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Prof. David López Sánchez
Kinesiologyst; Chiropractor D.C.
Director of Chiropractic Program
Central University of Chile
Director of Manual Therapy Diplomats
Saint Thomas University, Chile
“Osteopathic Manipulative Therapy (OMTh)
of Extremities: revisited by other Manual
Therapist”, Poland, 2014
XX edition of International Disabled People’s Day.
International Scientifique Symposium
20-23 March 2014. Zgorzelec, Poland.
The therapeutic application of manually guided forces by an
osteopath to improve physiologic function and/or support
homeostasis that has been altered by somatic dysfunction.”
From: Glossary of Osteopathic Terminology Usage Guide
http://www.aacom.org/om/Glossary.pdf
Definition: Osteopathic Manual
Therapy
Spinal Osteopathic Manipulative Therapy:
Summary
Asymmetry
Restricted Range of Motion
Tissue Texture Changes
Position of Elements
Restricted Motion Direction
Free Motion Direction
Skeletal structures
Myofascial structures (Tozzi, 2012)
Tissues: Vascular, Lymphatic and
Neural related elements (Langevin,
2006)
Somatic Dysfunction
Impairment
Disorder
Paolo Tozzi, Selected fascial aspects of osteopathic practice, Journal of Bodywork & Movement Therapies. 2012;16, 503-519.
Helene M. Langevin, Karen J. Sherman, Pathophysiological model for chronic low back pain integrating connective tissue and
nervous system mechanisms, Medical Hypotheses, 2006; 68,74-80.
3David Lopez Sánchez DC, PT
David Lopez Sánchez DC, PT 4
Spinal Osteopathic Manipulative Therapy:
Summary
Joint Motion
ROM/Kinetic Chain
Passive stability components
(ligaments, capsule, cartilage,
shape of joint surfaces).
Tendon, fascia and muscle
length & stiffness
Joint Integrity/Artrokinematics
Active Stability (results from
mutual contribution between
passive stability components and
muscle action).
Joint Homeosthasis
Muscle Performance/
Motor Control
Force
Trophism
Sensory Motor integration
Tone
Muscle Synergies
OMTh: Joint ROM Determinants
Spinal Osteopathic Manipulative Therapy:
Summary
Joint ROM: Kinetic Chain
Components Governing Stability in the
Musculoskeletal System
 The myofascial passive tonicity/tension.
 The fascial system passive network.
 The osteo-ligamentous system passive component.
 The muscular system active contractile response.
 The neural system control of reflex or active
contractions
* Expanded from Panjabi, 1992; Lardner, 2001
Spinal Osteopathic Manipulative Therapy:
Summary
Joint ROM: Kinetic Chain
 Each system works interdependently to allow functional efficiency
 If they do not—compensations and adaptations occur in other systems
 Compensations lead to tissue overload, decreased performance, and
predictable patterns of injury and dysfunction
 This leads to decreased neuromuscular control and initiates the
cumulative injury cycle
Biomechanics of Sport Techniques Hay, J. 1993 4th edition, Prentice . 1st and 2nd editions RC 1235 .H38
David Lopez Sánchez DC, PT 7
The osteopath refers as a manipulable lesion those
somatic dysfunctions of musculoskeletal components
caused by myofascial, vascular, lymphatic, and neural
elements (1).
 The entire body is a kinetic chain and operates as
an integrated functional unit that consists of
muscular, articular and neural components (Prentice
W., 2005)
 Specific joints elements shall suffer overload in
presence of deficitary control of the neuromuscular
system to perform dynamic eccentric, isometric, and
concentric actions efficiently in multiple planes
(Prentice W., 2005).
1.- Greenman, P.E. Principles of manual medicine, (Lippincott Williams & Wilkins, Philadelphia, 2003).
The Body as an Unity
• Forward Head
• Diminished Suboccipital Space & increased
thoracic kyphosis
• Bruxism
• Cervicothoractic Hypomobility
• Forward Shoulder (Scapular Protraction)
• Humeral Internal Rotation
• Shoulder impingement
•Lewis JS, Green A, Wright C. Subacromial impingement syndrome: the role of posture and muscle imbalance. J Shoulder Elbow Surg.
2005;14:385–392.
•Finley MA, Lee RY. Effect of sitting posture on 3-dimensional scapular kinematics measured by skin mounted electromagnetic tracking
sensors. Arch Phys Med Rehabil. 2003;84:563–568.
