Tips For Osteopathic Physicians:
Understanding how to interpret the information the body communicates can be the difference between helping a patient get pain relief or leaving them in pain. In this day and age, pain is poorly understood and pain management can be dangerous. Currently, prescription related deaths are higher than cocaine or heroine combined. To understand pain, we have to change the way we think about pain and how we approach it as practitioners. Perhaps we need to look at the bigger picture instead and consider the “forest instead of the trees.” In order to progress, we may need to let go of our current assumptions or be open that our current understanding of the body may be incomplete. To properly understand what the body is communicating, it is important to operate with the following mindset during your osteopathic treatment:
- Pain is occurring for a reason: Pain is not random. The body is expressing it for a reason and the reason is legitimate. As practitioners, you should be asking yourself during treatments, “why is the body doing this?” There is an answer in the anatomy and considerations of possible dysfunctions and pathology. This will be explained more clearly during the example below.
- The cause of pain is not inflammation: During my medical training, I often heard doctors tell patients that the cause of their pain was from inflammation. Let’s be clear – inflammation is never a cause of pain. Inflammation is a result to an insult. If you cut your finger, inflammation and pain would result. It was the insult, or the cut in this case, that was the real cause of the pain. Not the inflammation. Inflammation does cause pain, but it does not occur randomly and is always an effect, not a cause. Therefore taking anti-inflammatory medications and steroids do not address the cause, they only minimize the resulting inflammation to the underlying problem. A more helpful approach would be to look for the reason for the inflammation.
- The cause of pain may not be where the patient experiences pain: Osteopathic physicians are taught this. This is just to re-emphasize this concept and the example below is meant to go deeper into this thought process. The cause of the pain can be from ANYWHERE in the body. For example, dura and autonomic irritation can be strong pain generators. There has to be a logical thought system to figure out what other areas should be considered. The cause may not even be structural, but can result from a nutritional deficiency. Osteopathic physicians do not believe all pain is structural.
- The musculoskeletal system is not separate from the other systems: The musculoskeletal system gives important clues on what is wrong. The musculoskeletal system will reflexively respond to structural problems of ANY body tissue. If an organ has any pathology, including simply not being in it’s ideal structural position, then the overlying muscles will contract and feel sensitive over the area. We treat ALL structures, not just the musculoskeletal system. In addition there will be musculoskeletal changes over the spinal segments associated with that organ. Many medical specialists believe that their systems (GI, cardiovascular, etc.) have nothing to do with each other, including the musculoskeletal system. This perspective is an assumption by the specialists. The musculoskeletal system can tell you where the problem may be regardless of what type of tissue it is.
- Most pain is not felt by the patient: Most pain that people have is only experienced by patients during palpation. The pain is only tender to touch. This does not mean that pain that is tender to touch is “less important” than pain that is actively felt by the patient. It is this pain that is stimulated only during palpation that gives you great clues about what may be happening.
- All structures are important: It is natural for humans to categorize things in order of importance. I have noticed practitioners often times only treat the structures that they consider “important” and disregard the others they consider “less important.” If we recognize that it is us making that assumption, we may realize that the body does not categorize the body in the same way. You may assume a finger is less important than your lungs because we can live if we have a finger amputated. When it is attached, the body does not treat the finger as an “inferior” structure that is “less important” than others. The body does not operate that way and you should always evaluate the associated “less important” structures if treating the “important” structures does not work. I always ask myself, “what am I missing?” during treatments to remind myself to look at everything.
- Even the slightest dysfunctions can cause pain: Understanding this concept forces a provider to look for even the slightest variation from normal anatomy. Therefore you look for even minor alterations even if other practitioners and doctors consider them “within normal limits.” The medical community thinks that pain can only come from structural issues if it appears on an x-ray or MRI. This is a big assumption about pain that is not based on evidence.
Example of a thought process: Let’s say during your treatment, you find a patient is very tender over the coracoid process of a shoulder. You may consider the bigger picture that there may be a structural dysfunction or dysfunctions in the rib cage. An excessively kyphotic thoracic spine may change the way the shoulders sit upon the rib cage usually pulling them forward. Structurally a problem in the rib cage and the change in the orientation of the scapula on it may cause the pectoralis minor to reflexively contract. Tenderness over the pectoralis minor may support your findings. This may be a reason for tenderness over the coracoid process. However, you cannot stop there. You will want to consider evaluating the coracobrachialis and short head of the biceps brachii for tenderness, which you would expect to find. A dysfunction at the olecranon process of the elbow may cause a contraction of the biceps, which also shows up as tenderness over the coracoid process. In addition, it is important to consider the effect the clavicle may be having over the coracoid process. There are ligaments between the two structures that may become dysfunctional. Addressing these, you can look to see if there is a dysfunction at the glenohumeral joint, which you can be certain is dysfunctional if the shoulders are pulled forward. Sometimes the tension in the biceps and pectoralis major can compress the head of the humerus into the glenoid. Finally, you may consider evaluating the acromioclavicular joint with shoulder dysfunction, which can have an effect on the coracoid process by its short proximity. Treatment of all these structures above gives your patient relief and increased range of motion. When you evaluate, you can look for the most dysfunctional structure and treat that first and then see how the other things you evaluated changed. If you treated the correct problem, then you may get multiple things that release all at once.
The example above is not complete. It does not, for example, consider the autonomic, dural influence in this pain, vasculature, and visceral possibilities. Hopefully it can help one understand a helpful thought process to “dig deeper” and gain insight into how to approach complex problems with patients. Each problem is unique and must be approached with an investigative attitude. A deep understanding of anatomy is crucial with the osteopathic mindset to solve problems so you can logically understand what your next steps may need to be. I hope this post helps to gain a new perspective into approaching and treating patients.