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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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study on low back pain demonstrated that osteopathic spinal manipulation
used fewer days for medication and physical therapy compared with standard
medicine.1 In 2003, a randomized controlled study demonstrated a similar
reduction in physical therapy days as well as a decrease in overall cost in
patients with low back pain.2 In 2004, a systematic review noted that in
patients with acute low back pain, manipulation provided more short-term
relief than several other physical therapy techniques.3 When evaluating
chronic low back pain, manipulation was found to have an effect essentially
equal to that of NSAIDs and provided short-term relief equivalent to medical
management and long-term relief similar to that of physical therapy.
Although positive evidence was reported, none of these studies demonstrated
overwhelming improvement when compared with other treatment modalities.
A 2010 study in the United Kingdom examined a broad variety of both
medical and pain-related ailments and found spinal manipulation to be
effective for acute and chronic back pain as well as neck pain and
cervicogenic headache.4 Thoracic manipulation was found to improve
cervical pain, but cervical manipulation alone was inconclusive. A 2011
study comparing structured exercise with manipulation found improvements
to be equivalent in pain complaint and function at 8 weeks.
5
Many studies have conclusions with familiar descriptions such as
inconclusive, no worse than, and not superior to.
6-8
These results appear to be
the most common; therefore, they are frequently used as evidence to discount
any benefit from manual techniques in patients with spine problems. The
most recently performed meta-analysis reported at least modest benefit with
the use of spinal manipulative therapy in patients with acute back pain.9 In
this study, however, no specific modality, treatment type, or clinical operator
could be identified as superior to another. One difficulty in developing
specific, robust, evidence-based practice recommendations is the inadequate
number of studies performed; however, it is necessary to consider why the
studies that have been conducted have demonstrated little or no statistical
difference among nonsurgical treatments. The challenge of interpreting
outcomes and making recommendations in these studies is similar to the
challenges faced by those investigating interventional pain procedures.
Establishing evidence in interventional pain treatment and manual treatment
is difficult because of confounding variables. Essentially, the categorization
of these patients becomes vaguer, which results in inconclusive evidence.
Similarly, each intervention must be performed by a clinician, who will have
his or her own processes, techniques, and approaches, all of which are
counterproductive for achieving a successful, repeatable investigation
resulting in level I evidence. The reasonable conclusion that can be drawn
from the available evidence is that manipulation may be one of many tools
used against the vagaries of musculoskeletal axial spine complaints, and
although a balanced approach is necessary, manipulation can be included as a
worthwhile treatment for patients with acute and chronic neck- and backrelated problems.
The Knowledge Gap Between Osteopathy and the Traditional
Medical Approach
One of the barriers to understanding between physicians who practice manual
medicine (as well as physical and occupational therapists, chiropractors, and
licensed massage therapists) and most physicians is not a lack of knowledge
but a lack of a common language. What exactly is the goal of manipulation?
What is being treated aside from vague musculoskeletal problems? Manual
practitioners should choose their techniques and focus areas based on the
appropriate diagnosis of an injury. In osteopathic medicine, the problems
being treated are referred to as somatic dysfunction, which means disrupted
function of the body, typically at the local level. These disruptions most
frequently occur in articular areas (such as facet joints), in muscles, and
throughout the high-tension zones of the soft tissues.
Although some practitioners use generic, universal treatment routines for
all patients with similar problems, this approach is similar to offering an
epidural steroid injection for every patient who reports back pain: some
patients will improve, but establishing a clear diagnosis before treatment is
begun should result in a better, more efficient, and more economical
outcome. The location of the individual’s symptoms is of some value, and the
patient history also helps, but most diagnoses in manual medicine result from
primarily palpatory examinations.
Evaluation for somatic dysfunction relies largely on asymmetry (both
static and with movement) and restriction of motion. In osteopathy, perfect
alignment is not the actual goal because many patients have anatomic
asymmetry as their baseline. Rather, freedom of motion and full range of
motion within the anatomic limits is the goal; therefore, any restriction is
primarily considered the starting point. In the axial spine, vertebral segments
are first assessed as a group and then individually, considering the changing
mechanics as the spine enters lordosis, transitions to kyphosis, eases through
neutral, and then returns to lordosis. Tissue texture changes also are
important clues (particularly in soft-tissue concerns and acute symptoms in
the axial spine) and tenderness of the area also can be of value in making a
diagnosis. In soft tissues, particularly the layers from the surface to the outer
muscle layers, tissue texture changes (the so-called lumps and bumps) often
are evidence of somatic dysfunction. The more acute the dysfunction or
injury, the more acute the findings, including redness, local microedema,
tautness, and warmth. Soft-tissue somatic dysfunction that is more chronic
tends to produce findings that are more chronic, often described as ropey or
stringy, and even a leathery feeling of the overlying dermis, which is typical
with more dense soft tissue.
