The Osteopathic Family Physician's Role in Treating the Surgical Patient
OMT Facilitates Post Operative Healing, Reduces Pain
By Cameron Gates, OMS IV
Family physicians have a unique role in the care of their patients in that they can affect the health of an individual throughout that person’s entire life. From conducting a baby’s first well child exam to managing a patient’s hypertension and diabetes, the family physician is the true proprietor and advocate of health maintenance. This ownership is arguably one of the most important endeavors in medicine.
There are, however, periods during the patient’s life when the family physician seeks input from colleagues with broader expertise, sharing ownership of the patient’s health. Such a period is when the patient must endure a surgical procedure. Whether it is a simple hernia repair, or an ominous coronary artery bypass grafting, the family physician assumes a secondary role in the care of the patient and allows the surgeon to take the wheel during this operative interval.
Although the surgeon directs the operative course, the family physician can continue to contribute to the patient’s health and well being during the perioperative period. In fact, osteopathic family physicians are in a unique position to truly improve the quality of life for his surgical patient by visiting patients immediately postoperatively in the hospital, or arranging follow-up in the office soon after surgery.
In either scenario, family physicians can augment recovery using osteopathic manipulative treatment. Postoperative benefits of OMT include prevention of post-op ileus1, decreased incidence of atelectasis2, increased cardiopulmonary function4, increased lymphatic return5, and improved control of postoperative pain6. Following are a brief overview of these techniques, as well as a case report and review of research done to support the use of OMT.
Case Report
A 43 year-old female presents to the emergency department with diffuse abdominal pain. Her symptoms have worsened over the last three to four weeks, and she attributes the pain to “hemorrhoid problems.” The patient reports worsening in the last two to three days with the addition of nausea, vomiting, and diarrhea. She has also noticed blood in her stools. She rates her pain as a seven out of 10 in severity.
Her past medical history includes hypertension, angina, and gastroesophageal reflux disease, and her past surgical, social, and family history are unremarkable. She takes Metoprolol XL for blood pressure control, nitroglycerin for chest pain, and esomeprazole for reflux.
On exam, the patient appears alert and oriented and in moderate pain. Her temperature is 99.1, blood pressure 100/60, pulse 105, respirations 18, oxygen saturation 98 percent on room air. She appears volume depleted. Exam of the head, neck, chest including heart and lungs, and extremities is unremarkable. On abdominal examination, bowel sounds are diminished in all four quadrants. There are no visible pulsations. There is diffuse tenderness to palpation over all quadrants with increased tenderness over the left lower quadrant with guarding. Rebound is positive, and there are no aortic or renal bruits. On rectal exam, there is a palpable mass along the anterior wall.
On admission, the patient has the following abnormal labs: Potassium 2.6; WBC 27.8; Cortisol 30.3; CPK total 396 and CKMB 2.5; Total protein 2.8; Total bilirubin 3.7; Lipase 5.0; UA is positive for bacteria, leukocyte esterase, and blood. A CT of the abdomen shows findings concerning for bowel perforation with multiple areas of pneumoperitoneum and prominent stranding inflammatory changes involving the mesentery of the mid and lower abdomen. An ECG shows sinus tachycardia.
A diagnosis of bowel perforation was assigned based on clinical findings and imaging. The decision was then made to proceed with a laparotomy followed by a complete colectomy with terminal ileostomy. Pathologic review of surgical specimens showed ulcerative colitis.
The patient was admitted to the ICU postoperatively. On post op day #1 OMT was initiated to reduce the incidence of ileus. Techniques included soft tissue to the lumbar spine as well as inhibition of the iliotibial bands bilaterally. Fascial restrictions within the abdominal wall were also assessed and treated accordingly. OMT was also employed to augment the recovery of lung function postoperatively. Using the thoracic pump technique after releasing Sibson’s fascia augmented inspiratory efforts. Rib raising also helped correct functional limitations. The patient recovered and was discharged from the ICU without developing ileus or fever from atelectasis.
Review of Literature
The role of OMT for the surgical patient has been described for many years.9 Osteopathic studies throughout the last century have documented the benefit of use of OMT in decreasing or even preventing a variety of surgical complications. This discussion will be limited to those listed above.
Ileus is a major complication that can occur after most any surgery. Ileus is defined as “the functional inhibition of propulsive bowel activity, regardless of the pathogenic mechanism.”2 Differentiated from bowel obstruction, ileus is further divided into postoperative and paralytic.
