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 ingly appropriate care, referring to an resulting findings, in turn, can lead the dysregulatory phenomenon or a dys- osteopathic algorithm (Figure 1) can sug- physician to explore functional demand function of descending antinociception gest approaches and rationale for issues associated with potential mecha- pathways.16 Conditions involving applying OPP and OMT to patient care. nisms of repeated injury or cumulative myofascial trigger points (MTrPs) The pain management algorithm is struc- microtrauma caused by habitual, occu- demonstrate specific peripheral dys- tured to identify frequently overlooked pational, or postural ergonomic stresses. function at a spinal level perpetuated by underlying etiologies included in an One way to determine whether a nonspecific biomechanical factors osteopathic differential diagnosis, as well given structure or somatic dysfunction (eg, untreated postural strain, visceroso- as to address the persistent tangible and is a primary cause of significant discom- matic reflexes). holistic impact of pain on the body unit. fort in a patient is to determine if it is a In many cases, chronic pain path- Evaluation of two main factors guide the “pain generator” tissue. Comparing the ways involving allodynia (generalized osteopathic physician’s timing for imple- anatomic location, quality, and unique lowered thresholds to pain) develop menting OMM treatment strategies: the referral distribution of a patient’s pain when changing gene expression allows patient’s capability to mount a homeo- symptoms with known myotomal, neu-

Kuchera • Applying Osteopathic Principles for Treatment of Patients With Chronic Pain JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES29 Figure 1. Algorithm for integration of osteopathic principles and practice and osteopathic manipulative medicine in diagnosis and management of persistent pain.

rologic, and sclerotomal pain maps Sclerotomal tissues (ie, skeletal, generators. In addition, these pain pat- increases the likelihood of locating pain arthrodial, and ligamentous generators) terns are infrequently taught to physi- generators. In many cases, such diag- typically mediate pain described by cians. The “Glossary of Osteopathic Ter- noses can be confirmed by an effective patients as “deep, dull, and toothache- minology” contains sclerotomal maps therapeutic response—albeit even tem- like.” Sclerotomal pain patterns are fre- relating spinal segmental levels to scle- porary—to local anesthetic injection or quently overlooked because they may rotomal appendicular pain.23 manual correction of dysfunction. project some distance from their pain Figure 2 illustrates segmentally

ES30 • JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 Kuchera • Applying Osteopathic Principles for Treatment of Patients With Chronic Pain A B C

Figure 2. Sclerotomal pain referral regions from ligaments: (A) iliolumbar ligament, (B) sacrospinous and sacrotuberous ligaments, (C) pos- terior sacroiliac ligament.

A B C D

Figure 3. Myotomal pain referral regions from muscle trigger points: (A) quadratus lumborum, (B) piriformis, (C) iliopsoas, (D) rotatores and multifidi muscles. related sclerotomal examples of liga- when overused, refer pain in recogniz- tors can originate in a single muscle. mentous pain patterns commonly seen in able patterns26,27 (Figure 3). Antigravity Alternatively, multiple peripheral inputs patients with low back pain (LBP). (postural) muscles harboring MTrPs are may establish more complex patterns of Patients with ligamentous pain genera- frequently hypertonic, whereas postural muscle dysfunction. Peripheral input can tors often cannot find a comfortable posi- antagonist muscles harboring MTrPs also produce a central imprint that per- tion and are continuously shifting posi- demonstrate weakness upon strength sists as a primary source of pain-modi- tion—a presentation sometimes referred testing.24 fying peripheral referral patterns to as “theater-cocktail party syndrome.”24 Both antigravity and postural antag- (ie, somatosomatic reflex). Common Myotomal (muscle) pain is poorly onist muscles are likely to contain taut myotomal patterns also include muscles localized, and the patient may describe bands that demonstrate a local twitch sharing the same radicular innervation symptoms located at a substantial dis- response within the affected muscle (as occurs in patients with discogenic tance from the actual lesion. Patients typ- during perpendicularly applied snap- disease) and muscles contributing to the ically describe myotomal pain as ping palpatory examination. This phe- same general function (as in the myotatic “crampy” or “stiff,” with the pain sud- nomenon has been linked to the pres- unit pattern occurring in patients with denly “grabbing” them during a partic- ence of segmentally related spinal overuse syndromes). ular motion. Muscle dysfunction may reflexes (ie, segmental facilitation).16,28 In structure-function considerations, include latent and active MTrPs25 that, Peripheral myotomal pain genera- osteopathic physicians using osteopathic

