Thoughts on OMM

[Bacchus]

I use OMM on all my LBP/Sciatic patients at their initial encounter.

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[as1212559]

OMT is actually quite useful in a lot of clinical situations. Palpatory skills are too. I even did cranial on someone with tension headache once in clinic. I think cranial in adults is total BS but she was responding unbelievably well to everything I did with her cervicals so I did some suture spreading. Placebo'ed her right into happiness.

Walked in with pain walked out without it. That's pretty alright by me. Don't be hatin.

 

[apr27]

I think it's great.

I think it's helpful to think of it as an extra tool in your tool belt. I think there's something beautiful in being able to offer an alternative treatment that doesn't require a pill and that you can do with your hands.

Yes, there will be times like during cranial or chapman's where you are just like "bruuhhhhhhh, srsly?"

 

[guitar25]

My biggest recommendation is any D.O.'s with some appreciation of this unique skill SCREAM at the AOA to get
osteopaths mentioned every time the Dr Oz's, etc talk about chiropractors only. If you are a D.O. and find some
benefit with OMT, DOCUMENT it. I know "sham" studies seem the only " legitimate" studies and anecdotes may not "count". But at least the results should be charted.
And I know of no legitimate scientific work being demanded from chiropractors - just great marketing.

This won't apply to you all, I know. But if you do learn some technique that saved another patient a harmful pill,
please STAND UP. You do have a unique skill. And with our society glued to our cellphones, never talking directly, those who understand HUMAN TOUCH is a medical skill, you may very well be the physician of choice, regardless of your specialty.

 

[Seth Joo]

OMT is actually quite useful in a lot of clinical situations. Palpatory skills are too. I even did cranial on someone with tension headache once in clinic. I think cranial in adults is total BS but she was responding unbelievably well to everything I did with her cervicals so I did some suture spreading. Placebo'ed her right into happiness.

Walked in with pain walked out without it. That's pretty alright by me. Don't be hatin.

I thought it was a distraction.

 

[Aql]

Apparently you are not sorry about offending anyone. There is more and more research being done to identify and quantify the changes associated with OMM. But I guess that doesn't matter to you since your 3 months of OMM classwork has made you such expert.

Please do your colleagues a favor. Either learn to appreciate OMM and what it can do to help alleviate pain and suffering. Or drop out of school and become that allopath you think is so much better. If you should stay in your DO program, do the rest of us a favor and stop trashing our profession.

(Steps off soapbox)

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Do humanity a favor and stop encouraging the baaing sheep mentality.

I completely disagree with the OP's opinion that OMM should be a less integral part of OME, but how's about you step off your high and mighty soapbox and substantiate with some research articles that you're claiming are more and more prevalent. It should be the collective responsibility of all OMSI-IV, OGME, and our DO attendings/preceptors to continually QUESTION and educate all on the efficacy of OMM in order to continually refine / provide quality studies to prove OMM helps to alleviate pain, restore function, etc.

Frankly, I am sick of sitting in on OMM lectures and hearing ridiculously flawed uncontrolled small group studies from the 1930s being quoted as reasons for why we practice certain OMT (this is the sad trend I've observed from big name presenters at the OMS through OGME level at several institutions).

 

[GUH]

Do humanity a favor and stop encouraging the baaing sheep mentality.

I completely disagree with the OP's opinion that OMM should be a less integral part of OME, but how's about you step off your high and mighty soapbox and substantiate with some research articles that you're claiming are more and more prevalent. It should be the collective responsibility of all OMSI-IV, OGME, and our DO attendings/preceptors to continually QUESTION and educate all on the efficacy of OMM in order to continually refine / provide quality studies to prove OMM helps to alleviate pain, restore function, etc.

Frankly, I am sick of sitting in on OMM lectures and hearing ridiculously flawed uncontrolled small group studies from the 1930s being quoted as reasons for why we practice certain OMT (this is the sad trend I've observed from big name presenters at the OMS through OGME level at several institutions).

Do you exercise the same amount of skepticism when it comes down to antibiotics, surgery, or other modalities?

 

[Drrrrrr. Celty]

Do you exercise the same amount of skepticism when it comes down to antibiotics, surgery, or other modalities?

Lets be frank in admitting that at the very least these modalities are being researched at volumes larger in both size and quantity.

 

[LChristmas]

Lets be frank in admitting that at the very least these modalities are being researched at volumes larger in both size and quantity.

