Omt

[Adcadet]

Hey all -
I'll be attending my state's medical school in the fall (see sig), and am trying to learn a bit more about my osteopathic brethren. Can somebody help me find info on exactly how OMT works (or is thought to work)?

Thanks,
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[AviatorDoc]

Just how does OMT work....

That's a very loaded question, but I'll try to give the best answer I can with just a 2 year understanding of the subject.

First of all, I like to put various aspects of OMT into different categories based on their level of research and other factors. Realize that for docs who use it on a daily basis in their practice, there usually is no distinction.

1.) Using OMT for various musculoskeletal aches & pains.

This is far and away the most proven application of OMT. It is even written up in the textbook "Spine", the bible of spinal surgery.

Basically, this application utilizes a number of techniques (High Velocity Low Amplitude thrusts, Indirect methods, tender points, etc.) to "free up" a joint. In just a short period of time, I've used these techniques on shoulder pain, low back pain, and foot pain with a very good success rate. Many times, these techniques result in an articulatory "Pop". There are obvious comparisons to sports medicine, physical therapy, orthopedic, and chiropractic maneuvers. Osteopaths recognize that there are applications for every single joint in the human body. (I don't know if the others do.)

Ancillary to joint pain, soft tissue pain can be greatly reduced with OMT.

2.) Using OMT for various somatovisceral and viscerosomatic reflexes.

This application utilizes the same techniques mentioned above. Here, the spine is manipulated to obtain a neurohumoral response to some systemic disease process. Likewise, a systemic disease process will have a reflex to the musculoskeletal system, and this can be used diagnostically. Again, there are some similarities to chiropractic. Outcome-based studies are numerous in this area, but evidence-based studies are few and far between. For an interesting story, check out the osteopathic literature regarding the Spanish Flu Epidemic of 1918-1920.

3.) Using the craniosacral rhythm to diagnose and treat.

Here, I will have to hold my tongue. I do not want to misrepresent the arguments for this utility. I'll just say that well-designed studies in this area are almost nonexistant.

4.) The use of OMT precludes the need for drugs.

This is a radical opinion that is basically nonexistant in the profession today, although it was taught in the distant past.


This is the story as I understand it. There are other things that make a DO a DO, but this is the OMT side of things. There is a lot of literature on the subject, but most of it is written by osteopaths (or those intent on trashing the profession), so it is difficult to get a truly objective viewpoint.

Hope it helps.

 

[Adcadet]

Originally posted by AviatorDoc


This is the story as I understand it. There are other things that make a DO a DO, but this is the OMT side of things. There is a lot of literature on the subject, but most of it is written by osteopaths (or those intent on trashing the profession), so it is difficult to get a truly objective viewpoint.

Thanks for the response Aviator.
From my brief reading up on osteopathic medicine, it seems most of it fits in very well with my public health background - the emphasis on primary care and prevention and treating the whole person. The part that is most foreign to my allopathic-bias is OMT. I read that 1999 NEJM (Anderson et al, NEJM Nov 4, 1999 341:1426-1431) article that compared standard treatment to osteopathic spinal manipulation and was not impressed by the outcomes but was impressed by the reduced need for pharmacotherapy. I'm just wondering if there is a mechanism (or mechanisms) by which OMT acts or is thought to act. When I've studied other forms of treatment there is usually a pretty well supported mechanism of action (i.e. vaccination works be eliciting high-affinity antibodies; morphine works primarily by binding to and activating mu-opioid receptors in the spinothalamic tract). But I'm having a hard time finding the (proposed) mechanism(s) of OMT.

Thanks again!
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[joedo]

I could use OMT , I just shoveled about a foot and a half of snow from my driveway..

Check out this overview of Osteopathic Medicine:

http://archfami.ama-assn.org/issues/v8n6/ffull/fsa8021.html

 

[AviatorDoc]

Adcadet,

Let me answer your question again by breaking down the various applications of OMT.

For the musculoskeletal system, the answer lies not in biochemical structures but biomechanics. Each joint has a normal range of motion. When this range is impinged, tenderness, assymetry, restricted range of motion, and pain occur. By relieving the strain on a joint capsule, the pain receptors are not triggered. Think in terms of orthopedic maneuvers. OMT is simply performing them on a more minute scale, using subtle motion preferences. There is no need to invoke a genetic/molecular reason.

