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