Osteopathic Manipulative Medicine for Inflammatory Skin Diseases

J. Hibler, DO,* Jessie Perkins, DO,** David Eland, DO, FAAO,*** Dawn Sammons, DO, FAAO****

*Dermatology Resident, 2nd Year, O’Bleness Memorial Hospital, Athens, OH **Traditional Osteopathic Intern, Largo Medical Center, Largo, FL ***Attending Physician, University Medical Associates, Athens, OH ****Program Director, Dermatology Residency Program, O’Bleness Memorial Hospital, Athens, OH

Abstract Osteopathic manipulative medicine (OMM) is a defining feature of osteopathic physician training and can be used in practically all areas of medicine. While the use of OMM by osteopathic-trained physicians continues to decline, its use will be an important feature that distinguishes DOs from their allopathic counterparts as osteopathic and allopathic training programs come to be governed by a unified body. Even in dermatology, OMM can be a useful tool for numerous disorders. We present several different OMM techniques that can be used for inflammatory skin diseases. their level of post-graduate training.2 In another we propose the use of manipulative medicine in Introduction The planned emergence of the Unified survey-based study, dermatologists reported the treatment of inflammatory skin disease. Accreditation System in 2015, a merger zero use of OMM, citing a variety of reasons for between the American Osteopathic Association not incorporating OMM into their daily practice Discussion 3 The skin is the primary interface between the (AOA) and the Accreditation Council for (Table 1). It was found that specialists were environment and the body, making it the initial Graduate Medical Education (ACGME), most likely to avoid performing OMM due to defense against insults like radiation, heat, has created numerous obstacles for virtually barriers in use, practice protocols, attitudes microbial invasion and trauma. When these the entire medical community. These recent toward OMM, and deficiencies in training. organizational changes to graduate medical Table 1. Reasons for decreased use of OMM by osteopathic physicians and specialists.3 education in the United States will undoubtedly affect how osteopathic post-graduate medical Barriers to OMM Use Example(s) training is conducted. Whether in primary care Practice protocols Exam-room size constraints, lack of administration support or in specialty medicine such as dermatology, preserving the identity of the osteopathic Lack of emphasis in Use of video/online tutorials instead of hands-on training profession will likely be a challenge as these post-graduate training programs merge. Osteopathic dermatologists Time constraints Some OMM techniques may take 30 minutes or more are in a special position to promote osteopathic Procedure-based Mohs, dermatopathology manipulative medicine (OMM) because specialties numerous dermatologic disease processes can Decreased practical Lack of use reduces comfort with techniques be treated with manual therapies. This review focuses on inflammatory skin diseases that can exposure be treated with OMM. Included here is also Attitudes toward OMT Belief that technique may not be useful a brief review of the basic techniques used in With the Unified Accreditation System, the insults occur, cutaneous inflammation arises, a OMM. 5 instruction in and use of OMM in specialty result of an innate and adaptive immune system. Table 2 summarizes a variety of cutaneous Background medicine is in danger of even further decline. Also known as osteopathic manipulative However, all osteopathic dermatologists do inflammatory processes by the primary cause of treatment (OMT), OMM is based on an have the training and potential to perform most inflammation. understanding of the musculoskeletal system’s of these techniques, especially for reduction One of the four primary principles of osteopathy role in local and systemic fluid management of tissue congestion and inflammation due to states that the body has a propensity for self- and tissue mobility, as well as its influence, via inflammatory skin diseases. healing and is capable of homeostasis and 6 the nervous system, on pain, proprioception Despite the decline in use of manipulative health maintenance. While medications such and autonomic elements. The core techniques medicine, it remains a potential adjunct in treating as antibiotics for bacterial infection and steroid- of OMM utilize these relationships between the internal as well as cutaneous disease. Some sparing immune-modulating medications for musculoskeletal system and other body systems. manual- and physical-medicine techniques, such psoriasis remain the mainstay of treatment, The use of OMM, regardless of specialty, has as compression wrapping for stasis dermatitis manipulative medicine offers a supplementary 7 been declining for the past several decades. In and scar massage for scarring, are used widely. approach to treatment. For example, rib raising dermatology, it is hardly used at all. One survey Campbell et al. promoted the use of OMT for is a technique used to normalize or reduce found that half of all responding osteopathic dysethesia syndromes, hyperhydrosis and stasis autonomic output to blood and lymphatic vessels. physicians used OMT on less than 5% of their dermatitis using the rationale that alteration of Normalization of this output can enhance blood patients.1 Spaeth et al., focusing on osteopathic the underlying pathophysiologic mechanisms and lymphatic flow to areas of trauma, infection physicians in Ohio, found a negative correlation can alter and possibly prevent the disease or stress, supporting the healing process. It may between osteopathic physicians’ OMM use and processes.4 It is under this same rationale that also help with delivery of medication to these areas where tissue congestion is often found.

