Doubts about OMM

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Originally Posted by K31

Virtually anything is better than standard care for back pain. Sham acupuncture is better than standard care for low back pain and also decreases NSAID use. That doesn't mean it actually has a physiological effect.

In my opinion, these studies tell us two things:
1) The clinical encounter can be a powerful placebo
2) Standard therapy for low back pain sucks

Indeed.

But the problem arises when physicians (or other professionals) bill for such practices. Then you're faced with an interesting ethical/legal dilemma.

Originally Posted by toxicwombat

Indeed.

But the problem arises when physicians (or other professionals) bill for such practices. Then you're faced with an interesting ethical/legal dilemma.

Is there an ethical issue with billing for a treatment that is as good as NSAID therapy?

Originally Posted by K31

Virtually anything is better than standard care for back pain. Sham acupuncture is better than standard care for low back pain and also decreases NSAID use. That doesn't mean it actually has a physiological effect.

In my opinion, these studies tell us two things:
1) The clinical encounter can be a powerful placebo
2) Standard therapy for low back pain sucks

What is "standard care" care for back pain?

Originally Posted by bala565

I know this is equivalent to heresy on SDN and I’m going to get lot of “supportive” responses, but here we go:



Even IF it is placebo effect, who cares? If it relieves patients’ pain/ailment, who cares what it is? You think as a patient, one would care why he/she is no longer in pain? It practically has zero side effects (unless it is performed by an OMS) and AT LEAST it provides some symptomatic relief…

Now, some of the claims people make is BS and contrary to popular belief, it does NOT cure cancer BUT it is a VERY useful tool for treatment of SOME musculoskeletal and lymphatic problems.



Even if you are not going to use it/hate it/etc, think of it as an extra “functional anatomy class.” There has been numerous times that the information I have learned in OMM class has saved my a** on rotations which had nothing to do with OMM.

The emboldened text is my biggest issue with this stuff (hey everyone.... new here)

statements like this stand in the face of medical progress. aside from OMM, other potentially pseudoscientific treatments have near cult followings which dont tolerate scrutiny or criticism. Ever been nearly punched out by a chiropractic patient after telling them that you think the treatment is akin to a deep tissue massage? Those people get MAD!

if we accept the treatment just because we feel like it is working, we become complacent and dont investigate further. ive got a sore spot for practitioners of chiropractics, acupuncture, herbal medicine, ect.... but that is entirely because I think there may be some validity to some treatments and their jealous protection of the techniques means we dont get to expand our understanding, educate the public, and trim the fat when it comes to alternative treatments



TL;DR
"who cares if it works?" is not a valid argument

Can someone here please set illustrate a model of how they should study these techniques in the setting of back pain?

I'm glad that everyone thinks so critically but how about some constructive remarks. Instead of just saying "there's no double blind RCT or placebo," please enlighten us on how to do so or design such a study.

Originally Posted by fozzy40

Can someone here please set illustrate a model of how they should study these techniques in the setting of back pain?

I'm glad that everyone thinks so critically but how about some constructive remarks. Instead of just saying "there's no double blind RCT or placebo," please enlighten us on how to do so or design such a study.

Fozzy,

I think our best bet is to get a large group of subjects who meet the clinical prediction rule for benefit from spinal manipulation, and an equally large group of subjects with non-specific, non-radicular LBP, and divide them up into 4 treatment groups:

1. subjects who meet the rule and get manipulation and ROM exercises x 2 sessions
2. subjects who don't meet the rule and get manip plus ROM x 2 sessions
3. subjects who meet the rule and get "standard care" which I think can be reasonable defined as NSAIDS, muscle relaxers, advice to stay active and assurance they will improve, with patients seeing their doctor for 2 sessions over a similar time frame as the two manip plus ROM sessions
4. subjects who don't meet the rule and get "standard care"

Outcome measures: Oswestry Disability Index, Global Rating of Change, and possibly pain scale, all taken at intake, after their two sessions, at one month, and six months.

Just throwing out an idea here - anyone else have suggestions? It's not a perfect study, as it isn't fully blinded, but I'm not sure that's possible when studying manual therapy.

JessPT,

You're stealin' my thunder! I should've known that you would speak up You're awesome! Here is the article citation that JessPT is referring to about clinical prediction rules. Kudos to the PTs for doing great studies on spinal manipulation.