Postoperative ileus resolves within two to three days post-op and usually is confined to the colon, while paralytic ileus continues longer and affects the entire bowel. It is important for the clinician to keep in mind the visceral facilitation locations of the GI system in the thoracic spine. The facilitated segments for the foregut (distal esophagus, stomach, and proximal duodenum) are T5-T9, for the midgut (the remainder of the small bowl up to the splenic flexure of the colon) are T8-T11, and for the hindgut (from the splenic flexure distally) are T11-L12. Pain from each of these areas of the GI system refers anteriorly to the epigastric, periumbilical, and hypogastric regions, respectively2.
In 1968, Herrmann1 presented his chart review of 317 surgical patients who received OMT postoperatively. Treatment was administered for two minutes every two hours, and only one case in those 317 was reported as developing ileus. Seven out of 92 patients who did not receive the same treatment did develop some form of ileus.
The recommended treatment approach to prevent ileus, as outlined in Foundations of Osteopathic Medicine includes, gentle inhibition of hypertonic thoracic and lumbar paravertebral muscles to the point of relaxation, indirect fascial release of the diaphragm, thoracic inlet, and mid-cervical spine, and treating Chapman reflex points along the outer thigh and paravertebral regions2.
Another complication of many surgeries is atelectasis, which can occur in up to 90 percent of patients having general anesthetic3. The most frequent side effect is an unexplained fever that begins less than 48 hours post operatively3. Because reversing it and expanding the collapsed alveoli is a completely physiologic process, OMT has a unique role in treating this complication.
In and of itself, atelectasis is not a worrisome problem. However, in severe cases, the decrease in oxygen exchange can lead to pneumonia. Anything the physician can do to prevent the development and worsening of atelectasis is a great service to the patient. Encouraging smoking cessation at least eight weeks before surgery can reduce the incidence of perioperative respiratory complications3. Often the incentive spirometer is used to facilitate deep breathing postoperatively. Proper head and chest angle positioning (60 degrees being more optimal than 30 degrees), and diaphragm mechanics are crucial for successful utilization2.
Doming the diaphragm via direct stretching and myofascial release can correct restrictions in respiration, and thoracic lymphatic pump can encourage deeper breathing and lymphatic return9. Knott, et al9, in 2005, demonstrated a statistically significant increase in lymphatic return through the thoracic duct using the thoracic pump technique. Also, positive pressure created by the physician’s hands prevents full chest wall expansion, opening collapsed alveoli. When the physician removes his hands, the sudden cessation of the external positive pressure augments the natural negative pressure within the thoracic cavity increasing lymphatic & cardiac return and volume of inspired air2.
Other authors have outlined treatment plans demonstrating the effectiveness of OMT in a specific surgical patient. Dickey4 illustrated the benefits of OMT in the post-coronary artery bypass graft (CABG) patient in a 1989 case report. A preoperative, early postoperative (within four weeks post-op), and a late postoperative treatment plan were included.
The patient should be screened preoperatively for rib cage dysfunction, breathing patterns, and somatic dysfunction of the cervical, thoracic, and lumbar spine as it relates to excursion of the diaphragm. Proper pre-op spinal, rib, and respiratory mechanics are important for a more expeditious recovery form anesthesia and intubation4. Before surgery, identified areas of somatic dysfunction should be treated according to techniques suitable for the patient. Following surgery, fascial strain patterns of the chest, back, and diaphragm can be addressed with indirect myofascial release4.
Rib dysfunctions can be treated with indirect methods, as well. Special attention should be paid to the cervical spine as this area has most likely been in static extension during the operation. A combination of flexion stretching, occipito-atlantal inhibition, and encouraging full range of motion will help return spinal mechanics to their preoperative state as well as normalize parasympathetics via the vagus4. Finally, trigger points along the trapezius muscles and the anterior chest wall can be identified and treated appropriately.
In 2005, O-Yurvati, et al.5 proved that following a treatment plan similar to that outlined by Dr. Dickey improves post-CABG cardiopulmonary function. In this pilot study, changes in thoracic impendence (an indirect measure of central blood volume), cardiac index, and mixed venous oxygen saturation (SvO2) were measured before and after post-op OMT. The authors found that using techniques such as balanced ligamentous tension, indirect myofascial release of the sternum, indirect release of the respiratory diaphragm, occipito-atlantal decompression, rib raising, and Sibson’s fascial release, augment the measured parameters mentioned above. An OMT group showed an increase in SvO2 of 3.7 percent while the control group decreased by 3.28 percent. The OMT group also had an increase in cardiac index of 0.51 whereas the control group’s CI only increased by 0.145.
