therapist monitors tissue change and waits for optimum improvement to occur.

The shortened position of a muscle is a non-threatening position for a muscle in spasm. The communication from the muscle to the nervous system at this time is one of relaxation. The nervous system no longer receives the excessive feedback from the muscle and instructs the muscle tone to change from spasm to a resting tone. Relief and restoration of motion is often immediate. By disarming muscle spasm in major muscle groups the body is able to return to pain free function and pain free movement can be restored and built upon with exercise.

This technique lays the groundwork for rehabilitation of any painful condition. This technique is best used for:

• Spasm in any area of the body
• Post surgery in any area of the body
• Restoring more upright posture (tightened muscles can pull you into poor posture)
• Chronic pain

Can a muscle be in spasm (hypertonic) without a person knowing it?

Yes! People experience decreased mobility, tightness, or nothing at all if another muscle is compensating for it.

British College of Osteopathic Medicine Teaching Philosophy

Holistic Osteopathy at BCOM

Historically the College has, for many years, promoted the idea that optimal health depends not just on the impact of physical stresses but also the impact of biochemical, environmental and psychological stresses on the individual. Naturopathic osteopathy is a complex interaction which recognises the significance of each of these areas for the individual and attempts to restore a 'healthy balance' by the appropriate treatment and/or advice. These ideas were, at one time, considered to be somewhat radical but, particularly in the last decade, good quality research has confirmed their validity. Following on from these pioneering ideas a whole new area has now opened up in within medical research : the field of bio-psycho-social interaction on health.

Osteopathic Medicine

The therapeutic principles of osteopathic medicine are based on the understanding that the human body functions as a unit and has an inherent ability to self-regulate and self-heal. Holistic, or Naturopathic Osteopathy, as taught and practiced within BCOM's teaching clinics, is based on the Bio-Medico-Psycho-Social model of health care.

The treatment/therapeutic aims are to:

1. identify abnormalites/dysfunctions within the human structure and function.
2. facilitate the body's inherent abilty to self-heal by addressing the physical, bio-chemical, mental and environmental factors that may be either causing, pre-disposing or maintaining the state of disease.
3. empower the patient with knowledge and skills that can be used to not only promote wellbeing but also to prevent recurrence. Osteopathic medicine is therefore not prescriptive but preventative medicine.

Like any other form of healthcare, osteopathic medicine has it's own strengths and weaknesses, and therefore Osteopathic practitioners work closely with other health and medical practitioners in order to provide complete healthcare to patients.

Naturopathy is the particular philosophy which informs our osteopathic approach. The Naturopathic approach retains the fundamental elements of original Hippocratic doctrine.

Naturopathic Osteopaths hold that, in ideal circumstances, the individual has the capacity to adapt to and compensate for a great many (but not all) challenges to health. Under non-ideal circumstances certain adverse factors may result in the patient experiencing symptoms and/or signs of ill health. These adverse factors fall into three main categories: physical stressors, biochemical stressors, psychosocial stressors.

Definition of Osteopathic Medicine

Osteopathic Medicine is a system of manipulation, using the hands to correct joint and tissue abnormalities. Restoring physical and mental well-being, it makes it easier for a patient's body to function normally and use its own recuperative powers more effectively. Naturopathic, or holistic osteopathy focuses on more than diagnosing and treating the structural and mechanical problems of the body. It encompasses looking at diet, lifestyle and mental well-being to restore the state of balance within the total bodily function.

DOs and MDs Guide to Billing for OMT: OSTEOPATHIC MANIPULATIVE MANAGEMENT

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GUIDELINES FOR CODING OSTEOPATHIC MANIPULATIVE MANAGEMENT


The following is the description of the new OMT codes as published in the 1994 edition of CPT. There are more than 500 new and revised codes in CPT 1994. The CPT Editorial Panel voted to accept the proposal of the AOA to move the osteopathic manipulative treatment codes from the HCPCS alpha-numeric system into CPT. With the advent of these new codes 98925-98929, one should no longer report claims using the M codes or 97260, 97261.

CPT - Codes Procedure Description


98925 - OMT; one to two body regions involved

98926 - OMT; three to four body regions involved

98927 - OMT; five to six body regions involved

98928 - OMT; seven to eight body regions involved

98929 - OMT; nine to ten body regions involved



These codes replace the MC700 series once found in HCFA's Common Procedure Coding System (HCPCS).

Note: For Medicare, the -25 modifier must be attached to the E/M code reported in conjunction with OMT. The entire coding system for evaluation and management (E/M) was changed. The new E/M codes range from 99201 to 99499 and are organized according to site of service, new vs. established patient and the level of care provided. The appropriate code to report is based on key components: history; examination; medical decision making; counseling, coordination of care; nature of presenting problem; and time. The first three components (history, examination and medical decision making) are considered the key components in selecting a level of E/M service.


Appropriate Use of OMT Codes

After the physician evaluates the patient and arrives at a diagnosis, it is allowable to use an evaluation and management (ElM) code in addition to the appropriate OMT code (98925-98929) provided the physician has documented in the patient's record the E/M service provided using the SOAP format. SOAP is an acronym for: Subjective complaints and histories from the patient; Objective findings of the physician's examination and any diagnostic tests performed; Assessment or differential diagnosis based on the first two items; and Plan, which is the recommended course of treatment developed by the physician.

Osteopathic Manipulative Treatment

Osteopathic manipulative treatment is a form of manual treatment applied by a physician to eliminate or alleviate somatic dysfunction and related disorders. This treatment may be accomplished by a variety of techniques. Body regions are defined as head, cervical, thoracic, lumbar, sacrum, lower extremity, upper extremity, pelvis, ribs, abdomen and viscera. (Such regions are defined in ICD-9 codes 739.0-739.9.) This information should be shown on the claim form or in the physician record.


Osteopathic Structural Diagnosis Includes: Somatic Dysfunction (By Region)

739.0 Head Region: Occipitocervical Region

739.1 Cervical Region: Cervicothoracic Region

739.2 Thoracic Region: Thoracolumbar Region

739.3 Lumbar Region: Lumbosacral Region

739.4 Sacral Region: Sacrococcygeal Region, Sacroiliac Region

739.5 Pelvic Region: Hip Region, Pubic Region

739.6 Lower Extremities: Acromioclavicular Region, Sternoclavicular Region

739.7 Upper Extremitiee

739.8 Rib Cage: Costochondral Region, Sternochondral Region, Costovertebral Region

739.9 Abdomen and Other

OMT Overview

However, it was only statistically significantly higher at 25 weeks postvaccination. In a cohort of patients with carpal tunnel syndrome, OMT was associated with both symptomatic and electrodiagnostic improvement.50, 75

In a blinded, randomized, controlled trial (n = 14) comparing standard medical care with standard care plus OMT for hospitalized patients with pancreatitis, patients in the OMT group had significantly fewer days in the hospital (mean reduction, 3.5 days, P = .04).76

There were no significant differences in time to oral feeding or amount of pain medications between the groups. Based on the exclusion criteria, the reader can infer that the 2 groups were roughly equal in terms of disease severity; however, the authors did not specifically state that the treatment and control groups were comparable based on Ranson criteria, Acute Physiology and Chronic Health Evaluation scoring, or some other objective measure of disease severity.

Osteopathic manipulative therapy has been used as adjunctive therapy in the treatment of pneumonia since the early 1900s. The only large-scale study evaluating the efficacy of OMT against pneumonia was a case series that was collected during the 1918 influenza epidemic in the United States consisting of 6258 patients with influenza complicated by pneumonia.

The average mortality rate for patients treated in the usual fashion with the prevailing therapy was approximately 25%. The mortality rate for patients who were treated with OMT in addition to the usual prevailing therapy was allegedly 10%.77 The only randomized control trial of OMT in this same setting also revealed a favorable trend.

In this trial, the mean duration of leukocytosis, intravenous antibiotic treatment, and hospital stay were shorter in the patients treated with OMT compared with the control group who received either a sham treatment or no additional physical contact.

However, none of these differences were statistically significant, possibly owing to insufficient power from the small sample size. The only outcome measure that did reach significance was total time taking oral antibiotics while in the hospital.77

Osteopathic manipulative therapy provided acute benefits in a small group of patients with idiopathic Parkinson disease (IDP).78 Ten patients with IDP and 8 age-matched controls without IDP having similar physical conditions, underwent computerized gait analysis before and after a single session of OMT.

A separate group of 10 patients with IDP underwent a sham manipulative treatment. The patients did not know when the measurements for gait analysis were being taken, and were not aware of whether the treatment they were given was the sham treatment or OMT. Before motion analysis, all patients with IDP underwent a 12-hour medication washout period.

All patients with IDP had mild to moderate disease with a Unified Parkinson's Disease Rating Scale Motor Score average of 14.3; however, the study lacks a comparison table, so how well the groups were matched cannot be fully determined. Patients with IDP who were treated with OMT had statistically significant increases in stride length, cadence, arm swing, and maximum velocities of upper and lower extremities, compared with the control group without IDP.

Significant differences occurred only in patients with IDP who were treated with OMT and not in IDP patients who received a sham treatment, suggesting that the improvements were the result of OMT. The duration of this beneficial effect is unknown because patients were not followed up further.

The single report of OMT as an isolated treatment for episodic tension-type headache found a reduction in pain intensity immediately after the treatment, but the subjects were also not evaluated further.79

A controlled trial of chiropractic spinal manipulation did not show a positive effect on episodic tension-type headaches.80 Another similar trial did, however, find a beneficial effect of manipulation on cervicogenic headache.81

CONCLUSIONS

Osteopathic medicine is similar to allopathic medicine, but places a greater emphasis on the importance of the musculoskeletal system and normal body mechanics as central to good health. To support this emphasis, more basic research and controlled trials for the effectiveness of manipulation are needed.

GLOSSARY

Autonomic Innervation of Selected Viscera

Sympathetic fibers supplying the heart and lung and part of the esophagus originate in the first 5 thoracic segments.

Those supplying the pancreas, liver, stomach, and gallbladder arise in the 5th through 10th thoracic segments, and those supplying the small and large intestine and kidneys arise in the eighth thoracic to second lumbar segments.

Facilitation

Facilitation is the maintenance of a pool of premotor neurons or preganglionic sympathetic neurons in 1 or more segments of the spinal cord in a state of partial or subthreashold excitation; in this state less afferent stimulation is required to trigger the discharge of impulses.

It is also a neurophysiological theory regarding the neural mechanism of somatic dysfunction.

Somatic Dysfunction

Somatic dysfunction is the impaired or altered function of the skeletal, arthrodial, and myofascial structures and their related vascular, lymphatic, and neural elements.

The positional aspects of somatic dysfunction are described using 1 or more of 3 parameters: (1) the position of the body part as determined by palpation and referenced to its adjacent defined structures, (2) the direction in which motion is freer, and (3) the direction in which motion is restricted.

Somatic dysfunction is characterized by one or more of the following: vasodilatation, edema, tenderness, pain, constriction, asymmetry of motion, motion restriction, and changes in tissue texture. It may or may not be associated with organic disease.

Author/Article Information

From the Internal Medicine Service, US Army Medical Activity, Heidelberg, Germany.

Corresponding author: Emil Lesho, DO, CMR 442 Box 594, APO AE 09041-0501. Accepted for publication November 13, 1998.

Archives of Family Medicine,Vol. 8 No. 6, November/December 1999

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Somatic Dysfunction and OMT.

Somatic Dysfunction

An integral part of the prevention of disease and maintenance of health in Osteopathic medicine has involved the diagnosis and treatment of somatic dysfunction. However, epidemiologic studies of somatic dysfunction in the normal population are not widely documented. The current study was initiated following the results of a pilot study designed to define the incidence of somatic dysfunction in the general population.

Structural exams were performed on 196 persons to screen for somatic dysfunction. There were 137 females and 59 males with an average age of 39. The most prevailing disease states recorded by questionnaire were frequent low back pain (27%), migraines/frequent headaches (17.8%), urinary tract infections (17.3%), heartburn (12.7%), TMJ disease (10.2%), hypertension (9.6%), and arthritis (9.6%).

The frequency distribution of somatic dysfunction was variable, ranging from 27% at T11 and 85% at OA. Discriminant analysis was used to build a model that described the various illnesses based on the fundings of SD in this population The predictability of hypertension was 100%, with SD at C4, T2, T4, T9, T12, and L4. A high predictability was also found in TMJ disease and migraines/frequent headaches with several' areas of SD. In conclusion, somatic dysfunction was found in all persons screened. A high frequency of somatic dysfunction was not found in all transitional areas of the spine as previously suggested by the pilot study.

The data from the discriminant analyses suggest that somatic dysfunction is strongly associated with certain disease processes, however, further studies are required to determine the role of somatic dysfunction as a predictor of inherent diseases.
-----------------
Incidence of somatic dysfunction in the general population. C McKay-Hart, Fields. R. Erickson, J. Shore, RD Page. JOAO Research Conference Abstracts 1992

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OSTEOPATHIC CARE IN WOMEN WITH MULTIPLE SCLEROSIS

OMT and MULTIPLE SCLEROSIS

PROLONGED EFFECTS OF EXERCISE AND OSTEOPATHIC CARE IN WOMEN WITH MULTIPLE SCLEROSIS
Herbert A. Yates,(1)* Terence C. Vardy,(2) Michael L. Kuchera,(3) Brett Ripley,(1) Jane C. Johnson,(1) Bruce Stouch(3)

(1)Kirksville College of Osteopathic Medicine in Kirksville, MO (2)Neuromuscular Clinic, Tweed Heads. Australia; (3)Philadelphia College of Osteopathic Medicine in Philadelphia, PA; *Deceased
ABSTRACT


This study documents the effects of a physical intervention protocol combining maximal effort exercise (MEE) and osteopathic manipulative treatment (OMT) on strength, endurance, fatigue, coordination and ambulation in female Multiple Sclerosis (MS) subjects.

