As many of you know I am an osteopathic physician. In the mid 70s I decided to apply to an osteopathic medical school, as they seemed to be more in-line with my views of natural medicine.

While that was certainly true when the profession first started over 100 years ago, like many professions with time the starting values become distorted. The actual type of care that is rendered by DOs is not much different than that given by MDs. I do believe that the profession in general tends to be more interested in selecting students who are sincerely interested in people rather than relying on academic potential, however.

Throughout the years the comments I continuously receive from patients is that DOs generally seem to be more interested and caring as a profession. I really don't believe that I receive that feedback because they know I am a DO. However, on the other hand, many patients select DOs because they are interested in finding physicians who practice with an orientation on natural medicine.

In this area they will be sadly disappointed as nearly all DOs are still rooted in the traditional paradigm.

Generally, people would be far better off selecting a chiropractor, as their profession has typically maintained a stronger relationship with their founding roots. Not all chiropractors have this orientation, however, and some rely merely on adjustments for their care, so be careful. Naturopathic physicians are also another strong choice, but they are few and far between and can't obtain licensing in most states.

The key to finding a health care professional who will help guide and mentor you through your health care challenges will be to ask health food store employees what type of feedback they have had about the different doctors in your area. Don't rely on one answer, ask as many people as you can.

At this time, this is the best way I can help you identify knowledgeable professionals who also have a good bedside manner and will listen to you and serve as your coach to achieving the health you deserve.

Please be aware though that it is very rare for a health care practitioner to have a good handle on the emotional side of health, and this is frequently a major factor in most illnesses.

If you want a shorter version of what DOs are about you can review this link.

Despite an initial lack of acceptance by mainstream medicine, and amidst projections of a serious oversupply of physicians, the osteopathic profession continues to grow, successfully competing for shrinking health care resources and attracting the attention of insurers and those in managed care.

However, a recent telephone survey of 800 health maintenance organization beneficiaries suggested that the public is not yet familiar with osteopathic medicine. The history, philosophy, and current status of the osteopathic profession are presented, along with theories of the physiologic basis of and supporting evidence for palpatory diagnosis and manipulative therapy.

Definition

Osteopathic medicine is a diagnostic and therapeutic system based on the premise that the primary role of the physician is to facilitate the body's inherent ability to heal itself. Osteopathic philosophy maintains that the structure and function of the body are inseparable and that problems in one organ affect other organ systems.

It is the smaller of the two major schools of medicine in the United States, the other being allopathic medicine. Doctors of osteopathy follow accepted allopathic methods of diagnosis and treatment but place additional emphasis on the achievement of normal body mechanics as central to good health. Because of the close association between the spinal vertebrae and the autonomic nervous system via the sympathetic trunk and ganglia, the neuromuscular system is considered to play a vital role in maintaining homeostasis.

This association is believed to be one mechanism by which changes in the musculoskeletal system can affect other organs (somatovisceral reflex) or allow visceral pathology to manifest as aberrations in musculoskeletal tissue texture and intervertebral joint motion (viscerosomatic reflex).

These aberrations are termed "somatic dysfunctions" and can be useful aides in the physical diagnosis of both musculoskeletal and visceral disease.

Whereas allopathic practitioners of manual medicine use manipulation to address problems that are primarily limited to the musculoskeletal system, osteopathic teaching posits that manipulation has a distinct effect beyond the musculoskeletal system. Manipulation is not considered a substitute for conventional allopathic therapy and should be used only when not contraindicated or in conjunction with other therapies.

History

Andrew Taylor Still, MD, founded osteopathy in 1874. The son of a Methodist minister, Still attended the College of Physicians and Surgeons in Kansas City, Kan, served as a state legislator, and enlisted in the Ninth Kansas Cavalry and attained the rank of major during the Civil War. He was an ardent abolitionist and held strong opinions on other controversial subjects.

