Osteopathic family physicians embody the philosophy of whole-person care, including using a biopsychosocial approach to incorporate mental health into patient care. The creation of the Behavioral Health Integration Collaborative increased support for a system-level adoption of whole-person care in primary care settings. With the increase in both mental health symptoms and diagnoses among Americans, and the increasing support for integrated physical and behavioral healthcare in the primary care setting, this paper shares various approaches, as well as challenges to, adapting integrated care in the primary care office. This includes reviewing best practices for implementing this care approach. The two leading models for integrated care are the Primary Care Behavioral Health (PCBH) model and Collaborative Care model (CoCM). Both models include clinically embedding licensed mental health professionals into the primary care setting, thus increasing access to colleagues with this specialized approach. The PCBH model utilizes a warm hand-off approach, resulting in a collaboration between physician and mental health provider in the care of the patient. The CoCM focuses on a registry of patients who are overseen by a behavioral health manager with treatment decisions guided by a consulting psychiatrist. Blended models are also emerging to better suit the needs for different practices and the patient populations they serve. Challenges to full implementation include acquiring buy-in from practice leadership, hiring appropriately trained mental health providers, and defining billing and coding procedures.
Many osteopathic textbooks include treatment modalities and techniques that could improve frequently experienced ailments of pregnancy, such as nausea, vomiting, gastroesophageal reflux disease, constipation, and edema. However, there is little scientific evidence to support the use of osteopathy for these conditions, particularly among the pregnant population. The aim of this literature review is to identify and evaluate current evidence regarding the use of osteopathy in the management of common discomforts of pregnancy. Several search engines and journals were used to identify peer-reviewed articles written between 2003 and 2023. Eleven articles were included in total, including a variety of case reports, pilot studies, and journal articles. The results show that although osteopathy does appear to be safe to perform during the third trimester and its efficacy in the treatment of these conditions is promising, current evidence is insufficient to guide treatment protocols. Further research is needed to establish efficacy and determine osteopathic treatment regimens.
Infertility affects one in four female physicians in the United States, yet the topic of fertility among female physicians is understudied and warrants focused strategies to implement change. Factors that exacerbate the rates of infertility in female physicians include intentional delays in family planning that are driven by the length of medical training and career advancements, age, long working hours, and physician burnout. While the effects of COVID-19 on reproductive health remain uncertain, the virus may have played a role in illuminating an already existing issue in women’s reproductive health. Burnout rates among female physicians have reached record highs contributing to reproductive disorders that warrant well-deserved attention to this issue. Initiatives should focus on fertility education in undergraduate medical education, organizational-level interventions, better insurance coverage for infertility treatments, and addressing burnout. Collaborative efforts between individuals, institutions and organizations are needed to prioritize reproductive health among female physicians.
Histiocytic sarcoma is a rare and frequently missed diagnosis. With unusual and varied presentations, it typically indicates a rapid patient decline and poor outcomes. The diagnosis requires a high degree of clinical suspicion. In this case, we explore the progression of illness in a 56-year-old white male who initially presented with a 2-week history of soft-tissue nodules scattered throughout his head, neck, torso, and limbs, as well as shortness of breath and knee pain. After a thorough workup including computed tomography imaging of the neck, chest, and lower extremity, as well as a biopsy of a nodule with immunoperoxidase staining, a diagnosis of histiocytic sarcoma was established. Due to the severity of his malignancy, his hospital course was complicated by a deep vein thrombosis. Clinicians should be mindful of the risk of acute decompensation in such cases and can employ the various tenets of osteopathic theory to improve patient quality of life. Depending on the severity of illness, physicians may proceed to facilitate end-of-life measures with grace and dignity.