Twelve weeks of twice weekly MEE/OMT supplemented existing care of seven female MS subjects (aged 42-68 years; mild-moderate disease severity; EDSS=2-6). Isometric and eccentric vertical leg presses and isometric semi-erect whole body exercise (lunge) were conducted on specialized equipment. Each session, exercises (with Valsalva) were repeated 3-5 times lasting 4-8 seconds each. OMT reduced somatic dysfunction each session.

Every 0.25 seconds during exercise an IsoPump® load-cell measured MEE strength and endurance. Subjects completed a Subjective Perception of Fatigue Scale (SPFS) before and after every session. Coordination and ambulation were measured by Block & Box (BB) and Timed 25-foot Walk (TW-25) tests respectively. Subjects were tested throughout the 12-week protocol and every three months thereafter for nine months. There was no further MEE/OMT after the 12-week training/treatment period.

Immediate effects previously published documented post-intervention positive changes (p<0.05) in TW-25 and BB tests, improved strength and endurance with no session fatigue, and a 45% baseline SPFS decrease overall.

This study documented prolonged effects of the protocol. MEE/OMT increases in isometric lunge strength (170%) and TW-25 reductions were maintained for nine months. Leg press strength gains (87% isometric; 36% eccentric) began to decline after six months, but retained significance from baseline for nine months.

CONCLUSION: Without creating fatigue during exercise, an MEE/OMT protocol increases strength, ambulatory ability, coordination and endurance while decreasing overall fatigue in women with mild-moderate MS impairment. Measurable benefits in walking and strength still existed nine months after discontinuing the protocol.

KEYWORDS: Eccentric exercise, Clinical trial; Fatigue; Manipulation
INTRODUCTION


Paragraph Number 1 The purpose of this study was to investigate the benefits of an intervention for de-conditioned patients with multiple sclerosis using progressive maximal effort isometric and eccentric exercises. The pilot study conducted was a single blind, within subject repeated measures and report design. It was used to test the hypothesis that progressive anaerobic maximal effort exercise (MEE) together with osteopathic manipulative treatment (OMT) would produce prolonged positive benefits including increases in strength, physical performance, and dexterity in a cohort of women with mild-to-moderate MS, while simultaneously showing a reduction in fatigue.

PREVALENCE OF MULTIPLE SCLEROSIS

Paragraph Number 2 Multiple Sclerosis (MS) is a disease of the central nervous system (CNS), accompanied by secondary de-conditioning of the muscular system; particularly the muscles of the lower extremities. Currently unknown causes lead to an autoimmune dysfunction characterized by the eventual formation of plaques on the myelin sheath.(15,22,25) Better understood is the de-conditioning process that is often the result of prolonged bed-rest and/or restriction of normal physical activities.

Paragraph Number 3 MS appears between the ages of 10 and 60 with the peak onset at age 22 years. 28. Due to the relatively long life expectancy of most patients with the disease, the average age of an MS patient is 45 years. The tremendous impact of MS on the financial and biopsychosocial structure of families is aggravated by this disorder’s propensity to affect those who may otherwise be most active and productive in business and family life.

Paragraph Number 4 More women than men suffer from MS – a ratio of 1.8:1. (28) This gender difference, coupled with de-conditioning and reduced time weight-bearing, means that osteoporosis is another common secondary condition frequently seen in 60% of this patient group. Independent of gender, other common symptoms of MS patients (see Table I) include extreme fatigue, loss of balance, blurred or double-vision, speech difficulties and slurring, weakness and loss of lower and/or upper extremity control, continence problems, bowel dysfunction, hand tremors, tendency to drag one foot, numbness or pins and needles sensations, as well as problems with or changes in memory functioning.

Paragraph Number 5 The above diversity of symptoms indicates individual specific physical weaknesses that are highlighted and exacerbated by a general systemic dysfunction. Disease progress is therefore most typically assessed by a number of evaluations assessing different physical, mental, and emotional domains. Physical evaluation components most frequently include timed walking tests, tests of dexterity, and self-assessment of fatigue.

Paragraph Number 6 The Multiple Sclerosis Functional Composite (MSFC) is a multidimensional clinical outcome measure that includes quantitative tests of leg function/ambulation (Timed 25-Foot Walk), dexterity (9-Hole Peg Test), and cognitive function (Paced Auditory Serial Addition Test). Correlations among the three MSFC components were weak, suggesting they assess distinct aspects of neurological function in patients with MS. Among the MSFC components, the Timed 25-Foot Walk correlated most closely.
PHYSICAL EVALUATION OF MS PATIENTS


Paragraph Number 7 Currently the most widely used functional standard for classifying MS subjects is the Expanded Disability Status Scale (EDSS). (10) The EDSS is a global rating of neurological impairment. It summarizes the score of the eight functional systems (pyramidal, cerebellum, brainstem, cerebral cortex, sensory responses, bowel and bladder, visual and spasticity) and correlates well with the MSFC. An EDSS score can range from 0 (representing a positive diagnosis with no apparent neurological impairment) to 10 (complete disability due to MS) with minimal to moderate levels warranting an EDSS score below 6.

Paragraph Number 8 Accurate EDSS scores may guide clinicians in the choice of safe and effective exercise recommendations for MS patients. In persons with a minimal to moderate level of neurological impairment (EDSS scores of 2-6), abnormalities in heart rate (HR) and blood pressure are not often present and cardiovascular responses during exercise are not affected. (21) Furthermore, findings indicative of the exercise response of persons with MS appear to be influenced by the level of physical impairment of the experimental cohort. (21)

Paragraph Number 9 EDSS scores are heavily influenced by lower extremity function and the ability to ambulate effectively. As such, it is not surprising that EDSS scores and the Timed 25-foot Walk (TW-25) correlate well. The TW-25 (7) is included in most studies of MS. Furthermore, after adjustment for age, race/ethnicity, weight, and height, increasing knee extensor strength was associated with significant increases in feet walked per second.

Paragraph Number 10 Another physical test used in evaluating subjects with MS is specific to the upper extremity. The prevalence of upper extremity dysfunction in multiple sclerosis, as measured by the Block & Box (BB) test, is higher than previously appreciated. The BB test, along with the Nine-Holed Pegboard Test is more sensitive in detecting upper extremity functional status change (dexterity) than the EDSS. (4)

Paragraph Number 11 General fatigue is another common symptom monitored among many MS patients even though it is considered to have primary, secondary, and tertiary origins. Fatigue was common to both MS subjects and controls who participated in the Ponichtera study. (21) The maximal effort exercises used by Yates and by Vardy were all anaerobic and did not increase fatigue on the Subjective Perception of Fatigue Scale (SPFS) during the course of the exercise session. (26,27) This also supports the conclusion of Ponichtera-Mulcare’s study. (21)
EXERCISE IN MS PATIENTS


Paragraph Number 12 Most MS research is focused on establishing the pathology which is of little assistance to those patients suffering with this disorder currently. Despite 58 percent of all and 69 percent of female MS sufferers manifesting limitation of activity (12), there are few reports of MS patient rehabilitation strategy outcomes, particularly those focusing on specific exercise design. (1,3,8,17-20,23,27)

Paragraph Number 13 Current treatments for MS are directed at maintaining current abilities or reducing the number and intensity of exacerbations. From this perspective, exercise may offer an efficient and economical adjunct, or even alternative, to current treatments. In a stratified survey of over 300 MS subjects in the U.K., advice about exercise was the single most requested area. (24) Exercise in MS patient populations also intrigues many leading researchers. Our present understanding of the exercise response in individuals with MS comes primarily from studies by physical therapists, neurologists and occupational therapists. In addition to the effects of thermal stress, research here has focused on cardio-respiratory responses to exercise (autonomic cardiovascular regulation) and muscle function (strength and endurance). (1,3,8,18,19,21,23,25,27)

Paragraph Number 14 Petajan (16) clearly demonstrated that those MS patients who participated in an aerobic exercise program had better cardiovascular fitness, improved strength, better bladder and bowel function, less fatigue and depression, a more positive attitude, and increased participation in social activities. Furthermore, Moseley (15)studied exercise stress and the body’s “Immune Conversation” and concluded “exercise is an attractive model for the study of the change in immune function”.

Paragraph Number 15 While exercise activity is regarded as being universally beneficial for people from a mental, metabolic and musculoskeletal viewpoint, it is not uniformly applied in the treatment of physically de-conditioned persons such as those with MS. Inactivity in people with or without MS can result in numerous risk factors associated with coronary heart disease. In addition, it can lead to muscle weakness, decreased bone density with an increased risk of fracture, and shallow, inefficient breathing.

Paragraph Number 16 While regular exercise is believed to influence the course of an MS patient’s life by minimizing the de-conditioning process and maintaining an optimal level of physical function (3) the type, intensity, and frequency of exercise for optimum results have not been standardized. For example, few researchers outside Kraft/Alquist (8), Ponichtera-Mulcare et al (17,21), Yates et al (30) and Vardy (27) have exercised their MS subjects to a maximum level. Alternatively, a sub-maximal effort endpoint, such as that selected by Schipiro (23) has been used in many studies for safety reasons to minimize the risk of exacerbating MS symptoms, even though the use of high intensity and maximal levels of exercise per se has not been shown to provoke immediate and/or latent MS related symptoms. (10,20,21) Gehlsen (3) used one-hour sessions of aquatic exercise and Svenssen (25) had subjects doing 50 repetitions of knee extensions. Ponichtera-Mulcare(17,20,21)used prolonged aerobic exercise (averaging 40 minutes) and suggested that a combined arm and leg exercise could be more effective in utilizing full maximal effort. (17)The IsoPump® Lunge exercise phase is a combined, leg and torso or whole body exercise.
OMT IN CONJUNCTION WITH EXERCISE FOR PATIENTS WITH MS


Paragraph Number 17 Somatic dysfunction is defined as “impaired or altered function of related components of the somatic system: skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements. (29) Exercise, especially eccentric exercise, commonly results in delayed-onset somatic dysfunction, reduced range of motion, muscle swelling, and tender myofascial points capable of creating local and referred pain. (6) Maximal effort during exercise has also been implicated in the initiation of a variety of overuse phenomena, including somatic dysfunction and myofascial trigger points (MTrPs).

Paragraph Number 18 Osteopathic manipulative treatment (OMT) is most commonly used to reduce or remove somatic dysfunction (29) including MTrPs. OMT and many other hands-on approaches, including massage, physical therapy, chiropractic, and manual medicine treatments, are frequently used in conjunction with more traditional pharmacological approaches to multiple sclerosis. (9) While numerous other reasons involving postulated vascular, autonomic, and nociceptive mechanisms might justify exploring the role of OMT in the treatment of MS subjects, (9) this study is not designed to consider them.

Paragraph Number 19 OMT was paired with MEE in this study for a variety of specific reasons. The palpation of skeletal, arthrodial, and myofascial structures for somatic dysfunction prior to instituting OMT serves to provide secondary data with potential importance should injury or persistent dysfunction arise during the exercise portion of the study. Furthermore, treatment of pain is important in maintaining compliance in exercise studies. The OMT techniques employed in this study were selected to diminish any discomfort associated with somatic dysfunction or MTrPs that might arise from the exercise protocol.

Paragraph Number 20 Regardless of whether an exercise program would introduce somatic dysfunction in this population or not, approximately 55% of the people in this study reported what is called “clinically significant pain” at some time during the course of a lifetime with MS; almost half (48%) were troubled by chronic pain. Another rationale for the MEE/OMT combination to serve as the somatic adjunct in this protocol considers recent studies that suggest a combination back of exercise and manipulation may be superior to exercise alone in back pain. (26)
METHODS


Paragraph Number 21 Seven (7) female subjects between the ages of 42 and 68 years, diagnosed with chronic progressive MS and having an EDSS rating of between 2 and 6, were recruited to participate in this study. All were permitted complete written and oral informed consent according to national standards and those imposed by the Institutional Review Board of the Kirksville College of Osteopathic Medicine. All subjects in this study continued their existing pharmacological care regimen as prescribed by their attending physicians. All subjects participated in an adjunctive specialized somatic care protocol consisting of maximal effort exercise (MEE) program using a three-phase MS IsoPump® exercise protocol in combination with osteopathic manipulative treatment (OMT).

Paragraph Number 22 The IsoPump® is an electrically driven exercise device with which a subject can exert maximum forces through major muscle groups. The proposed effect of these forces is threefold:

1. Increase muscle strength without adding muscle bulk
2. Challenge the muscle component of the arterial system
3. Establish a changed proprioceptive feedback loop by pressure overload

OMT is a form of manual medicine delivered to remove somatic dysfunction and to enhance homeostatic mechanisms.
RESEARCH DESIGN


Paragraph Number 23 The study employed a single blind within subject repeated measures and report design to evaluate the effects of the Isopump® MEE program and OMT over a 12 week period. All seven subjects had the following inclusion and exclusion criteria:

1. were remitted from MS exacerbation for at least six months
2. had been diagnosed with MS for at least two years
3. gave informed consent to participate in this study
4. had no significant spasticity or ataxia
5. had no changes in prescription medicine within previous three months
6. had no clinically diagnosed depression
7. had no pulmonary or bladder infections, or were febrile (>100 deg. F.) at the time of the exercise session.

