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Osteopathy
Introduction
Historical Background
Scientific Principles
Mechanism of Action
Clinical Evaluation
Clinical Applications
Risks, Side Effects, Adverse Events
Contraindications
Additional Clinical Outcomes
The Future
Training, Certification, and Licensing Requirements
Resources
References

Introduction

Osteopathy is a holistic approach to healing based on the premise that a misaligned musculoskeletal system is the source of most health problems and that structure and function of the body are inseparable (Lesho 1999; Wagner 1996). Doctors of osteopathy, called DOs, are fully licensed physicians who also practice allopathic medicine and usually specialize in primary care (American Osteopathic Association 2000). The training to become a DO requires the same length of study as becoming an MD and the post-graduate residency is generally parallel (see Training, Certification, and Licensing section below) (Kappler et al. 2000). In addition to standard primary care, DOs use a wide range of techniques collectively referred to as osteopathic manipulative therapy (OMT), along with conventional treatments such as medication and surgery (Zorski 2000). Some OMT techniques may resemble chiropractic adjustments. One difference is that osteopathic manipulation tends to stay within the anatomical and physiological range of motion of the joint while chiropractors may manipulate a joint beyond that range (Lesho 1999). A wide variety of OMT techniques may be applied by the practitioner to realign the musculoskeletal system; unify the circulatory, nervous, endocrine, immune, and musculoskeletal systems to function as an integrated whole; and restore the body's inherent self-regulatory and homeostatic functions (Kappler et al. 2000).


Historical Background

Andrew Taylor Still, MD, an itinerant physician on the Missouri frontier, developed osteopathy in 1874 (American Osteopathic Association 2000). Still became disillusioned with the failure of allopathic medicine to treat many illnesses effectively and believed that pharmaceuticals frequently caused more harm than good. Still's extensive knowledge of anatomy and physiology led him to conclude that the musculoskeletal system was the key to optimal health. He created osteopathic treatments as an outgrowth of traditional bone-setting methods that were used to align broken bones (Vickers and Zollman 1999).

As was the case with other alternative healing methods of the time, allopathic physicians ridiculed and refused to endorse osteopathy. Despite this opposition, an increasing public demand for his services led Still to open the first osteopathy school in Missouri in 1892. Vermont became the first state to license DOs in 1896. In 1901, the American Osteopathic Association was created to regulate the profession. Nevertheless, mainstream medicine continued to disapprove of osteopathy until the early 1960s. In 1962, the California Medical Association, the state branch of the American Medical Association, invited DOs to join its group in order to swell its ranks and gain a voting majority in the national association. By 1973, DOs had full practice rights in all 50 states (Lesho 1999).

Today, there are 19 osteopathic colleges in the United States and approximately 42,000 DOs, who make up five percent of the physician population (Kappler et al. 2000; Lesho 1999). Like other physicians, DOs have full hospital privileges, prescribe medication, and perform surgery. However, the public remains largely unaware of their methods and practice (American Osteopathic Association 2000).


Scientific Principles

The body's neurological, visceral, metabolic, and endocrine functions respond to the requirements of the musculoskeletal system through a complex system of reflex arcs, local mediators, and adrenocortical hormones, which link communication between the somatic and visceral systems. Osteopathy is based on the premise that dysfunction in the musculoskeletal system produces abnormal neural activity (Kappler et al. 2000). This affects the central nervous system via the sympathetic trunk and ganglia, and disturbs the function of the internal organs. The mechanism by which the musculoskeletal system affects the internal organs is known as a somatovisceral reflex (Lesho 1999).

At the same time, organ dysfunction manifests as abnormal tissue texture and restricted range of motion. The mechanism by which the organs affect the musculoskeletal system is known as a viscerosomatic reflex (Lesho 1999). In addition, sustained abnormal neural output induces facilitation of segmentally related areas of the spinal cord. Since communication is bidirectional, the viscera and the musculoskeletal system become linked in an abnormal cycle of afferent and efferent impulses that maintains and exacerbates the disturbance (Kappler et al. 2000). Thus, OMT aims to readjust abnormalities in the musculoskeletal system to induce far-reaching effects on the rest of the body (Lesho 1999).


Mechanism of Action

OMT is believed to work on mechanical, neurophysiological, and psychological levels to restore musculoskeletal alignment. The process is thought to reduce nociceptor activity and motor neuron firing, relax muscle fibers, release endorphins, enhance neuronal cellular transport, ensure proper blood and lymph flow, and stimulate joint lubrication (Lesho 1999).


