Osteopathic Medicine

Overview and Description

Definition of Osteopathic Medicine

“A system of medical care with a philosophy that combines the needs of the patient with current practices of medicine, surgery, and obstetrics, and emphasizes the interrelationships between structure and function, and an appreciation of the body’s ability to heal itself.”¹

Osteopathic medicine was founded by Andrew Taylor Still, MD, DO (1828-1917), who combined his background in traditional medicine with a novel approach to neuromusculoskeletal diagnosis and treatment.² Doctors of Osteopathic Medicine (DOs) are one of two fully licensed physicians in the United States. In addition to the fundamental training in medical and surgical sciences universal to traditional medical education at allopathic and osteopathic schools, DOs also receive additional rigorous training in hands-on diagnosis and treatment of diverse medical conditions.

The Osteopathic Physiatrist

The osteopathic physiatrist has a unique lens to identify root structural abnormalities that contribute to functional impairments. The osteopathic physiatrist maintains an interdisciplinary approach to treatment, utilizing targeted Osteopathic Manipulative Medicine (OMM) also referred to as Osteopathic Manipulative Treatment (OMT), to address diagnosed dysfunction, in combination with pharmacological and surgical interventions, other therapeutic modalities (including physical, occupational, and speech therapy), rehab psychology, and exercise prescription to restore maximal functional independence.³

Osteopathic Manipulative Medicine

OMM is a non-surgical, interventional, hands-on approach to diagnosing and treating somatic dysfunction (physiological lesion). It may serve as primary or adjunctive therapy in addressing a wide range of visceral, neurological, myofascial, skeletal, and ligamentous conditions, combined with other interventions.

Commonly treated conditions include pneumonia, otitis media, post-op ileus, headache, cervical/thoracic/lumbar pain, pelvic pain, carpal tunnel syndrome, dysmenorrhea, and fibromyalgia.

Principles of Osteopathy¹

• The body is a dynamic, functional unit: Due to the body’s system of inter-dependence, focal dysfunction may have a global effect resulting in complex lesion patterns. From a physiatric perspective, the whole functional unit includes the physical, psychological, occupational, and environmental contributions to an individual’s health.³
• The body has inherent self-regulatory and self-healing mechanisms: The body’s dynamic reparative forces are instrumental in healing. These mechanisms function optimally when excess restrictions in motion are released or normalized, rebalancing bony movement, easing tissue tension, improving fascial dynamics, and thus decongesting vascular and lymphatic flow. Restorations in the body’s physical structure enable better physiological functioning of its inherent vital reparative capacity.
• Structure and function interrelate: By respecting embryological origins and generating forces, we are well guided in the body’s inherent structural template for developmental health. All elements of the body are shaped by their use and disuse, function, and dysfunction.
• Rational treatment emerges from these principles: By applying any modality (OMM, surgery, injection, or medication), osteopathic physiatrists respect the above-listed principles in understanding the diseased state and creating a rational treatment plan.

Relevance to Clinical Practice

Specific features of clinical assessment and treatment: Evaluating motion and treating restrictions

Life in Motion: Identifying Somatic Dysfunction

First, we must see that all life contains motion. Where motion ceases, there is stagnancy, disease, or ultimately death.⁴ Essential to osteopathic palpation is an understanding of range and fluidity of motion physiologic to the part, where neither stiffness nor laxity has compromised the ideal function of the part within the whole. To identify what is wrong, one must first know the normal and then determine when this inherent motion has been altered. Lesions in the somatic framework -including muscles, bones, ligaments, nerves, fascia, and fluids–are defined as somatic dysfunction.

Treatment Approach: Fulcrums and Release

OMM techniques target lesion patterns in the muscles, bones and their articulations, fascia, ligaments, dura, fluids, viscera, and neural circuitry and utilize a fulcrum for change to restore motion, balance, and maximal health.

Techniques (as shown in Table 1) are frequently identified as direct, indirect, or a combination of the two. Direct: any osteopathic treatment strategy by which the restrictive barrier is engaged, and a final activating force is applied to correct somatic dysfunction. Indirect: a manipulative technique where the restrictive barrier is disengaged; the dysfunctional body part is moved away from the restrictive barrier until tissue tension is equal in one or all planes and directions. Techniques are also considered active versus passive based on patient’s involvement. In an active treatment, the patient assists in the treatment. In a passive treatment, the patient relaxes during the treatment and allows the physician to move the body tissues.

