Good morning, thank you guys for joining virtually. I'm Gautam Desai, I'm professor and chair of primary care at KCU. I originally joined in the OMM department and now I'm in the primary care department, which encompasses family medicine, pediatrics and internal medicine. So thank you guys so much for joining. And if you guys have neighbors in the hotel room or connecting suite, feel free to knock on the door and see if you can find a partner that way. If you have any questions, I'm gonna ask people to monitor the chat room. So please put them in the chat room if you have any questions, if you're joining online. Otherwise, the rest of you, feel free to interrupt at any time. So as a young child, I was traumatized because my pillow fell off my bed. I woke up like this and I was supposed to go to Boy Scout camp and I couldn't go. So this is a very near and dear diagnosis for me, but I'm sure you guys have had patients who've had motor vehicle accidents, who've come in with corticalis, either rotational or side bending. And patients are pretty nervous and scared because they can't drive. They come in, they're walking like this. They can't turn their neck. They're afraid to get in an accident. And this is one technique that I think really is just a great one for DOs to do if they're not already doing muscle energy technique. It's a great way to improve the range of motion. And so we just adapt a lot of these techniques for our patients. We do some global health work. So we go to Kenya, Guatemala, Dominican Republic. And so we'll do OMT on people and just wherever we are, that's where we set up our clinics. We'll do sometimes seated, sometimes on the ground, just depends on the situation for the patient. So most of these today will be from a seated position, but you can definitely adapt them. And in fact, you guys will probably recognize them from when you guys were in the lab. So hopefully it's not triggering for you guys back to your days of the lab. And this just assumes that each patient has had a workup as you guys would do in your offices anyways for reflexes, strength, sensation, and any red flags. So I'll usually start off for patients that do come in with acute torticollis and just do a soft tissue technique, but I'll start off with suboccipital release. And so this is the one where AT still, he took his forces and reins, he tied them between two bushes and he put his neck there and he's kind of felt his neck go back and relax. And often that's what I prescribe for patients when they go home, especially those that have tension headaches that come into working all day, leaning forward, just have that pain there. I don't just put their pillow like that, just let it lean back. And as they exhale, they can feel the musculature relax. So for the seated technique, I'll just modify it slightly by just putting my hands on the back of the patient's neck and up with my other hand on the forehead. And I'm just giving a little bit of axial traction and then slowly as a patient inhales and exhales, just feeling the muscles relax and going back a little bit. That's a great idea. Can you sit facing that way, please? Thank you. And if there's any other views that you guys have challenged with, let me know. Oh, anyone got any scissors? Yeah. Yeah. There you go. And is it possible to switch the camera so I can see if I can switch the cameras where it's larger for the video part. But anyway, so I'm just going up from the bottom of her neck, just to where I feel the bones and just pulling up and then just kind of just doing gentle massage there. You kind of wait and feel for that to relax. Thank you. And then I think, there we go. Okay. And let's say that her torticollis, let's say that she came in and she was side bent to the left and she was like this. So for muscle energy, you guys probably recall that you want to go towards the barrier. So if she's side bent left, the patient does not want to side bend to the right. So you're going to take her towards the barrier as far as she can go. And I usually have the patients do it first actively so I know how far they go before I take them past that barrier. So have her gently side bend to as far as she can go. And then I'll just ask her to straighten her head by pushing the top of her, her left side of her head straight. One, two, three, relax. A little further. One, two, three, relax. And a little further. One, two, three, relax. Doctor, just a question for you. Yes, sir. Why are you choosing to use muscle energy on an acute patient rather than doing something like a counter strain where you're doing an indirect technique? Yeah, so good question. So for those Zoom viewers, the question was why use a direct technique for an acute injury versus an indirect technique? Why am I choosing to do that instead of a patient using indirect technique like counter strain? So I found good relief in patients and I just use very much less force than I demonstrated here. So some patients will come in and they're just so tender they can't even move their neck. So I'll have them use their eye muscles. So I'll have them use, you know, it's weird, but it actually works. It's called the oculocephalogyric reflex. So you have the patient just looking towards the right where you have your fingertip on the patient's cheek and using that as the activating force. But in general, it's a little bit of gentle muscle energy. It gets the patient through so they can have a little bit of increased range of motion. So, good question. To go to the side, to his back or from the side? Going to where it doesn't want to go. So if she doesn't want to go to the right, you're going to go to the right just to where you'll feel the muscles start to tense up or where the patient has pain or discomfort. And then you have them push the opposite way, hold it for three to five seconds. And it's supposed to be isometric. So the patient's not supposed to be moving. You're not supposed to be wrestling