Osteopathic Manipulative Medicine

Anthony Digirolamo, DO

Joshua Minori, DO

Karen Snider, DO

FAST FACTS

Osteopathic manipulative medicine (OMM) can be used to treat a variety of painful conditions.
The goal of OMM is to identify somatic dysfunction and reduce or remove the dysfunction.
Osteopathic manipulative treatments improve pain by normalizing biomechanical function, removing structural impediments to vascular and lymphatic drainage, restoring nervous system tone, and decreasing the energetic demand on the body.

OSTEOPATHIC MANIPULATIVE MEDICINE IN THE TREATMENT OF ACUTE AND CHRONIC PAIN

History and Philosophy

Osteopathic manipulative medicine (OMM) is the use of hands-on structural diagnosis and osteopathic manipulative treatment (OMT). OMM is a therapeutic modality used by the osteopathic medical profession as part of a holistic approach to patient care governed by osteopathic principles and practice (OPP). Osteopathy was founded in the 19th century by Andrew Taylor Still, MD, DO, an American frontier physician who partially rejected the existing framework of medical practice that included toxic medicinal substances and questionable surgeries.¹ Still believed that the body had the inherent ability to heal itself, but this ability was adversely affected by abnormal musculoskeletal mechanics affecting nerve, vascular, and lymphatic functioning.² The effect of the musculoskeletal system on the natural healing potential of the body formed the basis of his philosophy.² Dr. Still applied the term “osteopathy” to this new medical philosophy to highlight how clinical pathology throughout the body was reflected within the skeletal system. The modern osteopathic medical profession is not a system that solely
relies on a musculoskeletal-oriented diagnosis and treatment; it is a scientifically comprehensive school of medicine that embraces a holistic philosophy. This philosophy recognizes the whole person, the body’s homeostatic mechanics, and its structure-function relationships. Osteopathic treatment focuses on health-oriented principles utilizing the full scope of treatment options including pharmaceuticals, surgery, lifestyle interventions, and OMM.³

OPP is summarized in the following 4 tenets³:

1. The human being is a dynamic unit of function integrating mind, body, and spirit.
2. The body possesses self-regulatory mechanisms that are self-healing in nature.
3. Structure and function are reciprocally interrelated at all levels.
4. Rational treatment is based on these principles.

Multidisciplinary pain programs are recognizing that many hands-on approaches to patient care and associated modalities, such as OMM, chiropractic manipulation, and massage, may provide solutions to treating persistent pain conditions.⁴ The use of OMT by a practitioner trained in OMM has been viewed by many patients as highly effective.⁵^,⁶^,⁷^,⁸ Studies have shown OMM to be a safe method of reducing pain, increasing mobility, and ultimately improving function.⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³

Current Practice of Osteopathic Manipulative Medicine

OMM is taught at all colleges of osteopathic medicine within the United States. Licensure examinations taken by graduating doctors of osteopathic medicine (DO) ensure that all DOs are competent to practice OMM. Many residency programs will continue to provide OMM training and one specialty, osteopathic neuromusculo-skeletal medicine (ONMM), focuses on OMM as the primary treatment modality within the specialty.

Many osteopathic physicians specializing in primary care provide OMM to their patients. Specialists who focus on the musculoskeletal system, such as physical medicine and rehabilitation (PM&R), sports medicine, and orthopedic surgery, may also provide OMM to their patients.

Osteopathic Models of Care

The osteopathic approach to patient care recognizes the multitude of interdependent functions within the body. The Educational Council on Osteopathic Principles (ECOP) of the American Association of Colleges of Osteopathic Medicine defined 5 diagnosis and treatment models that, when applied to patient care, guide a physician to consider these interdependent functions. The 5 osteopathic diagnosis and treatment models are the biomechanical, respiratory-circulatory, neurologic, metabolic-energy, and behavioral models.³ These 5 models each focus on homeostatic mechanisms that affect the adaptability of the body to environmental stressors and can all be affected by or predispose a patient to persistent pain symptoms. The biomechanical model stresses optimization of structure-function relationships within the musculoskeletal system. The respiratory-circulatory model stresses optimization of respiratory mechanics and vascular and lymphatic drainage. The neurologic model stresses normalization of somatic and autonomic nervous tone. The metabolic-energetic model focuses on minimizing energetic demands on the body and optimizing metabolic and physiologic processes. The behavioral model focuses on the improving health through the effect of the mind and spirit on the body.³^,¹⁴ By applying these models to each patient, the physician considers a variety of avenues for diagnosis and management of conditions causing both acute and chronic pain.³