Chronic limb-threatening ischemia (CLTI) is an advanced form of peripheral vascular disease with high rates of morbidity and mortality. Patients often present with claudication, impaired walking, and ischemic pain. Screening for CLTI and peripheral arterial disease is recommended with ankle-brachial indexing. To prevent progression to CLTI, family medicine physicians can intervene with lifestyle modification of hyperlipidemia, obesity, smoking, and encouraging well-rounded high-fiber diets. OMT can be useful in increasing lower-extremity circulation and collateral-vessel development. If refractive to optimized medical management and lifestyle modification, surgical intervention is required. Regardless of intervention, CLTI maintains a high rate of morbidity and mortality, with halting progression being the primary objective.
Human parechovirus (HPeV) infections have been increasing in the United States since May 2022, according to the Centers for Disease Control and Prevention. HPeVs are a member of the Picornaviridae family and share similarities with enteroviruses, though they differ in genomic structure. HPeV commonly affects children, with disease manifestations ranging anywhere from an asymptomatic infection to severe disease. HPeV typically affects the gastrointestinal and respiratory tracts but may rarely also cause severe infection of the central nervous system (CNS), leading to sepsis-like illness, meningitis, and encephalitis. Of the 19 established serotypes of HPeV, serotypesA1 and A3 are most commonly identified in humans. HPeV serotype A3 is of particular importance as it more commonly causes sepsis and CNS infection, especially in children. In the United States between 2014 and 2016, a total of 2758 cases of enteroviruses and parechoviruses were reported to the National Enterovirus Surveillance System. Of those cases, 2.3% were distinguished as HPeVA3. This case details the clinical course of an eight-day-old infant with HPeV meningoencephalitis. The infant initially presented with fever and other nonspecific symptoms, which later progressed to include diffuse erythroderma and seizure activity. Although current management of HPeV meningoencephalitis involves supportive care and close monitoring, determining HPeV as a cause of infection is important due to the long-term sequelae that patients may develop. Potential complications of infection include white matter lesions of the brain, cerebral palsy, developmental delay, and visual impairment. This case was documented to increase awareness of the rising incidence of HPeV infections in children in the United States, as well as to detail the signs and symptoms of HPeV meningoencephalitis in a neonate.
Primary care physicians are crucial in diagnosing and managing hand and wrist pain. As the first point of contact for patients, primary care physicians develop individualized treatment plans, which may involve prescribing medications, recommending physical therapy, providing joint injections, or referring patients to appropriate specialists. By coordinating care and closely monitoring patients’ progress, primary care physicians play a vital role in improving patients’ quality of life and ensuring appropriate referrals and interventions are pursued when necessary. This article will review common hand and wrist orthopedic disorders and help primary care physicians better understand hand and wrist pathophysiology and management.
Rheumatoid arthritis (RA) is a chronic autoimmune disorder that primarily affects the joints. The condition causes inflammation, pain, stiffness, and sometimes deformity in the affected joints. RA can also affect other parts of the body, including the lungs, heart, and eyes, and it can lead to long-term disability if left untreated. By this report, we aim to: (1) evaluate the effectiveness of osteopathic manipulative medicine (OMM) as a treatment option for RA, with a focus on the patient’s symptoms and overall quality of life, and (2) identify best practices for incorporating OMM into a larger treatment plan for RA. We present a vignette case of a 56-year-old female patient with a diagnosis of RA treated with OMM. While awaiting hydroxychloroquine clearance, the patient was treated with radiocarpal extension dysfunction (post isometric relaxation), counter strain of the dorsal wrist, and high velocity, low amplitude (HVLA) of the posterior radial head dysfunction with a supination emphasis. On follow-up, the patient noticed significant relief of her symptoms after treatment and reported that her pain level had diminished to 0/10. This report highlights the effectiveness of OMM in treating RA symptoms. The patient’s follow-up information supports the initial improvement in symptoms and suggests that OMM may reduce wrist pain in a patient with RA a few weeks posttreatment. Further studies should be evaluated to see the effectiveness of OMM techniques for RA across an entire patient population.