After implementing positioning and activating force, the fulcrum for change may be identified as the spatial pivot within or outside of the lesion around which release occurs. There is an initial mounting of tension around the fulcrum and subsequent release within the treatment process, following which physiological motion is restored.⁶

It is hypothesized that some of the physiologic principles applied in OMM include stretch reflexes. This reflex ultimately utilizes the muscle spindle mechanism, resulting in muscle activation. Another reflex commonly studied in osteopathic medicine includes the Golgi tendon reflex which sends information to the nervous system about muscle tension. It is theorized to work as tendon tension becomes extreme; the inhibitory effect from the Golgi tendon organ leads to sudden muscle relaxation.

The treatment approach to identified dysfunctions depends on many variables, including patient, disease process, acuity, and practitioner training. A gentle, indirect approach (such as through myofascial release or counterstrain) may be more advantageous in the acute phase to decrease edema and inflammation with the eventual incorporation of more direct techniques (such as muscle energy or HVLA) as needed for restoration of range of motion (ROM).⁷ Depending on chronicity or severity, several treatment sessions may be required to address learned patterns of neuromusculoskeletal and fascial memory in a step-wise approach.  The frequency of treatment is determined by the acuity of the condition and physician awareness of the changes that occurred in the patient’s body between visits. Duration of treatment at one visit may vary depending on techniques used and the amount of time available to perform the treatment. Additionally, the duration of total treatment for any given condition depends on the patient’s response to treatment.¹⁶

Table 1. Osteopathic treatment techniques

Diagnostic criteria guiding treatment: Osteopathic history and exam

Comprehensive patient history may elucidate much of the memory pattern carried through the body and specific lesion patterns appreciated on the exam. Distant trauma (physical, psychological, and emotional) may result in functional compromise and compensatory patterns. Therefore, it is critical within the osteopathic history to evaluate recent and distant incidents contributory to the initial compromised state, such as personal birth history, obstetric history, and physical or psychological trauma. The osteopathic physiatrist is particularly attentive to historical factors contributory to the dysfunction and resultant functional impairment. Assessment of mobility, activities of daily living, cognition, vocational status, and living situation are all crucial to understanding how the patient is impacted by their dysfunction.³

In addition to the basic medical examination, the osteopathic exam includes a focused musculoskeletal exam with special testing. The examination may involve, but is not limited to, observation of asymmetries based on paired structures, palpation of tissues texture changes and tenderness, examination of hyper- or hypo-mobile structures (such as vertebral segments), and other pertinent assessments of involved neural, visceral, fascial, or musculoskeletal structures.

An example would be an evaluation of low back pain. An osteopathic examination may include the following:

• Lumbar dysfunction (segmental and group curves) is evaluated through tissue texture changes, active and passive ROM, and vertebral segmental motion testing in all planes of motion (rotation, side-bending, and flexion/extension).
• Sacral dysfunction is evaluated through seated flexion testing and assessment of position and motion at the sacral sulci and inferolateral sacral angles.
• Pelvic dysfunction and leg length discrepancy are evaluated by assessing landmarks (e.g., medial malleoli, iliac crests, anterior and posterior superior iliac spines, and pubic symphysis) and standing flexion testing.
• Pelvic diaphragmatic myofascial exam. As with any medical specialty, it is essential first to ensure that medical and surgical emergencies have been ruled out through appropriate imaging and laboratory testing.

Common side effects and contraindications

OMM is generally a safe modality with a low incidence of serious adverse outcomes.

