Osteopathic medicine in the United States: Difference between revisions

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Revision as of 05:42, 4 January 2006

Osteopathic medicine (known as osteopathy in the past) is a branch of medicine which views the human body holistically, and emphasizes the prevention and treatment of illness and injury through the use of manual and physical therapies, along with traditional medical practices such as drugs and surgery. Doctors of Osteopathic medicine (D.O.s) educated in the United States are fully licensed physicians equivalent to M.D.s. Osteopaths educated in the United Kingdom and elsewhere have a scope of practice limited mainly to musculoskeletal conditions and treatment of some other conditions by manual means.

The traditional osteopathic approach emphasizes the significance of the neuromusculoskeletal (NMS) system to one's general health and well-being, and the role of NMS dysfunction in the etiology of many diseases. A key goal of osteopathic medicine is the maintenance of healthy body mechanics using a holistic approach that also includes traditional western medicine.

History

Osteopathic practice started just before the chiropractic movement in the Midwest of the United States in the nineteenth century. Early in the twentieth century, the American osteopathic profession adopted the use of medicine and surgery, whereas chiropractors continue to use strictly manipulative techniques. Outside of the US, particularly in the United Kingdom, osteopaths tended to stay closer to their traditional approach. Osteopathy was founded by Andrew Taylor Still, M.D., D.O., who was born in 1828 in Virginia. Dr. A.T. Still was trained by apprenticeship and was employed as an army doctor during the American Civil War in the U.S. Army. The horrors of battlefield injury and the subsequent death of his wife and several children from infectious diseases left him totally disillusioned with the traditional practice of medicine. Still perceived the medical practices of his day to be ineffective. Troubled by what he saw as problems with the medical profession, Still founded osteopathic practice. Using an alternative philosophical approach, he dogmatically opposed the use of drugs and surgery. Instead, he saw the human body as being metaphysically capable of curing itself through the use of manipulation techniques.

Over time he and his followers developed a series of specialized physical treatments, for which he coined the name Osteopathy. Dr. Still founded the American School of Osteopathy (now the Kirksville College of Osteopathic Medicine) in Kirksville, Missouri, for the teaching of osteopathy on May 10, 1892. Kirksville was one of few places where he was not figuratively "chased out of town" by other doctors. While the state of Missouri was willing to grant him a charter for awarding the M.D. degree, he remained unhappy with the practices of his peers and chose instead to grant his own D.O. degree.

In the late 1800s Still taught that "dis-ease" was caused when bones moved out of place and disrupted the flow of blood or the flow of nervous impulses; he therefore concluded that one could cure diseases by manipulating bones to restore the supposedly interrupted flow. His critics point out that he never ran any controlled experiments to test his hypothesis; his supporters point out that many of Still's writings are philosophical rather than scientific in nature. He questioned the drug practices of his day and regarded surgery as a last resort. As medical science developed, osteopathy gradually incorporated all its theories and practices. Today, except for additional emphasis on muscoskeletal diagnosis and treatment, the training and scope of osteopathy in the United States is very similar to that of allopathic or bio-medicine. Internationally, all osteopathic training incorporates at least the basic biomedical sciences and differential diagnosis, while emphasizing non-surgical orthopedics.

Osteopathic Principles

These are the eight major principles of osteopathy and are widely accepted throughout the osteopathic community. They are taken from the curriculum of the Kirksville College of Osteopathic Medicine.

(1) The body is a unit.

(2) Structure and function are reciprocally inter-related.

(3) The body possesses self-regulatory mechanisms.

(4) The body has the inherent capacity to defend and repair itself.

(5) When the normal adaptability is disrupted, or when environmental changes overcome the body’s capacity for self maintenance, disease may ensue.

(6) The movement of body fluids is essential to the maintenance of health.

(7) The nerves play a crucial part in controlling the fluids of the body.

(8) There are somatic components to disease that are not only manifestations of disease, but also are factors that contribute to maintenance of the disease state.

These principles are not held by osteopaths to be empirical laws, nor contradictions to orthodox medical principles; they are thought to be the underpinnings of the osteopathic perspective on health and disease.

