Details of OMT

In strain and counterstrain, this indirect approach involves positioning the patient’s body in order to provide a position of ease, where tenderness and tension are virtually eliminated, and then holding the position for about ninety seconds. It focuses on at least one of more than 200 tenderpoints, which tend to be small and discrete areas of marked tenderness often found within muscle tendons or within the belly of the muscle itself. Some may also exist in the myofascial tissues rather than the muscle.

Remember that tenderpoints do not necessarily relate to the point of actual trauma but can be distant from the affected traumatized area. Often, multiple tenderpoints exist, with the goal of strain and counterstrain being to treat the most painful tenderpoints first. Those tenderpoints associated with traumatic injury should involve a position of treatment that mimics the position of trauma while maintaining maximal comfort.

When balanced ligamentous tension or BLT is used, there will be tension of the ligaments and of the membranous structures that are balanced through positioning of the joints. Because this is an indirect approach, this type of balance allows for the natural and inherent release of the affected tissues. The patient action of breathing itself is commonly used to facilitate the release of ligamentous tension.

In facilitated positional release, which is also indirect, the physician provides a facilitating force to release tissue tension over a shorter period of time. Often, this facilitating force involves either the application of tension or compression of the affected tissues. It is a technique that can be used for any tissue texture changes found or for joint restriction that has been caused by myofascial tension on the joint. The affected joint is first placed into a neutral position prior to adding the facilitating force.

DETAILS OF OMT

In this section, we will talk further about the different OMT that can be applied, including the indications and contraindications of each procedure as well as the typical sequence you will be expected to know and follow as you apply the various techniques.

HVLA is a commonly applied OMT, in which you will apply a sudden and quick force to a restricted joint over a low amplitude so the actual movement of the joint is very small.

This is a particularly common technique used when the restriction itself is articular in origin.

The main indication for HVLA is not going to be just the presence of a static asymmetry but must involve restriction of a given joint to both active and passive range of motion in at least one direction. Its main contraindications include any one of the following:

• Muscle contracture secondary to trauma • Any bony fracture at the site • The presence of a hypermobile joint, mostly because the application of HVLA can contribute to joint instability • Ankylosis or advanced degenerative joint disease of the affected joint. In such cases HVLA will not be effective and can further damage the joint. • Inability to relax the muscles around the affected joint, which could involve doing additional damage to the surrounding muscles and will decrease the effectiveness of the technique itself. • The presence of an indistinct or rubbery tissue barrier, which generally means that HVLA will not be effective when applied to the joint. It may also mean that the patient has a viscerosomatic reflex. • Osteoporosis by itself is not an absolute contraindication to HVLA but it means that you should probably try another technique first that is less forcefully applied to the affected joint.

During the HVLA sequence, you need to first position the patient so that the restricted joint is firmly engaged at the level of its restricted barrier. This is so that a small amplitude thrust will have the maximum impact. Perform the thrust maneuver over a very short distance until you have broken through the restrictive barrier, which often leads to a popping sensation. Then you should reassess the joint to see if the barrier has been released and that the joint is now more freely mobile.

Muscle energy or ME is also direct but involves the patient using active muscle force in order to affect a somatic change in the tissues. Specific positioning of the patient is necessary so that the physician can apply the appropriate counterforce to the force applied by the patient. It makes use of the feather edge, which is where you first feel

there is restriction to motion. The restriction to motion is generally caused by soft tissue restriction rather than articular restriction and feels different from the restriction you would feel if you were applying HVLA. Because this is a soft tissue and not an articular restriction, very little force needs to be applied.

Indications for ME include muscle hypertonicity or joint motion asymmetry with the goal of the procedure being to lessen joint restriction, reduce restrictions to breathing, decrease hypertonicity of the muscles so the muscle fibers lengthen, and strengthen those asymmetries that are caused by muscle weaknesses.

There are different categories of ME, based on differing amounts of force necessary for the application of the technique. As you will see, these can range from a few ounces of force to up to 50 pounds of force. Let’s take a look at some of these:

• Crossed extensor reflex—just a few ounces of force are applied, involving the contraction of a flexor muscle in an extremity that causes relaxation of both the flexor muscle and contraction of the extensor muscle on the opposite side of the body. • Reciprocal inhibition—just a few ounces of force are applied, in which an agonist contraction leads to reflex relaxation of the antagonist muscle group. • Oculocephalogyric reflex—just a few ounces of force are involved in eye movements that will reflexively affect the muscles of the trunk and neck. • Respiratory assistance—in this common technique, exaggerated breathing movements provide the necessary muscle force. • Postisometric relaxation—this involves between 10 and 20 pounds of force.

Muscles are contracted and then are able to relax, which allows them to be stretched to a greater degree. • Joint mobilization—this involves using between 30 and 50 pounds of force, in which the patient contracts a muscle in order to mobilize the affected joint.

The major precautions and contraindications to ME include the presence of any acute injury, a very young patient who cannot cooperate, muscle pain, and anything comorbid in the patient that prevents their cooperation in the procedure itself.