Indications for Treatment
Although practitioners who primarily focus on manipulation likely can find
some type of subacute dysfunction to treat in almost any patient, certain
patients and diagnoses are more appropriate for a manual treatment plan.
Many common back and neck pain conditions can be treated effectively with
osteopathic manipulation, particularly because it is used to maintain proper
body mechanics and motion. The goal of treatment for all conditions is to
improve function, and ultimately, quality of life, by means of treatment to
relieve motion restrictions. This goal is accomplished via proper diagnosis of
areas of restriction within the neuromusculoskeletal system and by restoring
optimal tissue texture, body symmetry, and range of motion. By improving
motion and flexibility within the spine by means of mobilization of the joints,
muscles, fascia, muscle function, and spine mechanics can be optimized,
allowing improvement in the patient’s day-to-day activities and function.
Most spinal pain results from the complex interactions between the spine
with normal age-related degeneration and the sensitivity and responsiveness
of the nervous system, which regulates the consciousness of pain.10 When
pain is present, compensatory patterns often develop to alleviate the patients’
pain, resulting in restrictions in joint motion, hypertonicity within muscles,
and fascial strain patterns. These patterns also are identified as somatic
dysfunction and can affectively be improved with osteopathic manipulative
treatment resulting in the normalization of physiologic motion and decreased
pain.
Osteopathic manipulative treatment also should be considered in patients
with pain resulting from muscle strains/sprains or myofascial pain such as in
athletic injuries, whiplash injuries, or even from performing housework. By
applying osteopathic manipulative treatment techniques to the restricted joint,
muscular and/or fascial motion can be restored more effectively, facilitating a
return to normal mechanics, improvement in pain, and reduced use of oral
medication.
In conditions such as spinal stenosis, disk herniations, radiculopathy, or
scoliosis, osteopathic manipulative treatment can alleviate chronic somatic
symptoms and potentially optimize tissue mechanics to improve back pain
over time.
5,6,11-13
The likelihood of worsening a single-level disk herniation
by means of spinal manipulation is exceedingly low.14 Although
manipulation is unlikely to resolve underlying problems, there is value in
potentially improving mobilization and function and reducing pain levels by
treating somatic dysfunction with osteopathic manipulative treatment.
2,5,8
When to Avoid or Modify Treatment
Certain patients and diagnoses respond well to manual treatment, whereas
other patients and diagnoses are unlikely to improve after manipulation. In
certain patients (specifically, patients with a history of cancer, acute fracture,
osteomyelitis, discitis, severe osteoporosis, or rheumatoid arthritis),
manipulation should be used with caution to prevent trauma or worsening
dysfunction. Osteopathic manipulative treatment is not contraindicated in
these patients, but the treatment technique and duration needs to be selected
carefully. High velocity–low amplitude thrust techniques should be avoided
because of the risk of fracture. In the setting of rheumatoid arthritis, a risk of
spinal cord compromise exists with cervical manipulation if the cruciform
ligament has sustained damage. Indirect techniques are recommended in
these patients.
During osteopathic manipulative treatment, if progressive neurologic
decline develops in a patient or associated constitutional symptoms such as
night pain, fever, or bowel/bladder dysfunction occur, the appropriate workup
with further diagnostic tests should be performed to determine the proper
treatment course.
Technique
Many categories of techniques have been developed, with some targeting
specific types of dysfunction and others offering multiple approaches for
managing the same type of dysfunction. The osteopathic model has two
major technique types: direct techniques that engage the restriction and
indirect techniques that work away from the restrictive barrier to relieve
tension and pressure. The choice of technique often relies as much on a
practitioner’s knowledge, experience, comfort level, and preference as it does
the specific dysfunction because many dysfunctions can be approached either
directly or indirectly. Information regarding osteopathic principles and
techniques is abundantly available.
