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International Journal of Osteopathic Medicine 11 (2008) 106e111

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Case study

Osteopathic support for a survivor of

gastric cancer: A case report
Janine Leach*
Clinical Research Centre for Health Professions, University of Brighton, Aldro Building, 49 Darley Road, Eastbourne BN20 7UR, UK
Received 5 February 2007; received in revised form 4 March 2008; accepted 4 March 2008

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.

Keywords: Osteopathy; Gastric cancer; Quality of life; Case report

1. Introduction orthodox treatment of gastric cancer. A number of

There have been few reports published in the litera-
ture about the role of osteopathy in the palliation of
symptoms following cancer. Anecdotally, it appears
that osteopaths are often consulted by patients who
present with complaints which may be associated with
the after effects of cancer diagnosis or treatment, such
as lymphoedema, respiratory symptoms, or nerve pain.
This case study documents the care and outcomes for
a patient who presented for osteopathic care of muscu-
loskeletal symptoms following the diagnosis and
* Tel.: þ44 1273 643457; fax: þ44 1273 643944.
E-mail address: c.m.j.leach@brighton.ac.uk
physical symptoms often reduce quality of life after
gastrectomy.1,2 The aim of this report is to document
a case where osteopathic management was applied for
palliation of cancer-related symptoms, and to initiate
debate and discussion within the profession in this area.
Informed consent was obtained from the patient to
publish an account of his treatment. The patient has
commented on and validated the manuscript.
1.1. History
Mr B was aged 66 years at the time of initial presen-
tation to the author at the author’s private practice in
June 2005. He was a married, lively vegetarian who

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
had worked as student advisor at a local further educa-
tion college until he was diagnosed with stomach cancer
in 2002. His main complaint was of chronic pain and
restricted rotation of the neck of several years duration.
The neck ‘‘locked’’ most nights and the pains radiated
over the occiput which he described as ‘‘funny heads’’.
His neck symptoms had been present for the past 5
years, and had become worse in the past 2e3 years.
The patient believed that the main cause of his neck
pain was his sleeping position: since his stomach cancer
in 2002, he had to sleep semi-reclined in order to prevent
gastric reflux.
His sleep was also frequently disturbed by episodes of
aching in the arms and legs at night. These symptoms
had bothered him for several years prior to his cancer
diagnosis, and were partially relieved if he got out of
bed and walked about for some time.
In addition, he mentioned a number of other symp-
toms he had suffered since the cancer treatment: delayed
nausea after bending forwards for any length of time,
extreme fatigue arising after normal levels of activity,
abdominal discomfort for 1e2 h during and after meals;
erratic and unpredictable bowel movements ranging
from constipation to severe diarrhoea; pain and discom-
fort during defecation followed by feeling ‘‘drained’’;
and intermittent bouts of breathlessness, unrelated to
exercise. The frequent erratic bowel movements re-
stricted him considerably, making him nervous of going
to new places or travelling on public transport. The
discomfort triggered by eating had made it difficult for
him to maintain or gain weight, and also restricted
activity for several hours each day. He was having
difficulty gaining weight, having lost approximately
16 kg pre-operatively, and was about 60 kg when he
presented for osteopathic treatment.
Mr B’s previous medical history included partial
gastrectomy for bleeding ulcers in 1974, keyhole surgery
for an abdominal hernia in 1994, haemorrhoid surgery
in 1998, labyrinthitis in about 2000, total gastrectomy
and splenectomy in 2002 followed by chemotherapy in
2003 for gastric cancer, and repair of a left inguinal
hernia in 2003. He had a severe familial hearing impair-
ment since childhood, with which he coped well.
The patient reported that he did not know the stage
of his cancer, but the surgeon had told him that the
tumour was ‘‘the size of a tangerine’’, and that the
cancer had spread to six lymph nodes in the abdomen.
The spleen had been clear of cancer but was adherent
to the stomach due to prior surgery and was removed
because the bleeding could not be stopped. He had
made a good recovery despite a 6-h operation.
