Osteopathic manipulation

Osteopathic manipulative medicine (OMM)

osteopathic manipulative treatment (OMT)
Alternative therapy
Benefits| Placebo
MeSH| D026301
ICD-10-PCS| 7
ICD-9-CM| 93.6
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Osteopathic manipulation or osteopathic manipulative medicine is a core set of techniques of osteopathy and osteopathic medicine distinguishing these fields from the rest of medicine.[1] Parts of osteopathy, such as cranial therapy, have been labeled pseudoscience and have no therapeutic value.[2][3] The techniques are based on an ideology created by Andrew Taylor Still (1828–1917) which posits the existence of a myofascial continuity - a tissue layer that connects all parts of the body. Non-physician osteopaths and osteopathic physicians attempt to diagnose and treat somatic dysfunction by manipulating a person's bones and muscles and therefore address a variety of ailments. OMT techniques are most commonly used to treat back pain and other musculoskeletal issues, and are less commonly used to treat systemic conditions such as asthma and Parkinson's disease.[1][4]

OMT is based on the idea that a myofascial continuity "links every part of the body with every other part"; a practitioner, through a "skillful and dexterous use of the hands" treats what was originally called "the osteopathic lesion", but which is now named "somatic dysfunction".[1] The most commonly treated ailment is back pain, although some practitioners claim OMT can be used to treat a wide range of conditions.[4]

## Contents

* 1 History
* 2 Clinical practice
* 2.1 Muscle energy
* 2.2 Counterstrain
* 2.3 High-velocity, low-amplitude
* 2.4 Myofascial release
* 2.5 Lymphatic pump treatment
* 3 Effectiveness
* 4 Criticism
* 5 See also
* 6 References
* 7 Further reading

## History

Andrew Taylor Still in 1914

Andrew Taylor Still, M.D., D.O. was a 19th-century American physician and Civil War surgeon who founded osteopathic medicine. Following the loss of three of his children to spinal meningitis, Still became dissatisfied with contemporary medical practices and sought to further medical understanding and treatment.[5] Still claimed that human illness was rooted in problems with the musculoskeletal system, and that hands-on manipulations could solve these problems and so effect a cure by harnessing the body's own self-repairing potential.[6] Still's proposed treatment regime also included as strong dose of healthy living: he advocated abstinence from alcohol, and patients were forbidden from taking medicine.[1]

## Clinical practice

Osteopathic manipulative treatment (OMT) involves palpation and manipulation of bones, muscles, joints, and fasciae.

According to the American Osteopathic Association (AOA), osteopathic manipulative treatment is considered to be only one component of osteopathic medicine and may be used alone or in combination with pharmacotherapy, rehabilitation, surgery, patient education, diet, and exercise. OMT techniques are not necessarily unique to osteopathic medicine; other disciplines, such as physical therapy or chiropractic, use similar techniques.[7]

One key concept osteopathic medical students learn is that structure influences function. Thus, if there is a problem in one part of the body’s structure, function in that area, and possibly in other areas, may be affected. Another integral tenet of osteopathic medicine is the body’s innate ability to heal itself. Many of osteopathic medicine’s manipulative techniques are aimed at reducing or eliminating the impediments to proper structure and function so the self-healing mechanism can assume its role in restoring a person to health.[8]

Osteopathic medicine defines a concept of health care that embraces the concept of the unity of the living organism's structure (anatomy) and function (physiology). The American Osteopathic Association (AOA) state that the four major principles of osteopathic medicine are the following:[9]

1. The body is an integrated unit of mind, body, and spirit.
2. The body possesses self-regulatory mechanisms, having the inherent capacity to defend, repair, and remodel itself.
3. Structure and function are reciprocally interrelated.
4. Rational therapy is based on consideration of the first three principles.