15,16
Direct Techniques
Muscle Energy
The osteopathic term muscle energy is not used as extensively as activated
stretching or contract-relax, both of which better describe the technique. The
targeted somatic dysfunction may be in the muscle belly itself, or may be an
articulating joint spanned by the muscle; in either case, the restrictive barrier
is engaged, most frequently by stretching the muscle to the edge of tolerable
range of motion and maintaining it in a static position. The patient is directed
to activate that muscle in an isotonic contraction while the practitioner holds
against that force (Figure 1). The contraction is held for 3 to 5 seconds, and
the muscle is then allowed to relax. After a few seconds of elapse to allow
complete relaxation of the muscle, the muscle is stretched further to the new
edge of its range of motion. This is repeated until the restriction is gone or
until no further improvement is obtained.
Figure 1
Photograph depicts the practitioner performing a muscle
energy (contract-relax) treatment for a dysfunctional
hamstring muscle during the isotonic contraction phase.
High Velocity–Low Amplitude
High velocity–low amplitude techniques are the thrust techniques most
individuals think of in a discussion of manipulation. The purpose of a high
velocity–low amplitude technique is to articulate a joint that is held in a
dysfunctional pattern. This is similar to cracking a stiff proximal
interphalangeal joint, and should be no more forceful or painful when applied
appropriately. Some individuals use broad-range, high velocity–high
amplitude techniques for the general treatment of an entire region, such as the
whole cervical or lumbar spine, with a single technique. These shotgun
techniques are quick and can be relatively successful in young patients, but
the potential exists for unintended injury, so a more targeted approach is best.
The low amplitude aspect of a high velocity–low amplitude technique implies
a targeted, localized, and fine-tuned setup of a single vertebral segment pair
(Figure 2) or other joint to apply a short, brisk thrust. This technique should
Figure 2
not be painful for the patient; pain implies a problem with the setup or
technique chosen. Some patients may be uneasy and have strong
apprehensive muscle tension. Patients should not be pushed through these
techniques; rather, a different technique should be chosen.
Photograph demonstrates preparation for a thrust
technique. The cervical spine is positioned with careful
localization to a C5 somatic dysfunction.
Soft-Tissue Techniques
Soft-tissue techniques are most appropriately compared with massage both in
appearance and effect. The techniques are typically direct (working into the
restrictive barriers) but can be indirect (working with and away from the
restriction) and are often alternating combinations of both. Often, a general
area surrounding the specific somatic dysfunction is treated to reduce outside
tension forces on the targeted somatic dysfunction. The techniques involve
using the pads of the fingers and the heels of the hands to gently mobilize the
soft tissues, typically in a lateral direction (Figure 3). Force is typically
applied at 15° to 30° from horizontal and should not be particularly
Figure 3
uncomfortable for the patient. As the restrictions are released, other
techniques can be applied to treat the deeper dysfunction.
Indirect Techniques
Indirect techniques present minimal risk of injury or agitation because they
are directed away from the restriction; however, the techniques are more
challenging to perform because they require the palpatory capacity to feel the
tissues release tension as they relax and the restriction dissipates.
Photograph demonstrates using the thenar eminence as a
bar to mobilize the thoracic soft tissues in a medial-to-
lateral direction.
Counterstrain Technique
Counterstrain techniques, also called strain-counterstrain, is a somewhat
broad category that focuses on treating individual areas of somatic
dysfunction in the belly of individual muscles referred to simply as tender
points. After a tender point is identified in an individual muscle, the muscle
around the tender point is shortened by the practitioner while continuously
palpating the tender point with a single digit, based on the directionality of
the particular muscle fibers (Figure 4). Most commonly, patient feedback is
elicited while a position of greatest comfort is attempted and held for a varied
amount of time (novices are taught to hold this position for approximately 90
seconds). Ideally, complete resolution is achieved at this point. The concept
of this technique is to reduce as much tension as possible from the fibers
surrounding the tender area to completely reset muscle fiber length to
baseline levels.
Facilitated Positional Release
Facilitated positional release techniques are similar to counterstrain
techniques in most ways. Tender points, or dysfunctional segments, are
palpated and focused on. The area is arranged in multiple planes to find a
position of comfort, whether subjectively for the patient or relative to a
balance point of neutral tension for the practitioner. After such a position is
identified, a facilitating force is applied to the area (Figure 5), typically
compression or distraction, to refine the amount of tension. The use of this
facilitating force typically requires control of both ends of the joint, which
makes this maneuver easily executable for the cervical spine, wrists, and
ankles, but more challenging for the lumbar spine and hips.
Figure 4
Photograph demonstrates a counterstrain technique to treat
a lower lumbar somatic dysfunction in the iliolumbar
ligament essentially. The tense tissues are folded around the tender
point as it is monitored with the second digit of the monitoring hand.
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