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The Osteopathic Approach to Chronic Pain Management: Assessing Its Biopsychosocial Processes and Relationships to Clinical Outcomes
Licciardone, J. C. [75]
Lin, A. [4]

Journal: Journal of Osteopathic Medicine Date: 2019/12, 119(12):Pages: e118-e120. doi: Subito , type of study: descriptive study

Full text    (https://www.degruyter.com/document/doi/10.7556/jaoa.2019.128/html)

Keywords:

chronic pain [204]
descriptive study [37]
low back pain [413]
prescription [14]
USA [1086]

Abstract:

Statement of Significance: Chronic low back pain is a common symptom responsible for primary care visits and a major cause of disability. The osteopathic approach to chronic pain management is thought to be distinctively based on osteopathic principles. These include: (1) the human being is a dynamic unit of function; (2) the body possesses self-regulatory mechanisms that are self-healing in nature; (3) structure and function are interrelated at all levels; and (4) rational treatment is based on these principles [1]. Such principles are highly congruent with the biopsychosocial model of pain. This study will assess how aspects of the biopsychosocial model may be manifested in differences between patients with chronic low back pain who are treated by DOs or MDs. Research Methods: A total of 345 patients were selected for study from the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION Pain Research Registry) at the University of North Texas Health Science Center from April 2016 through April 2019. A comprehensive overview of the registry, including procedures for collection of patient-reported data and biological specimens, has been published elsewhere [2]. The Dallas-Fort Worth metroplex of over 7 million persons served as the catchment area for the registry during this period. Patient selection criteria included: (1) being 21 to 79 years of age; (2) having chronic low back pain according to criteria established by the National Institutes of Health Task Force on Research Standards for Chronic Low Back Pain [3]; (3) having sufficient English fluency to respond to study research instruments; and (4) having the same physician for low back pain care for at least 1 year. Patients were excluded if they reported being pregnant or institutionalized. Current use of NSAIDs and opioids was assessed at the baseline visit. The Pain Catastrophizing Scale (PCS) [4] and Pain Self-Efficacy Questionnaire (PSEQ) [5] were also administered to patients at this visit. The research protocol was approved by the North Texas Regional Institutional Review Board (#2015-169). All eligible patients provided written informed consent prior to enrolling in the registry and participating in the study. Data Analysis: Differences in the frequency of use of NSAIDs or opioids in patients treated by DOs or MDs were assessed using contingency table methods, including odds ratios (ORs) and 95% CIs (CIs). The underlying distributions of PCS and PSEQ measures were examined for adherence to the assumption of normality using the Kolmogorov-Smirnov test. Differences between patients treated by DOs or MDs were then tested with the Student's t test or Mann-Whitney U-test as appropriate. Statistical analyses were performed with the IBM SPSS Statistics software (version 23, Armonk, NY). All hypotheses were tested at the 0.05 level of statistical significance using 2-sided alternatives. Results: A total of 100 (29.0%) patients were treated by DOs. There were no significant differences in age, gender, race, ethnicity, educational level, employment status, or legal claims relating to low back pain between patients treated by DOs or MDs. Among patients treated by DOs, 57 (57.0%) and 25 (25.0%) used NSAIDs or opioids, respectively, as compared with 168 (68.6%) and 91 (37.1%) among patients treated by MDs. Thus, patients treated by DOs were significantly less likely to use NSAIDs (OR, 0.61; 95% CI, 0.38-0.98; P=04) or opioids (OR, 0.56; 95% CI, 0.33-0.95; P=.03). Neither PCS (P<.001) nor PSEQ (P=0.01) measures were normally distributed. Patients treated by DOs reported significantly lower pain catastrophizing scores than patients treated by MDs (median PCS score, 8; IQR, 4-22 for DOs vs median PCS score, 16; IQR, 8-29 for MDs) (P=.001). Patients treated by DOs also reported greater pain self-efficacy scores than patients treated by MDs (median PSEQ score, 40; IQR, 27-50 for DOs vs median PSEQ score, 35; IQR, 23-45 for MDs) (P=.049). Conclusion: This study found that DOs were significantly less likely than MDs to prescribe NSAIDs or opioids for their patients with chronic low back pain. These findings are generally consistent with previous research [6-7], and now suggest that DOs more closely adhere to current clinical practice guidelines for treatment of chronic pain [8], including low back pain [9]. These findings may also reflect principles of osteopathic medicine, such as self-regulation and self-healing, which enable DOs to more often use non-pharmacological treatments such as osteopathic manipulative treatment to address structure and function before considering pharmacological treatments. Patients treated by DOs also reported lower levels of pain catastrophizing and greater pain-self efficacy. The latter findings suggest that osteopathic philosophy and practice are closely aligned with the biopsychosocial model of pain that considers not only local pathology in developing a treatment plan, but that also addresses psychological and social aspects of the patient's overall experience and environment to help optimize medical care. Additional research is being conducted by us to determine if better pain and functioning outcomes are reported over 6 months of follow-up by patients treated by DOs as compared with patients treated by MDs and, if so, to identify factors associated with osteopathic medical care that may be related to such better outcomes.

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