OSTEOPATHY: Nudging the Anatomy in the Right Direction

In discerning what osteopathy is and what it can do, it helps to have an osteopathic medical student perspective. Osteopathic students are taught the four tenets of osteopathy and apply them in all aspects of their practice:

• A person is a unity of body, mind and spirit.
• Structure and function are interrelated.
• The body has an innate capacity to heal itself.
• Rational therapy by an osteopathic physician is based on an appreciation of the above three principles.

Osteopathic education has gone through much evolution since the first osteopathic medical school opened in Kirksville, Missouri, in 1892. Schools of osteopathic medicine are today leaders in the teaching of manual medicine while also engaging in mainstream medical education of every description. Today there are 30 osteopathic medical schools in the United States, with the number growing steadily.

An osteopathic physician has full medical training in all the standard medical disciplines as well as hundreds of hours of additional training in osteopathic manipulation. Two equivalent terms have come into common use in scientific and teaching settings: osteopathic manipulative treatment (OMT) and osteopathic manipulative medicine (OMM). For a large population of patients, it makes a big difference to be manually treated by someone who really understands their diagnosis. Such patients will usually decide to receive manual therapy from osteopathic physicians, that is, physicians who have full medical practice licenses and the anatomical discrimination that is unique to osteopaths.

After graduating from Western University’s College of Osteopathic Medicine of the Pacific, I completed a four-year residency in physical medicine & rehabilitation at the University of Michigan. My first four years in practice, including 10,000 OMT treatments, took place at St. Mary’s Spine Center in San Francisco. Over the past 14 years of private practice in San Francisco and Marin County, I have performed approximately 25,000 OMT treatments.

Usually results using OMT are incremental, but once in a while something dramatic takes place. While at St. Mary’s, I received a patient with low back pain who had a diagnosis of severe lumbar spinal stenosis. I considered not treating her with OMT because it seemed unlikely I could benefit her with hands-on treatment. But I decided to try applying a precise force with my hands to decompress her right sacroiliac joint, which felt compressed in my exam. When the patient returned for the next visit, she was smiling and seemed to be in a lot less pain. Over the next two years, that patient referred to me 50 patients who were her friends and/or family.

When performing OMT on the neuromusculoskeletal system, there is potential for interconnectedness with every organ system of the body. With OMT, we adjust the anatomy to its normal position, with normal motion, thus promoting normal physiology, which allows innate self-regulating powers of the body to accomplish what is necessary for healing to occur.[1]

In theory, osteopathy is effective for pain relief for several reasons. With careful and accurate anatomical positioning of the patient’s body, changes in muscle and connective tissue length and tone can occur. Changes may also take place in central, peripheral and autonomic nervous system tone, joint surface motion, and vascular and lymphatic function.[1]

The patients who seem to respond best to OMT are those who have experienced trauma and surgery. It makes sense that trauma, planned or unplanned, can produce a strain pattern that could remain in the tissue. With precise positioning of our hands, OMT can help release and unwind traumatic strains, either produced from a single event or from repetitive strains that accumulate over time. In my experience, radiculopathy and other acute conditions may require, in addition to OMT, adjunctive therapy, such as pain medications, epidural steroid injections and, rarely, surgery.

Some osteopaths use OMT as a supplement to standard treatment methods for addressing specific ailments, such as back and neck pain. Other osteopaths use OMT for all their patients, occasionally supplementing with more traditional methods and/or referring to colleagues as needed. Though I classify myself in the latter group, I believe it is good for the osteopathic profession to have a wide variety of types and scopes of practice.

I believe MDs should consider referring patients to osteopaths for almost any painful condition, and also for some conditions where pain is not the chief complaint, such as congestive heart failure, chronic obstructive pulmonary disease, asthma, otitis media and Parkinson’s disease. My practice, for example, has become more general over the last few years, but the most common referral continues to be for back and neck pain.