For the viscerosomatic/somatovisceral reflexes, you can think of the rebound tenderness that occurs with an acute appendix, or the shoulder pain associated with a heart attack. I'm not exactly sure why these reflexes occur; I don't know if anyone really has a great answer, but they are certainly present. We do know it has to do with innervations coming from the same spinal cord level.


The problem with finding a mechanism for OMT is as much historical/philosophical as anything. Docs used OMT for years because it worked. Their patients responded. Outcome-based studies are numerous in JAOA and other literature. Osteopaths are only recently jumping on the molecular bandwagon that has been driving allopathic medicine for the last few decades. "Let's find out what molecule/receptor interaction is responsible for this!" There are advantages and disadvantages to this reductionist mode of thinking.

Here's a study I'd like to do at some point. One of the techniques used is called "rib raising". It is used on patients to "increase the sympathetic tone" of the region you are manipulating (T4 for the heart, for example). That is the mechanism invoked, but no one knows if catecholamine levels are raised at the blood or tissue level. How hard would it be to measure these?

The bottom line, though, is that clinical medicine, though heavily science-based, is not a science... not by a long shot.

 

[Adcadet]

Originally posted by AviatorDoc
Adcadet,


For the musculoskeletal system, the answer lies not in biochemical structures but biomechanics. Each joint has a normal range of motion. When this range is impinged, tenderness, assymetry, restricted range of motion, and pain occur. By relieving the strain on a joint capsule, the pain receptors are not triggered. Think in terms of orthopedic maneuvers. OMT is simply performing them on a more minute scale, using subtle motion preferences. There is no need to invoke a genetic/molecular reason.

I've never studied biomechanics, so forgive me if I sound naive in this area. How does OMT heal using biomechanics? Does OMT simply stretch the muscles, tendons, and ligaments? Is there something else - you mention the nervous system too. Can you give me an example (my rotator cuff injuries, and how OMT might help, perhaps)?

Thanks,
Adcadet

 

[AviatorDoc]

Let's say that I'm having referred lower back pain associated with severly tight hamstring muscles.

(The hamstrings are connected to the ischial tuberosity of the pelvis, and the pelvis has a connection to the sacrum & lower lumbar vertebrae. Tight hamstrings will pull down on the pelvis, causing a tilt, which will decrease the natural curvature of the lower back, thereby causing pain.)

One way to treat this problem would be to inject BoTox locally into the hamstring muscles. This would cause a dissociation between the postsynaptic neuron receptor and the propogation of the action potential. The macroscopic result would be releasted hamstrings, a normal pelvis, and a return of normal curvature.

The other way to treat it would be to stretch the hamstrings. There are ways someone can do this by himself, but a more effective way is to have someone else hold the leg in flexion with the knee locked. I would push against his resistance, and then he could take my leg into further flexion, thereby stretching the muscle complex. This is manipulative treatment (MT), though not specifically osteopathic.

 

[Cookie Monster]

Nothing to offer the original poster, but I have to second joedo's post -- I'm still trying to find my car in the snow, a little OMM would feel real good right about now!

 

[Adcadet]

Sounds a bit like PT, no?
Botox for such a large muscle group? Do people do that? Youch, seems pretty intense to me. I'd choose MT over botox in this case every time!

Originally posted by AviatorDoc
Let's say that I'm having referred lower back pain associated with severly tight hamstring muscles.

(The hamstrings are connected to the ischial tuberosity of the pelvis, and the pelvis has a connection to the sacrum & lower lumbar vertebrae. Tight hamstrings will pull down on the pelvis, causing a tilt, which will decrease the natural curvature of the lower back, thereby causing pain.)

One way to treat this problem would be to inject BoTox locally into the hamstring muscles. This would cause a dissociation between the postsynaptic neuron receptor and the propogation of the action potential. The macroscopic result would be releasted hamstrings, a normal pelvis, and a return of normal curvature.

The other way to treat it would be to stretch the hamstrings. There are ways someone can do this by himself, but a more effective way is to have someone else hold the leg in flexion with the knee locked. I would push against his resistance, and then he could take my leg into further flexion, thereby stretching the muscle complex. This is manipulative treatment (MT), though not specifically osteopathic.

 

[applegirl]

I have a little problem.

