DERMS DO 5: A Proposed Curriculum for Dermatologic Training in 5 Osteopathic Competencies

Direct

OMT can be classified as direct, engaging the pathologic restrictive barrier, or indirect, moving away from the restrictive barrier. One of the most frequently used OMT techniques is muscle energy, a direct treatment that has been shown to alleviate chronically contracted restrictor muscles that compromise the body's normal range of movement^9,10 (Table 2). The mechanism is thought to involve the effect of the Golgi tendon reflex on the agonist and antagonist muscles, the pair of muscles that cause and inhibit a movement, respectively.^11,12 Specifically, Golgi tendon organ activation results in direct inhibition of agonist muscles, and a reflexive reciprocal inhibition occurs at the antagonistic muscles. As the patient relaxes, agonist and antagonist muscles remain inhibited, allowing the joint to be moved further into the restricted range of motion.

This quick, concise technique can be used to optimize the skin's biomechanical-structural relationship. Patients undergoing excisions, especially Mohs micrographic surgery of multiple layers, are often contorted in unnatural positions for extensive periods of time, likely leading to somatic dysfunctions. A brief application of muscle energy to the regions involved following the procedure would likely be appreciated by and beneficial to these patients. It is also particularly applicable for dysesthesia syndromes, characterized as an unpleasant and/or abnormal sense of touch, which have been linked to nerve impingements. The sensation of pruritus is transmitted to the central nervous system through unmyelinated C-fibers and thinly myelinated Aδ nerve fibers.¹³ Numerous neuropathic conditions are known to cause dysesthesia and pruritus, such as notalgia paresthetica, classically presenting as macular amyloidosis on the medial scapula. Although the exact pathophysiology is unclear, a recent study showed that 61% of patients with the condition had underlying vertebral pathology.¹⁴ One proposed mechanism is that the spinal nerves of vertebrae T2 to T6 emerge from the multifidus muscle at right angles, leaving them susceptible to chronic injury.¹⁵ Other dysesthesia syndromes by region include burning mouth syndrome involving the oral mucosa, trigeminal trophic syndrome involving the nasal ala, cheiralgia paresthetica involving the hand, brachioradial pruritus involving the dorsolateral forearm, meralgia paresthetica involving the anterolateral thigh, pudendal neuralgia and pruritus ani/scroti/vulva involving the perineal area, and postherpetic neuralgia, typically unilateral and involving 1 to 3 unilateral dermatomes.¹⁶ These cutaneous conditions may all benefit from muscle energy directed at the appropriate cord levels of the spine that correspond to the involved dermatome; however, further research is needed to investigate this.¹⁷ Other techniques such as soft tissue, myofascial release, and rib raising may also be adjunctive to muscle energy, as demonstrated in a case report of a patient with sustained improvement in her notalgia paresthetica following a single 20-minute treatment session with these techniques.¹⁸ Burning mouth syndrome in particular may be treated with a direct technique known as sphenopalatine ganglion release. The sphenopalatine ganglion's parasympathetic innervation derives from the facial nerve and contains sensory fibers from the trigeminal nerve.¹⁹ Stimulation of the ganglion may reduce xerostomia and pain by normalizing the activity of the parasympathetic nervous system and sensory components of the trigeminal nerve. To perform this technique, the 5th finger is used to manually massage and stimulate the sphenopalatine ganglion in the superior, posterior, lateral aspect of the patient's pharynx.

Empathy

In order to appreciate and approach a patient as a unit of mind, body, and spirit, the osteopathic physician must strive to understand his or her experiences, perspectives, and concerns. Empathy is the vehicle to achieve this level of insight. Interestingly, empathy has been shown to decline over time among allopathic physicians during medical school and residency.^20-22 Whether this same trend is observed among osteopathic medical students is unclear,^23-25 although higher empathy scores have been directly correlated to those who embrace the osteopathic philosophy and provide more frequent OMT.²⁶ Additionally, a recent survey found patients reported more favorable perceptions of osteopathic physicians than allopathic physicians on interpersonal manner and empathy.²⁷ It is well-known that the connection between the skin and the mind is a powerful one. Examples include the impact of stress on psoriasis, acne, rosacea, atopic dermatitis, and scars.^28,29 Also noted are high rates of depression, body dysmorphic disorder, and suicide in acne patients.³⁰ Additionally, the negative consequences of smoking on the integumentary system are well characterized.³¹ Further illustrating this observation are various psoriasis comorbidities, including sleep disorders, metabolic syndrome, and erectile dysfunction³²(Table 1).

Dermatologists can embody empathic skills by exploring these psychosocial comorbidities that frequently accompany cutaneous conditions and how they impact the patient as a whole, exemplifying the metabolic-nutritional osteopathic model. Counseling or referring patients to a psychiatrist may be considered when there are signs of psychologic distress. Healthy lifestyles with a balanced diet and exercise should routinely be encouraged. Scars should be approached with treatments to help improve cosmetic outcomes (eg, employing Mohs surgery appropriate use criteria, or considering how a facial scar will look not only at rest but with dynamic movements).³³ Educating patients can be very influential, such as explaining how and when to apply topical products for maximum results or the importance of keeping scars covered from the sun and applying sunscreen after surgery. Numerous resources exist to help dermatologists simplify and achieve this task.³⁴ Nonverbal communication can also play a role in empathy. Making eye contact improves communication and trust and understanding of the patient. Respect for personal space by sitting at the same level as the patient increases the physician's ability to move closer in a nonthreatening manner, rather than standing close and talking down to convey superiority. When performing OMT, communication is essential and achieved by clarifying objectives, answering questions, asking permission, and describing intentions with each movement and position. All of these factors can make the patient more receptive to treatment if the physician is culturally competent and recognizes the unique perspectives of physician-patient relationships among different cultures.

