Is Osteopathic Medicine Faith-Based?

[AviatorDoc]

It is starting to disturb me that there is large number of osteopathic physicians and students who say that manipulation should be used because "they believe that it works."

Maybe it's just a semantics issue. I "believe" that manipulation works, but that's no reason to use it. I plan to use it because in some cases I "know" that it works, and in others, I "think" that it works.

I realize the philosophical problem of using the word "know", so I'll define it for this purpose. "Know" means that it has been demonstrated in multiple, well-designed studies. "Think" means it has been demonstrated in a single, well-designed study, or at least documented in innumerous patient encounters.

And I don't want to hear the BS about "it's hard to design a test for manipulation." That's just a cop-out. Pain is hard to quantify in studies, but it is done routinely. Manual care is subject to the one performing it, but that doesn't preclude a well-designed single-blind study, using the subjects as their own controls.

Osteopathy has been around for 128 years. That's more than enough time to get away from the "belief" that manipulation works, and on to the "proof" that it works. (I know, I know. "Proof" is a tricky word. Again, semantics. Different topic.)

Osteopathy is not aurveydic medicine, it is not oriental medicine, it is not Native American medicine. All of these are important forms of health care for their people. Osteopathy is western science-based. If you don't believe me, dig up Ol' A.T. himself & ask him.

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[Nic_machiavelli]

AviatorDoc
Excellent points. Truth be told osteopaths share some of the blame for not conducting experiments to prove OMT. The studies that have been done are sporadic and downright old.

However, keep in mind that the anecdotal evidence is there, and such evidence often leads to harder evidence once double-blind studies are conducted.

Osteopathy really needs to get more research-oriented. There seems to be a push in the AOA to do this, but it will take some time before large-scale studies are designed and completed.

 

[Dr JPH]

OMM works for me.

 

[drusso]

FYI: Click on the link for more information...

Osteopathic Research Center

 

[bones]

Originally posted by AviatorDoc
It is starting to disturb me that there is large number of osteopathic physicians and students who say that manipulation should be used because "they believe that it works."

yo dude, our omm practicals got ya bummed?
j/k, I agree totally. I think thats more the nature of the practicioner though, few OMM clinicians know what the heck reseach even is Thats where we come in i guess.. gotta bring all those research skills from undergrad to bare and kicks some a$$...

remember the mantra "body mind spirit". maybe thats what they mean by the "spirit" part

And I don't want to hear the BS about "it's hard to design a test for manipulation." That's just a cop-out. Pain is hard to quantify in studies, but it is done routinely. Manual care is subject to the one performing it, but that doesn't preclude a well-designed single-blind study, using the subjects as their own controls.

What I been sayin about this part is that EVIDENCE-BASED medicine is hard to do with OMM. Thats the truth. Outcome based is easy, and there are plenty of poorly designed outcome-based studies (and a few good ones) that you can check out for more info. its suprising how many drugs have been only tested in outcome-based studies (many have only been compared against other drugs and never a placebo). It is quite easy to compare OMM treatment outcomes to drugs, surgery, chiropractic, etc.- but try setting up a double-blind placebo control group sometime. How do you make the clinitcian blind to what his hands are doing???
just wanted to make that clear.

Evidence-based, of course, should still be our goal. If you have any bright ideas about how to do double blind studies with OMM please let me know because I might be doing some 'o that work soon.


bones

 

[Stillfocused]

Double blind OMT?????

How about double blind surgery? Ouch!

Even sham OMT is pretty loopy and quite useless.

See this letter published in NEJM http://www.meridianinstitute.com/article9.html

Beware, EBM has plenty of intellectual pitfalls of its own - it is an approach to medicine partially driven by the deamands of insurance companies.

Any treatment is acceptable to EMB if it "works" whether it be aromatherapy, accupcture or angioplasty. And, outcome research is necessary, but in some ways it misses the point. In terms of science, the more important questions than "does it work" are "Why and how does it work?" Except for a very few studies, these questions have not been looked at since Louisa Burns' time. Try getting a major study funded that looks at these questions - it isn't easy, believe me.

 

[slindsay198]

Nic,
actually there are current, as in occuring as we speak, research projects testing the efficacy of OMT going on at PCOM. The results are quite promising and show that OMT does in fact work. Take a look around campus and you'll see the results of some of the research posted outside the various research labs.