with, you know, we do this for the legs sometimes. Patients are pretty strong. So you want to make sure that you're not moving, the patient's not moving, hold it. And then as the patient relaxes, you relax, but go a little further towards where it does not want to go. And as you guys recall, if you want to add in the AA joint, if you're doing muscle energy of that, you want to get a full flexion of the cervical spine, which typically is much easier with the patient laying on their back. But here you can just have them bend forward. And I usually monitor where the chin goes on the shirt. So actually here, she's not going as far to the left in rotation of her AA joint. So she doesn't want to go to the left for that. So I'll take her to the left. I'll have her gently push to the right or rotate your chin to the right. Yeah, one, two, three, relax. A little further to where she doesn't want to go. One, two, three, relax. And then again to the right, one, two, three, relax. We always make our students reassess at the end. So we're going to flex again and see if we've improved her range of motion and seemed a little bit better. I haven't paid her extra money to pretend that it's better. Let me see, is that the last one for this section? For some people who have a tendency to want to go ahead and then convert a muscle energy to an HVLA, you want to point out that that's the one technique you never want to do with thrust out. Yeah, so for the AA joint, I usually don't do a thrust. The OA joints, great, typical spine. OA joints and AA joints are thrust, but not at that angle. Unless I'm bringing back what I learned at a small little school outside of Columbus, Georgia in 1969, where I was talking about past the anatomical barrier. Wow. He's laughing because he knows it's the army range. Nice. Okay, thank you for that reminder. And then you can do the same thing with the same principles for the typical cervical spine. So as you guys may or may not recall, you typically have side bending and rotation to the same side. So that's why this diagnosis says it's extended, rotated right, and side bent right. So right now, and this is just a gross exaggeration, but her neck is extended, rotated right, and side bent right. So we want to do the opposite. So we're going to try and flex the patient, rotate left, and side bent left. And then you're going to monitor and have the patient try and straighten their head. And this is one where you might vary your positioning based on how large your hands are and how large the patient's head is. Amanda has a pretty average head. Sorry, Amanda. So I can hold it like this. Some people will put their hand and their forearm like this, controlled that way. Some will grab two hands and twist around. So this time, I'd like to ask you guys to partner up and just do a little bit of the soft tissue and just rotate the cervical spine and see if you can detect a difference. And I'll walk around a little bit and help. All right, I'm going to try and keep us on track here. I'm going to show a still technique. So this one is attributed to Andrew Taylor Still, who described it in his earlier text and then other doctors have modified it. But this is a non-repetitive articulatory technique, and you can do this with the upper extremity, the lower extremity, the neck. So for the cervical spine, for a still technique, you'll take them to where they already want to go. So if they're rotated right, you're going to rotate them right. If they're side bent to the right, you'll side bend them to the right. If they're extended, you'll extend them. So you take them to where they want to go and then maybe exaggerate that a little bit so the muscles relax. And then you're going to add a compressive force down and then take them to where they don't want to go. And the hope is that you'll get some linkage that will help remove that restriction. So let's say that Amanda is rotated right. I think I have an example on the next slide. Yeah, let's say that she's extended and again, just exaggerating, she's rotated right and she's side bent right. That's my diagnosis I made when I examined her. I would take her into those positions. I would extend her, rotate her right, side bend her right, and then try and take her a little further and see if I can get my monitoring hand to feel the muscles underneath her relax a little bit or perhaps the dysfunction to give a little bit. And then I'll add pressure and compression and then I'm going to slowly start to rotate her left, side bend her left, and flex her, see if I can get in motion at that dysfunctional segment. So it's a pretty nice quick technique. Sometimes you don't want to do HPLA on all of your patients. They may have risk for osteoporosis. They may have some radicular symptoms and signs. So it's a nice little quick technique. And so if you guys want to take a second to go over that, then I'll go over Stills technique for the upper back too. So just take them to where they want to go, add compression, go where they don't want to go. All right, we're going to go on to the upper extremity rhomboid stretch. And I love doing this one when the patient is laying on their side and they're facing me, but sometimes we'll modify it. So if you guys have ever done seated rib raising, you'll be a little bit familiar with the position, but if someone's had a long flight, they have a headache, you know, maybe their hairdresser you've been working all day on the field, you'll be tight, especially under your scapula there. So you can have the patient put their arm on top of yours. And I like to put my fingertips just at the scapula border, and I'm going to push and give a little counter pressure either on their shoulder or their anterior thoracic wall. Can you guys see okay? So I'm with this hand that's on the shoulder, I'm pushing back towards the scapula and my fingertips are curled under the scapula and I'm pulling towards me. And you can modify this to go from