His current medications included a permanent
prescription for daily prophylactic antibiotics to prevent
opportunistic infection (routine after splenectomy). He
also received regular Vitamin B12 injections, as its
synthesis depends on intrinsic factor normally produced
107
in the stomach; B12 deficiency can cause pernicious
anaemia. At the time of presentation, he was still under-
going regular annual follow-up checks with his cancer
surgeon and six monthly reviews with his oncologist.
During the treatment of his cancer, Mr B had
received advice from the dieticians at both his local
NHS hospital and the NHS Cancer Centre where he
received chemotherapy. The recommendations3 were to
eat frequent small meals, to use high-starch foods such
as rice, pasta and potatoes, avoid sugar and consume
high calorie nutritious drinks; and in order to increase
body weight, he had been told to include sugar and
consume full cream milk. He found these recommenda-
tions difficult to comply with, being a long-term vegetar-
ian used to wholefoods and he disliked full cream milk
and sugary foods which he complained made him feel
‘‘breathless’’. He had adapted the advice, using rice
milk and oat milk, and at the time of consultation his
weight was stable.
For some months prior to presenting for osteopathic
treatment, he had been attending the local Cancer Sup-
port Centre and had received hypnotherapy and Reiki (a
form of faith healing originating in Japan) about which
he was very positive. He had a very positive approach to
getting back to normal activities, although his enthusi-
asm meant that he tended to over-tire himself at times.
1.2. Physical examination
On observation, he appeared thin and wiry. He
walked briskly, and appeared fit and alert, with bright
eyes, and firm skin of a healthy colour. He had a neat
gastrectomy scar down the midline of the upper abdo-
men, and a smaller scar in the left groin from the hernia
repair. His thoracic posture was kyphotic, which he at-
tributed to having spent the first 20 years of his working
life ‘‘bent over a composing frame in the printing trade’’.
Physical examination revealed that active cervical
mobility was stiff and limited: rotation left was painful
and less than 40 degrees. His range of neck flexion and
extension were reasonable for his age. On palpation,
the muscles of the neck and shoulders were hypertonic
and non-tender, especially upper trapezius. Passive
movement of the cervical and upper thoracic spinal
segments revealed multi-segmental limited movement
especially at the level of the cervicothoracic junction
(C7eT1). There were no neurological signs and forami-
nal compression (Spurlings test) was negative for nerve
root irritation in the cervical spine. The abdomen was
tense with thickened fibrous tissues in the area underly-
ing the scar. Using the model of the primary respiratory
mechanism, the cranial rhythm was of low amplitude
particularly around the diaphragm, which prompted
the author to talk to him about emotions around loss
of his stomach4; the impression generated during
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
but are often useful in clinical practice. The patient
understood the question and revealed that he was find-
ing it difficult in various ways to adjust to the changes
in his body’s behaviour and his physical capabilities.
1.3. Diagnosis and management plan
The musculoskeletal diagnosis in relation to the
patient’s main complaint was one often encountered in
practice, of non-specific neck pain. The author specu-
lated that the stiffness was probably associated with
degenerative changes due to years of occupation-related
postural stresses, recently exacerbated by muscle con-
tracture due to compromised sleeping posture, following
a period of inactivity during treatment which may have
caused loss of muscle tone. A sinister cause for his
‘‘funny heads’’ was considered unlikely due to the long
duration of symptoms, lack of other symptoms sugges-
tive of cranial nerve dysfunction, and recent follow-up
with his oncologist. His prior cancer diagnosis contrib-
uted to his assessment in two ways, first, to acknowledge
that a cancer diagnosis inevitably increases psychosocial
stresses which heightens pain perception. Secondly and
more importantly, the health of the tissues of the muscu-
loskeletal system were likely to have been compromised
by systemic cytotoxic chemotherapy and poor nutrition
due to malabsorption of food. It was reasoned that only
minimal force osteopathic manipulative techniques were
to be applied in this case.
In order to improve the quality of life of this patient,
a holistic view of his symptoms was needed. It was neces-
sary to understand his symptoms in more depth, and to
consider whether those symptoms were within the osteo-
pathic scope of practice. Online information for cancer
patients is accessible from reliable sources such as the
National Health Service5 and cancer charities3 as well
as electronic databases such as PubMed. An initial survey
of the literature identified that recovery from gastric
cancer is often accompanied by reduced quality of life.
