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Omm

Discussion in 'Medical Students - DO' started by Flintstone, Nov 1, 2002.

  1. Flintstone

    Flintstone Member
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    Hello All!

    I will be in the class of 2007 and I am very excited in the prospect of practicing OMM in the future. I was talking to a MD friend the other day about OMM and how I can practice my techniques on family and friends ....well, he was kind of scared that I will practice it on him because he heard that there is a case of OMT dislodging a clot in a female patient and that patient ended up with a heart attack.....:(

    Anyone heard of similar cases? Are you taught in class as to how to avoid similar situations from happening?


    Thanks!
     
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  3. Dr JPH

    Dr JPH Membership Revoked
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    Sure it can happen.

    Just like you can dislodge a clot by massaging the calves. (NOT an osteopathic manipulation)

    You can dislodge a clot by doing several things. OMT is not the only thing that can cause this.

    If your friend is an MD, he should know this.

    As far as contraindications to using certain techniques, they are most certainly part of the discussion. Teaching you when NOT to do something is just as important as teaching you when to do something.
     
  4. Flintstone

    Flintstone Member
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    Thank you for your insights!

    :)
     
  5. PJMCD

    PJMCD Member
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    While I have not heard of something like that happening, there is no doubt that it can. I will give you your first med school lecture, the key to successful treatment, is a GOOD HISTORY. A good history is 90% of your diagnosis. IF a situation like that did happen the doctor may have over looked something, or not taken a good history. However, there is the chance that the patient was asymptomatic in that case the Dr. would not have known there was a clot.. I am just babbling too avoid studying.. Best of luck to you in school. :)
     
  6. SLE

    SLE
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    Yes this is possible albeit rare. Anytime you manipulate vasulature you run the risk of embolization. Remember this (and if you have to do an OSCE you better remember this) always ascultate the carotids before palpating for carotid pulse. In a patient with bruits you could dislodge an athlerosclerotic plaque and stroke them out (not to mention you will lose points on the OSCE)
     
  7. applicant2002

    applicant2002 Senior Member
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    What is an OSCE?
     
  8. Resident Alien

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    Objective Skills Clinical Exam, or something like that.
     
  9. DrQuinn

    DrQuinn My name is Neo
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    Just to be complete... the absence of a carotid bruit does not imply no atherosclerosis in the vessel.

    And there are many cases of cervical manipulation causing vertebral artery thrombosis.

    Even if its 1 in 100,000, the risk is still there. And there is no doubt of a causal relationship.
     
  10. SLE

    SLE
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    Quinn,
    Never said that atherosclerosis would require a bruit. Actually by age 25 most people have some degree of atherosclerosis. My point was ascultate then palpate. Pts with bruits have a significant plaque.

    Applicant2002,
    The OSCE is what resident said. It is a proposed exam that is supposed to be in effect starting with the class of 2005. Basically evaluates you ability to perform a PE. Personally I think it is a way to make money. The exam costs an additional $1000 and quite frankly if you can't perform a PE after 2 clinical years, I don't think you would have passed clinical rotations.
     
  11. DOSouthpaw

    DOSouthpaw Senior Member
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    The posibility of knocking something loose is soooo low. Before doing cervicals, have the patient look over their shoulder like they are backing up a car, if they don't stroke out doing that, manipulation should not stroke them out....unless you totally bite at manipulation because the same amount of force is used to turn the head as it is to manipulate. The majority of the time, manipulative force is inversely proportional to manipulative skill. If you are unsure, just use a functional technique and nothing will happen at all. You shouldn't be doing HVLA on people that are old and sick anyway. Stick to Muscle Energy and Fuctional and save the HVLA for Thoracic Fibrotics on the young folk!
     
  12. bones

    bones Osteopathic Physician
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    I agree with southpaw on this one.

    The people who dissect vertebral arteries via HVLA are usually quite reckless. With proper approach to patient treatment I suspect the incidence of such occuring is next to nothing. Monkeys might fly out of my butt, but I go in public anyway.
     
