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Osteopathic Support For A Survivor of Gastric Cancer: A Case Report
Osteopathic Support For A Survivor of Gastric Cancer: A Case Report
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Case study
Abstract
This case study describes an osteopathic approach to improving the quality of life of a survivor of gastric cancer. An older male
patient received eight consultations over a period of 10 months, some three years after his cancer diagnosis and treatment. Osteo-
pathic management included manual treatment to improve musculoskeletal mobility, cranial osteopathic treatment to release ten-
sion in the deeper fascia, discussion of dietary strategies and advice and education about the origin of his symptoms due to a total
gastrectomy and cancer chemotherapy. After treatment his physical symptoms were reduced. His neck pain was reduced. Nausea
and discomfort after eating disappeared. Frequency of diarrhoea, breathlessness and fatigue were improved. He gained weight
and resumed social activities. This case study illustrates how osteopathy can play a role in the supportive care of cancer patients
after their conventional treatment; a wide range of systemic and musculoskeletal symptoms fall within the scope of osteopathic
knowledge and problem-solving skills. The training of osteopaths as primary health care practitioners equips them with a high level
of knowledge in pathology and differential diagnosis. Osteopathic consultations provide time to engage in complex problems that
may benefit from a holistic approach. The touch and body work involved in osteopathy can help the patient come to terms with
altered body image and to talk openly about anxieties. The Hay approach to diet appeared to be valuable in improving the quality
of life for this particular patient after his gastrectomy.
Ó 2008 Elsevier Ltd. All rights reserved.
1746-0689/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijosm.2008.03.005
J. Leach / International Journal of Osteopathic Medicine 11 (2008) 106e111 107
had worked as student advisor at a local further educa- in the stomach; B12 deficiency can cause pernicious
tion college until he was diagnosed with stomach cancer anaemia. At the time of presentation, he was still under-
in 2002. His main complaint was of chronic pain and going regular annual follow-up checks with his cancer
restricted rotation of the neck of several years duration. surgeon and six monthly reviews with his oncologist.
The neck ‘‘locked’’ most nights and the pains radiated During the treatment of his cancer, Mr B had
over the occiput which he described as ‘‘funny heads’’. received advice from the dieticians at both his local
His neck symptoms had been present for the past 5 NHS hospital and the NHS Cancer Centre where he
years, and had become worse in the past 2e3 years. received chemotherapy. The recommendations3 were to
The patient believed that the main cause of his neck eat frequent small meals, to use high-starch foods such
pain was his sleeping position: since his stomach cancer as rice, pasta and potatoes, avoid sugar and consume
in 2002, he had to sleep semi-reclined in order to prevent high calorie nutritious drinks; and in order to increase
gastric reflux. body weight, he had been told to include sugar and
His sleep was also frequently disturbed by episodes of consume full cream milk. He found these recommenda-
aching in the arms and legs at night. These symptoms tions difficult to comply with, being a long-term vegetar-
had bothered him for several years prior to his cancer ian used to wholefoods and he disliked full cream milk
diagnosis, and were partially relieved if he got out of and sugary foods which he complained made him feel
bed and walked about for some time. ‘‘breathless’’. He had adapted the advice, using rice
In addition, he mentioned a number of other symp- milk and oat milk, and at the time of consultation his
toms he had suffered since the cancer treatment: delayed weight was stable.
nausea after bending forwards for any length of time, For some months prior to presenting for osteopathic
extreme fatigue arising after normal levels of activity, treatment, he had been attending the local Cancer Sup-
abdominal discomfort for 1e2 h during and after meals; port Centre and had received hypnotherapy and Reiki (a
erratic and unpredictable bowel movements ranging form of faith healing originating in Japan) about which
from constipation to severe diarrhoea; pain and discom- he was very positive. He had a very positive approach to
fort during defecation followed by feeling ‘‘drained’’; getting back to normal activities, although his enthusi-
and intermittent bouts of breathlessness, unrelated to asm meant that he tended to over-tire himself at times.