Gastrectomy, whether total or partial, reduces consider-
ably the amount that the patient can eat and drink before
feeling full. Rapid satiety after consuming even small
amounts of food can, therefore, make it challenging to
reverse pre-operative weight loss. Post-operatively,
patients may experience loss of energy or depresssion6;
activity tends to be limited by decreased food consump-
tion and there may also be symptoms such as reflux,
‘gastric dumping’, nausea and vomiting, difficulty swal-
lowing, pain, and difficulty passing stools.2,7e9 Dumping
syndrome is a term used to describe symptoms soon after
a meal such as faintness, light-headedness, drowsiness,
flushing, sweating, tachycardia, abdominal pain or
diarrhoea.5 A second set of symptoms occur late after
a meal due to hypoglycaemia: these may include sweat-
ing, palpitations, faintness or excessive hunger.1 Despite
making the process of digestion more difficult, removal of
the stomach is reported to have little detrimental effect on
the absorption of food.1 Loss of weight is a risk for
patients recovering from cancer, and being underweight
can lead to decline in body function, malnutrition, and
possibly the complex metabolic wasting state called
cachexia. Nearly one third of cancer deaths are due to
cachexia rather than tumour burden.10
Mr B’s systemic symptoms such as fatigue, breath-
lessness and digestive disturbance were typical of those
seen after gastrectomy, but it was thought that osteo-
pathic treatment should be able to improve digestive
function. Meals were a source of pain and contributed
to his reduced quality of life.
Like many UK osteopaths, the author also holds a di-
ploma in naturopathy and has undertaken continuing
professional development in nutrition and naturopathic
osteopathy. In addition to osteopathic manual tech-
niques, a nutritional intervention was also proposed.
The chosen approach was the Hay system11 which is
based on the principle of separating carbohydrate-rich
meals from protein-rich meals, because different
enzymes are required for the digestion of starches and
proteins. The approach was explained to him in the
context of his loss of gastric enzymes and he accepted
the concept and elected to adopt this strategy. The
Hay system is reasonably flexible as the user can make
food selections they like, provided they follow the basic
principle. Mr B was provided with an information sheet
which listed foods in to three groups: high-starch, high-
protein and intermediate foods. It was also suggested his
wife should follow the diet as it is often easier to adopt
dietary changes if the whole family is involved.
A management plan comprising four points was
discussed and agreed with the patient: (1) osteopathic
manual treatment to improve mobility of the thoracic
and cervical spine e soft tissue, segmental oscillation
and positional release techniques; (2) cranial osteopathic
treatment to release the perception of tension in the fascia
of the whole torso, neck and head with a focus on the tho-
racic diaphragm and abdominal wall; (3) discussion of
dietary strategies that may improve digestive symptoms
and that would fit with the patients individual eating
preferences and (4) discussion of his symptoms to educate
and reassure him that they were part of the normal recov-
ery from gastric cancer. Finally, because the patient’s
travel to the clinic took over an hour and was tiring, treat-
ments were spaced initially at 3-week intervals to avoid
depleting his energy levels. The avoidance of fatigue
was considered more important than slowing of progress
in resolution of his chronic musculoskeletal symptoms.
1.4. Management and clinical progress
Mr B received three treatment sessions at 3-week
intervals initially, then as he improved a further five
 J. Leach / International Journal of Osteopathic Medicine 11 (2008) 106e111
sessions spaced over a total of 10 months, when he was
discharged with advice to return as required. His ‘‘funny
head’’ were resolved after the first treatment, and the
neck stopped locking at night after three treatments,
although the neck remained stiff.
Within three weeks of the initial consultation he had
started trying to eat according to the Hay system and
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
of the session was used to discuss how to increase his
energy intake in a way acceptable to the patient’s food
preferences. This resulted in a number of suggestions
for how to increase his use of protein, which were
subsequently well tolerated.
By the third session (5 weeks) the neck symptoms were
improving and both he and his wife were adapting to the
new eating regimen. By three months he reported feeling
fitter and leading a more active lifestyle. At this session,
prone oscillation of the thoracic spine was introduced,
but this produced nausea (interestingly at T5, in particu-
lar) and his energy levels were affected adversely for
several days afterwards. After four months he reported
having started a part-time voluntary job and was suffi-
ciently confident to join his wife on a coach touring
holiday, which they enjoyed except that the meals upset
his digestion and it took some weeks to recover.
