A. Overview and Description
Definition of Osteopathic Medicine
“A system of medical care with a philosophy that combines the needs of the patient with current practice 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, M.D., D.O. (1828-1917) who combined his background in traditional medicine with a novel approach to neuromusculoskeletal diagnosis and treatment.2 Doctors of Osteopathy (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 through which he or she may identify root structural abnormalities that contribute to functional impairments. The osteopathic physiatrist maintains an interdisciplinary approach to treatment, utilizing targeted Osteopathic Manipulative Medicine (OMM) 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 diagnosis and treatment of 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, in combination 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: Through respecting embryological origins and generating forces, we are well guided in the inherent structural template for developmental health in the body. All elements of the body are shaped by their use and disuse, function and dysfunction.
- Rational treatment emerges from these principles: Through application of 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.
B. 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 have compromised ideal function of the part within the whole. To identify what is wrong, one must first know the normal and then identify when this inherent motion has been altered. Lesions in the somatic framework ”inclusive of 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 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: 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.5
An activating force or vector is applied following indirect or direct positioning such as articulatory thrust (e.g., in High Velocity Low Amplitude or HVLA), compression or traction (e.g., in facilitated positional release), vibration (e.g., through application of percussion hammer), and time (e.g., counterstrain). The fulcrum for change once positioning and activating force have been implemented may be identified as the spatial pivot within or outside of the lesion around which release occurs. Within the treatment process, there is an initial mounting of tension around the fulcrum and subsequent release, following which physiological motion is restored.6
It is hypothesized that some of the physiologic principles applied in osteopathy include stretch reflexes. In a monosynaptic pathway, sensory fibers synapse with motor fibers, which control the dynamic stretch reflex. This reflex ultimately utilizes the muscle spindle mechanism, resulting in muscle activation. The muscle spindle reflex, also known as the load reflex, is used in active resisted myofascial techniques.
Another reflex commonly studied in osteopathic medicine includes the golgi tendon reflex. In essence, the golgi tendon reflex 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. This is commonly seen in active myofascial therapy. Similarly, when performing muscle energy techniques, extreme tension is used to cause an inhibitory effect that leads to sudden muscle relaxation.
Other commonly used techniques, counterstrain and facilitated positional release, incorporate similar principles. During a 90 second counterstrain treatment, a muscle is shortened and gamma motor neurons increase their firing rate to maintain muscle tone. Shortening the muscle shortens the muscle spindle and ultimately leads to normal firing with resetting the gamma motor neurons. 16
As previously mentioned, techniques frequently implemented include muscle energy, articulatory techniques (including HVLA), balanced ligamentous or membranous tension, counterstrain, myofascial release, visceral manipulation, biodynamics, and craniosacral therapy. Many techniques can be applied in direct or indirect manner. Treatment approach to identified dysfunctions depends on many variables, including patient, disease process and its acuity, and practitioner training. Gentle, indirect approach (such as through myofascial release or counterstrain) may be more advantageous in the acute phase to decrease edema and inflammation with 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, a number of treatment sessions may be required to address learned patterns of neuromusculoskeletal and fascial memory in a step-wise approach.
Diagnostic Criteria Guiding Treatment: Osteopathic History and Exam
A comprehensive patient history may elucidate much of the memory pattern carried through the body and specific lesion patterns appreciated on exam. Distant trauma (physical, psychological, and emotional) may give way to functional compromise and compensatory patterns. Therefore, it is key 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, as well as 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, osteopathic exam includes a focused musculoskeletal exam with special testing. 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 hypomobile structures (such as vertebral segments), and other pertinent assessments of involved neural, visceral, fascial, or musculoskeletal structures.
An example would be evaluation of low back pain. Osteopathic examination may include the following:
- Evaluation of lumbar dysfunction (segmental and group curves) through tissue texture changes, active and passive ROM, and vertebral segmental motion testing in all planes of motion (rotation, sidebending, and flexion/extension).
- Evaluation of sacral dysfunction through seated flexion testing and assessment of position and motion at the sacral sulci and inferolateral sacral angles.
- Evaluation of pelvic dysfunction and leg length discrepancy through assessment of 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 to first assure that medical and surgical emergencies have been ruled out through appropriate imaging and laboratory testing.
Common Side Effects and Contraindications
OMM is a relatively safe modality with a low profile of serious adverse outcomes.