Let's also be frank in admitting that OMM (like surgery) cannot be studied on the same size and quantity as pharmaceutical studies.

 

[Zaphod42]

Let's also be frank in admitting that OMM (like surgery) cannot be studied on the same size and quantity as pharmaceutical studies.

Let's also also be frank in admitting that there are aspects of OMM that are complete pseudoscience and you cannot blame people for being extra skeptical.

 

[Drrrrrr. Celty]

let's be frank that frank is an overrated frank, frankly...

in other news the English language spontaneously combusted.

 

[Drrrrrr. Celty]

Let's also be frank in admitting that OMM (like surgery) cannot be studied on the same size and quantity as pharmaceutical studies.

I don't know about that. An uncommon surgery? Sure. Chapman points for patients with COPD or respiratory disorders? That can be done very easily, I mean we're talking literally going into a few hospitals and nursing homes and sorting patients a bit for a few hours, doing it, and then checking in maybe over the course of 1-2-4 weeks with a self recording and also a breathing test.

 

[HotLunch96]

Do you exercise the same amount of skepticism when it comes down to antibiotics, surgery, or other modalities?

You're the worst

 

[jw3600]

I don't know about that. An uncommon surgery? Sure. Chapman points for patients with COPD or respiratory disorders? That can be done very easily, I mean we're talking literally going into a few hospitals and nursing homes and sorting patients a bit for a few hours, doing it, and then checking in maybe over the course of 1-2-4 weeks with a self recording and also a breathing test.

Is is understood that if the scientific community does not even consider the proposed concept/hypothesis to be logical or with a valid construct then there is no need to research the issue. Chapmans points literally are kilometers past the point of an even remotely valid scientific concept. It's legitimately the dumbest thing I have seen taught in an academic environment.

 

[Mad Jack]

We are all entitled to our opinions but not to the facts that we want to be facts. Medicine needs to be evidence based, and when we know at least 30% of people in trials respond to placebo, we can't use anecdotes as a way to justify what we do.

There's a lot of times you can't get evidence for a given thing that is up to scientific standard.

The only way to realistically do a trial involving OMM would be to train an entire group of people with sham treatments that they believed worked over a period of years, then having them treat patients with the exact same diagnosis as those who were taught actual OMM. That just isn't practical (or ethical, in regard to how it would affect those trained in sham treatments' lives- they'd have to be highly compensated afterward to make up for their years of wasted time).

Then there's the issue of every patient being different, and many situations just not coming up enough. I had a guy that nearly died of status asthmaticus secondary to using cocaine that was laced with talc. We'd pretty much given up on everything, and were about at the point where we were going to start talking to the family. A medication error occurred that sent his blood pressure dangerously high, but, miraculously, his kidneys started perfusing again (he hadn't been making urine for hours), his SpO2 increased back into the normal range, and his asthma completely resolved within a day. We won't see enough patients in a decade that are similar enough to this one to say whether or not repeating the same mistake might or might not be such a good idea, and those patients might have substantial comorbidities this patient did not have that would make any repeat of the process faulty at best. That's just one of hundreds of anecdotes I amassed in critical care over the years where evidence based medicine cannot be practiced because the cases are too few and far between for evidence to be gathered, and even if there were enough cases, it would be unethical to perform a study due to the extremely high degree of risk to the patients involved.

There is a place for anecdotes in medicine. If you're all aboard the EBM train, spend some time in environments where the rare and unusual happen with great frequency, and you'll realize why that is so. I worked at a hospital with one of the most prestigious internal medicine programs in the country, and we saw a lot of weird **** and I swear it makes me want to punch people when they insist we should be doing studies on everything when it's completely impossible at worst and unethical/impractical at best. EBM is not the be-all end-all of medicine, and it never will be. Worse still, EBM can result in manipulation of data by companies to show that their drug/product should be best practice, when in fact they've thrown out all of the studies they did that did not confirm the results they wanted (this is a RAMPANT practice in the pharmaceutical industry). You need to learn to parse evidence, analyze it to determine when it is or is not actually worth being applied to practice, and to determine when a situation is beyond the purvey of evidence due to the uniqueness of the circumstances involved or the difficulty in effectively testing the methods being employed.

