OMT in ER

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docdoc121

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i'm going to be starting D.O. school in the fall. i'm very, very interested in EM. i've searched this site and other sources and it seems that DOs hardly ever use OMT in EM. is this due to

1. time restrictions/high patient load
2. billing issues
3. lack of skill
4. contraindications and
5. lack of applicability of OMT in the emergency room

?

which specialties utilize (or are capable of utilizing) OMT the most? primary care, sports medicine, physiatry, neurology, and during surgical post-op?

not a troll. genuinely want to know.

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Actually...there was a somewhat recent study of DOs in the ED that said about 55% of them used OMT regularly and 30% used it daily!

There are a number of techniques that are useful, well supported in the literature and time-efficient for an experienced practitioner. The use of OMT for ankle sprains, lower back pain and headaches are just a few.

I would say any lack of use is more due to DOs who were not exposed to much if any OMT during their EM residencies.

I'm not the strongest with my OMT skills, and I still have a hard time with certain modalities (cranial!), but the more I learn about the EM specific uses for OMT, the more I'm planning to try and keep it in my skill set for my career! Also...apparently being good at OMT will make you a BIG hit with the staff! :p

Nate.
 
My group has a large number of DOs. None of them use it at all in their practice. In 8 years I have seen 1 guy do it once and that was on a staff member with a backache.
 
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OMT for acute ankle sprains out of the ER?

I'd punch you if you tried to "manipulate" my acute ankle sprain.
 
Remember that not all OMT is cracking bones! The researchers used a combination of soft tissue techniques, counter-strain and light muscle energy (think active stretching).
While your initial reaction may be to say you'd punch me...the study clearly showed that the patients who received OMT had a significant improvement in pain and edema immediately following the treatment, and had significantly better ROM at one-week follow up!
I'm not saying that every patient in the ED should get OMT, I'm just saying that there is research to support it, and physicians who do use it in the ED. Now I don't know if I'll wind up using OMT when I finally get into the ED, but I'd like to think that I'll use what works.
Here's the citation if you care:

"Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries." Eisenhart AW, Gaeta TJ, Yens DP. J Am Osteopath Assoc. 2003 Sep;103(9):417-21.

Looks like you can get it free on PubMed.
 
"Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries." Eisenhart AW, Gaeta TJ, Yens DP. J Am Osteopath Assoc. 2003 Sep;103(9):417-21.

Looks like you can get it free on PubMed.

The results for 2/3 parameters in the above study after a 1 week follow up were not statistically significant. As for acute improvement, I'll believe it when I see higher powered studies with a sham therapy (placebo) control group.
 
I can hear the discussion at the ER doctor station now.

"Where is Terra Medic? I haven't seen him for 30 minutes."

"I saw him massaging some lady's ankle in bed 4."

Attending walks over and opens door to bed 4 finding you gently stroking/manipulating an ankle of a confused looking patient:

"Terra Medic, get your butt out of that room, there are 2 chest pains an abdominal pain, and a vag bleeder that need to be seen."

When out of room...

"Terra Medic, what the heck are you doing, you are going to get a sexual harrassment claim. If you wanted to run a massage parlor, you should have gone to chiropractor school. We've got a department to run and if you don't cut out this DO crap, you're out!"

At least, that's what I'd tell you.
 
All the attendings I knew as a paramedic were MD's, but they did a bunch of things my osteo instructors claim is "OMT": Reducing a nursemaid's elbow comes to mind.

The spinal manipulation stuff... yeah, not so much.

And this is just a personal opinion, but I don't think people will change practice based on a JAOA article... at least, given what I've read in there, I wouldn't.
 
I can hear the discussion at the ER doctor station now.

"Where is Terra Medic? I haven't seen him for 30 minutes."

"I saw him massaging some lady's ankle in bed 4."

Attending walks over and opens door to bed 4 finding you gently stroking/manipulating an ankle of a confused looking patient:

"Terra Medic, get your butt out of that room, there are 2 chest pains an abdominal pain, and a vag bleeder that need to be seen."

When out of room...

"Terra Medic, what the heck are you doing, you are going to get a sexual harrassment claim. If you wanted to run a massage parlor, you should have gone to chiropractor school. We've got a department to run and if you don't cut out this DO crap, you're out!"

At least, that's what I'd tell you.
Okay, so I'm just wondering from your post: Do you have any experience with OMT for treating acute ankle sprains? If you do and it's taking you 30 minutes, you're likely doing it wrong. Also, inserting a confused looking patient in your scenario is great for comedic relief but in actuality OMT has to be explained and agreed to like any other sprain treatment.

AND, OMT does not equal massage therapy.

To the OP-From what I've heard from people in smaller ERs, OMT is more likely to be used than in the bigger ERs. It's more likely to be accepted and the physician has more leeway over treatment of patients.
 