  13. ItNeverEnds

    ItNeverEnds Senior Member
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    If anyone out there doing research to determine if OMM is actually efficacious in treating certain medical problems?
     
  14. DrQuinn

    DrQuinn My name is Neo
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    Actually, the physical test to check for vertebral artery patency (is it the Wallenberg test? I'm really pulling it out of the dark for that one... Sandberg? cant' remember) has been studied before for clinical significance, and it has been shown (and published) that it is not a reliable test.

    I agree that the risk of manipulation is inversely proportional to the skill of the manipulator. No question. However, the risk is still there.

    I am a 4th year DO student, applying for EM residency now. I also work as a medical malpractice defense paralegal (4 yrs experience). I have tried to defend one case about a DO manipulator who caused a stroke in a patient. A young, healthy patient. A nice big old vertebral artery dissection. Lost $1 million. I have also done a neurology rotation where we saw a patient s/p manipulation who stroked out shortly after the manipulation. A healthy young patient. My neuro attending pointed to the pt, looked at me, and said "That's why you don't do cervical manipulation."

    My point is be sure you know what you're doing. I believe in manipulation. I just will never do cervical manipulation myself.
     
  15. bones

    bones Osteopathic Physician
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    regarding the research, a lot has been done and is being done. NIH has several grants running now, and TCOM is building/has build a research center, several of the others schools have good research going. unfortunately though I compare OMM to surgery in that its more of an art than a science- so outcome studies are MUCH easier to do than efficacy studies... after all how do you do sham OMM or a sham surgery? the skill of the practicioners vary widely too.

    I dont have the links to papers at the moment, but they are out there. Try checking the schools webpages or email OMM faculty directly.
     
  16. bones

    bones Osteopathic Physician
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    QuinnNSU,
    thats interesting and a little shocking actually. Nobody I know of in the history of work done here at KCOM has caused such a dissection (many more than 100,000 necks) but then again, they might not advertise that sort of thing... This being such a small town though I would be shocked if word didnt get around fast.

    Did you receive any info about the practicioners who caused these dissections? I understand the vast majority of dissections that are reported via chiropractors, but I know that there have been a few cases with DO's (for whom it was explained used excessive force w/o a clear diagnosis just hoping to pop some segments- more chiropractic style).

    Personally I tend to set patients up on the barrier- localized well enough they just "click" and everything is straightened out. Usually no activating force other than the weight of their head against my hand.
    I cant imagine that ever causing a dissection this way. I suspect I wont ever go to the rip-roaring multi-segment pops I see some crazy docs doing, for just that reason. With reasonable skill and caution I think OMM is quite safe.

    Keep in mind that chronic neck pain sucks, and a carefully places and well localized neck treatment can really make a difference in some patient's lives. Just look at the folks with locked up segments who can barely move their heads. It allows them to function again.

    so far as I know, cervicals are really the only danger spot in OMM (short of releasing a blood clot or something- which would be super rare- no more common than via massage).

    tell me if you have any more info about the docs Quinn, k?

    cheers,
    bones
     
  17. DrQuinn

    DrQuinn My name is Neo
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    Well, client confidentiality won't let me give out any names or anything... but the DO was an ACOFP member, residency trained (DO-FP obviously), and was very comfortable in manipulation.

    And as far as the pt in the hospital where the neurologist looked at me, I believe that was a chiropracter.

    No difference to me. I am not willing to take that risk.

    We had NO defense whatsoever in the DO case, by the way. ;)
     
  18. AthensfromCols

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    All the previous posts refer to cervical HVLA. The thing we learned is that there are many other techniques (LAR, FPR, Counterstrain, ME, Soft Tissue) that can be employed in the cervical area that are just as effective as HVLA but much less worrisome. I personally like the alternatives to HVLA in the cervicals because many patients are hesitant to have their necks "cracked" and if the patient isn't relaxed it doesn't work well anyway. With the other techniques, you have much less to worry about concerning side effects also...
     
  19. DOSouthpaw

    DOSouthpaw Senior Member
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    For real, there is absolutely no way that you can hurt someone treating somatic dysfunction using a functional technique. It takes longer sometimes for the results to be noticed whereas HVLA gives instant relief.
     
