Optimizing COPD
Outcomes Through the
Lens of Osteopathic
Medicine
Robert A. Cain, DO
October 2018
Disclosures for Robert Cain, DO
• No commercial conflicts to disclose.
• Dr. Cain is the author of “Promoting Osteopathic Thought in Clinical
Education, Every Patient, Every Day…”
• A pulmonologist by training, he operated a private practice in Dayton, Ohio
for fourteen years.
• He is currently employed by the Ohio University Heritage College of
Osteopathic Medicine as the Associate Dean for Clinical Education.
• Dr. Cain is an ACOI Board member and the immediate past chair of the
ACGME Osteopathic Principles Committee.
“The object of this corporation is to establish a College of Osteopathy, the design of which is to improve our present system of surgery, obstetrics, and treatment of diseases generally, and place the same on a more rational and scientific basis.”
Legal Charter of the American School of Osteopathy, State of Missouri, circa 1894
Doctors with a mission…
Andrew Taylor Still
Museum of Osteopathic Medicine,SM [1985.1023.08]
1890 2018
OMT
Disease
State
(presentation)
PATIENTInitiators
Responses
Health
Potential
“Determinants
of Health”
“Disease Care”
Describing An Osteopathic Approach
to COPD Patient Care
Smoking
Airway inflammation
Loss of elastic recoil
Bronchospasm
COPD
Guideline-based
diagnosis and treatment
“Health Care”Cain, R, Promoting Osteopathic Thought in Clinical Education: A Patient-centered, Systems
Approach to Health and Illness, 1st Edition, iTunes eBook, 2012
“Determinants of Health”
Structure-function relationships
Genetics
Immune system function
Nutritional state
Sleep quality/rest-fatigue balance
Functional state/level of activity and physical conditioning
Body habitus
Psychosocial health
Abuses/Behaviors
Cain, R, Promoting Osteopathic Thought in Clinical Education: A Patient-centered, Systems
Approach to Health and Illness, 1st Edition, iTunes eBook, 2012
Osteopathic MedicineAn Operational Framework for Approaching the Patient
Principles and Practice
The ‘Why’
To improve our present system of surgery, obstetrics,
and treatment of diseases generally
The ‘How’
Promotes structural
health of the body
Assists innate
mechanisms of the
human body to
function as intended
Recognizes the inter-
relationship of mind,
body, and spirit
Remains focused on
the patient, not on
their problem
The ‘What’
Incorporates manual
manipulation of
somatic structures
(OMT)
Medically and
surgically removes
impediments to
health and promotes
a healing
environment
Emphasizes primary
care
Emphasizes
biopsychosocial
aspects of care
Incorporates
empathic listening
“Thinks differently”
(Holistic)
Cain, R, Promoting Osteopathic Thought in Clinical Education: A Patient-centered, Systems
Approach to Health and Illness, 1st Edition, iTunes eBook, 2012
Promoting Structural HealthRational Application of OMT
DISEASE disease
HOSTIL
LN
ES
SILLNESS
ILLN
ES
S
The addition of OMT
better enables the patient
to realize their full ‘health
potential’
OMT is likely to be
successful with a
lesser role for
medical/surgical care
host Medical/surgical care is
most likely to be
successful with a limited
role for OMT
ILLNESS
Based upon the work of Edward Stiles, DO
Pikeville College-School of Osteopathic Medicine
Think ‘black box’
Think ‘initiators’ and ‘responses’
When initiating bronchodilator therapy for
COPD patients, my primary concern(s) is/are:
• Symptom improvement
• Functional improvement
• PFT/spirometry improvement
• A and B
• All of the above
How often do you test for functional improvement
when treating COPD in your office?
• 0-25% of patients
• 26-50% of patients
• 51-75% of patients
• 76-100% of patients
The 6-Minute Walk Test
• Has limitations
– Ceiling effect (at ‘near normal’)
– Self-paced (uncontrolled work rate)
– Training effect (improves with repeated testing)
– Mechanisms of exercise limitation and other contributors
• Is responsive to interventions
– Pulmonary rehabilitation, drug therapy, surgery (LVRS), oxygen
use
• Correlates with important outcomes
– Hospitalization
– Mortality
– QOL
Barst RJ, et al. AJRCCM 2004; 169:441-447, Holland AE, et al. Eur Respir J 2014: 44:1428-1446, Singh SJ, et al. Eur Respir J
2014: 44:1447-1478
CPT Coding
94618 (Pulmonary stress testing (eg, 6-
minute walk test), including measurement of
heart rate, oximetry, and oxygen titration,
when performed).
The total RVUs for 94618 (professional and
technical) are 0.97.
Multiplied by the conversion factor, this equals
about $35.00.
The be considered clinically significant the
minimum improvement in 6MWD must be:
• 10m
• 20m
• 30m
• 40m
• 50m
Based upon a systematic review by Singh SJ, et al. Eur Respir J 2014: 44:1447-1478
Interpretation of treatment changes in 6-minute walk distance in patients with COPD, M. A. Puhan, M.