Treatment of the musculoskeletal system with OMM can play a role in each of the 5 osteopathic diagnosis and treatment models. The musculoskeletal system has a rich afferent input into the central nervous system and, through its effect on vascular and lymphatic drainage, has a multitude of mechanisms to interact with other organ systems. The interaction of the musculoskeletal, immune, neurologic, and endocrine (MINE) “supersystem” creates a collective network that can be dysregulated by nociception and attribute to chronic persistent pain.¹⁴ The behavioral model recognizes the effect of persistent pain on the mind-body-spirit connection and its impact on quality of life. Similar to the biopsychosocial models that are incorporated into the multidisciplinary pain approach, the 5-model approach focuses on physical, mental, emotional, and spiritual functions often affected by chronic persistent pain. Therefore, it is reasonable to assume that structural and functional disturbances placed on the musculoskeletal system will have consequences on homeostatic processes throughout the body. The 5-model approach to diagnosis and treatment focuses on restoring health by influencing repair and recovery from illness, sickness, and disease via multiple mechanisms.³

PHYSIOLOGY OF OSTEOPATHIC MANIPULATIVE MEDICINE

Nociceptive Neuromuscular Reflexes

OMM reduces pain through several physiologic mechanisms. One such mechanism is known as the nociceptive neuromuscular reflex. During an injury to a muscle or tendon, muscle spindles composed of afferent sensory and gamma efferent nerves are rapidly stretched. Nociception afferents communicate with alpha motor neurons via excitatory interneurons within the spinal cord to cause a reflexive muscle contraction to avoid further injury. The reflexive contraction may cause localized muscle spasm, creating more nociception and additional spasm.¹⁵^,¹⁶ This cycle, known as the pain-spasm-pain cycle can persist leading to lowered firing thresholds of the neurons at the level of the dorsal horn of the spinal cord. This phenomenon known as sensitization or segmental facilitation can affect the somatic and visceral structures innervated from the sensitized area of the spinal cord. OMM is thought to disrupt these nociceptive neuromuscular reflexes by decreasing nociceptive input, thus
reducing activation of the gamma motor neuron, which lessens the sensitivity of muscle spindles to stretch.

Somatic Dysfunction

Somatic dysfunction is defined as the impaired or altered function of interconnected components of the somatic system, including skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements.¹⁷ Somatic dysfunction is diagnosed by the presence of one or more physical findings: excessive sensitivity (S) or tenderness (T), asymmetry (A), restrictive motion (R), and tissue texture abnormalities (T).¹⁷ Collectively known as STAR or TART findings, the individual findings provide clues to the underlying mechanisms of a patient’s injury and pathophysiologic status.¹⁴ Collectively, somatic dysfunction findings reflect the peripheral and central physiological mechanisms that underlie the condition disrupting a patient’s health and function.¹⁸

The presence of somatic dysfunction is the clinical indication for performing OMT.¹⁹ The goal of OMT is to improve physiologic function and restore homeostatic mechanisms that have been altered by the somatic dysfunction.¹⁷ OMT encompasses a variety of hands-on techniques, but the choice of techniques is based on the specific TART findings found on physical examination. Through palpation, the physician localizes the techniques to the somatic dysfunctions, monitors tissue texture changes during the treatment, and determines the effectiveness by assessing the tissue response.²⁰ OMT effects pain generators by reducing or removing somatic dysfunction and by modulating central and peripheral mechanisms responsible for producing or maintaining pain.

Pain Generators

Pain generators are commonly defined as the nociceptive sources of pain.²¹ They are found by correlating anatomic location, quality, and referral distribution of the pain with well-studied dermatomal, sclerotomal, and myotomal pain maps.¹^,²² The different pain generator types and associated structures have unique characteristics that can direct the physician into making an appropriate diagnosis and formulating a custom treatment plan. It is up to the physician to determine if the cause of pain is coming from a given structure and/or identified somatic dysfunction.

Dermatomal pain is pain that follows along the sensory distribution of a spinal nerve root. The character of the pain may vary depending on the cause. For example, herpetic neuralgia is often described as burning, whereas compression of the dorsal sensory root may cause a lightning or electric type of sensation. Sclerotomal tissues such as skeletal, arthrodial, and ligamentous structures produce pain that is often described as “deep and dull,” and the pain patterns are usually located distal to the actual pain generators. Myotomal pain is often described as “cramping or stiffness,” can be associated with certain movements, and may include active or latent myofascial trigger points (MTrPs). Like sclerotomal pain, myotomal pain symptoms are usually located at a distance away from the pain generator and have predictable referral patterns.

Segmental facilitation within the dorsal horn of the spinal cord can contribute to pain referral through sensitization of nociceptive neurons of the affected tissues as well as neurons in adjacent areas of the spinal cord.¹ This central nervous system sensitization can lead to pain referral patterns into body areas that are not directly related to the origin of disease or insult as is seen with a myocardial infarction radiating pain into the left arm.²³

Applying the 5 Models of Care

The 5 osteopathic diagnosis and treatment models help the osteopathic physician develop an appropriate plan for applying OMT and setting individualized treatment goals. Incorporating a mixture of these models into the plan of care allows the physician to view the patient holistically. Diagnosis and treatment of the musculoskeletal system with OMM can play a role in each of the 5 models. The osteopathic physician can use OMT to correct the somatic dysfunction in order to normalize biomechanical function, remove structural impediments to vascular and lymphatic drainage, normalize nervous system tone, decrease the energetic demand on the body, and improve pain.²⁰ Table 24-1 reviews the 5 models as they pertain to assessment and treatment.