exercise. The frequent erratic bowel movements re-
stricted him considerably, making him nervous of going 1.2. Physical examination
to new places or travelling on public transport. The
discomfort triggered by eating had made it difficult for On observation, he appeared thin and wiry. He
him to maintain or gain weight, and also restricted walked briskly, and appeared fit and alert, with bright
activity for several hours each day. He was having eyes, and firm skin of a healthy colour. He had a neat
difficulty gaining weight, having lost approximately gastrectomy scar down the midline of the upper abdo-
16 kg pre-operatively, and was about 60 kg when he men, and a smaller scar in the left groin from the hernia
presented for osteopathic treatment. repair. His thoracic posture was kyphotic, which he at-
Mr B’s previous medical history included partial tributed to having spent the first 20 years of his working
gastrectomy for bleeding ulcers in 1974, keyhole surgery life ‘‘bent over a composing frame in the printing trade’’.
for an abdominal hernia in 1994, haemorrhoid surgery Physical examination revealed that active cervical
in 1998, labyrinthitis in about 2000, total gastrectomy mobility was stiff and limited: rotation left was painful
and splenectomy in 2002 followed by chemotherapy in and less than 40 degrees. His range of neck flexion and
2003 for gastric cancer, and repair of a left inguinal extension were reasonable for his age. On palpation,
hernia in 2003. He had a severe familial hearing impair- the muscles of the neck and shoulders were hypertonic
ment since childhood, with which he coped well. and non-tender, especially upper trapezius. Passive
The patient reported that he did not know the stage movement of the cervical and upper thoracic spinal
of his cancer, but the surgeon had told him that the segments revealed multi-segmental limited movement
tumour was ‘‘the size of a tangerine’’, and that the especially at the level of the cervicothoracic junction
cancer had spread to six lymph nodes in the abdomen. (C7eT1). There were no neurological signs and forami-
The spleen had been clear of cancer but was adherent nal compression (Spurlings test) was negative for nerve
to the stomach due to prior surgery and was removed root irritation in the cervical spine. The abdomen was
because the bleeding could not be stopped. He had tense with thickened fibrous tissues in the area underly-
made a good recovery despite a 6-h operation. ing the scar. Using the model of the primary respiratory
His current medications included a permanent mechanism, the cranial rhythm was of low amplitude
prescription for daily prophylactic antibiotics to prevent particularly around the diaphragm, which prompted
opportunistic infection (routine after splenectomy). He the author to talk to him about emotions around loss
also received regular Vitamin B12 injections, as its of his stomach4; the impression generated during
synthesis depends on intrinsic factor normally produced palpation was of fear or rejection of this part of the
108 J. Leach / International Journal of Osteopathic Medicine 11 (2008) 106e111
body e such impressions may not have scientific validity making the process of digestion more difficult, removal of
but are often useful in clinical practice. The patient the stomach is reported to have little detrimental effect on
understood the question and revealed that he was find- the absorption of food.1 Loss of weight is a risk for
ing it difficult in various ways to adjust to the changes patients recovering from cancer, and being underweight
in his body’s behaviour and his physical capabilities. can lead to decline in body function, malnutrition, and
possibly the complex metabolic wasting state called
1.3. Diagnosis and management plan cachexia. Nearly one third of cancer deaths are due to
cachexia rather than tumour burden.10
The musculoskeletal diagnosis in relation to the Mr B’s systemic symptoms such as fatigue, breath-
patient’s main complaint was one often encountered in lessness and digestive disturbance were typical of those
practice, of non-specific neck pain. The author specu- seen after gastrectomy, but it was thought that osteo-
lated that the stiffness was probably associated with pathic treatment should be able to improve digestive
degenerative changes due to years of occupation-related function. Meals were a source of pain and contributed
postural stresses, recently exacerbated by muscle con- to his reduced quality of life.
tracture due to compromised sleeping posture, following Like many UK osteopaths, the author also holds a di-
a period of inactivity during treatment which may have ploma in naturopathy and has undertaken continuing
caused loss of muscle tone. A sinister cause for his professional development in nutrition and naturopathic
‘‘funny heads’’ was considered unlikely due to the long osteopathy. In addition to osteopathic manual tech-
duration of symptoms, lack of other symptoms sugges- niques, a nutritional intervention was also proposed.