EBM is very good for figuring out the best course of action to take in high frequency, easily reproducible events that have easy-to-measure outcomes and a well-defined patient population in which testing is not contraindicated due to ethical concerns and the study can be conducted without utilizing an excess of financial resources. That makes it great for sorting out high blood pressure or diabetes or whatever. It doesn't make it a good way to sort out the best way to approach a woman with SLE, sarcoidosis, heart failure, liver failure, and asthma that is currently undergoing an exacerbation due to an allergic reaction to inhaled heroin that was cut with unknown substances. There's too may variables and unknowns to ever get a best practice approach to a patient with this many issues.

The problem with med students is that they think about one little thing at a time. Comorbidities, med interactions, and circumstances are often a great deal of the picture, and an "EBM can solve everything" approach often fails to account for the unique circumstances of a great number of patients. Blind belief in EBM as the grand savior that will determine the right path for each and every patient is straight up ignorant.

 

[meliora27]

Seeing as there is no pathophysiologic basis for Chapman's points, they should be dropped immediately. I would love to see a letter from whatever the Osteopathic pathology college is, sent to the AOA/AACOM/NBOME explaining how this nonsense lacks a pathologic basis, and recommend their removal from the curriculum/testing.

 

[Drrrrrr. Celty]

Is is understood that if the scientific community does not even consider the proposed concept/hypothesis to be logical or with a valid construct then there is no need to research the issue. Chapmans points literally are kilometers past the point of an even remotely valid scientific concept. It's legitimately the dumbest thing I have seen taught in an academic environment.

Yes, and yet they do research on the topics because usually it's important to disprove them. Ex. Acupuncture.

 

[meliora27]

Yes, and yet they do research on the topics because usually it's important to disprove them. Ex. Acupuncture.

Before you jump to false conclusions, I suggest you take a look at the evidence. I'll point your towards the following: NIH Consens Statement. 1997 Nov 3-5;15(5):1-34.

 

[Mad Jack]

http://www.health.harvard.edu/blog/acupuncture-is-worth-a-try-for-chronic-pain-201304016042

Yes, and yet they do research on the topics because usually it's important to disprove them. Ex. Acupuncture.

 

[meliora27]

Yes, and yet they do research on the topics because usually it's important to disprove them. Ex. Acupuncture.

And there's also this, from NEJM First Watch, released just today...

http://www.jwatch.org/fw110806/2015/11/03/acupuncture-and-alexander-technique-help-alleviate

 

[wjs010]

Counterstrain. Lol.

 

[AlbinoHawk DO]

There's a lot of times you can't get evidence for a given thing that is up to scientific standard.

The only way to realistically do a trial involving OMM would be to train an entire group of people with sham treatments that they believed worked over a period of years, then having them treat patients with the exact same diagnosis as those who were taught actual OMM. That just isn't practical (or ethical, in regard to how it would affect those trained in sham treatments' lives- they'd have to be highly compensated afterward to make up for their years of wasted time).

Then there's the issue of every patient being different, and many situations just not coming up enough. I had a guy that nearly died of status asthmaticus secondary to using cocaine that was laced with talc. We'd pretty much given up on everything, and were about at the point where we were going to start talking to the family. A medication error occurred that sent his blood pressure dangerously high, but, miraculously, his kidneys started perfusing again (he hadn't been making urine for hours), his SpO2 increased back into the normal range, and his asthma completely resolved within a day. We won't see enough patients in a decade that are similar enough to this one to say whether or not repeating the same mistake might or might not be such a good idea, and those patients might have substantial comorbidities this patient did not have that would make any repeat of the process faulty at best. That's just one of hundreds of anecdotes I amassed in critical care over the years where evidence based medicine cannot be practiced because the cases are too few and far between for evidence to be gathered, and even if there were enough cases, it would be unethical to perform a study due to the extremely high degree of risk to the patients involved.

There is a place for anecdotes in medicine. If you're all aboard the EBM train, spend some time in environments where the rare and unusual happen with great frequency, and you'll realize why that is so. I worked at a hospital with one of the most prestigious internal medicine programs in the country, and we saw a lot of weird **** and I swear it makes me want to punch people when they insist we should be doing studies on everything when it's completely impossible at worst and unethical/impractical at best. EBM is not the be-all end-all of medicine, and it never will be. Worse still, EBM can result in manipulation of data by companies to show that their drug/product should be best practice, when in fact they've thrown out all of the studies they did that did not confirm the results they wanted (this is a RAMPANT practice in the pharmaceutical industry). You need to learn to parse evidence, analyze it to determine when it is or is not actually worth being applied to practice, and to determine when a situation is beyond the purvey of evidence due to the uniqueness of the circumstances involved or the difficulty in effectively testing the methods being employed.

