Anyone seen this anti-osteopathic article?

[t-bone]

This piece floored me! I know quackery is a threat to true medicine, but I thought Dr. Barrett's "guilt by association" techniques in this piece were infuriating! He seems to think that osteopaths succomb more readily to quackery than their MD counterparts.

I know this is a long article, but I thought it was worth posting. He has other pieces on this page that paint osteopaths as slow-on-the-uptake (or worse).

Also: some responses to this article are ridiculous, enraged, and not helpful. But I wanted to know what everyone else thinks of this doctor and "quackwatch" in general.

Or am I opening a can of worms?

t-bone

Quackwatch Home Page


Dubious Aspects of Osteopathy


Stephen Barrett, M.D.

Osteopathic physicians (DOs) are the legal and professional equivalents of medical doctors. Although most offer competent care, the percentages involved in chelation therapy, clinical ecology, orthomolecular therapy, homeopathy, ayurvedic medicine, and several other dubious practices appear to be higher among osteopaths than among medical doctors. I have concluded this by inspecting the membership directories of groups that promote these practices and/or by comparing the relative percentages of MDs and DOs. listed in the Alternative Medicine Yellow Pages [1] and HealthWorld Online's Professional Referral Network. The most widespread dubious treatment among DOs appears to be cranial therapy, an osteopathic offshoot described below.
Cultist Roots
Andrew Taylor Still, MD (1828-1917) originally expressed the principles of osteopathy in 1874, when medical science was in its infancy. A medical doctor, Still believed that diseases were caused by mechanical interference with nerve and blood supply and were curable by manipulation of "deranged, displaced bones, nerves, muscles -- removing all obstructions -- thereby setting the machinery of life moving." His autobiography states that he could "shake a child and stop scarlet fever, croup, diphtheria, and cure whooping cough in three days by a wring of its neck." [2]
Still was antagonistic toward the drug practices of his day and regarded surgery as a last resort. Rejected as a cultist by organized medicine, he founded the first osteopathic medical school in Kirksville, Missouri, in 1892.
As medical science developed, osteopathy gradually incorporated all its theories and practices [3]. Today, except for additional emphasis on musculoskeletal diagnosis and treatment, the scope of osteopathy is identical to that of medicine. The percentage of practitioners who use osteopathic manipulative treatment (OMT) and the extent to which they use it have been falling steadily.

Osteopathy Today

There are 19 accredited colleges of osteopathic medicine and about 40,000 osteopathic practitioners in the United States [4]. Admission to osteopathic school requires three years of preprofessional college work, but almost all of those enrolled have a baccalaureate or higher degree. The doctor of osteopathy (DO) degree requires more than 5,000 hours of training over four academic years. The faculties of osteopathic colleges are about evenly divided between doctors of osteopathy and holders of PhD degrees, with a few medical doctors at some colleges. Graduation is followed by a one-year rotating internship at an approved teaching hospital. A majority of osteopaths enter family practice. Specialization requires two to six additional years of residency training, depending on the specialty. The American Osteopathic Association (AOA) recognizes more than 60 specialties and subspecialties. AOA membership is required for specialty certification, which forces some practitioners to belong to the AOA even though they do not approve of the organization's policies. Since 1985, osteopathic physicians have been able to obtain residency training at medical hospitals, and the majority have done so. Since 1993, DOs who completed osteopathic residencies have also been eligible to join the American Academy of Family Practice, which had previously been restricted to MDs or DOs with training at accredited medical residencies [4].
Osteopathic physicians are licensed to practice in all states. The admission standards and educational quality are a bit lower at osteopathic schools than they are at medical schools. I say this because the required and average grade-point averages (GPAs) and the Medical College Admission Test (MCAT) scores of students entering osteopathic schools are lower than those of entering medical students [5,6] -- and the average number of full-time faculty members is nearly ten times as high at medical schools (714 vs. 73 in 1994) [6]. In addition, osteopathic schools generate relatively little research, and some have difficulty in attracting enough patients to provide the depth of experience available at medical schools [7]. However, as with medical graduates, the quality of individual graduates depends on how bright they are, how hard they work, and what training they get after graduation. Those who diligently apply themselves can emerge as competent.
In January 1995, a one-page questionnaire was mailed to 2,000 randomly selected osteopathic family physicians who were members of the American College of Osteopathic Physicians. About half returned usable responses. Of these, 6.2% said they treated more than half of their patients with OMT, 39.6% said they used it on 25% or fewer of their patients, and 32.1% said they used OMT on fewer than 5% of their patients. The study also found that the more recent the date of graduation from osteopathic school, the lower the reported use [8].
AOA Hype
Many observers believe that osteopathy and medicine should merge. But osteopathic organizations prefer to retain a separate identity and have exaggerated the minor differences between osteopathy and medicine in their marketing. According to a 1987 AOA brochure, for example: (1) osteopathy is the only branch of mainstream medicine that follows the Hippocratic approach, (2) the body's musculoskeletal system is central to the patient's well-being, and (3) OMT is a proven technique for many hands-on diagnoses and often can provide an alternative to drugs and surgery [9]. A 1991 brochure falsely claimed that OMT encourages the body's natural tendency toward good health and that combining it with all other medical procedures enables DOs to provide "the most comprehensive treatment available." [10] Such statements are consistent with a 1992 AOA resolution that defines osteopathy as:

A system of medical care with a philosophy that combines the needs of the patient with current practice of medicine, surgery, and obstetrics and emphasis on the interrelationships between structure and function and an appreciation of the body's ability to heal itself [11].
A 1994 AOA resolution describes osteopathy as "a complete system of health care and as such is much more holistic than medicine in the classic sense." [11].
The American Osteopathic Association's web site glorifies Andrew Still and asserts that osteopathic medicine has a unique philosophy of care because "DOs take a whole-person approach to care and don't just focus on a diseased or injured part." I consider it outrageous to imply that osteopathic physicians are the only ones who regard their patients as individuals or who provide comprehensive care or pay attention to disease prevention. Another AOA web document states:

Osteopathic physicians frequently assess impaired mobility of the musculoskeletal system as that system encompasses the entire body and is intimately related to the organ systems and to the nervous system. Using anatomical relationships between the musculoskeletal and these organ systems, osteopathic physicians diagnose and treat all organ systems [12].
This statement strikes me as the same sort of baloney chiropractors use to suggest that somehow their attention to the spine will have positive effects on all body processes. Spinal manipulation may produce pain relief in properly selected cases of low back pain [13]. However, OMT has no proven effect on people's general health.

Chelation Therapy

Chelation therapy is a series of intravenous infusions containing EDTA and various other substances. Proponents claim it is effective against atherosclerosis and many other serious health problems. However, no controlled trial has shown that chelation therapy can help any of them. Chelation therapy with EDTA is one of several legitimate methods for treating cases of lead poisoning, but the protocol differs from that used inappropriately for other conditions. To its credit, the AOA has adopted a negative position statement on chelation therapy:

WHEREAS, chelation therapy utilizing calcium disodium edetateis currently labeled by the Food and Drug Administration and recognized by most physicians as medically acceptable only in the management of acute or chronic heavy metal poisoning; now, therefore, be it
RESOLVED, that pending the results of thorough, properly controlled studies, the American Osteopathic Association does not endorse chelation therapy as useful for other than its currently approved and medically accepted uses. Adopted 1985, revised and reaffirmed, 1990, 1995 [11].
The 1998 member referral list of the American College for Advancement of Medicine (ACAM) , the principal group promoting chelation therapy, identifies about 400 MD members and 121 DO members who list chelation therapy as a specialty. These numbers strongly suggest that the percentage of osteopathic physicians doing chelation therapy is about four or five times as high as the percentage of medical doctors doing it. Curiously, Ronald A. Esper, DO, of Erie, Pennsylvania, who was AOA's president in 1998, is an ACAM member and does chelation therapy.
Cranial Therapy
Practitioners of "cranial osteopathy," "craniosacral therapy," "cranial therapy," and similar methods claim that the skull bones can be manipulated to relieve pain (especially of the jaw joint) and remedy many other ailments. They also claim that a rhythm exists in the flow of the fluid that surrounds the brain and spinal cord and that diseases can be diagnosed by detecting aberrations in this rhythm and corrected by manipulating the skull. Most practitioners are osteopaths, massage therapists, chiropractors, dentists, or physical therapists.
Cranial osteopathy's originator was osteopath William G. Sutherland, who published his first article on this subject in the early 1930s. Today's leading proponent is John Upledger, DO, who operates the Upledger Institute of Palm Beach Gardens. Florida. An institute brochure states:

CranioSacral Therapy is a gentle, noninvasive manipulative technique. Seldom does the therapist apply pressure that exceeds five grams or the equivalent weight of a nickel. Examination is done by testing for movement in various parts of the system. Often, when movement testing is completed, the restriction has been removed and the system is able to self-correct [14].