From this data, the authors concluded that the benefits of OMT include: “(1) possible reduction in pulmonary complications (such as atelectasis and pneumonia); (2) possible reduction in length of stay in the hospital; and (3) possible decreased risk of fluid mismanagement [by augmenting lymphatic return and the cardiac index, which leads to an increase in renal perfusion], a problem that can lead to pulmonary edema or renal compromise”5.
Osteopathic principles allow for consideration of lymphatic flow, reminding us that maximizing cardiopulmonary function is an important consideration in the recovery of the patient. Rogers and Starzinki6 of the Detroit Osteopathic Hospital in 1989 utilized OMT to treat lymphatic vessels. The authors note how edema leads to peri-incisional edema and chest congestion. Early post-op treatment (as early as post-op day one depending on patient’s attitude and condition) can provide essential lymphatic benefits leading to decreases in third-spacing complications. After release of Sibson’s fascia, general lymphatic pump followed by pedal pump, stimulation of extremities with methods such as myofascial unwinding and peripheral-to-central lymphatic massage/milking, and rib raising can augment lymphatic return6.
Finally, the aspect of surgery for which the patient is most acutely aware is pain. Advances in pain management have greatly aided the physician in dealing with postoperative discomfort as well as the development of chronic pain.6 Most physicians rely solely on chemical analgesia, such as morphine sulfate.
Goldstein, et al.7, found that OMT reduces patient analgesic use after total abdominal hysterectomy. Patients were randomized and given either saline or morphine sulfate preoperatively. After surgery, all patients were offered morphine, but some were given true OMT while others were given a sham treatment. The sham treatment consisted of the physician placing his hands on the appropriate treatment area, either over the sacrum or paravertebral musculature, but no pressure was applied and no changes were made in patient position. Patients receiving preoperative morphine sulfate and postoperative OMT used less morphine sulfate (mg/kg) after surgery than all other groups, both 24 hours and 48 hours post-op. This was further quantified by measuring serum morphine sulfate concentrations, which were shown to be lower in this group as well. The osteopathic manipulative treatments employed were sacral myofascial release, and thoracic and lumbar myofascial soft tissue release7.
Discussion
In today’s world of modern medicine, where every minute counts and costs, it is convenient to employ a readily available medication or mechanical intervention to manage our patient’s health and recovery instead of implementing use of our hands and our time. Will our patients heal themselves without the benefit of OMT? The answer is, “most likely.” Will our patients heal themselves more expeditiously and with greater satisfaction if we employ OMT as an adjunct to baseline treatment? The answer is, “almost always.”
Although much of the aforementioned research focuses on specific surgical cases including the post-CABG patient and post-total abdominal hysterectomy patient, the treatment modalities and techniques described can be applied to any appropriate patient undergoing inpatient or outpatient surgery.
Several treatment plans and approximate amount of time needed to execute them efficiently are presented here. The physician’s particular focus during the visit and whether the patient is treated in the hospital setting or in the physician’s office will determine which modalities to utilize. Often patients can comfortably tolerate two to three techniques per session in the immediate postoperative period4.
Prevention of atelectasis (inpatient)*2,8:
Total time: four to six minutes once a day for the first 48-72 hours postoperatively
*choosing three of the above techniques for each treatment session is optimal and release of Sibson’s fascia should be included when any manipulation is performed that augments lymphatic return2
Prevention of ileus (inpatient)2:
Total time: five minutes, minimum treatment frequency is once per day
Decrease postoperative pain (inpatient or outpatient)7:
Total time: four to six minutes every 12 hours prn pain
Post-CABG patient (inpatient or outpatient)4:
Total time: five to nine minutes
Summary
Using the information and treatment plans above, the osteopathic family physician has a guide to using OMT to augment patient care prior to and following surgery.
Offering OMT to patients in the perioperative setting allows the osteopathic physician an opportunity to maintain continuity in the care of their patients. In addition, it has been demonstrated that using OMT postoperatively enhances the quality of the physician-patient interaction4, improves the physiologic response5, decreases post-op pain7, promotes faster healing4, and does not require a large time commitment.
Our patients are waiting and wanting to be cared for, and it is the gift of doctors of osteopathic medicine that they can use their hands to ease, comfort, and help heal.
Cameron Gates is currently a fourth year medical student at the University of North Texas Science Center – Texas College of Osteopathic Medicine in Fort Worth. He is expected to graduate in May 2008.
References
Other references not cited