Despite Mocking OMM for the first 6 months, I just Cracked My First Neck...

[Ifellinapothole]

---

Members don't see this ad.

And still haven't been converted, but felt pretty cool doing it. I like the techniques.

Any of you go to D.O. school thinking OMM was a joke and feel differently now?

Am I being brainwashed?

 

[Taus]

don't forget that you have the ability to make a choice about which techniques you like and will use.....no one said you have to like 'em all....

 

[Bill_Brasky]

Yeah, I think I felt the cranial respiration in lab twice now. There is definitely some cognitive dissonance going on.

-Bill Brasky
-----------------------------------------------------------------------------
"Fourth: Bill Brasky once gave me a videotape of him having sex with my wife, and it was the most beautiful damn thing I ever saw!

Second: I have that tape!

Guy At Bar: [ turning around ] So do I!"

 

[Kevbot]

I didn't know what to think of it, until my girlfriend was diagnosed with thoracic outlet syndrome. She has had cyanosis and debilitating pain along the C6-T1 dermatomes for an entire year now. After physical therapy didn't work, her neurologist was talking about surgical removal of her 1st rib to relieve the impingement. Because of her lack of ability to see doctors outside a certain medical center (insurance issue) and because some of her doctors are DO's that don't use OMM, none of the doctors she's seen have even considered OMM as a treatment option.

Suddenly a class I had barely acknowledged until that point had become some of the most important important medical information I had learned all year. There is no success story yet. But I've gone to some length learning the methods of treatment including spencers techniques which we won't learn officially until next year. So far no improvement. But her neurologist is continuing to see her, and I'm continuing to learn more about treating thoracic outlet syndrome.

I'm hoping for the best, and aside from a very invasive surgery, OMM may be her only hope.

 

[CatsandCradles]

This is an interesting post. I'm definantly going to go into OMM with both scepticism and optomism now.

I feel like a detective already! 🙂

 

[Taus]

Heres my take on it...
I know that I will likely not love or remember every little bit of OMM that I am taught. I also know that I will probably not be an OMM specialist of FP/OMM doc. However, from the techniques that I have learned so far and the ones that I will continue to learn, I can say that having the ability to quickly take care of someones backpain, muscle pain, headache etc is something that I am very happy about. Again, if there are a few techniques that I don't like, am not good at, or simply dont "get"....I will still be satisfied if I can take away a few "bread and butter" OMM techniques to help people when it is needed. Just keep an open mind...

 

[OMMFellow06]

I didn't know what to think of it, until my girlfriend was diagnosed with thoracic outlet syndrome. She has had cyanosis and debilitating pain along the C6-T1 dermatomes for an entire year now. After physical therapy didn't work, her neurologist was talking about surgical removal of her 1st rib to relieve the impingement. Because of her lack of ability to see doctors outside a certain medical center (insurance issue) and because some of her doctors are DO's that don't use OMM, none of the doctors she's seen have even considered OMM as a treatment option.

Suddenly a class I had barely acknowledged until that point had become some of the most important important medical information I had learned all year. There is no success story yet. But I've gone to some length learning the methods of treatment including spencers techniques which we won't learn officially until next year. So far no improvement. But her neurologist is continuing to see her, and I'm continuing to learn more about treating thoracic outlet syndrome.

I'm hoping for the best, and aside from a very invasive surgery, OMM may be her only hope.

I am still amazed that there are so many people out there that are still so skeptical about OMM. And sometimes it does take a case where OMM helps a friend or loved one to make them "BELIEVE"

I am glad that KEVBOT is considering learning some techniques to help his girlfriend out. Before you can treat her thoracic outlet you have to know what is causing it. There are many different reasons that she could have it and not all techniques would be the right choice. That is where you get to use your hands and your palpatory skills to guide you to the cause. Does she have it because of spasmed scalene muscles, a first rib that isn't moving properly, or tight pec minor muscle? or it could be something else. Thats where you get to play detective to find out. Once you think you may have figured it out, then look up some techniques for the problem. I don't think the Spencer technique is specifically for thoracic outlet, but it may help. I suggest you ask some of the fellows or attendings for some help on figuring out the cause and some techniques that may help her. Definitely want to avoid the surgery. If you want more info from me, definitely feel free to PM me.

Oh, it's not brainwashing, it's just your mind opening up to what's right in front of you, a great way of treating you patients.

 

[DOctorJay]

I just want to put out there that I was a PT first and am a DO student now. You guys have no idea how similar the 2 are (I would argue however that PTs have a better understanding of kinesiology as we take that course at the graduate level and DO school just sort of sprinkles that in). The allopathic world wholeheartedly accepts PT in most cases and lots of manual therapy PTs are clamoring for more manual technique courses (that's our land guys, meaning DO). Some states limit PTs in manipulation but others don't and some just limit the terminology.

Remember this when in the future you have a pt who you want to send for PT. Think first, do I have the skills to do what I want done for this pt? Or do I not want to be bothered and therefore just refer out to someone else. This stuff does pay guys, our OMM facutly is doing QUITE well, especially the ones in strictly OMM practices.

Finally, if you don't want to use OMM, fine. But take pride in the fact that you are a master of the musculoskeletal system, something allopaths cannot claim coming out of med school (residency trained orthopods, pm&r docs, etc are extremely competent but coming out of 4th year DOs own the musculoskeletal system - the Journal of Bone and Joint Surgery has multiple articles suggesting substandard mskel education in the MD med schools).