The long-term problem of aching in his arms and legs
at night continued to disturb his sleep from time to time.
It was suggested that Mr B trial the use of an oscillation
device (the Zen Chi http://www.zenlifestyles.co.uk/)
which oscillates the feet when lying supine and may act
as a means of promoting lymphatic and venous drainage
prior to sleep. Lymphatic drainage is considered safe for
cancer patients provided they do not have active dis-
ease.12 Daily use of this device before bed for some weeks
did not substantially alter the aching symptoms.
By five months his weight had increased to 61 kg.
Eight months into treatment, he reported that his diges-
tive system was functioning well 75e80% of the time,
but reported that he still ‘‘ran out of energy’’ by late
afternoon, even if he had not been physically active. In
an attempt to improve symptoms further, he and his
wife were avoiding all processed foods apart from
processed mycoprotein products (‘Quorn’ in the UK)
which were reasonably well tolerated. Otherwise, they
used exclusively fresh produce, organic vegetables and
dairy products. He was enjoying home cooking, often
using the recipes provided by the organic box scheme
to which he had subscribed.
At 10 months his weight had increased to 65 kg. Fol-
lowing a scan in December 2005 and an oncologist
check-up in January 2006 which showed him all clear of
cancer, he reported that ‘‘the consultant felt I was very
healthy! Not so sure about this!!’’. He and his wife were
going out more socially, and he was enjoying a creative
109
writing degree course. Mr B felt that he now had a better
understanding of his digestive system and new symptoms
no longer triggered anxiety. He felt more confident
among people, whereas previously he had ‘‘felt frail’’.
Some months into his voluntary job, he experienced an
exacerbation of the bowel symptoms for no obvious
reason, but this settled within a few weeks.
2. Outcomes
The case reported here was not planned as a case
study from the outset, so no formal outcome measures
were employed prospectively. However, at the final
treatment session prior to discharge the patient was
asked to provide a summary of the effects of treatment
in his own words (Table 1).
Both Mr B and his wife are following the Hay system,
have invested in a book11 on the topic and feel that this
diet has benefited their health. They are now experi-
menting a little to determine if they can relax the ‘rules’,
or if they have to adhere to the system rigidly.
The aching legs and arms was a long-term problem he
had suffered for several years prior to the cancer, and
proved to be unresponsive to manual treatment, or to
daily sessions of oscillation to improve lymphatic flow,
or to temperature regulation.
At the time of writing two years since his first osteo-
pathic treatment, and more than five years since his
cancer diagnosis, Mr B continues to be well. His weight
is now up to 67 kg and he reports that ‘‘I have now
reached a point where it is unlikely that I will see any
more improvement, and I have to accept the bad days
and realise that I cannot expect too much on those
days. We had four holidays last year so I have slowly
got my life back on track.’’
Table 1
Outcomes of treatment: patient-reported improvement in presenting
symptoms
Symptoms Patient-reported improvement after
eight sessions over 10 months
Restricted left rotation of ‘‘improved with treatment but
neck necessity of having a raised pillow still
causes problems’’
‘‘funny heads’’ Resolved after first treatment
Aching in legs and arms at Still bothering him
night
Fatigue, rapid onset ‘‘energy levels maintained as a result of
better absorption using the Hay diet’’
Delayed nausea on forward No longer a problem
bending
Intermittent diarrhoea The proportion of days affected has
dropped from 60 to 25%
Discomfort after eating Disappeared 2e3 days after starting
the Hay system
Breathlessness ‘‘as energy sources are maintained this
helps to stabilise breathing’’
110 J. Leach / International Journal of Osteopathic Medicine 11 (2008) 106e111
3. Discussion
Gastric cancer is frequently fatal: the 5-year survival
rate for men is 13%.13 Medical and surgical oncology treat-
ment were very successful in saving the life of this patient,
but left him with a reduced quality of life. Osteopathic
treatment appears to have made an important contribution
in improving his quality of life in terms of musculoskeletal
and digestive function, therefore, enabling him to return to
a normal active social and daily life. The improvement in
physical symptoms was pleasing, although he remains sen-
sitive to temperature: the fatigue is more marked in hot
weather and he finds the cold winter months depressing.
