Osteopathic Medicine in Pain Management
Osteopathy is a philosophy of medical care that combines the needs of patients with the current practices and specialties of medicine but with an emphasis on the interrelationships between structure and function and appreciation of the body's ability to heal itself.1 There are four key principles of osteopathic philosophy:2
- The body is a single system that includes effects from the mind and spirit as well as the muscles, bones and organs.
- The body is capable of self-healing, self-regulating and self-maintenance.
- The structure of parts of the body will effect the functioning of those body parts.
- Treatment should consider the unity of the body, the interactivity and propagating effects of specific treatment modalities, and harnessing the self regulatory ability of the body as much as possible.
Osteopathic physicians have long been known to be primary care providers who can do manipulation. While osteopathic physicians are viewed as providing more “natural” medical interventions, osteopathic practice actually overlaps other health-related fields in that it is based on the chemical, physical and biological sciences in the maintenance of health and the prevention, cure and alleviation of disease.3
Pain is the most common reason patients seek osteopathic manipulation. Other reasons may include psychological issues, wellness, athletic performance, or medical problems without clear musculoskeletal etiology such as asthma, or malignancy.
What is Osteopathic Manipulation?
Osteopathic manipulative treatment (OMT) is the manual application of forces to the body to restore maximal pain-free movement of the musculoskeletal system.4 As a complimentary therapy and unique system of practice, OMT uses its own vocabulary and methods for approaching patients that are markedly different from those of traditional medicine.1 For example, the term somatic dysfunction is used to identify a “problem area” during a patient’s physical exam. The term is defined to diagnose areas of regional asymmetry, restricted motion and texture changes of tissues.3,5
Two types of treatments are commonly used in clinical practice: passive (no patient participation) and active (patient participation). These types are further subdivided into subgroups: direct and indirect. Patients experience indirect techniques as “going away from a restriction” and direct techniques as “going against a restriction.” Some examples of treatments used include soft tissue type techniques and articulatory type techniques. Table 1 summarizes the osteopathic modalities used in the management of pain (see also Table 2 for detail descriptions of the osteopathic treatment modalities). Note that ‘indirect’ techniques activate inherent mechanisms to reduce inappropriate neuromuscular afferent impulses, and involves movement in the opposite direction of motion restriction. ‘Direct’ techniques, on the other hand, involve a force applied in the same direction of movement that encounters a motion restriction or pathological barrier.
The Value of Therapeutic Touch
OMT is an holistic approach involving patient-practitioner interaction and purposeful physical contact. Clinical studies have reported decreased blood pressure6-9 and decreased anxiety6 following a “hands-on” type of treatment. While it is tempting to reduce osteopathic manipulation to a series of specific treatments for specific problems, osteopathic practice would lose its identity as osteopathic manipulation and become merely manual medicine. The term manual medicine implies a general form of treatment applied by the hands. The term osteopathic manipulation, however, indicates that the physician is applying the four basic principles of osteopathic philosophy. The true osteopathic approach cannot be broken down into isolated procedures specific for particular complaints—the osteopathic approach treats the patient as a whole.
Referred Pain and Recurrent Musculoskeletal Pain
Early descriptions of referred pain resulting from cardiac disease by Head13 and Mackenzie14 led to an interest in somatic tissue reference sites. Pottenger15 identified changes in specific spinal segments associated with visceral disease, which he attributed to sites related to the visceral autonomic system. Physicians have reported clinical findings of segmental dysfunction in cardiac diseases, which have included changes in the skin (ie. vasomotor reactions, temperature changes, increased moisture on the skin surface, and tissue texture changes), as well as in subcutaneous tissue, muscle hypertonicity, hyperesthesia, and a limitation of segmental mobility of vertebrae and ribs.16 The most common distribution of segmental dysfunction in the cardiac patient (including patients with hypertension, coronary artery disease, and ischemia) involve two or more adjacent spinal segments from T1 to T5 (thoracic vertebrae) to the left of the spinal column, with T2 and T3 being most commonly affected.16
Osteopathic manipulative treatment (OMT) is an holistic approach involving patient-practitioner interaction and purposeful physical contact
The postulated mechanism to describe this phenomenon is that viscerosomatic reflexes are causally related to somatic dysfunction. These reflexes involve visceral afferents that send signals to the spinal cord at specific spinal levels and connect to the afferent limb of the reflex arc. Activation of autonomic and somatic motor nerves thereby results in localized somatic changes involving the skin, subcutaneous tissues and muscles.16
There have been other studies which have demonstrated that other visceral organs replicate the same mechanism. Johnston17 describes that inflammation of a visceral organ, organ distention, large compression forces, spasms (if the organ is muscular), ischemia, and endogenous or exogenous chemical irritants are major sources of stimuli for diseased visceral organs. Johnston17 explains that the kidney receives preganglionic sympathetic fibers from the tenth thoracic through the first lumbar sympathetic ganglia, and afferent fibers from the kidney enter mainly at cord levels T10-12. Reflex responses in segmentally related somatic tissues have been observed experimentally, both in laboratory preparation of animal models18 and human subjects in a surgical setting.19,20,21 Clinical observations have linked somatic manifestations of sensory, motor, and vasomotor disturbances in the somatic tissues to a number of visceral diseases.15,22
Although a musculoskeletal examination cannot be solely used to diagnoses visceral disease, it can be used to supplement the physical exam in support of verifying a diagnosis of cardiovascular, renal or other visceral disease.