These principles are not held by Doctors of Osteopathic Medicine to be empirical laws; they serve, rather, as the underpinnings of the osteopathic approach to health and disease.[citation needed]

### Muscle energy

Main article: Medicine:Muscle energy technique

Muscle energy techniques address somatic dysfunction through stretching and muscle contraction. For example, if a person is unable to fully abduct her arm, the treating physician raises the patient's arm near the end of the patient's range of motion, also called the edge of the restrictive barrier. The patient then tries to lower her arm, while the physician provides resistance. This resistance against the patient's motion allows for isometric contraction of the patient's muscle. Once the patient relaxes, her range of motion increases slightly. The repetition of alternating cycles of contraction and subsequent relaxation help the treated muscle improve its range of motion.[10] Muscle energy techniques are contraindicated in patients with fractures, crush injuries, dislocations, joint instability, severe muscle spasms or strains, severe osteoporosis, severe whiplash injury, vertebrobasilar insufficiency, severe illness, and recent surgery.

### Counterstrain

Main article: Medicine:Counterstrain

Counterstrain is a system of diagnosis and treatment that considers the physical dysfunction to be a continuing, inappropriate strain reflex, which is inhibited during treatment by applying a position of mild strain in the direction exactly opposite to that of the reflex.[11] After a counterstrain point tender to palpation has been diagnosed,[12] the identified tender point is treated by the osteopathic physician who, while monitoring the tender point, positions the patient such that the point is no longer tender to palpation.[13] This position is held for ninety seconds and the patient is subsequently returned to her normal posture.[12] Most often this position of ease is usually achieved by shortening the muscle of interest.[13] Improvement or resolution of the tenderness at the identified counterstrain point is the desired outcome.[12] The use of counterstrain technique is contraindicated in patients with severe osteoporosis, pathology of the vertebral arteries, and in patients who are very ill or cannot voluntarily relax during the procedure.

### High-velocity, low-amplitude

High velocity, low amplitude (HVLA) is a technique which employs a rapid, targeted, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint and engages the restrictive barrier in one or more places of motion to elicit release of restriction.[14] The use of HVLA is contraindicated in patients with Down syndrome due to instability of the atlantoaxial joint which may stem from ligamentous laxity, and in pathologic bone conditions such as fracture, history of a pathologic fracture, osteomyelitis, osteoporosis, and severe cases of rheumatoid arthritis.[15][16] HVLA is also contraindicated in patients with vascular disease such as aneurysms, or disease of the carotid arteries or vertebral arteries.[15] People taking ciprofloxacin or anticoagulants, or who have local metastases should not receive HVLA.[15]

### Myofascial release

Main article: Medicine:Myofascial release

Myofascial release is a form of soft tissue therapy used to treat somatic dysfunction and the resultant pain and restriction of motion. Treatment requires continual palpatory feedback to achieve release of myofascial tissues.[14] This is accomplished by relaxing contracted muscles, increasing circulation and lymphatic drainage, and stimulating the stretch reflex of muscles and overlying fascia.[17]

Fascia is the soft tissue component of the connective tissue that provides support and protection for most structures within the human body, including muscle. This soft tissue can become restricted due to psychogenic disease, overuse, trauma, infectious agents, or inactivity, often resulting in pain, muscle tension, and corresponding diminished blood flow.[18] Although fascia and its corresponding muscle are the main targets of myofascial release, other tissue may be affected as well, including other connective tissue.[17]

Some osteopaths search for "Chapman release points" as part of a diagnostic procedure; these are small lumps of tissue that can appear in certain positions, and are thought to signal involvement of viscera in complaints.[19]

### Lymphatic pump treatment

Main article: Unsolved:Lymphatic pump

Lymphatic pump treatment (LPT) is a manual technique intended to encourage lymph flow in a person's lymphatic system.[citation needed] The first modern lymphatic pump technique was developed in 1920, although osteopathic physicians used various forms of lymphatic techniques as early as the late 19th century.[20]

Relative contraindications for the use of lymphatic pump treatments include fractures, abscesses or localized infections, and severe bacterial infections with body temperature elevated higher than 102 °F (39 °C).[21]

