By Kenneth E. Nelson, DO, FAAO, FACOFP dist.

It’s déjà vu, all over again. You and I may not specifically remember it. But it is indelibly etched into the collective memory of osteopathic medicine. We are presently in the midst of a viral pandemic that is, as of this moment, without proven effective pharmacotherapy or immunization.

This pandemic bears a striking similarity, although the causative organism is a distinctly different virus, to the Spanish flu pandemic of a century ago. The Spanish flu commonly presented as an upper respiratory infection, that in its most lethal manifestation rapidly progressed through tracheobronchitis to hemorrhagic pneumonitis and death.

It is a very similar presentation and progression as that of COVID-19. As of March 1, 2020, among COVID-19 patients in China, 2,873 deaths had occurred, equivalent to a mortality rate of 3.6%.1 The global mortality rate for the Spanish flu pandemic has been reported as 2.5%.2 At the time of the Spanish flu pandemic, the osteopathic profession had been in existence for only about a quarter century. The mortality rate, however, reported for osteopathic care during that pandemic was 0.25%.3 Since there was no definitive medical treatment for the Spanish flu, the only difference between osteopathic and the conventional medical treatment at the time was osteopathic manipulative treatment (OMT).

When caring for COVID-19 patients, the recommended infectious disease protocols4-6 must, of course, be rigidly adhered to. There are, however, no official recommendations for when and how to employ OMT. Based upon reported outcomes from the 1918 Spanish flu pandemic, it is logical to conclude that OMT should, as determined by patient tolerance, be employed. OMT is a physical medicine procedure. Its application is predicated upon the diagnosis of somatic dysfunction (CD-10-CM M99.0#, categorized further by the anatomic site of the identified dysfunction7).

The physical diagnosis of somatic dysfunction is accomplished by palpation. TART, a mnemonic of the four diagnostic criteria for identifying somatic dysfunction, stands for: tissue texture abnormality, asymmetry of position, restriction of motion and tenderness. The palpable presence of any one of these is justification for the diagnosis of somatic dysfunction.8

OMT, like any other therapeutic intervention, is subject to dosage criteria and contraindications. The dosage of OMT is determined by patient tolerance that is established, to a great extent, by the age of the patient, the severity of illness and the presence or absence of concomitant illness. Patient tolerance dictates the level of aggressiveness and duration of application of the OMT procedure(s) employed. When in doubt, a lower dosage of OMT is judicious. Hospitalized patients in the past were treated for short periods of time, as often as two or three times daily.

How much OMT is enough? Treat the patient until a response occurs. What kind of response should the physician look for? Relaxation of the soft tissues in the area being treated is a good response. Increased muscle spasm during the application of a procedure indicates that the patient’s tolerance has already been exceeded and that a less aggressive procedure should be selected, or that treatment should be stopped and attempted again at a later time. Altered autonomic tone is also an indication of a response. Peripheral vasodilatation resulting in increased skin temperature or redness and increased perspiration indicates that it is time to stop.

One should remain aware of the patient’s vital signs during the application of OMT. Increased heart or respiratory rate indicates that one has reached the patient’s level of tolerance. If the patient feels that the intervention is too uncomfortable, the physician should stop and choose another approach, or wait and try again later. Contraindications, beyond the relative contraindication of exceeding the patient’s level of tolerance include applying OMT to areas of musculoskeletal instability. OMT is often employed to enhance available tissue mobility. Therefore, it is contraindicated in areas of musculoskeletal hypermobility and instability. The direct manipulation of localized inflammatory processes is also contraindicated.9

The application of manipulative procedures to a patient on a ventilator may initially appear to be contraindicated. However, these patients are regularly moved during routine nursing procedures without untoward effect. With this consideration, the use of the least aggressive OMT procedure(s) is always the best option. One point of consideration for the treatment of ventilated patients is that they are essentially always experiencing positive intrathoracic pressure, with consequent decreased respiratory intrathoracic pressure gradient and resultant propensity for passive congestion. This is when tolerated OMT procedures that are directed at augmenting lymphatic circulation should be considered.

For further discussion of the treatment of patients with upper and lower respiratory tract disease, and descriptions of applicable OMT procedures, see chapters 24 and 25 in the second edition of Somatic Dysfunction in Osteopathic Family Medicine.10, 11 Videos of these OMT procedures are also available from ACOFP.12

For an additional thorough presentation of the available historic materials concerning the 1918 Spanish Flu pandemic see: or visit; The Museum of Osteopathic Medicine Facebook page, post-dated Friday, March 20, 2020 4:19 pm.

ACOFP is supporting members during this unprecedented pandemic by providing complimentary access to six videos of OMT techniques that address upper and lower respiratory issues and can be used to treat COVID-19 symptoms.


  • Cervical Treatment C2 Through T7
  • Cervical Muscle Energy
  • Thoracic Abdominal Release
  • Thoracic Lymphatic Pump
  • Thoracic Inlet Release
  • Rib Raising Stimulate Sympathetic

Somatic Dysfunction in Osteopathic Family Medicine, 2nd Edition chapters of interest:

  • Chapter 24 The patient with an upper respiratory infection
  • Chapter 25 The patient with lower respiratory tract problems
  • Chapter 5 Diagnosing somatic dysfunction
  • Chapter 6 The manipulative prescription
  • Chapter 19 The hospitalized patient


  1. Baud D, Qi X, Real estimates of mortality following COVID-19 infection. Published: March 12, 2020. DOI: The Lancet. Accessed March 20, 2020.
  2. Billings M. The Influenza Pandemic of 1918. June, 1997 modified RDS February, 2005. Accessed March 20, 2020.
  3. Smith RK. One hundred thousand cases of influenza with a death rate of one-fortieth of that officially reported under conventional medical treatment. 1919. Reprinted: J Am Osteopath Assoc. 2000;100(5):320–323.+
  4. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. Center for Disease Control and Prevention.
    Accessed March 22, 2020.
  5. Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19). Center for Disease Control and Prevention. Accessed March 22, 2020.
  6. Infectious Disease Society of America. COVID-19: Expanded Resource Center. Accessed March 22, 2020.
  7. ICD-10 Coded. Accessed March 22, 2020.
  8. Nelson KE. Diagnosing somatic dysfunction. Chapt. 5. In: Nelson, Glonek, eds. 2nd edition, Somatic Dysfunction in Osteopathic Family Medicine. Baltimore, MD: Wolters Kluwer / Lippincott, Williams & Wilkins; 2014:33-44.
  9. Nelson KE. The manipulative prescription. Chapt. 6. In: Nelson, Glonek, eds. 2nd edition,, Somatic Dysfunction in Osteopathic Family Medicine. Baltimore, MD: Wolters Kluwer / Lippincott, Williams & Wilkins; 2014:45-49.
  10. Nelson KE, Allgeier J. The patient with an upper respiratory infection. Chapt. 24. In: Nelson, Glonek, eds. 2nd edition,, Somatic Dysfunction in Osteopathic Family Medicine. Baltimore, MD: Wolters Kluwer / Lippincott, Williams & Wilkins; 2014:258-273.
  11. Comeau ZJ. The patient with lower respiratory tract problems. Chapt. 25. In: Nelson, Glonek, eds. 2nd edition, Somatic Dysfunction in Osteopathic Family Medicine. Baltimore, MD: Wolters Kluwer / Lippincott, Williams & Wilkins; 2014:274-286.
  12. ACOFP OMT essentials. Accessed March 22, 2020.


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