•Kebaetse M, McClure P, Pratt NA. Thoracic position effect on shoulder range of motion, strength, and three-dimensional scapular
kinematics. Arch Phys Med Rehabil. 1999;80:945–950.
Shoulder: Kinetic Chain Dysfunction?
Shoulder: Kinetic Chain Evidence?
 Falla D. et Als. Below experimental muscle nociceptive
stimuluation obtained differents responses among
trapezius muscle subdivisions during repetitive
shoulder flexion. (1)
 Recently Diederichsen L. et Als, 2009 confirmed that
induced pain in the supraspinatus muscle caused a
significant decrease in activity of the anterior deltoid,
upper trapezius and the infraspinatus and an increase
in activity of lower trapezius and latissimus dorsi
muscles. (2)
(1)Experimental Brain Research, Volume 178, Number 3 / 2007
(2) Experimental Brain Research Volume 194, Number 3 / 2009
10
T.A.R.T.
Tenderness
Asymmetry
Range of Motion changes
Tissue texture changes
And all related Clinical Findings
David Lopez Sánchez PT, DC
Osteopathy & Diagnosis
Spinal Osteopathic Manipulative Therapy:
Summary
• Direct • Indirect
• Soft tissue
• Muscle energy
• HVLA
• Articulatory / Still’s
• Osteopathy in the Cranial Field
• Strain-CounterStrain
• Facilitated Positional Release
• Balanced ligamentous tension /
ligamentous articular strain
• Osteopathy in the Cranial Field
• Osteopathy in the Biodynamic
Field
Osteopathic Techniques
Source: From the American Osteopathic Association, 2013
Spinal Osteopathic Manipulative Therapy:
Summary
Osteopathic Techniques Evidence
• Strong evidence supporting thrust and/or non-thrust manipulation plus exercise
to improve short- and long-term outcomes of care for patients with neck pain
disorders
• (Source:www.apta.org/manipulation)
Manipulation/Mobilization Systematic Review
(HVLA, articulary techniques)
(Gross, Cochrane Collaboration, 2004)
Spinal Osteopathic Manipulative Therapy:
SummaryStrain - Counterstrain (SCS):
“…Relieving spinal or other joint pain by passively
putting the joint into its position of greatest
comfort.” H. Jones, 1955.
 One of most common osteopathic techniques
used by osteopaths (1).
 The diagnostic of tender-points (TP) located in
muscles, fascias or tendons is central to SCS (Jones
L.H., 1995).
 Lewis demonstrated reduced electrical
detection (hyperaesthesia) and electrical pain
threshold (hyperalgesia) at DTPs (2).
1.- Johnson and Kurtz, J Am Osteopath Assoc. Vol 103. No 5. May 2003. 219-224
2.- Lewis C, Souvlis T, Sterling M. Sensory Characteristics of Low Back Tender Points
(2010) Manual Therapy, 15, 451-456
David Lopez Sánchez DC, PT 14
 Several studies investigating SCS report decreased pain
or palpation tenderness.(1).
 A restricted range of motion and a reduced ability to
generate adequate levels of force to move the joint is
common in muscles with tenderpoints (Simons et al.,1999).
 Tenderness and trigger points never follows a
dermatomal pattern.
 Typically postural muscles are most affected by trigger
points, specifically those in the neck, shoulders, and pelvic
girdle (2)
1.- Wong CK, Schauer Alvarez CS. The effect of strain counterstrain on pain and strength. Journal of Manual and Manipulative
Therapy 2004; 12 (4): 215-24.
2.- Chaitow L. Ligaments and positional release techniques. Journal of Body work and Movement Therapies 2009; 13: 115-6.
Strain - Counterstrain (SCS):
OMTh: Myofascial Release
 Mechanical
 support (vascular & structural)
 compartmentalization
 Mechanical Transduction (1)
 The fascia tension is determinant
in the muscle stiffness (2)
 Metabolic
 Diffusion: Fluids Continency
 energy storage: elastic potential energy
 Immunologic
 line of defense: lymphoid tissue
 Barrier: compartments
1. Schleip R. 2003. Fascial plasticity – a new neurobiological explanation. Journal of Bodywork and Movement
Therapies 7(1):11-19 and 7(2):104-116
2. Schleip R, Naylor IL, Ursu D, Melzer W, Zorn A, Wilke HJ, et al. Passive muscle stiffness may be influenced by active
contractility of intramuscular connective tissue. Med Hypotheses. 2006;66,66-71. 2005
Spinal Osteopathic Manipulative Therapy:
SummarySCS: Muscle Tone
The muscle tone and connective TenseActive Behavioral
1.- Masi, MD et Als. Clinical, Biomechanical, and Physiological Translational Interpretations of Human Resting Myofascial Tone or Tension.
