Osteopathic manipulative medicine

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Osteopathic medicine in the United States
Andrew Taylor Still (founder)
Doctor of Osteopathic Medicine (DO) Medicine US Medical education Schools Physicians Osteopathic Manipulative Medicine AOA AACOM AAO COMLEX MD & DO Comparison Specialty Colleges AOA BOS

Osteopathic manipulative medicine is a core set of techniques of osteopathy and osteopathic medicine distinguishing these fields from the rest of medicine.^[1] Parts of osteopathy, such as cranial therapy have been labeled pseudoscience and are said to have no therapeutic value.^[2][3] The techniques are based on an ideology created by Andrew Taylor Still (1828–1917) which posits the existence of a myofascial continuity – a tissue layer that connects all parts of the body. Non-physician osteopaths and osteopathic physicians attempt to diagnose and treat somatic dysfunction by manipulating a person's bones and muscles and therefore address a variety of ailments. OMT techniques are most commonly used to treat back pain and other musculoskeletal issues, and are less commonly used to treat systemic conditions such as asthma and Parkinson's disease.^[1][4]

OMT is based on the idea that a myofascial continuity "links every part of the body with every other part"; a practitioner, through a "skillful and dexterous use of the hands" treats what was originally called "the osteopathic lesion", but which is now named "somatic dysfunction".^[1] The most commonly treated ailment is back pain, although some practitioners claim OMT can be used to treat a wide range of conditions.^[4]

History

Andrew Taylor Still in 1914

Andrew Taylor Still, M.D., D.O. was a 19th-century American physician and Civil War surgeon who founded osteopathic medicine. Following the loss of three of his children to spinal meningitis, Still became dissatisfied with contemporary medical practices and sought to further medical understanding and treatment.^[5] Still claimed that human illness was rooted in problems with the musculoskeletal system, and that hands-on manipulations could solve these problems and so effect a cure by harnessing the body's own self-repairing potential.^[6] Still's proposed treatment regime also included as strong dose of healthy living: he advocated abstinence from alcohol, and patients were forbidden from taking medicine.^[1]

Clinical practice

Osteopathic manipulative treatment (OMT) involves palpation and manipulation of bones, muscles, joints, and fasciae.

According to the American Osteopathic Association (AOA), osteopathic manipulative treatment is considered to be only one component of osteopathic medicine and may be used alone or in combination with pharmacotherapy, rehabilitation, surgery, patient education, diet, and exercise. OMT techniques are not necessarily unique to osteopathic medicine; other disciplines, such as physical therapy or chiropractic, use similar techniques.^[7]

One key concept osteopathic medical students learn is that structure influences function. Thus, if there is a problem in one part of the body’s structure, function in that area, and possibly in other areas, may be affected. Another integral tenet of osteopathic medicine is the body’s innate ability to heal itself. Many of osteopathic medicine’s manipulative techniques are aimed at reducing or eliminating the impediments to proper structure and function so the self-healing mechanism can assume its role in restoring a person to health.^[8]

Osteopathic medicine defines a concept of health care that embraces the concept of the unity of the living organism's structure (anatomy) and function (physiology). The American Osteopathic Association (AOA) state that the four major principles of osteopathic medicine are the following:^[9]

1. The body is an integrated unit of mind, body, and spirit.
2. The body possesses self-regulatory mechanisms, having the inherent capacity to defend, repair, and remodel itself.
3. Structure and function are reciprocally interrelated.
4. Rational therapy is based on consideration of the first three principles.

These principles are not held by Doctors of Osteopathic Medicine to be empirical laws; they serve, rather, as the underpinnings of the osteopathic approach to health and disease.

Muscle energy

Muscle energy techniques address somatic dysfunction through stretching and muscle contraction. For example, if a person is unable to fully abduct her arm, the treating physician raises the patient's arm near the end of the patient's range of motion, also called the edge of the restrictive barrier. The patient then tries to lower her arm, while the physician provides resistance. This resistance against the patient's motion allows for isometric contraction of the patient's muscle. Once the patient relaxes, her range of motion increases slightly. The repetition of alternating cycles of contraction and subsequent relaxation help the treated muscle improve its range of motion.^[10] Muscle energy techniques are contraindicated in patients with fractures, crush injuries, dislocations, joint instability, severe muscle spasms or strains, severe osteoporosis, severe whiplash injury, vertebrobasilar insufficiency, severe illness, and recent surgery.

