In this issue of the Journal, Andersson et al. report a comparison of osteopathic spinal manipulation, a form of osteopathic manual therapy, with standard care for patients with low back pain.7 Patients were randomly assigned to standard care (72 patients) or to treatment including manipulation (83 patients). Pain, functional ability, and the patients' satisfaction with their treatment were assessed with a variety of measures. After 12 weeks, there was significant improvement in both groups, and there was no difference between the two groups in any of the primary outcome measures. However, patients given standard therapy without osteopathic manipulation used significantly more medication and more physical therapy.
Some claim that osteopathic physicians are more parsimonious in their use of medical technology. Thus, they can provide more cost-effective medical care and reduce the need for medications, which, although effective, can have serious side effects. The specific mechanism that would account for any improvement in back pain directly related to osteopathic manipulation is unclear, but the most important studies will be those that test whether the technique works in clinical practice. Part of the success of osteopathic manipulation for patients with back pain may come from the fact that physicians who use osteopathic manipulation touch their patients.
Osteopathic manual therapy is claimed to be useful for treating a wide range of conditions, from pancreatitis to Parkinson's disease, sinusitis, and asthma. Some leading osteopaths say that manual therapy should be part of almost every visit to an osteopathic physician. A recent president of the American Osteopathic Association claimed that he "almost always turned to [osteopathic manipulation] before considering any other modality," and he asserted that 90 percent of his patients got better with osteopathic manipulation alone.8 Such claims underscore a raging debate within osteopathy and a disconnection between its theories and its practice. A 1995 survey of 1055 osteopathic family physicians found that they used manual therapy only occasionally; only 6.2 percent used osteopathic manipulation for more than half of their patients, and almost a third used it for fewer than 5 percent.9 The more recent their graduation from medical school, the less likely practitioners were to use osteopathic manipulation, a finding consistent with the view that osteopathic practice is moving closer to allopathic practice. A decreasing interest in osteopathic manipulation may also indicate that more physicians enter osteopathic medical school not as a result of a deeply held belief in the osteopathic philosophy but after failing to be admitted to allopathic medical schools.10 The osteopathic physicians who are more committed to osteopathic manipulation tend to be more likely than their colleagues to have a fundamentalist religious orientation.10
With or without manipulation therapy, osteopathic medicine seems to be undergoing a resurgence. Although the number of allopathic medical schools in the United States has remained stable since 1980, at about 125, the number of osteopathic medical schools has increased from 14 to 19. The number of graduates each year has increased at an even more disproportionate rate. The number of graduates of allopathic medical schools has increased only slightly, from 15,135 in 1980 to 15,923 in 1997, whereas the number of graduates of osteopathic medical schools has almost doubled, from 1059 to 2009, over the same period. Osteopathic medical schools have not done as well as allopathic medical schools in recruiting underrepresented minorities and women, and students entering osteopathic medical schools have somewhat lower grade-point averages and lower scores on the Medical College Admission Test. On the other hand, the ratio of applicants to those admitted is higher for osteopathic medical schools, 3.5 applicants for each person admitted, as compared with 2.4 for allopathic medical schools.11,12,13
Overall, osteopathic medical schools have come to resemble allopathic medical schools in most respects; some students even share classes. Graduates of osteopathic medical schools more often than not go on to residency training in allopathic programs.14 An evaluation of performance on the certifying examination of the American Board of Internal Medicine in the 1980s noted that although physicians from osteopathic medical schools did not do as well as those from allopathic programs, overall they "did well" and could be an "untapped reservoir of talented physicians" for internal medicine.15
Although they constitute only about 5 percent of U.S. physicians, osteopaths may be disproportionately important for the health care system by virtue of their distribution in terms of specialty and location: 60 percent of graduates of osteopathic medical schools select generalist fields.16 Because osteopathic education is more community-based than allopathic education, and because osteopathic schools are smaller, osteopathic education may be able to adapt more quickly to new approaches to health care delivery.17 Many more osteopaths than allopaths (18.1 percent vs. 11.5 percent) select rural areas in which to practice.18 One osteopathic medical school found that 20 percent of its graduates were practicing in underserved communities.19
At the end of the century, osteopathy continues its uneasy dance with allopathy, but only one partner is really paying attention. The resurgence in the numbers of osteopaths should not mask the precarious position of osteopathy. At its birth, osteopathy was a radical concept, rejecting much of what allopathic medicine claimed was new and useful. Today, osteopathic medicine has moved close to the mainstream ? close enough that in general it is no longer considered alternative medicine. The long-term survival of osteopathic medicine will depend on its ability to define itself as distinct from and yet still equivalent to allopathic medicine. That argument may best be articulated not in theoretical terms, but by demonstrating treatment outcomes. The paradox is this: if osteopathy has become the functional equivalent of allopathy, what is the justification for its continued existence? And if there is value in therapy that is uniquely osteopathic ? that is, based on osteopathic manipulation or other techniques ? why should its use be limited to osteopaths?
Joel D. Howell, M.D., Ph.D.
University of Michigan
Ann Arbor, MI 48109-0604
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