Michael L.Kuchera
Complementary Therapies in Neurology: An Evidence-Based Approach Edited by Barry S.Oken
ISBN 1-84214-200-3 Copyright © 2004 by The Parthenon Publishing Group, London
INTRODUCTION AND HISTORY
The osteopathic profession in the USA consists of approximately 50000 physicians, with more than 60% of the profession made up of primary care practitioners. With the number of osteopathic colleges quadrupling to 20 since 1969, it is the fastest growing health profession in the USA. Osteopathic practitioners (DOs) include specialists in every specialty field practiced by allopathic physicians (MDs) in the USA, but maintain their own educational system based upon four tenets; for this reason it has been referred to as a
‘parallel but distinctive’ profession1.
Osteopathic medicine has been described as an integration of science, philosophy and art2. It is defined as ‘a complete system of medical care with a philosophy that combines the needs of the patients with the current practice of medicine, surgery, and obstetrics;
that emphasizes the interrelationship between structure and function; and that has an appreciation of the body’s ability to heal itself’3. Such emphasis on structure (anatomy) and function (physiology) naturally increases the emphasis on the central role of the neuromusculoskeletal system. Indeed, the early development of osteopathic medical concepts emphasized the role of the nervous system as an integrator of function between the various systems of the body4, especially the soma and the viscera.
Regardless of their eventual specialty field, all of the profession’s caregivers spend a comparatively heavy amount of their pre-doctoral training in the study of anatomy—
especially the structure and function of the somatic system (skeletal, arthrodial and myofascial components) and their functional interrelationships to neural, vascular and lymphatic structures—and neurophysiology (especially the autonomic nervous system).
In addition to the more traditional neurology and neurosurgery specialties, the osteopathic profession includes an additional residency program and specialty known as neuromusculoskeletal medicine (until 1998 referred to as osteopathic manipulative medicine, OMM).
While osteopathic medicine and surgery are recognized as mainstream practices throughout all 50 of the United States, the profession is perhaps most distinctive in its educational approach and in its expectation that, prior to graduation, its eventual practitioners are all required to study and demonstrate safety and efficacy in applying
osteopathic principles and practices (OPP) and osteopathic manipulative treatment (OMT). Testing involves written and practical examinations within the individual schools as well as through all three levels of the national board examinations administered by the National Board of Osteopathic Medical Examiners. Some osteopathic specialty boards (including osteopathic family medicine—the largest board) conduct a hands-on practical examination of OMT. Also, a number of states require additional demonstration of safety and efficacy in OMT before granting a license to practice as a physician or surgeon in that state.
By the definition of the National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine (NCCAM), the same OMT that is taught and required to be mastered by all DOs in the USA is, in isolation, categorized by them as being a ‘complementary and alternative’ therapy. For this reason this text includes a chapter on osteopathic medicine but will not attempt to describe all facets of the profession.
This chapter provides a brief overview of the impact that OPP and OMT have made in the profession’s history and why there was a general lack of acceptance of the profession by the traditional medical profession until the 1960s and 1970s. It also comments on the evolution of OMT as a treatment modality and mentions techniques that are commonly used. It focuses on some of the contributions that the osteopathic profession has made to health care generally by maintaining a distinctive philosophy and modality. Finally, this chapter discusses the rationale and outcomes of applying an osteopathic approach that includes OMT as part of the care for patients with varying neurological conditions.
History of osteopathy
Osteopathy began in rural Kirksville, Missouri. It was developed and named by a traditional physician, Andrew Taylor Still, MD. Disillusioned when drugs failed to save the lives of several immediate family members during a spinal meningitis epidemic and when a brother became addicted to morphine, Still re-examined the orthodox medicine of his day, found it wanting and began a pathway of study of somatic structure and function.
He came to believe that the body contained all substances needed for health, that ‘perfect anatomy’ should lead to removal of waste products and that the delivery of nourishing blood and trophic substances improved health at the cellular level. He believed that structural impairment would restrict this process, initiating instead the progressive processes of dysfunction, ‘dis-ease’ and eventual disease.
During the period in which osteopathy developed, Still was not alone in his pursuit of an alternative to ‘mainstream’ or ‘regular’ medicine. Regular medical practice was generally criticized both professionally (Oliver Wendell Holmes) and popularly (Mark Twain—also from Missouri and an osteopathic advocate). The public was initially impressed by a number of the alternative medical practitioners of the day, then called
‘irregulars’. Still investigated several of their therapies—including ‘magnetic healing’
and ‘lightening bone-setting’—practices that some say influenced his thinking and techniques. Others suggest that scientific treatises discussing the somatic treatment of
‘spinal irritation’5,6 mayhaveinfluenced his integration of a manual approach to the spine in treatment of individuals with a wide range of illnesses.