Counterstrain

Counterstrain is a system of diagnosis and treatment that considers the physical dysfunction to be a continuing, inappropriate strain reflex, which is inhibited during treatment by applying a position of mild strain in the direction exactly opposite to that of the reflex.^[11] After a counterstrain point tender to palpation has been diagnosed,^[12] the identified tender point is treated by the osteopathic physician who, while monitoring the tender point, positions the patient such that the point is no longer tender to palpation.^[13] This position is held for ninety seconds and the patient is subsequently returned to her normal posture.^[12] Most often this position of ease is usually achieved by shortening the muscle of interest.^[13] Improvement or resolution of the tenderness at the identified counterstrain point is the desired outcome.^[12] The use of counterstrain technique is contraindicated in patients with severe osteoporosis, pathology of the vertebral arteries, and in patients who are very ill or cannot voluntarily relax during the procedure.

High-velocity, low-amplitude

High velocity, low amplitude (HVLA) is a technique which employs a rapid, targeted, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint and engages the restrictive barrier in one or more places of motion to elicit release of restriction.^[14] The use of HVLA is contraindicated in patients with Down syndrome due to instability of the atlantoaxial joint which may stem from ligamentous laxity, and in pathologic bone conditions such as fracture, history of a pathologic fracture, osteomyelitis, osteoporosis, and severe cases of rheumatoid arthritis.^[15][16] HVLA is also contraindicated in patients with vascular disease such as aneurysms, or disease of the carotid arteries or vertebral arteries.^[15] People taking ciprofloxacin or anticoagulants, or who have local metastases should not receive HVLA.^[15]

Myofascial release

Myofascial release is a form of soft tissue therapy used to treat somatic dysfunction and the resultant pain and restriction of motion. Treatment requires continual palpatory feedback to achieve release of myofascial tissues.^[14] This is accomplished by relaxing contracted muscles, increasing circulation and lymphatic drainage, and stimulating the stretch reflex of muscles and overlying fascia.^[17]

Fascia is the soft tissue component of the connective tissue that provides support and protection for most structures within the human body, including muscle. This soft tissue can become restricted due to psychogenic disease, overuse, trauma, infectious agents, or inactivity, often resulting in pain, muscle tension, and corresponding diminished blood flow.^[18] Although fascia and its corresponding muscle are the main targets of myofascial release, other tissue may be affected as well, including other connective tissue.^[17]

Lymphatic pump treatment

Lymphatic pump treatment (LPT) is a manual technique intended to encourage lymph flow in a person's lymphatic system. The first modern lymphatic pump technique was developed in 1920, although osteopathic physicians used various forms of lymphatic techniques as early as the late 19th century.^[19]

Relative contraindications for the use of lymphatic pump treatments include fractures, abscesses or localized infections, and severe bacterial infections with body temperature elevated higher than 102 °F (39 °C).^[20]

Effectiveness

In 2014, a systematic review and meta-analysis of 15 randomized controlled trials found moderate-quality evidence that OMT reduces pain and improves functional status in acute and chronic nonspecific low back pain.^[21] The same analysis also found moderate-quality evidence for pain reduction for nonspecific low back pain in postpartum women and low-quality evidence for pain reduction in nonspecific low back pain in pregnant women.^[21] A 2013 systematic review found insufficient evidence to rate osteopathic manipulation for chronic nonspecific low back pain.^[22] In 2011, a systematic review found no compelling evidence that osteopathic manipulation was effective for the treatment of musculoskeletal pain.^[23]

In 2013, a Cochrane Review reviewed six randomized controlled trials which investigated the effect of four types of chest physiotherapy (including OMT) as adjunctive treatments for pneumonia in adults and concluded that "based on current limited evidence, chest physiotherapy might not be recommended as routine additional treatment for pneumonia in adults." Techniques investigated in the study included paraspinal inhibition, rib raising, and myofascial release. The review found that OMT did not reduce mortality and did not increase cure rate, but that OMT slightly reduced the duration of hospital stay and antibiotic use.^[24] A 2013 systematic review of the use of OMT for treating pediatric conditions concluded that its effectiveness was unproven.^[25]