Just some things to think about!

-J

 

[OHMAN0125]

musculoskeletal system - the Journal of Bone and Joint Surgery has multiple articles suggesting substandard mskel education in the MD med schools).

Just some things to think about!

-J

Easy now bud. Please link me these articles. And does it say DO is better as compared to MD or just that it may be lacking in allopathic curriculum. This doesnt make DO better trained in musculoskeletal. Don't be ridiculous unless u show me proof.

👎 👎

 

[Taus]

Ask and you shall recieve...see below...

 

[Taus]

Musculoskeletal Curricula in Medical Education
Filling In the Missing Pieces
Elizabeth A. Joy, MD; Sonja Van Hala, MD, MPH
THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 11 - NOVEMBER 2004
________________________________________
It's 8:00 pm on a Monday night. Just as you're getting ready to put your 5-year-old son to bed, he falls from a chair, landing on his wrist. It quickly swells, requiring a visit to a nearby urgent care clinic. At the clinic, a pleasant young resident takes a history, performs a physical exam, and orders an x-ray to evaluate the injury. You are told that nothing is broken, and a wrist splint is placed. The following day, however, you receive a phone call from the clinic informing you that upon further review of the radiographs, a fracture was detected, and your son will need a cast for definitive treatment.
This scenario, while fictitious, is not unusual. According to some studies, up to 10% of wrist fractures are missed at the initial evaluation.1 While pediatric fractures are often difficult to detect, this example highlights a problem that continues to plague medical education: inadequate instruction in musculoskeletal medicine in both medical school and residency training.
Conditions affecting the musculoskeletal system are the primary reason patients seek medical care from physicians, accounting for nearly 100 million office visits per year.2 Musculoskeletal conditions are the most common cause of long-term pain and physical disability.3 As our population ages and becomes increasingly obese, the number of people affected by osteoarthritis will increase significantly.3 Adding to the clinical burden of illness in the United States, an estimated 54% of postmenopausal women have osteoporosis, which increases their risk for bone fracture.3 Osteoarthritis and osteoporosis are just two examples of long-term disabling musculoskeletal conditions that physicians must be competent to diagnose and treat. Yet many physicians feel ill prepared to care for patients who have any number of musculoskeletal conditions.4 Why?
Defining the Problem
Surveys and testing of medical students and residents suggest that opportunity and training in musculoskeletal medicine during medical school and residency are woefully inadequate.
Several studies4-7 have drawn attention to the educational shortcomings in musculoskeletal medicine. Freedman and Bernstein5,6 found that 82% of recent medical school graduates failed a 25-question, written basic competency examination in musculoskeletal medicine. Among the 85 graduates tested, the average time spent in rotations or courses devoted to orthopedics during medical school was only 2.1 weeks. One third of these examinees graduated without any formal training in orthopedics.
As would be expected, these data suggest that limited educational experience contributes to poor performance. Clawson et al7 surveyed nearly 2,000 second-year residents in US allopathic and osteopathic residency programs. They found that up to 60% of allopathic residents felt poorly to very poorly prepared to conduct a musculoskeletal examination of the foot.
Matheny et al4 surveyed 351 graduating family practice residents about their confidence in the management of musculoskeletal conditions. They found that the residents were far more confident in making a diagnosis of acute myocardial infarction or treating hypertension than they were in diagnosing musculoskeletal conditions. In the same survey, residents ranked their overall musculoskeletal and orthopedic training as a 5.4 on a 10-point scale of least adequate to most adequate.
Changing Courses
It is imperative that education in musculoskeletal medicine undergoes significant improvement at both medical school and residency levels. In May 2003, the American Medical Association (AMA) passed Resolution 310 on musculoskeletal care in graduate medical education.8 The resolution was introduced by the American Orthopaedic Foot and Ankle Society and the American Academy of Orthopaedic Surgeons (AAOS). Resolution 310 recommends that:
• Medical schools formally reevaluate the musculoskeletal curriculum with the input of AAOS and the orthopedic subspecialty societies;
• Medical schools make changes to ensure that their students have the appropriate education and training in musculoskeletal care, and make competence in basic musculoskeletal principles a requirement for graduation; and
• The AMA encourage its representatives to the Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education (ACGME), and the various Residency Review Committees (RRCs) to promote higher standards in basic competence in musculoskeletal care.
In the spring 2004 preliminary draft of revision of requirements, the RRC for Family Practice proposed increasing the musculoskeletal experience from 140 hours to 200 hours (or 2 months) of orthopedic and musculoskeletal problems, including sports medicine. If these changes are adopted, they will go into effect in January 2006. We await the other agencies' responses to the recent AMA recommendations.
The American Academy of Family Physicians through the Residency Assistance Program publishes recommended curriculum guidelines for family practice residents.9 Two sections, "Conditions of the Musculoskeletal System" and "Sports and Recreational Medicine," provide a framework for the family practice resident to obtain knowledge and skills in musculoskeletal medicine. However, these guidelines do not provide direction as to how the resident should acquire this information.
The RRC for the American Board of Family Practice currently requires that residents complete 140 hours of structured experience in the care of orthopedic disorders, and that this experience must include caring for patients with acute, emergency, and chronic musculoskeletal injuries and disorders. Additionally, residents must be provided with experiences in casting and splinting, and in caring for children who have orthopedic conditions. The RRC specifies that these experiences should occur primarily in the outpatient setting and include a structured didactic component. Nowhere in this document is competency in caring for the patient who has a musculoskeletal disorder addressed.
Curricular goals and content will vary between medical school and residency training. Medical schools should emphasize basic anatomy, physiology, and pathophysiology, as well as musculoskeletal physical exam technique. The orthopedic training in primary care residency programs, such as family medicine, internal medicine, and pediatrics, should include a greater depth of knowledge in a wide variety of topics related to musculoskeletal medicine. These topics include normal anatomy and physiology, normal growth and development, testing and interpretation of laboratory data, pathophysiology, management and therapy of musculoskeletal conditions, prevention principles, and the skills of history taking and physical examination.10
Building Competency