Jarabacoa: I respect the fact that you're an attending, and I'm only a student, but I know plenty of DO attendings who use OMT regularly in the ED. Attendings who not only have higher Press-Ganey scores but also consistently bill more RVUs than anyone else in their departments! Like Vols said, most OMT you're going to do in the ED only takes an extra 5-10 minutes (if that).

Altruist: I generally have to agree with you about JAOA, I never read it 'cause I'm generally pretty disappointed with the quality of the research. Unfortunately, I doubt you're going to see many studies about OMT in Annals as there is still a prejudice against it (see above). I'm not new to reading research articles, and the one I cited above isn't bad. It certainly has its weaknesses, but its better than a LOT of articles I've read in plenty of other journals (including Annals!).

OP (and all the lurkers): Please remember that SDN is a very, VERY biased forum!! Look at the research yourself, talk to a range of physicians that you respect, make up your own mind!
 
No, I'm an MD an have never done OMT for anything. OK, I used to pop my sister's and Dad's back when I was a kid. Does that count?

How would manipulation of acutely torn, stretched ligaments do anything but cause more pain, tearing and swelling?

I'll try to give you the benefit of the doubt here and accept the practice if you can give me a good mechanism by which acute OMT corrects the pathology of ankle sprains.

OP (and all the lurkers) just realize that DO's are VERY,VERY biased!! Think about the pathophysiology of what they claim, look at their literature, talk to a range of physicians that you respect, and make up your own mind!!!
 
No, I'm an MD an have never done OMT for anything. OK, I used to pop my sister's and Dad's back when I was a kid. Does that count?

How would manipulation of acutely torn, stretched ligaments do anything but cause more pain, tearing and swelling?

I'll try to give you the benefit of the doubt here and accept the practice if you can give me a good mechanism by which acute OMT corrects the pathology of ankle sprains.

OP (and all the lurkers) just realize that DO's are VERY,VERY biased!! Think about the pathophysiology of what they claim, look at their literature, talk to a range of physicians that you respect, and make up your own mind!!!

Two primary mechanisms:

1) Restore functional anatomy. Specifically, addressing torsions of the tibia-fibula and interosseous ligament by addressing displacement of the fibular head proximally, and correcting any misalignments in the foot (commonly the cuboid) from laxity of the fibularis muscle (which can also be treated for tenderness).

2) Probably the more important part is mobilizing lymphatic flow to reduce edema. Reduction in edema not only reduces pain, but also decreases the likelihood of adhesions forming and encourages the patient to engage in earlier mobilization. Same reason we recommend RICE and NSAIDs.
 
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I dispute the idea that you can restore functional anatomy after acute ankle sprain. A person just ripped and stretched out several ligaments in the ankle with hundreds of pounds or more of force. You come in, and think you can just "pop it back into place." Great, so you "get it back in place", it'll just pop right back out again. There is no ligament strength there, that is the very definition of sprain. If you think you can see torsion of the tibia fibula in a patient with an ankle twice the size of a normal ankle, you are delusional. The idea that you can just yank on the fibula and make it stay there is laughable. I simply don't believe that you can diagnose a subtle cuboid dislocation and correct it acutely in the ER. Admittedly, that whole paragraph is something that I've never even heard of in ER residency, so I'm not quite sure how to react to it other than shake my head in disbelief.

The second assertion that massage will DECREASE the swelling acutely doesn't quite make sense to me. There is bleeding tissue that the capillaries are in the process of clotting off, and you come along, push on those clotting capillaries and make them continue to bleed. That action doesn't go along with my typical definition of "Rest". People usually give you dirty looks when you push on the contused, swollen, severely tender acutely sprained ankle.

All-right, go out and do the study. Get 500 ankles and randomize half to get your OMT crap. Do an MRI before and after and see if the proximal fibular misplacement/torsion/cuboid/thingamobobber displacement is changed before and after. Do it with non-DO attendings that have no stake in trying to recruit fellow DO students and maybe you'll convince me.
 
I'm about to graduate from an osteopathic EM residency. We, as an entire group of residents, supposedly have to document a certain # of patient encounters a year where we use OMM. For a while I was incorporating some quick things (legit, but literally could be done in a minute or two) into my low back pain exam just so I could document something to get us credit. I haven't done that or any other OMM in at least a year. I did an OA decompression for a tension HA once, but that really took too long for me (maybe 4-5 mins).

All of my attendings are DOs and I've never seen them do OMM in the ER. Ever.

I can't say that I would never use any OMM in the ER, just that it is a very rare case that would lead me to consider it. Even the OMM docs that trained me acknowledged that acute pain is not a good patient presentation for OMM use. I know of family docs that treat acute pain with meds/ice/heat/etc first and then have the patients come back a few days later for the OMM.

And in case you think I'm one of those anti-OMM DOs: I actually have my own nice OMM table and treat family/friends and I've been asked to treat multiple ER nurses and staff. I think it is a great set of treatment modalities for the right complaint/presentation and situation.
 
I also don't buy the idea that you want to mimimize adhesions acutely in the ER. You've just ripped ligaments. The only way that those are going to heal is to allow them to scar down. Isn't a scar an adhesion? How do you direct scar tissue formation?