Paragraph Number 24 The short duration (12 weeks) of the program was intended to minimize maturation while the inclusion and exclusion factors maintain homogeneity of the sample and allowed externalization to the female MS population of a mild (2) to moderate (6) EDSS rating. An independent neurologist conducted the initial neurological evaluation and EDSS rating to insure that the inclusion and exclusion criteria were fully enforced.
MAXIMAL EFFORT EXERCISE INTERVENTION


Paragraph Number 25 The specialized Isopump® exercise program used in this study was a three-phase protocol combining isometric and eccentric vertical leg presses with an isometric semi-erect lunge exercise. In the first two exercise phases the major leg muscles are used while the whole body (leg:torso:arm) is used in the third exercise phase. The exercise protocol was performed twice weekly for twelve weeks. At each session, each individual exercise was performed for 4-6 seconds concomitant with a Valsalva maneuver. Initially, three repetitions were performed in each phase with a minimum rest period of less than 30 seconds between repetitions.

Paragraph Number 26 Frequency of the tests increased as planned from three repetitions of each exercise during the first four weeks, to four repetitions for weeks 5-8, to five repetitions during the last four weeks of the protocol. On the other hand, voluntary duration of exercise effort for all three types of exercise did not change significantly from the start to the end of the exercise intervention period. Exercisers were only capable of exerting maximal forces with Valsalva for an average of 4-8 seconds throughout any of the exercises.

Paragraph Number 27 The Isopump® isometric and eccentric leg exercise phases incorporated a supine anti-orthostatic body position of minus six degrees from horizontal to maximize elevation of torso segment volume. The Isopump® features a visual read-out screen displaying load-cell measurements of the forces applied during all exercises. Strength measured by the load cell was directly recorded every 0.25 seconds by a linked computer for subsequent analysis.
OSTEOPATHIC MANIPULATIVE INTERVENTION


Paragraph Number 28 Twice weekly, after each of the seven subjects exercised, each subject received OMT from an osteopathic physician with special expertise in delivering this somatic intervention. Throughout, the osteopathic physicians involved in the study applied OMT to each subject as determined most individually appropriate. Each OMT session consisted of a variety of techniques as needed to remove somatic dysfunction. This was to maximize axial and appendicular functions, and/or to enhance venous-lymphatic drainage and autonomic functions.
OBJECTIVE MEASUREMENTS


Paragraph Number 29 During interventions, weekly measurements were taken utilizing the Block and Box (BB) test and a Timed 25-foot Walk (TW-25). The Subjective Perception of Fatigue Scale (SPFS) was self-recorded twice weekly before and after each session. Summative evaluations, including the SPFS, TW-25, and BB tests, were conducted at the commencement and completion of the 12-week intervention program as well as at 3, 6 and 9 months after the cessation of the intervention period.

Paragraph Number 30 The SPFS is a seven-item questionnaire assessing features of fatigue on a 7-point Likert Scale; a standard for neurodegenerative disorders. It has demonstrated high test-rated reliability and interval consistency reliability. The BB test counts the number of blocks put into the box in 60 seconds and is a measurement of upper extremity dexterity. The TW-25 simply measures the number of seconds required to walk 25 feet, correlates highly with the EDSS, and also reflects lower extremity strength and endurance.

Paragraph Number 31 Measures of strength (PEAK), endurance (AREA), and duration of maximal effort (TIME) were collected twice weekly by the IsoPump® load-cell during each of the three isometric and eccentric maximal effort exercises. (See Figures 1 for Lunge PEAK. Figure 2 for Isometric Leg Press PEAK. Figure 3 for Eccentric Leg Press AREA). Maximum effort (PEAK) was measured in pounds. Duration of maximal effort (TIME) was measured in seconds. Endurance, indicated by the area under the load-cell generated peak-duration period (AREA), was measured in pound-seconds.
RESULTS


Paragraph Number 32 As reported in the May 2002 JAOA article (30), all individual strength, endurance, ambulation, coordination, and fatigue measures were analyzed to ascertain whether any significant gains were made from Baseline to the end of the 12-week MEE/OMT adjunctive intervention period. Consistent with this study’s additional hypothesis, the statisticians at KCOM and Philadelphia College of Osteopathic Medicine (PCOM) were also asked to evaluate the significance and duration of prolonged effects during a follow-up period without the benefit of further exercise or OMT. The relevant statistics were provided at 3, 6 and 9 months post intervention.

Paragraph Number 33 As previously reported in the (30) univariate analysis by parameter and observation time was conducted calculating arithmetic averages, medians, standard deviations and the associated 95% confidence intervals associated where relevant (see graphs 1-2 and tables 2-3). For each task, a two-factor analysis of variance with repeated measures on both factors test number (see graphs 1-2 and tables 2-3) was used to determine whether there were changes within a session and over the intervention period. Multiple comparisons were performed, when appropriate, using Duncan’s Multiple (DM) Range Test. For the purpose of this study, all participants’ results were assessed from the DM Range Test on five (5) separate occasions: Baseline, Post-Intervention, and at three Follow-Up points timed 3-, 6-, and 9-months after cessation of MEE/OMT.

Paragraph Number 34 Compared to baseline, measures of both strength (PEAK) and endurance (AREA) showed significant improvement (p<0.05) at the end of the 12-week long intervention period as did indicators of quicker ambulation (TW-25) (see graph 1, table 2), improved coordination (BB test) (see graph 2, table 3), and reduction of fatigue (SPFS) as reported in the 2002 JAOA article by Yates, et.al..

Paragraph Number 35 Beyond the original report, this study showed substantial prolonged effects after discontinuing the intervention. Total body strength, as demonstrated by PEAK Lunge (PEAKL) measurements had increased 70% over baseline (p=0.03) and was retained without diminution at all sample points over the nine months following MEE/OMT cessation.

Paragraph Number 36 Although both isometric and eccentric PEAK Leg Press (PEAKLP) measures increased throughout the intervention as previously reported and showed varying degrees of continuing without adjunctive care, the Post-intervention isometric PEAKLP had increased by 36%, Post-intervention eccentric PEAKLP had increased 87%, and, compared to baseline, these eccentric PEAKLP values were significant 3- and 6-months post-intervention. Isometric PEAKLP remained significantly improved for the full 9-month follow-up period.

Paragraph Number 37 As measured by the initial pilot study (30), by the end of the MEE/OMT period, endurance (AREA) increased for both total body lunge (AREAL) and leg presses (AREALP). Endurance measures by the end of the intervention period varied significantly (p<0.05) with isometric AREAL increasing by 93%, isometric AREALP by 113%, and eccentric AREALP by 44%.

Paragraph Number 38 In addition to these substantial strength and endurance improvements, MEE/OMT created a 30.5% reduction (p=0.03) in the Timed 25-foot Walk test. This improvement was fully retained from the end of the intervention throughout the 9-month follow-up period. Dexterity, as measured by the Block & Box test, demonstrated a 13% improvement at six months follow-up for seven subjects.
DISCUSSION


Paragraph Number 39 Overall, research (20,21)suggests that exercise would not be expected to exacerbate MS symptoms except when the physical activity is aerobic and/or performed in hot and humid conditions. (27) Outside these concerns then, MS patients should expect to gain many, if not all of the health-related benefits of an optimally designed exercise protocol. (13)

Paragraph Number 40 Concerning the type of exercise for de-conditioned subjects, a combination of exercise types similar to those selected for this study is recommended over a single isometric or concentric type. Research indicates that a resistance exercise protocol that includes eccentric as well as concentric exercise, particularly when the eccentric exercise is emphasized, results in greater strength gains than concentric exercise alone. (5) Lastayo further demonstrated that significant gains in isometric leg strength were seen in the eccentrically trained subjects only without muscle injury and with minimal increase in metabolic demand for oxygen. 11 (11)

Paragraph Number 41 Brockett demonstrated that continued eccentric exercise of the hamstrings was capable of shifting the optimal angle of human muscle “as a protective strategy” against injury from eccentric exercise. (2) In his study of normal subjects, initial discomfort, swelling, and internal distress caused upon initiation of eccentric exercise disappeared with repeated eccentric training. He and others have postulated that the well-known training effect involves increasing the number of sarcomeres in muscle fibers. (2,14)

Paragraph Number 42 To date most, if not all, studies have failed to conduct substantive follow-up programs to evaluate the prolonged effects of exercise in individuals with MS. There remains a need to conduct follow-up exercise and OMT research to establish what effect each intervention has on the course of Multiple Sclerosis. With the wide variance of symptoms experienced by the subjects, what systemic changes are initiated by these interventions to effect the beneficial changes noted in this pilot study? If MS is an immune dysfunctional response, does exercise and/or OMT provoke the pituitary or endocrine system to facilitate compensatory responses in MS individuals? Further, study is needed to determine whether the whole body (ie. Lunge exercise) is more effective than combined lower extremity exercise (ie. Leg Press). Other questions requiring investigation include whether eccentric exercise has a more lasting effect than isometric type exercise, what interval is most effective between each exercise session, and whether further strength gains are possible with the application of follow-up exercise sessions.

Paragraph 43 The design of the IsoPump® equipment allows the speed of the eccentric exercise to be varied thus altering the resistance applied by the exerciser. This may have important effects for MS sufferers who have bone density loss and who require a longer application of eccentric forces at a slower speed. The current view is that over 60% of MS sufferers may have bone density loss greater than 1.5%. It was observed that the average non-MS exerciser exerts maximal pressure for eight seconds in both isometric and eccentric exercise phases. What fluid and cellular effects does the Valsalva Maneuver maintained for this period of time have on the human mechanism and is this different in individuals with MS?

Paragraph 44 The beneficial effects and strength gains maintained over such a prolonged period of time as found in this study may have applications in a wide range of medical rehabilitation and exercise areas. That strength gains of such a magnitude can be maintained for over six months provoke thought as to the possibility of sustained changes without chemical intervention. Eccentric exercise would appear to be the key to safely and progressively overloading the muscular system and provoking such change. The maintenance of increased strength gains without further exercise sessions offer potential applications for zero gravity situations and increased technique training pre-competition for athletes.


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12. Lindsey, J. and J. Wolinsky. IX Demyelinating Diseases. 11 Neurology. ACP Medicine Online. Available at: http://www.acpmedicine.com Accessed, 2005.

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How Osteopathic Manipulative Treatment (OMT) treats Herniated Lumbar Disk, Lumbar Radiculopathy And Mechanical Low Back Pain

Yamamoto New Scalp Acupuncture (YNSA)
Acupoint Frequency In The Treatment
Of Herniated Lumbar Disk, Lumbar Radiculopathy,
And Mechanical Low Back Pain


Richard A. Feely, DO

ABSTRACT

Background Yamamoto New Scalp Acupuncture (YNSA) is an acupuncture microsystem used for treating pain and dysfunction. To date, there has not been a large-scale study of the use, acupoint frequency, or location of YNSA in the treatment of various diagnoses of back pain.

Objective To determine the location frequency of YNSA Basic and Ypsilon points.
Design, Setting, and Patients A retrospective 2-year study of 115 successive patients seen at a private practice who received YNSA: 22 lumbar herniated nucleus propulsus (HNP) cases, 38 lumbar radiculopathy (LR) cases, and 55 somatic dysfunction/low back pain (LBP) cases.

Intervention All patients received osteopathic manipulative treatment (OMT) for identified somatic dysfunction and if pain persisted, YNSA
was used.

Main Outcome Measure Location and frequency of YNSA acupoints to achieve pain relief.

Results A total of 115 patients with back pain had a mean average of 3.17 visits. Ypsilon points most commonly used were Yin of YIN, 86.4%, and the least common were Yang/YANG, 1.6%. The most common Basic points were YIN D1-6, 11.14%, and most common Ypsilon points were left Yin of YIN GB, 3.65%. This treatment approach resulted in mean visits per patient of HNP: 5.27, LR: 2.42, and LBP: 1.82.

Conclusions The use of YNSA and OMT for low back pain resulted in immediate pain relief with a minimum of needles. YNSA should be further studied for this application.

KEY WORDS
Acupuncture, Yamamoto, YNSA, Scalp, Low Back Pain, Lumbar Radiculopathy, Herniated Lumbar Disk, Ypsilon Points, Osteopathic Manipulation

A heads-up for neck pain sufferers: Try isometrics

A heads-up for neck pain sufferers: Try isometrics
Poor fitness, neglected muscles and bad posture weaken the neck, but a few exercises can help.
By John Briley
Washington Post

December 11, 2006

Today's topic is a pain in the neck. Literally.

Neck pain may seem to stem from a single action — an awkward sit-up, turning your head to see merging traffic or yelling "hi-YA!" while performing martial arts on a mosquito. But for recreational athletes or civilians pursuing a fitter life, these injuries usually stem in part from longer-term neglect.

The culprit, says Dr. Stephen Rice, director of sports medicine at Jersey Shore University Medical Center in Neptune, N.J., is sometimes a poor fitness strategy.

"Many, many people focus [their workouts] on the muscles in the front of their bodies," such as those in the chest, shoulders, abs and biceps, Rice says. But developing those "mirror muscles" while ignoring the muscles that support the spine and torso pulls the body off its preferred balance point on the spine.

Another culprit is bad posture. Many people sit with their shoulders scrunched high, neck craned toward the computer screen and back rounded — for, say, 7 1/2 hours a day. Even a good workout regimen and strong core can do little to neutralize the daily torture.

And so the muscles in and around the neck work harder to keep the head vertical. This continual engagement fatigues the muscles, leaving them vulnerable to strain from even a minor twitch or rotation.

"Your head weighs about the same as a honeydew," Rice says. "If it tilts forward, even 5 degrees, that is a lot of added pressure. Your head won't fall off, but you will use muscle to hold it up."

In proper standing posture, Rice says, "you could drop a plumb line from your earlobe and it would hit your shoulder, hip, knee and ankle." In such alignment, the craftily designed spinal column will support much of the body's weight.

Contrary to what many people are told as children, a ramrod-straight spine is not the goal: The spinal column naturally curves inward at the neck and again in mid-back to help dissipate shock to the vertebrae during impact.

