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Letters to the Editor  |   July 2009
Response
Author Affiliations
• Carman A. Ciervo, DO
Department of Osteopathic Manipulative Medicine
Department of Family Medicine University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, Stratford
Article Information
Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment / Pediatrics
Letters to the Editor   |   July 2009
##### Response
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 377-378. doi:10.7556/jaoa.2009.109.7.377
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 377-378. doi:10.7556/jaoa.2009.109.7.377
Dr Sucher seems to express concern primarily about two topics in our clinical practice article1—one related to our recommendations on the use of osteopathic manipulative treatment (OMT) in neonates, the other to our citations of three articles that he wrote. We would like to take this opportunity to respond to these concerns. Afterward, we will respond to Dr Mychaskiw's letter.
In regard to Dr Sucher's first concern, he states that we “do not readily distinguish muscle strains' from plexopathy.” He further implies that we do not understand “that brachial plexus injuries in neonates are not considered a form of TOS [thoracic outlet syndrome].” However, the following complete statement from our article1 (which Dr Sucher quotes only in part) is a clear acknowledgment that brachial plexus injuries are not of the same etiology as TOS—though the anatomic area is the same in both conditions:

Although the etiologic processes involved in thoracic outlet syndrome and neonatal brachial plexus injuries are clearly different, the osteopathic principle of restoring form to improve function—assisting in the body's natural ability to heal itself—suggests that this OMT technique may improve neonatal function in patients with less severe injury as well.

As this statement suggests, it is important to apply basic osteopathic principles in the treatment of patients with either condition. The application of such principles is what makes osteopathic physicians unique.
Later in our article,1 we discuss muscle strains and the mechanisms that may lead to somatic dysfunction:

Muscle strains cause a reflexive relative shortening of the affected muscles, which acts as a protective mechanism. Therefore, adults and infants alike may have hypertonic muscles, reduced range of motion, and tissue edema.

Stretch injury in neonates as in adults initiates inflammatory response as well as myospasm and scar tissue formation. In addition, when used, involuntary splinting also results in limited range of motion that will require adjunctive exercise.

Treatment of any patient with a muscle strain should be directed toward restoring symmetry and removing areas of potential nerve impingement by addressing diagnosed somatic dysfunctions.

Furthermore, we carefully stratify the levels of treatment that are appropriate for patients with brachial plexopathy in the following passage1:

The mainstay of treatment for neonates and infants with brachial plexus injury is conservative, particularly when no evidence of substantial vascular compromise or motor loss is present.2 Standard treatment options include splinting and range-of-motion exercises.3

For neonates with severe injuries, such as nerve avulsion or rupture, invasive treatment options such as neurolysis or nerve transfer may be required. Infants with mild injuries who have not responded to standard treatment by age 3 months may also need surgical attention.4,5

A fundamental point that must be respected when using OMT is that there are indications and contraindications for its use. The only acceptable indication for which to use OMT is to remove somatic dysfunction. The use of OMT is appropriate only after a complete physical examination, as described in our article,1 and identification of any TART (Tissue Texture Abnormality, Asymmetry, Restriction of Motion, Tenderness) findings associated with somatic dysfunction. If there are no indications for using OMT in particular cases of brachial plexopathy or TOS, each of these conditions can be managed with conservative and surgical approaches—as widely recommended in the literature.
Dr Sucher's second concern is expressed by his statement, “Moreover, in the Osteopathic Manipulative Treatment' section of the article,1 I was concerned by the authors' citation and application of three articles that I wrote on the treatment of adults with [TOS].6-8“We did not intend to state that one should consider using in neonates the same aggressive, often painful direct myofascial stretching techniques used to treat adults. Dr Sucher clearly did not suggest using gentle techniques in his articles on the treatment of adults with TOS.6-8 However, during the editing process, the context of our original, intended meaning was inadvertently altered. A formal correction of this error appears on page 388.
In light of these errors, we understand Dr Sucher's concern. Our intention was to suggest that the osteopathic physician assess the neonate patient for somatic dysfunction and then consider using gentle myofascial stretching, along with careful patient monitoring, to remove the somatic dysfunction and restore normal anatomic relationships around the thoracic inlet area. The corrected version of our article more accurately reflects our original intent.
Common sense and constant monitoring of a patient's condition should direct the osteopathic physician's initial decision to use OMT, and tactile and visual feedback should direct the application of OMT. To blindly apply any technique to a patient without such careful monitoring is negligent. Our February article expressed these concepts in the following paragraph1:

Stretching of any myofascial structure on the restricted side can be achieved by restricting motion of one attachment and applying a gentle force longitudinally through hypertonic structures.... To reduce the possibility of injury, physicians should constantly monitor the tissues. In addition, osteopathic physicians should palpate for tissue texture changes or muscle spasms and watch for patient response to treatment such as grimacing or analgesic posturing.