I agree with the above poster that said you need a sham treatment to compare it with or you are comparing results with physicians who spend 2 minutes with patients and physicians who spend 10-15 minutes with patients. In general, the longer you spend with a patient, the more they are going to think you care and that you've done something...in other words- placebo.

Why not just give them a pretty purple pill labeled "skelegro/reducto swelling?"

There has got to be a Harry Potter spell out there for this. Any Hermiones out there?
 
OP (and all the lurkers): Please remember that SDN is a very, VERY biased forum!! Look at the research yourself, talk to a range of physicians that you respect, make up your own mind!
I don't think SDN is biased against DOs. A lot of the senior ledership of SDN are DOs and some of SDNs history is based on providing prospective DOs with parity in the when MDs dominated many areas. The fact that several of us are noting less of A role for OMM in the ED setting does not reflect a bias. This is evident from some of the DOs who have chimed in. It's simply our experience or observation for practice in the ED. Is the a role for OMM in the ED? Possibly but I have not observed it by watching my DO colleagues.
 
All-right, go out and do the study. Get 500 ankles and randomize half to get your OMT crap.

Why not just give them a pretty purple pill labeled "skelegro/reducto swelling?"

There has got to be a Harry Potter spell out there for this. Any Hermiones out there?

Wow. I get that you don't believe OMM has a place in the ER, and that you may not agree with the mechanisms the other poster was talking about, but Jeeze. Why so harsh???
 
I don't think SDN is biased against DOs. A lot of the senior ledership of SDN are DOs and some of SDNs history is based on providing prospective DOs with parity in the when MDs dominated many areas. The fact that several of us are noting less of A role for OMM in the ED setting does not reflect a bias. This is evident from some of the DOs who have chimed in. It's simply our experience or observation for practice in the ED. Is the a role for OMM in the ED? Possibly but I have not observed it by watching my DO colleagues.

While SDN as a site may not be biased, there are biases in both directions, with some MDs being completely opposed to OMT as a treatment modality and some DOs thinking it's the be all/end all of treatment.

The stance that Jarabacoa has taken in this thread actually demonstrates TerraMedicX statement. Having no experience using OMT, Jarabacoa has in two posts denigrated OMT, comparing it to crap and Harry Potter spells. Yet there are other MDs out there who actively pursue learning OMT and are interested in gaining certification in it because they recognize the validity of the treatment. There are also MDs who recognize that OMT has a place in EM and that steps need to be taken to further its use.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729220/


I don't think anyone is stating that OMT should be used on every patient in every situation. And there are going to be DOs that never think about it again after graduation. But for those DOs who wind up in EM and are truly good at OMT, there should be a way for them to incorporate it without feeling like they'll be attacked for it.
 
I would like to chime in and say: I really like the idea of OMM, and I sincerely hope it works. Where is the research? There should already be considerable amounts of data on the use of OMM on acute injuries, considering that osteopathy had been around for over 100 years. Where are the studies?
 
While SDN as a site may not be biased, there are biases in both directions, with some MDs being completely opposed to OMT as a treatment modality and some DOs thinking it's the be all/end all of treatment.

The stance that Jarabacoa has taken in this thread actually demonstrates TerraMedicX statement. Having no experience using OMT, Jarabacoa has in two posts denigrated OMT, comparing it to crap and Harry Potter spells. Yet there are other MDs out there who actively pursue learning OMT and are interested in gaining certification in it because they recognize the validity of the treatment. There are also MDs who recognize that OMT has a place in EM and that steps need to be taken to further its use.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729220/


I don't think anyone is stating that OMT should be used on every patient in every situation. And there are going to be DOs that never think about it again after graduation. But for those DOs who wind up in EM and are truly good at OMT, there should be a way for them to incorporate it without feeling like they'll be attacked for it.

Ok, I'll buy that. But it's important to make the distinction that the bias you were talking about is on the part of some of the posters here, not an institutional bias on the part of the site. I think there is a pretty typical cross section here. You noted that there are a few who are totally against it, a few who are totally for it, and a mojority in the "I don't know." catagory. That's a good reflection of the population at large.
 
I would like to chime in and say: I really like the idea of OMM, and I sincerely hope it works. Where is the research? There should already be considerable amounts of data on the use of OMM on acute injuries, considering that osteopathy had been around for over 100 years. Where are the studies?

I think vols posted a link that contains some a few posts back...I mean granted some of those aren't the best and there are A LOT more out there (with varying degrees of validity, I'm sure) but that's a good jumping off point. Not that I'm a huge advocate of Google in a case like this but if you google "use of OMT in acute" and then click at the top where it says "Scholarly articles for use of OMT in acute" you might find some interesting reading.
 