Whatever his influences, Still wrote that his original thoughts were clearly identified in 18747. His insistence on incorporating handson treatment was considered
‘blasphemous’ and prevented him from opening a school to teach his approach in Baldwin, Kansas at a university that his family helped to found. He was subsequently ejected from the Methodist church on the basis that only Christ was allowed to heal by the ‘laying on of hands’8. When he opened the American School of Osteopathy (ASO) in Kirksville in 1892, the stated goal of the school was ‘to improve our present system of surgery, obstetrics, and treatment of diseases generally, and (to) place the same on a more rational and scientific basis, and to impart information to the medical profession’9.
In 1889 he had named his new approach ‘osteopathy’ from the roots osteon, meaning bone, and pathos, meaning to suffer. He selected this name because it denoted the bony skeleton that had served as his ‘starting point’ for understanding clinical problems and it paralleled other medical system names of that period, including allopathy and homeopathy. While the name seems to imply a unifocal fixation on bone, Still taught that
‘the fascia is the place to look for the cause of disease and to begin the action of the remedy’ and that ‘the rule of the artery was supreme’. Bones were available for ‘use as levers to relieve pressure on nerves, veins and arteries’7. Manipulative procedures were designed to release bony and soft tissue barriers affecting nervous and circulatory functions with the expectation that the body’s self-healing (homeostatic) mechanisms would then return the person to health. He taught that ‘Rational methods of treatment are based upon an attempt to provide normal nutrition, innervation and drainage to all tissues of the body, and these depend chiefly upon the maintenance of normal structural relationships’10.
Throughout Still’s lifetime and thereafter, the osteopathic profession did not consider OMT to be an isolated treatment modality. From the beginning, the ASO and its infirmary promoted the use of antiseptics and anesthetics in surgery and antidotes to poisons. Still continued to practice and teach obstetrics. The centrality of OMT in the curriculum—even to the potential exclusion of teaching pharmaceuticals—was frequently debated, but the osteopathic teaching institutions decided to prepare their graduates for complete licensure regardless of Still’s personal thoughts about the Materia Medica.
Within two decades, osteopathic medicine in the USA moved from a single practitioner to ten colleges with practitioners located in the majority of the United States and in several international sites. It escaped the trap of many other alternative medical approaches that became virtual cults by revering their founders’ words to the detriment of the integration of new discoveries and approaches. One hundred years later, a conclusion by both MD and DO leaders in the Macy Foundation Report13 was that the USA benefits from the parallel but distinct medical systems. It is predicted on the potential of each to contribute uniquely and synergistically to health care.
History of research in osteopathic palpatory diagnosis and osteopathic manipulative treatment
From almost the beginning of the profession, researchers at the ASO in Kirksville investigated what was called the ‘osteopathic lesion’. In 1898, researchers used skiagraphy, an early form of X-ray, to look at alignment of bones and distribution of the vascular and lymphatic systems14.
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Profession-wide funding for the A.T. Still Research Institute beginning in 1906 with Louisa Burns, DO as the director, resulted in nearly four decades of publication 15–17. Her research at the institute focused on the effect of extrinsically induced somatic dysfunction in a rabbit model. The results indicated that straining specific vertebral segments produced reproducible constellations of change in organs and tissues sharing the same segmental innervation as the area of strain. Wilbur Cole, using various neural stains, later substantiated many of these changes18.
From 1945 to 1970, human measurements and further inquiry into the basic mechanisms underlying somatic dysfunction were undertaken in Kirksville by a team of osteopathic physicians and PhD physiologists19–22. Both the palpatory characteristics and the physiological impact of segmental spinal somatic dysfunction were documented with a variety of emerging neurophysiological tests including electromyography. Somatic dysfunction (called the ‘osteopathic lesion’ until the 1960s) was demonstrated to be an objective finding with reproducible and predictable effects on neurophysiological parameters. The results from studies of muscle reactivity, sweat gland and electrical skin resistance changes, and histamine responses (among others) contributed to the physiological concept of a facilitated spinal cord segment—generally an expansion of the concept of neural facilitation. Yet other studies from the Kirksville team led to a better understanding of axoplasmic and reverse axoplasmic flow23. In short, the research of this laboratory resulted in a conceptual framework that has supported much of today’s thought concerning palpatory diagnosis and use of OMT to modify neurophysiological function24–27.