Kuchera • Applying Osteopathic Principles for Treatment of Patients With Chronic Pain JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES31 diagnostic palpation seek to identify “any The beneficial role for manual Pain in the overworked sacroiliac joints impaired or altered skeletal, arthrodial, modes of therapy, including OMT, has posteriorly distracts the physician from and/or myofascial function” been documented for patients with acute, looking for the cause coming from (viz “somatic dysfunction”)23 that adds to subacute, and chronic LBP.35-38 In patients restricted motion of the pubic symph- the nociceptive load, and to recognize with LBP, spinal manipulation gener- ysis in front. any related lymphatic, neural, and/or ally—and OMT specifically—produce Removal of myofascial somatic dys- vascular elements that might complicate physiologic effects similar to efficacious function, including MTrPs, has been underlying pathophysiologic conditions. prescription nonsteroidal anti-inflam- shown to be extremely effective in The palpatory characteristics sought by matory drugs (NSAIDs), and effects reducing or eliminating persistent osteopathic physicians include sensitivity more beneficial than either physical LBP.25,26 Patients with the muscle trigger to measured palpation (S), tissue texture therapy or home back exercises.13,38 Ben- points displayed on common composite changes (T), asymmetry (A), and eficial long-term functional outcomes for MTrP charts (Figure 3) responded well restricted motion (R) (together known have also been demon- to a wide range of treatment modalities, as STAR characteristics). Tissue texture strated in patients with chronic LBP.40 including such OMT techniques as coun- changes often provide the most impor- Based on a review of the literature, terstrain, variants, and tant information concerning the under- Mein41 postulated that patient popula- post–isometric relaxation muscle lying pathophysiologic status of the tions with subacute (secondary) and energy.25,26 In addition, manual correc- patient’s periphery and homeostatic chronic (tertiary) LBP would benefit most tion of articular or myofascial somatic response status. from manipulative care, rather than from dysfunction has proved to be an effec- After weighing risk-to-benefit ratios more costly behavioral modification, tive adjunct therapy, regardless of associated with the tentative diagnosis functional restoration, and chronic pain whether pain radiates into the lower of a patient’s condition, OMT may be management programs. extremities.26,43 delivered to reduce or remove the iden- Using a structure-function approach, With recurrence of the same pattern tified somatic dysfunction or to modulate Greenman39 examined 183 patients who of pain and somatic dysfunction in a central and peripheral mechanisms had persistent LBP for an average of patient after otherwise effective OMT, involved in pain generation. Currently, 31 months. With osteopathic palpation, the osteopathic physician should con- palpated peripheral tissue texture char- he identified three or more of six sider dysfunctional homeostatic mecha- acteristics have the greatest influence on common diagnoses of somatic dysfunc- nisms and a range of perpetuating factors the osteopathic physician’s choice of an tion in 50% of this cohort (Table). Treat- (eg, postural decompensation), as well activating force for OMT. However, ment with OMT to eliminate the identi- as site-specific primary viscerosomatic sophistication in making this choice fied somatic dysfunctions resulted in reflexes (Figure 1). should improve as studies reveal how nearly 75% of the dysfunctional group Similarly, headache and neck pain differing manual forces affect mechanore- returning to work or to their other activ- have been extensively studied with ceptors and mechanonociceptors in the ities of daily living.39 respect to various somatic dysfunctions tensegrity-integrin model, spinal cord The present author has also noted and manual approaches.38,44,45 For gating mechanisms, and synaptic plas- that undiagnosed somatic dysfunctions, example, placebo-controlled diagnostic ticity.29-33 particularly “nonphysiologic dysfunc- investigations have documented the asso- tions” (eg, traumatically induced pelvic ciation of cervical pain with dysfunction Ⅵ Exemplars: Low Back Pain and shears), may result in several years of of zygapophyseal joints in patients who Headaches—The two best-documented persistent pain (either locally or at distant have whiplash injury.46 exemplars for application of structure- sites linked through compensatory mech- function approaches in diagnosis and anisms) or the development of MTrPs.42 Ⅵ Functional Demand and Somatic treatment of patients with persistent pain Dysfunction of one sacroiliac joint Perpetuating Factors—Functional symptoms are LBP and cervicogenic due to nonphysiologic pelvic shear forces demand plays a precipitating and/or headache.34-38 These two high-incidence greatly increases functional demand on perpetuating role in various persistent conditions are multifactorial, yet typi- the other sacroiliac joint and its stabi- pain disorders and recurrent somatic cally neuromusculoskeletal in origin, and lizing ligaments.42 Shears or compres- dysfunctions. Increased functional they each have great propensity for dis- sion at the pubic symphysis are common demand on somatic structures underlies ability. The evidence base is strongest in dysfunctions that can happen post- repetitive strain/sprain injuries, ranging these two regions for interexaminer reli- partum, after a fall, and after a missed from carpal tunnel syndrome in key- ability of STAR objective findings in pal- step.42 Yet, these dysfunctions are fre- board operators and poultry-processing patory diagnosis,34 as well as for mea- quently overlooked because the pain knife handlers47 to L5-S1 isthmic spondy- surable benefit from manual treatment associated with them is located in the lolisthesis in individuals who must stand in reducing pain and disability.35-38 Fur- frequently used sacroiliac joints. Pubic for extended periods.24,28 thermore, studies have identified a spe- shears restricting motion at the pubic Prolonged functional strain/sprain cific role for OMT in LBP manage- symphysis causes the two sacroiliac joints is known to activate fibroblast mechano- ment.14,39 to overwork and therefore be painful. chemical transduction, modulate gene

