Integrating osteopathic manipulative treatment into prenatal care visits in a family medicine resident clinic

Barriers: clinic environment and logistics

All prenatal appointments were 30 min in duration. The length of the appointment was a prominent barrier to integrating OMT due to the required aspects of prenatal care visits and the characteristics of a resident clinic. The amount of time available for OMT was most dependent on patient comorbidities, specific complaints on that clinic day, and if an interpreter was utilized during the clinic visit. For instance, visits where additional lab work, imaging, or medication management took place left less time for OMT. Examples include managing gestational diabetes, chronic or gestational hypertension, and incongruence between fundal height and gestational age that required imaging. Chronic conditions or pregnancy-related maladies were always of higher priority than MSK pain.

A challenge unique to resident clinics was being mindful of the time required to present each patient to the supervising physician before each visit was complete. This typically took 2–5 min per patient. Another resident-specific barrier was experience providing prenatal care. Prenatal care visits in the resident clinic were longer to allow more time with patients and for resident education.

The setup of the examination rooms, the type of examination table, and the lack of OMT tables in the clinic served as barriers to integrating OMT (Figure 1). Like many clinics, none of the examination rooms in our clinic had OMT, massage, or portable OMT tables. Our examination tables did not have a height adjustment, and the head of each table was in the corner of the room preventing the clinician from being able to stand at the head of the bed or behind the patient. Unfortunately, the examination tables were not able to be moved due to size and weight. Examination table type and location made it difficult to screen and treat the cervical and thoracic spine.

Figure 1:

(A–C) images of the examination table and room layout taken from different angles.

The last clinic environment barrier was suboptimal awareness of OMT by patients, nursing staff, and support staff. The overall awareness of OMT and osteopathic medicine by patients and clinic medical staff seemed less in comparison to previous states in which the resident performing OMT had trained (Missouri, Michigan). This was not quantified during clinic visits; rather, it was noted throughout the course of 1 year when offering and discussing OMT with patients and clinic staff. Notably, all other first-year residents and supervising physicians in the clinic were aware of OMT and its utility in pregnancy.

Barriers: supervising physician awareness of OMT in pregnancy

Because OMT is a procedure, resident physicians must have an attending physician present or readily available in clinic when performing OMT. Attending physician knowledge and comfort with OMT may impact the ability of residents to offer OMT. Our clinic attendings did not perform OMT in pregnancy but were aware of OMT and its benefits. Prior to utilizing OMT, it was necessary to review with the supervising physician the evidence describing the efficacy of OMT, its safety, modalities to avoid, and the contraindications of OMT in pregnancy. These discussions also included which modalities would be utilized and avoided when treating patients. If OMT was performed, the MSK complaint, the OMT modalities utilized, and the treatment response were included in the patient presentation to the attending physician.

Barriers: treating physician knowledge of OMT in pregnancy

Another barrier we identified was the treating physicians’ clinical experience performing OMT in pregnancy and the recall of OMT in pregnancy. This included having less experience modifying treatment based on equipment in the room (i.e., immovable examination table, poorly placed table for OMT). The treating resident had far more experience treating nonpregnant compared to pregnant adults due to clinical training and makeup of traditional family medicine practice.

Second, the treating resident had a general sense of evidence supporting OMT in pregnancy, the modalities contraindicated, and the techniques to alter OMT in pregnancy. However, a review of each of these areas was needed prior to performing OMT in pregnancy and discussing it with the attending physician. We were not able to identify a succinct resource that contained contraindications to OMT in pregnancy, modalities to avoid, patient positions to avoid, and examples of altering treatments in pregnancy. We searched for literature describing integrating OMT into routine clinic visits or prenatal care visits, although the data were limited. The lack of a succinct resource for OMT in pregnancy, specifically one that can be readily accessible via smartphone or laptop, served as a barrier, especially early on in the study period.

Solutions: clinic environment and logistics

Clinic appointment duration was the most notable barrier to integrating OMT in pregnancy. A previous study regarding the use of OMT in the resident clinic setting also noted time as the most significant reason that residents were not able to perform OMT [22]. Routine prenatal care always took precedence over MSK complaints along with any conditions we were managing. In addition, integrating OMT was difficult if an interpreter was required. These barriers simply left less time to perform OMT if MSK complaints were present. The variability in time allotted for OMT prevented us from implementing a protocolized treatment approach such as screening all body areas of each patient with MSK complaints and treating noted somatic dysfunctions. Appointment duration barriers were overcome by performing complaint-specific OMT, thinking through how treatments would need to be altered in the clinic space, and for pregnancy prior to clinic visits.

The next notable barrier was the exam room layout and equipment. This challenge by familiarizing self with clinic space prior to patients being present. We thought through which treatments would need to be altered based on our space, and such treatments included diagnosis and treatment of the cranium, cervical spine, thoracic inlet, and upper thoracic spine (Table 4). We were unable to assess cranial motion in our space. We had patients hang their legs off the side of the table while sitting upright to screen the axial spine. For diagnosis and treatment of the cervical spine, thoracic spine, and thoracic inlet, we either elevated the head of examination table or had the patient sit in a chair. We did not have a portable OMT table available in the clinic; however, a portable table could eliminate many of the challenges associated with standard examination tables and those that are poorly placed.