HIBLER, PERKINS, ELAND, SAMMONS Page 11 Table 2: Inflammatory skin conditions by primary cause. in inflammatory skin disease is release of the diaphragms, including the abdominal diaphragm Primary Cause Condition and the thoracic inlet. A flattened diaphragm is Infectious ·Bacterial (cellulitis, abscess formation, acne) less effective as a lymphatic pump. Myofascial ·Fungal (kerion) release of the diaphragm allows the diaphragm ·Viral (herpetic lesions, Molluscum contagiosum, Verruca vulgaris) to move more efficiently, maximizing its potential as a lymphatic pump through improved Autoimmune ·Psoriasis intrathoracic pressure changes.8 The thoracic ·Systemic lupus erythematosus inlet is considered the endpoint of lymph flow as it reaches the venous system; the lymphatic Idiopathic/Other ·Brachioradial pruritus system is a low-pressure system in which flow ·Notalgia paresthetica can be interrupted or impeded by changes in fascial tension. Congestion in this area will cause ·Raynaud’s phenomenon end resistance to lymphatic flow even when Osteopathic manipulative medicine has two indirect treatment. Indirect methods disengage all other areas of lymph flow are adequate.8,9 main branches of techniques: direct and indirect. the restrictive barrier, placing the dysfunctional Myofascial release is often considered the Direct treatments engage a restrictive barrier, body part in a state of ease in all directions until primary step in correcting lymphatic drainage and a final activating force is applied to correct tissue tension is equal, thus potentially taking and should be done in conjunction with other the somatic dysfunction.8 Types of direct the tension off the lymphatic vessels in the area lymphatic treatments. treatments include muscle energy, HVLA, rib of treatment. Indirect treatments also include Recently, lymphatic-pump techniques have been raising and myofascial release. counterstrain. shown to enhance the lymphatic and immune Myofascial release can also be accomplished via An example of myofascial release that may aid systems through increase of lymph flow and re-

Table 3. OMT techniques and their potential benefits in inflammatory skin disease.8,9 Treatment Type Mechanism of Action Therapeutic Benefits Contraindications Myofascial Release Direct or indirect; tissue is guided Promotion of balanced, homeostatic Open wounds, recent surgery, deep to a point of maximal restriction equilibrium and decreased venous thrombosis, neoplasms or with constant force until release resistance internal injury is achieved, or is guided along the path of least resistance until release is achieved Lymphatic Techniques Group of techniques employed to Decreased resistance to lymphatic Relative: cancer ·Effleurage encourage movement of lymphatic and venous flow; mobilization of Absolute: coagulopathy (e.g., ·Pedal pump fluid local congestion, encouraging re- deep venous thrombosis), chronic entry into circulation infections or infections with risk of reactivation (e.g., tuberculosis) Counterstrain Indirect; patient is placed in a point Relief of identified tender point, Ligamentous or tendinous tears, of ease that lessens the identified encouraging patient comfort fracture tender point by greater than 70% and is held in that position for 90- 120 seconds Rib Raising Direct technique; physician Prolonged reduction in sympathetic Anuria, necrotizing fasciitis applies slow, methodical pressure tone after initial SNS stimulation, anteriorly and laterally on the rib encouraging increased blood and angles while encouraging caudal lymphatic flow motion High Velocity-Low Amplitude Direct; a rapid force carries a joint Increased range of motion, Severe osteoporosis, metastatic or through the restrictive barrier decreased pain bone cancer, cervical rheumatoid within the anatomic range of arthritis, fracture, carotid or motion vertebrobasilar disease Muscle Energy Direct; patient is placed into the Increased range of motion Recent surgery, poor vitality of restrictive barrier; patient’s muscles patient, unstable joints are then actively used against a physician’s counterforce for 3-5 seconds

