osteopathy in the ICU

[Hamhock]

At one of my teaching hospitals, there is an FM program with many DOs. Some of them believe in osteopathy and twice now I have come across their recommendation to use osteopathic "manipulation" in the ICU. (most recent example was left trapezius pain in a young patient who had been in bed too long with DKA)

I asked them to show me any evidence supporting such practices. None has been provided. In fact, I have been given multiple publications describing manipulations of anatomical structures that don't exist. Osteopathic physicians describe to me the manipulation of soft tissue that they "feel" the "release" of fascial plans. They explain to me this changes not just blood flow but even CSF flow to optimize healing.

I struggle to avoid incredulous facial expressions. These are typically friendly residents and I don't want to alienate them or come across as a jerk.

Does anyone have suggestions on discouraging such practice and belief in the ICU? Of course, I can easily prevent it's use on my patients, but that's just draconian.

Additionally, is there any evidence any of this manipulation is helpful in the ICU beyond generic massage, physical therapy, and placebo?

If there is good evidence, I would certainly want to incorporate this into my practice. For now, I remain convinced there is only one medicine (as opposed to the belief that there is osteopathic and allopathic medicine).

HH

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[thumbz]

What's the direct patient harm in doing trapezius release in the ICU?

Sure, it may not help, but good luck convincing me it's gonna hurt the patient. And depending on your payment model, RVUs are RVUs. If you have the time and the patient feels better after, why not.

And if you consider the placebo effect is usually a good 30% .... as long as you're not using OMT in place of antibiotics in septic shock you may actually see some good outcomes.

Edit: and just for giggles, I did find this.

Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial

The Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) is a registered, double-blinded, randomized, controlled trial designed to assess the efficacy of osteopathic manipulative treatment (OMT) as an adjunctive treatment in elderly patients ...

www.ncbi.nlm.nih.gov

 

[jdh71]

I predict this ending well

 

[Hamhock]

What's the direct patient harm in doing trapezius release in the ICU?

Sure, it may not help, but good luck convincing me it's gonna hurt the patient. And depending on your payment model, RVUs are RVUs. If you have the time and the patient feels better after, why not.

And if you consider the placebo effect is usually a good 30% .... as long as you're not using OMT in place of antibiotics in septic shock you may actually see some good outcomes.

Edit: and just for giggles, I did find this.

Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial

The Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) is a registered, double-blinded, randomized, controlled trial designed to assess the efficacy of osteopathic manipulative treatment (OMT) as an adjunctive treatment in elderly patients ...

www.ncbi.nlm.nih.gov

Yes, there may not be a lot of harm from trapezius "release" (what does that even mean?!) to the patient at that moment...but to science-based medicine and to medical education? I see great harms. I bet you do too.

And doing extra nonsense for RVUs carries many harms to our reputation and economics.


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The linked publication your provided seems of slightly higher quality than what the residents have given, however I can't understand who would approve these "methods":

" thoracolumbar soft tissue, rib raising, doming of the diaphragm myofascial release, cervical spine soft tissue, suboccipital decompression, thoracic inlet myofascial release, thoracic lymphatic pump, and pedal lymphatic pump...

...Rib raising articulates each rib for the purpose of improving rib cage motion and theoretically stimulates the sympathetic chain ganglia. ... Doming the diaphragm and thoracic inlet myofascial release techniques are used to improve diaphragmatic movement and lymphatic drainage. Suboccipital decompression involves traction at the base of the skull, which is considered to release restrictions around the vagus nerves, theoretically improving nerve function. The thoracic lymphatic pump with activation combines rhythmical compressions to the chest wall and the rapid removal of the hands from the chest wall during deep inhalation with the intention of enhancing lymphatic circulation and triggering a sudden expansion of airways and alveoli. The pedal lymphatic pump gently rocks the patient in a superior-inferior rhythmical motion while supine, to theoretically enhance lymphatic circulation."

Really? Does anyone "dome the diaphragm"? This increases lymphatic drainage? I honestly don't know what the authors are talking about? It seems completely nonsensical to me; almost a parody of medicine!

@thumbz Do you articulate each rib to stimulate the sympathetic ganglia? Does anyone in your ICU do this?

@everyone Why do we continue to tolerate this nonsense?

HH

 

[Hamhock]

I predict this ending well

Yeah, I know this may not go well...but I think the risk of eventual deterioration of this thread is worth the potential benefit of me understanding how other intensivists deal with proposals from DO residents to incorporate osteopathy.

If someone proposed reiki or cupping, an abrupt dismissal would be accepted.

If I dismiss osteopathy to a resident on rounds, it will not be tolerated similarly.

How am I supposed to respond on rounds when this is proposed?