ES32 • JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 Kuchera • Applying Osteopathic Principles for Treatment of Patients With Chronic Pain expression patterns, and introduce inflammatory and tissue remodeling pro- Table cesses.31,48,49 In this fashion, persistent “Dirty Half-Dozen” Dysfunctions in Persistent Low Back Pain (PLBP) strain and/or pain patterns lead to peripheral structural pathologic change. Somatic Dysfunction (SD) SD in PLBP, % in PLBP (nϭ183)* Key Palpatory Findings†‡ Postural strain/sprain is among the most frequent of functional demand condi- Ⅺ Nonphysiologic pelvic 76 Palpatory “step off” between tions that create persistent pain from SD (pubic shears) pubic rami at the pubic musculoskeletal sources. symphysis; tenderness Inattention to ergonomics at work Ⅺ Nonphysiologic pelvic 15 (1) Iliac crest-ASIS-PSIS-ischial or play increases functional demand, SD (sacroiliac shears) tuberosity all elevated on one side; which can, in turn, perpetuate chronic or (2) dramatically inferior and or recurrent pain. Thus, osteopathic slightly posterior inferolateral sacral angle on the side of the deep physicians should review occupational sacral sulcus and personal biomechanical stressors as part of patient history. By providing edu- Ⅺ Sacral nutation failure 49 ϩ Sphinx test; ϩ Spring test cation to patients suffering from such (including nonneutral and (particularly painful with type II L5 SD backward sacral torsion SD) rotating in opposite direction from S1) discomfort, osteopathic physicians can better address persistent pain resulting from various prolonged activities, Ⅺ Pelvic tilt/”Short leg 63 After treatment ϩ standing combined Ϫ including holding a phone between ear with syndrome”/unlevel sacral base seated flexion tests; standing unlevel iliac crests and greater trochanters; and shoulder, using a keyboard with possible functional scoliosis improper seating relative to desk height, and falling asleep slumped forward in Ⅺ Muscle imbalance 90 Asymmetric muscle balance; psoatic ϩ a recliner. (including psoas syndrome) or scoliotic posturing; sharp tenderness over iliacus or psoas muscles Otherwise effective pain manage- ment strategies aimed at peripheral pain Ⅺ Type II lumbar SD 85 Typically a single lumbar segment generators often initially fail outright, or demonstrating F RxSx or E RxSx the pain generators will recur after these strategies if the presence of excessive * From Greenman PE. Syndromes of the lumbar spine, pelvis, and sacrum. Phys Med Rehabil Clin North Am. functional demand, postural imbalance, 1996;7:773–785. or other perpetuating factors are not con- † Note: In PLBP, patients had between three and six of these diagnoses; osteopathic manipulative sidered.27,50 Unfortunately, prior failure of treatment corrected 75%. ‡ ASIS indicates anterior superior iliac spine; PSIS, posterior superior iliac spine; F RxSx, E RxSx, where E pain management strategies may prompt indicates extension; R, rotation; S, side bending, and x, left or right. osteopathic physicians to eliminate such strategies from their rightful place among approaches to be considered in the early Body Unity Considerations: adding strategies designed to empower stages of treatment programs. Prior Tangible Impact of Persistent Pain the patient to modify environmental fac- failure of pain management strategies Although acute pain provides essential tors and cognitive processes associated may also cause physicians or patients to information for survival, persistent pain with the disability. Well-established dismiss the strategies later in treatment often results in anxiety, depression, and behavioral interventions, including programs, after complicating postural a reduction in the quality of life. Such patient education, are commonly used stress or adjacent dysfunctions have been body unity (or mind-body-spirit) effects in body unity approaches to managing addressed. of persistent pain can best be evaluated chronic disabling pain. Timing, tissue response, and multi- by carefully performing a traditional factorial conditions within the body unit patient history and physical examina- Ⅵ Mind-Body Unity and Persistent affect OMM treatment strategies that are tion, supplemented by palpation. The Pain—Chronic persistent pain is not prompted by applying the structure-func- resulting findings can provide diagnostic simply acute pain that has lasted a long tion principle. These conditions can both clues, as well as targets of opportunity, to time. Positron emission tomography affect and be affected by other portions of reduce precipitating, perpetuating, and scans of the brains of patients with the proposed algorithm (Figure 1). Phys- magnifying factors associated with per- chronic neuropathic pain reveal a shift ical examination of patients with persis- sistent pain. of acute pain activity from the sensory tent pain must go beyond identification of Discovery of a body unity dysfunc- cortex to regions associated with affec- peripheral pain generators and screening tion in a patient with chronic pain often tive-motivational processing, such as the for other perpetuating causes of pain. A shifts the treatment focus from simply anterior cingulate gyrus.51 For this reason, properly constructed OMM approach identifying and removing the underlying patients with chronic pain often attempt rarely focuses on only one principle. organic disease (ie, pain generator) to to describe their “suffering” and its