- Common potential side effects include pain and stiffness, myalgias, fatigue, and emotional release.8
- Contraindications are specific to technique, patient, and acuity of injury.
- Appropriate screening for risk factors and contraindications may prevent potentially devastating neurological sequellae that, although extremely rare, could arise from certain manipulative maneuvers. For example, history of rheumatoid arthritis (atlantoaxial ligamentous instability with potential for laxity or rupture), osteoporosis or malignancy (potential for pathological fracture), or disc protrusion (potential for herniation) would herald caution in application of a more direct, articulatory technique such as vertebral HVLA.9
- One large review of 134 case reports involving adverse events in cervical manipulation (including vertebral artery dissection) revealed potential to reduce the risk of adverse events by nearly 45% with appropriate screening and application. This included screening for contraindications (such as acute fracture, rheumatoid arthritis, ankylosing spondylitis, tumor, vascular disease, or connective tissue disease) or red flags (eliciting symptoms of nausea, dizziness, diplopia, or visual disturbances with neck movement).10
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 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 in comparison to traditional allopathic or chiropractic approach.
- This paucity of cost-analysis data in assessment of 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 uptrending healthcare costs.12
- These limitations guide sustainable reimbursement methods for osteopathic practitioners, propagating a largely variable milieu of mixed insurance acceptance and cash practice among practitioners.13
Other factors that may influence clinical decision-making in application of OMM
Geographical location may be a limiting factor in availability of a local OMM practitioner. Furthermore, there may be large 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 important 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.
C. Cutting Edge/Unique Concepts/Emerging Issues
The integration of OMM with traditional physiatry can be profoundly beneficial in treating musculoskeletal dysfunctions (especially chronic) and optimizing functional outcome. The osteopathic physiatrist may utilize OMM and prescriptive exercise in conjunction with other therapeutic modalities to target lesion patterns, empower the patient in a treatment plan, and create more long-lasting effects in structural integrity.
D. Gaps in Knowledge/Evidence Base
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 strong RCTs in evaluation of OMM are establishment of suitable sham control (examples: no intervention, sham manipulation, and sham ultrasound) and treatment standardization. In this review, 5/16 trials demonstrated efficacy of OMM 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 in comparison to placebo at short, intermediate, and long-term follow-up in evaluation of six RCTs.15 Additional RCTs are needed to further evaluate the potential benefits of OMM 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
- Ward RC, Hruby RJ, Jerome JA, et al, eds. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003: 1242.
- Seffinger MA, Hollis HK, Ward RC, Jones JM, Rogers FJ, Patterson MM. Osteopathic philosophy. In: Ward, op cit.: 3-4.
- Wieting JM, Lipton JA. Osteopathic physical medicine and rehabilitation. In: Ward, op cit: 518-520.
- 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
- Ward, op cit: 1240-1241.
- Fulford RC. Are We On the Path? The Collected Works of Robert C. Fulford, DO, FCA. Cisler TA, ed. Indianapolis, IN: Cranial Academy; 2003: 243-244.
- Wieting, op cit: 524.
- Rajendran D, Brigh P, Bettles S, Carnes D, Mullinger B. What puts the adverse in “adverse events?” Patientsâ€™ perceptions of post-treatment experiences in osteopathyâ€”A qualitative study using focus groups. Manual Therapy. 2012;17(4):305-311.
- Kappler RE, Jones JM III. Thrust (high-velocity/low-amplitude) techniques. In: Ward, op cit: 856-857.
- 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.
- 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.
- 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.
- Raymond R. Out-of-network: Why some DOs donâ€™t take insurance. The DO. Jan 2013. www.do-onlinge.org/TheDO/?p=125741. Accessed April 23, 2013.
- Posadzki P, Ernst E. Osteopathy for musculoskeletal pain patients: a systematic review of randomized controlled trials. Clinical Rheumatology. 2011;30(2):285-291.
- 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.
- DiGiovanna, Eileen L., Stanley Schiowitz, and Dennis J. Dowling. An Osteopathic Approach to Diagnosis and Treatment. Philadelphia, PA: Lippincott Williams and Wilkins, 2005; 42-50. 80-81.
Original Version of the Topic
Teresa L. Such-Neibar, DO, Rebecca R. Wilson, DO. Osteopathic. 09/20/2013.
Savitha Bonthala, MD
Nothing to Disclose
Kelly Cameron, DO
Nothing to Disclose