Scott-MSII
PCOM

 

[ItNeverEnds]

While OMT may indeed be an effective and/or ultimately efficacious treatment, there is simply not enough research to support it. I have read several reports about how osteopathic clinical research is on the rise, but it will take at least 10-20 years -- if not more than that -- to obtain solid results. Once people start reading about the effectiveness and efficacy (there IS a difference) of OMT in treating common medical conditions in top medical journals, osteopathic medicine and OMT will earn the recognition they deserve. As it is, less than 1% of DO school graduates end up pursuing an OMT residency. There's probably a good reason for that.

 

[minime]

OMT does work for some things, BUT for the average doctor, the don't have time to do it, nor have they practiced it as much as they need to do it well.

I personally think that Still would roll over in his grave if he knew what crap was being taught in DO schools. By crap i mean anything that is indirect:counterstrain(I call it quackerstrain), balanced lig tension, cranial(not really indirect, but still hokey), etc.

He did OMT because there was nothing else, but he only did things that he could tell worked, he didn't do any of the Crap that I mentioned before.

If you have never done OMT on an actual patient please don't reply with the normal BS answers.

 

[AviatorDoc]

Very good responses. I'm glad some people are willing to hold manipulation up to the light & see it for what it really is... whatever that may be. I think there may be some who are unwilling to truly work on these ideas b/c it in some ways challenges the foundation of the profession. But that's the price of progress.

Ok. So here's a simple test. Measure blood/tissue catecholamine levels before & after rib raising. Has this been done? Is it worth pursuing? I'd be willing to work on it if it hasn't.

Again, thank you to all who are treating this thread openly and honestly.

 

[bones]

Originally posted by minime

I personally think that Still would roll over in his grave if he knew what crap was being taught in DO schools. By crap i mean anything that is indirect:counterstrain(I call it quackerstrain), balanced lig tension, cranial(not really indirect, but still hokey), etc.

He did OMT because there was nothing else, but he only did things that he could tell worked, he didn't do any of the Crap that I mentioned before.

I was about to agree until I read you're interpretation of "crap" LOL. Counterstrain and indirect are awesome in the hands of someone with skillz (and counterstrain works for just about everyone... I am suprised you have difficulty with it). Thing is, once you do this stuff a little, you feel the muscles go under your hands, and rechecks look good, patient feels better- but you dont have "proof" (if there can ever be such a thing) until the research is done. We don't have the research.

Now, "Still technique" makes use of indirect in virtually all applications, so I think your bit about Still not using it is off. A few of his followers actually did away with his subtle techniques in DO schools after his death in favor of HVLA- since this material was easier to teach. A whole generation of DO's were brought up on this. Now many are trying to rebuild the stuff that has been lost over the years due to these limited teaching methods. I fear that OMM education has fallen from an art form to a conglomeration of techniques (the last thing big AT woulda wanted..). If you want to reclaim old school OMM, the way to go today is to use what you learn in class as a starting place- attend convocation, and shadow lots of different OMM specialists along the way.

and dont forget to have fun along the way

 

[Bevo]

from what current DOs have told me is that OMT works but is not very practical. They would love to do OMT but it takes a lot of time and multiple visits for it to be effective which isn't very practical these days.

 

[slindsay198]

Have you ever heard of chiropractic? Just wondering, lmbedo, because you just fully explained the tenet behind how chiropractic works.

Scott-MSII
PCOM

 

[bones]

Originally posted by lmbebo
from what current DOs have told me is that OMT works but is not very practical. They would love to do OMT but it takes a lot of time and multiple visits for it to be effective which isn't very practical these days.

are you a current DO student? go check it out yourself before you go around quoting people.


lots of time? ya. if this is your primary mode of treatment, it will take 10mi to 30min to do a good job per patient. you need a good history, and some things just take time.

multiple visits? only if u suck, or for chronic problems- but these will still often resove after a few visits (unlike just medicating them). If you are good, acute problems and some chronic problems will entirely resolve on the first visit. Unlike some chiropractors, we dont try to make our patients "regulars" Of course, there are probably some morally ambiguous DO's that do.

more important than either of the issues you mentioned is the skill factor. To have adequate skill, you need to invest effort into your training. Some get through DO school with enough ability to crack a back and not much else. These people should not be using OMM on lots of patients- simple cracks will not solve the underlying problems. Comfort with counterstrain, indirect, and muscle energy in combo with HVLA and a keen sense of how to spot the "key" lesion that underlies a variety of scattered symptoms around the body, and you'll have an invaluable tool for your medical practice. This, of course takes practice, and the best way to learn it is to shadow a doc as your skills are developing. Spotting the "key" lesion is critical, and its usually not something they teach you in class- you only get this through practice.


cheers

 

[bones]

one thing I forgot to mention-
the time factor doesnt matter so much, because you get very well compensated from the insurance forms I've seen. as an OMM-using doc you can afford to spend 20 or 30 minutes with a patient and still do as well as a normal family doc.