  20. EUROdocMOM

    EUROdocMOM Senior Member
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    I was really concerned about manipulation and possible contraindications, but as a first year I have found that at UHS, our faculty does a great job in making sure we take careful H & P's. They really stress proper DIAGNOSIS, and learning which types of treatment are appropriate for which conditions, and, of course... when you should NOT do something.

    If you want to be nervous about possibly injuring a patient, I would study DRUG interactions!!!
     
  21. AthensfromCols

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    Southpaw...

    Is it that HVLA gives instant results, or instant gratification?

    I think most docs use HVLA cause it's quick and the patient gets "gratified" because they hear a popping/cracking noise that is often associated with chriopractic/manipulative treatment.

    I've used indirect techniques just as efficaciously, but it took me much longer with the patient. Often, however, those patients treated with slower indirect techniques will not have somatic dysfunctions that recur as often... or at least in my experience.

    OSM-II
    Ohio University
    College of Osteopathic Medicine
    Athens, Ohio
     
  22. DOSouthpaw

    DOSouthpaw Senior Member
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    I think both probably. I've had joints pop before using muscle energy (yes, I know it is a direct technique too), but that is certainly not the norm. I know for a fact that good results can be achieved using both direct and indirect. What I meant by immediate was that it seems with HVLA, not only is the Somatic Dys. corrected, but the tissues around the dysfunction loosen up quicker. The tissues will eventually loosen up with other techniques (within hours) but sometimes the patient doesn't want to wait that long, or they'll think that you didn't "do anything".

    As far HVLA being faster for the doc....hmmm... Personally, I think that good HVLA takes just as long as anything else. If the doc takes the proper amount of time positioning the patient, the majority of the time the impulse is so minimal it's barely noticed. Sometimes, just setting the patient up in the correct position will allow the dys. to correct without even adding the impulse.

    With that said, don't get me wrong, I'm not a big fan of HVLA. I've used it some, but it was mainly to loosen stuff up so I could get to the dysfunction to treat with muscle energy. I haven't had any proper training using it either (We do muscle energy and functional the first year) so all that I do is self taught. Therefore, I only do some small nonspecific HVLA to loosen tissue.

    You are right though, if a doc uses HVLA as a "shotgun" technique, then I would go to another doc because it is lazy and bad manual medicine most of the time. It's like diagnosing someone with an infection and prescribing a broad spec antibiotic instead of figuring out what the infection is and prescribing an antibiotic specific to that infection. Why not take the time to properly screen the patient, localize the dys., properly set the patient up, and then treat?
     
  23. WillUseOMT

    WillUseOMT New Member

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    Quinn,
    As stated by other people here, there are other techniques besides HV/LA to treat the cervical neck. I personally do not like HV/LA on this area. That's just my thing. Muscle Energy and Functional work VERY well and are VERY safe techniques to use. Even with a good H&P I don't like the idea of HV/LA. Saying you're not going to treat cervical dysfunctions is like saying you're not going to treat the whole body. If you don't treat a dysfunction that is there, how can you consider your treatment complete???
    As for your previous experience as a paralegal, I wouldn't brag so much about getting people money for malpractice cases. Most med students don't like to hear that type of thing. Oh, how I can't wait until a nice cap is put on the amount you can sue a doctor for. And to think, people wonder why healthcare costs so much. Gee, if we didn't hand out $1 million all the time, maybe it wouldn't be???

    :cool:
     
  24. WillUseOMT

    WillUseOMT New Member

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    Oh, by the way keep in mind what calls for HV/LA: simple fibrotic......NOTHING else. It's not for pain, edema, muscle spasm, osteoarthritis or fused disk areas. Use the other OMT techniques for these and complex fibrotic. At least that's what I'm taught (and will go by).
    Later.:cool:
     
  25. bones

    bones Osteopathic Physician
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    hah
    silly people. :D
    problem may be the way HVLA is taught today.
    Dr. Yates, who was one of our best here at KCOM before his recent death, was an HVLA master- and made every effort to do it the way AT Still did. To him though, HVLA wasnt as distinct from other treatments in osteopathy as it seems to be for most docs- it was really more of an extension of "Still" technique. in fact, sometimes you could barely tell the difference between when he did HVLA, Still technique, counterstrain, and indirect... they almost blended together.