 

[Taus]

At a minimum, medical schools must provide dedicated opportunities for students to attain the knowledge and skills of musculoskeletal medicine. Historically, undergraduate orthopedic training has occurred in inpatient and surgical settings that do not correlate with the musculoskeletal conditions commonly seen in outpatient settings. Geyman and Gordon11 described "office orthopaedics" seen in general practice or family practice as involving a relatively small spectrum of traumatic strains, sprains, and fractures, with nontraumatic conditions accounting for more than half the orthopedic visits. Among 2,285 visits to a family practice clinic, 23% involved musculoskeletal conditions, with osteoarthritis and regional joint pain as the most frequently noted problems.12
To address the disparity between the content of medical education and the clinical burden of musculoskeletal conditions in outpatient practice, medical schools should require a minimum set of core competencies in orthopedics. Options for elective study are desirable—but not sufficient—to meet this educational need. To adequately prepare students for managing these conditions, Craton and Matheson13 recommend that medical school education emphasize outpatient orthopedic training. This experience may be obtained in a variety of outpatient venues, including clinics with sports medicine, rheumatology, physical medicine and rehabilitation, and in the emergency department.
However, it is not sufficient to simply require completion of a rotation. The educational experience should be directed by specific learning objectives and outcomes. Curricular content should include a solid foundation in anatomy as well as clinical exposure to the most common musculoskeletal conditions. Finally, evaluation of students' knowledge and skill should follow the training.
Likewise, residents in primary care should receive structured and pertinent orthopedic teaching and evaluation. Kahl12 recommends that residents receive formal instruction in physical exam techniques and in prescribing exercise programs and assistive devices. Kahl also advocates that residents in a supervised outpatient setting manage a sufficient number of patients who have orthopedic conditions. The outpatient experience should include training in ordering and interpreting laboratory data and in performing proper joint injection and aspiration procedures.
Although medical curricula may be structured in several ways, a relatively recent approach, the "competency-based" method, has several compelling characteristics for orthopedic education. This method begins by assessing the competencies required by a practicing clinician and then tailoring the educational curriculum to meet these competencies.13 Once the competencies are defined, they become the learning objectives for the curriculum. After curricular implementation, the students may be evaluated on these competencies. At this point, we cannot presume to know what makes a physician competent in a particular area of medicine. Measuring competency is a vital issue that requires much more study and consensus.
The competency-based approach to developing musculoskeletal curricula is certainly endorsed by the recent mandate from the ACGME to implement core competencies in all residency programs. The challenge with this practical and elegant curricular structure is that it is somewhat labor-intensive to implement the teaching and evaluation components.13
Fine-Tuning Educational Methods
Educational methods should complement the educational goal: the competencies. Medical students and residents spend a considerable amount of time in lectures, despite the lack of evidence that classroom lectures change physician practices.14-16 Instead, learning is successful when the student has the opportunity to rehearse behaviors and reinforce the learned material,14 and skills are best learned through demonstration, practice, and repetition.17-19
Teaching the musculoskeletal physical exam can be time- and labor-intensive because of the multiple components of the exam. Residencies may be challenged by a small faculty-to-student ratio that limits the ability to provide hands-on instruction. Several studies20-22 have shown that senior medical students can teach physical exam skills to underclassmen as effectively as faculty can. With appropriate training, residents-as-teachers could be an innovative way to provide one-on-one instruction for the musculoskeletal exam.
Evaluation methods, likewise, should complement the educational goal. Typically, the "summative evaluation" occurs at the end of a rotation or educational experience and serves primarily to give a score or grade. After the evaluation is given, the learner has no opportunity to correct any deficiencies. In contrast, "formative feedback" provides immediate feedback and evaluation at the point of the encounter.23 This creates an opportunity for learning and correction in future experiences. Formative feedback can be provided during real clinic experiences or in staged scenarios, such as with simulated patients or objective, structured clinical examinations.
Musculoskeletal curricula designed to meet the needs of future physicians should be competency- based and outpatient-centered. When weighing the goals for the curriculum, matching objectives to competencies is a higher priority than is validation. The curriculum should span both undergraduate and graduate training, and the time devoted to it should reflect the relative clinical burden of musculoskeletal conditions. The challenge for those of us involved in teaching medical students and residents is to create opportunities for participants to learn and understand basic principles in musculoskeletal medicine, to acquire and practice physical exam skills related to the musculoskeletal system, and to evaluate students and residents in a manner that reflects the learning objectives. Each institution will have its own barriers to overcome.