Another Upledger brochure states:

The rhythm of the craniosacral system can be detected in much the same way as the rhythms of the cardiovascular and respiratory systems. But unlike those body systems, both evaluation and correction of the craniosacral system can be accomplished through palpation.
CranioSacral Therapy is used for a myriad of health problems, including headaches, neck and back pain, TMJ dysfunction, chronic fatigue, motor-coordination difficulties, eye problems, endogenous depression, hyperactivity, attention deficit disorder, central nervous system disorders, and many other conditions [15].
British osteopath Robert Boyd, who developed a variant he calls Bio Cranial Therapy, claims that it is "extremely helpful" for "chronic fatigue syndrome (CFS); varicosity and varicose ulcers; tinnitus; bladder prolapse; prostate disorders; Meniere's syndrome; cardiovascular disturbances including hypertension, angina; skin disorders (psoriasis, eczema, acne etc); female disorders (dysmenorrhoea, PMS (PMT), menorrhagia etc); arthritis and rheumatic disorders; fibromyalgia and heel spurs; gastric disorders (hiatus hernia, ulceration, colitis); asthma and a range of bronchial disorders including bronchiectasis and emphysema."
The theory underlying craniosacral therapy is erroneous because the bones of the skull fuse during infancy and cerebrospinal fluid does not have a palpable rhythm. Nor do I believe that "the rhythms of the craniosacral system can be felt as clearly as the rhythms of the cardiovascular and respiratory systems," as is claimed by another Upledger Institute brochure [16]. The brain does pulsate, but this is exclusively related to the cardiovascular system [17]. In a recent study, three physical therapists who examined the same 12 patients diagnosed significantly different "craniosacral rates," which is the expected outcome of measuring a nonexistent phenomenon [18]. At least 15 of the 88 items listed in the October 1996 American Osteopathic Association's list of "Osteopathic Literature in Print" were written by Sutherland, Upledger, or others who appear to advocate cranial therapy [19].
Osteopathic web sites that espouse cranial therapy can be located by using Infoseek's Advanced Search with the top line set at "must contain the phrase cranial osteopathy" and the second line set as "must contain the name Sutherland." The most illuminating source I have found (which no longer appears to be posted) was The Cranial Letter, published quarterly by the Cranial Academy, a component society of the American Academy of Osteopathy,which is a practice affiliate of the AOA. The Summer 1993 issue stated that the Cranial Academy had 989 members. Other issues contained case reports stating that cranial therapy can cause knee pain to disappear within a week (Summer 1992), cure hives (Summer 1993), improve the mental condition of Down syndrome patients (May 1995), and correct crossed eyes (May 1996). The American Osteopathic Association's 1998 continuing education calendar listed a 40-hour cranial osteopathy course it cosponsored with the American Academy of Osteopathy.

The Bottom Line

I believe that the American Osteopathic Association is acting improperly by exaggerating the value of manipulative therapy and by failing to denounce cranial therapy. If you wish to select an osteopathic physician as your primary-care provider, your best bet is to seek one who: (1) has undergone residency training at a medical hospital; (2) does not assert that osteopaths have a unique philosophy or that manipulation offers general health benefits; (3) either does not use manipulation or uses it primarily to treat back pain; and (4) does not practice cranial therapy.

AOA Protests

On January 23, 1988, I received a letter from the AOA's law firm objecting to certain passages in a previous version of this article [20]. Since that time, I have clarified some of the points they raised and added additional information and references. I also invited the AOA to submit a letter for posting and further discussion. Through their attorney, they agreed to do so, but none has arrived so far.

For Additional Information


* Observations about Osteopathy in Early 1960s
* Further Comparison Between Medical and Osteopathic Education
* The Paradox of Osteopathy (New England Journal of Medicine Editorial)


Reader Comments


An osteopathic student complained about my criticism of the misleading statements the AOA makes about OMT on its web site:

The AOA is not reflective of the majority of osteopathic physicians. To begin with, if one ever hopes to achieve a leadership position in the AOA, one must complete both an osteopathic internship and an osteopathic residency, this effectively eliminates somewhere around 70% of DOs (at least that's the figure tossed around this campus). The remaining 30% of DOs unfortunately includes those who make many questionable claims about OMT. It also includes many excellent physicians. The DOs who continue to make these claims are a very vocal minority; most of us become a little embarrassed when we read this sort of thing.
I replied:
I would suggest that you and your future colleagues who think that the AOA is making deceptive claims bring pressure on the AOA because it is the only publicly identified spokesperson you seem to have.
Another osteopathic student commented:
I am greatly impressed by your web site. I found out about it from one of my Biochemistry professors who highly recommended it. (I am a first year student.) I am glad to see that you address some of my (and many of my classmates) concerns about the promotion of osteopathy by the AOA in your article. My class has had the usual slogans and propaganda, like "Osteopaths treat the patient not the disease," etc. (implying that the "allopaths" don't, of course) thrown at us from day one. Two members of my immediate family are M.D.'s, and they both find the not-so-subtle disparaging of allopathic medicine by the AOA and the hard-core osteopathic physicians rather amusing.
A former osteopathic medical school faculty member wrote:
I spent 12 years teaching basic sciences and 7 years as an associate dean at the an osteopathic medical school. However, since the school's faculty came from institutions throughout the United States, I doubt that what I observed differed much from the situation at other osteopathic schools.
Students carried a heavy curriculum in osteopathic manipulative therapy (OMT), beginning in their freshman year. The department of manipulative medicine was completely segregated from the other departments, both in principles and in practice. The osteopathic faculty members in the standard medical departments neither practiced nor taught OMT. Nor did the OMT faculty practice or teach the standard forms of medicine. It was as if OMT was a freestanding form of health care -- one that, unlike other departments, was not necessarily bound by scientific foundations. Being a basic science researcher, I have made attempts to set up an animal model to objectively test the claim that certain harmful forms of sympathetic nerve traffic could be altered by spinal OMT. However, I never received any support from the osteopathic faculty in seeing such a study completed. The general attitude of the osteopathic manipulation physicians was, "since we already know it works, why should we bother with proving it."
Cranial therapy was a large component of the manipulative medicine department, both for patient care as well as for teaching the medical students. Interestingly, while the other faculty accepted most forms of OMT even though they did not use them, they did not endorse the use of cranial therapy. Indeed, I heard many criticisms of the practice by the non-OMT faculty. Their objections were the same as mentioned on Quackwatch -- that the cranial bones fuse early in infancy, after which no motion of these bones takes place. As you indicate, the alleged sensing of such motion forms the heart of cranial therapy.
I have never heard any attempt by an OMT practitioner to offer a tenable defense to such criticism. To me it almost seemed as if the OMT practitioner felt that the practice could not be defended with ordinary logic since its basis lay somewhere in the metaphysical and that only their gifted hands were able to "sense" the cranial motion.
But the seemingly metaphysical did not stop with the practice of cranial therapy. I know of one case in which a student with an undiagnosed illness consulted one of her OMT mentors who concluded that she had "a "hole in [her] aura."

David E. Jones, Ph.D.

An osteopathic physician from Texas wrote:
ANYONE IGNORANT ENOUGH TO QUESTION THE BENEFITS OF MANIPULATION THERAPY IN 1999 SHOULD HANG THEMSELVES IN THEIR UTILITY CLOSET. 95% OF DOCTORS THAT PRACTICE CHELATION THERAPY ARE M.D.s. CHELATION THERAPY IS 85-95% EFFECTIVE IN ALL PATIENTS THAT TAKE A FULL COURSE OF THERAPY. WHOEVER THE STUPID MOTHER****ER IS THAT MADE THIS WEB PAGE SUCKS DICKS AND DESERVES TO DIE OF THROAT CANCER. PLEASE USE ALL MAINSTREAM METHODS TO ATTEMPT TO CURE THE ESOPHAGEAL CANCER I HAVE JUST WISHED ON YOU. I TRULY HOPE THEY HAVE TO REMOVE YOUR MANDIBLE AFTER YOUR RADIATION THERAPY. DIE MOTHER****ER!!!!!

References

1. Alternative Medicine Yellow Pages. Puyallup, Washington. Futurer Medicine Publishing, Inc., 1994. 2. Still AT. Autobiography -- with a history of the discovery and development of the science of osteopathy. Reprinted, New York, 1972, Arno Press and the New York Times. 3. Gevitz N. The D.O.'s: Osteopathic Medicine in America. Baltimore, 1982, The Johns Hopkins University Press. 4. Gugliemo WJ. Are D.O.s losing their unique identity? Medical Economics 75(8):201-213, 1998. (Clarification regarding AAFP membership published in Medical Economics 75(14):21, 1998.) 5. Doxey TT, Phillips RB. Comparison of entrance requirements for health care professions. Journal of Manipulative and Physiological Therapeutics 20:86-91, 1997. 6. Ross-Lee B, Wood DL. Osteopathic medical education. In Sirica CM, editor. Osteopathic Medicine, Past, Present and Future. New York, Josiah Macy Jr. Foundation, 1996, page 95. 7. Jones DE. Allopathic (M.D.) versus osteopathic (D.O.) medical Schools: Views of a basic scientist with experience in both. Cardiovascular Concepts Web site, accessed 5/21/99. 8. Johnson SM et al. Variables influencing the use of osteopathic manipulative treatment in family practice. Journal of the American Osteopathic Association 97:80-87, 1997. 9. Osteopathic medicine: A distinctive branch of mainstream medical care. Undated brochure, distributed in 1987. Chicago: American Osteopathic Association 10. What is a D.O.? (Brochure) Chicago: American Osteopathic Association, 1991, 11. AOA Position Papers, Aug 1996. In AOA Yearbook and Directory. Chicago: American Osteopathic Association, Jan 1997, pages 565-588. 12. Position Paper on Osteopathic Manipulative Treatment (OMT) & Evaluation and Management services. Part II: The Standard of Care for Osteopathic Manipulation and the E&M Service. AOA web site, September 1998. 13. Gunnar BJ and others. A comparison of of osteopathic spinal manipulation with standard care for patients with low back pain. New England Journal of Medicine 341:1426-1431, 1999. 14. Discover CranioSacral Therapy. Undated flyer distributed in 1997 by the Upledger Institute. 15. Upledger CranioSacral Therapy I. Brochure for course, November 1997. 16. Workshop catalog, Upledger Institute, 1995. 17. Ferre JC and others. Cranial osteopathy, delusion or reality? Actualites Odonto-Stomatologiques 44:481-494, 1990. 18. Wirth-Pattullo V, Hayes KW. Interrater reliability of craniosacral rate measurements and their relationship with subjects' and examiners' heart and respiratory rate measurements. Physical Therapy 74:908-16, 1994. 19. Osteopathic literature in print, October 1996. In AOA Yearbook and Directory. Chicago: American Osteopathic Association, Jan 1997, pages 756-757. 20. Prober, JL. Letter to Dr. Stephen Barrett, January 23, 1998.