OMT’s efficacy in pulmonary infections was recently highlighted in the Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE). In this prospective, randomized controlled trial, OMT was evaluated as an adjunct to current pharmacologic therapy in elderly patients hospitalized with pneumonia. MOPSE demonstrated that OMT is helpful in treating lower respiratory infections, reducing length of stay in the hospital and lowering drug use.[2] For patients with low back pain, OMT has also been shown to lead to lower medication use and less physical therapy.[3]

To paraphrase noted osteopath Dr. James Jealous, we osteopaths believe that the body has the innate capacity to heal and that it functions as a whole. We use our hands to treat the whole patient and all levels of illness. We believe the autonomic nervous system plays a major role in disease and healing. At their best, osteopathy, OMM and OMT bring about an ease of motion, without tension, and with the capacity for change.[4]

The founder of osteopathy, Dr. Andrew Taylor Still (see sidebar) asked that his students use their hands to “find the health” in their patients. In an osteopathic treatment, there is always some healthy, therapeutic process that can be found and potentially augmented, even when significant pain and disease are present. I often find myself telling patients that the hardest and best thing they can do is to get out of their own way. With osteopathy, I try to follow my own advice, nudging the anatomy in the right direction as precisely as possible, then getting out of the way to let my patient’s body do the rest.

Dr. Andrew Taylor Still, Founder of Osteopathy

The founder of osteopathy, Dr. Andrew Taylor Still, was born in Virginia in 1828. While in his youth, he moved with his family to the Kansas-Missouri Territory, where he trained as a physician. He served with distinction as a surgeon for the Union Army in the Civil War and then returned to his medical practice. Over the next several years, he became progressively more disenchanted with medicine as it was practiced in that day. “Treatments” such as purgatives and leeches were common, as there was no knowledge of antibiotic therapy or the immune system. In his theories, he anticipated by 20 years key aspects of the immune system.

After 1874, Dr. Still began developing an alternative medical profession. The cornerstone of this new profession was anatomy. Dr. Still’s tireless study included whittling a wood replica of each of the 206 bones of the human body. He found that when he adjusted the anatomy to normal, the body would take care of the rest.

To test his theories, Dr. Still travelled from town to town for many years treating patients. There reached a point when so many people wanted to receive his treatments that he decided to teach his method to others. His American School of Osteopathy (now A.T. Still University) opened in Kirksville, Missouri, in 1892.

During Dr. Still’s lifetime, many promising advances occurred in osteopathy, including the opening in 1915 of the Still-Hildreth Sanatorium in Macon, Missouri, where thousands of mentally ill patients were treated with osteopathy. Many previously institutionalized patients improved dramatically or were cured.

In 1919, two years after Dr. Still died, osteopathic medicine had a stern test during the Spanish influenza pandemic. While allopathic hospitals used antitussives, opiates and strychnine, osteopathic treatment targeted autonomic changes, blood delivery, lymphatic drainage and biomechanical improvements in respiration. Recovery rates were much better in osteopathic hospitals.

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For a comprehensive biography of Dr. Still, see A.T. Still: From the Dry Bone to the Living Man, by John Robert Lewis (Dry Bone Press, 2012).
Dr. Etemad, a San Rafael physiatrist, is board certified in osteopathic manipulative medicine.

Email: dr.jeff.etemad@comcast.net

References

1. Jones JM, “Osteopathic Medicine,” in Micozzi M, Fundamentals of Complementary and Alternative Medicine, Saunders (2010).
2. Noll DR, et al, “Clinical and research protocol for osteopathic manipulative treatment of elderly patients with pneumonia,” J Am Osteo Assoc, 108:508-516 (2008).
3. Andersson GBJ, et al, “Comparison of osteopathic spinal manipulation with standard care for patients with low back pain,” NEJM, 341:1426-31 (1999).
4. Jealous J, “Osteopathy is Service,” www.jamesjealous.com.