Virginia Research Day 2021

An Integrated Osteopathic-Neurological Examination Enhancing Patient Care: The “ONE” Approach Michael P. Cargill, OMS-III, Alyssa M. Jackson, OMS-III, Jessica K. Morris, OMS-III Charles R. Joseph, MD, Michael D. Lockwood, DO, FCA, FAAO

Abstract Neurological disorders are a leading cause of disability and death worldwide. By incorporating the osteopathic structural somatic examination with the traditional complete neurological examination, somatic dysfunction occurring because of neurologic injury or independently, can be identified and treated using osteopathic manipulative techniques at the time of the patient’s visit. Our proposed integrated osteopathic-neurological examination (ONE) approach provides the physician with more diagnostic and treatment modalities by allowing the physician to determine the interplay between structural and neurological findings. To the degree somatic components exist, Osteopathic Manipulative Treatment (OMT) can be applied as a primary or adjunct treatment modality and is easily mastered by uninitiated physicians through accredited skills workshops. OMT has been shown to improve musculoskeletal complaints, facilitate pain processing, and enhance activity of central neural centers related to perception of wellbeing, proprioception, balance, and gait. With limited treatment options for many progressive neurological diseases often contributing to physician burnout, visible patient improvement post- treatment may provide more fulfillment in patient care. These tangible benefits from the ONE approach translate to enhanced patient care and physician satisfaction. Step 1: Physical Exam and Osteopathic Screening The ONE approach includes motor, sensory, and somatic components. Motor components include assessing muscle bulk, tone, and strength. Sensory components include assessment of vibration, proprioception, touch localization, light touch, and temperature perception. Steregnosis, two-point discrimination, and graphesthesia should also be tested. The somatic osteopathic assessment includes changes in tenderness, asymmetry, restriction, and tissue texture (TART). The osteopathic concept of facilitation, in which a pool of neurons is at a constant state of elevated sensitivity, results in muscle hypertonicity and increases the utility of assessing tenderness along with the sensory exam.

Step 3: Treatment Techniques Table. Common neurological disorders with frequently associated structural findings and specific treatment techniques.

Step 2: Objective Findings

Neurological Disorder Structural Findings

Techniques

Migraine Headache

● Hypertonicity (muscle tightness) of the Upper Cervical and Thoracic Paraspinal Muscles ● Occipitocondylar Compression

● Soft Tissue Techniques ● Suboccipital Decompression ● Muscle Energy ● Myofascial Release

(reduced mobility at the craniocervical junction)

Radiculopathy

● Hypertonicity of the Cervical, Thoracic, and/or Lumbar Paraspinal Muscles ● Tender Points of the Muscles Innervated by Affected Nerve ● Median Nerve Sensory Injury ● Weakness/Atrophy of APB (Abductor Pollicis Brevis) ● Dysfunction of the Carpal Bones ● Hypertonicity of the Cervical and Thoracic Paraspinal Muscles ● Pectoral and Scalene Hypertonicity ● Hypertonicity of the Cervical and Thoracic Paraspinal Muscles ● Dysfunction of Clavicle

● Myofascial Release ● Soft Tissue Techniques ● Counterstrain

Carpal Tunnel Syndrome

● Articulatory Techniques for Carpal Bones ● Thoracic Outlet Myofascial Release ● Soft Tissue Techniques

Thoracic Outlet Syndrome

● Myofascial Release ● Articulatory Techniques ● Muscle Energy Techniques

Sciatica Neuralgia

● Hypertonicity of the Lumbar Paraspinal Muscles ● Piriformis Hypertonicity ● Sacral Dysfunction

● Soft Tissue Techniques ● Myofascial Release ● Counterstrain ● Advanced Sacral Techniques

Conclusion The ONE approach in a neurologic setting can improve patient outcome and enhance physician satisfaction as objective and symptomatic improvements are directly observed. Osteopathic examination and treatment, in addition to improving outcomes, will aid in differentiating functional causes of patient complaints from identifiable organic causes. Additionally, physicians employing the ONE approach may desire to expand their skills in osteopathic techniques by attending widely available CME accredited workshops. Following initial treatment, patients with complex somatic problems may warrant referral to a board- certified OMT specialist. References 1. Cerritelli, F., Ruffini, N., Lacorte, E., & Vanacore, N. (2016). Osteopathic manipulative treatment in neurological diseases: Systematic review of the literature. Journal of the neurological sciences , 369 , 333–341. https://doi.org/10.1016/j.jns.2016.08.062. 2. Seffinger, M.A. (Ed.). (2019). Foundations of Osteopathic Medicine, 4th Edition . Wolters Kluwer .

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