Since 1970, the rapid expansion of university-based and/or state-sponsored osteopathic colleges as well as the acceptance of US-trained osteopathic physicians as medical colleagues with valuable information to offer about manual medicine has led to a series of national and international congresses concerning the evidence base of manual medicine including OMT28–31 The diagnosis and definition of ‘somatic dysfunction’, as proposed by the osteopathic profession, was accepted into the Hospital Adaptation of the International Classification of Disease. During this period, DOs from the USA were allowed representation in the physicians-only International Federation of Manual/Musculoskeletal Medicine with subsequent rich exchange of professional information, advancing the evidence base and treatment options in this field.
By systematically studying somatic dysfunction and its effects, the osteopathic profession has contributed greatly to the literature and therefore to the understanding of a wide range of health-care professionals who assess the function of the neuromusculoskeletal system. Likewise, it has benefited from the basic science contributions of other professions studying chiropractic subluxations, myofascial trigger points, or other ‘impaired or altered functions’ of components of the neuromusculoskeletal system.
The wide range of osteopathic manual techniques designed to treat somatic dysfunction has largely been adopted by the bulk of those health-care professionals currently delivering hands-on care. Inter-professional collegiality also permitted the osteopathic profession to integrate studies of manual techniques from others. In this arena, for ‘technique’ or fixed ‘technique protocol’ studies, the degree of the researcher or ‘technician’ delivering the technique is less important than their documented skill to do so in a consistent manner to obtain a certain specified goal.
Looking ahead, however, the osteopathic profession needs to move beyond adding a technique or technique protocol to conservative care and towards completing larger out-come studies and studies of the cost-efficacy of the ‘osteopathic approach’. Statewide analysis of Workers’ Compensation data32–34 by different health-care practitioners, including physical therapists, chiropractors, MDs and DOs, revealed that, in every body region and in every condition, the osteopathic practitioners were the most cost-effective with their approach. The data, however, did not indicate where palpatory diagnosis might have been used to exclude the need for a more expensive radiological study; where manipulation might have facilitated recovery and decreased the time absent from work;
or, for that matter, when OMT had been a treatment modality and when it had not. In other words, these data cannot be used to prove the cost-efficacy of OMT but raise some interesting considerations regarding the importance of the application of osteopathic thinking and treatment modalities for the care of patients with injuries, dysfunctions or disease.
That OMT is capable of altering or eliminating somatic dysfunction is not contested;
nor that somatic dysfunction treated with OMT (or other clinical approaches) leads to beneficial change in a number of physiological and neurological parameters. Nonetheless, until recently, the evidence that OMT affects significant clinical outcomes for given conditions has been largely anecdotal.
Today, osteopathic schools are the recipients of research grants from the NIH and other sources. While such research contributes significant new knowledge in a wide range of clinical and basic science fields, only a small percentage of the total research output of the osteopathic profession today is focused on expanding the evidence base for somatic dysfunction and manipulative techniques, or for the osteopathic approach to patients with specific medical, traumatic, obstetric, or surgical conditions. By virtue of the nature of the questions asked and the research design required, it has been particularly difficult to obtain sufficient research dollars to construct longitudinal studies in OMM.
Accessing and building upon osteopathic research
While the osteopathic profession has embraced research since its inception, it has been primarily recognized for its clinical service (especially in primary care) rather than for its research contributions. This is partially due to the fact that the profession’s research contributions in this area are difficult to locate and also because its research conclusions translate poorly into clinically relevant practice.
A brief historical comment is pertinent to understanding part of the difficulty in accessing large portions of the evidence base for OMT. Prior to 1970, the policy of the American Medical Association (AMA) was to consider interactions between MDs and DOs as ‘unethical,’ thus osteopathic research was, by necessity, published within the profession’s own journals (such as the Journal of the American Osteopathic Association and Osteopathic Annals) and the American Academy of Osteopathy’s yearbooks. In 1966, AMA policy changed and the Journal of the American Osteopathic Association was accepted as an Index Medicus-referenced, peer-reviewed journal. The profession also was slow to develop and publish a standardized Glossary of Osteopathic Terminology to provide language, a thesaurus for indexing its literature, and the resources and personnel to accomplish these tasks. This glossary was first published in 1981. In the mid-1990s,
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the American Osteopathic Association (AOA) Bureau of Research and the American Association of Colleges of Osteopathic Medicine authorized finances needed to catalog the older osteopathic landmark research and the earlier basic studies and to place these into a database allowing computerized literature searches. (The current site for search is http://ostmed.hsc.unt.edu/).
It is understood that the research designs required for drug trials are not ideally suited to the study of many of the pertinent questions raised by the osteopathic approach. The randomized, double-blind research ‘gold-standard’ is often difficult to apply to the study of the osteopathic approach because of the profession’s philosophical emphasis on health rather than disease and its prioritization of individual host factors in constructing a therapeutic prescription. Blinding, with respect to manual techniques generally, has been problematic and consensus on an adequate ‘sham treatment’ for such manual approaches has not been reached.