 

[Taus]

part 3

Looking Toward the Future
Curricular change such as we are suggesting requires more time commitment from faculty, more financial support from the institution, and time taken away from other activities. Medical schools must prepare students to apply their knowledge and skills in musculoskeletal medicine during subsequent residency training. Residency programs need to create opportunities for residents to evaluate and treat patients who have a wide variety of musculoskeletal problems. Programs must commit to ensuring the competency of their graduates. The burden of illness in musculoskeletal medicine will only increase in future years. Inadequate preparation of tomorrow's physicians will not meet the demands of the population. It is imperative that we step up the effort in a multidisciplinary fashion and use the knowledge and skills of physicians in orthopedic surgery, rheumatology, physical medicine and rehabilitation, and family medicine to ensure the musculoskeletal education of future physicians.
References
1. Guly HR: Injuries initially misdiagnosed as sprained wrist (beware the sprained wrist). Emerg Med J 2002;19(1):41-42
2. Praemer A, Furner S, Rice DP, et al: Musculoskeletal conditions in the United States. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999
3. Woolf AD, Pfleger B: Burden of major musculoskeletal conditions. Bull World Health Organ 2003;81(9):646-656
4. Matheny JM, Brinker MR, Elliott MN, et al: Confidence of graduating family practice residents in their management of musculoskeletal conditions. Am J Orthop 2000;29(12):945-952
5. Freedman KB, Bernstein J: The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am 1998;80(10):1421-1427
6. Freedman KB, Bernstein J: Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am 2002;84(4):604-608
7. Clawson DK, Jackson DW, Ostergaard DJ: It's past time to reform the musculoskeletal curriculum. Acad Med 2001:76(7):709-710
8. American Medical Association: Annual 2003 Reports and Resolutions: Resolution 310: Musculoskeletal Care in Graduate Medical Education. Available at http://www.ama-assn.org/ama/pub/category/10640.html. Accessed September 29, 2004
9. American Academy of Family Physicians: Recommended Curriculum Guidelines for Family Practice Residents. Available at http://www.aafp.org/x16524.xml. Accessed September 29, 2004
10. American Academy of Family Physicians: Recommended curriculum guidelines for family practice residents. Available at http://www.aafp.org/eduguide.xml. Accessed September 29, 2004
11. Geyman JP, Gordon MJ: Orthopedic problems in family practice: incidence, distribution, and curricular implications. J Fam Pract 1979;8(4):759-765
12. Kahl LE: Musculoskeletal problems in the family practice setting: guidelines for curriculum design. J Rheumatol 1987;14(4):811-814
13. Craton N, Matheson GO: Training and clinical competency in musculoskeletal medicine: identifying the problem. Sports Med 1993;15(5):328-337
14. Davis DA, Thomson MA, Oxman AD, et al: Evidence for the effectiveness of CME: a review of 50 randomized controlled trials. JAMA 1992;268(9):1111-1117
15. Davis DA, Thomson MA, Oxman AD, et al: Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274(9):700-705
16. Warner S, Williams DE, Lukman R, et al: Classroom lectures do not influence family practice residents' learning. Acad Med 1998;73(3):347-348
17. George JH, Doto FX: A simple five-step method for teaching clinical skills. Fam Med 2001;33(8):577-578
18. McLeod PJ, Steinert Y, Trudel J, et al: Seven principles for teaching procedural and technical skills. Acad Med 2001;76(10):1080
19. Kern DE, Thomas PA, Howard DM, et al: Curriculum Development for Medical Education: A Six-Step Approach. Baltimore, The Johns Hopkins University Press, 1998
20. Haist SA, Wilson JF, Brigham NL, et al: Comparing fourth-year medical students with faculty in the teaching of physical examination skills to first-year students. Acad Med 1998;73(2):198-200
21. Haist SA, Wilson JF, Fosson SE, et al: Are fourth-year medical students effective teachers of the physical examination to first-year medical students? J Gen Intern Med 1997;12(3):177-181
22. Barnes HV, Albanese M, Schroeder J, et al: Senior medical students teaching the basic skills of history and physical examination. J Med Educ 1978;53(5):432-434
23. Quillen DM: Challenges and pitfalls of developing and applying a competency-based curriculum. Fam Med 2001;33(9):652-654
________________________________________
Dr Joy is a clinical associate professor and the primary care sports medicine fellowship director and Dr Van Hala is a clinical instructor, both in the department of family and preventive medicine at the University of Utah in Salt Lake City. Dr Joy is also a team physician for the University of Utah. Address correspondence to Elizabeth A. Joy, MD, U Family Health Clinic, 555 Foothill Dr, Salt Lake City, UT 84112; e-mail to [email protected].

 

[bustbones26]

I didn't know what to think of it, until my girlfriend was diagnosed with thoracic outlet syndrome. She has had cyanosis and debilitating pain along the C6-T1 dermatomes for an entire year now. After physical therapy didn't work, her neurologist was talking about surgical removal of her 1st rib to relieve the impingement. Because of her lack of ability to see doctors outside a certain medical center (insurance issue) and because some of her doctors are DO's that don't use OMM, none of the doctors she's seen have even considered OMM as a treatment option.