Any physician guided by the basic tenets of osteopathic medicine will not simply use a “cookbook” approach to either brachial plexopathy or TOS. The complete physical examination and diagnosis of somatic dysfunction will allow the osteopathic physician to develop a rational individualized treatment approach for each patient. This treatment may include OMT in certain cases but not in others. The treatment technique chosen in each situation is relevant only to that patient.
Regarding Dr Mychaskiw's letter, he begins with a backhanded compliment that is unnecessary:

They are also to be complimented for their diagnostic skills. As an osteopathic physician who has participated in the care of infants for more than 15 years, I doubt that many other practitioners could perform the palpatory, visual, and range-of-motion examinations in the unsedated infant that are described by the authors.1 Certainly, such examinations are beyond my capability.

We note that, in a previous letter to the editor, Dr Mychaskiw9 wrote: “In my practice of pediatric cardiac anesthesiology, I do not use OMT.” Thus, perhaps he should not be expected to have the palpatory or observational skills needed to perform the examinations we described in our article.
Dr Mychaskiw next expresses concern about the lack of data presented in our article. Often, an idea for a research project is stimulated by a discussion, such as that represented by the current series of letters. We believe it would be quite appropriate for someone who may agree with our approach or a modification thereof to perform the research that Dr Mychaskiw is requesting.
However, if every aspect of clinical practice had to be based on double-blind placebo-controlled trials, there would be no room for individualized treatment or innovation leading to new research. A profession that allowed only the application of the results from such studies would quickly become stagnant. Furthermore, disciplines in the profession would become susceptible to takeover by less qualified para-professionals who could input data on signs and symptoms into a computer, read the resulting information on the computer screen, and mindlessly apply any treatment suggested on screen.
We do agree that the osteopathic medical profession should continue to support clinical research into the physiologic mechanisms and clinical outcomes associated with applying OMT adjunctively to patients who have identifiable somatic dysfunction.
We found the following comment by Dr Mychaskiw to be especially disturbing: “Finally, I fail to understand the point of including unsupported and nonreferenced statements in JAOA—The Journal of the American Osteopathic Association about the alleged benefit of therapeutic touch to `facilitate the body's innate ability to heal.'”1 We did not believe it was necessary to reference a statement that is so widely accepted by our profession that it is considered a basic tenet of osteopathic medicine. We believe that any DO who has remained in touch with the osteopathic medical profession would be aware of these tenets, which can be found in the latest edition of Foundations for Osteopathic Medicine.10
Mason DC, Ciervo CA. Brachial plexus injuries in neonates: an osteopathic approach. J Am Osteopath Assoc. 2009;109:87-91. Available at: http://www.jaoa.org/cgi/content/full/109/2/87. Accessed May 1, 2009.
Leffert RD. Thoracic outlet syndrome. In: Omer GE, Spinner M, eds. Management of Peripheral Nerve Problems. Philadelphia, Pa: WB Saunders Co; 1980:593-601.
Grossman JA. Early operative intervention for birth injuries to the brachial plexus [review]. Semin Pediatr Neurol. 2000;7:36-43.
Terzis JK, Kokkalis ZT. Shoulder function following primary axillary nerve reconstruction in obstetrical brachial plexus patients. Plast Reconstr Surg. 2008;122:1457-1469.
Gilbert A, Pivato G, Kheiralla T. Long-term results of primary repair of brachial plexus lesions in children. Microsurgery. 2006;26:334-342.
Sucher BM. Thoracic outlet syndrome—a myofascial variant: part 1. Pathology and diagnosis. J Am Osteopath Assoc. 1990;90:686-696,703-704.
Sucher BM. Thoracic outlet syndrome—a myofascial variant: part 2. Treatment. J Am Osteopath Assoc. 1990;90:810-812,817-823.
Sucher BM, Heath DM. Thoracic outlet syndrome—a myofascial variant: part 3. Structural and postural considerations [published correction appears in J Am Osteopath Assoc. 1993;93:649]. J Am Osteopath Assoc. 1993;93:334 ,340-345.
Mychaskiw G II. Will the last DO turn off the lights [letter]? J Am Osteopath Assoc. 2006;106:252,302. Available at: http://www.jaoa.org/cgi/content/full/106/5/252. Accessed May 27, 2009.
Seffinger M, King HH, Ward RC, Jones JM III, Rogers F, Patterson MM. Osteopathic philosophy. In: Ward RC, ed. Foundations for Osteopathic Medicine. 2nd ed. Baltimore, Md: Lippincott Williams & Wilkins; 2003: 5-12.