    That means he always took the patient indirect FIRST to loosen the tissues, then, if it seemed appropriate, smoothly took them through the barrier with a little click. no loud cracks, NO PAIN. If HVLA hurts, the practicioner is doing something terribly wrong and not localizing well. Tell them to get more training/supervision. if you get nervous in their hands, that may very well be a sign they are not where they should be with their skills to be using these techniques.

    I maintain that HVLA done correctly is not dangerous. Some patients need it, even if indirect works well for you. That said, not ALL patients need it... many, perhaps most dont. acute articular problems often need a little help, and of course, chronic things often respond better to indirect alone. dont be silly though and fall into the trap of being a one-technique wonder... all too often patients are more complicated than that.
     
  26. AthensfromCols

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    Very well said, bones!
     
  27. DrQuinn

    DrQuinn My name is Neo
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    Will-
    Actually, if you had actually read my post, I stated that I am a medical malpractice DEFENSE paralegal... so inherently I do not BRAG about "getting people money for malpractice cases" as I would actually be defending my fellow colleagues against these cases. And I agree that tort reform does need to be pushed to the forefront (although there are many other techniques that really need to be put into effect to help the PLI issue, such as legislation on the expert witness debacle).

    And as far as my treatment of cervical dysfunction, I am applying to, and hopefully matching into, Emergency Medicine. Thankfully, there is little use of cervical OMT in the ED (usually it is used in the outpatient setting).

    We learned in OMM class that one of the contraindications to OMT is physician (un)confidence. If I do not feel comfortable doing OMT to a patient complaining of cervical pain... then it technically is a contraindication that one should not be pushed into doing. Also, I feel very comfortable doing ME or FPR or whatever indirect techniques the patient may need.
    Q
     
  28. DocWagner

    DocWagner Senior Member
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    Many of the respondants need to be FAR less strict in their use of OMT techniques (ie when the ONLY time to use HVLA etc is acceptable). One should use any of the tools made available to his/herself. To live by strict guidelines regarding manual techniqes does a disservice to your patients...I am certain there have been no randomized blinded studies that look at success rates of "shotgun vs joint specific techiques" with regards to patient functional improvement. And quite honestly, the comparison of using shotgun techniqes to using "big gun antibiotics" is simply silly. Certainly an Apples and oranges comparison.
    It is good that many young DO students take pride in their learning of OMM/OMT...but don't be so strict that you are bound by rules that simply aren't proven.

    Quinn, yeah, I have used OMT in the ED...not alot but some. Mostly I use my P.T. background to teach stretches and exercises...but that certainly uses osteopathic principles.
     
  29. DOSouthpaw

    DOSouthpaw Senior Member
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    "If I do not feel comfortable doing OMT to a patient complaining of cervical pain... then it technically is a contraindication that one should not be pushed into doing."


    It seems to me that if you just treated where the person felt pain, you might not be treating correctly. You always treat the area of greatest restriction first (AGR) even if the pain is elsewhere.
     
  30. DrQuinn

    DrQuinn My name is Neo
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    DOSouth-

    Perhaps I should be more specific. If I do not feel comfortable using OMT on a patient with a cervical dysfunction, that is a contraindication to use OMT.

    Also as a background, I am very comfortable using OMT and am extremely competent in it (scored 100% on all four semesters of OMT) so do not think that I am a person who blows off OMT or doesnt' respect it.
     
  31. doc2belee

    doc2belee New Member

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    any procedure that one does to a patient has an element of risk, as well as an inherent risk in not acting. OMT is by and large very safe, if applied as you are taught. I have worked with many osteopaths over the past 10 years, and have never seen a harmful result. So, they must be doing something right!:)
     

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