Flynn et al. - 2002 - A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation

I like what you have laid out as a model. My point about "standard care" is that there is no standard care for back pain. For the purposes of this study, medication use should be clearly defined. Often times practitioners use NSAIDs but do not apply the correct dosage to achieve an anti-inflammatory effect. Same thing goes for muscle relaxants.

Pain scales are so subjective and often up for different interpretations by the patient. Outcome measures I would like to see are:
-medication use
-number of tests ordered
-days of from work/return to work
-improved sleep
-ambulation distance or 6 minute walk test
-sitting/standing tolerance

As JessPT pointed out, it's tough to have a completely blinded study when applying manual therapy. Plus, it's not unethical to not do anything at all and most patients aren't going to sign up for that study.

There are numerous confounding factors that make studying manual medicine. That's what makes this hard.

Fozzy, I would look up some of the low back pain research coming from Pitt. I would check out anything done by Greg Hicks. He performs most of his research on the elderly; however, his methodology is near flawless.

Interesting

For those of us without sufficient medical terminology and random abbreviations, what exactly does OMM stand for?

Originally Posted by Seria

For those of us without sufficient medical terminology and random abbreviations, what exactly does OMM stand for?

Osteopathic Manipulative Medicine

Sometimes called OMT, for "Osteopathic Manipulative Therapy"

Thank you for the answer!

It is always nice when others answer a question simply.

Originally Posted by spiceylife

I have posted quite a bit under another userid, but I have created a second ID for the purposes of this question. I am quite identifiable under my usual id.

I am now an MS1 at an Osteopathic school. I love my school and my fellow classmates and I have no problems with my education except one. This OMM stuff looks and feels like bunk. Every time a teacher tells me how wonderful their patient feels after OMM, I want to ask if they offered them a happy ending.

I'm not saying that physical thereapy isn't useful, I just don't think it takes a doctor to do it. All the techniques that I have been studying look like pretty simple physical therapy (muscle energy and HVLA) or simple massage (bowstringing and longitudinal stretch). It might take a doctor to diagnose tennis elbow, but why (after giving a cortisone shot) doesn't he just prescribe daily or weekly massages and have a trained physical therapist or massage place on rolodex?

And the idea of teaching "philosophy" to medical students is quite annoying. What if one day a scientific study proves that the "rule of the artery" ISN'T supreme. What is this stuff about the body being a unit? Didn't Darwin already prove that the purpose of the body is to successfully procreate - not self-regulate.

Also, the AT Still worship bothers me. Why in the world do the philosophical/religious opinions of a not terribly rational man from the early 1900's matter to us in the treatment of patients? Aren't we supposed to be dedicated to science? Ok, the 1918 flu patients treated by DO's survived better. Wonderful - now what have you done for me lately? They were still working on viral theory in 1914. Maybe Osteopaths were better scientists than phlebotemists, but what recommendation is that today?

Look, I'm being really critical here and overstating my point a bit. I believe that DO's are as good of doctors as MDs. I believe that the education at osteopathic schools is wonderful and we are producing great physicians. I just think that the OMM education is a waste of time.

I am willing to be corrected. I am only an MS1 and may have a different opinion next year.

I recognize that this is an inflammatory post, and I am really not intending to be a troll. I hope that the admins will forgive my using a second ID to post this. I will reveal my identity to the admins if they request it and they can verify that I really am a DO student and a regular poster. I would just like to hear an answer to my challenge to Osteopathic orthodoxy without losing my career.

you sound very much like a first year. I had a terrible experience with OMT in my lab cramped with 200+ kids in one smelly, stinky room with not enough fellows for 2 years. Something that turned me on to DO school was the manipulations. After the first 2 years, between not studying it enough, not practicing it enough, being not confident with it at all (HVLA, forget it!). Fast forward 2 years, I've had 2 OMM rotations, one my 3rd year where I really learned the fundamentals of OMT in the practical setting, and my last rotation where I was able to do OMT without someone standing over me, make clinical decisions, handle billing, etc. And yes, I really do enjoy OMT (HVLA, **** yes!) now. I think probably 90% of my classmates won't use it, and you might not as well either, but in reality it's an amazing tool set to have, if only for the anatomic landmarks. That bull**** they feed you about being confident to touch a patient, it's true, we have that over allopaths (I had my allopathic attending tell me all about the SI joint the other day and the L4 illiac crest landmarks as if we weren't spoon fed that for 2 years straight.

http://www.youtube.com/watch?v=UTe9sG7K6ck

i love how the description mentions difficulty in palpating something that does not exist

This thread has blown my mind about D.O. school.

I cannot believe this.