With respect to irritable bowel syndrome, a 2014 review found that there had been a limited number of studies done and that all these studies had small sample sizes; with that caveat, it found preliminary evidence that osteopathic manipulation may be beneficial in this condition.^[26]

A 2005 Cochrane Review of OMT in asthma treatment concluded that there was insufficient evidence that OMT can be used to treat asthma.^[27]

Criticism

Initially, D.O.s were regarded by M.D.s as "cultists" whose treatments were rooted in "pseudoscientific dogma", and tensions between the two continued for many years.^[6]

In 1988, Petr Skrabanek classified osteopathy as one of the "paranormal" forms of alternative medicine, commenting that it has a view of disease which had no meaning outside its own closed system.^[28]

In a 1995 conference address, the president of the Association of American Medical Colleges, Jordan J. Cohen, pinpointed OMT as a defining difference between M.D.s and D.O.s; while he saw there was no quarrel in the appropriateness of manipulation for musculoskeletal treatment, the difficulty centered on "applying manipulative therapy to treat other systemic diseases" – at that point, Cohen maintained, "we enter the realm of skepticism on the part of the allopathic world."^[6]

In 1998 Stephen Barrett of Quackwatch posted a highly critical article online entitled "Dubious Osteopathic Practices", in which he said that the worth of manipulative therapy had been exaggerated and that the American Osteopathic Association (AOA) was acting unethically by failing to condemn craniosacral therapy. The article attracted a letter from the law firm representing the AOA accusing Barrett of libel and demanding an apology to avert legal action.^[6] In response Barrett made some slight modifications to his text, while maintaining its overall stance; he queried the AOA's reference to "the body's natural tendency toward good health" and challenged them to "provide [him] with adequate scientific evidence showing how this belief has been tested and demonstrated to be true."^[6] Barrett has been quoted as saying "the pseudoscience within osteopathy can't compete with the science".^[6]

In 1999, Joel D. Howell noted that osteopathy and medicine as practiced by M.D.s were becoming increasingly convergent. He suggested that this raised a paradox:

if osteopathy has become the functional equivalent of allopathy, what is the justification for its continued existence? And if there is value in therapy that is uniquely osteopathic – that is, based on osteopathic manipulation or other techniques – why should its use be limited to osteopaths?^[1]

In 2004, the osteopathic physician Bryan E. Bledsoe, a professor of emergency medicine, wrote disparagingly of the "pseudoscience" at the foundation of OMT. In his view, "OMT will and should follow homeopathy, magnetic healing, chiropractic, and other outdated practices into the pages of medical history".^[29]

In 2010, Steven Salzberg wrote that OMT was promoted as a special distinguishing element of DO training, but that it amounted to no more than "'extra' training in pseudoscientific practices".^[30]

See also

• Chapman reflex points
• Chiropractic
• Doctor of Osteopathic Medicine
• List of osteopathic colleges
• Osteopathic medicine in the United States
• Spinal manipulation

References

Further reading

• American Association of Colleges of Osteopathic Medicine (2011); Glossary of Osteopathic Terminology.
• Crislip M (4 October 2013). "Pump it up: osteopathic manipulation and influenza". Science-based Medicine. Retrieved February 2014.  Check date values in: |access-date= (help)
• Savarese, Robert G.; Copabianco, John D.; Cox, James J. (2009). OMT review. ISBN 978-0967009018. 
• Smith JC (2009). "Manipulative and Body-based Practices". Pseudoscience and Extraordinary Claims of the Paranormal: A Critical Thinker's Toolkit. John Wiley & Sons. p. 342. ISBN 978-1-4443-1013-9. 
• DiGiovanna, Eileen L.; Schiowitz, Stanley; Dowling, Dennis (2005). An osteopathic approach to diagnosis and treatment (3rd ed.). Philadelphia, PA: Lippincott Williams and Wilkins. ISBN 978-0781742931. 
• Ward, Robert C. (2002). Foundations for Osteopathic Medicine (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. ISBN 0-7817-3497-5.