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Applying Osteopathic Principles to Formulate Treatment for Patients cian approaches to chronic disorders, a growing number of patients actively pursue complementary or alternative Applying Osteopathic medical care, including manual modes of Principles to Formulate therapy and mind-body practices.4,5 If Treatment for Patients properly prescribed and delivered by With Chronic Pain professionals, such approaches—which are rapidly becoming an expected stan- dard of care for patients with chronic Michael L. Kuchera, DO pain6,7—may confer some clinically sig- nificant benefits. Multidisciplinary pain clinics recognize that many hands-on approaches to patient care, including osteopathic manipulative treatment (OMT), chiropractic adjustments, and massage, can provide distinct solutions for individuals with chronic pain—solu- tions that would be unavailable from Osteopathic manipulative medicine (OMM) is a physician-directed approach practitioners who ignore or dismiss non- to patient care that incorporates diagnostic and therapeutic strategies to address touch modalities.8 body unity issues, enhance homeostatic mechanisms, and maximize structure- Osteopathic manipulative medicine function interrelationships. Osteopathic physicians integrate a thorough med- (OMM) is the component of the osteo- ical history with palpatory examination of a patient to ascertain distinctive pathic medical profession that approaches characteristics and origins of the patient’s pain, to evaluate how pain uniquely total patient care by emphasizing appli- affects the patient, and to determine whether segmental, reflex, or triggered pain cation of distinctive osteopathic princi- phenomena coexist in the patient. Osteopathic manipulative medicine expands ples and practice (OPP). Osteopathic differential diagnoses by allowing the physician to consider somatic dysfunc- manipulative medicine provides a tion and implement treatment options via integration of specific aspects of patient-centered approach that integrates complementary care into state-of-the-art pain management practices. recognized and rational healing methods, Prescriptions formulated through an OMM algorithm integrate each osteo- including OMT, to improve the health pathic tenet with biopsychosocial and patient education models, as well as and physiologic function of patients. It is manual medicine, pharmacologic, and rehabilitation techniques proportionate the part of the osteopathic philosophy in to individual needs. This “refreshed” version of an article originally published which we discuss the physical spectrum in September 2005 includes the addition of an anecdotal case scenario in which that considers an individual’s “dis-ease to application of osteopathic principles and practice created a personalized, effec- disease” and the body unity link of tive treatment plan for the described patient’s chronic pain. mental/emotional dis-ease that coexists J Am Osteopath Assoc. 2007;107(suppl 6):ES28-ES38 with physical disease. Although OMM is recognized by the National Institutes of Health (NIH) in the United States as a mainstream medical discipline, OMT in hronic pain is a common medical alone overlooks important patient-cen- isolation is classified by the NIH’s Cproblem with a relatively high inci- tered treatment strategies that are National Center of Complementary and dence and a low recovery rate.1 Patients capable of modulating pain perception Alternative Medicine (NCCAM) as one of frequently relapse after initially suc- and quality of life. In other instances, several promising “complementary” pro- cessful treatment. Persistent or relapsing patient noncompliance with otherwise cedures among a variety of other hetero- pain often results from misdiagnosis or successful treatment programs may geneous manipulative and body-based inadequate treatment.2 In many result from inadequate patient educa- practices.9-12 Regardless of NIH classifi- instances, focusing on pain generators tion concerning the prognosis and man- cation, the use of OMT in OMM specialty agement of chronic disorders such as clinics is commonplace and has been per- arthritis.3 ceived by many patients as highly effec- Address correspondence to Michael L. Dissatisfied with ineffective, incom- tive in decreasing their pain and in Kuchera, DO, FAAO, Professor and Director, OMM plete, and sometimes impersonal physi- increasing their mobility.13 Research, Clinical Director, Center for Chronic Dis- orders of Aging, Philadelphia College of Osteo- pathic Medicine, 4190 City Ave, Suite 320, Philadel- phia, PA 19130-1633. Dr Kuchera has no conflicts of interest to dis- This continuing medical education publication is supported by close. an educational grant from Purdue Pharma LP. E-mail: [email protected] ES28 • JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 