As many of you know I am an osteopathic physician. In the mid 70s I decided to apply to an osteopathic medical school, as they seemed to be more in-line with my views of natural medicine.

While that was certainly true when the profession first started over 100 years ago, like many professions with time the starting values become distorted. The actual type of care that is rendered by DOs is not much different than that given by MDs. I do believe that the profession in general tends to be more interested in selecting students who are sincerely interested in people rather than relying on academic potential, however.

Throughout the years the comments I continuously receive from patients is that DOs generally seem to be more interested and caring as a profession. I really don't believe that I receive that feedback because they know I am a DO. However, on the other hand, many patients select DOs because they are interested in finding physicians who practice with an orientation on natural medicine.

In this area they will be sadly disappointed as nearly all DOs are still rooted in the traditional paradigm.

Generally, people would be far better off selecting a chiropractor, as their profession has typically maintained a stronger relationship with their founding roots. Not all chiropractors have this orientation, however, and some rely merely on adjustments for their care, so be careful. Naturopathic physicians are also another strong choice, but they are few and far between and can't obtain licensing in most states.

The key to finding a health care professional who will help guide and mentor you through your health care challenges will be to ask health food store employees what type of feedback they have had about the different doctors in your area. Don't rely on one answer, ask as many people as you can.

At this time, this is the best way I can help you identify knowledgeable professionals who also have a good bedside manner and will listen to you and serve as your coach to achieving the health you deserve.

Please be aware though that it is very rare for a health care practitioner to have a good handle on the emotional side of health, and this is frequently a major factor in most illnesses.

If you want a shorter version of what DOs are about you can review this link.

Continued from Last Issue

Evidence for Palpatory Diagnosis

A Medline literature search was conducted using the terms "manipulation," "osteopathic manipulative therapy," "random," "clinical trials," "diagnosis," and "cohort studies" from 1966 to present. All controlled trials that were identified were included in this report. The reference sections of controlled trials were also culled for other trials.

Standardized or systematic analysis of the identified trials was not possible because of variation in quality of design and method and because of the breadth of articles included. Emphasis was given to controlled trials and studies that used appropriate comparison groups. Where possible, guidelines of McMaster were used. Published case reports were excluded at the recommendation of the peer reviewers. Historically, the osteopathic profession has not emphasized research, so there are very few controlled trials of osteopathic manipulation.

In addition to the reasons discussed elsewhere, research on the effectiveness of palpatory diagnosis and manipulation is troublesome because of the difficulty of standardizing treatments and responses, the apparent lack of interexaminer agreement, and the self-limited natural history of many musculoskeletal conditions.

Additionally, a completely double-blinded trial of manipulation is impossible because the third level of blinding cannot be met, i.e., the treating clinician knows what treatment was rendered. The long-term results of manipulation for lower back pain are difficult to assess because given enough time, many patients will recover regardless of the treatment. Interexaminer agreement of osteopathic palpatory diagnosis has not been widely studied. In one small study, experienced osteopathic practitioners achieved a 62 percent rate of agreement.

Other studies have shown variable amounts of agreement. Recurrent patterns of somatic dysfunction in some patients have been identified. A review of nine studies suggests that somatic dysfunctions are more likely to occur in the cervicothoracic and lumbosacral transition areas of the spine. However, the incidence of somatic dysfunction in normal or asymptomatic populations is unknown. Finally, osteopathic diagnosis is sometimes based on subtle or minimal physical findings and subjective reporting of symptoms.

In an effort to reduce subjectivity and more objectively quantify one aspect of palpatory diagnosis, Warner et al developed a technique of motion analysis that uses an anatomical torsion monitor and a hysteresis feedback loop to measure the lower back tissue response.

Tissue response or quality of motion is a reflection of how the tissues of the musculoskeletal system react when force is applied, maintained, and removed. "Ease," "stiffness," "end-feel," "crepitant," and "joint play" have been used to subjectively describe tissue response.

Although the pathological significance of seemingly minor physical examination findings may be questionable, some studies have suggested an association between palpatory findings and diseases for which musculoskeletal palpation is considered to have little or no diagnostic role, such as hypertension, myocardial infarction, psychiatric illness, and carpal tunnel syndrome.

In a case series of 150 consecutive patients with noncongenital heart disease, 92 percent were noted to have both radiographic and palpable evidence of somatic dysfunction at the T1 through T6 vertebral levels. Manipulative therapy was often followed by varying degrees of relief of both musculoskeletal and cardiac symptoms, while discontinuation of manipulative therapy was usually followed by exacerbation of symptoms and varying degrees of cardiac decompensation.

However, the examiner in the study was not blinded, no comparison of palpatory findings in a group of patients without heart disease was made, and no comparison to a placebo or "sham manipulation" for effect was made. In a randomized, examiner-blinded study in which patients were matched as closely as possible to controls including body habitus and cardiac monitoring equipment, patients who had a recent myocardial infarction had a significantly higher incidence of soft tissue changes in upper thoracic segments detectable by osteopathic examination as compared with control patients without infarctions.