tive of cranial nerve dysfunction, and recent follow-up The chosen approach was the Hay system11 which is
with his oncologist. His prior cancer diagnosis contrib- based on the principle of separating carbohydrate-rich
uted to his assessment in two ways, first, to acknowledge meals from protein-rich meals, because different
that a cancer diagnosis inevitably increases psychosocial enzymes are required for the digestion of starches and
stresses which heightens pain perception. Secondly and proteins. The approach was explained to him in the
more importantly, the health of the tissues of the muscu- context of his loss of gastric enzymes and he accepted
loskeletal system were likely to have been compromised the concept and elected to adopt this strategy. The
by systemic cytotoxic chemotherapy and poor nutrition Hay system is reasonably flexible as the user can make
due to malabsorption of food. It was reasoned that only food selections they like, provided they follow the basic
minimal force osteopathic manipulative techniques were principle. Mr B was provided with an information sheet
to be applied in this case. which listed foods in to three groups: high-starch, high-
In order to improve the quality of life of this patient, protein and intermediate foods. It was also suggested his
a holistic view of his symptoms was needed. It was neces- wife should follow the diet as it is often easier to adopt
sary to understand his symptoms in more depth, and to dietary changes if the whole family is involved.
consider whether those symptoms were within the osteo- A management plan comprising four points was
pathic scope of practice. Online information for cancer discussed and agreed with the patient: (1) osteopathic
patients is accessible from reliable sources such as the manual treatment to improve mobility of the thoracic
National Health Service5 and cancer charities3 as well and cervical spine e soft tissue, segmental oscillation
as electronic databases such as PubMed. An initial survey and positional release techniques; (2) cranial osteopathic
of the literature identified that recovery from gastric treatment to release the perception of tension in the fascia
cancer is often accompanied by reduced quality of life. of the whole torso, neck and head with a focus on the tho-
Gastrectomy, whether total or partial, reduces consider- racic diaphragm and abdominal wall; (3) discussion of
ably the amount that the patient can eat and drink before dietary strategies that may improve digestive symptoms
feeling full. Rapid satiety after consuming even small and that would fit with the patients individual eating
amounts of food can, therefore, make it challenging to preferences and (4) discussion of his symptoms to educate
reverse pre-operative weight loss. Post-operatively, and reassure him that they were part of the normal recov-
patients may experience loss of energy or depresssion6; ery from gastric cancer. Finally, because the patient’s
activity tends to be limited by decreased food consump- travel to the clinic took over an hour and was tiring, treat-
tion and there may also be symptoms such as reflux, ments were spaced initially at 3-week intervals to avoid
‘gastric dumping’, nausea and vomiting, difficulty swal- depleting his energy levels. The avoidance of fatigue
lowing, pain, and difficulty passing stools.2,7e9 Dumping was considered more important than slowing of progress
syndrome is a term used to describe symptoms soon after in resolution of his chronic musculoskeletal symptoms.
a meal such as faintness, light-headedness, drowsiness,
flushing, sweating, tachycardia, abdominal pain or 1.4. Management and clinical progress
diarrhoea.5 A second set of symptoms occur late after
a meal due to hypoglycaemia: these may include sweat- Mr B received three treatment sessions at 3-week
ing, palpitations, faintness or excessive hunger.1 Despite intervals initially, then as he improved a further five
J. Leach / International Journal of Osteopathic Medicine 11 (2008) 106e111 109
sessions spaced over a total of 10 months, when he was writing degree course. Mr B felt that he now had a better
discharged with advice to return as required. His ‘‘funny understanding of his digestive system and new symptoms
head’’ were resolved after the first treatment, and the no longer triggered anxiety. He felt more confident
neck stopped locking at night after three treatments, among people, whereas previously he had ‘‘felt frail’’.
although the neck remained stiff. Some months into his voluntary job, he experienced an
Within three weeks of the initial consultation he had exacerbation of the bowel symptoms for no obvious
started trying to eat according to the Hay system and reason, but this settled within a few weeks.