Quackwatch Home Page

This page was revised on January 29, 2000.

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[Popoy]

Yikes

I wonder if the AOA is aware of this article being out there.... Everyone's a critique nowadays....

I'm just shock that something like this is out there possibly misinforming the public....

 

[t-bone]

Popoy:

There is something at the end of the article about Dr. Barrett being contacted by the AOA legal department...

But nothing has changed. If you really want to get pissed off, do a search on quackwatch for an article concerning allopathic vs. osteopathic schools...there is a by-line about "from a basic scientist with experience in both." Sorry, I can't link to the article. I'll try to find the link.

Anyway...that piece is full of anecdotal (sp?) stories about how professors in MD schools have to dumb-down their classes when teaching in DO schools, etc.

I really shouldn't surf at night. All it does is irritate me.

But many of my friends who heard that I was going into osteopathy referred me to this web-page! So I know that this guy has a large following!

Sorry for the rant!

t-bone

 

[Popoy]

I'll do just that....

 

[RockyMan]

First, this is old news. I initially read the document from Quackwatch when I was a 1st-yr KCOM student; it was posted on a bulletin board outside our main lecture halls.

Second, I would agree with many points the author brings up and references: A.T.
Still's ideas were derived primarily from vitalist and biomechanical concepts; osteopathy did gradually incorporate most or all of classic & current medical practice techniques and theories as DO's attained practice rights equivalent to MD's; many AOA members and publications greatly exaggerate the evidence that osteopathic manipulation techniques can cure non-musculoskeletal symptoms and diseases (e.g., hypertension); when quackery is defined by a general formulation as 'knowing treatment of patients using unproven/disproven techniques with no credible basis in physiological theory and for primary benefit-- financial or otherwise-- to the practitioner,' then chelation therapy for common illnesses, homeopathy and cranial manipulation all appear to me as fitting the definition.

Third, I think it's a very interesting question whether DO's are more likely to practice the author's listed 'dubious' techniques then MD's, although I don't know of any published data that bear on the argument, and the much greater prevalence of MD degree physicians makes it likely to me that, in terms of absolute numbers, even in this category DO's are a minority group. Still, given that several osteopathic medical schools have mandatory or elective courses in cranial osteopathy, and that the AOA and some of these medical schools still sponsor cranial osteopathy CME, it's certainly conceivable that DO students are given a push in this direction. Perhaps some of the members of this site who are interested in public relations could address this issue in the documentary video on osteopathy that they have been planning this summer?

Fourth, DO physicians of today may, in some ways, be quite different in educational and cultural background and outlook from DO's from previous generations, which makes historical DO/MD comparisons particularly perilous, especially if you are trying to make a case that they are relevant to medicine circa 2001. I think it's an excellent idea to look at education and different medical schools and compare quality of instruction (# of physician faculty, amount of clinical teaching time, etc.) -- in most walks of life, you generally will improve a lot more quickly if you look around and find good ideas from what others are doing. If DO schools are deficient in any ways, the AOA should be working to help remedy any and all areas where they fall short.

Fifth, overall I think it's a good idea for there to be organizations or sites like Quackwatch, where medical practice claims are scrutinized and challenged. We all have an overarching ethical obligation to our patients that we practice evidence-based medicine, so even if the critics don't always bat a thousand, its still good to have some independent watchdogs. Especially if they have no financial interest in the techniques that are being promulgated and discussed.

Rockyman

 

[Popoy]

I did a quickie search and found that this person is just full of criticism about everything not just osteopathic medicine.... I chose not to read as it might just be more frustrating that what I need/want for tonight....

 

[t-bone]

Rocky:

First, Whoop-te-do that this is old-hat to you. I'm sorry to have stumbled on to this article late in my (pre)medical career. That doesn't mean that my main objection is invalid: the tactic of this piece "guilt by association." There is no excuse for Dr. Barrett to list those who practice these odd things under the general rubric "dubious practices of OSTEOPATHY." These are dubious practices, no doubt, but to list them under such a broad heading is not fair--I hope you would agree to that.

Also: other pieces on this site seem to indicate the Dr. Barrett has a real problem with osteopathy in general. If any methods are "dubious" they are those of Dr. Barrett.

t-bone

 

[t-bone]

Here is the article about MD vs. DO schools on 'Quackwatch.'

BTW: I agree that we need organizations like this out there. But have you ever heard a 'basic scientist' rely on such anecdotal (sp?) evidence before? Raised eyebrows are good...up to a point. But this is ridiculous.

Sorry to throw this controversial article out for a topic, but this really upset me.

And please don't just tell me this is 'old news' to you. I was referred to this by skeptical relatives when I told them I was accepted to DMU.

t-bone

 

[t-bone]

Here is the link to the article about MD vs. DO schools on 'Quackwatch.'

BTW: I agree that we need organizations like this out there. But have you ever heard a 'basic scientist' rely on such anecdotal (sp?) evidence before? Raised eyebrows are good...up to a point. But this is ridiculous.

Sorry to throw this controversial article out for a topic, but this really upset me.

And please don't just tell me this is 'old news' to you. I was referred to this by skeptical relatives when I told them I was accepted to DMU.

t-bone

personal.mem.bellsouth.net/mem/k/e/keep/editorial2.html

 

[fisgig]

Just wanted to give my two cents:

I am a third year medical student at a college of osteopathic medicine. I do not agree with a lot of what this article says or what it implies, but it does bring up the problem that plagues all osteopathic students. OMT is not evidence-based medicine. I was so excited when I started med school.....now in my third year, I have become very disenchanted with OMT. We as students must address this issue! I promise, all of you first years, that the idea of holistic medicine with a hands on approach sounds so novel, but any MD that doesn't do the same is not practicing good medicine. Just wait until you do craniosacral therapy....then you'll see why osteopathic medicine is called in to question. Beleive me, my education so far has been more than adequate and comparable to any MD (just passed the USMLE). I love my school, but it is an everyday battle to defend osteopathy. What's the difference between osteopathy and allopathic medicine? I'm not sure, except for OMT which has little scientific evidence. Even if there is some benifit with OMT (which I believe there is), is it feasable to use it in the managed care environment of today? What's wrong with giving safe, effective pain medicines for back pain instead of using OMT. It would seem to me that the risk of using some OMT techniques vs. conventional medicines is far greater. Case in point, a local DO did HVLA on a patient(elderly with osteoperosis) and ended up breaking her neck. Poor judgement on the part of the doctor, but still the risk is there. Please understand that I love my school, but feel that all DO's must do some soul searching and determine what is it that really makes us unique..or the same. If osteopathic medicine didn't have a problem, I wouldn't be writing this to voice the opinions of myself and "MANY" of my classmates...and, I wouldn't have to log on to SDN and see so many forums with the same underlying tone: MD vs. DO, what's the difference?, ect.

 

[muonwhiz]

Wow! I declined several allopathic schools to attend an osteopathic school. According to Quackwatch, maybe I should have my head examined!

 

[osteodoc13]

Let me say two things about this article:

1: Yes, there are not a lot of randomized studies on the efficacy of OMT v allopathic medicine, but if you put some thought into the issue you can see why it is very difficult to perform such studies. First of all, there are simply not as many DOs interested in research. Most DOs are happy treating their patients and letting the results speak for themselves. Thank goodness that there are still those out there doing the research, but most of the supporting reasearch for OMT is coming from basic-science research into neurobiology and neurophysiology. Second, OMT is by it's very nature a subjective field. No two DOs are going to do the same treatment on the same patient. The course of treatment is determined by both the specific lesions present and the skill and preferences of the operator.

2: As far as OCF goes, Barret obviously is not up to date on the current research into the mobility and motility of the cranial bones. There are many quality articles, most coming from the labs of Moskalenko in Russia, confirming that the bones of the cranium not only have an ability to move at the sutural joints, but possess an inherent rate of motion independent from either the cardiac or pulmonary cycles. I don't mind discussing with someone the potential importance of these findings, or whether or not OCF can influence this rate, or what effect that can have on the body, but to have someone summarily dismiss the motion of the cranium by stating
"The theory underlying craniosacral therapy is erroneous because the bones of the skull fuse during infancy and cerebrospinal fluid does not have a palpable rhythm" means to me that they are completely closed to any meaningful discussion.

It is a fact that medical knowledge is in constant flux. Sometimes long-held ideas about the body are disproven by newer methods of research. The idea that the cranial bones fuse can be disproven by a simple test of common sense:
If a large joint like the knee is immobilized, it will begin to ossify within months, and surely within a few years it will no longer have a joint space. But the sutures of the vault are still visible in an 80 year old man, and his vault bones can be separated by the simple act of putting dry beans into the skull and soaking them in water. If you hold the skull of an elderly person up to the light, you can see light coming through the sutures. If the knee can ossify in a matter of months, why don't such small joints as the sutures ossify in 80 years?