Colorectal cancer is a leading cause of morbidity and mortality in the United States. Family physicians play an integral role in educating patients about the current screening recommendations and modalities of available screening to improve early detection and allow treatment at its earliest stages. Family physicians must have the tools to minimize barriers to screening, alleviate patient concerns about screening modalities available, and educate patients on lifestyle modifications that have the potential to significantly lower the risk of developing colorectal cancer. Osteopathic physicians should consider the five osteopathic treatment models when developing an individualized plan for each patient.
Hip pain and disorders are commonly seen in adults and children in the primary care setting. Primary care physicians can manage many of these disorders through physical examinations and basic radiographs, but some may pose a challenge requiring advanced imaging and specialist intervention. This article will review 12 common hip injuries encountered in primary care, when conservative management is feasible, and when a specialist referral is necessary.
There is historical and modern evidence for the use of osteopathic manipulative treatment (OMT) to treat patients with mental health disorders. The first section of this article examines the historical perspective, focusing intently on the Still-Hildreth Sanatorium. This hospital specialized in the osteopathic treatment of mental illnesses. While it was open, it saw patients with diverse mental disorders and reported exceptional recovery rates. However, some data from this institution were destroyed, so this perspective is incomplete. The second part of this article examines modern osteopathic research into this topic. Although there is some literature supporting the use of OMT for mental disorders, overall, it is underwhelming. Few mental illnesses have been researched, and for those that have been, there are too few studies to reliably assess the outcomes. Moreover, these studies have limited sample sizes, further affecting their credibility. To accurately gauge the benefits of OMT, future work should overcome these limitations.
Low back pain (LBP) is a common complaint in adolescents and has been increasingly reported in recent years. Affecting roughly 40% of adolescents, it leads to negative overall health, higher incidence of LBP in adulthood, and greater utilization of health care resources over one’s lifetime. LBP in adolescents differs from adult populations due to variations in structural anatomy, which contribute to differing approaches in diagnosis and treatment of this condition. The differential diagnosis of LBP in this population is extremely broad and can be attributed to many underlying etiologic factors. Clinicians must conduct a thorough history and physical examination and consider the appropriate diagnostic testing to accurately diagnose adolescents early on in their conditions to provide the most effectivetreatment. Treatment for this condition ranges from rest and rehabilitation, to oral medications, OMT, bracing, and rarely, surgery. Physicians must also be able to recognize clear risk factors and symptoms for serious underlying pathology that can be causing LBP. This article will focus on diagnosis and treatment of the most common causes of LBP in adolescents.
Suicide rates are alarmingly higher among emergency responders than the general public, and it is estimated that 30% of first responders develop behavioral health conditions compared with 20% in the general population. Emergency responders experience their share of work-related stresses, but mental health problems in this demographic are often under-reported. For example, only 40% of suicides committed by emergency responders are reported. Amid these issues, there is a lack of best practice guidelines for mental health treatment among emergency responders. Hence, the stage is set for legislation to focus on improving mental health among emergency responders. The Helping Emergency Responders Overcome (HERO) Act seeks to improve mental health among emergency responders through improved detection, prevention, and treatment, ultimately leading to decreased rates of suicide. The HERO Act would implement data systems to capture rates and risk factors related to suicide, establish behavioral health and wellness programs within emergency responder departments, and implement evidence-based best practices to identify, prevent, and treat post-traumatic stress disorder in emergency responders. Osteopathic family medicine physicians play a crucial role in screening and managing poor mental health among their patients. Caring for the body, mind, and spirit is a core tenet of osteopathic medicine; therefore, osteopathic family physicians are uniquely positioned to help emergency responders overcome their mental health struggles. Given the prevalence of emergency responders who receive care from such physicians, and the value osteopathic medicine can offer this population, we encourage the profession to contribute to discussions surrounding the HERO Act.