Kuchera • Applying Osteopathic Principles for Treatment of Patients With Chronic Pain JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES33 impact on their lives, rather than simply gies with patients for reducing mental, thetic activity need not accompany SMP. providing a location and quality descrip- spiritual, and emotional pain. Thus, although SMP syndromes tion of their pain. (including complex regional pain syn- An osteopathic palpatory examina- Persistent Pain, dromes) are often relieved by sympa- tion will also aid physicians in eliciting a Somatic Dysfunction, and thetic ganglion blocks,64 persistent pain thorough chronic pain history of a patient Homeostatic Responses with lesser SMP may be addressed by by helping to gain the patient’s trust.2 Various homeostatic coping and regu- using OMT to manage somatic dysfunc- An integrated patient history is essential lating mechanisms influence the physi- tion and modulate hypersympathetic in determining the impact of pain on ologic processes responsible for main- activity.65 physical, mental, emotional, and spiri- taining pain.58-60 Homeostasis may be Modulation of hypersympathotonia tual functions unique to each individual. altered through focused biochemical, bio- has been linked to pain reduction,66 Physician training for understanding electrical, neuroendocrine, and/or psy- enhanced healing rates,67 and improve- patients’ physical limitations (the most chosympathetic mechanisms that affect ment in a variety of visceral and somatic obvious manifestations of persistent pain) specific structures or target receptors. functions.68 This modulation is a hall- is part of standard medical education. Furthermore, an integrated series of mark effect of the OMM approach and However, nonphysical limitations in the homeostatic mechanisms may provide warrants consideration in conditions mental and emotional realms are less for panstructural biomechanical changes, characterized by chronic pain. often articulated by patients and, there- such as shifting weight-bearing respon- fore, greater effort is required by physi- sibilities away from painful sites. This Ⅵ Respiratory-Circulatory Homeostasis cians to recognize these limitations. process creates easily recognizable pat- Role in Pain—Controlled breathing Consideration by osteopathic physi- terns associated with certain pain syn- (ie, focused respiration) and relief of pain cians of mind-body connections in dromes. have long been linked. The ancient Chi- patients with persistent pain closely par- Osteopathic manipulative treatment nese prescribed controlled breathing for allels biopsychosocial models embraced has long been noted to produce inde- reducing arthritic pain,69 while lay and by multidisciplinary pain clinics.52 In pendent beneficial effects on certain auto- professional people in modern times such models, chronic pain is a frequent, nomic, circulatory, neuroendocrine, pos- have used it to reduce the pain of labor well-established cause of depression, tural, and respiratory mechanisms.61 and delivery.70 Beyond the mind-body impacting both the central and auto- Therefore, it is rational to consider that effect of focused respiration as used in nomic nervous systems.53 Furthermore, influencing these mechanisms may also meditation and in lowering blood pres- these models empirically recognize that have a beneficial impact on pain modu- sure, heart rate, and pain perception, the physical pain and connective tissue plas- lation, as depicted in Figure 4. respiratory-circulatory model popular- ticity mechanisms may be temporally ized by Zink and Lawson71 is character- linked to anger, fear, or loss.53-55 An Ⅵ Autonomic System Homeostasis: ized by reduction of edema and associ- example of this connection is pain that Pain and Osteopathic Manipulative ated peripheral biochemical molecules was traumatically introduced in an indi- Medicine—The importance of sympa- linked to nociception. vidual during a traffic accident when thetic nervous system involvement in Treatment goals associated with the there was enough time to hopelessly certain forms of neuropathic pain led to Zink-Lawson respiratory-circulatory anticipate the oncoming car’s approach. a taxonomic classification distinguishing model71 are traditionally administered Both fascial dysfunction and emotions sympathetically maintained pain (SMP) in the following sequence: associated with the physical injury serve from sympathetically independent pain Ⅺ 1. Opening fascial pathways. Somatic to anchor pain in such individuals, who (SIP).62,63 Sympathetically maintained dysfunction associated with fascial may require additional counseling to pain, defined as “pain attributable to restriction to fluid flow is corrected with deal with subsequently expressed non- sympathetic efferent function in periph- OMT at four regional transition zones of physical factors. eral tissues,”63 is abolished when sym- the body. Conversely, hands-on management pathetic supply to a painful region is Ⅺ 2. Maximizing primary-secondary of somatic dysfunction offers osteopathic modulated by manipulative techniques. respiration. Effective, deep synchronized physicians a unique and often valuable In contrast, SIP is not dependent on sym- respiration is sought using a variety of access to patients’ mind-body connec- pathetic efferent function and, thus, it is osteopathic manipulative techniques, tions. Effects of OMT are occasionally less likely to be affected by manipula- including doming of the thoracoab- dramatic, as in the catharsis effect of cer- tive techniques affecting the sympathetic dominopelvic diaphragms. tain somatoemotional releases56 or the nervous system. Ⅺ 3. Augmenting lymphaticovenous beneficial effects of the Fulford percus- The classification of SMP and SIP drainage. Homeostatic OMT is applied sion hammer technique in patients with dissociates the presence of pain from (often using one or more rhythmic lym- chronic posttraumatic dysfunctions.57 gross signs of sympathetic dysregulation phaticovenous pumps) to effect pressure Treatment of patients with somatic dys- (eg, altered temperature, excessive changes between the thorax and adja- function often offers opportunities for sweating, trophic changes), so that cent regions. Recent literature suggests osteopathic physicians to discuss strate- obvious evidence of abnormal sympa- that such rhythmic motion may also have

ES34 • JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 Kuchera • Applying Osteopathic Principles for Treatment of Patients With Chronic Pain Expansion of Biopsychosocial Model Touch-Stress Reduction Basilar Decompression–CV 4

Sympathetic Model Parasympathetic Model

Collateral ganglion inhibition III: Inion BMT; SBS Paraspinal inhibition VII: Sphenopalatine Thoracolumbar/costal OMT ganglion OMT Rib raising OMT Respiratory–Circulatory IX–X: OA-AA-C2A, Soft tissue OMT (Venous Lymphatic) Model occipitomastoid Open fascial pathways at Pelvic Splanchnics: SI joint transition zones Redome thoracoabdominal diaphragms Lymphaticovenous pumps Mobilize peripheral edema