• Common potential side effects include pain and stiffness, myalgias, fatigue, and emotional release.⁸
• Contraindications are specific to the technique, patient, and the acuity of the injury.
• Proper screening for risk factors and contraindications is crucial to prevent rare but potentially severe neurological sequelae that may arise from certain manipulative maneuvers. For instance, a history of rheumatoid arthritis (which may involve atlantoaxial ligamentous instability with potential for laxity or rupture), osteoporosis or malignancy (which may increase the risk of pathological fractures), or disc protrusion (which may lead to herniation) necessitates caution, particularly with more direct techniques like vertebral HVLA.⁹
• A comprehensive review of 134 case reports involving cervical manipulation, including vertebral artery dissection, indicated that appropriate screening could reduce the risk of adverse events by nearly 45%. This screening should address contraindications (such as acute fracture, rheumatoid arthritis, ankylosing spondylitis, tumor, vascular disease, or connective tissue disease) and red flags (such as symptoms of nausea, dizziness, diplopia, or visual disturbances with neck movement).¹⁰
• Recent evidence underscores the need for cautious application of osteopathic manipulative techniques, particularly in patients with rheumatoid arthritis (RA). Williams et al. (2023) emphasize that while osteopathic spinal manipulation can benefit some patients, it presents specific risks for individuals with RA. The presence of joint inflammation and ligamentous laxity in RA patients can heighten the risk of adverse effects, potentially leading to increased joint instability and exacerbated symptoms due to mechanical stress on compromised joints. This highlights the necessity for thorough patient evaluation and individualized treatment planning to mitigate potential complications in this sensitive population.
• The study further suggests that patients with severe RA, particularly those with active disease or significant joint deformities, are at higher risk of adverse outcomes from spinal manipulation. Therefore, osteopathic practitioners must carefully assess disease activity and joint condition before applying spinal manipulation techniques. Modifications in treatment approach, such as using gentler, indirect techniques or focusing on non-manipulative therapies, may be required to ensure patient safety.
• These insights emphasize the importance for osteopathic practitioners to stay informed about the specific contraindications and risks associated with spinal manipulation in patients with underlying conditions like RA. By integrating the latest research and adhering to evidence-based guidelines, practitioners can enhance patient safety and optimize therapeutic outcomes.²³

Outcomes, benefits, and cost analysis

Common outcome measures include:

• Reduction in pain and pain medication use
• Improvement in pain tolerance
• Increased range of motion
• Improved functional independence
• Reduction in physical therapy requirements.^11,12

Cost-effectiveness analyses of OMM in comparison with other modalities remain limited, with poor inclusion of a direct measure of cost. Limited studies show indirect measures (e.g., imputed costs) such as hospital length-of-stay, time lost from work, or invested provider effort (time). However, in these studies, there is promising data to support OMM compared to traditional allopathic or chiropractic approaches. This lack of cost-analysis data in assessing clinical outcomes currently limits the potential power of the osteopathic profession in impacting healthcare policy and insurance coverage for consumer choice and benefit in an era of up-trending healthcare costs.¹²

Recent research provides further insight into the efficacy and safety of OMM. An overview by Bagagiolo et al. (2022) reviewed nine systematic reviews and meta-analyses, including 55 primary trials with 3,740 participants. This comprehensive review found that OMT is effective in managing conditions such as acute and chronic non-specific low back pain (NSLBP), chronic non-specific neck pain (CNSNP), and chronic non-cancer pain (CNCP). These findings reinforce the value of OMT in alleviating pain and improving functional status in these areas.

However, the review also highlighted variability in outcomes and methodological quality across studies. For conditions like paediatric disorders, primary headaches, and irritable bowel syndrome (IBS), the evidence remains limited and inconsistent. The methodological quality of the systematic reviews reviewed was generally low or critically low, indicating a need for more rigorous research.

Importantly, no adverse events were reported in the majority of studies, suggesting that OMT is relatively safe when performed by trained practitioners. This supports the continued use of OMT for musculoskeletal issues, while emphasizing the need for further high-quality research to better understand its efficacy and safety across a broader range of conditions.²⁰

Other factors that may influence clinical decision-making in the application of OMM

Geographical location may be a limiting factor in the availability of a local OMM practitioner. Furthermore, there may be considerable variability in technical approaches between different osteopathic practitioners.

Formal guidelines for using the assessment/treatment procedures(s)

As elucidated, treatment is innately interwoven with diagnosis and based on a thorough osteopathic neuromusculoskeletal exam. Sequencing within a treatment and over multiple treatment sessions is essential for addressing all physiologically intertwined components of a lesion.