Clinical Evaluation

The majority of DOs practice allopathic medicine as primary care physicians, so a visit to a DO is similar to a visit to an MD (American Osteopathic Association 2000). However, a DO will typically include an assessment of the musculoskeletal system, range of motion testing, and palpation of muscles, joints and tissue (Kappler et al. 2000). DOs also note skin temperature and sweat gland activity to help assess local areas of dysfunction, and may order X-rays to ascertain underlying pathology (Vickers and Zollman 1999). If the patient does not have any contraindications to OMT (see Contraindications section below), the DO may perform a series of manipulations ranging from thrust techniques to soft-tissue methods. A session can take from 15 minutes to an hour. If the patient does not improve after treatments, the DO may refer him or her to a medical specialist (Zorski 2000).


Clinical Applications

The US Department of Health and Human Services endorses OMT as an effective treatment for acute low back pain (Kappler et al. 2000). Although one study of patients with back pain concluded that there was no statistical difference in clinical outcomes between patients who received OMT and patients who received the standard medical treatment for back pain, the OMT patients had a decreased need for pain medication. If future studies document that pain medications can be reduced by using OMT, this modality would have the advantage of fewer medication-related adverse events and side effects as well as potential cost savings (Andersson et al. 1999).

The study of osteopathy has been applied for non-musculoskeletal problems as well; for example, a blinded, randomized, controlled study of hospitalized patients with pancreatitis resulted in significantly fewer days in the hospital for those treated with OMT (Lesho 1999). Furthermore, a small, controlled study indicated that OMT improved gait in patients with idiopathic Parkinson's disease after only one treatment. A study of 100 hypertensive patients treated solely with OMT showed significant reductions in systolic and diastolic blood pressure. Researchers postulate that osteopathy may delay the onset of permanent hypertension by decreasing aldosterone levels in the blood. Furthermore, studies using rhinomanometry show that OMT reduces the amount of work required by the nose during breathing; these studies corroborate patient reports that OMT drains the sinuses and relieves the symptoms, duration, and recurrence of the common cold (Kappler et al. 2000).

Surgery for carpal tunnel syndrome is one of the most commonly performed surgical procedures on the hand in the United States (Rayan 1999). Repetitive motion injuries, among which carpal tunnel syndrome is the most prevalent, account for nearly fifty percent of work-related disorders (Szabo 1998). Studies suggest that osteopathy is an effective modality for carpal tunnel syndrome because it alleviates pressure on the median nerve and helps patients avoid surgery (Sucher and Hinrichs 1998). One small, uncontrolled study of 16 subjects who underwent manipulation showed them to manifest increased range of motion, decreased subjective symptoms, and improved nerve conduction. All 16 decreased restriction to a grade of 2 or less on a 1 to 5 point analog scale (Sucher 1994). If this effect is confirmed, osteopathic manipulation might help to eliminate or reduce unnecessary invasive procedures and provide some cost savings.

In addition to the above conditions, osteopathy is used to treat neck and shoulder pain, sports injuries, repetitive strain disorders, headaches, arthritis, and dysmenorrhea (Vickers and Zollman 1999); whiplash, scoliosis, lumbar radiculopathies, spondylolysis, and coccygodynia (Andersson et al. 1999); and muscle spasm, myofascial strain, myositis, piriformis syndrome, stress, tension headache, and cervical, thoracic, and lumbar strain or sprain (Kappler et al. 2000). Cranial osteopathy, an osteopathic technique that stimulates the craniosacral system, has been used to treat colic, constant crying, disturbed sleep patterns, and behavioral problems in young children (Vickers and Zollman 1999).


Risks, Side Effects, Adverse Events

There tend to be few risks associated with OMT, which may be explained by the fact that osteopaths generally do not attempt to move a joint beyond its restricted range of motion (Lesho 1999). Side effects reported in 25-50% of all patients include a temporary increase in pain, slight headache, and fatigue. Seventy five percent or more of all such complaints resolve within 24 hours. Stroke and spinal cord injury have been reported in the literature and are estimated to occur in 1 in 20,000 patients undergoing cervical manipulation. However, it is possible that greater awareness of these risks has improved osteopathic practice and reduced the rate of severe complications (Vickers and Zollman 1999). In addition, vertebral artery thrombosis following upper cervical manipulation has been reported in the literature at an incidence of 1 in 400,000 manipulations. A comprehensive literature review of English language journals revealed that of 78 reports of cerebrovascular manipulative injuries, only eight cases could be attributed to osteopaths (Kappler et al. 2000).


Contraindications

Most contraindications are related to high velocity thrusts, one of the many manipulative techniques used by osteopaths (Kappler et al. 2000). Contraindications to high velocity thrusts and other OMTs include acute inflammatory arthropathies, fracture, dislocation, ligament rupture or instability, infection, vertebrobasilar arterial insufficiency, aneurysm, acute myelopathy, and acute cauda equina syndrome (Vickers and Zollman 1999). Other contraindications include rheumatoid arthritic involvement of the cervical spine, bony metastasis, or severe osteopenia (Lesho 1999). Likewise, patients with osteoporosis can sustain pathological fractures if excess force is used (Kappler et al. 2000). Relative contraindications to high velocity thrusts include spondylolisthesis with ongoing slippage, articular hypermobility, recent joint surgery with signs of instability, benign bone tumors, and concurrent use of anticoagulant medication (Vickers and Zollman 1999). Patients with metastatic cancer, active pulmonary tuberculosis, or miliary tuberculosis should not undergo lymphatic pump techniques (Lesho 1999).


