Treat what you find: Osteopathic medicine and multiple sclerosis

My approach to osteopathic treatment is based on four words: Treat what you find. It’s a philosophy I picked up during my extra year in med school as an OMM Fellow at Touro University College of Osteopathic Medicine-California. At the time, I was reading up on treatment models like biomechanical, respiratory-circulatory, etcetera. Out of curiosity, I asked John Glover, DO, who was on faculty at the time, what model we use. Those four words were his answer.

As a treatment philosophy, it’s simple yet all-encompassing. I leaned on these words during my year as a fellow. By the end of the year, I was quite comfortable using OMT in patient care.

But that is not the story I’m here to tell. I’m writing to tell the story of a pickle I found myself in, and how I got myself out.

This story begins during my intern year of residency, a time when you’re mostly terrible at everything in medicine. Everything is unfamiliar. Terrifying. So, you try to lean on anything that you know reasonably well, just for comfort.

For me, that was OMT, the one area of medicine where I felt competent. I applied it liberally in clinic. I offered OMT for every ache and pain not well treated with NSAIDs. I used it for acute colds. I even offered treatments to patients with symptoms of complex illness already treated with standard of care. That is how I met Geri.

Geri’s story

Geri is a patient in her 60’s, with a PMH predominated by secondary progressive multiple sclerosis, the type of MS with constant symptoms. On our first visit, I met a woman experiencing frequent and visible muscle spasms that resulted in chronic pain. She was on appropriate medical therapy which included muscle relaxers and physical therapy. Despite this, there remained a heavy burden on quality of life.

As a new (and helpless) family medicine resident with no clue where to start, I offered OMT. Admittedly, I offered it as an experiment because I did not expect to cure her MS, and I wasn’t all that sure it would even help. She was willing to try.

The initial structural exam was paradoxical, with Geri’s anatomy pulled into directions I didn’t think possible. An innominate rotated anteriorly with the sacral torsion rotating into it, the other innominate with an inferior shear and yet the lumbar muscles contracted downward with it. There was scoliosis in the thoracic spine bending left but with right shoulder somehow inferior. Oh, and the most stubborn SI joint. All this created by a body pulling itself apart.

Our first session was an osteopathic battle, and I lost, beaten by spontaneous spasms that were elicited by both passive and active movements. I used every tool I could to help adjust transition points in the body, like applying Mitchel Model, correcting major somatic dysfunctions with positional releases or direct force. All of these techniques set off spasms that radiated throughout the body. This was reproduced over and over again.

No muscle energy. No positional release. No Mitchel Model. No HVLA. What to do?

I did what we often do in medicine when the treatment just doesn’t fit: Take a step back. Go back to the basics. Back to “treat what you find.” I also did that other thing we like to do in medicine: read.

What did I find? Besides the complex somatic dysfunction, this is a patient who had a decades-old spinal fusion of T8/9 with removal of right rib 8. There was significant scarring with fibrotic changes extending throughout the back. And then there was that SI joint, so horribly stuck. These seemed like two big pieces of the puzzle. But how to treat them?

A search for “OMT for MS” turned up very little. Findings could be summed up as: treat diaphragms, restore motion. Well, sure. But little help in this case. When I’m stuck in osteopathic medicine, I like to read up on A.T. Still. His technique is somewhat mysterious because his teachings are full of riddles. Like when he told a student struggling with a patient to figure out “how to turn the liver.” He didn’t want to tell his students the answer because he believed the real answer was understanding physiology.

When you understand the body, there is no technique, just putting things into place however possible. I found Von Buskirk’s Still Technique Manual extremely useful. For a patient who spasms in response to muscle contraction and manipulation, it seemed like use of compressive forces might be my best bet.

New approach

So, with a new approach in mind, we met for our next session. I went to work on the old surgical scarring in the back with extensive myofascial work and cross fiber massage. From there, we used a lot of compression into large areas of the body and specific vertebra to get a release—all aided by a well-timed dose of baclofen.

There was still that stuck SI joint. I decided to just force the thing, slowly and deliberately, using a low-velocity-high-amplitude treatment. There was a good deal of spasm, but I found that if I waited, I could time my forces in the short windows of relaxation between the spasms. We had some success that day. The patient kept coming back.

Fast forward 20 treatments over 12 months, and we’re getting somewhere. We have continued this osteopathic dance of striking between the spasms. The physical exam is making more and more sense as symmetry improves. Most importantly, the patient has experienced a reduction in pain and improved quality of life.

We haven’t changed the course of MS, and the daily struggle for this patient is real and challenging. But the associated somatic dysfunction can be addressed, resulting in a positive improvement for a patient who had previously been maxed out on medical intervention. According to Geri, “My physical therapist told me, ‘Ya know, this is just how it’s going to be.’ Everyone told me that, but not Dr. McHenry!” And that’s what OMT is all about.

Related reading:

OMT and cerebral palsy: A patient-centered approach