EBM is very good for figuring out the best course of action to take in high frequency, easily reproducible events that have easy-to-measure outcomes and a well-defined patient population in which testing is not contraindicated due to ethical concerns and the study can be conducted without utilizing an excess of financial resources. That makes it great for sorting out high blood pressure or diabetes or whatever. It doesn't make it a good way to sort out the best way to approach a woman with SLE, sarcoidosis, heart failure, liver failure, and asthma that is currently undergoing an exacerbation due to an allergic reaction to inhaled heroin that was cut with unknown substances. There's too may variables and unknowns to ever get a best practice approach to a patient with this many issues.

The problem with med students is that they think about one little thing at a time. Comorbidities, med interactions, and circumstances are often a great deal of the picture, and an "EBM can solve everything" approach often fails to account for the unique circumstances of a great number of patients. Blind belief in EBM as the grand savior that will determine the right path for each and every patient is straight up ignorant.

I'm not going to pretend to be an expert on research methods regarding physical modalities, but to me it sounds like this wall of text is a mountain of excuses. This is because physical therapists have evidence-based practice. I also know that just because not every variable will perfectly fit the next that you can't run a study. What we do in medicine is trying to approximate to evidence based treatment as we can. Of course not every case is the same, but there's a reason why we give SSRIs even when not every depression is from the same origin and manifests the same. What is straight up ignorant is to just say "oh, it's too hard to really know, so lets just continue doing it because."

 

[Mad Jack]

I'm not going to pretend to be an expert on research methods regarding physical modalities, but to me it sounds like this wall of text is a mountain of excuses. This is because physical therapists have evidence-based practice. I also know that just because not every variable will perfectly fit the next that you can't run a study. What we do in medicine is trying to approximate to evidence based treatment as we can. Of course not every case is the same, but there's a reason why we give SSRIs even when not every depression is from the same origin and manifests the same. What is straight up ignorant is to just say "oh, it's too hard to really know, so lets just continue doing it because."

You realize more than half the stuff we do is also done by physical therapists and they have their own page on Quackwatch for a reason right?

Anyway, no, it's not excuses- it's reality. I get frequently annoyed at those who have masturbatory fantasies of a world in which EBM rules over all, when in fact much of medicine can never be so, and I'd love for you to prove otherwise. It just isn't possible. And it isn't the OMM stuff that annoys me- I'm never going to use it save for on friends and family- but more the conventional stuff.

Good example is the US's leading expert on kids with the worst type of SMA. They usually only live to about 1 or 2, but this guy? He just made some stuff up and keeps them alive until their teens. We would refer everyone to him if they wanted to tough it out, because he's gotten kids to make it to 14+, something that shouldn't even be possible, and using noninvasive modalities as a first line no less. But there's not a whole hell of a lot of these patients out there and we sure as he'll aren't going to RCT them because that would be straight up killing half of them. Medicine is more than weighing and measuring and testing, there's an art to it as well, because there will always, ALWAYS be limits to the evidence and blindingly following it has the potential to kill your patients or ruin their lives.

 

[DOFOSHO]

.

 

[Bacchus]

flexeril is ME/HVLA/CS/BLT/FPR all in a tablet!

Until they say it doesn't work and you then have patient's asking you for the 'cets.

 

[AlbinoHawk DO]

You realize more than half the stuff we do is also done by physical therapists and they have their own page on Quackwatch for a reason right?

Anyway, no, it's not excuses- it's reality. I get frequently annoyed at those who have masturbatory fantasies of a world in which EBM rules over all, when in fact much of medicine can never be so, and I'd love for you to prove otherwise. It just isn't possible. And it isn't the OMM stuff that annoys me- I'm never going to use it save for on friends and family- but more the conventional stuff.

Good example is the US's leading expert on kids with the worst type of SMA. They usually only live to about 1 or 2, but this guy? He just made some stuff up and keeps them alive until their teens. We would refer everyone to him if they wanted to tough it out, because he's gotten kids to make it to 14+, something that shouldn't even be possible, and using noninvasive modalities as a first line no less. But there's not a whole hell of a lot of these patients out there and we sure as he'll aren't going to RCT them because that would be straight up killing half of them. Medicine is more than weighing and measuring and testing, there's an art to it as well, because there will always, ALWAYS be limits to the evidence and blindingly following it has the potential to kill your patients or ruin their lives.