Figure 4. Sample osteopathic manipulative treatment (OMT) protocols for enhancing homeostatic responses. Abbreviations: CV 4 indicates compression of the fourth ventricle; BMT, balanced membranous tension; SBS, sphenobasilar synchondrosis; IX-X, glossopharyngeal and vagus cranial nerves; OA-AA-C2, occipitoatlantal, atlantoaxial, and second cervical vertebral units; SI joint, sacroiliac joint. a beneficial effect on increasing release of unlevel cranial base, unlevel sacral base). sometimes an appropriate orthotic reg- endothelial nitric oxide synthetase, a Travell and Simons26 note that postural imen.28 In addition, the Zink-Lawson res- homeostatic molecule.44,72 decompensation is the most common piratory-circulatory approach71 is appli- Ⅺ 4. Enhancing cellular level health. precipitating and perpetuating cause of cable in preparing tissues for postural Local tissue techniques (eg, effleurage) MTrPs. These MTrPs are implicated in homeostasis because of a biologic ten- are used to mobilize local edema. many chronic pain syndromes, ranging dency to compensate for postural imbal- Deep breathing creates obvious from LBP and headaches to carpal tunnel ance at regional transition zones. motion in at least 136 joints and is pal- syndrome, temporomandibular joint dys- The following anecdotal case pable in all body tissues.73 It is a contin- function, and pain perceived as angina.27 vignette typifies presentation of a patient uous movement with active and passive Pain associated with postural stress who seeks treatment for chronic back components. Through tensegrity rela- and strain can be sclerotomal (ie, pos- pain. tionships, the patient or osteopathic tural ligaments) or myotomal (ie, pos- physician can focus deep breathing to tural muscles). It can also have a signifi- Case Presentation remove motion restrictions or engage cant role in radiculopathies associated Chuck, a 45-year-old farmhand, was seen in neuromuscular reflexes to achieve tight- with osteoarthritic and discogenic con- the clinic with the chief complaint of chronic ening or relaxation of selected tissues.73 ditions.50 Irvin74 demonstrated that back pain for 3 years. This discomfort, present chronic pain throughout the body could on his right side, was described as deep, nag- Ⅵ Postural Homeostasis in Pain and be attributed to an unlevel sacral base, ging, and constant, with periods of acute Dysfunction—Chronic or recurrent pain and reestablishing postural homeostasis exacerbation into the right hip, groin, and syndromes have been linked to condi- removed most of the symptoms. down the back of the leg to just above the tions predisposing patients to postural The OMM approach to postural care knee. Full symptoms would occur with pro- stress (eg, altered lordotic-kyphotic is described thoroughly in Foundations longed walking or standing and would per- curves, lower extremity asymmetry, pos- for Osteopathic Medicine and consists of sist for several weeks. The patient was unable tural muscle imbalance, scoliotic changes, patient education, OMT, exercise, and to lift more than 25 pounds (11 kg) without

Kuchera • Applying Osteopathic Principles for Treatment of Patients With Chronic Pain JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES35 aggravating his symptoms. His back took springing technique to the right sacral shear, factors directed toward both the under- several hours to fully relax after lying down, to the iliacus and piriformis lying cause and tangible impact of per- even on “good” days. tender points, and indirect balanced liga- sistent discomfort in patients. These prin- Pain onset had first occurred while the mentous tension to the thoracolumbar and ciples provide a framework for patient patient carried a small bale of hay in front of sacral regions. Fascial patterns were treated education to foster compliance built on his body. He had stepped in an unseen pothole, with high velocity low amplitude (HVLA) an understanding of complex interrela- stumbled, and fell. The next day, he noticed techniques aimed toward symmetry, and tionships among many different factors. full symptoms, which persisted as recurring abdominal and pelvic diaphragms were treated Each osteopathic prescription seeks episodes for several months. Between and with indirect and direct myofascial release, to discover and incorporate those factors during episodes, he achieved only partial relief respectively. Post-OMT iliac crest heights needed to address a patient’s unique with ibuprofen (800 mg/d). Physical therapy and flexion measurements were normal. The response to pain. The emphasis in reportedly aggravated his pain. patient left with instructions to drink lots of treating patients who have persistent During the next 3 years, the patient vis- fluid, switch to acetaminophen as needed, nonmalignant pain should be on ited several physicians, visits that were avoid jumping or lifting until his next visit, improving function, decreasing periph- prompted by three to four substantial recur- and return in 1 week for follow-up examina- eral nociception and central facilitation, rences of pain radiation per year. Negative tion. and empowering individuals to move results from electromyographic, magnetic res- At 1-week follow-up, the patient noted forward in resuming their normal activ- onance imaging, and radiographic studies— that both his acute and nagging pains had ities of daily living. coupled with negative results from tests of been relieved for nearly 4 days, but mild nag- When osteopathic principles and reflex changes and nonspecific, nonradicular ging pain had since recurred. A recurrence of practice are actively applied to create a patterns of muscle weakness—during these 3 sacral shear (approximately 40% of original) treatment plan for a patient with chronic years left the patient with no specific diagnosis and piriformis muscle dysfunction were also pain, the result is a personalized, effective beyond “low back pain with recurrent lum- noted and re-treated with OMT. Two weeks care plan typically combining nonphar- bosacral sprain.” later, the patient returned with no symptoms macologic treatment strategies with Chuck was unable to work on the farm and no recurrence of pain. He was instructed appropriate types and levels of pharma- and said that he had the impression that physi- to make an appointment for 1 month later, but cotherapy. The inclusion of patient edu- cians believed he was “malingering,” or to cancel the appointment if he remained cation in a comprehensive treatment plan “lazy.” He was depressed because he thought symptom-free. He phoned 1 month later, helps to improve quality of life and to his family also shared these beliefs, and he reporting that he was without pain and able break the vicious cycle resulting from became concerned about his marriage. to function normally at home. pathophysiologic mechanisms of persis- Clinical findings revealed a slim white tent pain. man who denied smoking or illicit drug use. Comment Review of his nonmusculoskeletal systems Persistent nonmalignant pain is not a References 1. Elliott AM, Smith BH, Hannaford PC, Smith WC, was noncontributory. Results of deep tendon single entity. It has many different causes Chambers WA. The course of chronic pain in the reflexes, pathologic reflexes, straight leg- and manifestations, each with varied community: results of a 4-year follow-up study. raising testing, Chapman’s viscerosomatic characteristics and names. In OMM, a Pain. 2002;99:299-307. reflex screen, and Lloyd’s kidney punch were complete patient history and physical 2. Stanton DF, Dutes J-C. Chronic pain and the all negative. The result for a Trendelenburg examination are used to reveal any pre- chronic pain syndrome: the usefulness of manipu- lation and behavioral interventions. Phys Med test (a test to determine any weakness of hip viously unidentified pain generator or Rehabil Clin North Am. 1996;7:863-875. abductors) of the right leg was questionable. underlying cause for persistent pain. In 3. Turk DC, Rudy TE. Neglected topics in the treat- Somatic dysfunction included reduced lumbar addition, osteopathic physicians often ment of chronic pain patients—relapse, noncom- lordosis, left iliacus tender point, right sacral screen patients for signs of depression pliance, and adherence enhancement. Pain. shear, and tenderness over the right iliolumbar or other significant nonphysical links 1991;44:5-28. ligament and posterior sacroiliac ligament, contributing to pain. Based on OMM 4. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alterna- as well as tenderness and hypertonicity in patient histories and examinations, osteo- tive medicine use in the United States, 1990-1997: the right piriformis muscle. Flexion tests and pathic physicians can develop individ- results of a follow-up national survey. JAMA. measurements of iliac crest height suggested ualized osteopathic prescriptions to 1998;280:1569-1575. a possible “short leg syndrome.” The common address their findings, with the goal of 5. Oken BS. Complementary and alternative medicine: overview and definitions. In: Oken BS, ed. compensatory pattern noted by Zink and decreasing biomechanical and biochem- Complementary Therapies in Neurology: An Evi- 71 Lawson was violated by the lumbopelvic ical stressors and empowering patients to dence-Based Approach. New York, NY: The junction, and the pelvic floor was tight. The reduce the impact of persistent pain on Parthenon Publishing Group; 2004:1-7. patient was informed that this constellation quality of life. 6. Rakel B, Barr JO. Physical modalities in chronic of somatic dysfunction could cause chronic In addition to providing appropriate pain management. Nurs Clin North Am. 2003;38:477-494. low back pain that often responded favorably strategies for management of pain, the to OMT.39 OMM pain management algorithm 7. Chen H, Lamer TJ, Rho RH, Marshall KA, Sitzman BT, Ghazi SM, et al. Contemporary management of Osteopathic manipulative treatment incorporates osteopathic principles to neuropathic pain for the primary care physician. given to the patient consisted of applying the identify and address a variety of host Mayo Clin Proc. 2004;79:1533-1545.

