Volume 105, Issue s4

Image-guided spine intervention is used primarily for its precise diagnostic capabilities. This article reviews basic principles of the more common image-guided diagnostic techniques specifically as they relate to patients with low back pain. It also includes discussion of advanced modes of therapy, including spinal cord stimulation and intrathecal therapy, providing primary care physicians with an understanding of the primary indications for these therapeutic modalities.

The headache problem with its debilitation and pain has been noted throughout medical history. It is one of the most common outpatient complaints and affects more than 45 million Americans. The lost days to work and family and the immeasurable suffering of patients can be lessened with the understanding and knowledge of a caring physician. Osteopathic physicians with expertise in holistic and musculoskeletal concepts are particularly well prepared to help. The establishment of an accurate diagnosis through a careful history and physical examination is essential before the physician can develop an effective treatment plan. Treatment can be abortive, prophylactic, or symptomatic, or a combination. Abortive treatment is geared to reverse the headache once begun; prophylactic treatment usually involves the use of daily medications to prevent, decrease frequency, or lessen severity of attacks; and symptomatic treatment is for relief of pain or accompanying symptoms. Most headaches experienced are of the tension type, whereas most debilitating headaches are of the migraine type. Cluster headache, though experienced by a small percentage of sufferers, is especially severe, and is useful in differential diagnosis.

Pain may be the most common reason patients seek treatment from physicians. When persistent and unrelieved, pain can frustrate both the person suffering with this condition and the physician trying to alleviate it. Relief from chronic pain may be particularly difficult to achieve and fraught with mis-conceptions. Treatment usually requires trials of physical, pharmacologic, and surgical interventions to achieve resolution. In cases that remain insoluble, patients must accept partial relief and seek adaptive strategies. The source of persistent pain may be nociceptive or neuropathic. Both utilize the same nervous system pathways for transmission, but significant physiologic differences exist in the mechanism through which the body processes and resolves these painful stimuli. Nociceptive pain that results from a known or obvious source (eg, trauma, cancer metastasis, ischemia, arthritis) is often easy to identify. Neuropathic pain, however, may occur in the absence of an identifiable precipitating cause. Physicians must remain alert to differences in presentation and course of neuropathic pain syndromes, some of which may be subtle or unusual.

Chronic pelvic pain is a common gynecologic complaint, affecting about 5% of American women. The differential diagnosis is broad, including many medical diseases, surgical indications, musculoskeletal problems, and somatic dysfunction. Women are more affected than men by pelvic pain because their bodies are subject to more changes. These changes include a cyclic hormonal milieu, major alterations in biomechanics during pregnancy, psychosocial stress, and other modifications during childrearing, and more adjustments during menopause. Both medical and surgical approaches to management exist, but integrative modes of therapy address the body-mind-spirit continuum. Osteopathic manipulative treatment is a valuable option for many affected women from childbirth to menopause.

Osteoarthritis (OA) is one of the most common forms of arthritis seen in primary care practice. The pain associated with this condition is the chief complaint of most patients, prompting them to seek medical attention. Pain can originate from the synovial membrane, joint capsule, periarticular muscles and ligaments, and periosteum and subchondral bone, among other sources. Osteoarthritis is traditionally thought of as a noninflammatory type of arthritis; however, inflammatory mechanisms can be present. Therefore, the management of osteoarthritic pain involves nonpharmacologic modes of therapy as well as pharmacologic agents. Nonpharmacologic therapeutic modalities include osteopathic manipulative treatment, physical therapy, exercise, use of assistive devices, and weight reduction. Pharmacologic options, categorized as topical, intra-articular, or oral, include acetaminophen, nonsteroidal anti-inflammatory agents, and cyclooxygenase type 2 inhibitors. Patients often benefit from use of a combination of these therapeutic modalities. Although pain relief is a chief motivator for patients with OA to seek medical attention, a secondary benefit of successful treatment is to delay the decreased quality of life associated with osteoarthritic pain.

Osteopathic manipulative medicine (OMM) incorporates diagnostic and therapeutic strategies that address body unity, homeostatic mechanisms, and structure-function interrelationships. In regard to pain, osteopathic physicians take thorough histories guided by palpatory examination to determine the quality, duration, and origin of this condition, how it uniquely affects the individual, and whether segmental, reflex, or triggered pain phenomena coexist. Osteopathic manipulative medicine expands differential diagnoses by considering somatic dysfunction and treatment options by integrating specific aspects of complementary care into state-of-the-art pain management practices. Prescriptions formulated through an OMM algorithm integrate each osteopathic tenet with biopsychosocial and patient education models and medication, rehabilitation, and manual medicine techniques proportionate to individual needs.