## Effectiveness

In 2014, a systematic review and meta-analysis of 15 randomized controlled trials found moderate-quality evidence that OMT reduces pain and improves functional status in acute and chronic nonspecific low back pain.[22] The same analysis also found moderate-quality evidence for pain reduction for nonspecific low back pain in postpartum women and low-quality evidence for pain reduction in nonspecific low back pain in pregnant women.[22] A 2013 systematic review found insufficient evidence to rate osteopathic manipulation for chronic nonspecific low back pain.[23] In 2011, a systematic review found no compelling evidence that osteopathic manipulation was effective for the treatment of musculoskeletal pain.[24]

In 2013, a Cochrane Review reviewed six randomized controlled trials which investigated the effect of four types of chest physiotherapy (including OMT) as adjunctive treatments for pneumonia in adults and concluded that "based on current limited evidence, chest physiotherapy might not be recommended as routine additional treatment for pneumonia in adults." Techniques investigated in the study included paraspinal inhibition, rib raising, and myofascial release. The review found that OMT did not reduce mortality and did not increase cure rate, but that OMT slightly reduced the duration of hospital stay and antibiotic use.[25] A 2013 systematic review of the use of OMT for treating pediatric conditions concluded that its effectiveness was unproven.[26]

With respect to irritable bowel syndrome, a 2014 review found that there had been a limited number of studies done and that all these studies had small sample sizes; with that caveat, it found preliminary evidence that osteopathic manipulation may be beneficial in this condition.[27]

A 2005 Cochrane Review of OMT in asthma treatment concluded that there was insufficient evidence that OMT can be used to treat asthma.[28]

A 2018 systematic review found that there is no evidence for the reliability or specific efficacy of the techniques used in visceral osteopathy.[29]

## Criticism

D.O.s were listed by the AMA as "cultists" and deemed M.D. consultation of D.O.s unethical from 1923 until 1962.[30] M.D.s regarded that their treatments were rooted in "pseudoscientific dogma", and although physicians from both branches of medicine have been able to meet on common ground, tensions between the two continue.[6]

In 1988, Petr Skrabanek classified osteopathy as one of the "paranormal" forms of alternative medicine, commenting that it has a view of disease which had no meaning outside its own closed system.[31]

In a 1995 conference address, the president of the Association of American Medical Colleges, Jordan J. Cohen, pinpointed OMT as a defining difference between M.D.s and D.O.s; while he saw there was no quarrel in the appropriateness of manipulation for musculoskeletal treatment, the difficulty centered on "applying manipulative therapy to treat other systemic diseases" - at that point, Cohen maintained, "we enter the realm of skepticism on the part of the allopathic world."[6]

In 1998 Stephen Barrett of Quackwatch posted a highly critical article online entitled "Dubious Osteopathic Practices", in which he said that the worth of manipulative therapy had been exaggerated and that the American Osteopathic Association (AOA) was acting unethically by failing to condemn craniosacral therapy. The article attracted a letter from the law firm representing the AOA accusing Barrett of libel and demanding an apology to avert legal action.[6] In response Barrett made some slight modifications to his text, while maintaining its overall stance; he queried the AOA's reference to "the body's natural tendency toward good health" and challenged them to "provide [him] with adequate scientific evidence showing how this belief has been tested and demonstrated to be true."[6] Barrett has been quoted as saying "the pseudoscience within osteopathy can't compete with the science".[6]

In 1999, Joel D. Howell noted that osteopathy and medicine as practiced by M.D.s were becoming increasingly convergent. He suggested that this raised a paradox:

> 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?[1]

In 2004, the osteopathic physician Bryan E. Bledsoe, a professor of emergency medicine, wrote disparagingly of the "pseudoscience" at the foundation of OMT. In his view, "OMT will and should follow homeopathy, magnetic healing, chiropractic, and other outdated practices into the pages of medical history."[32]

In 2010, Steven Salzberg wrote that OMT was promoted as a special distinguishing element of DO training, but that it amounted to no more than "'extra' training in pseudoscientific practices."[33]

## See also

* Chiropractic
* Doctor of Osteopathic Medicine
* List of osteopathic colleges
* Osteopathic medicine in the United States
* Spinal manipulation