Barriers posed by the clinic room layout, equipment, and appointment duration were best remedied by reviewing the clinic space before patient arrival, visualizing how techniques would be altered in given space, and performing complaint-specific OMT.

The last barrier noted from a clinic environment standpoint was the limited awareness of OMT by patients and clinic staff. This was likely due to the resident clinic being located in South Dakota. There are no osteopathic medical schools in South Dakota, and only one of the six states bordering South Dakota has an osteopathic medical school [23]. The 2022 Osteopathic Medical Profession report includes total DOs in practice by state. Only 0.2 % of all DOs in America practice in South Dakota [24]. The number of osteopathic physicians in South Dakota likely impacts the awareness of OMT.

Improving awareness of OMT for patients and clinic staff was done during and between appointment times, often by answering questions posed by patients or staff. Patient and clinic staff knowledge of OMT may be further improved by having materials available in the waiting room and examination rooms as well as the clinic staff work areas describing osteopathic medicine. These resources could include purchasing brochures created by AOA that describe OMT and what a DO is. A free option includes printing resources from osteopathic.org (findado.osteopathic.org/faqs). This site has individual webpages with brief lay-person descriptions of: what is a DO, what is osteopathic medicine, and OMT. Finally, resident-or faculty-led lectures to the clinicians and clinic stuff would improve awareness of OMT. We were not able to include printed-out resources or lectures to clinic staff during the study period.

Solutions: supervising physician awareness of OMT in pregnancy

Supervising physician familiarity with OMT may impact integration of OMT in prenatal care. Prior to utilizing OMT, resident physicians must ensure that attending physicians are aware of what OMT is, its proven safety, evidence for treatment of MSK pain in pregnancy, and which modalities we intend to utilize. This sounds like a challenging task; however, most osteopathic physicians will merely need to review OMT resources. From a safety and efficacy standpoint, numerous studies have demonstrated both the safety and benefit of OMT in pregnancy such as King et al. [25] with 321 participants, Licciardone et al. [8] with 144 women, and the PROMOTE study with 400 pregnant women [26].

Finding resources to review for OMT in pregnancy was challenging, especially in the clinic environment where textbooks or notes from medical school were not readily available. Overall, it was difficult to find literature, PowerPoint slides, or online textbooks that were succinct and readily available while having these discussions in the clinic.

We had conversations about OMT with attending physicians prior to patients being in a room and ready to be seen. This allowed time for supervising physicians to ask questions, clarify, and have a good understanding of what OMT in prenatal care looks like. Tables 1 –4 review contraindications, modalities to avoid, and strategies to integrate OMT. These tables were created to serve as a concise tool to review OMT in pregnancy. We viewed questions or uncertainty about OMT by colleagues as opportunities to develop rapport and educate. We improved supervising physician awareness of OMT in pregnancy and developed a rapport by discussing literature regarding OMT in pregnancy and reviewing OMT resources from medical school.

Solutions: treating physician knowledge of OMT in pregnancy

Resident physicians and medical students may have fewer total encounters treating pregnant patients due to the makeup of the family medicine panel, medical school training, or clinical rotation site. Luckily, the palpatory skills, screening techniques, and knowledge of various OMT modalities do not suddenly become useless if a patient is pregnant. Just like performing OMT on patients in hospital beds, pregnancy presents itself as a similar and equally doable challenge.

The resident performing OMT initially noted challenges with immediate recall of OMT in pregnancy. Before the first day in the obstetric clinic, the treating physician reviewed contraindications to OMT in pregnancy, modalities to avoid, and studies of OMT in pregnancy. We also thought through ways in which OMT would need to be altered to reflect the patient’s MSK complaint, examination room setup, and pregnancy (i.e., avoiding supine techniques in the third trimester). The vast majority of OMT in pregnancy content review occurred within the first month of beginning the resident obstetric clinic. Not having certainty of which modalities and positions to avoid, along with how techniques should be altered, can reduce resident physician confidence or create anxiety surrounding OMT in pregnancy. The treating resident utilized lectures and personal notes from medical school, the Foundations of Osteopathic Medicine textbook, and PowerPoint slides available online by osteopathic physicians. Tables 1 and 2 were created to allow for concise review of contraindications to OMT in pregnancy and what modalities to avoid [10, 13, 14]. Technical treatment tips include avoiding the supine posture during the third trimester, the use of a wedge or raising the head of the table during the third trimester, and utilizing the lateral recumbent position.

Next, we reviewed our clinic space to determine if any treatments would need to be altered or would not be feasible. Once our clinic space was reviewed, we visualized how OMT would be performed in our given space. Our confidence performing OMT in pregnancy was improved after reviewing evidence for contraindications and modalities to avoid. Our first few treatments were likely smoother because we reviewed our clinic space and visualized how we would perform OMT.

We recommend developing a succinct explanation of OMT for patients who have not heard of OMT previously. Finally, if patients have what seems like MSK pain, we recommend considering alternative diagnoses to avoid missing more serious maladies of pregnancy such as venous thromboembolism or symptoms of preeclampsia.

Limitations

Our study limitations relate to having one location and one resident physician providing OMT during prenatal care. Each clinic and residency training setting will have different examination room setups, clinic staff, and attendings with differing knowledge of OMT. The total number of patients seen was also limited by having one resident physician offering OMT.