Just a little food for thought. Barrett is obviously a very thoughtful and persistant watchdog, and I believe that his work is very important to the medical community and the public at large. But in this case he is without the facts.

 

[RockyMan]

More thoughts and questions:

1.) I agree that an article with a title about the purported dubious practices of osteopathy should focus on practices which are in fact endorsed by osteopathic organizations and physicians, or practiced by a significant majority of osteopathic physicians. Nevertheless, the truth or falsehood of its contents doesn't really depend on the title, and if osteopathic organizations don't endorse homeopathy or other delusions, that's great, but if we're going to try to be better doctors, let's focus on the things that they DO endorse that might be wrong, statements they make that may be wrong-headed, or things they possibly could do better.

2.) t-bone, you described "guilt by association" as "the tactic" of Dr. Barrett's article. Do you consider his criticism of cranial osteopathy as guilt by association, and if so, why? If not, could you be a bit more specific about which segments and sections of his article exemplify guilt by association?

It seems to me that since the AOA endorses cranial osteopathy, and since many if not all DO schools teach it, Barrett's criticism is directed against the persons who govern those institutions, and those who teach & practice cranial under their auspices. As a DO student who does not practice cranial osteopathy, or support its promulgation, I don't feel that his criticism of cranial osteopathy is a criticism of me, or any other DO students or physicians who feel the same way that I do.

3.) I think that a 'guilt by association' argument would run something like: "Lots of criminals post untrue statements on SDN." "You make posts on SDN." "Therefore you must be a criminal and your statements must be false." Barrett's argument, in most cases, seems to be more along the lines of "Lots of criminals post untrue statments on SDN." "Therefore SDN should be more vigilant about policing its members and their posts."

[A brief technical aside, mostly not applicable here I believe: in the proper circumstances, I think that 'guilt by association' arguments can be quite powerful; e.g., in a legal trial of persons accused of conspirary, guilt by association is widely recognized as valid when the context suggests that the participants act in a coordinated manner, use shared knowledge and have a common benefit/goal.]

4.) If the AOA adopts a policy that certain practices (e.g., chelation therapy for atherosclerosis and indications other than lead poisoning) are medically unfounded, and thus unethical, should it try to prevent its members from performing those practices? Maybe the AOA really does try to prevent DO's from doing chelation therapy, homeopathy and similar abuses, and we just never hear about it? Where could we find out? Is there any policing activity by the AOA and any publicly available data about what has or has not been done?

5.) t-bone, if Dr. Barrett criticizes lots of things about the AOA, DO schools, purported practices of DO physicians, etc., how does being very critical ("...has a real problem with osteopathy in general...") make him dubious? That seems like an ad hominem argument on your part. If his individual arguments were wrong that would be one thing, but I haven't seen you refute his specific claims.

6.) Osteodoc13, as we all know, A.T. Still began formulating osteopathy in 1874. It seems to me that over a century and a quarter is plenty of time to do serious, rigorous research on the physiological bases of his postulates and observations. It also seems to me that with nearly 20 schools of osteopathic medicine, there actually are lots of resources available for doing clinical studies on osteopathic treatment. I don't agree with the conclusion that DO schools have lacked the time, financial assets, faculty positions or clinical opportunities to test Still's theories, or those of his successors.

7.) Osteodoc13: When you offer proof for the efficacy of OMT techniques by stating that DO's are generally content with "...letting the results speak for themselves...", it seems to me that you are engaging in a serious logical fallacy. Proof that OMT works cannot come just because many DO's and/or many patients say that it works. Many people say that astrology works, as do adherents of homeopathy, faith healing, etc. Testimonials do not constitute scientific proof, there have to be objective studies. Isn't objectivity an ethical necessity?

8.) Osteodoc13, you wrote that "...most of the supporting reasearch for OMT is coming from basic-science research into neurobiology and neurophysiology." Could you please provide me with references to scientific studies that back up your statement? if possible, please start off w/ articles from established peer-reviewed journals such as Science, Nature, Cell, Neuron, Journal of Neuroscience, J. Neurophysiology, Brain Research, etc., and published within the last 10-15 years. If possible, could you please post references (complete text would be great, too) for the Moskalenko "...quality articles..." to which you refer? What in your mind makes a publication a "quality article"?

9.) Osteodoc13, what are the published studies which show that the CSF has a palpable rhythm? if you believe that there is a palpable CSF rhythm, I'd be interested in where you think the energy comes from to drive that rhythm?

10.) For osteodoc13: When you wrote that "It is a fact that medical knowledge is in constant flux" I believe that you mischaracterized the true state of things. I disagree that the term constant flux at all describes the current state of scientific medical knowledge. Granted that knowledge tends to increase, but 'increase' and 'flux' are quite different terms. As you say, 'a simple test of common sense' may suffice. For example, compare the most recent version of The Washington Manual of Medical Therapeutics with the previous version, or even with the one before that. Choose random chapters or pages if you wish. I will wager that overall you fill find an overwhelming amount of constancy over the last 5, 10 or even 20 years, in terms of pathophysiologic mechanisms, clinical presentations, anatomic localization, therapeutic options, etc. In many cases, improvement is not the same thing as falsification.

Thanks to all for the posts and have a fun weekend.

Rockyman

 

[osteodoc13]

Let me first say that I agree that there has been plenty of time for osteopaths to do more research. All I was trying to say is that most practicing DOs are not of the research mentality, at least not in the past. I think that's it is a good thing that there are more schools today, and they are probably letting in students who will be more interested in research.

As to letting the results speak for themselves, I wasn't saying that that constitutes scientific proof, just that most osteopaths and their patients are content with things the way they are. If you have to close your practice to new patients after about a year, which is what most docs doing OMT do, why do you care if someone is out there doing the research? You are successful both in terms of your practice and your patients. Research becomes unimportant to the average working doc.

As far as the research goes, I don't have the bibliography with me because I'm on an out of state rotation, but if you're interested the Cranial Academy has published a bibliography of research on OCF. You could contact them for that information.

I wouldn't say I "believe" there is a palpable rhythm to the cranium, because it's not a religion, it's fact. All I have to do is put my hands on a patient and I feel it. I know about the studies criticizing the interrelator reliability of palpating the CRI, but all I can say is that OCF is an extremely subjective thing, as is all OMT. It is part of the "art of medicine" that any clinician will tell you about. As far as what powers it, I don't know if anyone really knows, but I know that there are several studies concerning the inherent motility of astrocytes, even when they are isolated in a petri dish, and that they will synchronize their pulsations if they are mixed. I would also recommend the recent study in the JAOA concerning correlation of palbable CRI and the Traube-Herring waveform.

Finally, I think you are misreading my statement about flux in medical knowledge. By flux, I mean change. Change occurs quite frequently in medicine. As little as 5 years ago Digoxin and Lasix were the standard treatment for CHF. Now we know that ACE-Inhibitors, B-Blockers, and Spironolactone all are key elements in good medical care. It is true that 100, or even 50 years ago it was beleived that the cranium fused some time in childhood. But for people to continue with that belief in the face of the most current research in the field is ludicrous. I would suggest you contact the Cranial Academy for their bibliography if you are interested, because it is unwise to continue to debate a topic without understanding the facts as they are seen today.

Thanks for the lively debate, let's keep it going!

 

[droliver]

The sentiment tossed out about it not being important whether research can document several popular tenets of Osteopathic medicine will guarentee that Osteopathic philosophy will continue to be marginalized and (rightly or wrongly) be associated with voodoo medicine. Evidence-based practice should be the standard you aim towards!

Also, as a surgeon with not an insignifigant experience with head/neck & craniofacial orthopedics, I find 1) the idea rejecting the stability of cranial sutures and skeletal butresses of the face to be ridiculous & 2) the concept that you can palpate some "inner frequency" of the calverium to be as full of it as these ridiculous "no-touch energy filed/aura" manipulations that some nurses & now medical schools (God forbid) are perpetuating

 

[osteodoc13]

Again, I'm not saying that it's not important to do research on OMT, I'm saying that the general consensus among practitioners is that if the research is done, great, but I'm getting great results and my practice is full, so I don't have to prove myself to anyone.

droliver: I don't know how much reading you have done in the field of OCF, but no one is rejecting the concept of the buttressing action of the face and calavarium. In fact, the idea of cranial bone motion supports this concept by giving the skull a sort of "cushioning" action in absorbing forces. Since you are so educted in cranial anatomy, can you explain the differing shapes (ie bevels, dovetails, pivot points,) of the cranial articulations? And can you explain how it is that those articulations are still present in the skull of an 80 year old man. If the bones did fuse, how could you disarticulate the skull so easily and still identify the different sutures?

Finally, I do not utilize these so-called energy manipulations when treating patients, but I would urge you to spend some more time investigating the research corroborating the palpable motion of the CRI.

BTW, droliver, are you a DO? and if so, do you utilize OMT in your orthopaedics practice?