To protect the neck from injury, isometric exercises help build strength.

Do two sets of six to eight reps, twice a week, of the following, placing your hand on your head to provide moderate resistance:

• Lower chin to chest (hand on forehead).

• Raise chin toward ceiling (hand on back of head).

• Ear to each shoulder (hand on side of head).

• Turn head to each side (hand on chin).

Also, slow, light stretching through a normal range of motion helps loosen the neck before a workout. (This is a rare exception to the don't-stretch-a-muscle-that-hasn't-been-warmed-up rule. If anything hurts, stop immediately.)

You'll also want strong core muscles, front and back. Aside from serving as your powerhouse for running, biking and azalea-planting, the core helps support everything above it, including that melon-like noggin.

To self-treat minor strains, rest until it feels better, then try simple stretches (such as the ear-to-shoulder move without resistance). Again: Keep movements slow and painless.

If pain is severe or persists for more than a week, see a doctor. Once healed, regularly stretch the chest and shoulder muscles — to encourage torso balance — and work on that posture: shoulders down and slightly back, head approximately vertical, core firm.

Robert Morris U. advances planned osteopathic program

Robert Morris University's plans for a school of osteopathic medicine have moved ahead with recent approval from the state Department of Education for the school and its doctor of osteopathic medicine degree program.

The university now awaits national accreditation for the school from the American Osteopathic Association's Commission on Osteopathic College Accreditation, and continues to plan to enroll the school's first class in fall 2008.

Working with the accreditation process is the future school's dean, Oliver Hayes, D.O., also vice president of RMU's College of Health Sciences.

The school would be the third osteopathic medical school in the state.

Cervical Mobilization in Post Traumatic Headache/Cervicalgia by By Sherman Gorbis, DO, FAAO

All osteopathic physicians, in their first two years of osteopathic medical college training, are taught Osteopathic Palpatory Diagnosis and Osteopathic Manipulative Treatment (OMT). OMT is one type of manual medicine. OMT is defined as “The therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis that have been altered by somatic dysfunction” (1). Somatic dysfunction is defined as “Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements.” Somatic dysfunction is treated using OMT (1). The diagnostic triad for diagnosing somatic dysfunction is ART:

* Asymmetry-determined visually and by palpation
* Restriction of motion-determined by palpation
* Tissue texture abnormality-determined by palpation

Traumatic cervicalgia (neck pain) can occur as a result of a motor vehicle accident (commonly during/after a whiplash injury where the head and neck are thrown forward/backward), sports related injury, or a fall (such as from a ladder, horse, etc).

It would be very common and not un-expected for the patient who has experienced trauma to have Post Traumatic Headache/Cervicalgia (neck pain) with accompanying somatic dysfunction in her/his cervical spine (bones that make up the neck). The cervical spine is divided into two regions based on their motion characteristics:

Atypical cervical vertebrae. This includes C0-C2 (the upper surface of C2). C0 is the occipital bone, which is located in the lower back area of the skull. The occiput articulates (joined together to allow motion between them) with the first cervical vertebra, C1. C1 articulates with the second cervical vertebra, C2. Several muscles that have attachments in the cervical spine, or below, also attach to the occiput. When these muscles become hypertonic (a sustained contraction but not a spasm (as with a ‘charley horse'), headache can occur. If restriction of motion is present between vertebrae, due to a disruption in the motion of the facets (small joints between the vertebrae which have pain generators) neck pain and headache can occur.

The headache may also result from irritation of the right and/or left greater occipital nerve. This travels through the articulation between the occiput and the first cervical vertebra. It then travels up behind the ear and forward along the temple.

Typical cervical vertebrae. This includes C2-T1 (the lower surface of C2-the upper surface of T1). As above, both muscle hypertonicity and motion restriction can lead to headache and neck pain

Once a physician evaluates the patient who has been involved in trauma and he/she has determined that no contraindications (special conditions that render the use of the procedure inadvisable, usually due to risk) exist for manual medicine, the manual medicine provider then has several options. Various types of OMT include:

Soft tissue. This refers is directed toward tissues other than bone or joints (1).

Muscle energy. The patient voluntarily moves the body as specifically directed by the operator; this is from a precisely controlled position against a defined resistance by the operator (1). Muscle energy is, for the most part, directed at loosening tight muscles using isometric (the muscle does not shorten during the contraction) contractions of the affected muscles. It is also directed at providing proper motion of the facet joints between the vertebrae. Facet joints are located both on the inferior and superior surfaces of vertebrae to allow one vertebra to move freely in relation to the vertebra below. Muscle energy techniques can treat facets that are either dysfunctionally ‘opened' or ‘closed'.

Direct Action Thrust (Mobilization with Impulse). Uses a high-velocity/low-amplitude activation, or thrust, to move a joint that is experiencing somatic dysfunction to help restore appropriate physiologic motion (1). This can be, sometimes, accompanied by an audible ‘click' or ‘pop'. However, the goal of treatment is the restoration of motion, not the presence of the sound.

Myofascial Release. This approach engages continual palpatory (the provider's hands in contact with the patient) feedback to achieve release of myofascial (muscles and their soft tissue/fascial coverings) tissues. This can be employed when tissue hypertonicity is present without severe motion restriction.

Other types of OMT include functional indirect and cranio-sacral.

Chiropractic physicians are traditionally trained in the use of Direct Action Thrust. Physical Therapists are well trained in stretching and strengthening exercises; however, more recently, a large number of PT's have been learning the above approaches as well. It would behoove the patient with Post Traumatic Headache/Cervicalgia to have a dialogue with his/her manual medicine provider. The patient should inquire as to the provider's training and the type of modality(s) that might be used and why. Clinical experience has shown that most patients do well when manual medicine is used synergistically with proper stretching/strengthening exercises.

Many insurance companies cover OMT and many osteopathic physicians who include OMT in their practices accept these plans. It is always helpful for the patient to inquire with his/her insurance company, as well as the provider, regarding coverage.
Resources

Ward RC, exec. ed. Foundations for Osteopathic Medicine 2 nd ed. Philadelphia : Lippincott Williams & Wilkins, 2003.
American Academy of Osteopathy (AAO)
This group's mission is to teach, advocate, advance, explore, and research the science and art of osteopathic medicine, emphasizing osteopathic principles, philosophy, palpatory diagnosis and OMT in total health care. Most, if not all, members use OMT in some degree in their practices.
Phone (317) 879-1881
Fax (317) 879-0563
www.academyofosteopathy.org
American Osteopathic Association (AOA)
Patients can inquire about educational materials regarding OMT.
www.aoa-net.org

Sherman Gorbis, DO, FAAO is a graduate of the Kansas City (MO) College of Osteopathic Medicine . He interned at Riverside Osteopathic Hospital ( Trenton , MI ). He earned his certification in Osteopathic Manipulative Medicine (OMM) in 1991 and his Fellowship in the American Academy of Osteopathy (FAAO) in 1995. He is presently an Associate Professor in the Department of OMM at Michigan State University College of Osteopathic Medicine ( East Lansing , MI ).

Muscle Energy Techniques with DVD-ROM (Paperback)

MET is a comprehensive manual therapy system for evaluating and treating joint restrictions of the spine (segmental and intervertebral dysfunctions), rib cage(restricted respiratory motions, dislocations, intraosseous deformities of the ribs), pelvis (sacroiliac, inter-innominate restrictions and dislocations), and extremities (joint restrictions and impairments of muscle length and strength). When you put together all of the elements of somatic dysfunction that MET addresses, there are few manual therapy systems that are as comprehensive and prepared to address structural musculoskeletal dysfunctions and impairments as MET. Possibly because of the name, Muscle Energy has often been misperceived as solely a treatment modality for “tight” muscles. Far too often, MET treatment techniques have been taught without sufficient reference to MET’s distinctive diagnostic algorithms. MET is more than a method of treatment or therapy; it is also a biomechanics-based analytic diagnostic system, using precise physical diagnosis evaluation procedures designed to identify and quantify articular (i.e., joint) range-of-motion restriction. Once we have performed the initial assessment and the articular restrictions have been identified, and the rational sequence for treatment for these restrictions considered, the treatment part of MET can commence. In terms of treatment, “Muscle Energy Technique is a system of manual therapy for the treatment of movement impairments that combines the precision of passive mobilization with the effectiveness, safety, and specificity of reeducation therapies and therapeutic exercise. The therapist localizes and controls the procedures, while the patient provides the corrective forces and energies for the treatment as instructed by the therapist. … MET focuses on joint range-of-motion limitation, and uses light (generally grams or ounces) to moderate force muscular contractions precisely controlled to affect a specific joint, to restore normal joint motion.” (see The Muscle Energy Manual) Since it was originally developed over 45 years ago, MET is now part of the curricula at all of the Osteopathic colleges and physical therapy programs, and is practiced by many Osteopaths, physical therapists, chiropractors, and other manual therapists world-wide.




This comprehensive text describes the basis and practice of Muscle Energy Techniques (MET), a widely recognized approach to treating musculoskeletal dysfunction. It describes those manipulative techniques in which a patient, on request, actively uses his or her muscles from a controlled position in a specific direction against a distinct counterforce applied by the practitioner. These techniques are combined from methods used in physical therapy, osteopathy, chiropractic and manual medicine. A companion DVD-ROM includes video clips demonstrating the application of techniques.

A comparison of osteopathic spinal manipulation with standard care for patients with low back pain.

BACKGROUND: The effect of osteopathic manual therapy (i.e., spinal manipulation) in patients with chronic and subchronic back pain is largely unknown, and its use in such patients is controversial. Nevertheless, manual therapy is a frequently used method of treatment in this group of patients.

METHODS: We performed a randomized, controlled trial that involved patients who had had back pain for at least three weeks but less than six months. We screened 1193 patients; 178 were found to be eligible and were randomly assigned to treatment groups; 23 of these patients subsequently dropped out of the study. The patients were treated either with one or more standard medical therapies (72 patients) or with osteopathic manual therapy (83 patients). We used a variety of outcome measures, including scores on the Roland-Morris and Oswestry questionnaires, a visual-analogue pain scale, and measurements of range of motion and straight-leg raising, to assess the results of treatment over a 12-week period. RESULTS: Patients in both groups improved during the 12 weeks. There was no statistically significant difference between the two groups in any of the primary outcome measures. 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, P<0.05). More than 90 percent of the patients in both groups were satisfied with their care.

CONCLUSIONS: Osteopathic manual care and standard medical care had similar clinical results in patients with subacute low back pain. However, the use of medication was greater with standard care.

Keeping Kids Healthy: Holistic Medicine - An Alternative Approach

Is acupuncture right for your child? Will it alleviate his asthma? Can hypnosis help cure chronic her frequent headaches? What about his insomnia? Holistic or Integrated Medicine is an approach to medicine seeking to treat the whole person, integrating both traditional and non-traditional forms of medical care. Many doctors are exploring how these non-traditional forms can support traditional methods. Join host Dr. Winnie King as we explore the ways in which non-traditional therapies can work in concert to keep your kids healthy. Guests: Roberta Lee, MD - Medical Director, Director of Continuing Education and Co-director of the Fellowship in Integrative Medicine, Center for Health and Healing at Beth Israel Medical Center, New York, NY Ben Kligler, MD Associate Medical Director, Center for Health and Healing at Beth Israel Medical Center; Attending Physician, Beth Israel Medical Center; Assistant Professor of family medicine, Albert Einstein College of Medicine, New York, NY; Co-directed the nation's first required residency-training rotation in integrative medicine at Beth Israel Medical Center.

Craniosacral therapy

Spinal tissue rhythm, that is.

Confused?

“People don’t really understand it,” Grinnell readily admits of the new clinic she recently opened at 7451 E. Carson City Road (M-57) just west of Carson City.

The 45-year-old registered nurse has worked at the Carson City Hospital for the past 18 years. After two years of dreaming and planning, she started CranioSacral Therapy, a clinic to treat head, neck and back pain.

Craniosacral therapy is a method of alternative medicine used to assess and enhance the patient’s functioning by accessing the primary respiratory mechanism — the central nervous system’s membranes and spinal fluid.

Grinnell said the practice helps treat chronic headaches, neck and back pain, stress-related discomfort, chronic fatigue, motor coordinator difficulties, eye problems and central nervous system and temporomandibular joint (TMJ) disorders.

She works with Dr. Wesley Lockhart in the emergency room at Carson City Hospital. He inspired her to open the clinic.

“He kind of took me under his wing and he said, ‘I think you’d be good at this,’” Grinnell said. “I’ve always been a hands-on, feel-type person. I listen to the body. I listen to what the rhythm’s telling me and where to start.”

Lockhart works in Carson City on Tuesdays, has a private practice in Lansing and formerly taught at Michigan State University. He uses craniosacral therapy in his practice.

“I think it’ll be a real advantage to this area to have somebody doing the craniosacral therapy,” Lockhart said. “A lot of the people who benefit from it tell me they feel it’s a very deep tissue but indirect treatment. There’s rarely any pain associated with it. It usually just helps relieve things that are deep inside.”

Grinnell’s therapy is all about the right kind of pressure.

“If you put a nickel in your hand, that’s about the amount of pressure I use,” she said.

Grinnell checks for rhythm in a client’s tissue to tell her where the problem lies. Using her hands, she starts with a client’s legs and works her way up to the tailbone and then the head. She holds a client’s head in her hands and listens to the rhythm of spinal fluid to determine whether it’s off-balance.

“I work with the rhythm,” she said. “I overexaggerate the rhythm I’m picking up in your body.

“I just feel like this was something I was meant to do,” Grinnell said. “I really think people need to try it with an open mind and be open to new experiences. It’s very open and if people don’t understand it they can come out and experience it.”