Suddenly a class I had barely acknowledged until that point had become some of the most important important medical information I had learned all year. There is no success story yet. But I've gone to some length learning the methods of treatment including spencers techniques which we won't learn officially until next year. So far no improvement. But her neurologist is continuing to see her, and I'm continuing to learn more about treating thoracic outlet syndrome.

I'm hoping for the best, and aside from a very invasive surgery, OMM may be her only hope.

Some are believers in EMG guided botox, yes it will cost her out of the pocket, but will save her surgery. And yes, it should be EMG guided to avoid injection CN 11

They don't always have to take out the first rib, they can do a scalen-ectomy. Not as burutal, but chyle leaks are a big complication of such procedure.

OMT may help, but if she has chronic spasm, this will be difficult.

 

[Taus]

OHMAN0125: Here's another one...from the Journal of Family Medicine...enjoy

www.stfm.org/fmhub/fm2005/November-December/James693.pdf

 

[misparas]

Easy now bud. Please link me these articles. And does it say DO is better as compared to MD or just that it may be lacking in allopathic curriculum. This doesnt make DO better trained in musculoskeletal. Don't be ridiculous unless u show me proof.

👎 👎

Don't knock it until you know there is no proof.

 

[somnolent]

Ask and you shall recieve...see below...

While the fact-checker might look for fault, I think you gave excellent examples. Thank you. I'm surprised this doesn't show up more often with the always exciting "MD vs. DO" threads. Like many have said before, with low back pain being one of the main complaints at PCP visits, having a strong background in functional anatomy and musculoskeletal dysfunction is never a bad thing. It's that extra tool in your belt.

 

[Old_Mil]

I am still amazed that there are so many people out there that are still so skeptical about OMM. And sometimes it does take a case where OMM helps a friend or loved one to make them "BELIEVE"

Don't be amazed. The semi-religious attitude that promoters of OMT seem to have towards their chosen field doesn't help the issue much, either. An example would be the following:

Q: What happens if we treat someone and they don't have somatic dysfunctions in the required 6 of 8 areas for the treatment to count?
A: [basically]They will.

So it is written, so it shall be. Oh, and if it turns out that they don't? Of course they will. After all, with all the other things in the inbox one wouldn't want to have to do 50 full body treatments just to find 10 that count, right?

...and Taus, it's a huge step from saying that doctors need to be more aware of muscoloskeletal problems to saying that OMT is the answer for such problems.

 

[Taus]

Don't be amazed. The semi-religious attitude that promoters of OMT seem to have towards their chosen field doesn't help the issue much, either. An example would be the following:

Q: What happens if we treat someone and they don't have somatic dysfunctions in the required 6 of 8 areas for the treatment to count?
A: [basically]They will.

So it is written, so it shall be. Oh, and if it turns out that they don't? Of course they will. After all, with all the other things in the inbox one wouldn't want to have to do 50 full body treatments just to find 10 that count, right?

...and Taus, it's a huge step from saying that doctors need to be more aware of muscoloskeletal problems to saying that OMT is the answer for such problems.

I did not personally say it was the answer...someone asked for the articles in question and I provided them.....however our focus on the musculoskeletal system (even w/o OMT) does seem to address many issues....

 

[OHMAN0125]

I did not personally say it was the answer...someone asked for the articles in question and I provided them.....however our focus on the musculoskeletal system (even w/o OMT) does seem to address many issues....

I still dont see how this means that DO's get better education in musculoskeletal.
I didn't see any mention of OMM unless i missed it.

 

[PlasticMan]

I still dont see how this means that DO's get better education in musculoskeletal.
I didn't see any mention of OMM unless i missed it.