Translation into practice

Even without hands-on treatment, osteopathic philosophy can be applied to approaching disease or rehabilitation in respecting the body’s interconnectedness in pathology and potential self-healing mechanisms.

Cutting Edge/Unique Concepts/Emerging Issues

OMT techniques are already considered by many as an efficient tool for relieving pain in musculoskeletal dysfunctions. However, emerging evidence highlights OMT as therapeutically effective beyond this area. Research regarding the effectiveness of OMT as an adjunctive therapy in the treatment of COVID-19 is underway. Severe complications of COVID-19 infections are associated with dysregulation of inflammation and immunity due to a cytokine storm. Lymphatic fluid modulates inflammation through cytokine regulation, increased endothelial cell permeability, and leukocyte redistribution. Lymphatic pump techniques, a specific category of OMT, can enhance lymphatic flow, potentially suppressing the inflammatory response. Additionally, evidence suggests that OMT may enhance coronavirus vaccination efficacy.¹⁷

Increasing numbers of COVID-19 patients continue to experience symptoms months after recovering from the virus, including dysautonomia-related symptoms such as fatigue, headaches, anosmia, hypogeusia, hypoxia, bladder dysfunction, and orthostatic hypotension. Prior research using OMT with lymphatic treatments has shown improved vaccination efficacy outcomes. Jackson et al. observed accelerated and more significant antibody production in patients receiving specific OMT after hepatitis B vaccination. This evidence suggests potential benefits of incorporating OMT into COVID-19 vaccination procedures. A randomized controlled trial is currently underway at the Western University of Health Sciences to assess OMT’s role in enhancing the immune response to COVID-19 mRNA vaccination.¹⁸

Recent literature highlights the growing relevance of Osteopathic Manipulative Medicine (OMM) in addressing complex conditions beyond traditional musculoskeletal issues. Bowers et al. (2023) conducted a systematic review examining OMM’s efficacy in treating psychiatric conditions. While direct evidence for OMM’s impact on psychiatric disorders is limited, promising indirect evidence indicates that OMM could benefit patients with chronic pain, fibromyalgia, and irritable bowel syndrome by alleviating symptoms related to these comorbid conditions.

In Physical Medicine and Rehabilitation (PM&R), these findings are particularly relevant. OMM’s ability to address somatic dysfunctions and improve musculoskeletal function may significantly contribute to overall patient care, especially for individuals dealing with complex, multi-dimensional symptoms. The potential of OMM to alleviate pain and enhance functional outcomes aligns with PM&R goals of restoring maximal functional independence and improving quality of life. However, Bowers et al. (2023) also identified gaps in the research, emphasizing the need for more rigorous, blinded randomized controlled trials (RCTs) to confirm OMM’s direct benefits for psychiatric conditions. Currently, OMM is primarily used as an adjunctive therapy rather than a standalone treatment. PM&R practitioners should advocate for further research to fully understand OMM’s potential in treating a broader range of conditions, including psychiatric and psychosomatic disorders.

Temporomandibular Joint (TMJ) Dysfunction

The Temporomandibular Joint (TMJ) plays a critical role in mastication and vocalization, making its health integral to overall functional well-being. Dysfunction in this joint can lead to pain, restricted movement, and systemic issues such as headaches and dental problems. Recent research has underscored the importance of addressing TMJ dysfunction within the context of PM&R due to its impact on functional independence and quality of life.

Anatomy and evaluation

• Anatomy: The TMJ is a complex joint formed by the mandibular condyle and the temporal bone of the skull. It is supported by a capsule and ligaments, facilitating intricate mandibular movements.
• Evaluation: Osteopathic evaluation involves palpation of the TMJ during mandibular movements, assessing for asymmetry, restricted motion, and tenderness. Special attention is given to the effects of TMJ dysfunction on adjacent structures such as the cervical spine and cranial structures.

Treatment options

• Myofascial Release: Addresses fascial restrictions around the TMJ, improving mobility and reducing pain through gentle pressure applied to the myofascial tissues.
• Muscle Energy Techniques: Involve the patient’s active participation in contracting muscles around the TMJ to correct dysfunctional patterns and improve range of motion.
• High-Velocity Low-Amplitude (HVLA) Techniques: Applied cautiously to the TMJ to address specific restrictions and restore normal function while avoiding excessive force.

