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

1. 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
2. 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.
3. 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.
4. 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

Technique	Description	Direct/ Indirect	Active/ Passive
Myofascial release	Gentle sustained pressure to alleviate fascial adhesions; myofascial tissues are loaded with the restrictive barrier engaged or towards a position of ease	Both	Both
Counterstrain	Method of diagnosis and treatment in which the patient’s somatic dysfunction is diagnosed by an associated tender point and treated by positioning about this tender point while monitoring for spontaneous tissue release over 90 seconds	Indirect	Passive
Facilitated positional release (FPR)	A combination of neutral positioning, application of an activating force (compression, torsion, or distraction), and placement into a position of ease	Indirect	Passive
Muscle energy	Patient actively contracts muscles upon request, from a “precisely controlled position in a specific direction, against a distinctly executed counterforce”, resulting in sudden muscle relaxation	Direct	Active
High-velocity low amplitude (HVLA)	Performed by positioning a joint into its restrictive barrier and applying an activating force via a rapid (high velocity) and short (low amplitude) thrust to move the joint past the restrictive barrier, but within the anatomic range of motion	Direct	Passive
Cranial treatment	Diagnosis and treatment of cranial bones that address dysfunctions of the primary respiratory mechanism	Both	Passive
Lymphatic treatment	Techniques designed to improve lymphatic circulation and augment the flow of interstitial fluid and lymph	Direct	Passive
Chapman’s reflex	A group of palpable nodules occurring in predictable locations on the anterior and posterior surfaces of the body; considered a somatic manifestation of a visceral dysfunction	Direct	Passive

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:

1. 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).
2. Sacral dysfunction is evaluated through seated flexion testing and assessment of position and motion at the sacral sulci and inferolateral sacral angles.
3. 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.
4. 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 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 sequelae 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 the application of a more direct, articulatory technique such as vertebral HVLA.⁹
• One extensive review of 134 case reports involving adverse events in cervical manipulation (including vertebral artery dissection) revealed the 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 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
• 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 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 adjunction in the treatment of COVID-19 is underway. The scientific literature indicates that severe complications of COVID-19 infections are a result of dysregulation of inflammation and immunity caused by a cytokine storm. Lymphatic fluid modulates inflammation, mainly through cytokine regulation, increased endothelial cell permeability, and leukocyte redistribution. A specific category of OMT called lymphatic pump techniques can increase lymphatic flow, which ultimately can suppress the inflammatory response. There is also evidence that OMT can enhance coronavirus vaccination efficacy.¹⁷

Increasing numbers of COVID-19 patients continue to experience symptoms months after recovering from the virus. Amongst these symptoms, several are related to dysautonomia, such as fatigue, headaches, anosmia, hypogeusia, hypoxia, bladder dysfunction, orthostatic hypotension. ¹⁷

Prior research using OMT with lymphatic treatments has shown improved outcomes in vaccination efficacy. Jackson et al. observed a faster and more significant production of antibodies for patients who received specific OMT after hepatitis B vaccination. The clinical evidence from this study can be extrapolated for the potential effectiveness of the addition of OMT to COVID-19 vaccination procedures. A randomized control trial is currently underway at the Western University of Health Sciences to evaluate the efficacy of OMT in augmenting the immune response to COVID-19 mRNA vaccination. ¹⁸

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

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

Author Disclosure

Lailah Issac, DO
Nothing to Disclose

Brittany McCord
Nothing to Disclose