J. Mador, U. Held, R. Goldstein, G. H. Guyatt, H. J. Schünemann. European Respiratory Journal 2008 32: 637-643
Adapted from CHEST Board Review 2017
Improvement in 6MWD associated with
tiotropium bromide therapy is approximately:
• 30m
• 60m
• 90m
• 120m
• 150m
Functional improvement following
use of an inhaled bronchodilator
• Effect of inhaled Tiotropium Bromide and inhaled Ipratropium
Bromide in severe COPD
– 32 patients
– Severe COPD (GOLD)
– Increased 6 minute walk distance by a mean of 57 meters at 6 weeks
(Tiotropium)
• 6-min walking test for assessing the efficacy of formoterol in COPD
– 22 stable patients
– Stage II to stage IV (predominantly GOLD stage III)
– Increased 6 minute walk distance by a mean of 54 meters at 6 weeks
Prakash O, Kumar R, Rahman M, Gaur S, The clinico-physiological effect of inhaled Tiotropium Bromide and inhaled
Ipratropium Bromide in severe Chronic Obstructive Pulmonary Disease, Indian J Allergy Asthma Immunol, 20(2), 105-
111, 2006
Cazzola M, Biscione, G, Pasqua F, Crigna G, Appodia M, Cardacci V, Ferri L, Use of 6-min and 12-min walking test for
assessing the efficacy of formoterol in COPD, Respiratory Medicine, 102 (10), 1425-1430, 2008
Improvement in 6MWD with the addition of OMT to
pulmonary rehabilitation is approximately:
• 10m
• 20m
• 30m
• 40m
• 50m
Using a Scholarly Question (PICO) to Promote
OPP in Daily Patient Care
• In a patient with COPD receiving standard therapy,
does the addition of OMT to pulmonary rehabilitation
(as compared to pulmonary rehabilitation alone)
improve exercise tolerance?
Functional Improvement
Associated with Application of OMT• Osteopathic manipulative treatment effectiveness in severe chronic
obstructive pulmonary disease: a pilot study.
– 20 stable patients treated with standard bronchodilator therapy
– Stage III, severe COPD (GOLD)
– Treatment group Increased 6 minute walk distance by 49 meters
compared to control group
Zanotti E, Berardinelli P, Bizzarri C, Civardi A, Manstretta A, Rossetti S, Fracchia C, Osteopathic
manipulative treatment effectiveness in severe chronic obstructive pulmonary disease: a pilot study,
Complement Ther Med, 20 (1-2), 16-22, 2012
Creating a Personalized Best Practice:The Components of Evidence-based Practice
Best Evidence
Clinical Expertise
Patient Interest
Personalized Best Practice
Best practice as represented by a level stool with four equal legs
Clinical Circumstance
Brunner-La Rocca et al., Challenges in personalized management of chronic diseases—heart
failure as prominent example to advance the care process , The EPMA Journal (2016) 7:2
Cain, R, Promoting Osteopathic Thought in Clinical Education: A Patient-centered, Systems
Approach to Health and Illness, 1st Edition, iTunes eBook, 2012
Promoting OPP in Daily Patient Care3 Steps for Success
1. Approach patients from the perspective of
delivering osteopathic (holistic) care, not
disease care
– Ask about and understand the patient’s determinants
of health
2. Follow the osteopathic ABCs
– Set expectations
• Think about the role of structural health
• Look for and treat somatic dysfunction
3. Demonstrate inquiry and improvement
– Use scholarly questions as a development tool
Follow the Osteopathic ABCs
• Autonomics
• Biomechanical
• Circulatory
• Screening
Teaching Osteopathic Principles and Practice: Easy as ABCs, Pierce-Talsma S, et al. The AAO Journal 2018; 28(2):34-38
Integrating the Osteopathic ABCs
into the Care of the COPD Patient
• Autonomics
– Contributions to airway tone and diameter and mucous production
• The best tool is likely pharmacological with bronchodilators
• Additional research is needed to determine the full impact of OMT
• Biomechanical
– Contributions to respiratory mechanics and functional improvement
• The best tool is likely pulmonary rehabilitation and OMT
• Circulatory
– Contributions to gas exchange
• The best tool is likely oxygen supplementation or fluid management
• Additional research is needed to determine the full impact of OMT
• Screening
– Supplements available diagnostic information and informs our decision
making
IATPYou can’t find somatic dysfunction
if you don’t look for it…
What are your thoughts about the role of OMT for the
treatment of COPD?
Did this presentation change your opinion?
If yes, propose a change in your practice to better
integrate OMM into the care of your COPD patients.
If no, what additional information or research would be
needed?
ApplicationFraming Questions
Osteopathic
Medicine
Where we are…
Where we want to be…
Bridging the Gap