It is sometimes difficult to decide which OMT protocol or even which specific manipulative technique should be tested for patients with a certain dysfunction, injury, or disease. This is because OMT is typically not applied in such a way in practice. OMT, as practiced by osteopathic physicians, is generally not prescribed for the disease per se, but is instead selected and modified for the concomitant somatic dysfunction that is produced and found in each patient reacting to the disease. Thus, in real life, OMT sequences and technique choices are directed by continuous interpersonal feedback between patient and physician as well as by the local, regional and systemic response of the patient to the previous technique selected and delivered. Each patient responds differently. To write an OMT protocol, in advance, for a series of very different individuals having only a specific disease process in common is likely to miss the inherent questions that the profession would like to have answered.
DIFFERENTIATING OSTEOPATHIC MANIPULATIVE TREATMENT FROM OTHER MANUAL TECHNIQUES
Still observed that ‘Not all manipulators are osteopaths’. This is particularly true today, as many health-care professionals incorporate hands-on manual maneuvers.
Outnumbering DOs and possessing fewer overall therapeutic options, most manipulation in the USA is performed by members of the chiropractic profession. Founded several years after the osteopathic profession and only a few hundred miles from the birthplace of osteopathy, chiropractic was able to grow as a separate profession by virtue of the fact that there were wide differences in both the types of manual technique employed and the philosophical differences in practitioners’ decisions as to how, when, why and where to manipulate35. Significant differences still exist between the two professions in both diagnosis and the manipulative techniques that are employed, yet, as the evidence base increases, internationally and across all professions, these aspects are independently evolving in similar directions. Today, by virtue of education and license, the greatest difference between the chiropractic and osteopathic practitioners can be found in the training and the unlimited range of therapeutic options that are available to osteopathic physicians.
On the other hand, OMT is often reported to be the most outward and visible sign of the difference between MDs and DOs. Nonetheless, the modality of OMT alone does not differentiate the two professions. It should be pointed out that many DOs choose not to integrate OMT into their practices and many MDs learn manual techniques in postgraduate coursework and integrate these into their practices.
Neither is a manual modality appropriately termed ‘OMT’ just because it was delivered by a physician with a DO degree. OMT, by definition, is ‘the therapeutic application of manually guided forces…to improve physiologic function and/or support homeostasis that have been altered by somatic dysfunction’36.
OMM denotes the ‘application of osteopathic philosophy, structural diagnosis, and the use of OMT in the diagnosis and management of the patient’36. The importance of the integration of osteopathic philosophy and the OMM perspective cannot be overestimated in understanding the distinctiveness of the osteopathic profession. Just as the philosophical underpinnings of the acupuncturist differentiate needling from acupuncture, so the osteopathic perspective of philosophy, science and art modifies the choice and site of the application of a given manual technique and differentiates OMT from a chiropractic adjustment or an MD-applied manual medicine maneuver. Thus, for those critically evaluating clinical outcomes, for those referring patients for osteopathic care and also for the patient, the difference in the semantics is important.
It is probably for this reason that MDs currently practicing in the field of ‘manual medicine’ recognize that there is a difference between those who add manipulative/manual techniques to a medical practice and those physicians who have distinctive osteopathic training and are therefore practicing OMT as an ‘osteopathic’
manipulative treatment.
In summary, OMT played a central role in the history of the osteopathic profession and was a central component in discussions sponsored by the Macy Foundation. Leaders noted the specific need for expanding the evidence base and in demonstrating the mechanisms of action and clinical outcomes associated with OMT. Regarding osteopathic clinical practice, the Macy conference chairperson, D.Kay Clawson, noted,
‘There are some of us in the allopathic world who believe sincerely that osteopaths have something very special in their practice that needs to be highlighted by all of us.’13 Of OMT specifically, one keynote presenter from the Association of American Medical Colleges presented the conclusion: ‘And if, (the osteopathic) belief that this approach to patient diagnosis and therapy proves to be valid, then I think all physicians ought to utilize it to improve the quality of the health care that we deliver.’37
Palpatory diagnosis and osteopathic manipulative modalities
Dr Still’s teaching emphasized anatomy and not the specifics of his hands-on technique.
Today, however, the curriculum of osteopathic colleges includes several hundred hours reserved for specifically teaching the art of palpatory diagnosis and manipulative technique and for testing the cognitive, psychomotor and affective aspects of OMT and OMM. There are over 50 different types of technique taught for treatment of somatic dysfunction in every region of the body and for its effect on homeostatic functions in patients with diverse medical, surgical and other health problems38. (See Table 1 for some of the more commonly used techniques3,39.) Many of these techniques have been
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