## References

1. ↑ 1.0 1.1 1.2 1.3 1.4 Howell, Joel D. (1999). "The Paradox of Osteopathy". New England Journal of Medicine 341 (19): 1465–8. doi:10.1056/NEJM199911043411910. PMID 10547412. [non-primary source needed]
2. ↑ "Dubious Aspects of Osteopathy". http://www.quackwatch.org/04ConsumerEducation/QA/osteo.html.
3. ↑ "Why Cranial Therapy Is Silly". http://www.quackwatch.com/01QuackeryRelatedTopics/cranial.html.
4. ↑ 4.0 4.1 Manipulative Therapies: Osteopathy and Chiropractic. John Wiley & Sons. 1997. p. 15. ISBN 978-0-471-96645-6. https://books.google.com/books?id=Q_UnQNQPJ60C&pg=PA15.
5. ↑ "Andrew Taylor Still, The Father of Osteopathic Medicine". A.T. Still University - Museum of Osteopathic Medicine. http://www.atsu.edu/museum/ats/index.htm. Retrieved 2011-12-19.
6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Guglielmo, WJ (1998). "Are D.O.s losing their unique identity?". Medical economics 75 (8): 200–2, 207–10, 213–4. PMID 10179479.
7. ↑ "What Is Osteopathic Medicine?". Aacom.org. http://www.aacom.org/about/osteomed/Pages/default.aspx. Retrieved 2012-05-24.
8. ↑ "What is Osteopathic Medicine". American Association of Colleges of Osteopathic Medicine (AACOM). http://www.aacom.org/become-a-doctor/about-om#aboutom. Retrieved 17 December 2014.
9. ↑ "Statement of Healthcare Policies and Principles". American Osteopathic Association. http://www.osteopathic.org/inside-aoa/advocacy/Documents/aoa-healthpolicy-principles.pdf. Retrieved 1 July 2012.
10. ↑ DiGiovanna, Schiowitz & Dowling 2005, pp. 83–5
11. ↑ DiGiovanna, Schiowitz & Dowling 2005, pp. 86–8
12. ↑ 12.0 12.1 12.2 "Strain counterstrain technique to decrease tender point palpation pain compared to control conditions: A systematic review with meta-analysis". J Bodyw Mov Ther 18 (2): 165–73. April 2014. doi:10.1016/j.jbmt.2013.09.010. PMID 24725782.
13. ↑ 13.0 13.1 Wong CK (February 2012). "Strain counterstrain: Current concepts and clinical evidence". Manual Therapy 17 (1): 2–8. doi:10.1016/j.math.2011.10.001. PMID 22030379.
14. ↑ 14.0 14.1 "Glossary of Osteopathic Terminology, November 2011 Edition". AACOM. pp. 30–31. http://www.aacom.org/resources/bookstore/Pages/glossary.aspx. Retrieved 1 July 2012.
15. ↑ 15.0 15.1 15.2 Roberge, Raymond J.; Roberge, Marc R. (2009). "Overcoming Barriers to the Use of Osteopathic Manipulation Techniques in the Emergency Department". Western Journal of Emergency Medicine 10 (3): 184–9. PMID 19718381. PMC 2729220. http://escholarship.org/uc/item/31547932.
16. ↑ Savarese, Copabianco & Cox 2009, p. 146
17. ↑ 17.0 17.1 DiGiovanna, Schiowitz & Dowling 2005, p. 80
18. ↑ DiGiovanna, Schiowitz & Dowling 2005, pp. 80–1
19. ↑ Chila, Anthony G. (2010) (in en). Foundations of Osteopathic Medicine. Lippincott Williams & Wilkins. p. 568. ISBN 9780781766715. https://books.google.com/books?id=_ZR6elRmQKEC&pg=PA568.
20. ↑ Chikly, Bruno J. (2005). "Manual Techniques Addressing the Lymphatic System: Origins and Development". The Journal of the American Osteopathic Association 105 (10): 457–64. PMID 16314678. http://www.jaoa.org/cgi/pmidlookup?view=long&pmid=16314678.
21. ↑ Savarese, Copabianco & Cox 2009, p. 126
22. ↑ 22.0 22.1 "Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis". BMC Musculoskelet Disord 15 (1): 286. August 2014. doi:10.1186/1471-2474-15-286. PMID 25175885.