Musculoskeletal Curricula in Medical Education
Filling In the Missing Pieces
Elizabeth A. Joy, MD; Sonja Van Hala, MD, MPH
THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 11 - NOVEMBER 2004
________________________________________
It's 8:00 pm on a Monday night. Just as you're getting ready to put your 5-year-old son to bed, he falls from a chair, landing on his wrist. It quickly swells, requiring a visit to a nearby urgent care clinic. At the clinic, a pleasant young resident takes a history, performs a physical exam, and orders an x-ray to evaluate the injury. You are told that nothing is broken, and a wrist splint is placed. The following day, however, you receive a phone call from the clinic informing you that upon further review of the radiographs, a fracture was detected, and your son will need a cast for definitive treatment.
This scenario, while fictitious, is not unusual. According to some studies, up to 10% of wrist fractures are missed at the initial evaluation.1 While pediatric fractures are often difficult to detect, this example highlights a problem that continues to plague medical education: inadequate instruction in musculoskeletal medicine in both medical school and residency training.
Conditions affecting the musculoskeletal system are the primary reason patients seek medical care from physicians, accounting for nearly 100 million office visits per year.2 Musculoskeletal conditions are the most common cause of long-term pain and physical disability.3 As our population ages and becomes increasingly obese, the number of people affected by osteoarthritis will increase significantly.3 Adding to the clinical burden of illness in the United States, an estimated 54% of postmenopausal women have osteoporosis, which increases their risk for bone fracture.3 Osteoarthritis and osteoporosis are just two examples of long-term disabling musculoskeletal conditions that physicians must be competent to diagnose and treat. Yet many physicians feel ill prepared to care for patients who have any number of musculoskeletal conditions.4 Why?
Defining the Problem
Surveys and testing of medical students and residents suggest that opportunity and training in musculoskeletal medicine during medical school and residency are woefully inadequate.
Several studies4-7 have drawn attention to the educational shortcomings in musculoskeletal medicine. Freedman and Bernstein5,6 found that 82% of recent medical school graduates failed a 25-question, written basic competency examination in musculoskeletal medicine. Among the 85 graduates tested, the average time spent in rotations or courses devoted to orthopedics during medical school was only 2.1 weeks. One third of these examinees graduated without any formal training in orthopedics.
As would be expected, these data suggest that limited educational experience contributes to poor performance. Clawson et al7 surveyed nearly 2,000 second-year residents in US allopathic and osteopathic residency programs. They found that up to 60% of allopathic residents felt poorly to very poorly prepared to conduct a musculoskeletal examination of the foot.
Matheny et al4 surveyed 351 graduating family practice residents about their confidence in the management of musculoskeletal conditions. They found that the residents were far more confident in making a diagnosis of acute myocardial infarction or treating hypertension than they were in diagnosing musculoskeletal conditions. In the same survey, residents ranked their overall musculoskeletal and orthopedic training as a 5.4 on a 10-point scale of least adequate to most adequate.
Changing Courses
It is imperative that education in musculoskeletal medicine undergoes significant improvement at both medical school and residency levels. In May 2003, the American Medical Association (AMA) passed Resolution 310 on musculoskeletal care in graduate medical education.8 The resolution was introduced by the American Orthopaedic Foot and Ankle Society and the American Academy of Orthopaedic Surgeons (AAOS). Resolution 310 recommends that:
• Medical schools formally reevaluate the musculoskeletal curriculum with the input of AAOS and the orthopedic subspecialty societies;
• Medical schools make changes to ensure that their students have the appropriate education and training in musculoskeletal care, and make competence in basic musculoskeletal principles a requirement for graduation; and
• The AMA encourage its representatives to the Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education (ACGME), and the various Residency Review Committees (RRCs) to promote higher standards in basic competence in musculoskeletal care.
In the spring 2004 preliminary draft of revision of requirements, the RRC for Family Practice proposed increasing the musculoskeletal experience from 140 hours to 200 hours (or 2 months) of orthopedic and musculoskeletal problems, including sports medicine. If these changes are adopted, they will go into effect in January 2006. We await the other agencies' responses to the recent AMA recommendations.
The American Academy of Family Physicians through the Residency Assistance Program publishes recommended curriculum guidelines for family practice residents.9 Two sections, "Conditions of the Musculoskeletal System" and "Sports and Recreational Medicine," provide a framework for the family practice resident to obtain knowledge and skills in musculoskeletal medicine. However, these guidelines do not provide direction as to how the resident should acquire this information.
The RRC for the American Board of Family Practice currently requires that residents complete 140 hours of structured experience in the care of orthopedic disorders, and that this experience must include caring for patients with acute, emergency, and chronic musculoskeletal injuries and disorders. Additionally, residents must be provided with experiences in casting and splinting, and in caring for children who have orthopedic conditions. The RRC specifies that these experiences should occur primarily in the outpatient setting and include a structured didactic component. Nowhere in this document is competency in caring for the patient who has a musculoskeletal disorder addressed.
Curricular goals and content will vary between medical school and residency training. Medical schools should emphasize basic anatomy, physiology, and pathophysiology, as well as musculoskeletal physical exam technique. The orthopedic training in primary care residency programs, such as family medicine, internal medicine, and pediatrics, should include a greater depth of knowledge in a wide variety of topics related to musculoskeletal medicine. These topics include normal anatomy and physiology, normal growth and development, testing and interpretation of laboratory data, pathophysiology, management and therapy of musculoskeletal conditions, prevention principles, and the skills of history taking and physical examination.10
Building Competency

The article says they surveyed both allopathic and osteopathic residents, then point out that majority of allopathic residents did not feel comfortable performing the foot examination. They have chosen to omit what percentage of osteopathic residents did not feel comfortable with the same task. I'm guessing they omitted osteo residents b/c the number was not significant? They should have really included it.

 

[OHMAN0125]

The article says they surveyed both allopathic and osteopathic residents, then point out that majority of allopathic residents did not feel comfortable performing the foot examination. They have chosen to omit what percentage of osteopathic residents did not feel comfortable with the same task. I'm guessing they omitted osteo residents b/c the number was not significant? They should have really included it.

Ah w/e it doesn't really matter it's a survey which isn't really much proof of anything. I think that as long as osteopath's don't walk around assuming they are better trained than MD's then that's fine. I sure don't think I'm better trained than my DO counterparts. So please, to all those DO's and future DOs, stop w/ the comparisons about how ur more holistic, care more, etc etc etc. Allopaths do get angry when you always say that. geez....

 

[medhacker]

So please, to all those DO's and future DOs, stop w/ the comparisons about how ur more holistic, care more, etc etc etc. Allopaths do get angry when you always say that. geez....

oh no! do not piss off the Allopaths!

 

[OHMAN0125]

oh no! do not piss off the Allopaths!

