REVIEW ARTICLE The Role of Non-Opioid Analgesic Techniques in theManagement of Pain After Ambulatory SurgeryDepartment of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, TexasIn describing how patients feel after surgery, adelayeddischargefromtheday-surgeryfacilityortoArmitage (1) stated that “slapping the patient on theunanticipated
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Koya.nyit.eduClinical Integration of Osteopathic Manipulative Medicine
Family Medicine: Fibromyalgia
Author: Zahava Hersh, OMS IV and Sheldon C. Yao, DO Introduction: Fibromyalgia is a chronic pain disorder of unknown etiology characterized by widespread
pain, abnormal pain processing, sleep disturbances, and psychological distress. Criteria for classification
of fibromyalgia by the American College of Rheumatology is the presence of widespread pain for at least
3 months and pain on palpation in at least eleven of eighteen anatomic sites called tender points. Early
Fibromyalgia is prevalent in 2% of the population, affecting an estimated 5 million adults. However, it
affects women more than men at a 7:1 ratio. Furthermore, prevalence among women increases with age,
reaching 7.4% among females who are 70-79 years old. Treatment of fibromyalgia includes both
pharmacologic and non-pharmacologic methods. Manual modes of therapy such as OMT have been
promoted as therapeutic options for chronic rheumatic diseases on a theoretical basis but have not been
explored using controlled studies for treatment of fibromyalgia. Few studies however, have shown benefit
to treating fibromyalgia with OMT.
• Widespread musculoskeletal pain • Fatigue • Cognitive and mood disturbances • Headache • Sleep disturbances Differential diagnosis:
• Rheumatoid Arthritis • Systemic Lupus Erythematosis • Ankylosing Spondylitis • Polymyalgia Rheumatica • Sjogrens Syndrome • Inflammatory Myositis Clinical pearls and diagnostic tools:
• Fibromyalgia is a diagnosis of exclusion, described as pain that is not explained by another • Pathogenesis is multifactorial and includes genetic predisposition, neurohormonal disturbances, alteration in central nervous system pain processing, autonomic dysfunction, and peripheral nervous system hyperirritability. • Fibromyalgia is the most common cause of generalized musculoskeletal pain in women aged 20- • Commonly associated conditions include irritable bowel syndrome, painful bladder syndrome, • Standard treatment includes non-pharmacologic modalities including patient education, exercise, psychotherapy, OMT, relaxation techniques, and acupuncture as well as pharmacologic treatment with tricyclics (amitriptyline), SSRIs (duloxetine, milnacipran), or anticonvulsants (pregabalin) OMM Integration:
Although the exact etiology of fibromyalgia is not well understood, this musculoskeletal disorder
involves widespread pain in several body regions bilaterally including upper and lower extremities and
paraspinal regions the presence of multiple tender points, among other symptoms. In a study by Russell
Gamber et al it was found that OMT combined with standard medical care was more efficacious in
treating FM than standard care alone. In the study manipulative treatments including a combination of
counterstrain and other osteopathic modalities were performed in 15-30 minute sessions once a week to
tenderpoints identified as troublesome by the patient. Treatment was individualized to the patient, and
techniques used included myofacial release, muscle energy, soft tissue treatment, and craniosacral
manipulation. The participants were assessed in several ways including measurements of various
attributes of pain as well as assessment of activities of daily living and depression. Significant findings
were found between the treatment groups on measures of pain threshold, perceived pain, attitude toward
treatment, activities of daily living, and chronic pain attributes. In each of these areas the patients who
received OMT in conjunction with standard medical care had more favorable outcomes.
Additionally the pathophysiology of fibromyalgia according to the American Osteopathic Association
Annual Scientific Convention and Medical Education Conference is due to central and peripheral nervous
system sensitization. Therefore a goal of treatment in fibromyalgia patients is to restore and improve the
essential coordinated body functions including posture and motion, respiration-circulation and lymphatic
drainage, metabolic efficiency, and neurological. OMT is helpful in improving all of these body functions
since they each rely on the musculoskeletal system for their activities. Improving musculoskeletal system
functions improves motion and improves other body functions as well. Treatments recommended by the
AOA medical education conference include lumbosacral functional techniques, rib functional techniques,
upper thoracic spine muscle energy, diaphragm myofascial release technique, cervical functional and
counterstrain techniques, and TMJ muscle energy techniques.
Osteopathic Structural Examination:
• Presence of bilateral tenderpoints at the occiput, trapezius, supraspinatus, gluteal muscles, greater trochanter, cervical region, second rib, lateral epicondyle, and knee • Ribs • Diaphragm • Cervical, thoracic and lumbar spines • Sacrum • Mandible and temporal bones Possible Treatments Options:
• Counterstrain of various bilateral tenderpoints associated with Fibromyalgia • Rib raising • Myofascial Release • Muscle energy • Balance Ligamentous Tension (BLT) • Facilitated Positional Release (FPR) • TMJ treatments Citations:
1. Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum 2008;58(1):26–35. 2. Smith HS, Harris R, Clauw D. Fibromyalgia: an afferent processing disorder leading to a complex pain generalized syndrome. Pain Physician 2011;14 (2):E217-45. 3. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 1990; 33:160–72. 6. Gamber R., Shores J., Russo D., Jimenez C., Rubin B. Osteopathic manipulative treatment in conjunction with medication relieves pain associated with fibromyalgia syndrome: Results of a randomized clinical pilot project. JAOA 2002; Vol 102: No 6. 7. Seffinger M. Osteopathic Approach to the Patient with Fibromyalgia. American Osteopathic Association Annual Scientific Convention and Medical Education Conference. 2010.
GENERIC THERAPEUTIC COMPETENCES Knowledge and understanding of mental health problems During assessment and when carrying out interventions, an ability to draw on knowledge of common mental health problems and their presentation An ability to draw on knowledge of the factors associated with the development and maintenance of mental health problems An ability to draw on knowledge of the us