23. ↑ "Osteopathic intervention in chronic non-specific low back pain: a systematic review". BMC Musculoskelet Disord 14: 129. 2013. doi:10.1186/1471-2474-14-129. PMID 23570655.
24. ↑ "Osteopathy for musculoskeletal pain patients: a systematic review of randomized controlled trials". Clin. Rheumatol. 30 (2): 285–91. February 2011. doi:10.1007/s10067-010-1600-6. PMID 21053038.
25. ↑ Yang, M; Yuping, Y; Yin, X; Wang, BY; Wu, T; Liu, GJ; Dong, BR (2013). Dong, Bi Rong. ed. "Chest physiotherapy for pneumonia in adults". Cochrane Database of Systematic Reviews 2 (2): CD006338. doi:10.1002/14651858.CD006338.pub3. PMID 23450568.
26. ↑ Posadzki, P.; Lee, M. S.; Ernst, E. (2013). "Osteopathic Manipulative Treatment for Pediatric Conditions: A Systematic Review". Pediatrics 132 (1): 140–52. doi:10.1542/peds.2012-3959. PMID 23776117.
27. ↑ Müller A, et al. Effectiveness of osteopathic manipulative therapy for managing symptoms of irritable bowel syndrome: a systematic review. J Am Osteopath Assoc. 2014 Jun;114(6):470-9. PMID 24917634
28. ↑ Hondras, Maria A; Linde, Klaus; Jones, Arthur P (2005). Hondras, Maria A. ed. "Manual therapy for asthma". Cochrane Database of Systematic Reviews (2): CD001002. doi:10.1002/14651858.CD001002.pub2. PMID 15846609.
29. ↑ Guillaud, Albin; Darbois, Nelly; Monvoisin, Richard; Pinsaultn, Nicolas (2018). "Reliability of diagnosis and clinical efficacy of visceral osteopathy: a systematic review". BMC Complementary and Alternative Medicine 18 (2). doi:10.1186/s12906-018-2098-8.
30. ↑ Quinn, Thomas A. (2011). The Feminine Touch: Women in Osteopathic Medicine. Truman State University Press. pp. 81-85. ISBN 9781935503132.
31. ↑ Skrabanek P (April 1988). "Paranormal health claims". Experientia 44 (4): 303–9. doi:10.1007/bf01961267. PMID 2834214.
32. ↑ Bryan E. Bledsoe (2004). "The Elephant in the Room: Does OMT Have Proved Benefit?". J Am Osteopath Assoc 104 (10): 407. http://jaoa.org/Article.aspx?articleid=2092865.
33. ↑ Salzberg, Steven (27 October 2010). "Second Thoughts On Osteopathic Medicine". Forbes. https://www.forbes.com/sites/sciencebiz/2010/10/29/second-thoughts-on-osteopathic-medicine. Retrieved 18 September 2013.

## Further reading

* American Association of Colleges of Osteopathic Medicine (2011); Glossary of Osteopathic Terminology.
* Crislip M (4 October 2013). "Pump it up: osteopathic manipulation and influenza". Science-based Medicine. http://www.sciencebasedmedicine.org/pump-it-up-osteopathic-manipulation-and-influenza/. Retrieved 7 February 2014.
* Savarese, Robert G.; Copabianco, John D.; Cox, James J. (2009). OMT review. ISBN 978-0967009018.
* Smith JC (2009). Pseudoscience and Extraordinary Claims of the Paranormal: A Critical Thinker's Toolkit. John Wiley & Sons. p. 342. ISBN 978-1-4443-1013-9. https://books.google.com/books?id=ojd1sdVUydwC&pg=PA342.
* DiGiovanna, Eileen L.; Schiowitz, Stanley; Dowling, Dennis (2005). An osteopathic approach to diagnosis and treatment (3rd ed.). Philadelphia, PA: Lippincott Williams and Wilkins. ISBN 978-0781742931.
* Ward, Robert C. (2002). Foundations for Osteopathic Medicine (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. ISBN 0-7817-3497-5.

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