Chronic pain is defined as pain that has persisted for greater than 6 months. This type of pain may last longer than 6 months and can continue even after the injury or illness that has caused it has healed or resolved. Pain signals can remain active in the nervous system for weeks to months and even years. Individuals with a chronic pain syndrome can experience severe negative effects on their activities of daily living and their mental well-being. The osteopathic philosophy and osteopathic manipulative treatment (OMT) set the osteopathic physician up to provide a comprehensive treatment plan to manage patients with chronic pain. To direct osteopathic techniques to address pain, it is imperative to understand the anatomy and physiology of the way pain is signaled to the central nervous system. Pain can also be classified into multiple categories based on the origin of the signal, which is essential to decipher to direct therapy. The goal of osteopathic care in chronic pain syndrome is to relieve musculoskeletal somatic dysfunctions and to normalize sympathetic and parasympathetic neural tone. This would create the optimal environment to induce the body’s own self-healing capabilities.
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that primarily affects women and people of Hispanic, African, and Asian descent. The treatment goals are similar to other autoimmune diseases: preventing progressive damage to organs and decreasing disease activity to increase patient quality of life. Steroids can lead to rapid control of symptoms but have many longterm side effects; patients should be transitioned to steroid-sparing agents and new biologics when possible. Special populations require specific considerations, such as those experiencing renal or neuropsychiatric symptoms or drug side effects or those who are pregnant or planning to conceive. Sustained remission is very difficult to achieve, and current guidelines recommend targeting a low SLE activity state to optimize quality of life. An osteopathic approach to managing SLE attempts to reflect the principles of osteopathy into evidence-based medicine to optimize quality of life.
Context: Up to 15% of concussed patients experience persistent symptoms and functional impairment following injury. This is often related to headaches, dizziness, imbalance, and visual disturbances. Objectives: To perform a systematic review of the evidence for interventions used to manage postconcussion symptoms in working-aged adults falling within the headache-migraine, ocular, and vestibular postconcussion symptom cluster subtypes. Methods: A literature search was performed according to the PRISMA statement. PubMed, OVID, Cochrane Central, PEDro, OSTEMED, and the grey literature checklist were searched from the dates of creation of each database through December 29, 2020. The outcome measures were compared by generating the standardized mean difference (SMD) with 95% confidence intervals. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) was used to rate the overall quality of the evidence. Results: The literature search identified 496 candidate studies. After removing duplicates, 352 studies remained. The titles and abstracts of the remaining studies were screened for eligibility and 343 studies were excluded. The full text of the remaining nine studies was assessed for eligibility and risk of bias. None of these studies was excluded. This left nine studies for qualitative and quantitative analysis. Conclusions: Moderate-quality evidence suggests 4 interventions show promise for treating adults with headache-migraine, ocular, and vestibular postconcussion subtype symptoms.
The novel coronavirus disease 2019 (COVID-19) has given rise to a global pandemic, as well as a multitude of long-term sequelae that continue to perplex physicians around the world, including in the United States. Among the most common and impactful long-haul symptoms experienced by survivors is COVID-19 fatigue. This review will use long COVID-19, post-acute COVID-19 syndrome (PCS), and Post-Acute Sequelae of COVID-19 (PASC) as synonymous terms to refer to the chronic symptomatology; chronic fatigue associated with PASC will be referred to as COVID-19 fatigue. While the knowledge and research on the exact pathophysiological mechanisms involved in the disease is still limited, parallels have been drawn between fatigue as a component of long COVID-19 and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Current studies suggest applying principles of pathophysiology, diagnosis, and treatment similar to those for ME/CFS in order to aid in managing chronic fatigue in COVID-19 survivors, particularly in the primary care setting. The osteopathic family physician can use the proposed pharmacologic agents, along with osteopathic manipulative treatment (OMT), as therapeutic modalities that can be tailored to each patient’s unique case. Nevertheless, research on proven successful treatments is still scarce. For that reason, it is essential that COVID-19 fatigue is recognized early, especially since its longitudinal impacts may be debilitating for many. This review of the available literature on COVID-19 fatigue aims to help provide quality care and lessen the disease burden experienced by patients.