COMMON CONDITIONS/DIAGNOSES TREATED WITH OMM AND ASSOCIATED EXAM FINDINGS IN PATIENTS WITH CHRONIC PAIN

Common Treatable Conditions/Diagnoses Causing Chronic Pain

Osteopathic manipulation has been utilized with success for a wide variety of pain conditions.²⁴ Pain conditions that are commonly treated with OMM are summarized in Table 24-2. In the primary care setting, OMT is most commonly used to treat pain in the low back and head.²⁵ Specific conditions include degenerative disk and joint disease (spondylosis), piriformis syndrome, sacroiliac joint pain, coccydynia, psoas syndrome, short leg syndrome, cervicogenic headache (CGH), occipital neuralgia, migraine, and tension-type headache.²⁶^,²⁷ Low back pain (LBP), CGH, and postural strain/sprain tend to have the highest occurrence rate with increased tendency for disability due to persistent pain and the strongest evidence for the successful application of diagnosis and treatment using OMM.¹^,²⁸^,²⁹^,³⁰

Associated Exam Findings of Common Conditions/Diagnoses

A musculoskeletal examination that includes an assessment for TART/STAR findings is required for OMM.
TART/STAR findings can provide information for identifying the source of the pain generator. Conditions causing persistent pain may result in compensatory mechanisms, muscle spasms, and MTrPs. MTrPs are discrete, hypersensitive points in a muscle or fascia that can be felt as a nodule or band, and are associated with a localized twitch response and predicable pain referral elicited upon stimulation.³¹^,³² MTrPs are often associated with LBP, headaches, carpal tunnel syndrome, temporomandibular joint dysfunction, and pain perceived as angina.³³^,³⁴^,³⁵ A few examples of pain conditions with associated exam findings are described in the following sections.

TABLE 24-1 Five Osteopathic Models of Patient Care

MODEL	ANATOMICAL FOCUS	HOMEOSTATIC AND PHYSIOLOGICAL FUNCTIONS
Biomechanical	Skeletal muscle; connective tissue and ligaments; joints of the spine, extremities, and head	Postural balance, muscular function, connective tissue compliance, articular motion
Respiratory-circulatory	Thoracic cage; transitional areas between body cavities-thoracic inlet, abdominal diaphragm, pelvic diaphragms, and tentorium cerebelli	Mechanical respiratory motion; vascular and lymphatic flow; pulmonary and cardiovascular function
Neurologic	Central nervous system, peripheral nervous system including the sensory, somatic, and autonomic nervous systems	Regulation of visceral function; transmission of sensory input and motor control; proprioception; coordination of function between organ systems
Metabolic-energetic	Internal viscera, exocrine and endocrine glands	Biochemical and physiologic processes; energy demand and consumption; immunological and endocrinological regulatory processes; inflammation and repair; digestion and nutrition; waste removal and excretion; reproductive processes
Behavioral	Mentation, emotions, spirituality	Cognition and memory; psychological status including emotions, mood, motivations, and behaviors; lifestyle activities; spiritual beliefs

TABLE 24-2 Pain Conditions Commonly Treated With Osteopathic Manipulative Medicine Based on Anatomic Region

ANATOMIC REGION	CONDITION/DIAGNOSIS
Head	Headache Sinusitis Temporal mandibular joint dysfunction
Cervical region	Neck pain Cervical strain
Upper extremities	Carpal tunnel syndrome Shoulder pain Elbow pain
Thoracic spine and ribs	Thoracic strain Postural strain Postthoracotomy pain Thoracic outlet syndrome
Lumbar spine and abdomen	Back pain Lumbar strain Pancreatitis
Sacrum and pelvis	Sacroiliac pain Pelvic pain Sciatica
Lower extremities	Short-leg syndrome Knee pain Ankle pain Foot pain

Low Back Pain

Pain generators associated with LBP include the articular structures such as the lumbar facet and sacroiliac joints and soft-tissue structures such as muscle, fascia, and ligaments. Studies have shown that people with LBP have been found to have higher level of severity of somatic dysfunction in articular and soft-tissue structures than people without LBP.²⁸^,³⁶ Structures that can contribute to LBP include the thoracolumbar fascia; pelvic diaphragm; quadratus lumborum, hamstrings, and iliopsoas muscles; and the iliolumbar, interspinous, and sacrotuberous ligaments.¹⁸^,²⁷

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