those muscles to the muscles of the upper back as well. And just kind of rolling the tissues and you guys will probably hear that she's pretty tight but she works out all the time and probably doesn't stretch enough. And if you want to get a little bit more access to underneath the scapula, you can place the hand behind the back, so kind of make the scapula wing out a little bit so it's a little bit easier. And if you have a patient that's been immobilized, they're in a nursing home, they probably haven't had too much motion in this area for a while, especially if they've been laying back in a hospital bed. So this is just a nice technique to stretch that area out. Yeah, so if someone's had a rotator cuff injury or if you're watching your patient to start to wince when you're lifting the arm up or pushing, you can modify by just grasping here and avoiding that region there. So the scapula area is probably still okay, but just we always tell the students watch your patients, make sure they're not going googly eyes on you while you're twisting the neck around or whatever. Positive winch sign. Positive winch sign, exactly. And then the still technique for the thoracic spine is a little bit different than what I showed you guys for the cervical spine. But this technique is a good way to do, a good thing to do on patients. If you ever had patients that are super muscular, I had a patient who participated in the Highland Games and he did the caber toss, which meant he took a telephone pole and tried to throw it as far as he could. So I was trying to do OMTM on him for a couple of sessions and I was jumping on him with all my body weight. It was very hard to get anything to move because he was 330 pounds of just pure muscle. So I did stills technique and I was able to get some of the restrictions removed. And you can do this for basically anything you find. So if you have a rib that is out, if you have a transverse process that is rotated to one side or the other, or segment rotated there, and I use it for tight muscles as well. But basically you have two hands and I usually do this with a patient laying down. So I have my bottom hand on that dysfunctional segment and I would have my top hand on the electron process and I would move this arm around the top hand until I felt motion at the spot that I wanted to remove that restriction from. And then I would add a compressive force down and I'll go in a circle. So I've modified it a little bit. The book tells you that you should bring the arm up. You should check the humerus and external rotation and internal rotation and whichever one feels freer, you're supposed to continue the circle in that. So here she feels a little freer in external rotation. So you would be going in a, whatever this is clockwise or counterclockwise, but you're doing an external rotation movement while adding compression towards your back hand. Obviously it's easier with gravity to have your hand down and you're doing it that way. But this is a nice little technique just to remove any, any regional dysfunction. So as you're pushing back pretty hard, and again, you want to monitor and be careful if someone's had shoulder surgery or something, this is a nice way to get patients ready for HLA of the thoracic spine. And then thoracic muscle energy. This is a million and different one ways to hold the patient's elbows or snake your hand in through the elbows to get them to rotate. But the main thing is just being at that segment. So whatever the segment is here, I think we said is T1 through three is neutral. So this one is a group dysfunction. She's rotated to the right and she's side bent left. So what I want to do is rotate her left and side bend her right. So if you'd have the patient, you can either have them put their hands behind their neck. Yeah. And then bring your elbows forward, please. So you can do it this way based on, let's see, she was rotated right and she's side bent left. So I want to go to the barrier for doing muscle energy. So we're going to side bend right and rotate the left and you want to rotate till you feel motion at that segment and then ask the patient to try and straighten up to three. And as a patient is giving their muscular force, you should be feeling a little bit of tension underneath your fingers and that lets you know you're in the right spot. As the patient exhales, and then you can take them a little bit further to where they don't want to go. So it's the same principle as we did for the cervical spine. All right, so why don't you guys practice those, the still technique and rhomboid stretch. All right, we're going to go on now to addressing the patient that may have carpal tunnel syndrome symptoms and these are pretty good, you know, this is a nice modality and that's the great part about being an osteopathic physician is that we have something else to offer besides medication, so we can give education to the patient, we can do stretches to do at home and if you have a patient that's pregnant, you know, you can give acetaminophen to that but I personally have found that it works like a tic-tac for me, so I usually don't use acetaminophen, so I feel bad for pregnant patients who have the decreased or have increased pressure in their carpal tunnel, so one good stretch that you can do is if you take your between your fourth and fifth finger and if you guys want to do this with your partner now, so between your fourth and fifth digits, place those between the patient's fourth and fifth digit and the first and second digit, I'm going to turn sideways here so you can see, and then put your other fingers except for your thumb behind the patient's wrist, so they're kind of holding it like this and then place your thumbs on the bones of the carpal tunnel border, so you can push outward, so I'm pushing laterally I should say on each side, so I'm pushing away from the median nerve with both of my thumbs on the bone, I'm just holding it as the patient