Techniques of Osteopathic Medicine

There are different techniques applied to the musculoskeletal system. These techniques can be applied to:

(1) The joints (using High Velocity Technique, mobilization, etc.)

(2) Their surrounding soft tissues (using functional and soft tissue techniques, etc.)

(3) The muscles

(4) The fascia.

When combined, these forms of treatment allow the therapist to restore the normal contact within the joint and with other structures. This eliminates muscular spasms and tensions in the ligaments thereby restoring complete mobility to the joint.

Osteopaths have at their disposal a wide range of manual techniques including:

High Velocity (Low Amplitude) Thrust (HVT) (sometimes called an 'adjustment' or joint manipulation) Joint Mobilization Myofascial Release Muscle Energy Trigger or Myodysneuric Point Therapeutic Massage Cranial Osteopathy Visceral Manipulation Lymphatic Pump/Drainage

These are normally employed together with dietary, postural, and occupational advice, as well as counseling to help patients recover from illness and injury, and to minimize pain and disease. Most osteopaths view manual therapies as a complement to physiotherapy, and the judicious use of invasive therapies (pharmaceuticals and surgery) where necessary.

The goal of musculoskeletal manipulation is to restore maximal, pain-free movement of the musculoskeletal system in postural balance

Scope of Manual Therapies

There is now a well-established body of scientific literature that makes a strong case for the use of manual therapies in the treatment of many musculoskeletal pain syndromes, such as low back pain, alongside exercise and other rehabilitative techniques. In recent years, the mainstream medical profession has begun to accept the use of manual therapies to treat spinal pain of mechanical origin.

More controversial is the use of manual therapies in the treatment of organic conditions, such as asthma, middle ear infections in children, period pain, and pulmonary infection. While research is beginning to shed some light in this area exploration of the relationship between the NMS system and organic disease and the scope of manual therapies are in their infancy. Nevertheless, the sum of research to date suggests that osteopathic treatment can be a safe and cost-effective means of managing (or co-managing) certain diseases.

Cranial Osteopathy

Cranial osteopathy is a contested issue within the profession; it is not known what proportion of osteopaths are practitioners. Most medical insurance companies will not reimburse for 'cranial' treatment because it is not based on orthodox diagnostic criteria.

Cranial osteopaths claim they are trained to feel a very subtle, rhythmic shape change that is present in all physical tissues. This is known as the involuntary mechanism or the cranial rhythm. The movement is said to be very subtle, and it takes practitioners with a very finely developed sense of touch to feel it. This rhythm was first described in the early 1900's by Dr. William G. Sutherland, and its existence is not accepted by the mainstream scientific community. The theory underlying cranial osteopathy is rejected by many osteopaths and most orthodox medical doctors because cranial bones fuse by the end of adolescence. The brain does pulsate, but this is thought to be exclusively related to the cardiovascular system . Several studies have looked at inter-operator reproducibility of diagnostic findings when working with the 'cranial rhythm' and found there to be little agreement

How this mechanism is related to health/disease is not established, neither is the relationship between holding the head and re-establishing health. Many dismiss cranial osteopathy as pseudo-science. Moreover, cranial osteopathy is often marketed as being especially suitable for newborn babies and young children. All in all, this practice appears to be popular with patients and this may be a significant factor for osteopaths embracing it. Cranio-sacral therapy is based on the same principles but the practitioners are not qualified osteopaths. Chiropractors have developed similar techniques known as sacro-occipital therapy (SOT) or craniopathy.

Visceral Osteopathy

Proponents of visceral osteopathy state that the visceral systems (the internal organs: digestive tract, respiratory system, etc.) rely on the interconnected synchronicity between the motions of all the organs and structures of the body, that at optimal health this harmonious relationship remains stable despite the body's endless varieties of motion. The theory is that both somato-visceral and viscero-somatic connections exist, and manipulation of the somatic system can affect the visceral system.