DocB: You're right, sorry I wasn't clear in my statement. I don't believe that SDN is at all biased against DOs. I just believe that SDN is in general biased on pretty much all subjects because it is not a random sample but a self selection. Also, there are a select group that tend to be more vocal than others which again sways the discussion. I apologize that my statement was unclear! As Jarabacoa and Vols pointed out, the bias goes both ways! The funny thing is I'm not even that big a proponent of OMT! I do feel that it is useful in a select subgroup of patients though and there is some evidence to support that, which I feel deserves to be pointed out.

Jarabacoa: I am happy to argue the scientific merits of OMT with you! I think we should be skeptical of everything and engage in productive dialog about a technique's effectiveness. I'll readily admit (and did) that the research isn't great. It has a lot of flaws that need to be addressed and more research is certainly indicated, but it has some evidence in its favor and that's more than can be said for a lot of things that are "standard of care." I feel that your comments go beyond healthy, scientific skepticism though and show outright prejudice, and I don't think that's productive. So please, argue the strength of the research with me, point out flaws in the methodology, show me the study that says that DOs are unable to reliably and reproducibly palpate somatic dysfunctions. Don't come here though and defame me, my training or a set of techniques that you admit yourself that you have no knowledge or experience with, without evidence of your own!

We all benefit from a healthy discussion of the facts, particularly our patients. So lets keep it to that!
 
OMT or not, I don't have an additional 5 minutes per patient, much less 5-10 minutes. We're managing the waiting room as much as the actual emergency rooms. Patients "out there" are as much/more of a liability for us than the ones "in here" with us. We're always paranoid about what's in the waiting room and trying to move patients as quickly as possible because we know that we're only a few patients away from a complete meltdown.

I have no problem with my partners doing all the OMT they want, as long as they take their share of the patient load. There's no way they can do that if their spending an extra 10-15 minutes per patient. My bias isn't against OMT, it's against partners who don't help move the meat.

Fortunately, I've worked with lots of DOs in the ED and they never had a problem with speed. I'm pretty sure they didn't do much OMT, if any, in the ED, though.

Take care,
Jeff
 
OMT or not, I don't have an additional 5 minutes per patient, much less 5-10 minutes. We're managing the waiting room as much as the actual emergency rooms. Patients "out there" are as much/more of a liability for us than the ones "in here" with us. We're always paranoid about what's in the waiting room and trying to move patients as quickly as possible because we know that we're only a few patients away from a complete meltdown.

I have no problem with my partners doing all the OMT they want, as long as they take their share of the patient load. There's no way they can do that if their spending an extra 10-15 minutes per patient. My bias isn't against OMT, it's against partners who don't help move the meat.

Fortunately, I've worked with lots of DOs in the ED and they never had a problem with speed. I'm pretty sure they didn't do much OMT, if any, in the ED, though.

Take care,
Jeff

True that. I am an oem resident. Who the heck has the TIME to do OMT on a patient in the ED. I am way to busy. In my book OMT = stable pt. That mode of treatment belongs on a stable pt in an out-pt primary care setting. No place in the ED for it, and I will not do it. Neither do the attendings I work for, save one MD attending, who is already into alternative medicine to begin with. He should have been a D.O. who drinks the AOA kool-aid (the fringe 10%). He would fit right in. OMT does however make good foreplay with the little wifey:laugh:.

While I am at it. I can't stand the whole mantra of the "I like the DO philosophy of the whole pt and wholistic medicine, blah, blah, blah." It's a bunch of crap and lip service. DO's don't and can't treat pts wholistically and better than MD's unless you deviate from the current standards of care and get into alternative medicine, but this is a different issue for a different thread. Rant over...
 
I can't think of when you'd have time for it in the ED. With charts piling up and patients yelling, do you have time to give a massage?
 
I can't think of when you'd have time for it in the ED. With charts piling up and patients yelling, do you have time to give a massage?

Why in the world do people think OMT is 1) massage and 2)that it takes a long time? I mean, you'd take the time to reduce a dislocated shoulder wouldn't you?

OMT can be very quick.
I took my final exam today we had to identify a dysfunction, have our diagnoses checked, fix it, check it ourselves then have our correction checked. We only had 5 minutes for all of that and I was always finished in 3. OMT doesn't take a whole lot of time. It's not like you're going to do a full body treatment on everyone that walks through the door!

All that said I can understand the thought that OMT is better reserved for a stable patient. I'm not sure if that's a correct assumption or not (I haven't read the research or, you know, worked in an ED)but it makes sense. I just wanted to take a second to point out that OMT isn't some slow, drawn out massage.
 
Why in the world do people think OMT is 1) massage and 2)that it takes a long time? I mean, you'd take the time to reduce a dislocated shoulder wouldn't you?

OMT can be very quick.
I took my final exam today we had to identify a dysfunction, have our diagnoses checked, fix it, check it ourselves then have our correction checked. We only had 5 minutes for all of that and I was always finished in 3. OMT doesn't take a whole lot of time. It's not like you're going to do a full body treatment on everyone that walks through the door!

