Module 13

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Osteopathic EPEC
Education for Osteopathic Physicians on End-of-Life Care

Based on The EPEC Project, created by the American Medical Association
and supported by the Robert Wood Johnson Foundation. Adapted by the
American Osteopathic Association for educational use.

American Osteopathic Association
AOA: Treating Our Family and Yours

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Module 13:

Osteopathic Manipulative
Technique
in End-of-Life Care


E OMT Applications at End of
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E Life
C
• Generalized pain and disability
• cancer, metastasis
• heart disease,stroke, COPD, neuropathy
• neurodegenerative conditions/failure to
thrive:
e.g., Alzheimer or Vascular Dementia and
Parkinson Disease
– impair mobility
– cause musculoskeletal dysfunction

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P Goal of OMT: Normalization
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C
• The body is:
– Being assaulted by disease
– Suffering medication side effects
– Going through a closing down process
• The mind
• The spirit


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Psychosocial and Spiritual
E Issues Near the End of Life
C
Talking with a non-family member may assist
in eliminating past emotional baggage and
barriers
– Depression – Personal Issues
• Anything that can • Context and
be addressed? meaning of one’s
– Family Issues life
• Relationship • Personal faith
resolution – Hope
• The patient
• The family


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Compassionate Touch =
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OMT

biomechanically
Addresses emotions
alters physiology


E Compassionate Touch =
P
E OMT
C
• Compassionate touch has its own healing
quality

• People’s emotional barriers often soften
when compassionate touch is involved

• OMT is designed to biomechanically alter
physiology


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P MIND / BODY/ SPIRIT
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• Set goals: curative versus palliative
• Body
– assaulted by disease
– suffering from medical side effects
– going through closing down process
i.e., end-of-life phase ?


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Body/mind/spirit
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approach Principles
• Select your goal
– Extension of life
– Quality of life (Palliation)
• Diagnosis:
– Cause as little pain as possible
• Treatment:
– First, do no harm
– Treat one problem
– Allow the body to adjust

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OMT
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Treat one body part
Allow body to adjust
Re-assess
Re-treat


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P Treatment Type Decisions
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• Global disease • Local disease
– Area of greatest – Treat the local
restriction (AGR) somatic dysfunction
– Best method when – Commonly works!
problem is complex,
e.g., chronic LBP
– Best demonstrates OMM
– Best for hardest cases


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P Two Approaches
E • Global diagnosis
C – Sequencing area of treatment by area of greatest
restriction (AGR)
– Best method when the problem is complex
• E.g., chronic low back pain
– Best demonstrates osteopathic theory and philosophy
– Best for hardest cases

• Local diagnosis
– Easier method when you know the problem is local
• E.g., sprained ankle
– Most commonly used
– Does not completely demonstrate osteopathic theory
and philosophy
– Often works

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Two Approaches
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C •Which to choose? Dependent on:
•Time
•What the real problem is
•Your level of mastery
•Where the patient is in the end of life process

•Why you need both of these skills
•Global probably has the highest success rate
•Local approach can be done in less time to address
specific problems


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P Global Approach
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C • Examine the body for the area of
greatest restriction (AGR)
• Treat the AGR
• Reexamine other areas of restriction to
see if they have changed (or start
the whole process over)
• Treat successive areas of
greatest restriction (AGRs)


E Q: Why go global?
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E A: Chasing pain often leads to
C
failure
Consider the case of two people carrying a heavy load; one
drops most of his load. Which one complains the most?

THINK: The painful SI joint is frequently on the side opposite
the pain.

(Analogy for the classic presentation of sacroiliac joint
dysfunction. That is, the side exhibiting most pain is often
the side opposite the dysfunction!)

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Global Diagnostic
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Principle
• The AGR may be and frequently is in
a different body region than the site
of the chief complaint.
• In those cases, the area of pain is
where the body is compensating, not
where the problem is originating.


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The body is a unit…
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. . . with forces
distributed through a
tensegrity system


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P Global Treatment Principle
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• Sequence is vital…

• You have the right
numbers…

• But having the right
numbers won’t
always open the lock!


E Distant dysfunction
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E mechanisms manifesting as
C
low back pain
• Cranium
– Dural attachments
• Neck
– Fascia and muscle attachments, innervation of superficial low back muscles
• Thoracic and ribs
– Fascia and muscle attachments, abdominal muscles, diaphragm
• Upper extremity
– Scapular and latissimus dorsi attachments
• Lumbars
– Local problem
• Pelvis and sacrum
– Local problem
• Lower extremity
– Fascial and muscle attachments to ilia and sacrum


E Examination for AGR
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E • Based on the third principle of physiologic spinal motion
– When motion is induced in one plane, movement in the
C other two planes is decreased.

• We will induce motion in one plane
– This will restrict motion into the other two planes
• Then we will induce motion into the other two plane

• If you induce motion into a second plane, it also restricts
motion in the other two planes
– This will achieve what is called a physiologic lock.
– A normal joint will still have joint play, a small ability to
move.
– A restricted joint will not have the ability to spring.