Grinnell is studying with the Upledger Institute in Palm Beach Gardens, Fla., which was founded by John Upledger, an osteopathic physician whose research showed support for the concept of cranial bone movement and cranial rhythm

Difference Between the Letters Behind Doctors' Names

There's a D.O. behind Neil Propst's name, but not all of his patients realize that.

Neil Propst, D.O., says, "Especially, on correspondence that I get, a lot of people just assume that I'm an M.D. That's really common; people just don't think to look."

He says doctors of osteopathy take a more holistic approach to medicine, treating the patient instead of just treating the disease.

A good doctor of any kind will do both, but a D.O. receives extra training in what's called osteopathic manipulative treatment. They perform soft tissue massage and other body manipulations that improve circulation, lymphatic drainage and other systems helping the body heal itself.

Dr. Propst explains, "If a person comes in with a heart attack, I certainly don't think you adjust their back and they get better. I think there is a definite time and place for it. A lot of people come in with chronic back or neck pain - pregnant women especially. There's some manipulations you can do that can kind of help relieve their pain for a time."

Just like M.D.s, D.O.s go to college, medical school and complete a residency program. Then, they both must pass comparable state licensing exams.

As far as medical doctors are concerned, William Blanke, M.D., says, "A D.O., to me, is really not different from a M.D. to be perfectly honest. If anything, I think the D.O. has sometimes a little edge on things - especially in family practice because the D.O.s are more specifically trained. I believe [they] have more experience working the musculoskeletal system."

Unfortunately, Dr. Propst says he doesn't get to do the body manipulations on patients as much as he'd like. Time just doesn't allow it, and that's a problem shared by doctors of every kind.

There are nearly 50,000 D.O.s in the U.S.

A healing touch goes worldwide

A healing touch goes worldwide

RICHARD DYMOND
Herald Staff Writer

LAKEWOOD RANCH - As the holidays approach, five Lake Erie College of Osteopathic Medicine students are thankful for an experience that changed their lives.

The students all traveled to developing countries this year to volunteer their time in hospitals, clinics and refugee camps. And all came away with a gift.

"I really learned how to love and care for someone I never met before," said Jason Wright, 24, a second-year LECOM student from Seattle who traveled to Zambia as part of a Christian Medical Association outreach program.

Wright performed osteopathic manipulation he learned in his first year at LECOM to help a Zambian woman who was experiencing intense neck, lower back and leg pain from carrying a large basket on her head.

"I couldn't always treat them with medicines, but I could place my hands on them," Wright said. "I learned the value of compassionate care."

Second-year student Morganna Freeman lived with a host family in Guatemala for part of this year.

Freeman was taken to a hospital where children infected by AIDS since birth sleep two or three to a bunk.

Freeman recalled reaching into a crib and lifting out a three-year-old girl named Diana, who had shiny black eyes and ringlets of black hair.

"When I picked her up, she put her arms around my neck and didn't let go," Freeman said.

Freeman wasn't prepared for the portion of her medical training she now describes as love.

"Guatemala changed me," said Freeman, who was sponsored by Dartmouth Medical School. "Now I understand why I am doing what I am doing. I want to help those who need me."

The trip has made Freeman want to open clinics herself and mentor future doctors on compassionate care.

"Morgy will be the first doctor in our family," said Freeman's mother, Priscilla, a teacher in San Antonio, Texas, for 28 years. "When she told me she wanted to go to Guatemala I was uncomfortable at first. But now I'm proud of her."

Wright saw patients in shacks and on the street.

He saw 3,000 people in seven days at a copper mine.

"I saw HIV, tuberculosis and sexually transmitted diseases," Wright said. "I saw street kids who huff gasoline to help with their hunger."

LECOM students Aida Kousheshian, 26, Nery Diaz, 42, and Dempsie Morrison, 26, all visited the Dominican Republic this year on a trip sponsored by LECOM's International Medical Society.

"I will always remember a little girl in a hospital who couldn't stop shaking," Morrison said. "She had a fever they were trying to break."

Kousheshian will always remember children swarming around her for stickers of dinosaur airplanes and butterflies, donated by The Toy Lab of Sarasota.

"They put the stickers all over their faces," Kousheshian said.

Diaz, who was born and raised in Cuba, said the Dominican Republic gave her a global vision.

"People we were treating with an anti-parasitic for diarrhea have to go back and drink more contaminated water," she said. "Every developing country needs public health infrastructure."

The students' gifts will make them better doctors, their professors and fellow students said Wednesday.

"Morganna comes into problem-based learning well-prepared every day," said Dr. Emil Adamec, a LECOM professor of neuroscience and pharmacology.

Mark Shank, a fellow student of Freeman's, said Freeman has impressed him with her spirit.

"She has phenomenal leadership skills," Shank said. "She knows when to step up. She's become so confident in herself."

The fact that these students wanted to do something for their fellow man outside of their country is impressive, said fellow student Melissa Roewe.

Clarence "Chip" Colle, associate professor of microbiology and immunology, agreed.

"The choices they made show how compassionate they are about medicine," he said.

Mind Body and Spirit: Total Body Healing!

MIND:
Because osteopathy recognizes that all parts of the body work together to create healing, the mind or brain is considered part of this holistic system. Therefore, osteopathy considers that disorder in body structure can cause or exacerbate mental problems like depression. In turn, it is thought that mental disorder can cause or exacerbate physical disease.

BODY:
Osteopathic physicians use all of the tools available through modern medicine including prescription medicine and surgery. They also incorporate osteopathic manipulative treatment (OMT) into their regimen of patient care when appropriate. OMT is a set of manual medicine techniques that may be used to relieve pain, restore range of motion, and enhance the body's capacity to heal.

SPIRIT:
There is no distinct spiritual component of osteopathy, but some modern practitioners recognize a bodily “energy” (like the Eastern concept of chi) as a healing force.

How does osteopathy work?

Long nerves connect the spine to various organs in the body. Andrew Taylor Still believed that every disease or illness began with structural problems in the spine. According to Still, when problems arise in the spine the nerves send abnormal signals to the body's organs. Still called these spinal problems "osteopathic lesions" ("osteo" for bone and "pathic" for diseased), and devised osteopathic manipulation techniques (OMTs) to treat them. Such lesions are detected by the osteopathic doctor from abnormal texture of the skin and other soft tissues of the body as well as from restricted range of motion in the joints. OMTs range from light pressure on the soft tissues to high-velocity thrusts on the joints. These treatments, he believed, would return the nerves to their normal function and allow the blood to flow freely throughout the circulatory system. With structure restored, the body's own natural healing powers would then be able to restore the entire body to full health.

What happens during a visit to the osteopath?

A visit to a D.O. is much like a visit to your family doctor. The D.O. will ask you questions about your medical history, physical condition, and lifestyle. However, because D.O.'s have particular expertise in musculoskeletal systems (namely, bones, joints, and soft tissues like ligaments and tendons), the physical exam of that bodily system will be more extensive than one with your family doctor. During the physical, the D.O. will assess your posture, spine, and balance; check your joints, muscles, tendons, and ligaments; and may use his or her hands to manipulate your back, legs, or arms. Variations in your skin temperature and sweat gland activity will also be measured. If needed, the D.O. will order X-rays and laboratory tests. When the results are in, the D.O. will make a diagnosis and establish a treatment plan for you that may even include prescriptions for medications.

For problems involving the bones, muscles, tendons, tissues, or spine, many current day (but not all) D.O.s use OMTs. There are two categories of OMT procedures: direct and indirect. In direct OMT, "problem" or "tight" tissues are moved (by the D.O., the person being treated, or both) toward the areas of tightness or restricted movement. In indirect OMT, the D.O. pushes the "tight" tissues away from the area of restricted movement, in the opposite direction of the muscle's resistance. He or she holds the tissues in this position until the tight muscle relaxes.

What illnesses and conditions respond well to osteopathy?

OMTs can be applied to a variety of health problems, both musculoskeletal and non-musculoskeletal. According to the US Department of Health and Human Services, OMTs are most effective for back and neck pain. In fact, if you have back pain, you may be able to reduce the amount of pain medication you are taking if you receive OMT as part of your therapy. One study showed that patients with pancreatitis were able to go home from the hospital sooner when they had OMT.

In one small study, people with Parkinson's disease were able to walk better after only one session of OMT. Another study looked at 38 patients who had knee surgery. Those who had OMT were able to walk up stairs 20% earlier than those who did not have OMT.

A study of 100 people with high blood pressure treated only with OMT showed that OMT produced significant reductions in blood pressure.

Studies show that OMT eases breathing, drains the sinuses and relieves the symptoms, duration, and recurrence of the common cold.

Osteopathy may also be an effective way to treat carpal tunnel syndrome. More studies are needed to confirm this.

Examples of other conditions for which OMT may be helpful include:

* stress-related problems (such as tension headaches, muscle spasm)
* strains and sprains (especially of the neck and back)
* shoulder pain
* osteoarthritis
* headaches
* painful menstruation
* injuries (such as whiplash)
* scoliosis (side to side curvature of the spine)
* infantile colic
* insomnia

About Myofascial Release

What is it?
Myofascial release is relatively new. Osteopathic physician Dr. Robert Ward of Michigan State University taught the first course entitled "myofascial release" at that school in the 1970s, and references to it first began to appear in the medical literature in the 1980s. However, as a holistic treatment that looks at the body as an integrated whole, its roots go back a long way, to the soft-tissue manipulations and stretches of osteopathy, which was first done in the nineteenth century.

Myofascial release is a therapeutic treatment utilizing a gentle form of stretching, producing a healing effect upon the body tissues, eliminating pain and restoring motion. Fascia is a connective tissue that surrounds every muscle, bone, nerve, blood vessel, and organ of the body, down to the cellular level. Malfunction of the fascial system due to trauma, posture, or inflammation can create a binding down of the fascia, resulting in abnormal pressure on nerves, muscles, bones, or organs. By freeing up fascia that may be impeding blood vessels or nerves, myofascial release is also said to enhance the body's innate restorative powers by improving circulation and nervous system transmission. People with longstanding back pain, fibromyalgia, recurring headaches, sports injuries, and a host of additional complaints are all said to benefit from the technique

Like many alternative therapies, myofascial release is part of a larger philosophy of healing that emphasizes the importance of mind-body interactions and preventive care. It may also be part of a pain management program that would include behavioral health techniques, acupuncture, drug therapy, nutritional counseling, and relaxation techniques.

How is it practiced?
The therapy's easy stretches break up, or "release," constrictions or snags in the fascia. The stretch is guided by feedback the therapist feels from the patient's body. This feedback tells the therapist how much force to use, the direction of the stretch and how long to stretch. Small areas of muscle are stretched at a time. Sometimes the therapist uses only two fingers to stretch a small part of a muscle. The feedback the therapist feels determines which muscles are stretched and in what order.

Myofascial Pain Syndrome (MPS) and Osteopathic Manipulative Treatment

Myofascial Pain Syndrome (MPS) is a is a painful musculoskeletal condition, a common cause of musculoskeletal pain. MPS is characterized by the development of Myofascial trigger points (TrPs) that are locally tender when active, and refer pain through specific patterns to other areas of the body. A trigger point or sensitive, painful area in the muscle or the junction of the muscle and fascia (hence, myofascial pain) develops due to any number of causes. Trigger points are usually associated with a taut band, a ropey thickening of the muscle tissue. Typically a trigger point, when pressed upon, will cause the pain to be felt elsewhere. This is what is considered "referred pain".


These factors can cause trigger points:

•Sudden trauma to musculoskeletal tissues (muscles, ligaments, tendons, bursae)
•Injury to intervertebral discs
•Generalize fatigue (fibromyalgia is a perpetuating factor of MPS, perhaps chronic fatigue syndrome may produce trigger points as well)
•Repetative motions; Excessive exercise; Muscle strain due to over activity
•Systemic conditions (eg, gall bladder inflammation, heart attack, appendicitis, stomach irritation)
•Lack of activity (eg, a broken arm in a sling)
•Nutritional deficiencies
•Hormonal changes (eg, trigger point development during PMS or menopause)
•Nervous tension or stress
•Chilling of areas of the body (eg, sitting under an air conditioning duct; sleeping in front of an air conditioner)

The fascia is a tough connective tissue which spreads throughout the body in a three dimensional web from head to foot without interruption. The fascia surrounds every muscle, bone, nerve, blood vessel and organ of the body, all the way down to the cellular level. Therefore, malfunction of the fascial system due to trauma, posture, or inflammation can create a binding down of the fascia, resulting in abnormal pressure on nerves, muscles, bones or organs.

This can create pain or malfunction throughout the body, sometimes with bizarre side effects and seemingly unrelated symptoms. It is thought that an extremely high percentage of people suffering with pain and/or lack of motion may be having myofascial problems; but most go undiagnosed, as the importance of fascia is just now being recognized.

Many of the standard tests, such as x-rays, myelograms, CAT scans, eletromyography, etc., do not show the fascia. (John Barnes, P.T., 1992)

Occassionally, trigger points produce autonomic nervous system changes such as flushing of the skin, hypersensitivity of areas of the skin, sweating in areas, or even "goose bumps." The trigger points cause localized pain, although TrPs can involve the whole body.

In three studies, the prevalence of myofascial TrPs among patients complaining of pain anywhere in the body ranged from 30% to 93%; (among patients with chronic craniofacial pain, 55%; and for lumbogluteal pain, 21%.)

The characteristic electrical activity of myofascial TrPs most likely originates at dysfunctional endplates of extrafusal muscle fibers. This dysfunction appears to play a key role in the pathophysiology of TrPs. (Simons 1996)

Subjective shortness of breath can be part of the myofascial pain syndrome of the levator scapulae muscle. In one study, 75 patients who reported neck pain & shortness of breath were examined. Trigger points were located and inactivated with acupuncture needles (dry needling). 68 of the 75 patients in the study reported that their shortness of breath and soreness were abolished immediately after inactivation of the TrPs. The other 7 patients needed a second trial of inactivation. Eliminating the trigger points eliminated the symptoms. (Journal of Muskuloskeletal Pain, 1996)

Like fibromyalgia, Myofascial Pain syndrome is an often misunderstood condition. Even today, some doctors either don't believe that MPS exists or they don't understand its symptoms and treatment.


