Osteopathic Medicine Approach to Pain Management
Pain—specifically chronic pain— often requires a diverse interdisciplinary approach for its effective management.1 The interdisciplinary treatment team should include an osteopathic physician (capable of providing unique musculoskeletal diagnostic examinations and manual therapies), physical therapists, occupational therapists, and psychiatric health care professionals. Unfortunately, osteopathic manipulative medicine (OMM) and its role in the treatment of pain is widely misunderstood and underutilized. The major purpose of this article is to discuss the philosophy of osteopathic medicine (of which OMM is but one component) to provide a better understanding of its role in the treatment of pain. At the outset, it will be helpful to discuss the similarities of, and differences between, osteopathic physicians (DOs) and allopathic physicians (MDs). Osteopathic and allopathic physicians are similar in many ways. They both typically have a four-year undergraduate degree, a four-year medical education and they take comparable licensing examinations. Moreover, they are licensed to practice the full scope of medicine and surgery in all 50 states, they practice all specialties of medicine and complete postgraduate training at many of the same institutions.2,3 Despite all their similarities, there are a few differences that impact the practice of osteopathic medicine and, particularly, the approach to managing chronic pain. Osteopathic medicine focuses on primary care and emphasizes a holistic approach to the patient, as well as the relationship between structure and function. All osteopathic physicians are trained to use OMM to help diagnose and treat their patients.
Osteopathic Principles and Practices
Osteopathic medicine is one of the fastest growing health professions in the United States, including more than 60,000 osteopathic physicians. In spite of this, public awareness, perceptions,4,5 and understanding of this profession within the allopathic medical community still remains poor. If lay persons and health care professionals claim to know something about osteopathic medicine, they are often mistaken in their understanding. They commonly look at osteopathic medicine as a “second-tier profession,” “not real doctors,” or as being chiropractors. Quite to the contrary, osteopathic medicine is a complete system of medicine that utilizes all available modalities of diagnosis and treatment. Contrary to public opinion, it is not just osteopathic manipulative treatment (OMT) that makes osteopathic medicine different; it is the osteopathic philosophy on which the whole osteopathic system of medicine is based. At its July 2008 Annual Meeting, the American Osteopathic Association’s House of Delegates approved a consensus statement on the four tenets of osteopathic medicine6:
- The body is a unit; the person is a unit of body, mind, and spirit.
- The body is capable of self-regulation, self-healing, and health maintenance.
- Structure and function are reciprocally interrelated.
- Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.
Perhaps the most important of these tenets is the first one—that the person is composed of body, mind, and spirit. Thus, to treat the whole person, one needs to treat all three aspects. These tenets are at the core of osteopathic medicine and are what makes the osteopathic view of a patient distinct. Conventional pain treatment in the United States has consisted of treating the physiological aspects of pain (nociception, mechanical compression, neuropathy and inflammation) and has, until quite recently, neglected the psychosocial aspects of pain.7,8 OMM integrates osteopathic philosophy with the principles of evaluating somatic dysfunction and treating it using OMT.
Osteopathic Medicine and the
Biopsychosocial Model of Illness
It can be argued that osteopathic tenets and principles for the management of pain actually preceded the now widely accepted and heuristic biopsychosocial approach. This biopsychosocial model views physical disorders—such as pain—as the result of a dynamic interaction among physiological, psychological and social factors that perpetuates and may worsen the clinical presentation. A wide range of psychological and socioeconomic factors can interact with physical pathology to modulate a patient’s report of symptoms and subsequent disability. Thus, “knowing the whole person” is important in this model as well as in the osteopathic approach. It has been recently noted that, in general, this biopsychosocial model is quite congruent with osteopathic principles and that it provides a great deal of empirical evidence that supports the osteopathic approach.9
Indeed, as noted by Gatchel et al,10 the emergence of this biopsychosocial approach has paralleled the evolution of scientific thought in medicine:
“During the Renaissance, increased scientific knowledge in the areas of anatomy, biology, and physiology was accompanied by a biomedical reductionism, or a ‘dualistic’ viewpoint, that mind and body function separately and independently. This perspective dominated medicine until quite recently and affected the understanding of the relationships between mental health and pain. The gate control theory of pain introduced by Melzack and Wall (1965), however, began to highlight the potentially significant role that psychosocial factors play in the perception of pain. Pain is now viewed as a complex set of phenomena rather than as a simple, specific, or discrete entity.”
This biopsychosocial approach was widely embraced by osteopathic medicine, well before conventional allopathic medicine.
Osteopathic Manipulative Medicine and Osteopathic Manipulative Treatment
In addition to a standard history and physical examination, the osteopathic physician performs an osteopathic structural examination looking for impaired or altered function of the musculoskeletal system (bone, joints, muscles and fascia) and its related lymphatic, vascular and neural structures.11 These impaired or altered functions are called somatic dysfunction. Somatic dysfunction predisposes one to pathology and can maintain it once established.12 Somatic dysfunction is manifested in the body as palpable changes in tissue texture, tenderness, asymmetry and loss or restriction of motion.11