Visceral Osteopathy is said to relieve imbalances and restrictions in the interconnections between the motions of all the organs and structures of the body. During the 1940's, osteopaths like H.V. Hoover or M.D. Young built on the pioneering work of Andrew Taylor Still D.O., to create this method of detailed assessment and highly specific manipulation. The efficacy and basis of this treatment remains controversial even within the osteopathic profession.

Osteopathic Medicine Around the World

There are two main schools of thought within the osteopathic world. They are so different in practice as to be separate professions, but there have been attempts in the last few years to enhance exchange and dialogue between them.

In the United States osteopathic medicine is practice by those holding a Doctor of Osteopathic Medicine degree (D.O.). A doctor with a D.O. is a fully licensed physician, just like an M.D. (Doctor of Medicine). Many are unaware of the D.O. degree, yet those holding it serve as physicians and surgeons in all specialties from cardiothoracic surgery to family medicine. Since a doctor with a D.O. degree can prescribe the same medicines and perform the same surgeries as a doctor with an M.D., some have argued that the distinction between the two has become blurred. However, though the two degrees share a background in traditional Western medicine, a doctor with a D.O. strives for a more holistic and community-minded approach to health care.

The international model of osteopathic medicine is significantly different. "Osteopaths", as they are often called, continue to rely on non-surgical, non-pharmaceutical approaches, and see themselves as a complete school of manual medicine or NMS specialists, complementary to most mainstream medical practices. Commonwealth osteopathic students may spend up to ten times as many hours training in osteopathic diagnosis and technique as their American counterparts. Because of this specialization, they have traditionally remained relegated to the fringe of health care alongside naturopaths, chiropractors and others. In Commonwealth countries, osteopaths have also had to compete with physiotherapists, many of whom have integrated manipulative therapy into their practice. Nevertheless, osteopathy is growing in size and mainstream acceptance in many countries of the Commonwealth and Europe. More and more osteopaths are now working alongside the mainstream in interdisciplinary settings, and osteopathic departments are now well-established in many public universities.

Osteopathic Medicine in the USA

Acceptance by traditional M.D.s and their institutions has been an issue for osteopathic practitioners.

In the 1960s in California, the American Medical Association (AMA) spent some $8 million to end the practice of osteopathy in the state. After passing a proposition backed by the AMA, D.O.s were granted an M.D. in exchange for paying $65 and attending a short seminar. The College of Osteopathic Physicians and Surgeons became the University of California, Irvine, College of Medicine. However, the decision proved quite controversial. In 1974, primarily due to the efforts of Viola M. Frymann, D.O., FAAO, the California Supreme Court ruled that licensing of D.O.s in that state must be resumed.

This decision by the California Medical Association in the 1960s to grant D.O. physicians an M.D. license was one of two turning points for D.O.s in their struggle for acceptance, the other being the U.S. Army's decision to allow D.O.s to enter the military as physicians. The California Medical Association may have been attempting to eliminate the osteopathic competition by converting thousands of their physicians to M.D.s. While most Californian D.O.s did take the opportunity to become M.D.s, nationally it provided the osteopathic physicans the stamp of equivalency they desired. The last state to grant D.O.s equal practice rights as a fully licensed physician was Mississippi, in 1973.

Today in the USA, an osteopathic physician is sometimes described as a physician who, while practicing conventional medicine much like his or her M.D. colleagues, also maintains the ability to perform osteopathic manipulative medicine (OMM), also referred to as osteopathic manipulative treatment, or technique (OMT). It must be emphasized that manipulation, while very useful for certain disease states, is simply one tool that the D.O. employs in addition to traditional medical practice. Some D.O.s use OMT on a limited basis, while others use it more frequently.

The scientific merit of manipulative medicine continues to be a point of controversy. The American Osteopathic Association has made an effort in recent years to both support and promote scientific inquiry into the effectiveness of osteopathic manipulation as well as encourage D.O.s to consistently offer manipulative treatments to their patients.