Treatment of MPS can only begin after an accurate diagnosis is accomplished. Methods for managing this painful condition:

• Trigger Point Therapy {Myofascial release therapy, myotherapy, massotherapy (medical massage therapy)}
• Spray and Stretch technique (stretching of the muscles involved with a vapocoolant spray - a coolant is sprayed on the trigger point to lessen the pain and then the muscle is stretched. this is often done by a physical therapist.)
• Trigger Point Injections (local anesthetic,such as lidocaine, injected directly into the trigger points)
• Dry Needling (the use of a needle without injecting anything)
[TrP injections and dry needling mechanically disrupt the tirgger point. The use of lidocaine is no more effective, but it reduces the soreness afer injection. For MPS there is no role for injected steroids]

• Osteopathic manipulation treatment
• Craniosacral Therapy
• Physical Therapy (hands-on)
• Exercise
• Improvement of nutrition
• Changing sleeping habits
• The use of tricyclic antidepressants in low doses
• Elimination of stress; Biofeedback; Counseling for depression that may result from this painful condition

An active trigger point when treated well or with rest will become latent (quiet, or not causing active symptoms). It can often resurface after trauma after acute overload or fatigue, or even sudden exposure to cold. Conversely, new trigger points may arise elsewhere, or at least become more sinificant as others become latent.

For MPS, you should see a doctor knowledgeable in chronic pain such as a osteopathic physical medicine doctor (a physiatrist), or a osteopathic neurologist. The diagnosis is made by the history and physical exam. There is no lab test nor imaging studies to confirm the diagnosis. A history of acute trauma or chronic overuse should be looked for.. On exam, there is typically restricted motion with pain of the affected muscle. Other medical problems need to be ruled out with imaging or other studies. For instance, if a patient presents with back pain, disc and other problems need to be ruled out.

Altered Pain Perception Accompanies MPS: A Danish study indicates that people with chronic myofascial pain perceive and transmit pain differently than people without the syndrome. As many as 72 percent of people with fibromyalgia may have trigger points associated with myofascial pain.

Source: "Qualitatively altered nociception in chronic myofascial pain," by L. Bendtsen, R. Jensen, and J. Olesen, Pain, 65 (1996), pages 259-264

Breast Cancer and lymphedema: Can Lymphatic Pump Techniques work to reduce swelling?

The lymphatic pump is a method of manipulation used by osteopathic physicians to increase the rate of lymph flow in order to help fight infection.

Techniques to achieve this include the thoracic pump and abdominal pump. These methods increase the flow of lymph through the thoracic duct. It is believed that increased lymph flow is beneficial, as the lymphatic system is part of the immune system. Other techniques include Miller Pump (rhythmic, rapid, compression of the superior-anterior wall of the thorax), pedal pump, and diaphragmatic redoming. A modified version of Miller Pump can be used to treat atelectasis (loss of lung volume) by inducing sudden, rapid inflation of the lung. Indications for thoracic lymphatic pump include productive cough, upper respiratory tract infection, and extended bed confinement. Contraindications include osteopenia/osteoporosis, and injury (including surgical) to the thorax

Lymphatic treatments continue to be an important component of osteopathic manipulative medicine. [C.E.] Miller developed the lymphatic pump in 1926, stating that it is "an exaggeration of the movements of respiration." The lymphatic pump technique is used to treat patients with edema and infections because increasing lymphatic flow improves the filtering and removal of fluid, inflammatory mediators, and waste products from interstitial space.

During the influenza pandemic of 1917, [R.K.] Smith reported that osteopathic manipulative treatment (OMT) decreased the mortality rate from 5% to 0.25% among 100,000 patients.(Knott 2005)

Manual lymphatic drainage is a therapeutic technique used to a increase lymph flow. It consists of movement of the DO's hands over the patient's skin and subcutaneous tissue. The pressure applied is very gentle, and the movements are slow to correspond with the slow lymphatic pulsations. The massage sequence begins at the center of the body and moves to the periphery. The rationale for this is that the lymph nodes must be emptied before they can receive more lymph from the periphery. Each maneuver is performed in a distal to proximal direction.

A proposed benefit of osteopathic manipulative treatment (OMT) is enhancement of immune response to infection. This proposal intends to determine if lymphatic and splenic pumps can increase serum antibody and interferon levels against the varicella virus. Groups will consist of healthy adolescents not previously exposed to the virus. All subjects will receive the standard dose of varicella vaccine. The treatment group will receive OMT three times per week for two weeks after each vaccination. The control group will receive “sham treatment” consisting of standardized light touch protocol under the same schedule. Serum antibody levels will be measured using VZV latex bead agglutination assay. Interferon will be measured using cytopathic effect reduction technique. If osteopathic treatment is found to have an effect on antibody and/or interferon response, then results support benefits of OMT on immune response. This may result in using these methods among physicians to facilitate immune response post-vaccination.

Treating Spinal Stenosis with Osteopathic Manipulative Treatment

Source:
1. Jarski RW, Loniewski EG, William J, Bahu A, Shafinia S, Gibbs K, Muller M. The
Effectiveness of OMT as Complementary Therapy Following Surgery: A
Prospective Match-Controlled Outcome Study. Altern Ther Health Med 2000; 6(5); 77-81.

Ask the Doctor: What is spinal stenosis?
By Dr. Bharat Sangani

Q: What is spinal stenosis?

A: Spinal stenosis occurs when excessive soft tissue or bone narrows the openings in the bones of the back.

This can irritate, squeeze or pinch the nerves that come from the spinal cord. In many people, this can cause pain, numbness or weakness in the legs, feet and buttocks. Although sever disability is uncommon, if it is not treated it can lead to nerve damage or paralysis.

Q: What causes spinal stenosis?

A: As we age, our spine ages also. This can be accelerated with wear and tear. The soft tissues may thicken. The cartilage of the back joints may deteriorate. Bony growths (spurs) develop. The combination of all this narrows the openings for the nerves.

Q: What are symptoms of spinal stenosis?

A: Symptoms vary in different people. They may include: low-back pain, which may radiate from the back to the buttock and down the leg, sometimes to the foot; weakness, numbness, or cramping in legs, usually worse when walking and relieved by sitting. In severe cases, there is loss of bowel or bladder control.

Q: How is spinal stenosis diagnosed?

A: Diagnosis is based heavily on your symptoms and a physical examination at your doctor's office. Imaging studies can include MRI scans, CT Scans, Myelography (dye test) and conventional x-rays.

Q: How is spinal stenosis treated?

A: In most cases, it is best to start with conservative treatment. Heat, ice, topical creams and over-the-counter anti-inflammatories work for many people.

Prescription medications may include a stronger anti-inflammatory medications, steroids, and, for short periods, narcotic pain medications. Many people have good results with physical therapy or chiropractic treatments. Steroid (cortisone) injections performed by pain specialists can help.

If symptoms still persist with conservative measures, surgery can be considered. The most common surgery is a decompressive laminection, which removes the bone and thickened tissues that are squeezing the nerves.

This is usually an overnight hospital stay, with a six-week recuperation. Sometimes this is combined with a fusion, which uses bone graft and often metal instrumentation to stabilize sections of spine. Surgeries tend to be more effective for lower extremity symptoms. Surgery can be safely performed at any age, provided medical problems are controlled.

Q: How can spinal stenosis be prevented?

A: In many cases, there may be no way to prevent the aging changes that cause stenosis. Some of the symptoms, however, may be controlled by maintaining a healthy back. Regular exercise, weight control and good posture are all important.

Don't smoke. There is evidence that links smoking to back pain, disc problems, and decreased bone density (osteoporosis). This can increase your risk of fracture and bone deterioration. Smoking also makes bone healing more difficult after surgery.

Summary: Spinal stenosis, although common, is a very treatable condition. Please see your doctor, who can help guide you through the proper treatment regimen.

More on Spinal Stenosis:
Source: http://www.bonati.com/_dr-david-r-hirschauer.html

Definition of Spinal Stenosis
Spinal stenosis is a narrowing of the spinal canal, which places pressure on the spinal cord. If the stenosis is located on the lower part of the spinal cord it is called lumbar spinal stenosis. Stenosis in the upper part of the spinal cord is called cervical spinal stenosis. While spinal stenosis can be found in any part of the spine, the lumbar and cervical areas are the most commonly affected.

Description
Spinal stenosis is a progressive narrowing of the opening in the spinal canal. The spine is a long series of bones called vertebrae. Between each pair of vertebra is a fibrous intervertebral disk. Collectively, the vertebrae and disks are called the backbone. Each vertebra has a hole through it. These holes line up to form the spinal canal. A large bundle of nerves called the spinal cord runs through the spinal canal. This bundle of 31 nerves carries messages between the brain and the various parts of the body. At each vertebra, some smaller nerves branch out from these nerve roots to serve the muscles and tissue in the immediate area. When the spinal canal narrows, nerve roots in the spinal cord are squeezed. Pressure on the nerve roots causes chronic pain and loss of control over some functions because communication with the brain is interrupted. The lower back and legs are most affected by spinal stenosis. The nerve roots that supply the legs are near the bottom of the spinal cord. The pain gets worse after standing for a long time and after some forms of exercise. The posture required by these physical activities increases the stress on the nerve roots. Spinal stenosis usually affects people over 50 years of age. Women have the condition more frequently than men do.

Cervical spinal stenosis is a narrowing of the vertebrae of the neck (cervical vertebrae). The disease and its effects are similar to stenosis in the lower spine. A narrower opening in the cervical vertebrae can also put pressure on arteries entering the spinal column, cutting off the blood supply to the remainder of the spinal cord.

Causes
Some patients are born with this narrowing, but most often spinal stenosis is seen in patients over the age of 50. In these patients, stenosis is the gradual result of aging and “wear and tear” on the spine during everyday activities. There most likely is a genetic predisposition to this since only a minority of individuals develops advanced symptomatic changes. As people age, the ligaments of the spine can thicken and harden (called calcification). Bones and joints may also enlarge, and bone spurs (called osteophytes) may form. Bulging or herniated discs are also common. Spondylolisthesis (the slipping of one vertebra onto another) also occurs and leads to compression. When these conditions occur in the spinal area, they can cause the spinal canal to narrow, creating pressure on the spinal nerve.

Spinal stenosis causes pain in the buttocks, thigh, and calf and increasing weakness in the legs. The patient may also have difficulty controlling bladder and bowel functions. The pain of spinal stenosis seems more severe when the patient walks downhill. Spinal stenosis can be congenital, acquired, or a combination. Congenital spinal stenosis is a birth defect. Acquired spinal stenosis develops after birth. It is usually a consequence of tissue destruction (degeneration) caused by an infectious disease or a disease in which the immune system attacks the body's own cells (autoimmune disease). The two most common causes of spinal stenosis are birth defect and progressive degeneration of the tissue of the joints (osteoarthritis). Other causes include improper alignment of the vertebrae as in spondylolisthesis, destruction of bone tissue as in Paget's disease, or an overgrowth of bone tissue as in diffuse idiopathic skeletal hyperostosis. The spinal canal is usually more than 0.5 in (12 mm) in diameter. A smaller diameter indicates stenosis. The diameter of the cervical spine ranges is 0.6-1 in (15-12 mm). Any opening under 0.5 in (13 mm)in diameter is considered evidence of stenosis. Acquired spinal stenosis usually begins with degeneration of the intervertebral disks or the surfaces of the vertebrae or both. In trying to heal this degeneration, the body builds up the spinal column. In the process, the spinal canal can become narrower.

Symptoms
The narrowing of the spinal canal itself does not usually cause any symptoms. It is when inflammation of the nerves occurs at the level of increased pressure that patients begin to experience problems. Patients with lumbar spinal stenosis may feel pain, weakness, or numbness in the legs, calves or buttocks. In the lumbar spine, symptoms often increase when walking short distances and decrease when the patient sits, bends forward or lies down. Cervical spinal stenosis may cause similar symptoms in the shoulders, arms, and legs; hand clumsiness and gait and balance disturbances can also occur. In some patients the pain starts in the legs and moves upward to the buttocks; in other patients the pain begins higher in the body and moves downward. This is referred to as a “sensory march”. The pain may radiate like sciatica or may be a cramping pain. In severe cases, the pain can be constant. Severe cases of stenosis can also cause bladder and bowel problems, but this rarely occurs. Also paraplegia or significant loss of function also rarely, if ever, occurs.

Diagnosis
The physician must determine that the symptoms are caused by spinal stenosis. Conditions that can cause similar symptoms include a slipped (herniated) intervertebral disk, spinal tumors, and disorders of the blood flow (circulatory disorders). Spinal stenosis causes back and leg pain. The leg pain is usually worse when the patient is standing or walking. Some forms of spinal stenosis are less painful when the patient is riding an exercise bike because the forward tilt of the body changes the pressure in the spinal column. Doppler scanning can trace the flow of blood to determine whether the pain is caused by circulatory problems. X-ray images, computed tomography scans (CT scans), and magnetic resonance imaging (MRI) scans can reveal any narrowing of the spinal canal. Electromyography, nerve conduction velocity, or evoked potential studies can locate problems in the muscles indicating areas of spinal cord compression.

How Stenosis is Diagnosed
Before making a diagnosis of stenosis, it is important for the doctor to rule out other conditions that may have similar symptoms. In order to do this, most doctors use a combination of tools, including:

History: The doctor will begin by asking the patient to describe any symptoms he or she is having and how the symptoms have changed over time. The doctor will also need to know how the patient has been treating these symptoms including what medications the patient has tried.