After the war, Still provided health care to settlers and American Indians. As he faced the epidemics of his time such as cholera, pneumonia, smallpox, diphtheria, and tuberculosis, he became increasingly disenchanted with many prevailing medical practices. Searching for adjuncts or substitutes for various medical therapies, he eschewed the liberal use of drugs and compounds. Still believed that the primary role of the physician was to facilitate the body's inherent ability to heal itself.

He also believed that the structure and function of the body were closely related and that problems in one organ affected other parts of the body. He maintained that the physician could best promote health by ensuring that the musculoskeletal system was in as perfect alignment as possible and obstructions to blood and lymph flow were minimized or eliminated. To that end, Still developed various manipulative techniques and a philosophy of medicine similar to, but separate from, allopathic medicine.

Still's intent was not to create a separate profession, but, as stated in the charter of the first osteopathic medical school, "To improve our present system of medicine" that of the 19th century by giving it "a more rational and scientific basis." The medical milieu of the 19th century was characterized by multiple schools of healing, many of dubious value, and physicians who were often poorly or incompletely trained.

Treatments such as bloodletting and the use of purgatives, mercury, or alcohol-based compounds were not uncommon. The American Medical Association was the dominant medical organization of the time. In trying to establish order and improve quality, the American Medical Association had little tolerance for yet another school of thought.

Still's ideas were initially rejected by his peers, and this instigated a half-century long struggle for acceptance. On one occasion, after he successfully treated several people with manipulation, the local church authorities attributed his success to the devil. Ostracized by both medical and societal organizations, Still was forced to become an itinerant physician in Kansas and Missouri.

However, his attempts to improve circulation and correct altered mechanics through the use of manipulation became more successful. Increasing demand for his services led to the establishment of the first osteopathic medical school, the American School of Osteopathy, which opened in Kirksville, Missouri, in 1892, with a class of 17 students. The curricula emphasized anatomy, histology, physiology, toxicology, and manipulation.

In 1896, Vermont became the first state to establish formal licensure for DOs. In 1897, a group in Kirksville organized the American Academy of Osteopathy, which in 1901 became the American Osteopathic Association (AOA). The AOA is the main governing body for the osteopathic profession, enforcing a code of ethics, supporting professional development, providing accreditation, and lobbying politically.

Membership in the AOA is limited to graduates of approved osteopathic schools, none of which are located outside the continental United States. There are osteopathic schools in England, but the scope of practice of graduates of these schools is limited to manipulation only.

In 1902, the AOA adopted formal standards of approval of osteopathic colleges and began on-site inspections of training programs.

In 1934, the Advisory Board for Osteopathic Specialists was formed, and by 1943 there were 11 specialty boards. Early osteopathic medicine was primarily outpatient based. Formal hospital-based programs were not established until 1936. In 1947, the AOA granted formal approval for hospital residency training programs. In 1950, Missouri became the first state to allow DOs to practice in public hospitals with the same unrestricted privileges granted to their MD counterparts.

Osteopathic physicians were drafted in both World War I and World War II, but were not allowed to serve as medical officers. In 1950, the osteopathic profession petitioned the US Senate Armed Services subcommittee for legislation that would allow DOs to be commissioned as medical officers. However, owing to the opposition from the American Medical Association, this law was not implemented for another decade.

On the civilian front, the struggle for autonomy climaxed in California in 1962 when the California Medical Association attempted to garner a majority in the American Medical Association. The California Medical Association relaxed its opposition to the osteopathic profession and invited all osteopathic physicians to join the state allopathic medical association.

The College of Osteopathic Physicians and Surgeons in Los Angeles, Calif, was converted to an allopathic college. This institution, with the approval of the state Osteopathic Medical Association and the California Medical Association, and on receipt of $65 per applicant, granted approximately 2,500 unearned MD degrees to DOs in that state. The offer was also open to all DOs in the United States.

Although a significant number of DOs accepted the offer, most declined and chose to retain their osteopathic identity and degrees. However, a referendum was then passed that prohibited the granting of new medical licenses to DOs in California. Lengthy court litigation ensued, and the California Supreme Court later overturned the ruling.