HH

 

[DrGasPasser]

Sure. Why not? At least a third of what we do seems like anecdotal homeopathy - why not add a little osteopathy?

After all, who wouldn’t appreciate a little back rub before they die?

 

[thumbz]

Believe me, I don't intend to change your mind as to the tenants or benefits of OMT. I'm a hospitalist and I haven't done a lick of OMT in the last 15 months (and in reality I haven't done any significant OMT for 7 years... ever since I was an MS3).

But what I don't understand is why you're discouraging your residents from doing it. If they have the time and care to do so, the patient won't experience any harm but will potentially see some benefit. We know (anecdotally as I'm not going to go track down the studies) that when physicians spend more time with patients they have better outcomes. Satisfaction goes up. Understanding of their care goes up. Think of it as just a little more early mobilization which clearly has benefits in the ICU.

From an academic standpoint - why not tell your residents to study it? If the data doesn't exist, make them publish it. If they're this motivated to do OMT they'll probably be all about it.

 

[Hernandez]

There has only been 1 study showing much benefit in the hospital pts with pneumonia, and it was a **** study with **** outcomes that no one cares about and it was not intention to treat design.

Just tell them that **** doesn’t work. Yeah the risks are minimal, but it’s not beneficial. Some of the biggest blowhards I’ve ever met were the true believer osteopaths. I’m a DO, I did DO IM training and then ACGME fellowship. In residency we had a dedicated OMM doc and she’s prattle on about all the icu and pacu consults she’s been involved in and what great out comes she had. She’s even bloviate about the surgeons calling her to the or. Not once did I see her in our icu.

That being said, i think there is a place for that type of treatment and I will on occasion pop a back or pop a rib back in for people that are coughing their heads off for cough, but it sure as hell isnt a treatment I ever have done in the icu. And frankly feel that the treatment modality is best used in conjunction with PT and exercise.

 

[Hernandez]

Edit: and just for giggles, I did find this.

Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial

The Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) is a registered, double-blinded, randomized, controlled trial designed to assess the efficacy of osteopathic manipulative treatment (OMT) as an adjunctive treatment in elderly patients ...

www.ncbi.nlm.nih.gov

That’s the study I was alluding to. Outcomes no one cares about (except maybe length of stay but the fragility index is crap on that) and only beneficial on a per protocol testing but not intention to treat.

 

[deleted547339]

Believe me, I don't intend to change your mind as to the tenants or benefits of OMT. I'm a hospitalist and I haven't done a lick of OMT in the last 15 months (and in reality I haven't done any significant OMT for 7 years... ever since I was an MS3).

But what I don't understand is why you're discouraging your residents from doing it. If they have the time and care to do so, the patient won't experience any harm but will potentially see some benefit. We know (anecdotally as I'm not going to go track down the studies) that when physicians spend more time with patients they have better outcomes. Satisfaction goes up. Understanding of their care goes up. Think of it as just a little more early mobilization which clearly has benefits in the ICU.

From an academic standpoint - why not tell your residents to study it? If the data doesn't exist, make them publish it. If they're this motivated to do OMT they'll probably be all about it.

So I guess you’ve never seen a working father or mother under the age of 45 stroke out from a chiropractic neck manipulation. I’ve seen three.

Putting a voodoo doll at bedside probably doesn’t help, but we don’t do it. Why? Because we’re doctors. We use the best available evidence to treat our patients.

We should be above this nonsense.

 

[DrGasPasser]

I struggle to avoid incredulous facial expressions. These are typically friendly residents and I don't want to alienate them or come across as a jerk.

Does anyone have suggestions on discouraging such practice and belief in the ICU? Of course, I can easily prevent it's use on my patients, but that's just draconian.

HH

Good luck man. I have about as much use for osteopathic manipulation and myofascial release as I do a mysterious energy Force created by life that binds the galaxy together.

Anyone who wants to practice that bulli**** can do it in a galaxy far, far away from me and my patients.

As for being a thought of as a jerk by people who embrace quackery and mysticism, oh well. I show up to work everyday to chew bubblegum and kick ass - and I’m all out of bubblegum...

 

[jdh71]

Yeah, I know this may not go well...but I think the risk of eventual deterioration of this thread is worth the potential benefit of me understanding how other intensivists deal with proposals from DO residents to incorporate osteopathy.

If someone proposed reiki or cupping, an abrupt dismissal would be accepted.

If I dismiss osteopathy to a resident on rounds, it will not be tolerated similarly.

How am I supposed to respond on rounds when this is proposed?

HH

reiki as I understand it is just energy transfer (often enough without even touching) I might tell a resident to knock themselves out!!

I honestly don’t know enough about OMM to know how much is quackery, how much has some basis as a arguable treatment, and what has evidence weak to strong.

