OMM Case Studies

[Cuthbert]

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Oh, so evidence based medicine is not important for life threatening medical situations? We are only to use it in non-critical cases?

and I never said anything about rib raising...

I gave you the link for the evidence. I did not say it was not important.

True, you did not mention rib raising. I bring it up as a common misconception about what OMT can do.

I wish you the best bones. I've said my peace on the matter and apologize if what I said insulted you. Again, I just think your anecdotes need a counter from another trained DO.

 

[bones]

I've really enjoyed reading your case reports so far.

I'm only in the process of applying to schools right now and obviously have a long way to go in terms of medical education, including OMM if I'm accepted into an osteopathic medical school. Nevertheless, I was wondering if you've found OMM to be useful in treating patients with 1) MS and 2) fibromyalgia? If so, would you be willing to share some cases?

Thanks!!

no problem. I have never heard of a successful case treating MS, and a year ago I would have laughed at the question. I am a little more sober about it now. I did find a web page by a microbiologist you might find interesting.
http://www.davidwheldon.co.uk/ms-treatment1.html

Not proof, just one theory of MS. If you can treat meningitis with OMM (which i still doubt, but AT Still claims to have had success) in theory you could treat a chlamydophila meningitis, which in theory -could- be the real cause of some cases of MS.

If it were my family member, I would probably try the antibiotics. Its nowhere near proven yet though.


As for fibromyalgia- I hate using that term because it confuses everything you say after that. use the term Central Sensitization (or CS). One type of pain people can have is CS- which I think is caused primarily due to severe sleep deprivation over a long period of time, and they seem prone to chronic systemic infections (not sure if it is caused by immune suppression from sleep disturbance or if indeed the infection causes sleep disturbance). I don't have all the articles handy- but I might post a case later and I'll look them up. Take a normal healthy person and give them 2 hours per sleep per night for 4 nights and in most cases they will have central sensitization- the tender points, the migrating aches and pains, etc.

Everyone I've seen with the positive tender points also reports poor quality of sleep and often very little quantity as well.

causes include:

severe anxiety/sympathetic overdrive with severe associated celiac ganglion irritation/epigastric spasms.
PTSD (rape victims- share findings with anxiety above)
PTSD (war veterans aka gulf war syndrome- share findings with anxiety above)
head injury with "cranial compression" causing poor depth of sleep.
psychiatric depression (share findings with head injury above)
Sleep apnea
severe pain from an injury which routinely wakes them from sleep
bladder problems/uncontrolled diabetes which make them wake many times per night
drug abuse/dependence (especially opiate withdrawal symptoms)

Infectious comorbidities appear to include:
abnormal GI colonization with chronic diarrhea (C diff, parasitic infection, etc.)
lymes
mycoplasma
chlamydia pneumonia
hepititis B or C
HIV
other STDs
any of a long list of chronic viral infections

Must also rule out:
Cancer- common cause of sleep disturbance, myalgias, fatigue
thyroid disturbance
autoimmune disease (though many of these may actually be caused by one or more of the above infectious etiologies).
crazyness- yes some of them are just wacko, and they want attention or whatever. I believe this is a very small % of these cases. You can distinguish these because they dont respond instantly to pain when you touch their tender points... instead you'll get an "owww!" and no withdraw or a delayed withdraw. With real pain the tissue withdraws immediately.


Osteopathic philosophy would put you to task for figuring out the cause of the central sensitization. If it is one of the above factors- treat it with OMM, appropriate antibiotic therapy, CPAP, surgery or whatever it takes to get to the cause.... and then you have yourself a "cure" or at least the most direct way of handling the problem with the least long term side effects.

These are hard cases to work up. I am batting about 50-60% on getting a real diagnosis for patients that already carry the diagnosis of "fibromyalgia" when i first see them. Out of all of them I've worked up, two were cancers that were being treated with traditional fibromyalgia drugs- one was a stage 3 cecal adenocarcinoma. She was sitting on her diagnosis of fibromyalgia for 5 years before I saw her, and getting the tumor out "cured" her pain on the day it was removed. The other was a 90 year old with brain metastasis... nothing I could do there.

All "fibromyalgia" means is that someone else gave up on working them up. Keep trying. If you do give up and give them the normal fibro meds- I still wouldn't call them fibro- too many weird things on the internet about it, and the diagnosis holds a stigma for other docs and insurers who will immediately think the patient is nuts. Most aren't.