All that said I can understand the thought that OMT is better reserved for a stable patient. I'm not sure if that's a correct assumption or not (I haven't read the research or, you know, worked in an ED)but it makes sense. I just wanted to take a second to point out that OMT isn't some slow, drawn out massage.

A shoulder reduction is VASTLY different from OMT. However you define it, I don't know if it can be justified from when your partners are drowning in a a busy ED. I work with six DOs in my group and I've never once witnessed or heard of them using it on a patient.
 
A shoulder reduction is VASTLY different from OMT. However you define it, I don't know if it can be justified from when your partners are drowning in a a busy ED. I work with six DOs in my group and I've never once witnessed or heard of them using it on a patient.

Sorry, bad example maybe? Like I said, I've never worked in an ED and my experience with OMT is still limited to what I've learned in my preclinical years. My main point was that it can be very quick. It's also certainly not "massage" but I can't figure out how to properly articulate that without going into a whole lot of explanation that I'm sure you aren't interested in.
 
Jarabacoa: I am happy to argue the scientific merits of OMT with you!
OK, please address my concerns in my previous post.

I think we should be skeptical of everything and engage in productive dialog about a technique's effectiveness. I'll readily admit (and did) that the research isn't great. It has a lot of flaws that need to be addressed and more research is certainly indicated, but it has some evidence in its favor and that's more than can be said for a lot of things that are "standard of care."
Please give me an example of something that is "standard of care" that is supported by less evidence than OMT in ankle fractures.

I'm glad you admit how bad that study you site is. A piss-poor sample size. 30% of patients lost to follow-up (most of whom are in the treatment group). Patients in the treatment group who have significantly more minor injuries than the control group (more ROM, and less pain) at baseline. And the biggest glaring weakness in my mind, the examiner at follow-up was not blinded to the treatment groups.

I feel that your comments go beyond healthy, scientific skepticism though and show outright prejudice, and I don't think that's productive.

Neither is quoting studies that use treatment modalities that are vague and impossible to reproduce for me. You are advocating treatment modalities that you neither understand, nor have performed on real patients. That is not helpful to you or me.

The study said that the guy took 10-20 minutes on every ankle sprain in OMT alone. Take into acount the 5 minutes taking a history, and doing an exam, the 5 mintues of documentation, looking at x-rays, and giving patient advice and follow-up instructions, you are spending 40 minutes with an ankle sprain. I don't spend that much time with the average chest pain patient, let alone an ankle sprain, arguably the easiest patient you can see in the ER.
 
I'm an MD so I know nothing of OMT/OMM, but here's a quote from a DO student:

you're absolutely correct. 'experts' in the field of OMT therapy are incredibly shady when it comes to proving their techniques work. they do many 'in house' studies using ultrasound waves and random stuff to prove that the body's 'brain waves' and what not change after omt therapy, but nothing truly legit. i am astounded that with the growth of osteopathic medicine there hasnt been a large scale study to validify these techniques. I know a few studies were done on back treatments that showed OMT to be equally effective as some pain meds, etc etc , but the problem is all these studies are conducted by DO schools and specifically by OMT professors, so they can't really be trusted. noone has had enough interest to put money into studying OMT treatment.
 
I've had a number of DO colleagues admit to me that they don't believe in OMT and they don't use it. They just went to DO school so they could get into medicine. I'm not saying that all DOs believe this, just a fair number.

Had I not gone to MD school, I sure as hell would have considered DO school, and if accepted would have faked interest/belief in OMT just to get through.

BTW I'm generally skeptical of ALL "alternative" medicine that doesn't have a clear basis in science and evidence (beyond placebo effect). That goes for acupuncture, nutritional therapy, reading auras, and yes, OMT.
 
OMT can be very quick.
I took my final exam today we had to identify a dysfunction, have our diagnoses checked, fix it, check it ourselves then have our correction checked. We only had 5 minutes for all of that and I was always finished in 3.

You cannot compare a model patient or classmate you are doing OMM on for an exam to a real patient in the clinical world. The timeframe would be nowhere near the same. Model patients/classmates are efficient because they already know what you're going to be doing and how to "help out" in the process. It makes a huge difference.


TerraMedicX: in addition to the fact that I'm not going to spend the extra time on a nonemergent patient, including the ankle sprain you've thrown out there, I can't imagine a truly sprained patient letting anyone do any kind of manipulation on their acute injury. The average true minor/moderate sprain patient I see (not the "I sprained my ankle but it looks 100% like the normal ankle and I walked in the ER today") is barely willing to let me palpate their injury to evaluate them in the first place.

Again, in the real world busy ER, OMM is not a modality you're going to be using. Save it for your friends and family.
 