ES36 • JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 Kuchera • Applying Osteopathic Principles for Treatment of Patients With Chronic Pain 8. Berman BM. Integrative approaches to pain Dorman T, ed. Spine: State of the Art Reviews. and best evidence synthesis [review]. Spine J. 2004; management: how to get the best of both worlds. Philadelphia, Pa: Hanley & Belfus; 1995:463-490. 4:335-356. BMJ. 2003;326:1320-1321. Available at: http://www.bmj.com/cgi/content/full/326/7402/1320- 25. Kuchera ML, McPartland J. Myofascial trigger 39. Greenman PE. Syndromes of the lumbar spine, a. Accessed September 11, 2007. points as somatic dysfunction. In: Ward RC, ed. pelvis, and sacrum. Phys Med Rehabil Clin North Foundations for Osteopathic Medicine. 2nd ed. Am. 1996;7:773-785. 9. http://nccam.nih.gov/health. Baltimore, Md: Lippincott, Williams & Wilkins; 2003:1034-1050. 40. Ongley MJ, Klein RG, Dorman TA, Eek BC, 10. http://nccam.nih.gov. Hubert LJ. A new approach to the treatment of 26. Travell JG, Simons DG. Myofascial Pain and chronic low back pain. Lancet. 1987;2:143-146. 11. http://nccam.nih.gov/health/decisions/. Dysfunction. The Trigger Point Manual. Vol 2. Bal- timore, Md: Williams & Wilkins; 1992:168-185. 41. Mein EA. Low back pain and manual medicine: 12. http://nccam.nih.gov/health/bacgrounds a look at the literature [review]. Phys Med Rehabil /manipulative.htm. 27. Simons DG, Travell JG, Simons LS. Travell and Clin North Am. 1996;7:715-729. 13. Andersson GB, Lucente T, Davis AM, Kappler Simons’ Myofascial Pain and Dysfunction: The 42. Kuchera WA, Kuchera ML. Osteopathic Prin- RE, Lipton JA, Leurgans S. A comparison of osteo- Trigger Point Manual, Volume 1: Upper Half of ciples in Practice. 2nd ed. Columbus, Ohio: Greyden pathic spinal manipulation with standard care for the Body. 2nd ed. Baltimore, Md: Lippincott, Press; 1994:463-512. patients with low back pain [published correction Williams & Wilkins; 1999. appears in N Engl J Med. 2000;342:817]. N Engl 28. Kuchera ML. Postural considerations in coronal, 43. Blomberg S. A Pragmatic Approach to Low- J Med. 1999;341:1426-1431. Available at: http:// horizontal, and sagittal planes. In: Ward RC, ed. Back Pain Including Manual Therapy and Steroid content.nejm.org/cgi/content/full/341/19/1426. Foundations for Osteopathic Medicine. 2nd ed. Injections: A Multicentre Study in Primary Health Accessed September 11, 2007. Baltimore, Md: Lippincott, Williams & Wilkins; Care [dissertation]. Uppsala, Sweden: Faculty of Medicine, Acta Universitatis Upsaliensis; 1993. 14. Licciardone JC, Brimhall AK, King LN. Osteo- 2003:603-632. pathic manipulative treatment for low back pain: 29. Ingber DE, Heidemann SR, Lamoureux P, 44. Kuchera ML. Osteopathic considerations in a systematic review and meta-analysis of random- Buxbaum RE. Opposing views on tensegrity as a neurology. In: Oken BS, ed. Complementary Ther- ized controlled trials. BMC Musculoskelet Disord. structural framework for understanding cell apies in Neurology: An Evidence-Based Approach. 2005;6:43. Available at: http://www.pubmedcen mechanics. J Appl Physiol. 2000;89:1663-1678. Avail- New York, NY: Parthenon Publishing Group; tral.nih.gov/articlerender.fcgi?tool=pubmed&pub able at: http://jap.physiology.org/cgi/content/full 2000:51-93. medid=16080794. Accessed September 11, 2007. /89/4/1663. Accessed September 11, 2007. 45. Kuchera ML. Osteopathic principles and prac- 15. Licciardone J, Gamber R, Cardarelli K. Patient 30. Ingber DE, Dike L, Hansen L, Karp S, Liley H, tice/osteopathic manipulative treatment consider- satisfaction and clinical outcomes associated with Maniotis A, McNamee H, Mooney D, Plopper G, ations for cephalgia. J Am Osteopath Assoc. osteopathic manipulative treatment. JAm Sims J et al.: Cellular tensegrity: exploring how 1998;98(4 suppl):S14-S19. Osteopath Assoc. 2002;102:13-20. Available at: mechanical changes in the cytoskeleton regulate http://www.jaoa.org/cgi/reprint/102/1/13. Accessed 46. Lord SM, Barnsley L, Wallis BJ, Bogduk N. cell growth, migration, and tissue pattern during September 11, 2007. Chronic cervical zygapophyseal joint pain after morphogenesis. Int Rev Cytol. 1994;150:173-224. whiplash: a placebo controlled prevalence study. 16. Mense S, Simons DG. Muscle Pain: Under- 31. Chen CS, Ingber DE. Tensegrity and Spine. 