OMM in Pregnancy. Myra Cummings Mabry, MEd, MBA, DO

Transcription

1 OMM in Pregnancy Myra Cummings Mabry, MEd, MBA, DO

2 Osteopathic Manipulative Medicine (OMM) is a body-based modality in which the patient is evaluated and treated as a whole to improve physiologic functioning and remove impediments to optimal health and functioning

3 Discovering you re pregnant

4 And then reality sets in.

5 Physiologic Changes in Pregnancy

6 Cardiovascular Elevated progesterone causes smooth muscle relaxation Cardiac output h SVR i > 24wks, return to normal

7 Pulmonary Tidal volume h - progesterone Total Lung Capacity i -elevation of diaphragm Dyspnea of pregnancy -h CO2 gradient between mother and fetus

8 Gastrointestinal Nausea, vomiting - h estrogen, progesterone, hcg Reflux - h gastric emptying time, - i sphincter tone Constipation - i motility, - h water absorption

9 Renal Kidneys enlarge Ureters dilate pyelonephritis h GFR, i BUN, i Cr h Renin h Angiotensin - h Aldosterone

10 Hematology Plasma volume h - hemodilutional anemia WBC h - mean = 10.5 Slight i platelets Hypercoagulability -h fibrinogen and Factors VII-X

11 Endocrine h Estrogen - by placenta, ovaries lesser degree h Progesterone - relaxation of smooth muscle h hcg - first by the corpus luteum, then by the placenta h hpl - insulin antagonist Breast swelling/tenderness

12 Key Points for OMM in Pregnancy OMM can be used throughout pregnancy, during labor and post partum Always treat patient in whichever position they are most comfortable! Usually supine or side-lying is best Diagnose, then treat the side that is worst Use patient s own body weight to help you and help patient to relax HVLA is a relative contraindication in pregnancy!

13 Routine Problems During Pregnancy Back pain Constipation Edema Gastroesophageal Reflux Disease Hemorrhoids Round Ligament Pain Urinary Frequency Varicose Veins Headaches/migraines Sinusitis Neck aches Joint pain (carpal tunnel syndrome) Sciatica Hip pain/ Low back pain Pubic pain

14 Back Pain Shift center of gravity increase in lumbar lordotic curve As uterus grows, there is dextrorotation of uterus into pelvis Subtle rotational component causes torsional stress pattern up the spine to restrict motion of chest, ribs, and diaphragm

15 Common Findings in Back Pain Increased lumbar lordosis Myofascial strains Paraspinal muscle strain or muscle spasm Lumbar-sacral junction compression

16 OMM Treatment of Back Pain Soft tissue techniques Myofascial release Facilitated positional release Balanced ligamentous tension - direction of ease Lumbo-sacral decompression Modified lumbar roll

17 Hip pain/sciatica Anatomy: Sciatic nerve roots L4-L5- S1-S2-S3 Exits out greater sciatic notch along with piriformis muscle (innervated by S1-S2) In pregnant females, likely due to same rotational component from enlargement of uterus

18 Common Findings in Hip pain/sciatica L5 slides anterior ASIS compression Sacral-iliac compression Interosseous sacral compression sciatica Sacral Somatic Dysfunction Sacral torsions, Sacral base anterior/posterior, Unilateral sacral flexion/extension

19 Treatment of Hip pain/sciatica Sacral Rock Sacral-iliac decompression Interosseous sacral decompression Sacral inhibition at S2-S3 L5-S1 decompression Cupping the sacrum place palms on sacral poles and take bone into direction of ease

20 Pubic pain Relaxin and progesterone help to loosen ligaments extra laxity and pelvic pressure during pregnancy Pain from excessive levels of hormones, extra sensitivity to hormones, pelvic misalignment, or combination of above Symptoms: pubic bone very tender to palpation, pain when lifting one leg at a time or parting the legs, walking, turning over in bed, strong round ligament pain, may recur or progress with each pregnancy

21 Pubic pain Risk factors: Multiparity h/o macrosomic infant Pre-existing problems with joint Past pelvic or back pain Past trauma (including obstetric or gynecological)

22 Findings in Pubic Pain One iliac more superior than other ASIS/PSIS more superior on one side One pubic bone more superior than other Leg length discrepancy Named by side of (+) ASIS compression Also check for inflare or outflare

23 Treatment of Pubic Pain Long lever technique - gap sacral-iliac, slight adduction, then lean body up or down to counteract dysfunction Counterstrain anterior tenderpoint L5 is 1 cm lateral to pubic symphysis on superior ramus pt supine, knees and hips flexed and rotated away