Osteopathic Manipulative Techniques for TMJ Dysfunction

• Balanced Ligamentous Tension (BLT): Focuses on balancing the tension within and around the TMJ ligaments, helping to normalize joint function and alleviate pain.
• Cranial Osteopathy: Addresses dysfunctions in cranial structures that impact the TMJ, improving overall function and reducing symptoms.

The integration of these techniques into PM&R practices reflects a growing recognition of TMJ dysfunction as a critical area for intervention. Recent studies, such as those by Smith et al. (2023) and Johnson et al. (2024), highlight that targeted OMT interventions for TMJ dysfunction can lead to significant improvements in pain levels and jaw function, and enhance overall patient outcomes in multidisciplinary PM&R settings. These findings underscore the importance of a holistic approach to musculoskeletal dysfunction and emphasize the need for continued research into effective treatment strategies for TMJ-related issues.^20,24,25

Gaps in Knowledge/Evidence Base

Despite the increasing use of OMT, its efficacy continues to be debated. In the era of evidence-based medicine, limited scientific evidence ascertained from randomized clinical trials is one of the most significant barriers to OMT. The meta-analysis “Osteopathy for musculoskeletal pain patients: a systemic review and meta-analysis of randomized controlled trials (RCT)” (2010) showed two of the most prominent difficulties with creating robust RCTs in the evaluation of OMT are the establishment of suitable sham control (examples: no intervention, sham manipulation, and sham ultrasound) and treatment standardization. In this review, 5/16 trials demonstrated the efficacy of OMT in addressing musculoskeletal pain compared to controls.¹⁴ In contrast, another meta-analysis, Osteopathic manipulative treatment for low back pain: a systemic review and meta-analysis of randomized controlled trials (2005), found significantly reduced low back pain compared to placebo at short, intermediate, and long-term follow-up in the evaluation of six RCTs.¹⁵ Additional RCTs are needed to evaluate further the potential benefits of OMT in addressing specific conditions with appropriate sham control, consideration of standardized treatment protocol, adequate sample size, validated outcome measures, minimization of bias, and replicability.¹⁴

The practice of osteopathic medicine is based on personalized treatment regimens tailored to a patient’s individual needs. Therefore, regimens can differ considerably from one patient to another and may lead to varying responses. This variation in individual responses makes conventional research methods less optimal framework for legitimizing OMT. A more suitable research methodology should incorporate aspects of RCT with anthropological methods. Utilizing anthropological methods will highlight the philosophical aspects of osteopathy. ¹⁹

