Osteopathic manipulative medicine

Osteopathic manipulative medicine
Intervention
ICD-10-PCS	7
ICD-9-CM	93.6
MeSH	D026301

Osteopathic manipulative medicine (OMM), also known as osteopathic manipulative treatment (OMT), is the core technique of osteopathic medicine.^[1] It is based on a philosophy devised by Andrew Taylor Still (1828–1917) which posits the existence of a myofascial continuity – a tissue layer that interlinks all parts of the body. Practitioners believe they are able diagnose and address "somatic dysfunction" by manipulating the bones and muscles of a patient, so attempting to treat a variety of systemic ailments including asthma and Parkinson's disease.

Research into OMM has found it to be a generally ineffective therapy for conditions other than low back pain.^[2][3][4] Critics of OMT have characterized it as pseudoscience.^[5][6][7]

Origins and conceptual basis

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.^[8] 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.^[5] 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]

The osteopathic medical philosophy is defined as the 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:^[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 philosophy on health and disease.

According to medical professor Joel D. Howell, 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] OMT has been proposed as effective for treating a number of human ailments including asthma, pancreatitis and Parkinson's disease.^[1]

Reception

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.^[5]

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."^[5]

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.^[5] 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."^[5] Barrett has been quoted as saying "the pseudoscience within osteopathy can't compete with the science".^[5]

In 2004, the osteopathic physician Bryan E. Bledsoe, who is 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".^[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 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".^[7]

Treatment

According to the 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 chiropractics, use similar techniques.^[10] OMT can be considered as a treatment for certain musculoskeletal problems such as lower back pain.^[11]

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.^[12] 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.^[13] After diagnosis of a counterstrain tender point, 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.^[14] This position is held for ninety seconds and the patient is subsequently returned to her normal posture. Most often this position of ease is usually achieved by shortening the muscle of interest.^[14] 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.^[15] 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.^[16][17] HVLA is also contraindicated in patients with vascular disease such as aneurysms, or disease of the carotid arteries or vertebral arteries.^[16] Patients taking ciprofloxacin or anticoagulants, or who have local metastases should not receive HVLA.^[16]

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.^[15] This is accomplished by relaxing contracted muscles, increasing circulation and lymphatic drainage, and stimulating the stretch reflex of muscles and overlying fascia.^[18]

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.^[19] Although fascia and its corresponding muscle are the main targets of myofascial release, other tissue may be affected as well, including other connective tissue.^[18]

Lymphatic pump treatment

Lymphatic pump treatments are manual techniques which encourage lymph flow in the lymphatic system. Lymphatic pump treatment techniques increase lymph flow through the external application of forces to the thoracic cage, abdomen, pelvic diaphragm, legs, and over the spleen and the liver.^[20] 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.^[21] Research shows that two types of lymphatic techniques, the thoracic pump and the pedal pump, are both safe for patients with traumatic brain injuries, and do not raise intra-cranial pressure.^[22]

Research in animal models has demonstrated that lymphatic pump techniques produce a strong, short-term increase in the flow of lymphatic fluid, and stimulate the mobilization of immune cells in the lymphoid tissue of the gastrointestinal tract, from both the mesenteric lymph nodes and gut-associated lymphoid tissue; preliminary research in humans suggests that lymphatic pump techniques may be able to improve the immune response to vaccinations.^[20] 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).^[23]

Effectiveness

A 2013 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."^[2]

A 2013 systematic review of the use of OMT for treating pediatric conditions concluded that its effectiveness was unproven.^[3]

Earlier research

A 2005 systematic review of OMT's use in treating asthma concluded: "There is insufficient evidence to support the use of manual therapies for patients with asthma."^[24]

A 2005 meta-analysis and systematic review of six randomized controlled trials of osteopathic manipulative treatment (OMT) that involved blinded assessments of lower back pain in ambulatory settings concluded that OMT significantly reduces low back pain, and that the level of pain reduction is greater than expected from placebo effects alone and persists for at least three months.^[4]

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. 
• Savarese, Robert G.; Copabianco, John D.; Cox, James J. (2009). OMT review. ISBN 978-0967009018. 
• 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. 

v t e Osteopathic Medicine (ICD-10-PCS 7) General Osteopathic medicine in the United States Osteopathic medicine in Canada Treatments Articulatory technique Balanced ligamentous tension Chapman reflex points Counterstrain Cranial Lymphatic pump Muscle energy technique Myofascial release Paraspinal inhibition Soft tissue technique Somatic dysfunction Education List of osteopathic medical schools Doctor of Osteopathic Medicine Accrediting Commission Licensing COMLEX NBOME Organizations AOA COA AACOM Student Council Specialty Boards Specialty colleges Directors and Medical Educators American Academy of Osteopathy People List of osteopathic physicians Andrew Taylor Still S. S. Still Media The DO The Journal of the American Osteopathic Association Osteopathic Family Physician History History California merger Flexner Report Osteopathic medicine