1996;21:1737-1744. standing the Nature, Diagnosis, and Treatment. mechanoregulation: from skeleton to cytoskeleton Philadelphia, Pa: Lippincott, Willliams & Wilkins; 47. Fagarasanu M, Kumar S. Work-related carpal [review]. Osteoarthritis Cartilage. 1999;7:81-94. 2001. tunnel syndrome: current concepts. J Musculoskel Res. 2003;7:87-96. 17. Patterson MM, Steinmetz JE. Long-lasting 32 Boal RW, Gillette RG. Central neuronal plas- alterations of spinal reflexes: a basis for somatic dys- ticity, low back pain and spinal manipulative 48. Dodd JG, Good MM, Nguyen TL, Grigg AI, function. Manual Med. 1986;2:38-42. therapy [review]. J Manipulative Physiol Ther. Batia LM, Standley PR. In vitro biophysical strain 2004;27(5):314-326. model for understanding mechanisms of osteo- 18. Mantyh PW, DeMaste E, Malhotra A, Ghilardi pathic manipulative treatment. J Am Osteopath JR, Rogers SD, Mantyh CR, et al. Receptor endocy- 33. Pickar JG. Neurophysiological effects of spinal manipulation. Spine J. 2002;2(5):357-371 Assoc. 2006;106:157-166. Available at: http://www. tosis and dendrite reshaping in spinal neurons jaoa.org/cgi/content/full/106/3/157. Accessed after somatosensory stimulation. Science. 34. Seffinger M, Adams A, Najm W, Dickerson V, October 29, 2007. 1995;268:1629-1632. Mishra SI, Reinsch S, et al. Spinal palpatory diag- 49. Langevin HM, Sherman KJ. Pathophysiolog- 19. Woolf CJ, Salter MW. Neuronal plasticity: nostic procedures utilized by practitioners of spinal manipulation: annotated bibliography of content ical model for chronic low back pain integrating increasing the gain in pain. Science. 2000;288:1765- connective tissue and nervous system mechanisms. 1768. validity and reliability studies. J Can Chiroprac Assoc. 2003;47:93-109. Med Hypotheses. 2007;68(1):74-80. Epub August 21, 20. Loeser JD, Melzack R. Pain: an overview. Lancet. 2006. 1999;353:1607-1609. 35. van Tulder MW, Koes BW, Bouter LM. Con- servative treatment of acute and chronic nonspe- 50. Kuchera ML. Treatment of gravitational strain 21. Special Committee on Osteopathic Principles cific low back pain. A systematic review of ran- pathophysiology. In: Vleeming A, Mooney V, Sni- and Osteopathic Technic, Kirksville College of domized controlled trials of the most common jders C, Stoeckert R, eds. Movement, Stability and and Surgery. Interpretation of the interventions [review]. Spine. 1997;22:2128-2156. Low Back Pain: The Essential Role of the Pelvis. osteopathic concept prepared by committee at New York, NY: Churchill Livingstone; 1997:477- Kirksville. J Osteopath. October 1953;60:7-10. 36. Giles LGF, Muller R. Chronic spinal pain: a ran- 499. domized clinical trial comparing medication, 22. Willard FH. Nociception, the neuroendocrine acupuncture, and spinal manipulation. Spine. 51. Hsieh JC, Belfrage M, Stone-Elander S, Hansson immune system, and osteopathic medicine. In: 2003;28:1490-1502. P, Ingvar M. Central representation of chronic Ward RC, ed. Foundations for Osteopathic ongoing neuropathic pain studied by positron Medicine. 2nd ed. Baltimore, Md: Lippincott, 37. Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, emission tomography. Pain. 1995;63:225-236. Williams & Wilkins; 2003:137-156. Shekelle PG. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness rela- 52. Golden BA. A multidisciplinary approach to 23. Educational Council on Osteopathic Principles. tive to other therapies [review]. Ann Intern Med. nonpharmacologic pain management. JAm Glossary of osteopathic terminology. In: Ward RC, 2003;138:871-881. Available at: http://www.annals Osteopath Assoc. 2002;102(suppl 3):S1-S5. Avail- ed. Foundations for Osteopathic Medicine. 2nd .org/cgi/reprint/138/11/871.pdf. Accessed September able at: http://www.jaoa.org/cgi/reprint/102 ed. Baltimore, Md: Lippincott, Williams & Wilkins; 11, 2007. /9_suppl/1S. Accessed October 29, 2007. 2003:1229-1253. 38. Bronfort G, Haas M, Evans R, Bouter LM. Effi- 53. Magni G, Marchetti M, Moreschi C, Merskey H, 24. Kuchera ML. Gravitational stress, muscu- cacy of spinal manipulation and mobilization for Luchini SR. Chronic musculoskeletal pain and loligamentous strain and postural alignment. In: low back pain and neck pain: a systematic review depressive symptoms in the National Health and