International Journal Of Therapeutic Massage & Bodywork: Research, Education, & Practice, 2010 3(4), 16-28.
2.- Chaitow L. Ligaments and positional release techniques. J. Bodywork and Movement Therapies 2009; 13:115-6.
3.- Solomonow M. Ligaments: a source of musculoskeletal disorders. J. of Bodywork and Movement Therapies 2009; 13:136-54.
 The human resting tone role in helping to maintain
balanced postures is supported by biomechanical
principles of myofascial elasticity, tension, stress,
stiffness, and tensegrity (1).
 SCS may affect the protective ligamento-muscular
reflex through which ligamentous strain inhibits muscle
contractions that increase strain (2), or stimulates
muscles that reduce strain (3).
Treatment: Osteopatic Models
1.- *Rivers WE, Treffer KD, et al. Short-Tem Hematologic and Hemodynamic Effects of
Osteopathic Lymphatic Techniques: A Pilot Crossover Trial. JAOA. 2008; 108(11):
646-651 (1).
• Circulatory-Respiratory Model*
• Biomechanical/Postural/Tensegrity
Model
• Viscero-somatic/Somato-viscero
Model
• Neuro-Endocrine-Immune Model
• Bio-energetic Model
• Psychosomatic Model
Application of soft tissue manipulation also has demonstrated a decrease in plasma
fibrinogen and total fibrinolytic activity consistent with an increased parasympatic tone
and decreased sympathetic tone (1).
¿System or Philosophy?
David Lopez Sánchez DC, PT
18
Philosophy: clarifies and justifies
Principles: prescribe action based upon
philosophy.
Osteopathic Reasoning: Creates a clear
Identity.
Rational treatment is based upon a
systematic understanding and
application of the basic principles of
body unity, self-regulation, and the
inter-relationship of structure and
function.
(Adapted from the Foundations for Osteopathic
Medicine)
Thank YouDavid Lopez PT DC
consultas@dolordeespalda.cl
David Lopez Sánchez DC, PT 19

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Osteopathic manipulative therapy (om th) revisited 2014 extremities

  • 1. Prof. David López Sánchez Kinesiologyst; Chiropractor D.C. Director of Chiropractic Program Central University of Chile Director of Manual Therapy Diplomats Saint Thomas University, Chile “Osteopathic Manipulative Therapy (OMTh) of Extremities: revisited by other Manual Therapist”, Poland, 2014 XX edition of International Disabled People’s Day. International Scientifique Symposium 20-23 March 2014. Zgorzelec, Poland.
  • 2. The therapeutic application of manually guided forces by an osteopath to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction.” From: Glossary of Osteopathic Terminology Usage Guide http://www.aacom.org/om/Glossary.pdf Definition: Osteopathic Manual Therapy
  • 3. Spinal Osteopathic Manipulative Therapy: Summary Asymmetry Restricted Range of Motion Tissue Texture Changes Position of Elements Restricted Motion Direction Free Motion Direction Skeletal structures Myofascial structures (Tozzi, 2012) Tissues: Vascular, Lymphatic and Neural related elements (Langevin, 2006) Somatic Dysfunction Impairment Disorder Paolo Tozzi, Selected fascial aspects of osteopathic practice, Journal of Bodywork & Movement Therapies. 2012;16, 503-519. Helene M. Langevin, Karen J. Sherman, Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms, Medical Hypotheses, 2006; 68,74-80. 3David Lopez Sánchez DC, PT
  • 4. David Lopez Sánchez DC, PT 4 Spinal Osteopathic Manipulative Therapy: Summary Joint Motion ROM/Kinetic Chain Passive stability components (ligaments, capsule, cartilage, shape of joint surfaces). Tendon, fascia and muscle length & stiffness Joint Integrity/Artrokinematics Active Stability (results from mutual contribution between passive stability components and muscle action). Joint Homeosthasis Muscle Performance/ Motor Control Force Trophism Sensory Motor integration Tone Muscle Synergies OMTh: Joint ROM Determinants
  • 5. Spinal Osteopathic Manipulative Therapy: Summary Joint ROM: Kinetic Chain Components Governing Stability in the Musculoskeletal System  The myofascial passive tonicity/tension.  The fascial system passive network.  The osteo-ligamentous system passive component.  The muscular system active contractile response.  The neural system control of reflex or active contractions * Expanded from Panjabi, 1992; Lardner, 2001