By 1973, DOs had been granted full practice rights in all 50 states. Recently, Germany became the first European country to offer a full license to US-trained osteopaths. The same offer does not apply to graduates of British osteopathic schools. Additionally, the German Society of Manual Medicine, a component of the German Medical Association, offers a 480-hour osteopathic manipulative therapy (OMT)/manual medicine curriculum to residency-trained physicians. More than 8000 doctors of medicine in Germany practice manual medicine.

Manipulative Therapy

Manipulation is thought to cause mechanical, neurophysiological, and psychological effects. Mechanically, manipulation can help restore normal positional relationships of vertebrae and also reduce disk protrusion. Neurophysiologically, it stimulates mechanoreceptor endings, which results in the inhibition of the presynaptic cells of the substantia gelatinosa at the level of the posterior horn, possibly resulting in a reduction of nociceptive activity.

Manipulation also generates afferent input and activates Golgi tendon organs, which in turn diminishes fusimotor motor neuron discharge and relaxes intrafusal and extrafusal fibers. Manipulation is also thought to enhance the release of endorphins, cause an increase in the water content of collagenous and cartilaginous structures, and stimulate glycosaminoglycan synthesis, thereby increasing the pain threshold, cellular transport, and the lubrication of joint surfaces.

Immobilization of joints or prolonged periods of reduced range of motion are thought to result in the formation of abnormal collagen crosslinks. Manipulation may lyse these abnormal crosslinks and enhance the formation of normal ones. Axoplasmic flow and the microcirculation of nerves are adversely affected by compression. Manipulation, by reducing compression, might enhance axoplasmic intraneuronal flow.

The "laying on of hands" or tactile nature of manipulation also has a strong psychological effect that is further reinforced by the interest and concern of the evaluator. Patients experience a sense of satisfaction and relief due, in part, to a closer evaluation of their symptoms. In some cases, pain is reduced after a detailed musculoskeletal examination alone.

Osteopathic manipulative therapy contains over 100 different techniques or procedures. They are broadly grouped into six major types: high-velocity-low-amplitude (also called thrust or mobilization with impulse), muscle energy, counterstrain, myofascial release, craniosacral, and lymphatic pump techniques.

High-velocity-low-amplitude, also known as mobilization with impulse, is a general type of manipulative treatment that involves a quick thrust over a short distance through what is termed a pathologic barrier. The movement is within a joint's normal range of motion and does not exceed the anatomic barrier or range of motion. With proper positioning of the patient, high-velocity-low-amplitude requires very little force and can be targeted to specific spinal segments. The goal of the treatment is to restore joint play or a desirable gap between articulating surfaces that permits free translational or gliding motion in addition to the usual angular motion.

Of all the osteopathic techniques, high-velocity-low-amplitude most closely resembles the chiropractic technique and has the greatest number of contraindications. Contraindications include rheumatoid arthritic involvement of the cervical spine, carotid or vertebrobasilar vascular disease, the presence or possibility of bony metastasis or severe osteopenia, and a history of pathological fractures.

Muscle energy techniques involve the manipulator exerting an equal and opposite force to the patient's active force from a certain position and in a specific direction. The result is repeated isometric contractions with passive range of motion through the barrier after each isometric contraction. The goal is to increase joint mobilization and lengthen contracted muscles. Because no thrusting is done, this procedure has a very low likelihood of producing complications and can be used where high-velocity-low-amplitude is contraindicated. The mechanism of action is thought to be at least two-fold: (1) through reciprocal innervation and (2) through the Golgi tendon reflex.

When a stretch reflex excites one muscle, reciprocal innervation causes simultaneous inhibition of the antagonist muscle. The Golgi tendon organ reflex is an inhibitory reflex that can cause relaxation of a muscle when sufficient tension is placed on the Golgi tendon organ through either stretching or contracting the muscle.