In a typical ME sequence, you will position the affected body part at the feather edge, where the initial resistance is first felt. Have the patient contract a muscle or muscles in order to counteract the force you apply and then ask them to gradually release the contraction as you also release the force you have applied. Wait a few seconds until the muscles and tissues relax; then pick up the slack so that a new position of resistance is felt. This is repeated up to five times total so that there can be a gradual increase in joint range of motion.

The ultimate goal of ME is to provide some type of postisometric relaxation so that you will be able to further stretch the tightened tissues and muscles.

In the articulation technique, you essentially apply repetitive passive motion to the joint in a gentle manner in order to loosen the joint in the areas where there is restriction of motion. Often, the restriction itself is due to tightening of the connective tissue so that the goal is to restore the normal physiological motion of the affected area. Sometimes, this can be used for diagnostic rather than for therapeutic purposes.

Articulation can be used for any articulation movement restriction, including those often seen in patients who’ve been immobile for a period of time or who are postoperative. It is generally safe in most situations but should be used cautiously if there is significant soft tissue pain, areas of infection, burns, or sutures, bone fractures or traumatic muscle contractures, or areas involved in ankylosis or degenerative joint disease.

In an articulation sequence, you will maintain a comfortable position for the patient, while applying gentle range of motion of the joint to the point of tolerability or marked restriction. Repeat this after returning the joint to neutral and gradually increase the range of motion of the affected joint, which should be more easily accomplished over time. The procedure is done when maximum range of motion has been achieved. This will work well for old or very young patients as it is easily tolerated.

Myofascial release or MFR can involve release of tension in any muscle or fascia of the body. Direct or indirect forces are applied that will allow for the natural and inherent release of the affected tissue. Inhibition can be involved, which is the direct maintenance of pressure over a hypertonic tissue area until the area relaxes.

The main indication for this technique is muscle or fascial areas of tension and restriction. Joint restriction can be involved but the restriction is not due to an articular problem by itself but to hypertonic tissues. This technique may be necessary prior to any attempt at doing HVLA to the joint.

MFR is largely considered safe; however, it cannot be used if there is moderate to severe pain in the affected area or if there are burns, wounds, infections, or sutures overlying the area to be treated.

In this procedure, you can directly engage the tissues with the appropriate amount of pressure applied. The move the area into a restricted barrier while holding the stretch on the tissues in order to help them relax. Do this again in a rhythmic fashion so that the area is maximally relaxed. You can engage the tissues through distraction, direct compression, rotation, or translation.

If you are using the technique indirectly, you will also engage the tissues using pressure and will move the tissues to an area of least resistance, waiting for the natural and inherent release of the tissues. The goal in the direct technique is to stretch the tissues using your own force, while the goal in the indirect technique is to wait for the inherent release of the affected tissues without direct force applied.

The basics of strain and counterstrain involve gentle positioning of the affected area in order to decrease the tenderness associated with certain tenderpoints so that somatic function can be restored. Remember the 200 tenderpoints that can possibly be involved, which can consist of muscles, ligaments, and tendons. It is mainly done when there are specific tenderpoints found.

Strain and counterstrain is largely a safe technique but, like similar techniques, it is avoided when there is moderate to severe pain involved or when there is overlying tissue damage from infections, wounds, burns, or sutures.

During this procedure, you will move the patient into a comfortable position, while looking for areas of tissue tension and relaxation. Light touch is maintained with increased touch when attempting to define a tenderpoint area. Find out how tender an affected area is and attempt to reduce the level of tenderness by directing pressure for about 90 seconds, while monitoring the area for evidence of tension release. Slowly let

up on the applied pressure until a neutral point is achieved before rechecking the area for additional tenderness. Ideally, you should aim for less than 30 percent of the original degree of tenderness.

In balanced ligamentous tension or BLT, there is the indirect positioning of a dysfunctional or abnormal joint so there is a balance of the membranous and ligamentous tensions. This balanced position will allow for inherent bodily forces to correct the dysfunction so that the tissues re-balance themselves. Breath is often used as the patient’s active movement in order to restore this balance and aid in the release of tension in the tissues. It is used if there is articular asymmetry or joint restrictions.

This is generally considered to be a safe procedure that should be used with caution if there is moderate to severe pain or if there are tissue injuries or infection overlying the treatment area. The act of inhalation will help to flatten the spine in the AP direction, while the act of exhalation increases AP spinal curvatures. The ligaments do not stretch or become overly lax, in part because the motion necessary for this technique is quite small.

The BLT sequence generally starts with finding an area of restriction about a joint and placing the patient’s body with respect to the joint so that there is a point of balance in the ligamentous tension around the joint. The patient engages in a relatively small movement that further tunes the balance, while you hold the joint’s position until there is a release noted. The sequence is complete when the dysfunction is corrected and the joint’s neutral position is more physiological.

In facilitated positional release or FPR, some type of torsion or compression is applied to lessen the time it takes for a tightened tissue to release itself. Any joint dysfunction from tissue hypertonicity or tissue texture change can be treated with this technique, although more than mild pain or the presence of injury or infection overlying the affected area are contraindications to doing it.

In an FPR sequence, you will place the dysfunctional joint into a neutral position, such as neither flexion nor extension of the spine. Some type of facilitating force is applied so that the tissues can be further placed into positions of relative freedom. There is natural relaxation of these tissues within seconds and the joint is returned to a more original