Physical Examination: The doctor will then examine the patient by checking for any limitations of movement in the spine, problems with balance and signs of pain. The doctor will also look for any loss of extremity reflexes, muscle weakness, sensory loss, or abnormal reflexes which may suggest spinal cord involvement.

Tests
After examining the patient, the doctor can use a variety of tests to look at the inside of the body. Examples of these tests include:

X-rays - these tests can show the structure of the vertebrae and the outlines of joints and can detect calcification.

MRI (magnetic resonance imaging) - this test gives a three-dimensional view of parts of the back and can show the spinal cord, nerve roots, and surrounding spaces, as well as enlargement, degeneration, tumors or infection.

Computerized axial tomography (CAT scan) - this test shows the shape and size of the spinal canal, its contents and structures surrounding it. It shows bone better than nerve tissue.

Myelogram - a liquid dye is injected into the spinal column and appears white against bone on an x-ray film. A myelogram can show pressure on the spinal cord or nerves from herniated discs, bone spurs or tumors.

Bone scan - This test uses injected radioactive material that attaches itself to bone. A bone scan can detect fractures, tumors, infections, and arthritis, but may not tell one disorder from another. Therefore, a bone scan is usually performed along with other tests.

Treatment
Mild cases of spinal stenosis may be treated with rest, nonsteroidal anti-inflammatory drugs (such as aspirin), and muscle relaxants. Spinal stenosis can be a progressive disease, however, and the source of pressure may have to be surgically removed..

Surgical Treatment
In many cases, non-surgical treatments do not treat the conditions that cause spinal stenosis, however they might temporarily relieve pain. Severe cases of stenosis often require surgery. The goal of the surgery is to relieve pressure on the spinal cord or spinal nerve by widening the spinal canal. This is done by removing, trimming, or realigning involved parts that are contributing to the pressure.

The most common surgery in the lumbar spine is called decompressive laminectomy in which the laminae (roof) of the vertebrae are removed to create more space for the nerves. A surgeon may perform a laminectomy with or without fusing vertebrae or removing part of a disc. Various devices (like screws or rods) may be used to enhance fusion and support unstable areas of the spine.

Other types of surgery to treat stenosis include the following:

Laminotomy - when only a small portion of the lamina is removed to relieve pressure on the nerve roots;

Foraminotomy - when the foramin (the area where the nerve roots exit the spinal canal) is removed to increase space over a nerve canal. This surgery can be done alone or along with a laminotomy;

Medial Facetectomy - when part of the facet (a bony structure in the spinal canal) is removed to increase the space;

Anterior Cervical Discectomy - the cervical spine is reached through a small incision in the front of the neck.

What is Causing the Pain
Your spine must be stable to support upright posture, and also flexible, allowing you to bend and twist. This is mechanically very challenging and makes your spine vulnerable to injury.

The spine is made up of a chain of bones, called vertebrae, which are connected together by ligaments and muscles. The vertebrae cover and protect the spinal cord, which carries sensory messages to and from the brain, controlling all your body functions.



A disc separates each vertebrae and acts like a cushion, absorbing shock along the spine. The disc is made up of jelly like substance known as the nucleus, covered with many strong outer layers called the annulus. The discs do not have a supply of blood vessels to nourish and replenish them, rather, they depend on a transfer of fluids, nutrients and oxygen from the bones (vertebrae) above and below them. This transfer of fluid depends on the difference in pressure between the inside of the discs and the surrounding vertebrae and blood vessels. This is why most disc nutrition and regeneration takes place when we lie down and the pressure inside the discs is reduced. This process is not very efficient, and as we age, the disc is exposed to wear and tear greater than its ability to heal and regenerate.




The discs are prone to injury and degeneration as we use our backs each day, as they are compressed and torqued through sitting, bending and lifting. In the two lower levels of the lumbar spine, stress forces can equal 2,000 to 3,000 pounds of pressure per square inch. Repeated injury weakens the annulus, while the earliest changes that occur in the discs are tears in the annulus. With increased pressure inside the disc, the tears in the annulus may allow the disc to bulge like an old tire with a broken casing. Any internal damage to the disc may cause severe pain in the back. If all of the layers of the annulus break, the jelly-like nucleus will ooze out of the disc, causing a disc herniation. A bulging or herniated disc may press on spinal nerves, causing sciatica, which can be felt as weakness in your muscles, loss of sensation in the skin or a tingling or burning sensation along the nerves in your buttock and legs.


Repeated episodes of injury results in the degeneration of the disc, which becomes stiff and dry, causing it to lose its shock absorbing properties. This process may continue until the disc is collapsed, which increases the mechanical pressure on the bones and joints lending to arthritis (facet syndrome).

Treatment by Osteopathic Manipulative Medicine.

Osteopathic manipulation is used as an adjunct to other medical therapies that are used to manage acute and chronic pain. Recent studies have advocated the use of manipulation in algorithms for back pain and other musculoskeletal conditions. Osteopathy is a philosophy of medical care that combines the needs of patients with the current practices of medicine and its specialties with emphasis on the interrelationships between structure and function and appreciating the body’s ability to heal itself.1 In particular, most osteopathic medicine’s manipulative techniques are aimed at reducing or eliminating the restrictions to proper structure and function so the person’s self-healing mechanism can assume its role in restoring the person’s musculoskeletal health.

What is Manipulation?
Osteopathic manipulative treatment (OMT) is the manual application of forces to the body to restore maximal pain-free movement of the musculoskeletal system3 (Greenman). As a complimentary therapy and unique system of practice, OMT uses vocabulary and methods for approaching patients that are different from those of traditional medicine.1
Pain is the most common reason patients seek manipulation. Other reasons may include psychological issues, wellness, athletic performance, and medical problems without clear musculoskeletal etiology such as asthma, or malignancy. The reason for treatment is also important in that misdiagnosis and delay of appropriate treatment is an important complication.

The Value of Therapeutic Touch
Previous studies have reported decreased blood pressure and anxiety following “hands-on” type of treatment. OMT is holistic approach involving patient-practitioner interaction and purposeful physical contact.

How Popular Is Osteopathy?
Osteopathy has changed the lives of such well-known figures as John D. Rockefeller, Henry Kissinger former presidents Franklin Delano Roosevelt, Dwight Eisenhower and John Fitzgerald Kennedy. The growing demand for Osteopathic services among our population reflects an increasing desire by patients to resolve health problems without drugs or surgery. Osteopathic Medicine continues to gain national attention and remains the fastest growing health profession in the nation.

1. Jarski RW, Loniewski EG, William J, Bahu A, Shafinia S, Gibbs K, Muller M. The
Effectiveness of OMT as Complementary Therapy Following Surgery: A
Prospective Match-Controlled Outcome Study. Altern Ther Health Med 2000;
6(5); 77-81.

Osteopathic Manipulative Treatment In India

Osteopathic training for physicians proposed

Staff Reporter

Focus on manual treatment of musculoskeletal problems





CHENNAI: Physicians in the State will soon gain exposure to the natural healing principles of osteopathy, if a proposed training programme in this branch of alternative medicine gets underway.

Osteopathy is a non-medication, non-surgical system of healthcare that focuses on the treatment of musculoskeletal problems, especially lower back pains, joint aches and arthritis. It is used as an alternative approach to management of sports trauma, headaches, migraine, asthma and breathing problems.

The osteopathy maxim is founded on the body's ability to heal on its own, the acceptance of the spinal structure as the supreme governor of body functions and the importance of the artery network, according to Singapore-based osteopath David Tio. "The plan is to introduce osteopathy training to MBBS doctors, orthopaedicians, general surgeons, nurses and physiotherapists," said gastroenterologist N. Rangabashyam. The modalities of technical support from Dr. Tio, who runs the Osteopathic Treatment Centre in Singapore, are being worked out, he said.

Osteopathy advocates a form of manual medicine where the physician's hands become the tools in identifying the pain nodes and applying tactile pressure. The spine is the most important structure governing the entire range of functions and osteopathy attributes disorders to problems in the spinal structure, Dr. Tio said.

Osteopathy, developed in the modern era by 19th century physician A. T. Still, is now recognised across the United States, U. K. and Australia and practised by around 40,000 specialists.

Osteopathic Manipulative Treatment: What is the Muscle energy technique?

Muscle energy technique (or MET) is based on the principle of reciprocal inhibition, a theory that explains that muscles on one side of a joint will always relax to accommodate the contraction of muscles on the other side of that joint when indirect pressure is applied. MET is often applied to patients who suffer from muscle spasms.

Muscle energy techniques are applied to a patient in order to lengthen shortened or spastic muscles, to improve weakened ligament and muscle strength, and to improve range of motion. This procedure is performed when a patient is asked to contract a muscle for approximately 5-seconds against an anti-force applied by the therapist. The muscle contraction is performed by the client 2 or 3 times in a row in the hopes to stretch the muscle further each time.

Muscle Energy Technique is derived from Osteopathics (the study of the musculoskeletal system) by Dr. Fred Mitchell, Sr. and his son Dr. Fred Mitchell, Jr. The theory behind MET suggests that if a joint isnt used to its full range of motion, its function will lessen and it will be at risk of suffering strains and injuries. This form of muscular therapy makes use of a patient's own muscle energy (the force); while the therapist presents a stationary surface (or anti-force) the patient will contract their muscle against in order to stretch the muscle and joint to its full potential.

Muscle energy techniques can be applied safely to almost any joint in the body. Many athletes use MET as a preventative measure to guard against future muscle and joint injury. However, its mainly used by individuals who have a limited range of motion due to back, neck and shoulder pain, scoliosis, sciatica, unsymmetrical legs, hips or arms (for example when one is longer or higher then the other), or to treat chronic muscle pain, stiffness or injury.

Osteopathic Manipulative Treatment: Diagnosis, Treatment, and Results

Osteopathic medicine
M. SICKESZ AND E.B. BONGARTZ

Introduction
Pain that is relayed segmentally via a dermatome is of radicular origin. In osteopathic medicine, practitioners are frequently confronted with reflex differences, loss of sensitivity and/or loss of strength if the pain radiates to one of the limbs. Knowledge of segmental innervation is important for identifying the site of a possible neurogenic lesion. In very many cases, however, the complaints expressed by the patient cannot be placed in this category and no loss of sensitivity or strength can be established upon physical examination. In the absence of other causes, such as those of capsular or tendo-myogenic origin, this is referred to as pseudoradicular pain; in other words, there is no consensus on a diagnostic system for complaints of pain in the locomotor apparatus. From the therapeutic viewpoint a conservative approach is then appropriate, varying from rest to physiotherapy or from medication to alternative, additive methods.

In this article, one empirical method is described, viz.: osteopathic medicine. This method focuses on the use of palpation and examination to identify an abnormal position of the skeletal parts of the locomotor apparatus and to correct them by application of varying degrees of local pressure. This abnormal position is sometimes associated with local dysfunctioning. The abnormal position and the underlying pseudoradicular complaints must be positively influenced by manipulation (mobilization).

Diagnostics
Upon diagnosis, osteopaths establish deviations in the relative position of the different vertebrae by means of palpation and examination. To that end, an imaginary line is drawn between the fingers of the examining practitioner, which are placed on certain sites of the patient's body. These sites are determined on the spinal column, for example, by the spinous processes and the transverse processes, etc. Account is taken of the fact that the joint surfaces between the various vertebrae on the spinal column are practically all different in shape and size and their position relative to the co-ordinate system is consequently different each time. Knowledge of this is essential.

What are the deviations from the usual position that a vertebra in the co-ordinate system may display relative to the neighbouring caudally located segment? (The standard abbreviation used in osteopathic medicine is shown between brackets.)

1. The vertebra may rotate around the anterior-posterior axis (AP axis). It is assumed that this rotation continues so far, due for example to overloading, that it becomes locked in this position. This applies to cervical, thoracic and lumbar vertebrae. The vertebra tilts, as it were; it is in a lateroflexion position (LFP).

2. The vertebra may be displaced dorsally, both unilaterally and bilaterally, and will then be forced by the shape of the joint surfaces also to rotate slightly in the other two body axes. This applies to cervical, thoracic and lumbar vertebrae. The vertebra is displaced backwards, as it were, and we call this a dorsal displacement; it is in a dorsal position (DP).

3. The vertebra may shift sideways. Again, this is possible in the case of cervical, thoracic and lumbar vertebrae. Lumbar vertebrae present differently on palpation than cervical and thoracic vertebrae due to the shape of their joint surfaces. The vertebra shifts, as it were, laterally; it is in a lateral position (LP).

4. The vertebra may be displaced ventrocranially, either unilaterally or bilaterally. This is accompanied by rotation around a longitudinal axis and around the anterior-posterior axis; however, the latter occurs only in unilateral displacement. Bilateral displacements are seen after whiplash trauma: the vertebra is in a ventral position (VP).

5. The vertebra may rotate around a longitudinal axis. When this axis runs through the vertebral body, the dorsal part of the vertebra - in particular the spinous process - is displaced away from the median line. The vertebra rotates; this is a rotation position (RP). The positions may occur singly or in combination, i.e. a single vertebra could display all five of the deviations from the usual position at the same time.



How does one establish these deviations from the usual position in the separate parts of the spinal column?