There may be a relationship between a pattern of somatic dysfunction at the cervicothoracic junction and hypertension. In an examiner-blinded examination, musculoskeletal lesions were twice as frequent in patients with hypertension as compared with normotensive patients.

The difference was statistically significant and present at both the initial examination and at follow-up examinations 4 and 8 months later. Psychotic and affective disorders may also have characteristic musculoskeletal manifestations; the former being associated with lower extremity somatic dysfunction and the latter with cervical and thoracic dysfunction.

Evidence for Manipulation

Although many osteopaths use manipulation as an adjunct to treat many illnesses, there are no large controlled trials of the effectiveness of manipulation for conditions other than lower back pain. Several human trials have shown statistically significant benefits of manipulation for lower back pain.

Studies that have shown positive effects of manipulation for back pain have been criticized for not adequately controlling placebo effect. Studies that demonstrated no benefit from manipulation can also be criticized, mostly on the basis of selection bias. Doran and Newell concluded after studying 456 patients that although a few patients responded rapidly to manipulation, there were no significant differences compared with physiotherapy, corsets, and analgesics. Follow-up was at three weeks, three months and three years.

The data were not analyzed to see if clinical response was associated with certain patient characteristics. The study has significant selection bias because it only included patients referred to rheumatologists. Furthermore, many patients were excluded because of pregnancy, deviation of the lumbar spine from the vertical of more than 15°, or positive straight leg raising test.

These are not considered contraindications for OMT. Another controlled trial of 94 patients suggested that a course of manipulation may hasten improvement, but there was no difference in long-term outcome. However, patients were only enrolled if they had sufficient concern for ordering radiographs. In most uncomplicated cases of lower back pain, radiographs are not indicated unless there are warning signs such as weight loss, fever, or history of cancer.

A controlled trial by Godfrey showed no significant difference between manipulation and massage with electrostimulation. Approximately half of the patients who were initially referred to the study were excluded. During the study, an unblinded assessor had the option of breaking the randomization and reassigning the patients to different treatment or control groups. Nineteen patients from each group were reassigned because they reported no improvement, and their physical examination was unchanged. This occurred after the study design was complete, and although the authors stated it did not influence the results, they did not report the final outcome of these reassigned patients.

The long-term outcome for most uncomplicated cases of lower back pain is similar regardless of the type of treatment. However, several studies, including a systematic review, suggest that manipulation may shorten the duration of painful symptoms. If manipulated patients experience improvement sooner, they may be more likely to return to work sooner. Hoehler conducted a randomized controlled trial of 95 patients comparing manipulation with soft tissue massage. Even though the group receiving manipulation had a higher proportion of patients who reported their pain as "severe" or "very severe," the manipulated patients had significantly more subjective improvement in symptoms immediately after treatment. There was no significant difference at discharge and at three weeks after discharge.

In a systematic review and meta-analysis of the effectiveness of spinal manipulation for lower back pain, Shekelle concluded that the two studies with the highest quality scores both showed a statistically beneficial effect of manipulation in patient back pain that had been present for two to four weeks.

The meta-analysis of seven studies also showed a statistically significant effect of manipulation for recovery from acute lower back pain. (Only one of the aforementioned six positive studies was included in this meta-analysis.) There was insufficient data to support or refute the effectiveness of manipulation on chronic lower back pain. In 1995, the U.S. Agency for Health Care Policy and Research concluded that manipulation is safe and effective treatment for acute lower back pain but of unproven benefit for patients with radiculopathy.

A systematic review of 81 trials of manipulation for chronic lower back pain found that 25 percent were of high methodological quality. Results of this review were reported on the basis of level of evidence. For chronic lower back pain, strong evidence showed that manipulation was effective.

There is a small but increasing body of evidence that suggests that OMT may be beneficial in conditions other than lower back pain. Using an animal model of antigen-induced arthritis, Hallas showed that rates that were treated with manipulation and exercise had statistically significant improvement on computerized motion analysis, knee circumference, stride length, and ankle lift.

In a randomized, researcher-blinded trial comparing incentive spirometry to OMT in preventing postoperative atelectasis, patients treated with OMT had a statistically significant earlier recovery and quicker return to preoperative forced vital capacity and forced expiratory volume in one second than those treated with incentive spirometry. However, more than 50 percent of the patients who were initially included in the study were excluded for various reasons. Lymphatic pump techniques have long been thought to improve cellular activity by mobilizing fluids, enhancing removal of metabolic waste, and possibly boosting immunity.

There are no controlled trials supporting this. Recently, however, volunteer medical students developed a transient but statistically significant increase in serum basophils after application of lymphatic pump techniques compared with students who did not. In another study, serum antibody levels measured by enzyme-linked immunoassay of 19 volunteers who received the series of recombinant hepatitis B vaccinations were compared with those of 20 volunteers who, in addition to receiving the immunizations, had OMT consisting of lymphatic and splenic pump techniques.