 

[RockyMan]

Some questions and criticism re yesterday's post from osteodoc13:

1. How do you know that ?...most osteopaths... are content with things the way they are.? ? Is there some published survey data where DO?s were questioned about cranial theory and manipulation-- correct medical indications, success rates, bases in reality, etc.? Is your statement based on anecdotal evidence (e.g., your personal experience) and possibly biased by your enthusiasm and faith in crainial manipulation? But personal experience cuts both ways, and is clearly no basis for making statements about ?most osteopaths.? In my own anecdotal experience, most DO?s I?ve spoken with find cranial osteopathy risible, and something they are ashamed to be associated with as osteopathic physicians. When we had two weeks of cranial manipulation class at my school during 2nd year, many students openly ridiculed the teachers, who were consistently refusing to answer questions about the scientific basis of what they were teaching, or about evidence that the CRI even existed. Perhaps there were lots of students sitting there who believe in cranial manipulation, they just didn?t speak up... without asking everyone, you can?t for certain determine one way or the other. Don?t you think we should avoid making statements about what ?most osteopaths? think when we have no evidence to back them up?

2. Again, you stated that most physicians who use OMT have to close their practices to new patients after about a year, which is quite interesting, but how did you find that out? I?ve never seen that in any published survey data of OMT use among osteopaths-- could you please provide a reference? I?ve met a number of DO?s who do OMT on some of their patients, but none of them have stopped taking new patients-- they all took new patients when I was working with them.

And what does that statement have to do with the question of whether cranial manipulation lacks any convincing objective evidentiary basis, has any kind of tenable proposed mechanism, or is just another form of medical quackery? It seems to me quite possible, even likely, that only a very small percentage of DO?s practice cranial manipulation. Among the several DO?s I?ve met who practice OMT on patients, not one of them has stated that they do cranial manipulations. Wouldn?t you agree that DO?s have the ethical imperative to use objectively proven techniques, and that we don?t have to practice cranial manipulation in order to be osteopathic physicians?

3. If the physicians that you describe in your posting (i.e., the ones who do so much OMT) close their practices to new patients, that implies that they are treating the same patients over and over again, possibly for many years (otherwise, obviously, over time their patient rolls would dwindle down to few or none). Does that mean that cranial manipulation (or some types of OMT) doesn?t actually cure patients of their musculoskeletal strains, sprains, misalignments, etc., or cure other health problems, so that the patients are always coming back to have the same conditions ?treated? again and again with little or no prospect of actually being cured? That?s certainly not what I was taught in OMT class at my school! If cranial OMT allows the body to heal itself, I would expect the opposite to be the case: cranial practitioners should be taking on new patients continually, as their old patients are cured. What gives?

4. You wrote ?If you have to close your practice to new patients after about a year... why do you care if someone is out there doing the research? You are successful both in terms of your practice and your patients. Research becomes unimportant to the average working doc.?

It?s certainly an interesting question to what extent physicians care about whether anyone is doing research on medical practice, on evidence-based medicine. Why do you believe that for the majority of doctors-- the average, as you write-- research is unimportant? Certainly the ?flux? in medical knowledge and applications you wrote about before could not occur if someone wasn?t doing the research, and if physicians didn?t have a moral obligation to incorporate the best research knowledge into their practice.

One implication of your statement is that physicians, or potentially other practitioners, who have full offices and-- you assume-- happy patients are under no obligation to justify the evidentiary bases of their medical techniques, decisions, etc. I strongly disagree: when you put on that white coat, or hang up that diploma in your office, you are under a lifelong obligation to be interested in research and what it says about how you practice. To do otherwise is to risk disaster, or at the very least is an abuse of your patients? time and money. For example, over a generation ago I?m sure there were many successful Ob/Gyn doctors, with many happy patients, who wished that more research had been done on thalidomide before they began giving it to pregnant women. In another example, Tijuana clinics and American cancer quacks continue to prosper and to advertise their services, and have many patients come to them, in spite of their manifest failure to cure cancer (e.g., several years ago NIH did a clinical trial of laetrile, double-blind randomized and prospective, and found the treatment to be useless). If practitioners of cranial manipulation generally do not care about research, that is not to their credit.

Perhaps your intended message was that the physicians you speak of are in fact under the aforesaid obligation, they simply don?t care to recognize that duty, and as long as their practices thrive, they don?t bother about the validity of old beliefs, or the presence of new treatments. Would you say this characterizes the majority of cranial OTM doctors? Is there any survey or other data to tell us about the attitudes of these doctors?

5. You describe cranial manipulation as part of the art of medicine, and imply that it is widely recognized (?...any clinician will tell you about.?) Aside from the physicians or others who practice and/or profit from cranial manipulation, how many doctors would describe it as part of the ?art of medicine?? I don?t know of any published survey data, but given the absence of cranial OTM courses at MD schools, I?d speculate that the percentage of MD?s who would agree with your statement is below 10%, maybe even less than 1%; I also speculate that you?d get a similar number if you polled board-certified neurologists around the USA. Even with DO?s, given my personal experience here in the Midwest, I?d expect the number to be low, far less than a majority. As an example of how little impact cranial OTM has on general neurology practice, consider this: every year tens of thousands of neuroscientists, MD?s and DO?s and PhD?s, attend the Society for Neuroscience annual meeting, and among the many thousands of presentations that are given each year, I?ve never seen anyone there present a poster, slide presentation or talk that addressed cranial manipulation, the CRI, or any of Sutherland et al?s other theories.

Perhaps we should look at much smaller groups of researchers and clinicians. Outside of the Cranial Academy, is there a group of neurology or general practitioners who meet each year to give clinical research presentations about cranial OTM?

6. You state that you can feel the CRI so therefore it must exist (presumably as mechanistically described by Sutherland et al, the Cranial Academy or whomever); dismiss as essentially irrelevant the published, objective studies that disprove any ability of trained practioners to successfully palpate the precise underlying CRI rate in different patients; and write that ?...OCF is an extremely subjective thing...?. In other words, your direct physical experience determines your belief, you don?t care what anyone else says, and it doesn?t matter anyway because the thing we discuss here is a subjective matter. This trilogy-- belief from feeling, irrelevance of other?s viewpoints, and non-objectivity-- is in fact the necessary premise for faith-based beliefs. It seems to me that, despite your protests, your views about cranial OTM are related much more to faith than to reason. Medical wisdom, I think, requires a modicum of self-doubt, something which doesn?t seem to be included in your allegiance to cranial OTM.

As much as you might refer to this string as a lively debate, if in fact you believe in the CRI because of the sensation you feel when you touch patients-- and nothing else-- then there is no way to reason with you, because no matter what I or anyone else may say or write, in the end your belief rests upon the subjective sensation in your hands and nothing else.

On the other hand, if you are amenable to reason, that implies that there is more than subjectivity that underlies your affirmation of cranial osteopathy. You might say that you believe because the patients like it also, but that is simply adding in their own subjective impression of having their head held, lying in a peaceful room, etc., in other words, subjectivity times two. If you want to reason and debate, there must be something else there, some objective measurement and rationale beyond ?I feel, therefore I know.?

7. In your initial post on this string you wrote that new basic research in neuroscience is supporting the principles of cranial osteopathy, then in your second post referred us to a bibliography published by the Cranial Academy. Have you personally read any of the new neuroscience articles to which you referred in your first post? Which ones?

8. In your 7/28 post, you stated that there are ?several? studies which demonstrate intrinsic motility by astrocytes, that such motility occurs in vitro, and that astrocytes ?...will synchronize their pulsations if they are mixed.? In my reading I?ve seen these claims several times, but found only found one published article to which they were referred, a small paper by C. Lumsden published half a century ago in the joural Experimental Cell Research (2: 103-114, ?Normal oligodendrocytes in tissue culture?). Although there are many problems in extrapolating Lumsden?s observations to support postulates of cranial osteopathy, one major difficulty is that molecular probes capable of correctly labeling live human astrocytes in culture were not developed until the 1970?s and ?80?s, so Lumsden?s cultured cells were never in fact demonstrated to be astrocytes. Furthermore, the methods for successful long-term primary culture of astrocytes were developed post-1951: Lumsden may have seen some astrocytes, but just as easily might have been observing neurons, fibroblasts, microglia, etc., in his dispersed-cell preparations.

In any case, more recent studies of astrocytes in vivo and in vitro disprove the notion of astrocytes having intrinsic sychronized electrical depolarization or synchronized cellular contraction in vitro, much less in vivo. If you?d like to investigate for yourself, please look for articles from the laboratory of Dr. Martin Raff from the 1980?s and ?90?s, often published in the journal Nature, as well as from Dr. Steven Smith of Yale, beginning with an article published in Science magazine in the late 80?s, 1988 I believe. If you?ve ever looked at an electron micrograph of the human brain, you will appreciate the absurdity of proposing that synchronized astrocyte contraction gives the brain an intrinsic, directional motile force.

9. The most comprehensive and honest discussion I?ve seen about the evidence for cranial osteopathy is in Leon Chaitow?s 1999 book, ?Cranial Manipulation Theory and Practice,? published by Churchill Livingstone and likely to be found in bookstores at osteopathic med schools. I would recommend especially Chapters 1 and 2. Chaitow is generally poorly informed about biological mechanisms and neurobiology, and entirely uncritical of the spectacular leaps in logic that are made by many of the CRI proponents, and in the end he succumbs to proposed mechanisms that are essentially warmed-over vitalism, IMHO, but he at least points out contradictions between the various theories and the marshals together much of the fragmentary evidence that has been published.

RockyMan

 

[moo]

Originally posted by osteodoc13:
•Again, I'm not saying that it's not important to do research on OMT, I'm saying that the general consensus among practitioners is that if the research is done, great, but I'm getting great results and my practice is full, so I don't have to prove myself to anyone.