Can you link me to both the quackwatch page (I tried to google "physical therapy + quackwatch") and to the leading expert and what he "made up?" I'd be very surprised if you asked this expert if what he does is based on magic or that he's dismissive of EBM. It's also a false equivalency to take a small group of people that live to about 2 years old to leap and say OMM is the same standard when it comes to its treatments.

 

[Mad Jack]

http://www.curesma.org/documents/support--care-documents/bach-2009-sma-type-i-article.pdf

Can you link me to both the quackwatch page (I tried to google "physical therapy + quackwatch") and to the leading expert and what he "made up?" I'd be very surprised if you asked this expert if what he does is based on magic or that he's dismissive of EBM. It's also a false equivalency to take a small group of people that live to about 2 years old to leap and say OMM is the same standard when it comes to its treatments.

http://mobile.nytimes.com/2010/01/07/health/nutrition/07best.html?referer=

“There is a growing body of evidence that supports what physical therapists do, but there is a lot of voodoo out there, too,” Dr. Irrgang said. “You can waste a lot of time and money on things that aren’t very helpful.”

You do realize that more than half of OMM was stolen from physical therapists right? You can't say all of OMM is based on nonsense and all of PT is based on evidence when we both use ME, CS, myofascial release, etc.

And his name is Dr. Bach, he's done one retrospective report and zero trials, because he lives in the real world where we do the best we can and if all we get is really good anecdotes for data, fine. The plural of anecdotes is evidence. Doing a random controlled trial would be stupid in these kids and would effectively make you a murderer in the name of science. Go ahead and stick to your blind faith in the numbers, but I want you to promise me that you'll come to me the first time you reach something you can't feasibly or ethically test and apologize, because I promise you that day will come. His retrospective is above, btw, in which he describes the protocol he personally devised to keep some of these kids alive for ten times their life expectancy, sans any evidence aside from "they're alive, here's what I did" with zero study design.

And this isn't about OMM for the record, it's about how much I can't stand the limited mindset of EBM crusaders that have never worked in the real world and seem how limited it is in a great number of situations. I couldn't care less about OMM.

 

[Mad Jack]

 

[soon2BdocC]

Do humanity a favor and stop encouraging the baaing sheep mentality.

I completely disagree with the OP's opinion that OMM should be a less integral part of OME, but how's about you step off your high and mighty soapbox and substantiate with some research articles that you're claiming are more and more prevalent. It should be the collective responsibility of all OMSI-IV, OGME, and our DO attendings/preceptors to continually QUESTION and educate all on the efficacy of OMM in order to continually refine / provide quality studies to prove OMM helps to alleviate pain, restore function, etc.

Frankly, I am sick of sitting in on OMM lectures and hearing ridiculously flawed uncontrolled small group studies from the 1930s being quoted as reasons for why we practice certain OMT (this is the sad trend I've observed from big name presenters at the OMS through OGME level at several institutions).

My point was if you are going to a DO school, then at least have an open mind about osteopathy. That is not sheep mentality. How can you claim that it is junk science without learning about it, trying it for yourself, and then making an intelligent decision to include or exclude from your daily practice? Skepticism is one thing, but to be a first year student mid way through the first semester who decides that a subject is junk and should be excluded from curriculum forever is extremely narrow minded.

Sent from my SM-G920T using Tapatalk

 

[DOFOSHO]

.

 

[GUH]

i would argue that a new student, mid way through the FIRST lecture, that doesn't realize it's junk, shall be designated as narrow minded.

My first OMM lecture covered the anatomy of the superficial and deep back, as well as the range and planes of motion of the vertebrae. Any student who thinks that is junk exercised poor judgment in his decision to attend medical school, let alone in his active decision attend a school that teaches OMM.

 

[AlbinoHawk DO]

http://www.curesma.org/documents/support--care-documents/bach-2009-sma-type-i-article.pdf

http://mobile.nytimes.com/2010/01/07/health/nutrition/07best.html?referer=

“There is a growing body of evidence that supports what physical therapists do, but there is a lot of voodoo out there, too,” Dr. Irrgang said. “You can waste a lot of time and money on things that aren’t very helpful.”

You do realize that more than half of OMM was stolen from physical therapists right? You can't say all of OMM is based on nonsense and all of PT is based on evidence when we both use ME, CS, myofascial release, etc.