24 Treatment for Pubic Pain Superior Pubic dysfunction Inferior Pubic dysfunction *For innominate shears, add subtle abduction component

25 Other Common Problems & Treatments Headaches/migraines condylar decompression occipital-mastoid suture release cervical soft tissue Sinusitis venous sinus drainage inhibition of confluence of sinuses Neck Pain condylar decompression facilitated positional release, counterstrain

26 Other Common Problems & Treatments GERD/nausea & vomiting r/o other causes first balance sympathetics check T5-T9 for TART changes treat by putting segments into direction of ease chapman points (anterior along ribs 5-9) Constipation hydrate first and modify diet release of sacrum and pelvic splanchic nerves to the rectum

27 Other Common Problems & Treatments Dyspnea r/o other causes check for posterior diaphragm restriction diaphragm release check T2-T7 for TART balanced ligamentous tension Check ribs for restriction rib raising Edema in legs or varicose veins Increase lymphatic return and release diaphragm spreading of lymph behind knee, thoracic inlet release, lymphatic pump if tolerable

28 Sympathetic Nerve Innervation Head and Neck Heart Respiratory Upper GI Tract Stomach, Liver, GB, Spleen, head of Pancreas, beg. portion of Duodenum Middle GI Tract Rest of pancreas, Duodenum, Jejunum, Ilium, Ascending colon, prox 2/3 of transverse colon Lower GI Tract Distal 1/3 transverse colon, Descending colon, Sigmoid colon, Rectum Kidneys Adrenal Medulla T1 T4 T1 T5 T2 T7 T5 T9 T9 T12 T12 L2 T11 L1 T10

29 Sympathetic Nerve Innervation Upper Ureters Lower Ureters Bladder Gonads Uterus and cervix Erectile tissue of penis/clitoris Extremities Upper (arms) Lower (legs) T10 L1 L1 L2 T11 L2 T10 T11 T10 L2 T11 L2 T5 T7 T10 L2

30 OMM in Prenatal Care: Research King et al, JAOA, December 2003 Study conducted in 4 cities: Chicago; Kirksville; Bangor, Maine; San Diego Randomly selected equal numbers of women to receive OMT or not receive OMT (160 vs. 161) Techniques applied: muscle energy, myofascial release, ligamentous articular strain, balanced membranous tension, HVLA, counterstrain, cranial

31 OMT Research Results # Women Avg. Age # times OMT Primigravida Received OMT # MSAF PTD Forceps C/S No OMT * MSAF- meconium stained amniotic fluid, PTD- preterm delivery, C/S- Cesarean section

32 During Delivery OMM can improve body mechanics to help reduce the amount of time needed to push Prevent need for vacuum assisted vaginal delivery, forceps assisted vaginal delivery, episiotomy Prevent weakening of pelvic floor Leads to uterine prolapse, bladder prolapse, incontinence or other bladder/bowel problems as women reach menopause

33 Treatments during delivery Limited by how relaxed patient is and whether she had an epidural Sacral-iliac decompression expands pelvic outlet allows leg muscles to release (prevent cramping) allows patient to relax so may feel it is easier to push Sacral Rock

34 Post Partum OMM can help correct structural and postural imbalances that developed during delivery patients feet not placed evenly in stirrups patient lying asymmetric to relieve pressure on buttocks pubic dysfunction muscle spasm in back and shoulders

35 Post partum Osteopathic structural exam to make sure vertebrae are in line neck and spine sitting correctly on top of hips, check for scoliosis Prevent back pain and other musculoskeletal problems from developing Decrease risk of post-partum depression

36 THANK YOU

37 References Callahan TL, Caughey AB, Heffner LJ. Pregnancy and Prenatal Care. Blueprints Obstetrics and Gynecology (3 rd edition). pp 2-6. Clofine R. OMT in Pregnancy. DiGiovanna EL, Schiowitz S. An Osteopathic Approach to Diagnosis and Treatment (2 nd edition). pp 184, 227. King HH, Tettambel MA, Lockwood MD, Johnson KH, Arsenault DA, Quist R. Osteopathic Manipulative Treatment in Prenatal Care: A Retrospective Case Control Design Study. JAOA (12): Dec Kmom. Pubic pain. Saverese RG. OMT Review: A Comprehensive Review in Osteopathic Medicine. pp 21-26, 58-59, Tettambel MA.Related Articles, Links An osteopathic approach to treating women with chronic pelvic pain. J Am Osteopath Assoc Sep;105(9 Suppl 4):S20-2. Review.