Page 12 OSTEOPATHIC MANIPULATIVE MEDICINE FOR INFLAMMATORY SKIN DISEASES distribution of immune mediators, respectively, further aiding in the body’s ability to heal. The 1.References Johnson SM, Kurts ME. Diminished use of lymphatic pump has been shown to significantly osteopathic treatment and its impact on the uniqueness of the osteopathic profession. J Assoc Am Med Coll. increase total leukocyte count, interleukin-8, 2001 Aug;76(8):821-8. keratinocyte-derived chemoattractant and other 2. Spaeth DG, Pheley AM. Evaluation of osteopathic immune factors in lymphatic flow following manipulative treatment training by practicing treatment.11 Several of these factors have been physicians in Ohio. J Am Osteopath Assoc. 2002 found to be involved in the pathophysiology Mar;102(3):145-50. of inflammatory skin disease, including IL-8 3. Spaeth DG, Pheley AM. Use of osteopathic and keratinocyte-derived chemoattractant.12,13 manipulative treatments by Ohio osteopathic physicians in various specialties. J Am Osteopath Assoc. 2003 Extravasation of these products of inflammation Jan;103(1):16-26. into lymph flow by lymphatic pumps can 4. Campbell SM, Winkelmann RR, Walkowski S. help promote the immune process involved in Osteopathic manipulative treatment: Novel application inflammatory skin disease. to Dermatologic Disease. J Clin Aesthet Derm. 2012 Oct:5(10): 24-32. Table 3 summarizes manual medicine techniques and their advantages in treatment of 5. Robert C, Kupper T. Inflammatory Skin Diseases, T cells, and Immune Surveillance. Mechanisms of inflammatory skin conditions. Disease. N Engl J Med. 1999 Dec:341(24):1817-1828. 6. Kuchera WA, Kuchera ML. Osteopathic Principles in Conclusion Practice. 2nd ed. Dayton: Original Works Books; 1991. OMM remains a potential adjunct in treatment 7. Bolognia JL, Jorizzo JL, Schaffer J. Dermatology. 3rd of disease, internal and cutaneous. At a time of Ed. Philadelphia: Saunders; 2012. merging osteopathic and allopathic paradigms, 8. Chila A. Foundations of Osteopathic Medicine manipulative treatment becomes a key to [e-book]. Philadelphia: Wolters Kluwer Health/ maintaining osteopathic identity and promoting Lippincott Williams & Wilkins, c2011; 2011. OHIO osteopathic principles. Continued emphasis on UNIV – Main’s Catalog, Ipswich, MA. Accessed May osteopathic principles in diagnosis and renewed 20, 2014. focus on manipulation in post-graduate training 9. Wallace E, McPartland JM, Jones JM, Kuchera WA, Buser BR. Foundations for Osteopathic Medicine. may alleviate the decline of manual medicine in Philadelphia: Lippincott Williams & Wilkins; 2003. osteopathy as well as promote the uniqueness Lymphatic system: lymphatic manipulative techniques; of the profession. Osteopathic manipulation p. 1064-65. has been shown to aid in normalization of 10. Huff JB, Schander A, Downey HF and Hodge autonomic function and enhance the immune LM. Lymphatic pump treatment augments lymphatic process, thereby promoting the health of the flux of lymphocytes in rats. Lymphat Res Biol. 2010 Dec;8(4):183-7. individual. By employing methods of manual 11. Schander A, Downey HF, Hodge LM. Lymphatic medicine, both direct and indirect, osteopathic pump manipulation mobilizes inflammatory mediators physicians may enhance the treatment and into lymphatic circulation. Exp Biol Med. 2012 comfort of the patient as a whole. With few Jan;237(1):58-63. exceptions, employing OMM in the treatment 12. Kemeny L, Ruzicka T, Dobozy A, Michel G. Role of inflammatory skin conditions can assist of interleukin-8 receptor in skin. Int Arch Allergy in resolving a pathologic state, as manual Immunol. 1994 Aug;104(4):317-22. treatments have been shown to alter the flow of 13. Nakamura K, Williams IR, Kupper TS. Keratinocyte- lymph and inflammatory mediators that may be derived monocyte chemoattractant protein 1 (MCP-1): analysis in a transgenic model demonstrates MCP-1 involved in inflammatory skin disease. can recruit dendritic and Langerhans cells to skin. J Although the dermatology office is a fast- Invest Derm. 1995 Nov;105(5):635-43. paced environment, we hope to promote the use of OMM, either in-office or by referral Correspondence: J. Hibler, DO; [email protected] to a manipulative-medicine specialist, to encourage the health of patients as well as bolster that which is unique to osteopathic medicine. Continued research into the efficacy of manipulative medicine in dermatologic disease remains necessary as we seek new and innovative treatments for common dermatologic conditions.

HIBLER, PERKINS, ELAND, SAMMONS Page 13