7/31/2014 OMM in the Extremity (and in a tight office setting) Darren Grunwaldt, D.O. MAOFP Summer Family Medicine Update August 1, 2014 Common Complaints and diagnoses that will serve as scaffolding for today’s lecture • Carpal Tunnel Syndrome • Tennis or Golfers Elbow / Enthesopathy / Tendonosis • Knee Pain • Plantar Fasciitis OMT for CTS • Lymphatic Model • MFR/INR to CT and shoulder, Direct Inhibition to posterior axilla • Elbow and Forearm – pronation and supination screen • MET +/- MFR/INR • Wrist • Carpal Tunnel Soft Tissue Technique 1 7/31/2014 Lymphatic Model • Think of this in most instances with swelling and inflammation • Blockages downstream will impede movement and prolong congestion at the site of injury • Think of where the final drain is, and work backwards from there. • For CTS: • Consider Upper Thoracic Aperture and Axilla as high yield areas • Superficial fascia along length of arm Myofascial Release • Look for fascial bind comparing directions that are tight versus loose; this is deeper than just sliding skin • Think 3D where able; avoid thinking simple 2D planes where able • (usually) wind tissue into direct barrier • Hands are both treating and monitoring • Wait for fascial creep, the release, then disengage • To add a little kick to this dish (for Integrated Neuromuscular release), just add an enhancer! • Patient’s repetitive movement that ratchets area on/off but does not overwhelm your palpation – often initiated from a nearby joint or region • E.g., slightly bigger breaths, wrist bobble, tongue wag, feet clap Muscle Energy Technique • Start from position tissue LIKES to be (and name it in this position) • Move FROM this into the edge of the direct barrier (where tissue tightens) • Patient does gentle muscle effort BACK TOWARDS your original starting position • 3-5 efforts each held for 3-5 seconds • Have patient fully relax between each effort and “take up the slack” or re- engage the edge of the barrier between each muscle effort 2 7/31/2014 OMT to the wrist (at long last) Carpal tunnel soft tissue: Either Cracking Open A Book or Weird Vulcan Grip HEP: Self Carpal Tunnel Stretch OMT for elbow enthesopathy • Tender Point Localization • SCS • Consider trial of Fascial Distortion Model • very direct treatment of CD, HTP, TB based on patient report • observe patient’s hand signals when answering “Show me where it hurts” 3 7/31/2014 Strain Counterstrain • Diagnose point of tenderness to palpation, a Tender Point – this is usually also an area of TTA • Have patient note tenderness to compare to later • YOU monitor that spot lightly while YOU move the patient to a point where that tissue is as calm and loose as it can get • Press again with same force as original and ask patient to compare tenderness • Ideally ~70% improvement or more • Hold position 90 seconds • SLOWLY return to original position without any muscle effort from patient Fascial distortion model • Originated and developed by Stephen Typaldos, D.O. • FDM is a system of diagnosis and treatment which overlaps with our other traditional OMM models and modalities - although not seamlessly • It identifies 6 types of distortions in fascia and has treatments to address each separately • Many practitioners of FDM would emphasize that you use the entire model instead of picking it apart and using only one piece • American FDM Association – www.afdma.com • Some treatments within FDM are very direct and tend to be uncomfortable • Others are quite soft and should feel good while being done • Today, we will explore one of the direct approaches FDM – Trigger Band • A trigger band is a distortion in a band of fascia • Considered to be similar to a zip-lock bag that didn’t line up right and got sealed in the wrong places • Treatment is to follow along the distorted band to reset the seal 4 7/31/2014 FDM – Trigger Band • Ask the patient to show you where or how it hurts; then watch body language • Consider Trigger Band if patient sweeps fingers along a linear path when describing where there is pain • Check patient’s active range of motion – if limited ROM and/or pain at the site they specified upon certain ROM, then treating a trigger band there is strongly worth considering • Informed consent: • This will be painful • This may leave a bruise • Goal is to increase painless ROM – post treatment tenderness should fade and painless ROM should remain FDM – Trigger Band treatment • Have well trimmed nails and monitor your own proper joint mechanics • Properly diagnose: • Check for body language – fingers sweeping in a line • Check AROM (to compare afterward and to hone in on trigger band) • Palpate way to one end trigger band (TB) • May feel a ridge of sorts • Patient will note pressure if just nearby but WASABI if on it • Start at one end of the TB and use very firm thumb pressure following along the “ridge” of TB all the way to the other end – the patient may redirect you • It will be tender, but AROM should be improved. It should be harder for ROM to reproduce the pain. HEP: Wrist x 4 1. Stretch into wrist flexion. These are the more straight forward two 2. Stretch of the four wrist into wrist stretches. At least extension. do these if the others cause too much trouble. 5 7/31/2014 HEP: Wrist x 4 (cont) 3. Pronation / Internal Rotation These are similar to joint (Nikyo ) locks in martial arts, so do them gently! Flow slowly through all four positions pausing for 2-3 breaths at each one, then do the other wrist. 4. Supination / External Rotation (Kote Gaeshi ) OMT approaches for knee • Check Fibular Head • MET • Tibial Torsion (and Hamstring check) • MFR, INR • Ligamentous Dis-Ease • LAS • And option to treat any Trigger Bands if patient shows you one! Balanced Ligamentous Tension / Ligamentous Articular Strain • DISENGAGE • Compress or decompress joint or fascial plane to allow injured part to be moved • EXAGGERATE • Carry the injured part in direction(s) of least resistance (back to position it achieved upon its injury) • BALANCE • Monitor, maintain balance of forces and follow tissue • Anticipated for tissue to go further into dysfunction then return to proper position • Anticipated increase in PRI / CRI / Motility / etc 6 7/31/2014 HEP: Rectus Femoris Stretch is turned on by tucking tail under (12 o’clock pelvic tilt) and by keeping knee pointed down toward floor. Should feel stretch along front of thigh. Hold for 3-6 breaths. Do both sides. You may rest arm against wall for balance. HEP: Hamstrings / Calves Keep in 6 o’clock pelvic tilt as bend forward and keep foot dorsiflexed. Lead with the heel toward the ceiling when doing this supine. OMT for PF • Fibular Head (addressed earlier) • Trigger Bands again! (and other parts in the FDM) • Plantar Facia • LAS / BLT 7 7/31/2014 HEP for PF • Hamstrings and calf stretches as done earlier • Pre-stretch warm ups with, e.g. writing part of alphabet with feet before standing • Ice bottle massage • GOLF BALL – less messy, more portable! Ice Bottle Massage and ROM Alphabet Empty some water from bottle before freezing it. Then use it as an icy rolling pin to massage your plantar fascia. OR TRY A GOLF BALL Before getting out of bed or standing up after a long time sitting Suggested Readings or Pursuits • www.afdma.com • Ligamentous Articular Strain by Conrad Speece and William Thomas Crow • Principles of Manual Medicine by Philip E Greenman • MSUCOM CME Seminars – especially Exercise Prescription: • http://com.msu.edu/CME/Manual_Medicine_Courses/Exercise.htm 8.