Patients attending for osteopathic treatment with
a previous or current cancer diagnosis should be encour-
aged to follow the advice of the specialist cancer teams
as far as possible. For this patient, the advice from the
dieticians had proved very difficult to follow fully. The
Hay system recommended by the author was not incom-
patible with the advice of the oncology team and was
simply a different way of combining food at each
meal. The Hay system is usually not necessary for
people with good health status, but when digestion is
sub-optimal it is potentially useful. In this case, with
loss of digestive enzymes it was a reasonable strategy.
Dietary change is difficult. Food shopping, meal prep-
aration and eating are long established family rituals and
it can be quite stressful introducing change and it may not
always be appropriate to do so. Adopting new foods or
a new way of eating places extra demands on the patient
and family. Changing routines associated with eating
can be stressful and health care advisors and patients
should be wary of creating excessive or unreasonable
demands which can introduce strain for the patient or
within the family. Practitioners and patients should be
aware that compliance with a dietary regimen such as
the Hay system will require extra time and effort in food
selection and preparation. Additional expense in food
selection may also be incurred and this may all occur at
a time shortly after the diagnosis and treatment of cancer,
and may be a burden especially if the patient is no longer
employed. The Hay system does not fit easily with ‘nor-
mal’ eating habits in the UK, whether the conventional
British meal plan of ‘‘meat and two vegetables’’ or use
of processed foods. Sandwiches, pies and pizza commonly
combine a starch component such as bread or pastry with
a protein component such as meat, cheese or eggs. Mr B
said ‘‘an important point here is that it becomes necessary
to prepare meals rather than buy them as packaged food
is usually a mix of protein and starchy foods. An example
is a quiche. A supermarket one is a combination of both’’.
This patient was typical of many in whom the cancer is
effectively treated but many and various symptoms and
difficulties remain which reduce quality of life. Any unex-
plained new symptoms can cause considerable anxiety
that the cancer is returning. The training of osteopaths as
primary health care practitioners equips them with a high
level of knowledge in pathology and differential diagnosis,
which means they can play an under-appreciated role in
explaining patients health problems and devising practical
strategies for helping them. The length of the consultation,
the time to take a detailed history, and seeing the patient
over several weeks affords osteopaths an opportunity to
engage in complex problems that may benefit from a holis-
tic approach. Touch and body work may invoke an accep-
tance of the body and its scars which can help the patient
come to terms with their body image.14e17 Massage has
been shown to confer benefits on psychological well-being,
and there is some evidence of beneficial effects on anxiety
and physical symptoms.18 Establishing a strong therapeu-
tic relationship can encourage people to talk more openly
about anxieties, something that might not always be possi-
ble with members of the family for fear of worrying them.
This case study highlights the need for more research in
into the role of osteopathy in the supportive care of cancer
patients. Further research would also be useful to deter-
mine whether the Hay system is effective in improving
quality of life of other survivors of gastric cancer.
Key points
 This case illustrates how osteopathy can play
a role in the supportive care of cancer pa-
tients after their conventional treatment;
a wide range of systemic and musculoskele-
tal symptoms falls within the scope of osteo-
pathic 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 hence osteopaths
are well placed to deliver enhanced care for
patients with complex problems through
a broader and more holistic approach than
manual therapy alone.
 Osteopaths can play a valuable and under-
appreciated role in explaining and re-fram-
ing patients’ health problems.
 Osteopaths have an important role in edu-
cating patients about their health.
 The touch and body work involved in oste-
opathy can improve psychological well-
being and anxiety.
 Appropriate food combining during meals
may be valuable in improving the quality
of life of patients after gastrectomy.
 Osteopaths can play a role in helping patients
to find ways to integrate lifestyle changes into
their lives; engaging the patient’s family can
help implement such change.
 J. Leach / International Journal of Osteopathic Medicine 11 (2008) 106e111
Acknowledgements
Sincere thanks are due to the patient for allowing the
author to publish his case.
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