For those with a lot of epigastric spasm- fixing this often fixes their sleep problem and their central sensitization resolves spontaneously.... these comprise most who can be "cured" with OMM treatment, this is a substantial subset- maybe 30-40% of central sensitization cases I've seen (includes the common rape victim/fibro scenario). A few have OMM- fixable head injuries, and another chunk are helped by appropriately targeting the cause of the sensitization...tumor or parasite or bacteria or putting them on CPAP. The rest... negative for everything... I have no idea what to do with them- I still struggle with those. Traditional meds and Mg help with pain and sleep till my differential improves. IV micronutrient therapy using the "Myer's Cocktail" seems to work for those who can afford it- but it may just be the magnesium in it that is helping. This whole topic is still a work in progress for me.

 

[bones]

Looking for reproducible results under controlled conditions is a healthy (and essential!) part of the scientific process.

agreed. Will you put in the time? I can't do it all myself.

 

[homeboy]

That isn't what he said. read more carefully.

These outcomes seem too good to be true to someone without this training and way of thinking and this makes some people very uncomfortable... especially DO students that are already defensive about their title and think they will be labeled as snake oil salesmen by association. Most things that seem too good to be true definitely are. MOST. The best opportunities also seem too good to be true at first glance. The only way to distinguish snake oil from truth is to test it... right?

I'm confused...
He said, "It makes them feel like their chosen field is akin to faith healing, crystal therapy, and chiropractics. "
Unless this is some Clintonian exercise, I presumed "It" was referring to OMM/manipulation/etc...

Anyway, no need for me to beat a dead horse. I'll just say that I agree with his assessment that hesitant DO students are may use the 'EBM argument' to legitimate their concerns that are more akin to fear of being ostracized for endorsement of quackery.

 

[bones]

I was trained to evaluate CTS in much the same way, with the addition of the Phalen's sign, which our literature identifies as the most sensitive test in the physical exam. In fact, one of the hand surgeons from my internship would obtain an NCS/EMG if symptoms were consistent with CTS but Phalen's couldn't reproduce symptoms.

I agree, the pre- and post-NCS/EMG would be very interesting. Honestly, I think I would need to see those. I understand what you're describing, but it's a difficult thing for me to believe in, which I'm sure you understand. How many carpal tunnel releases do we do every year in this country? But it can be fixed with manipulation? Hard pill to swallow.

Intuitively (and of course I have nothing to back this up but opinion) I would want to argue that what you're seeing isn't actually true carpal tunnel, and is actually partial nerve entrapment of one of the cutaneous nerves, chronic pain from a prior sprain, or something like that. It's a lot easier for me (and probably most allopaths) to believe that manipuation results in pain relief, rather than a true anatomic alteration. Hence our constant mocking of BOOP.

Your descriptions do raise a lot of questions in my head though. I'll definitely be paying more attention to ROM in potential CTS cases. I doubt I could learn to do the manipulation you describe on my own, but should I run across any DOs in the future, I'll make sure I ask them about it and try to get a demo.

If you run into random DO's they probably will not be able to do much with CTS or other nerve entrapments beyond what you do. I as a specialist in OMM didn't know what to do until a few years ago and didn't start getting real results on almost every case until the last 1-2 years.

I don't expect you to believe me on such slim evidence, and I wouldnt want you to. The point is to raise these questions. If you have an extra 2 week elective floating around and don't mind hazarding rural america and want to see some for yourself you're welcome to come do a rotation with me and I'll show you the before and after and the process i use to get there... I usually get a few upper extremity nerve entrapment cases per week so you will probably get to see a few. You'd also see a how I manage a variety of other conditions- various types of acute injuries (meniscal injuries might be most interesting to you- but I might only see one every few weeks), chronic pain, migraines- etc.

As for phalens- yes it is sensitive, but not specific. Vascular or neurologic TOS can also give a positive phalens (especially if the patients arms are held up the whole time) and it compresses multiple structures so different nerve entrapment sites would all potentially be irritated (even Guyon's canal). I prefer very precise information which allows me to know exactly what is going on. Sensitivity is not the issue, as there are very- few case of arm numbness that I cannot find a precise neuro or vascular etiology for by following the process I described above. Once known, the etiology is almost always easily fixed. Almost always full nerve function is restored.