You cannot compare a model patient or classmate you are doing OMM on for an exam to a real patient in the clinical world. The timeframe would be nowhere near the same. Model patients/classmates are efficient because they already know what you're going to be doing and how to "help out" in the process. It makes a huge difference

makes sense. I was just using that as an example to illustrate how quickly it *could* be done (despite the rechecking/grading). Actually the best ( hands on-not standing in the corner watching a doc take a history/physical) clinical experience I have thus far is at an OMM clinic. What you said is absolutely true, but still I have trouble envisioning a common scenario in which a single diagnoses/treatment would take a ridiculously long time. I've yet to run into one in my time at an OMT clinic anyway. But I absolutely see your point. The point I was trying (and obviously failing) to make was that OMM isn't some long drawn out thing (at least not in regular circumstances). I have no personal experience with anytype of "ED OMT", I just took issue with the painting of OMT as "long, drawn out massage. :)
 
What you said is absolutely true, but still I have trouble envisioning a common scenario in which a single diagnoses/treatment would take a ridiculously long time.

Perhaps you haven't yet encountered the "poor historian" with a "positive review of systems" and a rather-lengthy-yet-very-important-to-the-current-"emergency"-life-story.

Take care,
Jeff
 
OK, please address my concerns in my previous post.

I'm not entirely sure which concerns you're talking about, I feel I addressed most of what you brought up that were actually substantial and not rants about magical spells and such.


Please give me an example of something that is "standard of care" that is supported by less evidence than OMT in ankle fractures.

How about the use of vasopressors (particularly epinephrine) in cardiac arrest? Even the AHA (http://circ.ahajournals.org/cgi/reprint/112/24_suppl/IV-58) admits that there is no evidence that it does anything other than bring back more vegetables from asystole.

I'm glad you admit how bad that study you site is. A piss-poor sample size. 30% of patients lost to follow-up (most of whom are in the treatment group). Patients in the treatment group who have significantly more minor injuries than the control group (more ROM, and less pain) at baseline. And the biggest glaring weakness in my mind, the examiner at follow-up was not blinded to the treatment groups.

I'm not entirely sure where you're getting some of this. The stupidly small samples size, the large loss at follow up and the lack of blinding I'll give you. There was almost identical loss at follow-up in both the treatment and the control groups (7 and 8 patients respectively). As for the "significantly more minor injuries" in the treatment group...how did you figure that? P values comparing initial severity of ROM and pain are 0.54 and 0.22 respectively. That's no where NEAR significant by any standard I've ever heard of.



Neither is quoting studies that use treatment modalities that are vague and impossible to reproduce for me. You are advocating treatment modalities that you neither understand, nor have performed on real patients. That is not helpful to you or me.

The treatment modalities are not really vague, the only reason you can't reproduce them is because you're unfamiliar with the techniques because you were never trained in them.

The study said that the guy took 10-20 minutes on every ankle sprain in OMT alone. Take into acount the 5 minutes taking a history, and doing an exam, the 5 mintues of documentation, looking at x-rays, and giving patient advice and follow-up instructions, you are spending 40 minutes with an ankle sprain. I don't spend that much time with the average chest pain patient, let alone an ankle sprain, arguably the easiest patient you can see in the ER.


In the end though, none of that matters, because I agree with you. The more I look at this study, the less I believe that it has any external validity. The thing that annoys me more than anything though is that this study was published almost 7 years ago, and STILL no one has bothered to perform a follow-up study and rectify any of the flaws! DOs as a whole are woefully under prepared as researchers (probably a side effect of the majority of the schools not being associated with large research universities). I think they're trying to work on that, and maybe my generation will finally get around to doing some GOOD science about OMT!

It really is telling that the only people here advocating for OMT are the students, and I imagine that its probably because we're still sheltered from the realities of time management (particularly in the ED), but just from my experience in EMS I totally agree that there's no way in HELL I'd spend 20 minutes on an ankle sprain!

As I said earlier, I'm not really a huge OMT guy, and I honestly don't know how I wound up in this argument (although I imagine it has something to do with the condescending tone of your posts, but I should know better than to bite!). I DO like using it on friends and family though. As a hands-on sorta person its very gratifying when you get those big "pops!" I have a suspicion though that you're all right and once I get into a clinical setting I won't have time to implement any of it, even if we do finally produce the proper research to support it!

Jarabacoa, I AM curious though why you're so hell-bent against OMT though? Is it REALLY that hard to believe that it works?
 
Jarabacoa, I AM curious though why you're so hell-bent against OMT though? Is it REALLY that hard to believe that it works?

Yes

You got me with the epinephrine thing. However, you are trying to raise people from the dead. Any last ditch effort is worth the effort

If you can give me one more standard of care with less evidence than OMT in ankle sprain, I will forever shut-up about OMT. I might even get my PCP to do a session on me to try it out.
 
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OMT is not used in the ER(ok, not absolute, but damn close). Boom. Next topic please.


It is wonderful(let me bold, highlight, underline that) for the office setting(double bold) or anything like that but seriously the ER. Frankly docs need to touch their patients a hell of a lot more, it could be the placebo effect, but seems to work sometimes, I'd rather be billed for that than right a script. FM docs should have to do OMT, more $$$ for them and the pts love it, but the ER is a different story.
No offense, but the OP lost all credibility with me when he said, you could spend an extra 5-10minutes with a patients to do OMT.... 5-10min... per patient.. in the ER... you have got to be kidding me.. frankly if you are coming to the ER with something that could be solved with OMT, you shouldn't even be in the ER... granted, lots of people shouldnt be in the ER.
 