Kuchera • Applying Osteopathic Principles for Treatment of Patients With Chronic Pain JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES37 Nutrition Examination. I. Epidemiologic follow-up 61. Kuchera ML, DiGiovanna EL, Greenman PE. 68. Kuchera ML, Kuchera WA. Osteopathic Con- study. Pain. 1993;53:163-168. Efficacy and complications. In: Ward RC, ed. Foun- siderations in Systemic Dysfunction. 2nd ed. dations for Osteopathic Medicine. 2nd ed. Balti- Columbus, Ohio; Greyden Press; 1994. 54. Sullivan M, Thorn B, Haythornthwaite J, Keefe more, Md: Lippincott, Williams & Wilkins; 2003: F, Martin M, Bradley L, et al. Theoretical perspec- 1143-1152. 69. Taylor SK. Tai Chi for chronic pain and arthritis. tives on the relation between catastrophizing and Techniques in Orthopaedics. 2003;18(1):110-114. pain [review]. Clin J Pain. 2001;17:52-64. 62. Roberts WJ. A hypothesis on the physiolog- ical basis for causalgia and related pain. Pain. 70. Niven CA, Gijsbers K. Coping with labor pain. 55. Hamilton NA, Karoly P, Kitzman H. Self-regu- 1986;24:297-311. J Pain Symptom Manage. 1996;11(2):116-125. lation and chronic pain: the role of emotion. Cogn Ther Res. 2004;28:559-576. 63. Campbell JN, Raja SN, Selig DK, Belzberg AJ, 71. Zink JG, Lawson WB. An osteopathic struc- Meyer RA. Diagnosis and management of sympa- tural examination and functional interpretation 56. Comeaux Z. Facilitated oscillatory release—a thetically maintained pain. In: Fields HL, Liebeskind of the soma. Osteopath Ann. 1979;7:12-19. dynamic method of neuromuscular and ligamen- JC, eds. Progress in Pain Research and Manage- 72. Salamon E, Zhu W, Stefano G. Nitric oxide as tous/articular assessment and treatment. J Body- ment. Vol 1. Seattle, Wash: IASP Press; 1994:85- work Movement Ther. 2005;9:88-98. a possible mechanism for understanding the ther- 100. apeutic effects of osteopathic manipulative 57. Koss RW, Stoll ST, Simmons SL. Introduction to 64. Bonica JJ, Causalgia and other reflex sympa- medicine. Int J Mol Med. 2004;14:443-449. the Fulford percussion vibrator hammer approach. thetic dystrophies. In: Bonica JJ, Liebeskind JC, 73. Lewit K. Manipulative Therapy in Rehabilita- Phys Med Rehabil: State of the Art Rev. Albe-Fessard D, eds. Advances in Pain Research tion of the Motor System. London, England: But- 2000;14:151-161. and Therapy. Vol 3. New York, NY: Raven Press; terworths; 1985:35-38. 1979:141-166. 58. Sterling P, Eyer J. Allostasis: a new paradigm 74. Irvin RE. Suboptimal posture: the origin of the to explain arousal pathology. In: Fisher S, Reason 65. Van Buskirk RL. Nociceptive reflexes and the majority of idiopathic pain of the musculoskeletal J, eds. Handbook of Life Stress, Cognition and somatic dysfunction: a model. J Am Osteopath system. In: Vleeming A, Mooney V, Snijders C, Health. New York, NY: John Wiley & Sons; Assoc. 1990;90:792-794,797-809. Available at: Stoeckert R, eds. Movement, Stability and Low 1988:629-649. http://www.jaoa.org/cgi/reprint/90/9/792. Accessed Back Pain: The Essential Role of the Pelvis. New September 11, 2007. 59. Seeman TE, Singer BH, Rowe JW, Horwitz RI, York, NY: Churchill Livingstone; 1997:133-155. McEwen BS. Price of adaptation—allostatic load 66. Schwartzman RJ, Maleki J. Postinjury neuro- and its health consequences: McArthur studies of pathic pain. Med Clin North Am. 1999;83(3):597- successful aging [published correction appears in: 626. Arch Intern Med. 1999;159:1176]. Arch Intern Med. 1997;157:2259-2268. 67. Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R. Psychoneuroimmunology and psychosomatic 60. McEwen BS. Protective and damaging effects medicine: back to the future [review]. Psychosom of stress mediators. N Engl J Med. 1998;338:178-179. Med. 2002;64:15-28.

ES38 • JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 Kuchera • Applying Osteopathic Principles for Treatment of Patients With Chronic Pain