Kuchera • Applying Osteopathic Principles for Treatment of Patients With Chronic Pain An OMM approach that integrates silent receptors to become active in the static response and the patient’s under- palpatory diagnosis and OMT provides spinal cord, or when facilitatory modu- lying pathophysiologic status as inter- the balance that patients with persistent lation results in “spinal cord learning.”17,18 preted by components of palpated nonmalignant pain seek between state- In such cases, the patient may simply somatic dysfunction. of-the-art interventions and individual- present with persistent pain. Treatment protocols formulated ized patient-centered care. Osteopathic The rational application of OMT for from this algorithm incorporate the inter- manipulative medicine incorporates patients with persistent pain cannot have dependence of all tenets of osteopathic strategies to both decrease pain and to a singular focus, nor can it be considered medicine,21 resulting in an individually enhance physiologic function in patients. a static phenomenon (ie, effects on gene designed prescription to address each For such patients, treatment with OMM expression as well as the changing face of patient who has persistent pain. In offers two major recognized advantages: pain and pain perceptions as chronicity applying this algorithm to patient care, an expanded differential of potentially alters the body unit).19,20 In formulating osteopathic physicians may also choose treatable etiologies and an individual- multimodal treatment plans, approaches to use some or all of the mainstream ized, patient-centered pain prescription based on OMM embrace principles of and/or complementary treatment based on the application of osteopathic body unity and integrate palpation and modalities used by other healthcare pro- principles. OMT techniques into each patient’s pre- fessionals. Many osteopathic physicians scription. Physician choices concerning emphasize patient education and offer OMT techniques and goals depend on Structure-Function Considerations: a pragmatic philosophy similar to that each patient’s unique pain presentation, Somatic Causes of Persistent Pain adopted by multidisciplinary pain man- suspected pathways involved in that pre- Certain somatic findings have been con- agement clinics. In addition, OMT offers sentation, and those body regions diag- sistently documented in various persis- patients an additional therapeutic option nosed as containing somatic dysfunc- tent pain conditions. Depending on the with a low risk-to-benefit ratio and a tion. particular situation, somatic dysfunction growing evidence base of efficacy.14,15 A complete review of diagnostic reg- may be causative, reflexive, reactive, or imens and therapeutic options for perpetuating (or some combination of General Osteopathic Manipulative patients with persistent pain is beyond these pathophysiologic mechanisms).22 Medicine Considerations the scope of the present article. Instead, Thus, differential diagnoses and treat- in Patients With Chronic Pain this article provides a concise overview of ment considerations depend on both the Chronic pain mechanisms encompass a the OMM paradigm and introduces a specific body region and underlying complicated array of different processes general algorithm for pain management pathophysiologic mechanism involved. (eg, biomechanics, genetics, neurophys- (Figure 1). Discussion of persistent pain The algorithm (Figure 1) contains gener- iology, psychology), each capable of con- management is limited to generalities alities taking these factors and structure- tributing to clinical manifestations and related to the integration of OPP in the function interrelationships into consid- symptoms. For OMM to be effective, sim- application of OMT. Where pertinent, eration. ilar symptoms in different patients may specific common chronic pain presenta- An osteopathic palpatory examina- require dissimilar treatment plans that tions are described as examples sup- tion often provides clues to the under- focus on various local, spinal, and porting the algorithm. lying mechanism(s) of a patient’s injury.2 supraspinal targets. For example, chronic Such palpatory insights can lead to fur- pain initiated by peripheral trauma may Pain Management Algorithm: ther questions, examinations, and tests, result when supraspinal structures con- Applying Osteopathic Principles each designed to identify structural fac- tinue to respond as if peripheral tissues and Practice tors associated with specific pain gener- were actively injured. In such chronic When patients present with chronic pain, ators or factors that interfere with cer- conditions as fibromyalgia, the patho- especially pain that persists despite seem- tain self-healing mechanisms. The logic process may reflect an autonomic
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