  • 6. Spinal Osteopathic Manipulative Therapy: Summary Joint ROM: Kinetic Chain  Each system works interdependently to allow functional efficiency  If they do not—compensations and adaptations occur in other systems  Compensations lead to tissue overload, decreased performance, and predictable patterns of injury and dysfunction  This leads to decreased neuromuscular control and initiates the cumulative injury cycle Biomechanics of Sport Techniques Hay, J. 1993 4th edition, Prentice . 1st and 2nd editions RC 1235 .H38
  • 7. David Lopez Sánchez DC, PT 7 The osteopath refers as a manipulable lesion those somatic dysfunctions of musculoskeletal components caused by myofascial, vascular, lymphatic, and neural elements (1).  The entire body is a kinetic chain and operates as an integrated functional unit that consists of muscular, articular and neural components (Prentice W., 2005)  Specific joints elements shall suffer overload in presence of deficitary control of the neuromuscular system to perform dynamic eccentric, isometric, and concentric actions efficiently in multiple planes (Prentice W., 2005). 1.- Greenman, P.E. Principles of manual medicine, (Lippincott Williams & Wilkins, Philadelphia, 2003). The Body as an Unity
  • 8. • Forward Head • Diminished Suboccipital Space & increased thoracic kyphosis • Bruxism • Cervicothoractic Hypomobility • Forward Shoulder (Scapular Protraction) • Humeral Internal Rotation • Shoulder impingement •Lewis JS, Green A, Wright C. Subacromial impingement syndrome: the role of posture and muscle imbalance. J Shoulder Elbow Surg. 2005;14:385–392. •Finley MA, Lee RY. Effect of sitting posture on 3-dimensional scapular kinematics measured by skin mounted electromagnetic tracking sensors. Arch Phys Med Rehabil. 2003;84:563–568. •Kebaetse M, McClure P, Pratt NA. Thoracic position effect on shoulder range of motion, strength, and three-dimensional scapular kinematics. Arch Phys Med Rehabil. 1999;80:945–950. Shoulder: Kinetic Chain Dysfunction?
  • 9. Shoulder: Kinetic Chain Evidence?  Falla D. et Als. Below experimental muscle nociceptive stimuluation obtained differents responses among trapezius muscle subdivisions during repetitive shoulder flexion. (1)  Recently Diederichsen L. et Als, 2009 confirmed that induced pain in the supraspinatus muscle caused a significant decrease in activity of the anterior deltoid, upper trapezius and the infraspinatus and an increase in activity of lower trapezius and latissimus dorsi muscles. (2) (1)Experimental Brain Research, Volume 178, Number 3 / 2007 (2) Experimental Brain Research Volume 194, Number 3 / 2009
  • 10. 10 T.A.R.T. Tenderness Asymmetry Range of Motion changes Tissue texture changes And all related Clinical Findings David Lopez Sánchez PT, DC Osteopathy & Diagnosis
  • 11. Spinal Osteopathic Manipulative Therapy: Summary • Direct • Indirect • Soft tissue • Muscle energy • HVLA • Articulatory / Still’s • Osteopathy in the Cranial Field • Strain-CounterStrain • Facilitated Positional Release • Balanced ligamentous tension / ligamentous articular strain • Osteopathy in the Cranial Field • Osteopathy in the Biodynamic Field Osteopathic Techniques Source: From the American Osteopathic Association, 2013
  • 12. Spinal Osteopathic Manipulative Therapy: Summary Osteopathic Techniques Evidence • Strong evidence supporting thrust and/or non-thrust manipulation plus exercise to improve short- and long-term outcomes of care for patients with neck pain disorders • (Source:www.apta.org/manipulation) Manipulation/Mobilization Systematic Review (HVLA, articulary techniques) (Gross, Cochrane Collaboration, 2004)