I use OMT in the ED once in a great while... and always on the same group of patients.

It's good for the "I have chronic back pain, and have had xrays MRI, and repeat steroid injections, etc, but nobody can find out why I am still in pain. What can you do for me?" I do a spinal exam, find the vertebral dysfunction they inevitably have, tell them what I find and explain how it may be contributing to their chronic pain, then send them out without a refill of their percocet/vicodin/mscontin because hey... these sorts of problems need an OMT-proficient DO, not more pain meds.

Amazingly, the patient's I've tried this on (n=4) always seem to accept my answer and don't yell and make a scene like those that just get denied a refill.

But note, I don't do any treatments to fix their problems because I don't have time for the muscle energy treatments they'd need in order to loosen things up before HVLAing the recalcitrant vertebral segment. If I had the time I'd probably try and fix problem. I am not a big believer in OMT, but spinal manipulation for somatic back pain is one of the areas that I do believe it has efficacy.

-Viscerosomatic reflexes? Not a big believer.
-Cranial? Voodoo (my apologies to practitioners of voodoo for associating their time honored practice with this crap).
-Muscle energy/HVLA for musculoskeletal problems? Effective when used in the proper situations.
 
I use OMT in the ED once in a great while... and always on the same group of patients.

It's good for the "I have chronic back pain, and have had xrays MRI, and repeat steroid injections, etc, but nobody can find out why I am still in pain. What can you do for me?" I do a spinal exam, find the vertebral dysfunction they inevitably have, tell them what I find and explain how it may be contributing to their chronic pain, then send them out without a refill of their percocet/vicodin/mscontin because hey... these sorts of problems need an OMT-proficient DO, not more pain meds.

Amazingly, the patient's I've tried this on (n=4) always seem to accept my answer and don't yell and make a scene like those that just get denied a refill.

I may have missed that day in medical school but what's a "Vertebral dysfunction"?
 
Within this last year, I rotated at three different hospitals for Osteopathic Emergency medicine. So, I worked with about 18 different DO attendings. I can say with 100% certainty that I have never saw OMT done once. And the few times that I offered to perform OMT on the pt, my attending gave me the "are you serious?" look :)

It's true that the ED is too busy for you to spend an extra 5-10 minutes per pt. But when my attending has the extra 1 or 2 minutes, he usually check on his stocks, not going around doing OMT etc. I don't blame him, do you?

I matched EM, will start PGY1 this July. As of right now, I don't see how I can incorporate OMT into my practice. But, I'm willing to learn and do some if I have time. As of right now, I do not own any stocks.
 
I may have missed that day in medical school but what's a "Vertebral dysfunction"?

It's a billable diagnosis :) Comes with its own ICD code.

Basically the vertebral bodies should line up on top of each other in a nice orderly column. But occasionally after various physical activities, sleeping positions, etc, the small intervertebral muscles (multifidus, rotatores, etc) can cause one or more of the vertebral segments to rotate or sidebend on the vertebrae below it. The result isn't enough to cause widespread dysfunction of the column (paralysis, restriction of movement, etc.), but the muscles attaching to the spinous/transverse processes get irritated from being stretched a little bit beyond their normal tolerances and start to cause pain.

There's more to it than that and I'm probably not doing a good job explaining it, but that's all I remember.
 
I do a spinal exam, find the vertebral dysfunction they inevitably have

:confused: are you serious?
this is creepy close to chiro

[you are a DO, right?]

i am admittedly very skeptical, but maybe you can change my mind:
how does one diagnose "vertebral dysfunction" with a "spinal exam"?

do you feel a "sidebend" with your hands? measure it with calipers or similar instruments?

can a "sidebend" be quantified? ...or be located (?diagnosed) by a second blinded "practitioner"?

HH
 
:confused: are you serious?
this is creepy close to chiro

Yes, it is creepily close to chiro. When patients ask what the difference between a DO and MD is, I tell them they're the same except I was forced to take an extra course in OMT. And when they look at me confusedly and ask what OMT is, I tell them it's basically chiropracty. They seem to grasp that.

Hamhock said:
[you are a DO, right?]
Yes I am.

Hamhock said:
i am admittedly very skeptical, but maybe you can change my mind:
how does one diagnose "vertebral dysfunction" with a "spinal exam"?

do you feel a "sidebend" with your hands? measure it with calipers or similar instruments?

can a "sidebend" be quantified? ...or be located (?diagnosed) by a second blinded "practitioner"?