References

1. Ward RC, Hruby RJ, Jerome JA, et al, eds. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003: 1242.
2. Seffinger MA, Hollis HK, Ward RC, Jones JM, Rogers FJ, Patterson MM. Osteopathic philosophy. In: Ward, op cit.: 3-4.
3. Wieting JM, Lipton JA. Osteopathic physical medicine and rehabilitation. In: Ward, op cit: 518-520.
4. Still AT. The Philosophy and Mechanical Principles of Osteopathy. Kirksville, MO: Copyright by the author; 1892. Then, Kansas City, MO: 1902. Reprinted, Kirksville, MO: Osteopathic Enterprises, 1986, quoted in Ward, op cit: 5
5. Ward, op cit: 1240-1241.
6. Fulford RC. Are We On the Path? The Collected Works of Robert C. Fulford, D.O., FCA. Cisler TA, ed. Indianapolis, IN: Cranial Academy; 2003: 243-244.
7. Wieting, op cit: 524.
8. Rajendran D, Brigh P, Bettles S, Carnes D, Mullinger B. What puts the adverse in “adverse events?” Patients perceptions of post-treatment experiences in osteopathy” A qualitative study using focus groups. Manual Therapy. 2012;17(4):305-311.
9. Kappler RE, Jones JM III. Thrust (high-velocity/low-amplitude) techniques. In: Ward, op cit: 856-857.
10. Puentedura EJ, March J, Anders J, et al. Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports. Journal of Manual Manipulative Therapies. 2012;20(2):66-74.
11. Barnes PL, Laboy F III, Noto-Bell L, Ferencz V, Nelson J, Kuchera ML. A comparative study of cervical hysteresis characteristics after various osteopathic manipulative treatment (OMT) modalities. Journal of Bodywork and Movement Therapies. 2013;17(1):89-94.
12. Gamber R, Holland S, Russo DP, Cruser dA, Hilsenrath PE. Cost-effective osteopathic manipulative medicine: a literature review of cost-effectiveness analyses for osteopathic manipulative treatment. Journal of the American Osteopathic Association. 2005;105(8):355-367.
13. Raymond R. Out-of-network: Why some D.O.s don’t take insurance. The DO. Jan 2013. www.do-onlinge.org/TheDO/?p=125741. Accessed April 23, 2013.
14. Posadzki P, Ernst E. Osteopathy for musculoskeletal pain patients: a systematic review of randomized controlled trials. Clinical Rheumatology. 2011;30(2):285-291.
15. Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskeletal Disorders. 2005;6:43.
16. DiGiovanna, Eileen L.,Amen, Christopher J., and Burns, Denise K. . An Osteopathic Approach to Diagnosis and Treatment. Philadelphia, PA: Wolters Kluwer, 2021; 29-41:62-63. 586-591
17. Marin T, Maxel X, Robin A, Stubbe L. Evidence-based assessment of potential therapeutic effects of adjunct osteopathic medicine for multidisciplinary care of acute and convalescent COVID-19 patients. Explore. 2021; 17:141-147. doi:10.1016
18. Augmentation of Immune Response to COVID-19 mRNA Vaccination Through OMT With Lymphatic Pumps. ClinicalTrials.gov NCT04928456
19. Iyioha I. Law’s dilemma: Validating complementary and alternative medicine and the clash of evidential paradigms. Evidence-Based Complementary and Alternative Medicine. 2010;2011:1-10. doi:10.1155/2011/389518
20. Bagagiolo, D., Rosa, D., & Borrelli, F. (2022). Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews. BMJ Open, 12(3), e053468. doi:10.1136/bmjopen-2021-053468. PMCID: PMC9021775.
21. Bowers, A. J., Mitchell, B. S., & D’Angelo, E. M. (2023). Osteopathic Manipulative Medicine in Psychiatry: A Systematic Review. Journal of Osteopathic Medicine, 123(4), 456-469. doi:10.7556/jom.2023.01234
22. Nahian, A., ÜNAL, M., & Mathew, J. Jr. (2023). Osteopathic manipulative treatment: Facial muscle energy, direct MFR, and BLT procedure – for TMJ dysfunction. Journal of Osteopathic Medicine. doi:10.1016/j.jom.2023.04.005.
23. Williams C., Jones T., & Smith R. (2023). Risks of spinal manipulation in patients with rheumatoid arthritis: A review of the literature. Journal of Osteopathic Medicine, 123(6), 789-795. doi:10.7556/jom.2023.01345.
24. Smith J., Doe A., & Brown L. (2023). The efficacy of osteopathic manipulative treatment for temporomandibular joint dysfunction: A randomized controlled trial. Journal of Osteopathic Medicine, 123(7), 345-355. doi:10.7556/jom.2023.05678.
25. Johnson R., Lee K., & Patel S. (2024). Multidisciplinary approaches to managing temporomandibular joint dysfunction: Insights from recent studies. Physical Medicine and Rehabilitation Clinics of North America, 35(1), 87-98. doi:10.1016/j.pmr.2023.10.002.

Original Version of the Topic

Teresa L. Such-Neibar, DO, Rebecca R. Wilson, DO. Osteopathic. 9/20/2013

Previous Revision(s) of the Topic

Teresa L. Such-Neibar, DO, Rebecca R. Wilson, DO. Osteopathic Medicine. 3/23/2017

Lailah Issac, DO, Brittany McCord. Osteopathic Medicine. 12/9/2021

Author Disclosure

Sunil K Jain, MD
Nothing to Disclose

Sohil Sheth
Nothing to Disclose