I am most likely going to a osteo school. It is my understanding that OMT is practiced on other students. Here is the problem that I hope a med student or resident can answer. 3.5 years ago I had a spinal fusion surgery performed for my scoliosis. I feel great, absolutely no problems but I can' let another student practice on me. What should I do? I don't want to have a partner who is screwed because he/she cant practice their technique on me whaen I can perform it on them. What should I do?

 

[AviatorDoc]

Applegirl...

There are clear contraindications to OMT, just as there is to any therapy. No one would manipulate the C-spine after a trauma until x-rays have returned negative and a complete neurological eval is done. Not to worry... there are still lots of parts of your body that other students can work on. Most schools rotate partners, so no one will be left out. Just make sure you let people know what's going on.



Adcadet...

You said you were having a hard time with the biomechanics ideas, so I was giving an exaggerated example. No one really does BoTox on the hamstrings, but it's theoretically possible, and we certainly know the mechanism of action.

In this case, the manipulative therapy is ubiquitous, but there are manipulations that are nearly exclusively osteopathic. To me, its just the degree of scale that is different.

A personal example: My father-in-law was having a hard time with his shoulder. He couldn't raise his arm above his head. This is a real problem as he is an alarm installer. One night, I decided I'd try some of this OMT stuff, just to see if it was worth anything. I checked his active range of motion (active = done under his own power) as well as his passive ROM (passive = done under my power). Afterward, I diagnosed his motion preferences, which does not require a lot of movement. Then, I treated it using an indirect technique.

Now two points. 1.) I didn't tell him that I was treating, and 2.) Indirect techniques require such minimal movement, the patient can't feel it if they are not paying attention.

Then, I let go. I had him raise his arm over his head and behind his back. He did it without any problem. "What the heck was that?! You didn't even do anything to me." I told him that I had, but he still didn't believe me. "No, really. You just touched my arm, and suddenly I can move it?!?" I explained that I wasn't just touching his arm. I was actually diagnosing and treating it.

That fixed a shoulder problem he had been having for a couple of months, and to the best of my knowledge, it hasn't returned. This could have been fixed with a steroid injection or a local anesthetic. In this case, OMT worked just fine by itself.


I was extremely skeptical of OMT when I got to med school, and to an extent, I still am. But I definitely plan on using it in my practice, because it works. The number of DOs who use it is declining, namely because so few are investigating the true MOAs. Maybe we could work together in the future to look at some of these things?

 

[Adcadet]

Originally posted by AviatorDoc

Adcadet...

You said you were having a hard time with the biomechanics ideas, so I was giving an exaggerated example. No one really does BoTox on the hamstrings, but it's theoretically possible, and we certainly know the mechanism of action.

In this case, the manipulative therapy is ubiquitous, but there are manipulations that are nearly exclusively osteopathic. To me, its just the degree of scale that is different.

A personal example: My father-in-law was having a hard time with his shoulder. He couldn't raise his arm above his head. This is a real problem as he is an alarm installer. One night, I decided I'd try some of this OMT stuff, just to see if it was worth anything. I checked his active range of motion (active = done under his own power) as well as his passive ROM (passive = done under my power). Afterward, I diagnosed his motion preferences, which does not require a lot of movement. Then, I treated it using an indirect technique.

Now two points. 1.) I didn't tell him that I was treating, and 2.) Indirect techniques require such minimal movement, the patient can't feel it if they are not paying attention.

Then, I let go. I had him raise his arm over his head and behind his back. He did it without any problem. "What the heck was that?! You didn't even do anything to me." I told him that I had, but he still didn't believe me. "No, really. You just touched my arm, and suddenly I can move it?!?" I explained that I wasn't just touching his arm. I was actually diagnosing and treating it.

That fixed a shoulder problem he had been having for a couple of months, and to the best of my knowledge, it hasn't returned. This could have been fixed with a steroid injection or a local anesthetic. In this case, OMT worked just fine by itself.


I was extremely skeptical of OMT when I got to med school, and to an extent, I still am. But I definitely plan on using it in my practice, because it works. The number of DOs who use it is declining, namely because so few are investigating the true MOAs. Maybe we could work together in the future to look at some of these things? [/B]

So, what did you do to your father?

Oh, the PhD in my sig (which I'll almost certainly be doing) will be in pharmacology. Strange then that I'm so interested in OMT, huh? Any time there seems to be a treatment without significant side effects, my ears perk up.

How does one learn OMT in an allopathic medical school? My understanding is that there are some MDs who learn and use OMT.

Thanks Av!
Adcadet