Just dont go sucking and charging crazy fees. your patient would be better off with a chiropractor then. what they pay for is the combo of your hands and medical training- if you got both, then you can provide them with something that neither chiropractors nor other Docs can provide.

 

[Bevo]

no, Im expressing what was told to me by two doctors who have been practicing for 10 and 20 years. One is a graduate of TCOM and is an anethisologist and the other has been practicing 10 years and came out of PCOM.

The guy from TCOM said he would love to do OMM but finds that its just not practical for him. If he practiced closer to TCOM he would ask for some students or what not to come in and perform it. As it stands now he doesn't have the time to give OMM. The PCOM grad said he rarely uses it unless its some sort of muscle strain. He does emergency medicine.

I understand that opnions will vary from doctor to doctor. But the people I have spoken too and shadowed have shown me what Ive said before.

 

[bones]

I am quite suprised that the anesthesiologist doesnt have time for OMM. I guess he's too busy reading the paper eh?

Seriously though, for most specialities like ER, surgery, pathology, radiology, or anesthesiology- OMM isnt practical or necessary (but its nice to know when surgical candidates can be fixed by non-surgical means). For most primary care fields however, it can be a valuable tool, so long as the doc knows how to do it.

 

[Bevo]

it might be. I tried to shadow some primary care physicians but they all turned me down.

 

[Doc Oc]

There aren't very many "OMT residencies", from which you become "board certified" in OMT as a specialty. This is why so many graduating D.O.s don't do them - they just aren't available.

I don't know how other schools do their OMT practicals, but for ours we have to diagnose our partner in the hour before our exam, then once in the exam they double check our diagnoses, and pick three areas for us to treat and a method to use. For example, they'll say "Treat her C5FSRL with FPR". So I have to treat it, then recheck, and when I think I have made a change, they come over and check. If we don't make a change, we don't get the points. If I think that the technique they told me to do won't work, then after I recheck and it didn't work, I can ask if I can use HVLA or something else. Sometimes they'll give you some treatment that they know won't work for that type of barrier just to see if you will lie and say you think you made a change.

This doesn't have alot to do with proving OMT works, but it is interesting to see that most of the treatments do /something/, even though I dont' always feel like I am doing anything (BLT on the thoracic spine while supine, etc.)

Just some thoughts on the subject (sort of)

- Doc Oc

UNECOM 2005

 

[AviatorDoc]

Practicals at KCOM work in much the same fashion. I've used OMM to successfully "treat-out" somatic dysfunction. In some cases, it has even successfully relieved pain. But in other cases, it hasn't done a thing. (Student physician error is HUGE, I know.)

So here's the crux of the problem. There is a ton of anecdotal evidence to show that OMM works. But only cases in which it is successful are documented in the literature. What about the cases that are not successful? Is the ratio any better than the placebo effect (usually 30%)? And in situations where it does work, are you treating the underlying problem? Counterstrain is an awesome technique, especially b/c it is so easy for beginners to have dramatic results. But a significant number of patients will return with the same tenderpoint shortly thereafter.

I'm not debating whether or not to use a placebo treatment... that's another issue. My questions are 1.) Which of the techniques work to alleviate pain at a rate greater than a placebo? 2.) What is the mechanism of action of this process, and can it be quantified?

Interestingly enough, manipulation that I've used with the most permanent success has been in treating low back pain. To the best of my knowledge, this is the only application that is well-documented in JAMA and NEJM (if that means anything to anyone).

 

[AviatorDoc]

Just as an aside, you don't need to be board certified to do manipulation. You don't need to be board certified to do brain surgery. The day you finish your intern year, you are a licensed physician in every sense of the word. The theoretical barrier to a GP doing brain surgery is his own acknowledgement of his limitations. The actual barrier is that no malpractice insurance company would cover it.