And his name is Dr. Bach, he's done one retrospective report and zero trials, because he lives in the real world where we do the best we can and if all we get is really good anecdotes for data, fine. The plural of anecdotes is evidence. Doing a random controlled trial would be stupid in these kids and would effectively make you a murderer in the name of science. Go ahead and stick to your blind faith in the numbers, but I want you to promise me that you'll come to me the first time you reach something you can't feasibly or ethically test and apologize, because I promise you that day will come. His retrospective is above, btw, in which he describes the protocol he personally devised to keep some of these kids alive for ten times their life expectancy, sans any evidence aside from "they're alive, here's what I did" with zero study design.

And this isn't about OMM for the record, it's about how much I can't stand the limited mindset of EBM crusaders that have never worked in the real world and seem how limited it is in a great number of situations. I couldn't care less about OMM.

I think you and I are probably not in contrast disagreement as it appears from your post. Yes, I do believe in EBM and I think above all we should strive for EBM and its treatments. Now, I understand that every single scenario cannot be accounted for. I don't think anyone that believes contrary to that. Maybe you've found different "EBM crusaders." I also realize that developing new treatments requires experimentation, which should be done under control studies. Dr. Bach's example is a fascinating one, but I would argue isn't contrary to EBM. You can have tangible studies about the length of survival without having to know the details as to why it works, so it would be in fact still EBM. My argument has been that certain modalities like OMM are (sometimes) contrary to evidence (e.g. cranial and chapman points) but also should be held to higher skepticism because there is a refusal to run studies. Just throwing your arms up in the air saying "it's impossible" is ludicrous and isn't a good reason for it to be kept being used. We need to strive to take our patients away from placebo and onto real treatments. OMM has real financial and time obligations associated with it.

 

[AlbinoHawk DO]

My first OMM lecture covered the anatomy of the superficial and deep back, as well as the range and planes of motion of the vertebrae. Any student who thinks that is junk exercised poor judgment in his decision to attend medical school, let alone in his active decision attend a school which teaches OMM.

Take figurative comment and answer as if its literal. Not sure if a reflection of your intelligence or a sad attempt at deception.

 

[jw3600]

Take figurative comment and answer as if its literal. Not sure if a reflection of your intelligence or a sad attempt at deception.

He/she has been an OMM fanboy kool-aid drinker for years. There is no progress to be made.

 

[GUH]

Not sure what you're referring to but let me make a guess that it was neither relevant to the original post nor made any substantive argument about mine.

 

[sunealoneal]

I usually don't comment on these OMM threads for various reasons. But I almost completely disagree with this post and felt like nobody else has really addressed it the way I would have.

There's a lot of times you can't get evidence for a given thing that is up to scientific standard.

The only way to realistically do a trial involving OMM would be to train an entire group of people with sham treatments that they believed worked over a period of years, then having them treat patients with the exact same diagnosis as those who were taught actual OMM. That just isn't practical (or ethical, in regard to how it would affect those trained in sham treatments' lives- they'd have to be highly compensated afterward to make up for their years of wasted time).

OMM research would have to follow similar design parameters as surgical research. You clearly cannot blind the practitioner. There are still many ways to create a powerful study despite this barrier. This article describes many possible designs without resorting to sham surgeries. I'm quite confident that good evidence can be created without resorting to the method you described above.

Then there's the issue of every patient being different, and many situations just not coming up enough. I had a guy that nearly died of status asthmaticus secondary to using cocaine that was laced with talc. We'd pretty much given up on everything, and were about at the point where we were going to start talking to the family. A medication error occurred that sent his blood pressure dangerously high, but, miraculously, his kidneys started perfusing again (he hadn't been making urine for hours), his SpO2 increased back into the normal range, and his asthma completely resolved within a day. We won't see enough patients in a decade that are similar enough to this one to say whether or not repeating the same mistake might or might not be such a good idea, and those patients might have substantial comorbidities this patient did not have that would make any repeat of the process faulty at best. That's just one of hundreds of anecdotes I amassed in critical care over the years where evidence based medicine cannot be practiced because the cases are too few and far between for evidence to be gathered, and even if there were enough cases, it would be unethical to perform a study due to the extremely high degree of risk to the patients involved.