In the case of the cervical vertebrae, the transverse processes and the spinous processes can be extremely well palpated, thereby allowing the position of the neck vertebrae to be well determined. The examination is done while the patient is seated with the head hanging down.
In the case of the thoracic vertebrae, the ribs give a magnified image of the position of the vertebrae. Together with palpation of the musculature adjacent to the spinous process on both sides while the patient is sitting straight and while the patient is lying in the ventral decubitus position, this provides sufficient indicators to determine the deviations from the usual position.
In the case of the lumbar vertebrae, the diagnosis is largely made while the patient is lying in the ventral decubitus position. The position of the individual spinous processes is examined and the position relative to the underlying vertebra is also determined, as well as the position of the palpating thumbs, pressed into the tissue lateral to the erector trunci muscle.
In addition, the position of the vertebrae relative to one another is also examined while the patient is lying in the left or right lateral decubitus position with the pelvis on a cushion. A properly functioning back should then show a certain curvature. The above-mentioned deviations from the usual position can soon be identified in this way.
The pelvis plays an important role in the diagnosis of deviations from the usual position in the spinal column. Three deviations may be established in the pelvis, viz.:

tilted sacrum relative to a vertical line;
distorted pelvis without fixation of the sacroiliac (SI) joints, and
distorted pelvis with fixation of one or two SI joints.
Re a. A tilted sacrum is established by placing the patient in the ventral decubitus position, if necessary with a cushion under the abdomen if the patient fails to relax sufficiently. You then stand at the patient's head and place both index fingers at left and right of the cranial end of the sacrum alongside the superior articular process and press the fingers in the caudal direction. When one finger then moves more caudally than the other, this indicates that the sacrum is tilted and clamped between the two halves of the pelvis. In many cases this can also be clearly seen when the patient is in the seated position. This deviation may be caused by an asymmetrical vertical force, as in:

falling on the buttocks;
sliding down the stairs while seated;
manual expression during labour.
Re b. A distorted pelvis is a pelvis in which one or both ossa ilii are rotated into the SI joint in the rest position, causing one or both cristae iliaca to be more cranial than the other. This is observed with the patient seated by placing the fingers left and right purely lateral on the crests.

In the case of a distorted pelvis without fixation of the SI joints, the functioning of the SI joints is checked as follows: sit behind the (standing) patient and place the right thumb on the sacrum alongside the spina iliaca posterior superior at the left side. A notional line is drawn to the left trochanter major and the left thumb is placed 2 cm away from the right thumb on this line. The patient is then asked to draw the left knee up to the abdomen, if necessary with the assistance of the hands. During the last part of the knee-lifting motion, the left thumb must describe a semi-circular movement and finish above the right thumb. If this happens, the functioning is in order. This examination applies to the left SI joint. For the right SI joint the placement of the hands should be symmetrically reversed.

The cause of the distorted pelvis may be due to deviations from the usual position of the lower lumbar vertebrae and/or to functional deviations or deviations from the usual position of the hip joint. A fused symphysis, which as syndesmosis should nonetheless show some mobility, may also be the cause of a distorted pelvis.



Re c. When no movement is observed in the SI joints bilaterally during functional examination of these joints in a distorted pelvis, there is nearly always a fairly appreciable (apparent) lower limb length discrepancy. This discrepancy is not true because it is based on the fact that the examination to determine the height of the two crests is repeated in the standing position and not in the seated position. If it is found upon repetition of this examination in the seated position that a tilted pelvis is still present, there is therefore mention of an 'apparent' lower limb length discrepancy.

A distorted pelvis due to bilateral SI joint locking is caused by fixation of one os ilium ventrally, as a result of which the acetabulum moves caudally; the other iliac bone is then fixed dorsally, which causes the acetabulum to move more towards the cranium. When these fixations are loosened, most of the torsion overstress is usually relieved. When the fingers are subsequently placed on the crests, bilaterally on the erector trunci muscle with the patient seated, one finger is frequently still found to be higher than the other; in this case a tilted pelvis is involved, where one of the os ilii has been displaced cranially or caudally.

A long existing tilted pelvis is 'cushioned' by the spinal column by allowing the vertebrae to rotate around the longitudinal axis, alternating left and right dorsally, up to and including C5. These twisting moments form a fixed pattern with fixed turning points. These fixed patterns are called 'formulae'. One of these formulae can be seen by asking a person with an anatomically normal back to rest one foot on an approximately 2 cm high platform and then stand with the knees straightened. One of the formulae - of which there are four - will then be formed. After removing the platform everything is restored to normal. The formulae are therefore physiological adjustments that can turn into deviations if they become fixed because the tilted pelvis becomes permanent. After correction of the tilted pelvis the formulae do not disappear unless they are treated adequately. This treatment, by manipulation, has a fixed, systematic sequence. The formulae are corrected in five treatments.

The cause of the tilted pelvis is excessive loading of the sacrum with opposing pressure in one of the acetabula; this occurs in sideward strain when lifting a load or in a fall on one of the os ischii.

The deviations from the usual position of the individual vertebrae are largely covered by the formulae. All the additional deviations of the vertebrae cannot be separately assessed and treated until approximately three treatments have been completed.

Complaints and symptoms
The above-mentioned deviations from the usual position of the vertebrae, which are often associated with dysfunctioning, frequently cause 'referred' complaints. The complaints are situated in the dermatome, viscerotome or myotome. In this way, for example, it is possible that complaints of pain in the leg with no radicular compression symptomatology on physical examination are caused by low lumbar deviations in the manual therapy sense. This also applies, of course, to cervicobrachialgia and to dizziness and headaches of diverse origin. With regard to the viscerotomes, it is noted that a connection is frequently found between diffuse cardiac complaints and deviations of the midthoracic spine. In nonspecific abdominal complaints a connection is also frequently seen with deviations of the lumbar spinal column. There is consequently also mention of a therapeutic approach to vegetative complaints that cannot be determined by means of instrumental diagnosis and which are susceptible to spinal column manipulation.

Therapy
Treatment consists generally of light pressure in the opposite direction to the deviation from the usual position, causing the vertebra to resume its normal position in the co-ordinate system. This will usually require several combined manipulations. It has been demonstrated empirically that the spinal column is governed by fixed laws. These laws entail, among other things, that:

each vertebra must be treated separately;
each deviation from the usual position must be treated separately, and
there is a certain sequence in the treatment of these deviations from the usual position.
This local and specific pressure is exerted on the transverse process or spinous process, in the course of which the adjacent segments either have to be relaxed or possibly fixed in torsion. During this treatment, use is made of cushions of different heights.



The authors would like to express their thanks to their colleague E. Keijzer, M.D., Doctor of Osteopathy, of Lelystad, for his valuable comments.

References
Cyriax F. Textbook of orthopaedic medicine. Vol. I. II. London: Baillière Tindall, 1980.
Lewit K. Manuele therapie. Part 1 and 2. Lochem: De Tijdstroom, 1979.
Niboyet JEN. La pratique de la médicine manuelle. Saint-Ruffine: Miasonneuve, 1968.
Williams PC. The lumbosacral spine. New York: McGraw-Hill, 1965.
Sickesz M. Orthomanipulatie. Alphen a.d. Rijn: Stafleu, 1981.
Biesinger E. Diagnosis and therapy of vertebrogenic vertigo. Laryngol Rhinol Otol (Stuttg) 1987; 66: 32-6.
Kunert W. Wirbelsäule, vegetatives Nervensystem und innere Medizin. Stuttgart: Enke Verlag, 1978.

Treating Acute musculoskeletal neck pain with Osteopathic Manipulative Treatment

Source: http://www.jaoa.org/cgi/content/full/105/2/57

JAOA • Vol 105 • No 2 • February 2005 • 57-68

Intramuscular Ketorolac Versus Osteopathic Manipulative Treatment in the Management of Acute Neck Pain in the Emergency Department: A Randomized Clinical Trial

Tamara M. McReynolds, DO; Barry J. Sheridan, DO

Acute musculoskeletal neck pain is a common complaint among the general population in the United States and is a frequent problem for patients presenting to the emergency department (ED). Up to 71% percent of Americans can recall experiencing an episode of neck pain or stiffness in their lifetimes.

In the ED, providing pain relief for patients with neck pain is the primary goal—after any significant pathology or injury has been excluded from diagnostic evaluation. Patients are commonly treated with nonsteroidal anti-inflammatory drugs (NSAIDs). Osteopathic manipulative treatment (OMT) is another treatment modality that may be considered, however. Manipulation of the cervical spine for neck pain (and headache) is the second most common use of spinal manipulative therapy.
Osteopathic manipulative treatment is based on osteopathic principles and practice. Fundamental to the science and art of osteopathic medicine is the recognition of the body's inherent ability to restore homeostasis and heal itself. Various osteopathic manipulative (OM) techniques are applied in regions of somatic dysfunction (ie, areas of impaired or altered function of the body framework) to promote blood flow through the tissues, thus enhancing the body's own healing ability.

Terminology used to describe manual therapies varies. Osteopathic physicians use the term manipulation to describe over 100 different OM techniques.In the literature, many researchers use the term manipulation to describe high velocity, low amplitude (HVLA) thrust techniques. A thrust is a force applied to the joint that moves it beyond the passive range of motion and often produces an audible click at the joint.Mobilization is a nonthrust form of manipulation that applies a manual force to the spinal joints within the passive range of motion.

The term manipulation in our study describes manipulative therapies as used by chiropractors, physiotherapists, other "manual therapists," and osteopathic physicians—as when we inquired of study subjects prior to study enrollment if they had ever received "prior manipulation." The term osteopathic manipulative treatment (ie, OMT), however, is used in our study only when osteopathic physicians in the treatment of patients use OM techniques. In this study, the OM techniques used by osteopathic physicians include HVLA thrust, soft tissue, and muscle energy techniques.

Read More: http://www.jaoa.org/cgi/content/full/105/2/57

Osteopathic Manipulative Treatment: Osteopathic Case Studies Now Present

Source: http://www.responsesource.com/releases/rel_display.php?relid=28311&hilite=

Here are a few quick scenarios which depict why OMT really works. Believe me, once you try it from a skilled physician, you will believe in it!

You can DO it!!!!!!

Christmas

Julia Young, Osteopath comments, ‘In the run up to Christmas I often see people who are suffering from Christmas shopping stress or injuries from carrying too much shopping; people falling when putting up decorations and those that over-do the house work. Post Christmas there are always a few ‘lifting the turkey’ or ‘playing Twister’ injuries and finally, people who have relaxed over the holiday and then start back to work or the gym but cease up because they are out of the habit.

Osteopaths seek to treat the cause as well as the symptom of pain and following a four year degree we are in a great position to give advice as well as provide treatment.'

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James Ball – Epilepsy

Born July 2005 James Ball was first diagnosed with epilepsy in January 2006

Challenges: Never interacted or looked into his mothers’ eyes. The common thought was that his eyes were adrift
James was experiencing frequent epileptic seizures – up to 10 to 15 a day and was placed on medication that was gradually increased to halt the seizures. However, seizures would increase before the medication caught up.

Osteopathy: On the 16th June his grandparents suggested he was taken to see Hector Wells, an osteopath based in Banbury.
The day after his first osteopathic treatment James started moving his neck in his pram and started to focus his eyes to look at his parents. He became more inquisitive and from this point onwards, with regular osteopathic treatments, James’ fits have stopped altogether without an increase in medication (October 2006)

The consultants are now considering taking him off medication

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Emily Savins – Hyperactivity

Born in 1997, Emily suffered from hyperactivity and learning difficulties from an early age

Her parents visited a local osteopath in 2004 and Emily started osteopathic treatment in 2004.
The benefits were immediate. Emily’s parents believe they can control Emily’s hyperactivity now through regular osteopathic treatment.
When Emily is treated Emily stops sleep walking, her eczema is better and she is more relaxed, is better company, mixes better, has more friends and is easier to live with

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Emma Williams – Unhappy Baby

Emma was taken to see an osteopath at 8 weeks old as a last resort. She had been screaming from about 6pm till 11pm daily since birth and in previous weeks had got worse and was now screaming from about 11am till night as well as waking through the night every couple of hours. She was also constipated and only emptying her bowels every two or three days. She had had a fairly traumatic birth by emergency caesarean section after a 36 hour labour. Her parents had no experience of osteopathic treatment let alone cranial osteopathy for babies and were very sceptical but basically desperate. They had been given the osteopath’s details by the health visitor.

On examination, Emma appeared a normal, pretty baby but there was some tension at the top of her neck and also in her left hip and groin. This had probably been causing tummy aches, colic and headaches. Most babies stop crying immediately a release of tension following treatment is felt, however some resume crying through sensations of hunger stimulated by treatment or just from sheer indignation!

Emma was brought back after a week with wonderful reports of peace and sleeping through the night. The osteopath now sees Emma once or twice a year and she has been doing very well.

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Sally (pseudonym) – Post Natal Depression

Sally suffered so badly from post natal depression that she was admitted into a psychiatric hospital.

Following very successful treatments from her osteopath she now feels that she can ‘talk about the pain and anguish’ she was suffering from. She is happy to be interviewed but needs her name to remain anonymous.

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Mark’s Story - Tourettes
Aged 27

Mark is incredibly flexible and suffers from autism and tourettes – both are controlled with osteopathic treatment

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Simon’s Story - Stress

40 years old

Following three treatments with an osteopath Simon was amazed at the difference with his attitude to life. He is far more relaxed, approachable, finds it easier to speak to people, is more tolerant and isn’t shouting at home. He says that he used to get pent up over the slightest of things but the osteopathic treatment (initially for his knee) has calmed him down completely. Apparently he hasn’t felt like this for 15 years (before his first child was born)
He is overwhelmed with the changes and says he has never felt so good

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Pregnant Women (article available)

Back pain is common in pregnancy but not normal it usually occurs because the body is not adapting to the 'new pregnancy posture.' As many as 50-80 per cent of women have back pain in their pregnancy most of them are told there is nothing you can do just put up with it until you have your baby it will then go away. - This is unacceptable. We would say that up to 80% of women can be helped with a combination of osteopathic treatment, which will include hands on treatment, postural and exercise advice.