Chronic pain mechanisms encompass a complicated array of different processes (eg, genetics, neurophysiology, psychology, and biomechanics), each capable of contributing to clinical manifestations and symptoms. For OMM to be effective, similar symptoms in different patients may require dissimilar treatment plans that focus on differing local, spinal, and supraspinal targets. For example, chronic pain initiated by peripheral trauma may result when supraspinal structures continue to respond as if the peripheral tissues were actively injured. In other chronic conditions like fibromyalgia, the process may reflect an autonomic dysregulatory phenomenon or a dysfunction of descending antinociception pathways. Other conditions such as myofascial trigger points (MTrPs) demonstrate specific peripheral dysfunction at a spinal level perpetuated by nonspecific biomechanical factors, eg, untreated postural strain, or through viscerosomatic reflexes.
In many cases, chronic pain pathways involving allodynia (generalized lowered thresholds to pain) develop as changing gene expression allows silent receptors to become active in the spinal cord, or when facilitatory modulation results in what is called “spinal cord learning.”
7,8 In each case, the patient may simply present with persistent pain.
Therefore, rational OMT of patients with persistent pain cannot have a singular focus, nor can it be treated as a static phenomenon. In formulating multimodal treatment plans, OMM approaches embrace body unity principles and integrate palpation and OMT techniques into each patient's prescription. Choices concerning OMT techniques and goals depend on each individual's unique pain presentation, the suspected pathways involved in that presentation, and the regions diagnosed as containing somatic dysfunction.
A total review of diagnostic regimens and therapeutic options for persistent pain is beyond the scope of this article. Therefore, this article provides a concise overview of the OMM paradigm and introduces a general algorithm for pain management. Discussion of persistent pain management is limited to generalities that concern the integration of osteopathic principles and practice (OPP) in the use of OMT. Where pertinent, specific common chronic pain presentations are described as examples supporting the algorithm (
Figure 1).