Wow show some class .... u don't respect other people's feelings? What an @ss.

 

[medhacker]

Wow show some class .... u don't respect other people's feelings? What an @ss.

Of course I do man, sorry if that offended you

I was going to talk about how DOs can charge for OMM even through medical insurance but could not hold myself at adding a bit of humor.

 

[bustbones26]

Amazing! We have yet another thread that started out as a serious post and now has become an MD vs. DO thread. Good job guys!

 

[Gregg]

I play rugby and am usually hurting every Monday but usually I am better by midweek.
Last weekend I ended up doing something to my left 2nd/3rd ribs (turns out they were both shoved anteriorly). Come Tuesday in OMM lab I was still hurting, couldn't move my head over my left shoulder, couldn't abduct my arm fully. One of my classmates did some counterstrain and Still, both of which helped. One of our professors took pity on me and did some work after class, using techniques that we havn't covered yet. Yes, I was still in pain, but I had full range of motion. Today I feel much better. Did the OMM fix me? Hell, yes. Without it my ribs would still be out of place and I'd most likely end up w/ a shoulder immobilizer and Percocet if I went to an allopath.

 

[medhacker]

I play rugby and am usually hurting every Monday but usually I am better by midweek.
Last weekend I ended up doing something to my left 2nd/3rd ribs (turns out they were both shoved anteriorly). Come Tuesday in OMM lab I was still hurting, couldn't move my head over my left shoulder, couldn't abduct my arm fully. One of my classmates did some counterstrain and Still, both of which helped. One of our professors took pity on me and did some work after class, using techniques that we havn't covered yet. Yes, I was still in pain, but I had full range of motion. Today I feel much better. Did the OMM fix me? Hell, yes. Without it my ribs would still be out of place and I'd most likely end up w/ a shoulder immobilizer and Percocet if I went to an allopath.

That's what I'm talkin' 'bout...

 

[DOctorJay]

well, if you had a good MD, they might prescribe the meds but also send you to a good out patient manual therapy PT in which case you would still have the same basic outcome although it might have taken a bit longer.

 

[Kevbot]

Some are believers in EMG guided botox, yes it will cost her out of the pocket, but will save her surgery. And yes, it should be EMG guided to avoid injection CN 11

They don't always have to take out the first rib, they can do a scalen-ectomy. Not as burutal, but chyle leaks are a big complication of such procedure.

OMT may help, but if she has chronic spasm, this will be difficult.

She doesn't have chronic spasms, only pain and cyanosis. But as far as what they take out; its the first rib and the part of the scalenes attached to it. In some cases they take out the entire scalene muscles and post surg depend on other muscles to compensate for stability of the head.

Here's how the surgery works: Thoracic Outlet Sydrome Surgery
(click the picture on the site for the specs)

 

[Fooman]

I wouldn't say I'm a true believer in OMM, but I do know that some of it does work..say HVLA, counterstrain, and muscle energy. During my first year of medschool, I had hip/leg pain that prevented me from sleeping well for 3 nights. It wasn't painful, just very discomforting. During OMM lab, I had one of the instructors "fix" me and I felt great afterwards. That's when I felt I truly wanted to learn more.

Since then, (I'm a MS-IV now), I've only performed OMM on my girlfriend and friends. I usually hesistate at first because I'm not good at it, but I've had success with counterstrain and HVLA.

I do not believe in any cranial manipulation however.

 

[elise]

I had shin splints in high school that got way out of hand and all the expensive thing I did, like orthodics, weren't working. My allopathic physician said I was taking a year off from running. He's a cool guy and a good doctor, so he explained a bit about OMM and referred me to a DO. I was back running in two weeks, with no further problems because of an OMM technique that took me 45 seconds a few times a day. My range of motion increased dramatically and that summer I went on a 30 mile run.

I'd tried taking time off before, but as soon as I started running again the problem returned. Taking that year off may not have done me any good. I think osteopathic medicine is useful and I want to use it to help my future patients (if I ever get in). I'd still never claim it was a panacea, but people still learn how to write an RX for antibiotics even though not every patient needs them.

I have a lot of respect for my allopath for bringing it up. If I would have brought it up and he had acted threatened, closeminded, and childish, I would have totally lost respect for him. (something for allopaths who like to bash DOs to consider)

 

[OHMAN0125]

I had shin splints in high school that got way out of hand and all the expensive thing I did, like orthodics, weren't working. My allopathic physician said I was taking a year off from running. He's a cool guy and a good doctor, so he explained a bit about OMM and referred me to a DO. I was back running in two weeks, with no further problems because of an OMM technique that took me 45 seconds a few times a day. My range of motion increased dramatically and that summer I went on a 30 mile run.

I'd tried taking time off before, but as soon as I started running again the problem returned. Taking that year off may not have done me any good. I think osteopathic medicine is useful and I want to use it to help my future patients (if I ever get in). I'd still never claim it was a panacea, but people still learn how to write an RX for antibiotics even though not every patient needs them.

I have a lot of respect for my allopath for bringing it up. If I would have brought it up and he had acted threatened, closeminded, and childish, I would have totally lost respect for him. (something for allopaths who like to bash DOs to consider)

Actually I don't think there is much bashing of DOs at all where I'm at (by MDs at least). Is this because of politeness or true acceptance...I don't know, but who cares. I think generally DO bashing only comes up as a topic on SDN or the among general public who is unaware of the workings of the healthcare world.