•

This is the kind of mentality that scares me. I can claim that I am healthy because of a magical rock that sits on my desk. Or I can claim that because I have gotten over the flu in a week, that the magical rock has effected a cure. This is illogical and so is your statement. Research NEEDS to be done. It's not a matter of "if" or "should." I'm not here to flame osteopathy or anything b/c (being from Canada) I don't know much about it but I can see why this type of thinking (if true) among DO's has gotten people like Dr. Barrett to write articles bashing the profession. (Again, I don't necessarily agree with his statements. In fact, I have yet to form an opinion on osteopathy and its techniques other than it's equivalent to medicine by law and most DO's are as competent as MDs)

And oh, I think that regular osteo docs SHOULD be concerned with research. They need not do it, but they should certainly keep themselves up to date with the latest developments. Medicine entails a lifetime of self-learning from reading journal articles, etc. It's important for the "average" doc (MD or DO) to read up on the latest research being done.

 

[osteodoc13]

WOW! that post by Rocky is incredibly well thought out and insightful (not to mention long!)

I don't have time to respond to all of his points right now, but let me first start off by saying that, yes, my generalizations concerning the "average" doc's interest IS based on my personal experience, both in my home area of southern CA and from discussions at national conferences such as the CA and AAO conventions. And when I discuss physicians closing their practices, what I mean is that they are so busy that they need to, at times, turn away new patients until there is time and space available. I do not think that patients of cranial osteopathy require life-long treatments, and most of the cranial osteopaths I have met would not continue to treat patients if they did not feel that there was any improvement, or potential for improvement.

As far as comments about "most osteopaths," I think it was clear in the context of my post that I was referring to practioners of OCF specifically. I am well aware that most osteopaths don't even use OMT on their patients, and the percentage of cranial osteopaths is even smaller, so obviously I am not to referring to the general population of DOs.

I would request some clarification on what Rocky meant when he said "most DO's I've spoken with find cranial osteopathy risible." Perhaps this is simply a spelling error, but I was unable to determine what work he could possibly have meant. Maybe if you spelled it phonetically we could understand you better.

I was very impressed with Rocky's knowledge of the current state of astrocytic research, and I will definately be investigating his statements for my own personal edification. Suffice it to say that at the current time no one can sufficiently state what the possible mechanism is for powering cranial motion. But I draw away from statements relating it to faith-based healing. I do not think that what I am experiencing when I feel the motion of the cranium is a subjective thing. It is most certainly objective, and the studies are there to prove it. I apologize for not being able to quote exact references, but as I said in a previous post I am away from home currently and do not have access to my files at home.

I also am not closed to other viewpoints. I would say that in the majority of encounters I have found the opposite to be true. I know that anecdotal evidence will never be able to prove scientifically that cranial osteopathy is as powerful a tool as I have seen it to be, but I would simply ask you to have more of an open mind and be willing to accept that there are people out there practicing a powerful form of treatment which gives results. I would never claim that cranial osteopathy, or any other form of OMT, is a panacea. There is no such thing. But, like any other treatment modality, it is extremely effective when utilized by a professional physician in appropriate patient populations.

I would like to challenge you, if I may. You seem to be well educated in research, more so than myself in any case. Perhaps you can come up with a randomized trial which would give us some ability to evaluate the efficacy of cranial manipulation. In this case, it is impossible to perform a double-blinded study, because the physician will always know if he is manipulating or not. I would be interested in anything you could come up with.

I am well aware that there are many students each year who dislike the cranial courses presented in school. I would wonder, though, if any of those students has ever been treated. I know that during our own 40-hour course at COMP several students had very bad reactions to treatments, such as vertigo, nausea, even emesis in one case. I myself have had flu-like symptoms after particularily powerful treatments. I wonder how the more educated, less cultish, DOs out there would explain such occurences. Granted they are not the desired outcomes, but doesn't their existence speak of some phenomenon occuring?

Finally let me say that in all of Rocky's post he never questioned the concept of the motion of the cranial bones. I wonder if he is saving this for part 2, or does he accept such a notion, after a critical review of the literature. No one has yet even bothered to address the questions I have presented concerning the persistenct of patent suture lines even in the elderly.

Beliefs are powerful entities, and I agree that if either of us are coming from a belief standpoint then there is obviously on point in continuing the discussion. But I don't think OCF is a religion. I think it is an emerging area of fact that, in the past 50 years or so, has made great strides in terms of scientific validation. In the mean time, are DOs restricted from utilizing methods of practice that they have had great success with in the past simply because they are not completely accepted? Off-label use of medications is an accepted practice in the medical community, and it is understood that the physician is taking the risk of bad outcomes solely in his hands if he/she chooses such a treatment regimen. I think cranial osteopaths should also be allowed to place the risk in their own hands (pun intended)

Thanks

 

[t-bone]

Dear RockyMan:

I've been away for a few days, but wanted to reply to your previous post.

I apologize if my initial reaction to this article and my reply to your response were strident. Here's a little background:

I am a nurse who became interested in medical school through my work and various nursing experience. When I shadowed several doctors and did some research, I became very interested in osteopathy. I applied only to osteopathic schools because I did then (and still do) wholeheartedly endorse their basic philosophy.

But when I told my family I was accepted to an osteopathic school, I was referred to this article--printed up by a deeply concerned family member who thought I should go to a 'real' medical school. I didn't think much of it then. But when I found the same article on my own in a simple web search, and when I really read the article in depth (and especially the links), I became upset.

So, again, I apologize if I became too agitated in my reply to you. I really think that we have some areas of agreement.

1) We agree that some of the practices Dr. Barrett mentions are indeed "dubious." In my work as a nurse, I've had to bite my lip while helping people put their magnets in place And I have (as a home health nurse) had several people ask me about other fly-by-night treatments. Quackery preys upon people with deep respect for the title "doctor." This is sad. I've seen it firsthand. I'm sure you have seen it firsthand, too. I think we agree here.

2) Also, I think we agree that organizations like "Quackwatch" are necessary and beneficial. I wish that more people would take advantage of resources like "Quackwatch".

3) And we agree that ad hominem tactics are not at all helpful. If I have resorted to these, I sincerely aoplogize.

Another necessary bit of prerequisite information is this: though I have worked as a nurse for many years, I am in no position to argue with you in many areas. You, I take it, are an experienced medical student (or resident?? -- I haven't looked up your profile)



But in the following areas I think we still have deep disagreements:

First, Dr. Barrett's methodolgy is faulty. You hinted that I may be guilty of ad hominem argumentation. But I did NOT attack his character or person (look up 'ad hominem' in a dictionary). I did indeed question his motives and methods--to do so is not ad hominem argumentation.

The title of the whole article is "Dubious Aspects of Osteopathy." I ask, in all fairness, are Chelation Therapy, Orthomolecular Therapy, and Homeopathy really "aspects" of "Osteopathy" in particular? He mentions these (and then attacks them) under the wide rubric of "osteopathy." I ask: do MD's practice these strange therapies too? If MD's pratice them, then Dr. Barrett has no business labeling the article, "Dubious Practices of OSTEOPATHY." Dubious, yes; purely osteopathic, no. It would be like labeling magnetic therapy a "dubious aspect of allopathic medicine."

But my main concern rests with the link provided by Dr. Barrett: a comparison of Allopathic and Osteopathic Medical Education. This is provided by a "Basic Scientist With Experience in Both." I don't know if you have read this link, but it is altogether and purely anecdotal--hardly worthy of a "basic scientist." The article is riddled with phrases like, "I was talking to a lawyer," and "As I stepped off the elevator, I saw..."

Well, when I was at a neighborhood barbeque, I heard a respected bus-driver friend say that osteopaths were three-times more likely to watch pornographic movies...

Do you believe me?

This article asserts, among other things (again, on purely anecdotal grounds), that professors in allopathic schools, when they go to teach in osteopathic schools, must 'dumb down' the content of their lectures for the osteopathic students!

Links on web-sites are given as supplementary argumentation for the main points of the main article--the 'proof of the pudding'. If you wonder where I get the idea that Dr. Barrett is prejudiced against osteopathy in general, just read what he offers as links to "Dubious Aspects of Osteopathy."

Again, I have the highest respect for you as a senior medical student--or doctor (?)! I a not qualified to question your judgment on many medical matters. But your reply to my (albeit angry) post concerning this Quackwatch article left many questions.

With heartfelt respect,
(and hope for continued conversation!)

t-bone
(DMU-'05)

 

[DMan]

After taking a few moments going through these posts, I must say that I generally agree with the questions raised, especially about OMT. As one who is getting ready to start his 2nd yr. I must admit that my knowledge is limited as compared to those who are practicing or getting close to graduating.

Before medical school, my personal physician has been a DO, and I've seen DOs for about twenty years. All without ever having OMT performed on me or my family. What attracted me to an osteopathic meical school was what I perceived to be a SLIGHT difference in philosophy of medicine between allopaths and osteopaths. That being that DOs are educated to be more preventative, "holistic"(I use this term losely), and to generally treat people. Whereas my perception was that MDs treat people, but in a manner which is slightly more reactionary to whatever disease/problem arises.

I would argue that BOTH of the approaches are good ways to practice medicine, as both MDs and DOs have enjoyed professional success.