Additional Clinical Outcomes

Osteopathy may also be suitable for adhesive capsulitis, anterior knee pain, asthma, epicondylitis, tendonitis (particularly of the rotator cuff), impingement syndrome, irritable bowel syndrome, plantar fascitis, thoracic outlet syndrome, temporomandibular joint syndrome (TMJ), and vertigo. It may be a useful adjunctive treatment for sinusitis, anxiety, depression, fibromyalgia, osteoarthritis, degenerative disc disease, spondylolisthesis without slippage, herniated disc, Bell's palsy, chronic obstructive lung disease, gastrointestinal disorders, pneumonia, reflex sympathetic dystrophy, pregnancy and childbirth, otitis media, and premenstrual syndrome (Kappler et al. 2000).


The Future

The number of DOs is growing in the United States. In 1996, the number of applicants to osteopathic medical schools increased by 5.2% from the previous year to a total of 10,781 (Lesho 1999). In recent years, there has been a perceived convergence of osteopathic and conventional medicine, which has increased accessibility to, and usage of, osteopathic manipulation. Despite the growing numbers of osteopaths and the greater utilization of OMT, however, there is concern for the future of osteopathic medicine. DOs tend to function primarily as primary care physicians, they generally pursue postgraduate study in conventional programs, and the parameters for their practice are patterned on conventional diagnostic and treatment principles. In such an environment, there is potential for the loss of osteopathic manipulative skills, along with decreased adherence to the principles and philosophy of osteopathic medicine. Continuing research and education are necessary in order to establish the scientific and clinical foundations of osteopathy (Wagner 1996).


Training, Certification, and Licensing Requirements

The educational requirements for DOs are practically identical to those for conventional doctors. DOs receive four years of basic medical education, one year of a general rotating internship (Kappler et al. 2000), and two to six years of residency training in a chosen specialty area (American Osteopathic Association 2000). The major difference between osteopathic and conventional medical education is that osteopaths receive extra training in the musculoskeletal system and OMTs (American Osteopathic Association 2000). In addition, osteopathic schools tend to have a more preventive and holistic focus than do conventional medical schools (American Osteopathic Association 2000). To obtain state licenses, DOs must also pass a national board examination that is comparable to the MD state licensing exam (American Osteopathic Association 2000). DOs are licensed in all 50 states; the American Osteopathic Association regulates their education, training, and practice.


Resources

For referral information, contact the American Osteopathic Association in Chicago, Illinois at 800-621-1773 or on the web at www.am-osteo-assn.org; and the American Academy of Osteopathy in Indianapolis, Indiana at 317-879-1881 or on the web at www.aao.medguide.net. The American College of Osteopathic Family Physicians in Arlington Heights, Illinois, at 800-323-0794 or on the Web at www.acofp.org, is one of the largest professional organizations for DOs in the United States.


References

American Osteopathic Association. What is a doctor of osteopathic medicine (D.O.)? Accessed July 27, 2000 at www.am-osteo-assn.org/Consumers/whatdo.htm.

Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med. 1999;341(19):1426-1431.

Kappler R, Ramey KA, Heinking KP. Osteopathic Medicine. In: Novey DW, ed. Clinician's Complete Reference to Complementary and Alternative Medicine. St. Louis, Mo: Mosby; 2000:325-337.

Lesho EP. An overview of osteopathic medicine. Arch Fam Med. 1999;8(6):477-484.

Rayan GM. Carpal tunnel syndrome between two centuries. J Okla State Med Assoc. 1999;92(10):493-503.

Sucher BM. Palpatory diagnosis and manipulative management of carpal tunnel syndrome. J Am Osteopath Assoc. 1994;94(8):647-663.

Sucher BM, Hinrichs RN. Manipulative treatment of carpal tunnel syndrome: biomechanical and osteopathic intervention to increase the length of the transverse carpal ligament. J Am Osteopath Assoc. 1998;98(12):679-686.

Szabo RM. Carpal tunnel syndrome as a repetitive motion disorder. Clin Orthop. 1998;351:78-89.

Vickers A, Zollman C. The manipulative therapies: osteopathy and chiropractic. BMJ. 1999;319(7218):1176-1179.

Wagner GN. Osteopathy. In: Micozzi MS, ed. Fundamentals of Complementary and Alternative Medicine. New York, NY: Churchill Livingstone; 1996:79-89.

Zorski KC. Osteopathy: restoring health through science. The Integrative Medicine Companion. Newton, Mass: Integrative Medicine Communications; 2000:40-41.


Copyright © 2000 Integrative Medicine Communications

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