reported a dramatic improvement in his digestive and
bowel function. At the second consultation he reported
having lost a little weight. This was worrying hence part 2. Outcomes
of the session was used to discuss how to increase his
energy intake in a way acceptable to the patient’s food The case reported here was not planned as a case
preferences. This resulted in a number of suggestions study from the outset, so no formal outcome measures
for how to increase his use of protein, which were were employed prospectively. However, at the final
subsequently well tolerated. treatment session prior to discharge the patient was
By the third session (5 weeks) the neck symptoms were asked to provide a summary of the effects of treatment
improving and both he and his wife were adapting to the in his own words (Table 1).
new eating regimen. By three months he reported feeling Both Mr B and his wife are following the Hay system,
fitter and leading a more active lifestyle. At this session, have invested in a book11 on the topic and feel that this
prone oscillation of the thoracic spine was introduced, diet has benefited their health. They are now experi-
but this produced nausea (interestingly at T5, in particu- menting a little to determine if they can relax the ‘rules’,
lar) and his energy levels were affected adversely for or if they have to adhere to the system rigidly.
several days afterwards. After four months he reported The aching legs and arms was a long-term problem he
having started a part-time voluntary job and was suffi- had suffered for several years prior to the cancer, and
ciently confident to join his wife on a coach touring proved to be unresponsive to manual treatment, or to
holiday, which they enjoyed except that the meals upset daily sessions of oscillation to improve lymphatic flow,
his digestion and it took some weeks to recover. or to temperature regulation.
The long-term problem of aching in his arms and legs At the time of writing two years since his first osteo-
at night continued to disturb his sleep from time to time. pathic treatment, and more than five years since his
It was suggested that Mr B trial the use of an oscillation cancer diagnosis, Mr B continues to be well. His weight
device (the Zen Chi http://www.zenlifestyles.co.uk/) is now up to 67 kg and he reports that ‘‘I have now
which oscillates the feet when lying supine and may act reached a point where it is unlikely that I will see any
as a means of promoting lymphatic and venous drainage more improvement, and I have to accept the bad days
prior to sleep. Lymphatic drainage is considered safe for and realise that I cannot expect too much on those
cancer patients provided they do not have active dis- days. We had four holidays last year so I have slowly
ease.12 Daily use of this device before bed for some weeks got my life back on track.’’
did not substantially alter the aching symptoms.
By five months his weight had increased to 61 kg. Table 1
Eight months into treatment, he reported that his diges- Outcomes of treatment: patient-reported improvement in presenting
tive system was functioning well 75e80% of the time, symptoms
but reported that he still ‘‘ran out of energy’’ by late Symptoms Patient-reported improvement after
afternoon, even if he had not been physically active. In eight sessions over 10 months
an attempt to improve symptoms further, he and his Restricted left rotation of ‘‘improved with treatment but
wife were avoiding all processed foods apart from neck necessity of having a raised pillow still
processed mycoprotein products (‘Quorn’ in the UK) causes problems’’
‘‘funny heads’’ Resolved after first treatment
which were reasonably well tolerated. Otherwise, they
Aching in legs and arms at Still bothering him
used exclusively fresh produce, organic vegetables and night
dairy products. He was enjoying home cooking, often Fatigue, rapid onset ‘‘energy levels maintained as a result of
using the recipes provided by the organic box scheme better absorption using the Hay diet’’
to which he had subscribed. Delayed nausea on forward No longer a problem
bending
At 10 months his weight had increased to 65 kg. Fol-
Intermittent diarrhoea The proportion of days affected has
lowing a scan in December 2005 and an oncologist dropped from 60 to 25%
check-up in January 2006 which showed him all clear of Discomfort after eating Disappeared 2e3 days after starting
cancer, he reported that ‘‘the consultant felt I was very the Hay system
healthy! Not so sure about this!!’’. He and his wife were Breathlessness ‘‘as energy sources are maintained this
helps to stabilise breathing’’
going out more socially, and he was enjoying a creative
110 J. Leach / International Journal of Osteopathic Medicine 11 (2008) 106e111