Now regarding OMT. This was new to me as I entered medical school, as I said before, MY Dr. never performed OMT on me. And the general approach at my school to OMT is that it is separate, and I am concerned that when OMT is taught, we are told that it works .... just because it does. Seldom are we told the whys. Now hopefully the why will come this year. I also would agree that scientific research needs to be done to see if there is quantifiable data on the benefits of OMT.

Would anyone else be willing to comment on how OMT was taught to you?

I also read a comment which said why not prescribe a drug for LBP instead of OMT? I would argue this.
1. Why not use both (assuming the patient doesn't have ankylosing spondylitis or osteoarthritis. God forbid I surely wouldn't want to break anyone's back). OMT could give your patient immediate relief and a good drug could sustain it.
2. After using OMT to relieve the pt's LBP discuss the pt's lifestyle as to the cause of his LBP. Obesity, laborer who incorrectly bends over and lifts 50 -60# repeatedly?
3. Suggest modifications to the identified cause of the LBP to at least decrease it recurrence.

This is an example of what I (stress an my belief) believe osteopathy to be. I think it is simply outrageous to think that OMT is a cure-all. But I think it's safe to say that OMT is one more tool that DOs have in their possession to effectively treat patients.

Any thoughts on what I've said???? Peace.

 

[osteodoc13]

While I agree that there needs to be more research into the efficacy of OMT, I have to wonder at how easily the student posts I have read dismiss OMT. Physicians use drugs all of the time which have unknown mechanisms of action. Their use is based on theory, and if they work they continue to be used. In most cases the science finally catches up with the medicine, and the mechanism is explained. But in some cases their never is a good explanation as to why the medication works.

SSRIs area good example. The seratonin-depletion theory of depression makes sense from an empiric sense, because patients treated with SSRIs get better. But it is not clear-cut that depression is caused by depletion of seratonin. If you take a depressed patient whose symptoms have resolved and deplete his 5HT, he will become depressed again. However, if you take a normal, non-depressed patient and deplete his 5HT, he will not become depressed. There is also the question of downregulation of 5HT in the brain, and the fact that, even though the 5HT levels in the brain are increased in a short period of time, the effects on depression is not seen for 2-4 weeks.

Despite these questions, nobody would say that they shouldn't be used because the exact mechanims of their effects is not known. They are effective, and their use is justified. I don't see why the same can't be said about OMT. There are plenty of (albeit small) pilot studies showing that OMT can decrease symptom time, length of stay, and medication use in many different situations. There needs to be more, but the initial studies should be enough to justify the use of OMT by qualified physicians in appropriate patients.

I would also return to the question of off-label use of drugs. SSRIs are often used for treatment of chronic pain, even though there are no indications for such use. The fact is they work, in some cases, to decrease the patients chronic pain. If someone using cranial osteopathy has similar results, shouldn't he continue his treatments in spite of a paucity of research evidence?

Let me also say that I agree whole-heartedly with t-bone vis-a-vis his initial reason for starting this thread. Barrett is well outside the boundaries of logic when he discusses such things as chelation, orthomolecular, etc. under the label of osteopathy. It is clear that he has an anti-osteopathy bias, or maybe more clearly an allopathic myopathy, and some of his posts border on slander. I saw in another thread that he is apparently being sued for libel; I am very interested in seeing how that case turns out.

 

[efs]

I would request some clarification on what Rocky meant when he said "most DO's I've spoken with find cranial osteopathy risible." Perhaps this is simply a spelling error, but I was unable to determine what work he could possibly have meant. Maybe if you spelled it phonetically we could understand you better.

No spelling error. Risible = laughable. If you had used a good dictionary you would have found it there.

 

[osteodoc13]

Learn something new every day!!!


Thanks!

 

[osteodoc13]

Here is an interesting compilation of references I found while surfing the net...I think it was on DOhealthnet.com or something like that.
http://www.iahe.com/press/P-MON.htm

Although it is written by John Upledger, it is still a good bibliography of information that some on this thread may be interested in reading and evaluating. I would be excited to hear any comments anyone has.

 

[RockyMan]

Osteodoc13--

Yes, very definitely, I agree that it would be an excellent idea for DO students to look at some of the articles on this list. While doing so, please keep in mind a few suggestions, from an experienced article reader, that may be obvious but still, I think, should be stated before we start debating the contents of Dr. Upledger's enthusiasm:

1. Always be consistent. Apply the same critical standards to these articles that you would to an article published in the New England Journal of Medicine, JAMA, Science, etc. In fact, you should apply the same standards that the editors and reviewers at NEJM, JAMA, etc, are applying. As they say, if you are not going to do it well, then don't do it at all. It would be illogical, and possibly self-serving, for proponents of cranial osteopathy to insist on the one hand that 'osteopathy is separate but equal to allopathy,' but then on the other hand to hold articles from DO's to lower standards than other doctors have to meet.

2. Errors of omission can be just as serious and confounding as errors of comission. Don't ferret out mistakes and overstatments and leave it at that-- there's always a lot more to the story of how somebody's efforts made their way into a publication. Look at these articles and ask yourself what information is missing, what experiments or controls weren't done, what alternative explanations were not considered.

3. Don't 'cherry-pick.' Too often what I seen in the papers from the osteopathic-published journals are authors who 'cherry-pick': they roam around the library, or the internet, and seemingly whenever they find a reference, an article, a piece of an article, a graph from an article, etc., they pick it out and incorporate it to support their viewpoint (exhibit #1 = taking a 1951 article on cultured cells and using it as evidence that dispersed astrocytes contract synchronously, therefore the CRI must exist).

Imagine that science, fundamentally, is a giant fruitcake. You can't describe what's in it just by picking out all the cherries and claiming that we have a cherry pie before us-- there's always tons of nuts and other stuff, and it MUST be considered all together if anyone is going to figure out what's really true.

4. No matter how many cards you can stack up, no matter how high they get or how baroque and enchanting the architecture eventually becomes... in the end, it's still a house of cards, and if the individual evidences are weak or null, then that weakness suffuses the entire structure. Arguments based on publications are empty exercises if the papers are bad. Bad evidence = wasting everyone's time (in academics, that's a hanging offence).

Well, that's enough rah-rah for tonight. I'm sure that, in discussing Dr. Upledger's favorites, other imprecations will come to me by and by.

On board next: The Cat in the Hat. Or, Dr. Adams and the very very very small spontaneous movement of the skull.

RockyMan

 

[DrSRBS]

I stumbled upon this thread late tonight and read the article you're discussing--it set me to thinking, so I thought I would share what I ended up writing as I mulled.

(I haven't had time to read the entire thread yet, so forgive me if it is out of place!)

"A.T. Still looked at Civil War Era medicine and decided to make a conservative departure from the practices he observed, which he found to be ineffective and downright harmful to the patient. For example: "calomel" used as a purgative (essentially a mercury concoction) and the practice of bloodletting. We know how damaging these treatments are now, but he was way ahead of his time then to think, "Maybe this isn't such a good idea." That's an important perspective to have; one which relied upon innovation and trial-and-error approaches-and these approaches were **significantly** less invasive than many recommended by the mainstream medical canon of the day. Still had a defiance against drug treatment, feeling that structure and function are intimately related, and so restoration of structure should bring about an improvement in function. This seems like a fairly commonsensical approach, but taken to the next level, it gets significantly amplified when applied as a philosophical approach to treatment of disease. The tenet is that if one realizes that if a patient is not well, trying to restore general physiological function may remove the offending problem, which "science" may yet be unable to identify.

A professor of mine said last semester, in reference to the clinical scenario he gave in which a patient in for low back pain was found to bear some psychological components to his/her symptoms (i.e. positive Waddell's Signs), despite this, it has never been proven that complaining to the patient that it might be all in their head is an effective arm of treatment. This can be extended to many other realms, including the one of which we speak here. If we don't know the problem, and we begin to treat by simply trying to restore or stimulate physiology in the patient-and then see improvements, the end result is that we've helped the patient. I think it is reasonable to conclude that withholding such a potentially valuable-if yet unexplainable-treatment would be unethical. Especially so, when one realizes that, when applied under recommended treatment guidelines, there has never been a catastrophic tale of OMT gone wrong in the 100+ years it has been performed.

I think it is unfortunate that there are those who (1) seek to discredit Osteopathic Medicine and its foundations?and yet (2) feel Osteopathic Physicians ought to give in and join the MD pack and carry a card that replaces O's with M's (i.e. DO, AOA to MD, AMA). We are criticized for being different and for trying to prevent our distinctiveness from being swallowed up by those who seek to offer nominal parity in exchange for giving up the perspective that our particular school of medicine has. We are different, being simultaneously acknowledged as fully competent and licensed practitioners of medicine (in my humble opinion, MDs are not the only ones who have the right to call their practice "medicine"), and also, often, being often qualified as one of the (albeit more mainstream) schools offering alternative approaches to medical care.

I think it is not often enough pointed out that the AMA historically (within the first 60-70 years of Osteopathic history) was officially of the opinion that all other schools of medicine that pass muster would be better off becoming absorbed into itself. Resultantly, after closed negotiations between the California Medical Association and the California Osteopathic Association, on July 14th and 15th of 1961, with AMA blessings, the CMA accepted approximately 2,000 California DOs into their organization, and provided them with MD degrees without any further training. This had profound repercussions in the AOA and in the federal government. The DO community was strengthened by this action because of 1) acknowledgement by the AMA (was it intended?), and on this basis by the US government, that DOs are fully qualified to practice as physicians, and 2) that DOs in other states definitely did not want to unify, but rather maintain their distinction as DOs. (I refer to the account given in sociologist Norman Gevitz's text, The DOs: Osteopathic Physicians in America.)