Fifty percent of the subjects who had OMT achieved protective hepatitis B antibody titers by the 13th week, whereas only 16 percent of the control subjects had protective levels. The mean antibody titer in the treatment group was higher than in the control group at all time intervals from the sixth week to the final measurement at 34 weeks postvaccination.

However, it was only statistically significantly higher at 25 weeks postvaccination. In a cohort of patients with carpal tunnel syndrome, OMT was associated with both symptomatic and electrodiagnostic improvement. In a blinded, randomized, controlled trial comparing standard medical care with standard care plus OMT for hospitalized patients with pancreatitis, patients in the OMT group had significantly fewer days in the hospital. There were no significant differences in time to oral feeding or amount of pain medications between the groups.

Based on the exclusion criteria, the reader can infer that the two groups were roughly equal in terms of disease severity; however, the authors did not specifically state that the treatment and control groups were comparable based on Ranson criteria, Acute Physiology and Chronic Health Evaluation scoring, or some other objective measure of disease severity. Osteopathic manipulative therapy has been used as adjunctive therapy in the treatment of pneumonia since the early 1900s.

The only large-scale study evaluating the efficacy of OMT against pneumonia was a case series that was collected during the 1918 influenza epidemic in the United States consisting of 6,258 patients with influenza complicated by pneumonia. The average mortality rate for patients treated in the usual fashion with the prevailing therapy was approximately 25 percent. The mortality rate for patients who were treated with OMT in addition to the usual prevailing therapy was allegedly 10 percent.

The only randomized control trial of OMT in this same setting also revealed a favorable trend. In this trial, the mean duration of leukocytosis, intravenous antibiotic treatment, and hospital stay were shorter in the patients treated with OMT compared with the control group who received either a sham treatment or no additional physical contact. However, none of these differences were statistically significant, possibly owing to insufficient power from the small sample size. The only outcome measure that did reach significance was total time taking oral antibiotics while in the hospital.

Osteopathic manipulative therapy provided acute benefits in a small group of patients with idiopathic Parkinson disease (IDP). Ten patients with IDP and eight age-matched controls without IDP having similar physical conditions, underwent computerized gait analysis before and after a single session of OMT. A separate group of 10 patients with IDP underwent a sham manipulative treatment. The patients did not know when the measurements for gait analysis were being taken, and were not aware of whether the treatment they were given was the sham treatment or OMT.

Before motion analysis, all patients with IDP underwent a 12-hour medication washout period. All patients with IDP had mild to moderate disease with a Unified Parkinson's Disease Rating Scale Motor Score average of 14.3; however, the study lacks a comparison table, so how well the groups were matched cannot be fully determined. Patients with IDP who were treated with OMT had statistically significant increases in stride length, cadence, arm swing, and maximum velocities of upper and lower extremities, compared with the control group without IDP.

Significant differences occurred only in patients with IDP who were treated with OMT and not in IDP patients who received a sham treatment, suggesting that the improvements were the result of OMT. The duration of this beneficial effect is unknown because patients were not followed up further.

The single report of OMT as an isolated treatment for episodic tension-type headache found a reduction in pain intensity immediately after the treatment, but the subjects were also not evaluated further. A controlled trial of chiropractic spinal manipulation did not show a positive effect on episodic tension-type headaches. Another similar trial did, however, find a beneficial effect of manipulation on cervicogenic headache.

Conclusions

Osteopathic medicine is similar to allopathic medicine, but places a greater emphasis on the importance of the musculoskeletal system and normal body mechanics as central to good health. To support this emphasis, more basic research and controlled trials for the effectiveness of manipulation are needed.

Glossary

Autonomic Innervation of Selected Viscera

Sympathetic fibers supplying the heart and lung and part of the esophagus originate in the first 5 thoracic segments. Those supplying the pancreas, liver, stomach, and gallbladder arise in the 5th through 10th thoracic segments, and those supplying the small and large intestine and kidneys arise in the eighth thoracic to second lumbar segments.

Facilitation

Facilitation is the maintenance of a pool of premotor neurons or preganglionic sympathetic neurons in one or more segments of the spinal cord in a state of partial or subthreashold excitation; in this state less afferent stimulation is required to trigger the discharge of impulses. It is also a neurophysiological theory regarding the neural mechanism of somatic dysfunction.

Somatic Dysfunction

Somatic dysfunction is the impaired or altered function of the skeletal, arthrodial, and myofascial structures and their related vascular, lymphatic, and neural elements. The positional aspects of somatic dysfunction are described using one or more of three parameters:

1. The position of the body part as determined by palpation and referenced to its adjacent defined structures,

2. The direction in which motion is freer, and

3. The direction in which motion is restricted. Somatic dysfunction is characterized by one or more of the following: vasodilatation, edema, tenderness, pain, constriction, asymmetry of motion, motion restriction, and changes in tissue texture. It may or may not be associated with organic disease.

Archives of Family Medicine November/December 1999

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