E Problem-based Local
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E Approach
C
Based on the knowledge that certain problems have
local solutions

• You can always go back to the global approach

• Weakness: forming the habit of relying only on the
local approach
– The local approach is more reductionist, and
therefore doesn’t always treat the cause of the
problem


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Local approach
E • Focused exam on a problem region and it’s
C autonomic connections
• Analyze:
– is there a biomechanical problem?
– is there a problem with fluid flow?
– are there autonomic imbalances that you can treat to
improve the patient’s condition?
• Choose:
– a model of diagnosis and treatment to treat, depending
on the condition of the patient
– Counterstrain - Still
– MFR - Muscle Energy
– HVLA

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Model of Dx and Tx
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C • Depends upon the patient!
• Options for frail and/or elderly:
– Counterstrain
– Myofascial release technique (MFR)
– Craniosacral technique (Still)
– Muscle energy technique
• requires patient effort
– High velocity low intensity - HVLA
• VERY cautiously, rarely best

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P Common problems at the End of
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C Life
• Pain • Gastrointestinal
• Dyspnea, secretions symptoms
• Disorders of the CNS • Fluid retention
• Disorders of skin and
mucous membranes


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P Dyspnea
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• Thoracic-sympathetic connection: improve
cardio-vascular and respiratory systems
– Upper thoracics normalization:
indirect MFR
• Musculoskeletal system
– Coughing, loss of muscle mass
– Rib dysfunction
– Mechanical structures
– Diaphragm

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P Dyspnea Treatment
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C • Cervical treatment
– OA decompression
– C 3/4/5: Phrenic nerve
– OA, AA: Vagus
• Rib dysfunction
• Diaphragm
– Doming it
– Indirect treatment
• Thoracic sympathetic connection


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P Dyspnea
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• Autonomics
• Cervical Treatment: OA decompression
– C 3/4/5 – phrenic nerve
– OA, AA – vagus nerve
– Ligamentum nuchae – MFR
– Suboccipital release: slight
compression/traction; let gravity do the
work
– CV- VI: “reset” button for autonomics

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Ligamentum Nuchae Regional
E Technique
C
A useful technique for balancing more than two
segments, or to address the general
connective tissue for the posterior neck.
3. Sit at the head of your supine patient.
4. Cradle the patient’s occiput in the palm of one hand.
5. Use your other hand to grasp the posterior neck. Your
thenar/hypothenar eminences are on one side, your
fingerpads at the contralateral articular pillars.
6. Use motion testing to determine and place the patient
in the position of ease, as determined by decreased
tissue tension, for the connective tissue: F/E, S, and
R

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Ligamentum Nuchae Regional
E Technique
C 1. You may use the following activating forces:
Respiratory cooperation
Release enhancing maneuvers
Slight compression, traction, or torque
2. Follow the changing tissue tension in the direction of its
relaxation, taking the tissue toward the decreased
tension.
3. When the tissue stops relaxing, slowly return the patient
to neutral
4. Retest for resolution of TART criteria for somatic
dysfunction.


E Ligamentum Nuchae
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P Suboccipital Release
E • Sit at the head of your supine patient
C • Place your finger pads against the inferior occiput so
that your fingertips are approximately at the atlas.
• Your palms are underneath the occiput, but it is
initially suspended above them.
• Allow the weight of the patient’s head to create the
release
• Enhance the release with use of traction, compression,
or by initiating micro-motion and following the
progressive tissue relaxation as it occurs
• The occiput gently settles into your palms as the
release occurs.
• Retest the area for TART resolution.


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C3-7 Segmental Technique
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• Sit at the head of your supine patient.
C
• Diagnose the key dysfunction (e.g., C4 ESRRR).
• Contact the articular pillars of the dysfunctional
segment with the pads of your long fingers.
• Induce F/E, then S, then R to match the direction in
which the vertebra is already drawn by the tissue
(go indirect). Use translation to achieve
sidebending.
• To enhance the release, you may use activating
forces.
• Continue until the desired tissue response is
obtained, then slowly return to neutral
• Retest for TART resolution.

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P C3-7 Segmental Technique
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P Segmental
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Release


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Gastrointestinal problems
E • N/V, diarrhea, ileus cause autonomic
C effects; attempt to “damp down”
• General Treatment
– upper thoracics
– vagus nerve (OA, AA)
– T 5-9
• Diarrhea and constipation
– Thoracic and lumbar – sympathetics
– Sacral – autonomics
– Abdominal treatment
• Nausea caused by CMTRZ will require meds

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P Gastrointestinal Problems
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Treatments
• Occipitomastoid decompression
• Vagus Nerve OA, AA
• Thoracic and Lumbar sympathetic connections
• Sacral autonomic connections
• Abdominal treatment
– Inhibition
– Facilitation


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P General Autonomic Reset
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• CV IV

• Lumbosacral decompression


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P Extremities
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• Evaluation of limitation of motion
– Flexion
– Extension
– Adduction
– Abduction
– Rotation
• Shoulders: bursitis, adhesive
capsulitis, or disuse syndromes.


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P Edema fluid
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• Lymphatic Pump
– Can be done easily at the bedside
• Mobilization of the patient
– To the extent possible
– May actually help reduce overall pain


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Additional Principles
E • Give patients hope
C – But not false promises
• Help them to have a sense of at least some
control over their pain
• If you’re using the global osteopathic approach:
– Explain to patients why you may not treat the area of
greatest complaint
– Do at least something with the area of greatest
complaint
• A number of patients do not wish to take more
medicine, but they do want to feel better
– Some have difficulty tolerating medication
– You may have to talk them into more medication


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The Last Days:
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The Actively Dying Patient
• Pain is addressed by medication

• Some pain is poorly addressed by
medication
– Rib pain with inspiration

• General autonomic treatment


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