Mechanical low back pain is one of the most common patient complaints expressed to emergency physicians in the United States. I could not be less concerned about adequate sample size. In some ways I'm jealous of my classmates who want to make OMM a big part of their careers. They have a fantastic opportunity to break some ground in a relatively unexplored area of medical research. As for the example you've described here, I'm completely sympathetic to such scenarios but case reports exist for this purpose. I've written up a case report and I'm in the process of writing another right now due to the unique nature of the pathologies of both patients. One of them may be mildly interesting, while the other may affect patient care.

There is a place for anecdotes in medicine. If you're all aboard the EBM train, spend some time in environments where the rare and unusual happen with great frequency, and you'll realize why that is so. I worked at a hospital with one of the most prestigious internal medicine programs in the country, and we saw a lot of weird **** and I swear it makes me want to punch people when they insist we should be doing studies on everything when it's completely impossible at worst and unethical/impractical at best. EBM is not the be-all end-all of medicine, and it never will be. Worse still, EBM can result in manipulation of data by companies to show that their drug/product should be best practice, when in fact they've thrown out all of the studies they did that did not confirm the results they wanted (this is a RAMPANT practice in the pharmaceutical industry). You need to learn to parse evidence, analyze it to determine when it is or is not actually worth being applied to practice, and to determine when a situation is beyond the purvey of evidence due to the uniqueness of the circumstances involved or the difficulty in effectively testing the methods being employed.

Your point seems to have veered a bit off track here. I'm not sure what impossible, unethical studies were suggested to you that warranted such feelings of frustration that you seem to have had. And the existence of these companies seems to be irrelevant to the discussion at hand. Are you afraid that Pfizer is going to fund an OMM study and then manipulate the data to demonstrate that NSAIDs are inferior to muscle energy? It seems to be a poor reason to not investigate OMM. Perhaps I misunderstood.

EBM is very good for figuring out the best course of action to take in high frequency, easily reproducible events that have easy-to-measure outcomes and a well-defined patient population in which testing is not contraindicated due to ethical concerns and the study can be conducted without utilizing an excess of financial resources. That makes it great for sorting out high blood pressure or diabetes or whatever. It doesn't make it a good way to sort out the best way to approach a woman with SLE, sarcoidosis, heart failure, liver failure, and asthma that is currently undergoing an exacerbation due to an allergic reaction to inhaled heroin that was cut with unknown substances. There's too may variables and unknowns to ever get a best practice approach to a patient with this many issues.

You're right that research for OMM poses unique challenges. Pain Medicine is a field that comes in mind with similar end points. I'm sure you'll not be surprised to hear that I consider it to be a bit less of a challenge than the investigation of a "woman with SLE, sarcoidosis, heart failure, liver failure, and asthma that is currently undergoing an exacerbation due to an allergic reaction to inhaled heroin that was cut with unknown substances".

 

[sunealoneal]

And his name is Dr. Bach, he's done one retrospective report and zero trials, because he lives in the real world where we do the best we can and if all we get is really good anecdotes for data, fine. The plural of anecdotes is evidence. Doing a random controlled trial would be stupid in these kids and would effectively make you a murderer in the name of science. Go ahead and stick to your blind faith in the numbers, but I want you to promise me that you'll come to me the first time you reach something you can't feasibly or ethically test and apologize, because I promise you that day will come. His retrospective is above, btw, in which he describes the protocol he personally devised to keep some of these kids alive for ten times their life expectancy, sans any evidence aside from "they're alive, here's what I did" with zero study design.

I'm sure you're ahead of me in your training, but I'm sorry to say that you may have a flawed understanding of how medical evidence is compiled.

 

[Mad Jack]

I'm sure you're ahead of me in your training, but I'm sorry to say that you may have a flawed understanding of how medical evidence is compiled.

He didn't do an RCT. Just as we often cannot in critical care or in OMM, because it just isn't all that feasible for various reasons. And that is the real issue people have with OMM- not having large enough RCTs.

 

[sunealoneal]

He didn't do an RCT. Just as we often cannot in critical care or in OMM, because it just isn't all that feasible for various reasons. And that is the real issue people have with OMM- not having large enough RCTs.

It was my fault for being so vague. I'll elaborate.

You're using these niche diseases and unusual presentations as a vehicle to say that EBM does not have all the answers and therefore is not worth pursuing at all. This is an odd leap to make since there is a near limitless supply of ethical subjects to design a study for.

Further, ethical subjects can be used as a framework that can be applied to a smaller case series.