December 30, 2005
Published in the JAOA (Journal of American Osteopathic Association)
Dr. Gilbert E. D’Alonzo
American Osteopathic Association
142 East Ontario Street
Chicago, IL 60611-2864
RE:Letter to the Editor
Dear Dr. D’Alonzo
Over the past few years, I have read JAOA articles on osteopathic research. Several issues back was an article on lymphatic pump; before that, one on osteopathic treatment of low back pain; before that, an article on osteopathic treatment in Parkinson’s disease. Each article applied osteopathic techniques to target areas by experienced osteopathic manipulators. Although the numbers in the studies were small, all studies showed measurable improvement. Wonderful!
I am writing this letter to see if one more aspect of the osteopathic approach can be incorporated into the current scientific method. That osteopathic aspect is the individualization of osteopathic treatment to the patient. To help explain what I mean, I wish to discuss a few cases in my practice and to see, if by surgical analogy, I can correctly communicate this idea of individualization. I hope that those who do research, far more educated in that field than I, would get the idea and find a way to incorporate this piece into their research protocols. I believe research along this individualization line would significantly improve study outcomes.
Osteopathic physicians analyze the entire musculoskeletal mechanism to understand how the dysfunction plays out to cause the patient’s symptoms. (I am assuming that the appropriate medical work ups have been done for the patient’s condition and that now, manipulative treatment has been deemed appropriate care).
Thus, any two patients with a named disease, such as sciatica, will have two different mechanical etiologies unique to their histories. These mechanical strains play out in their musculoskeletal systems to give the sciatica condition we so commonly see. To illustrate what I mean, I will briefly below describe a few cases that come to mind from twenty-eight years of practice.
One patient had left-sided sciatica from a hip strain lifting something heavy. The resulting malposition of the head of the femur in the acetabulum caused tension on pyriformis and inferior gemelli through which muscles the sciatic nerve passes. Relief of the femoral-coxal strain resolved the problem quickly.
One patient had right-sided sciatica after a skiing accident. He fell and his boot binding didn’t let go as quickly as it should have, thereby twisting his leg. The fibular head was pulled anteriorly, tractioning the superficial peroneal nerve lying on its anterior surface and bowstringing the sciatic nerve. The mechanical stretching of the sciatic nerve caused his sciatica symptoms. Release of this fibular head strain and other compensatory strains from the fall quickly resolved his sciatica.
One patient developed left-sided sciatica over many months. When seen and evaluated in the standing position, his left iliac crest was four inches cephalad to the right. The underlying cause resulting in this gravitational postural shift was a generalized weakness in the fascia from restricted normal fluid interchanges. The cause of the restricted normal fluid interchange might have been from a toxic chemical exposure. The elevated left hip with its resultant scoliotic curve and femoral coxal strain was the only position that his body could take in gravity, given the weakened fascial state. Such unbalanced posture in gravity, created stress in the femoral-coxal joint and through the resultant stress on pyriformis and gemelli, sciatica. When the normal fluid interchanges were encouraged to flow freely via lymphatic motions, the iliac crests leveled in the standing position. Other compensatory changes corrected resulted in complete relief within three weekly visits.
Each of the above patients had sciatica. Yet, each required a different osteopathic treatment. Paul Kimberly, D.O., my professor at KCOM (now ATSU) instructed us in “the manipulative prescription.” This prescription is the osteopathic analysis, individualized to each patient, a decision of “the what to fix.” The named disease condition could give no osteopathic mechanical clue. Only the musculoskeletal analysis could elucidate the offending body part.
The technique is the “how to fix it.” There are surely many excellent methods of how to fix it once the what to fix is known. This is how osteopathic physicians individualize their care to the patient’s unique musculoskeletal system.
The osteopathic research protocols, mentioned in the first paragraph, bring to mind an analogy for a surgical study. I am sure we would never see such a study but I present it to help get this individualization idea across from the medical model. Now, this is an analogy only. I understand and accept that certain aspects applying to OMT and surgery will not fit. I could compare the surgical research analogy below to, for example, the osteopathic treatment of low back pain in which a “lumbar roll” or other such local lumbar spine treatment only is given for the low back pain. (Of course, obviously, sometimes pain in the low back is solely due to lumbar spine somatic dysfunction.)
So, here it is : the surgical treatment of right lower quadrant belly pain.
A group of patients with acute right lower quadrant belly pain will all have their appendixes out. A control group will have medical treatment only. Since most right lower quadrant belly pain is due to appendicitis and surgery is generally the needed treatment, the experimental group will do better than the medical group. Since most right lower quadrant belly pain is due to appendicitis, perhaps 60% of the patients in the experimental group will be cured. This study would show significance.
This protocol will never be utilized because surgeons individualize their surgeries to the patient’s diagnosis. They investigate with a whole range of tools to discover which specific organ is the source of the patient’s distress and remove that organ or organs if more than one is the cause. They have a surgical prescription. Then comes how to take care of the prescription — the surgical technique and procedures.
In osteopathic practice, Osteopathic physicians performing osteopathic manipluative treatment have an osteopathic prescription too. It is where to do what after you have analyzed what needs to be done. You constantly monitor the patient’s tissue and clinical condition to see how that prescription is performing.
Once you have decided where the cause of the strain begins, the what, you choose which technique, the how, to fix it. You keep up this sequencing the strains and compensations until the musculoskeletal analysis reveals enough change for that treatment (dosage). Over a course of treatment, the process is continued until either the patient is well, reached maximum improvement you feel possible or has not progressed and another clinical course of action is needed.
Dr. Still wrote on this principle of individualization. Adding this individualization aspect to our osteopathic research protocols will demonstrate the clinical effectiveness of our applying our osteopathic principles to a wide range of named clinical conditions.
So, there you have it : my two cents to help increase the effectiveness of our osteopathic research. As a busy clinician, I have neither the time nor the resources to devise and carry out osteopathic research our eminent researchers do. I am hopeful they may find this idea useful and find a way to incorporate this aspect of Still’s philosophy and practice into their research protocols.
Steve Davidson, D.O., C-SPOMM