relaxes, I'll go a little further into extension and push a little further out, hopefully you guys can see that a little bit, but I'm basically just trying to get each bone to spread in a lateral direction away from that to increase the diameter of the carpal tunnel and then adding in a little bit of extension. The cubital tunnel, I don't know one like that because there's usually a different kind of encroachment there, but that would be a good thing to research for sure, and then I'll just go a little further and further into extension, and I'll walk around for a second if anyone has any question with hand placement. All right, and then this is one stretch that you can have a patient do at home or wherever they are. So, I usually ask the patient to put their elbow against their ASIS with their fingertips down leaning against the wall, actually it's not a good place to do it, yeah, and then have the patient grab their bottom thumb and then just add a little bit more extension. Sometimes they may not be able to get the thumb, but you're basically, let's just say Amanda's a wall, which actually her last name is Wall, so that makes sense, but you're going to push against it and then just, if you can grab the thumb, great, and have the patient pull down. So, you get a little bit more of a stretch in. And they can also do this seated, where they'll have the patient place their fingertips on their opposite knee and their elbow on their opposite knee, and then just pushing your knees towards each other so you get more extension of the wrist, and then if you want to be fancy, you can grab that thumb and pull it down either way. So, just little stretches, and this is just nice for pregnant patients because it helps, you know, give a little temporary relief without giving them medicine and stuff. All right, if you have someone that has plantar fasciitis, they're pretty quick little techniques, so you can have the patient place their leg on you. Can you guys see that over here? Yeah, hopefully I don't roll off this thing. And so, I usually will start off just addressing the fascia in general, so I have my fingers on the top of the foot and my thumb is the bottom, and just depending on how much the patient can tolerate, just doing basically a little massage. I'll usually give you a little bonus twisting of the forefoot, midfoot, and hindfoot, sometimes you get little straggler bones there. And then for plantar fasciitis, as you guys know, they're pretty tender when you're pushing up towards the calcaneus, and so, I don't know if you guys remember counterstrain. I never had counterstrain when I was at Michigan State. I don't know if they started teaching it after I left, but I never, as far as I recall, maybe I just blew it off for the test, but I don't remember ever being taught counterstrain when I was a student at Michigan State, so I learned that when I came here, and at first, I was a little bit skeptical, but actually, I found that sometimes it does work pretty well in surprising ways. And so, the good thing is that you can apply these principles of counterstrain to anywhere in the body that there's a tender point, so the tender point's not the same. Was he still there when you were there? I think he was, so I must have just blown it off. Yeah, he probably had a cardiologist. I could be, but Dr. Greenman taught at our school, who's a great osteopath, but anyways, so for this technique, it's a very simple technique, it gets complicated, so people have a lot of different spots for it, but the way that this evolved is that Larry Jones was an osteopathic physician, and he saw a young athletic male who, I think he was playing basketball or something, he had back pain that no one could figure out, you know, like what's wrong with your back. He went to a lot of different doctors and different places, and so when he saw Jones, Jones just put him in some position on his table, and when he came back, the pain was gone, so Dr. Jones spent the rest of his life trying to figure out, you know, how can I recreate this to help patients, and he discovered there's different tender points on the body, and for the majority of them, if you shorten the muscle fibers there, then he'll stop that reflex inhibition of that recurrent pain, so there's a lot of physiology behind it that we teach our students, so in the interest of having only 10 minutes left, I'm going to just go through the technique, but basically the gist is you find the tender points, so for plantar fasciitis, we know most of the time it's the flex calcaneus point that is when you're pushing up towards there, and so you tell the patient, it's a 10 out of 10, so unlike us asking patients on a pain scale, what is this, you're telling the patient, this is 10 out of 10, you're going to hold it there, and you're not pushing too hard, and then you're going to try and shorten the muscle fibers, so here, I'm just flexing her foot forward to try and make the muscle fibers shorter, and then you can just tweak it with side bending, rotation, whatever, and you want to try and get the pain down by 70%, so then you ask the patient, let me know when it's down to a three, and once it's down to a three, you'll then hold it, some people hold it for 90 seconds, some people hold it for 120 seconds, but you just want to hold it in that position, and then take the patient back to neutral without them helping, so in this case, it's easy for the patient not to help, but sometimes, if you're holding an arm up, it's a little bit easier for the patient to help you, so you want to take them back to neutral after 90 seconds, and you reassess. The reason you keep your finger there, so A, you can monitor, but B, sometimes patients wait a minute, that's not the right spot, because now it's not tender anymore, so they think you pulled a fast one or something, but that's the gist of counter strain, and you can do it for plantar fasciitis, I do not know, there you go, it was