Restore

The neurologic model of osteopathy emphasizes the close relationship between the somatic and autonomic nervous systems, connected through neuro-reflex pathways and allowing manipulation of sympathetic and parasympathetic functions.¹ OMT serves in the neurologic model to balance neural outputs, eliminate nociceptive drive, and restore autonomic function, which can be especially important in disorders with over- and underactivation of these systems.¹ Rib raising is a quick, efficient articulatory technique that encompasses this model. It is designed to decrease sympathetic tone, decrease afferent nerve signals, attain autonomic balance, and achieve pain relief. It can easily be implemented for dermatologic complaints.³⁵ Because the thoracic sympathetic ganglia lie anterior to their corresponding rib, gentle pressure on these ganglia initially produces a short-lived increase in sympathetic activity, followed by long-lasting sympathetic inhibition. This may be useful for cutaneous conditions with hypersympathetic activity such as hyperhidrosis or “burning mouth syndrome.” Hyperhidrosis can be a challenging condition to treat in dermatology and is thought to be due to localized hyperfunctioning of sympathetic fibers passing through the T2 and T3 ganglia. The rib raising technique may also be beneficial for patients with acute herpes zoster and postherpetic neuralgia, which is caused by the nerve inflammation leading to chemical and anatomical coupling between sympathetic postganglionic and primary sensory neurons.³⁶ Rib raising may therefore be a valuable supplement before or in addition to pharmacologic or surgical therapy for these conditions.

Mobilize

Complaints related to lymphatic dysfunction are common in dermatology, including stasis dermatitis, lipodermatosclerosis, lymphedema, chronic wounds, and atopic dermatitis.^19,37,38 Lymphatic pumps have been shown to have positive effects on the B- and T-cell components of the immune system.³⁹ Improving fluid imbalance can be very beneficial, especially in low-pressure venous and lymphatic states, by increasing total leukocyte count, interleukin-8, keratinocyte-derived chemoattractant, and other immune factors in lymphatic flow following treatment.⁴⁰ Lymphatic dysfunction can also play a role in pruritus, because the reduction of lymphatic drainage causes a build-up of inflammatory mediators in the skin.¹⁵

The respiratory-circulatory model emphasizes normalization of a patient's pulmonary and cardiovascular functions, as well as the circulation of fluids such as lymph, blood, and cerebrospinal fluid. The first step in any lymphatic treatment is to open diaphragmatic restrictors. This reopens proximal lymphatic pathways so that fluid mobilized distally can flow unimpeded back to the heart. Next, a lymphatic pump technique such as effleurage may be applied. The treatment location should be selected based on the distribution of the skin complaint, such as the area involved in an atopic dermatitis flare. Leone et al³⁷ proposed having atopic dermatitis patients and/or their parents perform this technique at home while applying emollients and creams in order to actively involve them in their care and ensure that an adequate amount of time is spent applying medications so that the medications are fully absorbed into the skin; Leone and colleagues created a sample patient handout to take home for this task.³⁷

These techniques can also be valuable when applied to the lower extremities for venous stasis dermatitis and ulcers. A recent meta-analysis showed the healing benefits of exercise in venous leg ulcers because of the importance of calf muscle contraction during ambulation.⁴¹ After opening proximal lymphatic pathways, the pedal pump technique can be used to contract the gastrocnemius muscle, mimicking ambulation. To perform this technique, apply a pump motion to the bilateral feet in a rhythmic fashion while patient is supine. The pedal pump is a simple bedside technique that can mobilize venous and lymphatic drainage back to the circulatory system. Various other lymphatic techniques applicable in dermatology have also been discussed by McIlwee et al.³⁸

Senses

The most obvious sense used during evaluation of the skin is sight. The other senses, however, are certainly not trivial. Even smell can offer insight into the clinical picture, such as the characteristic “grape juice” odor associated with Pseudomonas infections.⁴² Palpation of skin lesions may assist in identifying pathologies that would otherwise be missed by visual examination alone. Osteopathic physicians are wholly suited for this, with the art of palpation at the root of osteopathy. All osteopathic medical students are required to complete at least 200 hours of hands-on training in OMT, often starting on the first day of medical school.⁴³ Physicians should take full advantage of their palpatory skills during skin examinations to detect lesions that might otherwise go unnoticed. For example, an early actinic keratosis, a precancerous squamous cell carcinoma, may be detected more easily by palpation than by visual examination.⁴⁴ Physical palpatory examination findings can provide clues to the diagnosis, such as the dimple sign, Nikolsky sign, and dermatographism. Furthermore, palpatory skills can aid in identifying the depth of a lesion, which can then help in selecting the appropriate diagnostic test (eg, shave biopsy versus punch biopsy).

Touch supports a verbal-tactile interaction that is both diagnostic and therapeutic, offering meaningful and powerful potential to strengthen the physician-patient interaction.⁴⁵ Touching a patient's skin with intention complements the behavioral-biopsychosocial osteopathic model, providing reassurance that a rash (where appropriate) is not contagious, identifying tenderness, and assessing texture and temperature changes.⁴⁶ Therapeutic touch has been shown to promote relaxation of newborns in the intensive care unit, with reduction in their vital signs and basal metabolic rates, and to decrease pulse and respiration rates of patients before surgery.^47,48