Friday, February 27, 2009

CAM Paper Part IV: Osteopathy

Osteopathy is now regarded as a part of conventional medicine. Osteopathic physicians, who make up approximately 5.5% of American physicians, are fully licensed in all 50 states and have the same scope of practice as allopathic physicians. In addition, there is no longer a significant difference between allopathic and osteopathic medical school curriculums, and osteopathic principles like holistic medicine have been adopted by allopathic physicians.(9) However, since osteopathy arose as a competitor to allopathic medicine in response to the inadequacies of allopathic medicine of that time, a discussion of osteopathy is still appropriate here.

Andrew Taylor Still, the founder of osteopathy, was deeply affected by the inability of allopathic medicine to save his children from dying of meningitis. He became a harsh critic of many then common medical practices like blood-letting and purging, which he felt did more harm than good. Several of the principles advocated by Still continue to form the philosophical basis of osteopathic medicine today. These include focusing on health rather than disease, treatment of the entire patient rather than a reductionist approach, and relating the structure of the body to its function.(9,10) In the early days of osteopathy, practitioners treated patients with musculoskeletal manipulation (osteopathic manipulative treatment, or OMT) in order to restore their structural integrity and thereby their health. Still and other early osteopaths were opposed to the use of drugs, although osteopaths later acknowledged the importance of teaching pharmacology to their students and noted that drugs were useful and even necessary in some situations.(9)

Osteopathic principles and practice are heavily intertwined with competing medical systems. For example, although allopathic medicine is widely considered as following in the tradition of Hippocrates, the reductionist perspective that has historically characterized allopathic medicine was actually espoused by a second school of medicine that was the rival of Hippocrates. In contrast, the osteopathic principle of restoring the natural condition of the body to promote health is more in keeping with the ideas espoused by Hippocrates.(9) Second, many of the ideas held by Still were also held by Palmer, the founder of chiropractic, including an aversion to the use of drugs, rejection of the microbial theory of disease, and the belief that manipulation could be used to treat all human diseases.(7,9) In fact, some evidence suggests that Palmer learned his manipulation techniques from Still.(7) In spite of these similarities, osteopathy, unlike chiropractic, evolved over time to become part of conventional medicine.

In modern osteopathic practice, there continues to be overlap between osteopathy and these two other medical systems. An osteopathic physician’s office and practice are indistinguishable from any allopathic physician’s office and practice. Patients come in with the same complaints of sore throats and back pain. However, there is potentially some difference in how osteopathic and allopathic physicians treat patients who present with musculoskeletal pain. This is because an osteopathic physician may choose to use OMT along with or instead of muscle relaxing-drugs.

Upon observing an osteopathic physician perform OMT, I was struck by how similar it is to chiropractic musculoskeletal manipulation. In addition, the osteopathic physician and chiropractor used the same accessory modalities to treat patients with musculoskeletal pain, including heat, cold, and ultrasound. However, this osteopathic physician rarely performs OMT in his practice, in keeping with published reports that only a minority of osteopaths commonly treat their patients with OMT.(10) He pointed out that the current health care system often makes it financially and temporally impractical to perform OMT even when it would be helpful. For example, he is not able to bill many HMOs for OMT. Also, he does not have time to perform OMT when he must book patients every 15 minutes in order to keep his practice solvent.


medicine girl said...

I think it's a shame more DOs don't use manipulation since so many patients complain of back or other musculoskeletal pain or dysfunction.
I'd just like to note that on the whole, osteopathic manipulation is quite unlike stereotypical chiropractic treatment. In fact, most of the techniques don't resemble those used in traditional chiropractic at all.

In my osteopathic medical student opinion, so-called high-velocity, low-amplitude (HVLA) techniques used in chiropractic have their place, but are at times inappropriate and are also rarely enough to completely solve a musculoskeletal problem. For most problems, simply moving the joints back into place usually will not convince the adjacent muscles/tendons & fascia to go along for the ride. In fact, the muscles may react to a quick adjustment by holding on more tightly to their pathologic position!

CCLCM Student said...

As with our discussion in the subsequent chronic pain post, I agree with you that the combination of manipulation plus conventional treatments would be the best. Obviously osteopathic medicine has come a long way since the early days when manipulation was thought to treat everything, and I like the idea of there being more tools in the treatment arsenal besides cyclobenzaprine and tincture of time. It's unfortunate that the current structure of health care reimbursement doesn't lend itself very well to encouraging DOs to use manipulation on a more regular basis.

Thanks for telling me about the differences in osteopathic versus chiropractic manipulations. My experience with both osteopathic manipulation and chiropractic are obviously limited. It could certainly be that this chiropractor is not the norm. As I said in my post, I was extremely surprised by how hard he was working to persuade his patients and me that what he does is "real" medicine. It's also likely that I did not get a very representative exposure to osteopathic manipulation, since, as I said in the post, I did not actually see the DO use manipulation on a patient, only on myself.

Do you envision yourself using manipulation in your practice? Particularly if you go into a community outpatient primary care setting, do you think you would be able to afford doing manipulation?