My recollection from my 3 ortho surgery rotations in training is most patients were warned that the nerve might already be too damaged and sensation may not 100% return- and that is what happened in a good number of cases. In retrospect I think most of those cases actually represent double crush as I described above, or maybe even primary median nerve impingement at the proximal median nerve at the pronators- meaning surgery was done at the wrong place.

 

[bones]

If you have an extra 2 week elective floating around and don't mind hazarding rural america and want to see some for yourself you're welcome to come do a rotation with me and I'll show you the before and after and the process i use to get there... I usually get a few upper extremity nerve entrapment cases per week so you will probably get to see a few. You'd also see a how I manage a variety of other conditions- various types of acute injuries (meniscal injuries might be most interesting to you- but I might only see one every few weeks), chronic pain, migraines- etc.

fair warning though... the CEO at the hospital is building a new surgery center and if she heard you were coming for a rotation she might try to recruit you as we don't have ortho up here yet. At least she pays top dollar 😛

 

[bones]

Honestly, I think I would need to see those. I understand what you're describing, but it's a difficult thing for me to believe in, which I'm sure you understand. How many carpal tunnel releases do we do every year in this country? But it can be fixed with manipulation? Hard pill to swallow.

Intuitively (and of course I have nothing to back this up but opinion) I would want to argue that what you're seeing isn't actually true carpal tunnel, and is actually partial nerve entrapment of one of the cutaneous nerves, chronic pain from a prior sprain, or something like that. It's a lot easier for me (and probably most allopaths) to believe that manipuation results in pain relief, rather than a true anatomic alteration. Hence our constant mocking of BOOP.

This is exactly why I'm bothering to write this thread. These results do not appear to be contained to carpal tunnel cases either- they extend to many areas of medicine. Very few people in the country can produce results like this, but those that can appear to be able to reproduce them consistently- and these results should be studied in depth with every objective means of measuring we have available.

I don't know of any cutaneous nerves would produce the neuropathic distributions I speak of, mild sprains do not typically irritate nerves. I think my explanation makes more sense- though yes I agree it is a hard pill to swallow. It makes me somehow feel responsible for all the patients out there I dont get to see- which makes me want to see more patients - but it doesnt take long to do the math- no matter how hard I work there is no way I can see all of them even in my small town much less the rest of the US or the world. My time is better spent in education, trying to reach future docs that will each see many thousands of patients, or perhaps schools which will each influence millions of patient care visits, or research which might directly influence all of medicine. Unfortunately there are many more qualified people to be doing large NIH studies. I should probably collaborate with a team of highly qualified PhD's and physicians- and to do that I need to find or build a team. I'm not there yet.

 

[primadonna22274]

Hey Bones...I got OMT Review and an older (cheaper) edition of Foundations of Osteopathic Medicine...I think it's starting to click...maybe 😉 thanks for the advice--will check with the school OMT clinic for volunteering...and please keep posting!
Lisa

 

[dAnthony1918]

This thread is fantastic.

 

[bones]

This thread is fantastic.

Thx.

I've been away for a while teaching and seeing patients. Dozens of new cases I could post. Too little time to do all of them. If anyone has specific topic requests let me know. U can also pm me or try to shadow me for 2 wks or a month.

I have been doing more urgent care stuff lately to avoid going crazy with so much pain stuff. Last Friday I had 4 cases of sinusitis, all of which left my office with no sinus pressure or congestion and only one of which did I end up writing abx for. (I was worried she might be coming down w pneumonia too and though her rib movement was great post tx she was somewhat more frail).

The process I follow for sinusitis involves simply normalizing fascias of thoracic inlet, normalizing cervical spine mechanics, and using BLT on maxillary or frontal bones. The boggy ness over the sinuses should resolve within seconds and all the pressure and pain should drop off at that precise moment. Usually the patient reports drainage or a funny feeling in their face or neck which may continue for up to a day or two. After that they should be symptom free. This is a vastly better outcome than steroids and abx in most cases.

 

[acesup123]

So bones, where do you practice and are you a family med doc? I'm interested in learning more about that CTS treatment as I know family members with CTS and are too scared to go under the knife.