Ok, so lay the person on their stomach and start pushing down their spinous processes until they go "ow" (or until you feel one of the processes slightly out of line with the others). Then take both thumbs and dig in on either side to feel the transverse processes (but move up a 1/3rd of a level on average because remember the tips of the spinous processes sit lower than the tips of the transverse processes). If one transverse process is notably deeper than the other (and it's a small notable difference but even an OMT skeptic like me can tell the difference), then the vertebra is rotated. You can't really feel sidebending, but take a skeleton and slightly rotate one vertebra and you'll see it naturally take on a small amount of sidebending also because the ways the facets lock together force the concominant conformational change. A segment can't rotate or sidebend in isolation; it has to do both. And yes, a second blinded practitioner can diagnose the same dysfunction.
 
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It's a billable diagnosis :) Comes with its own ICD code.

Basically the vertebral bodies should line up on top of each other in a nice orderly column. But occasionally after various physical activities, sleeping positions, etc, the small intervertebral muscles (multifidus, rotatores, etc) can cause one or more of the vertebral segments to rotate or sidebend on the vertebrae below it. The result isn't enough to cause widespread dysfunction of the column (paralysis, restriction of movement, etc.), but the muscles attaching to the spinous/transverse processes get irritated from being stretched a little bit beyond their normal tolerances and start to cause pain.

There's more to it than that and I'm probably not doing a good job explaining it, but that's all I remember.


Not to offend, but this is utter nonsense. Assuming you can see this on X-ray 9(which I doubt) What you are describing would not be correctable by "manipulation". It's a subluxation which would result in possible spinal cord injury. The corrective "manipulation" would likely result in a worsening of the subluxation, as you likely would have ligamentous injury. This is extremely frightening and dangerous if you are doing this stuff on people with real vertebral injury.
 
It's a billable diagnosis :) Comes with its own ICD code.

Basically the vertebral bodies should line up on top of each other in a nice orderly column. But occasionally after various physical activities, sleeping positions, etc, the small intervertebral muscles (multifidus, rotatores, etc) can cause one or more of the vertebral segments to rotate or sidebend on the vertebrae below it. The result isn't enough to cause widespread dysfunction of the column (paralysis, restriction of movement, etc.), but the muscles attaching to the spinous/transverse processes get irritated from being stretched a little bit beyond their normal tolerances and start to cause pain.

There's more to it than that and I'm probably not doing a good job explaining it, but that's all I remember.

Wow this is scary. I mean.. Are you kidding me? Do they really teach this at DO school?

If the vertebral bodies are actually rotated around like that, aren't you worried of spinal cord damage with manipulation? I mean, if this were true, it would be a genuine subluxation and I would think you would need to be cautious not to cause further damage.
 
(or until you feel one of the processes slightly out of line with the others). Then take both thumbs and dig in on either side to feel the transverse processes (but move up a 1/3rd of a level on average because remember the tips of the spinous processes sit lower than the tips of the transverse processes). If one transverse process is notably deeper than the other (and it's a small notable difference but even an OMT skeptic like me can tell the difference), then the vertebra is rotated. You can't really feel sidebending, but take a skeleton and slightly rotate one vertebra and you'll see it naturally take on a small amount of sidebending also because the ways the facets lock together force the concominant conformational change. A segment can't rotate or sidebend in isolation; it has to do both. And yes, a second blinded practitioner can diagnose the same dysfunction.

Obviously I am not a DO, but if I were and I heard this stuff in medical school I would immediately ask for the supporting research. Certainly some of the curious DOs on this board must have done so. Is there research to support this? For example...

You said a second blinded practioner can diagnose the same dysfunction. I guess I should be more clear. I am not asking if a second practitioner who walks in after you to the same back pain patient will "diagnose" vertebral dysfunction. Rather, I am wondering if 25 patients (some with back pain, some without, some with "vertebral dysnfunction", some with radiographically diagnosed subluxation) were examined independently and blindly by two - or better yet, twenty-five - "expert practitioners", how accurate and reproducible would the diagnoses be...and would they be of the same degree at the same location. Of course, I just made up these numbers, but I think you get my point. Where is the research??????

And then, after someone gave me research similar to above, I would want to know what the CT spine showed for these same patients...AND the MRI (to check for ligament injury). This or similar work must have been done, right?!?

I suspect there are many DOs on this board...can someone point me in the direction of this type of research? I know, I know, I can go look it up myself, but certainly DOs must have access to it and have already looked it up or been provided with it during medical school. If no one can, I guess I will try after my shift today or tomorrow.

Lastly, if, in fact, DOs can reliably and accurately diagnose ligament injury of the spine using hands, I am now a bit frightened of DO residents. I am not an attending, but when I am, the last thing I want a resident to be doing is taking one of my patients with a subluxation or ligament injury of the spine and forcefully manipulating the spine! :eek::eek:

This may be OK in osteopathic residencies and maybe for some DOs attendings working in allopathic residencies, but I bet the great majority of MD attendings would be furious if a resident started "manipulating" such a spinal injury.

Possibly going off the deep end but still open to being "educated",
HH
**but getting very close to Veers' opinion: "this is utter nonsense"
 
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