Osteopathic Medicine in the UK, Australia, Canada and NZ

In the United Kingdom osteopathy developed as a distinct profession. The first osteopathic college was established in the UK in 1917 by a Scot, Littlejohn, who had studied under Dr Andrew Taylor Still. Littlejohn altered the osteopathic curriculum to include the study of physiology. The UK school he founded, the British School of Osteopathy, was the first osteopathic education institution outside the USA, and it still exists today . British osteopaths use manipulative techniques based on the philosophy of Dr Andrew Taylor Still, but are not medical doctors. Some medical doctors do undertake osteopathic training as a postgraduate interest. The profession is subject to statutory regulation following the passing of the Osteopathy Act in 1993. The General Osteopathic Council (GOsC) was established by the act to regulate the profession, to protect the public by maintaining a register of practitioners, to investigate allegations of professional misconduct, and to ensure the quality of training. Since 2001, there has been graduate only entry to the register. There are currently seven approved training institutions in the UK. There are approximately 5000 registered osteopaths in the UK, a small but growing profession. For the sake of comparison there are approximately 36,000 physiotherapists. Most medical services in the UK are delivered through the state funded National Health Service, osteopathy is largely excluded from this with most osteopaths working in private practice. Several large studies in the UK have produced evidence of the cost-effectiveness and clinical effectiveness of manipulation in the management of low back pain, the latest being the UK Back pain Exercise And Manipulation (UK BEAM) trial, , . There is an increasing interest in osteopathy amongst patients, but barriers remain to osteopathic provision within the state system; not the least being hostility from the orthodox medical profession and physiotherapists. Many UK osteopaths are also naturopaths, with one osteopathic college offering a dual training in osteopathy & naturopathy (the British College of Osteopathic Medicine) and another offering a post-graduate program (the College of Osteopaths).

In Australia and New Zealand the profession has developed along the same lines, and until recently neither country trained its own practitioners and relied on migrants from the UK. Likewise, each country maintains a state approved list of practitioners and private health insurance reimbursement is available for osteopathic treatment. Three publicly-funded Universities now offer osteopathic medical courses in Australia. Courses consist of a Bachelor's degree in clinical science (osteopathy) followed by a Masters' degree. Integration into the university system has given Australian osteopaths the opportunity to access research funding, raised the credibility of the profession, and focused attention on refining the scope of practice through clinical trials and basic research.

In Canada osteopaths are trained along similar lines to those in Britain and other Commonwealth countries, although US trained osteopathic physicians may also practice there.

In all four countries osteopathy straddles the boundary between orthodox and complementary/alternative medicine, with a variety of approaches and philosophies being brought to the practice. The model of osteopathy employed is essentially a drug-free system of manual therapy. Osteopaths are trained in standard medical differential diagnosis and have diagnostic competencies similar to primary care physicians, but with a scope of practice limited mainly to musculoskeletal conditions and treatment of some other conditions by manual means. Osteopaths in all four countries do not have prescribing rights, although the UK Government has included osteopathy in the list of professions allied to medicine that may be granted prescribing rights in the future. Unless separately qualified as a medical doctor or holder of a doctorate degree, osteopaths in New Zealand or the UK do not use the honorific title of Doctor. Contested by some osteopaths, there is a campaign to use the title Doctor anyway. Australian osteopaths routinely call themselves Doctor. There is a debate on what differentiates an osteopath from a chiropractor from a physiotherapist in these countries, rather than the DO/MD debate in the USA.

Osteopathic Medicine in the European Union

Within the European Union there is no standardized training or regulatory framework for the profession, although attempts are being made to coordinate the profession within the EU. At present there is a conflict between the principle of free movement of labor and right to practice osteopathy in different member states as there is little equivalency in training and regulation of the profession. Previously the practice of spinal manipulation by non-medically qualified practitioners was outlawed in many European countries. This led to the arrest and imprisonment of the osteopathic faculty in France in the 1960s, who on their release then sought refuge in the UK and established the European School of Osteopathy. The General Osteopathic Council, the UK osteopathic regulatory body, has issued a position paper on pan-European regulation of the profession. However, formation in osteopathy is built up in very few states : UK, France and Switzerland are the only countries to already have a solid, well-shaped conception of the osteopathy they wish to defend. In the other states, osteopathy is studied in rare schools.

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