  • 13. Spinal Osteopathic Manipulative Therapy: SummaryStrain - Counterstrain (SCS): “…Relieving spinal or other joint pain by passively putting the joint into its position of greatest comfort.” H. Jones, 1955.  One of most common osteopathic techniques used by osteopaths (1).  The diagnostic of tender-points (TP) located in muscles, fascias or tendons is central to SCS (Jones L.H., 1995).  Lewis demonstrated reduced electrical detection (hyperaesthesia) and electrical pain threshold (hyperalgesia) at DTPs (2). 1.- Johnson and Kurtz, J Am Osteopath Assoc. Vol 103. No 5. May 2003. 219-224 2.- Lewis C, Souvlis T, Sterling M. Sensory Characteristics of Low Back Tender Points (2010) Manual Therapy, 15, 451-456
  • 14. David Lopez Sánchez DC, PT 14  Several studies investigating SCS report decreased pain or palpation tenderness.(1).  A restricted range of motion and a reduced ability to generate adequate levels of force to move the joint is common in muscles with tenderpoints (Simons et al.,1999).  Tenderness and trigger points never follows a dermatomal pattern.  Typically postural muscles are most affected by trigger points, specifically those in the neck, shoulders, and pelvic girdle (2) 1.- Wong CK, Schauer Alvarez CS. The effect of strain counterstrain on pain and strength. Journal of Manual and Manipulative Therapy 2004; 12 (4): 215-24. 2.- Chaitow L. Ligaments and positional release techniques. Journal of Body work and Movement Therapies 2009; 13: 115-6. Strain - Counterstrain (SCS):
  • 15. OMTh: Myofascial Release  Mechanical  support (vascular & structural)  compartmentalization  Mechanical Transduction (1)  The fascia tension is determinant in the muscle stiffness (2)  Metabolic  Diffusion: Fluids Continency  energy storage: elastic potential energy  Immunologic  line of defense: lymphoid tissue  Barrier: compartments 1. Schleip R. 2003. Fascial plasticity – a new neurobiological explanation. Journal of Bodywork and Movement Therapies 7(1):11-19 and 7(2):104-116 2. Schleip R, Naylor IL, Ursu D, Melzer W, Zorn A, Wilke HJ, et al. Passive muscle stiffness may be influenced by active contractility of intramuscular connective tissue. Med Hypotheses. 2006;66,66-71. 2005
  • 16. Spinal Osteopathic Manipulative Therapy: SummarySCS: Muscle Tone The muscle tone and connective TenseActive Behavioral 1.- Masi, MD et Als. Clinical, Biomechanical, and Physiological Translational Interpretations of Human Resting Myofascial Tone or Tension. International Journal Of Therapeutic Massage & Bodywork: Research, Education, & Practice, 2010 3(4), 16-28. 2.- Chaitow L. Ligaments and positional release techniques. J. Bodywork and Movement Therapies 2009; 13:115-6. 3.- Solomonow M. Ligaments: a source of musculoskeletal disorders. J. of Bodywork and Movement Therapies 2009; 13:136-54.  The human resting tone role in helping to maintain balanced postures is supported by biomechanical principles of myofascial elasticity, tension, stress, stiffness, and tensegrity (1).  SCS may affect the protective ligamento-muscular reflex through which ligamentous strain inhibits muscle contractions that increase strain (2), or stimulates muscles that reduce strain (3).
  • 17. Treatment: Osteopatic Models 1.- *Rivers WE, Treffer KD, et al. Short-Tem Hematologic and Hemodynamic Effects of Osteopathic Lymphatic Techniques: A Pilot Crossover Trial. JAOA. 2008; 108(11): 646-651 (1). • Circulatory-Respiratory Model* • Biomechanical/Postural/Tensegrity Model • Viscero-somatic/Somato-viscero Model • Neuro-Endocrine-Immune Model • Bio-energetic Model • Psychosomatic Model Application of soft tissue manipulation also has demonstrated a decrease in plasma fibrinogen and total fibrinolytic activity consistent with an increased parasympatic tone and decreased sympathetic tone (1).
  • 18. ¿System or Philosophy? David Lopez Sánchez DC, PT 18 Philosophy: clarifies and justifies Principles: prescribe action based upon philosophy. Osteopathic Reasoning: Creates a clear Identity. Rational treatment is based upon a systematic understanding and application of the basic principles of body unity, self-regulation, and the inter-relationship of structure and function. (Adapted from the Foundations for Osteopathic Medicine)
  • 19. Thank YouDavid Lopez PT DC consultas@dolordeespalda.cl David Lopez Sánchez DC, PT 19