What is wrong with maintaining a separate school of medicine from that which bestows the MD degree? As has been iterated and reiterated, MD and DO colleges' basic science curricula are identical (for example, MSU's MD and DO schools share these courses). Our systems coverage is taught separately. However, the COMLEX (DO board exam series), is accepted as an equal determinant of an individual's capability of practicing medicine in all 50 states. DOs taking advantage of opportunities within the non-AOA affiliated residency program is actively condoned, and indeed counted upon. DOs have a slowly expanding framework of osteopathic regulatory administrations (including osteopathic schools and osteopathic hospitals) which depend upon ACGME programs to provide the residency experiences which cannot currently be afforded by the DO teaching hospital network. The AOA has recently voted to approve non-AOA affiliated residencies which have been approved by the ACGME as acceptable courses of GME for DOs to pursue AND still be able to maintain their activity within the AOA. From these examples, it is clear that DOs can remain equal to MDs and yet maintain a community of colleagues who share a similarly-founded philosophical focus.

A comment on the presence of practices which are more widely held in scrutiny, such as chelation therapy, which has been given as a point of criticism against osteopathic physicians. Osteopathic medicine as a rule applies itself to implementing what works. If there are those out there who believe fervently in chelation therapy, or cranial-sacral mechanism, or anything, let them believe in it. There is likely a reason why they have latched onto it. If patients suffer from treatments resulting from these interests, that is one matter, but it is entirely another to discredit those who seek to augment their more orthodox approaches with tools which bear no potential for harm to the patient. New ideas are, and should be, held to the light for examination by scientists. If a treatment works and scientists have yet to develop their craft in explaining it, then let's not bash the practitioner. If a particular treatment is thought not to be helpful, then I recommend discussing the merits of the treatment over trying to discredit whatever happens to be the practitioner's school of medicine.

(Additionally, along the lines of scrutinized therapeutics, the rather uninformed quoting of what was most likely a purposefully ironic comment made by Still in his autobiography. He was quoted as sayin he could cure scarlet fever by "wringing" a child's neck. Most likely, he referred to stimulation of the immune system from manipulating the neck. Today, we might refer to it as a Thoracic Outlet procedure. He might not have the mechanisms then, but today we theorize that stimulating the passage of lymph through the thoracic duct and releasing compressed arteries, veins and nerves in the subclavicular space can bring about marked improvement in patients with physiological impairments.)

In conclusion, old grudges die hard and names are powerful things. It is hard for me as a newly-advanced second year medical student to break myself from comparing my school of medicine to that of the MDs. MDs enjoy large numbers and universal recognition. We are taught at my college not to try to define ourselves by listing our differences from our MD colleagues (which is hard, especially when talking with someone who really doesn't understand just what a DO is and does). This task is not made easy by those who are constantly berating students and practitioners of osteopathic medicine. Such a practice, I argue, can do no good for the general welfare of patients, or indeed for that of medical science."

(Aren't forums great?)

 

[osteodoc13]

Rocky...thanks for the tips, and i look forward to what I am sure will be some scathing criticisms of the link I posted.

I still have yet to hear back from anyone re: my contention that use of OMT, even though not scientifically validated, is clinically justified based on historical successes as an adjunct to other medical treatments.

I would mention the historical record of the influenza epidemic of the early 20th centure (I can't remember the date.) I recall that osteopaths had a success rate in the 80% range with simply manipulative treatment, whereas allopaths had a success rate in the low 20% range, albeit without antibiotics. Clearly antibiotics are indicated in pulmonary disease of bacterial origin, but is it improper to use OMT in an effort to reduce the amount and length of antibiotic treatment? There was recently published in the JAOA a pilot study comparing OMT to sham manipulation in the treatment of hospitalized pneumonia. They were able to show a decreased length of stay and decreased antibiotic use with OMT. Clearly this is not a definative study, but what I don't understand is the requirement I hear from so many students and DOs of clear cut scientific trials before they will use OMT. If others are using it and getting results without harm, isn't it justified to use it?

Sorry that paragraph kind of rambled, but I think you will get my point.

BTW: in this case I am not talking about OCF persay, but any type of OMT.

 

[muonwhiz]

There is an article in the New England Journal of Medicine which cites a study done whereby patients with the same symptoms were treated by drugs (allopathic style) and another group treated by manipulation (osteopathic style). The results were equivalent for each group, but the patients treated with OMM used less drugs and physical thereapy than those on the allopathic regimine. The name of the article is "The Paradox of Osteopathy" and can be found at: http://www.nejm.org/content/1999/0341/0019/1465.asp

 

[prolixless]

This thread got me thinking of an idea for how to research the effectiveness of OMT.
Is it possible to design a study where one group of patients is treated with proper OMT techniques and another group is treated with improper techniques, and then the outcome of the two groups is compared? Because the patient pool would consist of laypersons, proper and improper manual techniques would not be decipered by them, hence they would not know if they are receiving the real OMT or the placebo OMT. Now, I don't know much about how proper OMT is performed. Nevertheless, the improper manual techniques would have to someway be performed so that they do not harm the patient and so that they do not someway overlapp with proper OMT techniques. Moreover, the improper manual techniques ought to involve as much palpating and manipulating as that of proper OMT techniques.


Like most ideas in life, this one has probably already been thought of before and possibly even perfomed, but for those of you who are osteopathic physicians, please tell me why it wouldn't work.

 

[cocobeanz]

wow, this is the first time i have read this article and i am flored. i am a student at msu, college of osteopathic medicine. all i can do is give my perspective. i chose the D.O. route over allopathic because i . believe in omt very much. i have been treated with omt many times for my medical condition. its true that we cannot prove with lab results that omt is beneficial for some people. but how is that differenet from that fact that many of the pharmaceuticals prescribed are under clinical studies that prove that they work but cannot explain why.
i spent my whole first year of med school with allopathic students so i know what their curriculum is like. we had all our classes together.i have made friends in the md school and they all recognize how as do students we had to carry 6 more credits per semester. when the we all took our finals for summer everyone was aware that osteopathic students here at msu dont get a summer vacation un like our md friends. as a result i feel like we have gained alot of respect from the md students and MANY OF THEM COME TO THE OMM CLINIC! so this is just my thought and to all the dos out there:
THIS GUY FEELS THREATENED BY DOS, HE OBVIOUSLY HAS ALOT OF FREE TIME ON HIS HANDS. I AM PROUD OF MY PROFESSION AND I DONT THINK ONE IS BETTER THAN THE OTHER.
ps lets not forget that omt is not the only things that dos practice. why is this such an issue?

 

[doughboy]

I was wondering if you could clarify something for me. I heard that DO's at Michigan State are pass/fail and they need a 70% for passing. I also heard that the MD's at Michigan State are required to have a 78% for passing. Is that correct? Why are the requirements higher for the MD students? If you have the same classes, then the passing requirement should be the same. Why do MD students get put to a higher standard? Plus, I think someone also told me that you only take certain classes together and mostly only during your first year. Do you guys have the same professors?

 

[cocobeanz]

dear doughboy,
we have all the same classes together. the md students have a pass fail curriculum too. the pass percent depends on the class. for example in anatomy everyone had to achieve a 78 to pass. for the most part, do have to pass with a 70% while the md students need a 75%. the reason is that we do students carry the md curriculum plus three more classes and their respective labs per semester. so that si why we need a 70 percent to pass. because we have a larger load to carry. to tell you the truth, this really comes down to a matter of 2 or 3 questions on a test for a 70 vs 75. and yes we have the same professors, the same classes and we even sit together in class! hey we evenm go out and hit the east lansing bars together. it is a very unique experience. hope that answers your questions. ps the md curriculum was at 70% pass rate at one time. just an fyi
take care
cocobeanz

 

[doughboy]

So does that also mean you get to rotate at the same sites? By the way you mention it, it sounds like there is no difference between DO's and MD's except for the OMM classes. What's the point in having two different medical schools then? Why not make it just one or the other? This is another reason why I wonder if the "holistic philosophy" and DO's being different is just a bunch of exaggeration. That's why I get disenchanted with the DO influence in med school. My school if you took out the OMM classes would be just like an MD school. So where does all the OMM that makes us unique make its mark? So far my only answer is during family medicine. My DO docs still prescribed antibiotics for every viral pharyngitis and URI. Anyways, I know that MSU DO students love their OMM, its just that without that class, you're just like the MD's.

 

[cocobeanz]

dear doughboy,
the difference is that as do students we have extra training so when i say that we have extra classes those are unique only to com. i guess i did not specify also that we only share first year not second. DO students take a systems curriculum, while md students have problem based learning their second year. two very different ways of learning. also as do students we got to do pelvic/ rectal exams, etc first year while md students do them second year. we also start seeing pts second year in preceptorships, while they dont. where is the holistic approach? it is not as holistic as they make it out to be but its definitely taught in the ost classes. no we dont rotate through the same hospitals, we have a choice of 12 facilities in the state, md from msu pick one of five. they are at different sites. hope that helps. by the way, which school do you attend?
c-ya,

 

[drchrislareau]

There are also many dubious aspects of allopathic medicine...but both allopathy and osteopathy have been accepted by the U.S. Federation of State Medical Boards: http://www.dohealthnet.com/article1171.html

The new emphasis in osteopathy should be on research. In the past, lack of funding has prevented this but there are changes occurring right now. See http://www.dohealthnet.com/article1204.html