But I do know that I wasn’t trained to use it and I dont think it has any place in the ICU. I think I’d simply tell the residents, “I’m the attending and we aren’t doing any of that. I’m like a mechanic who fixes cars with wrenches. I don’t know how to fix one with a screwdriver and it doesn’t make any sense. Someday when you are an attending you are free to have a different opinion but right now we do this all my way.”

 

[SurfingDoctor]

No need for me to bother or get involved. I just consult the physical and occupational therapists.

That being said, if I saw a resident doing some manipulation on a critically ill pediatric patient, I’d ask them to promptly leave the patient alone.

 

[engineeredout]

Fling the banner of osteopathy to the breeze!

 

[austintr]

The useful bits of OMT in my opinion are where there is significant overlap with PT/OT. I despise 75% of what we're taught, but there is some of it that can be beneficial. The trap 'release' referred to above is something that has made my traps feel a little looser and better on occasion. Something about taking the tension out of the muscle by providing feedback blah blah blah. But it feels decent. Popping ribs makes people feel better most of the time, but I doubt it helps them breathe better as we're indoctrinated to believe.

The stretching stuff (we're not supposed to call it stretching) and the massage stuff (we're not supposed to call it massage) can be great for people with postural issues and especially athletes or people with semi-chronic pains and injuries.

Cranial is voodoo and I can assure you if ANYone is promoting it in practice on ANYone older than 1yo (and probably ANYone in general), they've been indoctrinated.

Not gonna lie though, every patient I've done what little OMT I'm actually comfortable with and decent at seems to think it's pretty good. Probably just because they're being touched by someone and active in the treatment. It's kind of empowering, it seems.

At the end of the day, I plan to only use OMT in very limited cases and only on family/friends and MAYBE the occasional patient that could benefit from what is basically therapeutic touch. I'm 99% certain I won't bill for it though.

 

[DrStephenStrange]

The useful bits of OMT in my opinion are where there is significant overlap with PT/OT. I despise 75% of what we're taught, but there is some of it that can be beneficial. The trap 'release' referred to above is something that has made my traps feel a little looser and better on occasion. Something about taking the tension out of the muscle by providing feedback blah blah blah. But it feels decent. Popping ribs makes people feel better most of the time, but I doubt it helps them breathe better as we're indoctrinated to believe.

The stretching stuff (we're not supposed to call it stretching) and the massage stuff (we're not supposed to call it massage) can be great for people with postural issues and especially athletes or people with semi-chronic pains and injuries.

Cranial is voodoo and I can assure you if ANYone is promoting it in practice on ANYone older than 1yo (and probably ANYone in general), they've been indoctrinated.

Not gonna lie though, every patient I've done what little OMT I'm actually comfortable with and decent at seems to think it's pretty good. Probably just because they're being touched by someone and active in the treatment. It's kind of empowering, it seems.

At the end of the day, I plan to only use OMT in very limited cases and only on family/friends and MAYBE the occasional patient that could benefit from what is basically therapeutic touch. I'm 99% certain I won't bill for it though.

The questionable parts are mostly Cranial techniques and Chapman points. That's maybe about 10-15% of OMT. I would say the rest is Ok, or at least reasonable based on the anatomy and the MSK system.

 

[austintr]

The questionable parts are mostly Cranial techniques and Chapman points. That's maybe about 10-15% of OMT. I would say the rest is Ok, or at least reasonable based on the anatomy and the MSK system.

Tensegrity would like to have a talk with you. In all seriousness though, I tuned out for the rest of med school when it came to OMM because I was told by a professor that a 'pubic upshear' would not be able to be confirmed on X-ray because it's "too subtle". Yet somehow we can 'feel' it.

I don't hate ALL OMT, I just hate the bad/fabricated OMT -- we'll just have to continue to disagree on what percentage of OMT that is.

 

[DrStephenStrange]

Tensegrity would like to have a talk with you. In all seriousness though, I tuned out for the rest of med school when it came to OMM because I was told by a professor that a 'pubic upshear' would not be able to be confirmed on X-ray because it's "too subtle". Yet somehow we can 'feel' it.

I don't hate ALL OMT, I just hate the bad/fabricated OMT -- we'll just have to continue to disagree on what percentage of OMT that is.

Same.

Edit: Alright maybe I was too generous in saying only 15% of OMT are fabricated/questionable. It may be more in the ballpark of 40/60 to 50/50.

 

[Siggy]

Tensegrity would like to have a talk with you.

Well... if I crack my neck in one spot, I can often find another spot a few levels up or down to crack in the opposite direction (and one of these days I'm going to stroke out doing that, but meh).

Soft tissue techniques I use all the time... just not at the hospital.