written as 90 seconds, so that's that one, and then I have a standing HVLA technique, go ahead, and so this is pretty good, you can do it for the lumbar spine, I'm trying to think how I can make it most visible for, let's have you go back here, okay, there we go, and for this one, you can have the patient place their arms behind their neck and hold them together, and they have to be somewhat agile, like a stork, so can you lift your right leg, Amanda, please, and so I'll grab the patient's opposite knee, and I'll grab their opposite arm, and I will just twist them, and then you give a little thrust at the end, so it's a nice one, I actually had to do this on top of a volcano in Guatemala recently, some student had said her lumbar back was hurting, so I did that up there, and it worked there, she didn't have a dysfunction, so you have to do it for her, and a bonus technique for that, that are not on the slides, is a thoracic HVLA that you guys have probably seen before or done to each other before in class, two different ways to do it, one is with the patient's hands behind their neck, and put your feet apart a teeny bit, and take a big breath in, and let it out, so that's a quick and easy one, and another one you can do with the patient's arms in front, and take a big breath in, and let it out, and so that one you're using your chest as a fulcrum, you're just adding some extension, and it's just often a quick and easy hotel fix, the first one you did will get the top three, four, five, and the others will get the middle ones, yeah, then the lower ones, first technique for the body, so that's usually why I do both, even if I just get one to go there, so why don't you guys, I think that might have been, oh yeah, we have TMJ real quick, so let me do TMJ, stay on track, and then I'll walk around and help you guys, and so these are just basic techniques, we're just applying to a different region here, and you guys probably have a lot of patients that come in complaining of clicking of the jaw, I'll usually have them open and close their mouth, and so she has a C-shaped curve off to the left, so her jaw slightly goes to the left, and comes back to midline, it's a subtle little motion, some patients will have an S-shaped one, where it goes in two different directions, like they're going down a ski hill or something, so usually for patients that have TMJ symptoms, I will start off, and I'll do the soft tissue first, so these slides are a little backward, but I'll just do, you know, just soft tissue, just massage the muscles, you can do unilateral with the heel of your hand, you can do bilateral, I'll try and get in underneath the jaw as well, and feel the scalings, and sometimes they're tight and pulling on the jaw and causing that pain, and then for muscle energy technique, if the patient has a C-shaped dysfunction, where it's going to the left, I'll try and push it to the right, so if you have the patient open their jaw slightly, and then just have them push with their jaw laterally towards the left, one, two, three, relax, again, one, two, three, relax, and again, one, two, three, relax, and if a patient has an S-shaped dysfunction, I have them do muscle energy themselves, several times a day, they can push their jaw out, pull their jaw back, push the jaw to the right, push the jaw to the left, and try different things. You know, back in the day, Wrigley Gum said that, hey, we did a study, chewing gum helps patients with TMJ, so they were a little bit biased, I feel, in their study there, and these stretches I've shown, and then, yeah, I think this is actually the last one, but for whatever reasons, people sometimes get constipated when they travel, and so it might be due to a lack of fluid, or just eating, you know, different foods that they're not eating, so we do this in Guatemala all the time for our students, you get constipated, and there's a couple different techniques I'll show you quickly, and one is just the IT band, or at least the Chapman points from the lateral aspect of the leg, so if you cross your leg over, okay, thanks, and so a preceded technique can just have the patient's leg over to the side, and depending on how ticklish or painful it is, you can go to town pretty good using your hand, you can use the heel of your hand, you can use a ramen spoon, or whatever you like, my block, no, thanks, so you're just kind of going down, and then the other technique that we do is just doing a release of the mesentery, and people do this different ways, I actually just tend to follow the colon, yes, question there, that's a great question, so we have the visceral somatic reflex, so that's what some of the reasoning was behind that, that some of those points might manifest themselves in the lateral aspect of the thigh, yeah, and so for patients who are constipated, I just tend to follow the large colon, so I'll start the bottom right, I'll go up, across, and down, and it's not the most comfortable thing in the world for patients, but they're usually pretty grateful when they can go to the bathroom later on, so if you have a patient that's seated, you can have them just slouch back in their chair, I'm going to pretend like this chair is a back, I won't let you fall probably, I take the heel of my hand, that's okay, and usually I'll do it about three to four times, and again, you want to monitor your patient, and just see how comfortable they are with that treatment, and then you can also do the thoracolumbar diaphragm, but in the interest of time, I'll just briefly show that, where you can just help the colon a little bit by making the thoracolumbar diaphragm a little bit more mobile, and removing restriction there. All right, so I'll walk around, and I don't know how much time we have left, with a minute or two, just okay, I'll walk around, any questions, and help you with techniques.

primary care

osteopathic techniques

muscle energy

global health

torticollis

HVLA

TMJ disorders