When performing counterstrain, the manipulator places the symptomatic joint in the position of least discomfort while at the same time monitoring the degree of tenderness at a nearby tender point. This position of minimal discomfort is usually a position where the muscle is at its shortest length. The position is held for 90 seconds and the joint is slowly and passively returned to the neutral position.

This prolonged shortening of the muscle causes shortening of both the intrafusal (muscle spindle) and extrafusal fibers. The gamma motor neurons then increase their firing rate to maintain tone in the muscle, and the muscle spindle fibers become hypersensitive. If the hypersensitive muscle is now lengthened too rapidly, a reflex overstimulation of the alpha motor neurons will occur.

This sensory input travels to the higher centers of the central nervous system, which may misinterpret this input and respond with excessive gamma motor stimulation, maintaining the spasm. Reshortening the muscle allows the muscle spindle to shorten and resume normal firing. The central nervous system then resets its gamma motor neurons after about 90 seconds. The only contraindication for counterstrain is patient unwillingness or inability to cooperate.

Myofascial release techniques are similar to deep massage, but the hands of the manipulator are not merely slid along the skin surface. The goal is to stretch muscles and fascia to reduce tension. Traction is applied to the long axis of muscles. The mechanism of action is due in part to the Golgi tendon organ reflex and reciprocal innervation. Myofascial techniques can also be adapted to promote venous and lymphatic drainage.

Lymphatic pump techniques involve physical measures such as pectoral traction, postural drainage, effleurage, thoracic expansion, and rhythmic passive dorsiflexion of the feet in an attempt to enhance lymphatic return either by influencing negative intrathoracic pressure or mechanically assisting return of lymph from the lower extremities. Lymphatic techniques should not be performed in the presence or potential presence of metastatic cancer or active pulmonary tuberculosis or miliary tuberculosis.

Craniosacral therapy is based on the supposition that oscillatory motions of the cranial bones and sacrum exist. These movements are barely perceptible and are mediated through the tension of the various dural membranes such as the falx cerebri, tentorum cerebelli, and the dura along the entire spinal cord.

Their amplitude and rate are thought to provide information about the patient's health and are thought to be influenced by the application of gentle pressure over specific areas of the cranium and sacrum. Craniosacral therapy is also thought to influence parasympathetic tone because the origins of parasympathetic division of the autonomic nervous system are located in the craniosacral regions.

Complications From Manipulation

An estimated several hundred million manipulations are preformed each year. Determining the frequency of complications from manipulation is difficult because of uncertainties in the actual number of manipulative treatments performed and the number of unreported complications.

Doctors of osteopathy occasionally perform manipulation as part of an office visit for other conditions and do not bill it as a separate procedure. It is therefore harder to determine the actual number of osteopathic manipulations that are performed as opposed to chiropractic manipulations because chiropractors usually generate a separate bill for each manipulation.

Manipulation is relatively safe. In more than 15 controlled trials of manipulation, there were no adverse effects from manipulation. A review of 128 articles published between 1925 and 1993 revealed that there were 185 specific cases of major complications. Approximately 66 percent were cerebrovascular accidents, 12 percent disk herniations, eight percent pathologic fractures or dislocations, and three percent general increase in pain. Of these, only two cases involved osteopathic physicians.

One difference between osteopathic manipulative therapy and chiropractic therapy is that chiropractors may manipulate an affected joint beyond its physiologic and anatomic range of motion. Doctors of osteopathy look for restrictions in joint movement that occur within the normal or physiologic range of motion of the joint and attempt to correct them by moving the joint through the abnormal pathologic barrier, usually not beyond the physiologic range of motion. This may be one reason for the low incidence of adverse effects from OMT.

Ladermann reviewed the world literature and discovered 135 case reports of serious complications. Most involved chiropractic cervical treatments and were due to misdiagnosis or the unrecognized presence of neoplastic disease. The most common complication was a delay in diagnosis and treatment, and the most serious complication was paraplegia from manipulating a patient with a bleeding disorder who developed a meningeal hematoma.

Continued Next Issue

Archives of Family Medicine November/December 1999

What is a D.O.?