 

[laboholic]

I had shin splints in high school that got way out of hand and all the expensive thing I did, like orthodics, weren't working. My allopathic physician said I was taking a year off from running. He's a cool guy and a good doctor, so he explained a bit about OMM and referred me to a DO. I was back running in two weeks, with no further problems because of an OMM technique that took me 45 seconds a few times a day. My range of motion increased dramatically and that summer I went on a 30 mile run.

I'd tried taking time off before, but as soon as I started running again the problem returned. Taking that year off may not have done me any good. I think osteopathic medicine is useful and I want to use it to help my future patients (if I ever get in). I'd still never claim it was a panacea, but people still learn how to write an RX for antibiotics even though not every patient needs them.

I have a lot of respect for my allopath for bringing it up. If I would have brought it up and he had acted threatened, closeminded, and childish, I would have totally lost respect for him. (something for allopaths who like to bash DOs to consider)

I am curious, how did your doc fix your shin splints? ..What kind of manipulation did he/she do or teach you?

 

[Taus]

I am curious, how did your doc fix your shin splints? ..What kind of manipulation did he/she do or teach you?

me too....I'll have to ask the OMM fellows about it....

 

[elise]

I was 15 or so at the time, and didn't pay much attention to terms. He basically ran his thumb up the inside of my leg, towards the front, along the bone. When he came to where it was bothering me the most, he pushed down and held his hand there for a while.

At the time, I was a bit ticked off because he found the spot that hurt the most and dug his finger into it, but afterwards he had me stand up and put my toe against the wall and try to touch my knee to it. I had done it a few minutes before without much success. The second time, I was able to move my knee about 2/2.5 inches more than before.

The increase in range of motion is what made me stick with it to see if it would work. His explanation is fuzzy at best 8 years later, but I think he said that he was forcing the tissue to loosen enough that it wouldn't keep tearing every time I ran and could heal so the orthodics and everything else would work.

 

[jawicobike]

I was 15 or so at the time, and didn't pay much attention to terms. He basically ran his thumb up the inside of my leg, towards the front, along the bone. When he came to where it was bothering me the most, he pushed down and held his hand there for a while.

That sounds quite a bit like the way Joey's tailor checked Chandler's inseam...

 

[candyland]

I'm still pre-DO so I don't know anything about OMM yet...but I was wondering if any of you know if OMM has been or can be used to successfully stop the progression of scoliosis???

just curious...but I suppose I will be finding out anyways in less than a year or so.

thanks,

 

[OSUdoc08]

I'm still pre-DO so I don't know anything about OMM yet...but I was wondering if any of you know if OMM has been or can be used to successfully stop the progression of scoliosis???

just curious...but I suppose I will be finding out anyways in less than a year or so.

thanks,

Yes, as long as it is functional (pathological) scoliosis and not anatomic scoliosis.

 

[fab4fan]

Right now, I would pay big $$$ for a good OMT. I was in a bad car accident =20 years ago, and it left me with a lot of muscle spasms and chronic tension in my next and shoulders. When I am really desperate I'll take a tab of Soma, but OMT works so much better. Problem is the DOs around here don't really do good OMT--they seem to want to distance themselves from it.

 

[mysophobe]

I haven't been exposed much to OMM. Are there techniques for chronic tension headaches/neckpain? My PCP is a DO, but whenever I bring up the pain, he never mentions OMM, and I always forget to ask.

 

[OSUdoc08]

I haven't been exposed much to OMM. Are there techniques for chronic tension headaches/neckpain? My PCP is a DO, but whenever I bring up the pain, he never mentions OMM, and I always forget to ask.

Chronic tension headaches & neckpain are very commonly treated. We learn many different techniques to treat these symptoms in school.

Keep in mind that not all PCP DO's use OMM.

 

[OMMFellow06]

elise, from the sound of what you have described, ur doctor either used a technique called Inhibition or a technique called Balanced Ligamentous Tension(BLT). Both are great techniques and can hurt sometimes. I use then quite often with great success.

As far as tension headaches go, there are many things that can be done using OMM to help. I suffer from it myself and I am always treating myself and when I can find someone, I get treated for it. Also, daily stretching is VERY important to maintain the relief. As far as your DO not mentioning it, that is a shame. Too many people leave DO school and do not do any of it and what's worse is that they don't even think to mention it to their patients or refer them to a DO that does OMM.

 

[mysophobe]

Chronic tension headaches & neckpain are very commonly treated. We learn many different techniques to treat these symptoms in school.

Keep in mind that not all PCP DO's use OMM.

Neat-o torped-o. I should look into that.

 

[SigPi]

Chronic tension headaches & neckpain are very commonly treated. We learn many different techniques to treat these symptoms in school.

JUST TREATING THE SYMPTOMS, oh the horror. What kind of DO are you training to be??? LOL, honestly jk..dont bite my head off

 

[newyorkcougar]

We are doing HVLA right now (PCOM first years) and today I was practicing on a friend and I was astonished when his back went "pop!" It was exactly what it was supposed to be like...and I was so excited. It was cool to learn how to do something so immediately rewarding (unlike myofascial which is a little less theatrical).