Context: Chronic pelvic pain syndrome (CPPS) is a complex pain syndrome that affects 15%–30% of people of childbearing age (~10–20 million, US). Etiologies range from musculoskeletal conditions and visceral disease to neurological and psychological disorders. The interplay of many systems and disorders can manifest into a complex pathophysiology that is difficult to diagnose and treat. Dysfunction of the musculoskeletal system is often involved in patients with CPPS, either as the cause of pain or the result of underlying disease or dysfunction. Hypertonicity of pelvic floor muscles, myofascial trigger points, and dysfunctional shortening of the levator ani group of muscles contribute to the structural and functional abnormalities involved in CPPS. Osteopathic physicians are in a unique position to directly address this somatic dysfunction with a nonpharmacologic, nonsurgical approach: osteopathic manipulative treatment (OMT).Objectives: The purpose of this article is to review the literature on manual treatment efficacy for high-tone pelvic floor dysfunction (HTPFD) and the standardization of diagnosis to provide rational, medically based treatments. The second purpose is to elucidate the steps that the medical, and specifically the osteopathic profession can take to standardize pelvic floor evaluation, diagnosis, and treatment in the primary care setting. Methods: A search was conducted on the US National Library of Medicine’s PubMed database for studies involving manual therapy treatment for HTPFD. The authors excluded studies that described manual therapy interventions aimed at increasing pelvic floor muscle tone in patients with urinary incontinence and/or pelvic organ prolapse.Results: For perspective, the initial search using the keywords “chronic pelvic pain syndrome” led to 2,281 publications since 1974; the addition of “osteopathic” led to 10 results since 2009. The search for “high-tone pelvic floor dysfunction” led to 30 publications since 1992; the addition of “osteopathic” yielded no results. To evaluate the efficacy of manual therapy for HTPFD, the search was expanded to include any manual therapy protocols. While the consensus in the literature is that manual treatment for chronic pelvic pain (CPP) is efficacious, the finding is limited by the lack of a comprehensive protocol to appropriately diagnose and treat the patient. The authors propose a system to standardize the assessment of a patient with CPP in the primary care setting by an appropriately trained physician so that pelvic floor dysfunction is recognized, properly diagnosed and treated, or referred to specialized care.Conclusion: The literature supports that manual therapy is an effective treatment for CPP, and as primary care providers, osteopathic physicians are uniquely placed to recognize and treat patients with HTPFD, providing an empathetic, patient-centered approach. Standardization of the diagnosis and manual treatment of HTPFD is required to assess and monitor patients systematically. Development of an advanced training program for clinicians to learn diagnostic approaches and OMTfor the pelvic floor should be required since the techniques addressing the pelvic floor musculature are often not included in traditional training.
Chronic scrotal content pain affects 100,000 men in the United States annually. Up to 50% of these cases do not resolve by following conventional treatment algorithms and are deemed to be idiopathic. There is little peer-reviewed literature supporting the specific cause and effect relationship between pelvic floor dysfunction and chronic scrotal content pain. Additionally, the specificity of the physical exam in these types of patients is not present in the literature. Overall, the literature is deficient in proposed treatment algorithms that address the large number of cases that are deemed to be idiopathic. Patients presenting with chronic scrotal content pain may benefit from an osteopathic diagnostic and treatment approach. In these types of patients, we recommend osteopathic manipulative therapy (OMT) or pelvic floor manual therapy prior to surgical intervention. This conservative approach may reduce the large portion of cases that aredeemed to be idiopathic. The emphasis on structure and function within osteopathic medical education places osteopathic family physicians in a unique position to be able to properly diagnose and treat this type of pain. Since most cases of chronic scrotal content pain are initially addressed in the primary care setting, it is important for osteopathic primary care physicians to remain vigilant in considering musculoskeletal dysfunction when evaluating these types of patients. This clinical review is underscored by a unique case presentation of a male collegiate athlete who helps demonstrate the larger gap that is present in the literature on male pelvic floor and scrotal content pain.
