Osteopathic medicine
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Osteopathic Medicine (also known as osteopathy) is a system of medicine that applies a unique philosophy to medical care. With a strong emphasis on the inter-relationship of the body's nerves, muscles, bones and organs, Doctors of Osteopathic Medicine, or D.O.s, apply the philosophy of treating the whole person (holistic approach) to the prevention, diagnosis and treatment of illness, disease and injury using traditional medical practice such as drugs and surgery, along with manual and physical therapies (OMM).
Doctors of Osteopathic Medicine (D.O.s) educated in the United States are fully licensed physicians that practice the full scope of medicine, like Doctors of Medicine (M.D.s). Currently, there are 20 accredited D.O.-granting U.S. medical schools and 125 accredited M.D.-granting U.S. medical schools. Because of the abundance of M.D. schools, many people are more familiar with them; however, osteopathic medicine is growing at an unprecedented rate. Many new schools are planned to open in the coming years and existing schools have expanded enrollment to meet the increased demand for the physician workforce, particularly as baby boomers age. The majority of entering U.S. osteopathic medical students hold bachelor's degrees and many also hold master's (M.S., M.A.) or doctorate (Ph.D., J.D.) degrees.
M.D. and D.O.-granting U.S. medical schools have similar curricula. Generally the first two years are classroom-based, with certain programs providing patient contact, while third and fourth years consist of rotations through the different major specialties of medicine. Upon graduation, M.D. and D.O. physicians pursue residency training programs. Depending on state licensing laws, osteopathic physicians may also be required to complete a 1 year rotating internship. Osteopathic physicians also have the opportunity to pursue allopathic (M.D.) residency programs; however, the converse is not allowed. Within the U.S., osteopathic physicians practice in all medical specialties including, but not limited to, internal medicine, dermatology, surgery, radiology, etc. There is no distinction in pay between allopathic (M.D.) and osteopathic (D.O.) physicans; however, physician salaries differ noticeably among the various medical specialties.
Osteopaths educated in countries outside of the U.S. do not follow the same curriculum as U.S. trained D.O.'s and are referred to as "non-physician osteopaths". Their scope of practice is limited mainly to musculoskeletal conditions and treatment of some other conditions using manual treatment [OMM], not unlike chiropractors in the U.S.
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History
Osteopathic practice began approximately 120 years ago (before the chiropractic movement) in the Midwest of the United States. 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, even barbaric. Troubled by what he saw as problems in 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 Manual Medicine (OMM)
The goal of OMM is the resolution of somatic dysfunction. There are different techniques applied to the musculoskeletal system as OMM. 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) (usually called an 'adjustment' by Chiropractors or more generally 'joint manipulation') - in which a joint is quickly and skillfully taken by the practitioner beyond its normal range of motion, but within its physiological range, with the intention of normalizing 'joint play.'
Trigger (or Myodysneuric) Point Therapy
Balanced Ligamentous Tension (BLT)
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.
It is probably OMM's comprehensive and eclectic style that distinguishes it most from that employed by most other manual therapists.
The immediate 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 neuromusculoskeletal pain syndromes, such as low back pain and tension headache, 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 seemingly 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 and clinical experience 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 [1] 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 of the lack of awareness of research in the field.
Cranial osteopaths are trained to feel a very subtle, rhythmic shape change that is present throughout the head and body. 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[2]. The theory underlying cranial osteopathy is rejected by many osteopaths and orthodox medical doctors because cranial bones fuse by the end of adolescence. Cranial osteopathic teaching refers to movement remaining within the thin bone of the sutures, and that flexibility within living bone occurs, in contrast to dried specimen bones. The brain does pulsate, but some research suggests this is related to the cardiovascular system [3]. Several studies have looked at inter-operator reliability of palpating the 'cranial rhythm' and found there to be little agreement, [4] although modern understandings in the cranial field describe a number of simultaneous rhythms with differing rates, relating to different aspects of function.
How this mechanism is related to health/disease is not established. Many without direct experience of the benefits of treatment dismiss cranial osteopathy as pseudo-science. However, cranial osteopathy is increasingly being recognised as especially suitable for newborn babies and young children, with particularly good results in the treatment of colic and crying. All in all, this practice appears to be popular with patients with an increasing demand for experienced practitioners. Cranio-sacral therapy is based on the same principles but the practitioners are not qualified osteopaths, and do not have the same depth of training in the clinical sciences and differential diagnosis. Chiropractors are developing 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.
Neither cranial osteopathy nor visceral manipulation are the mainstay of most osteopathic practices.
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 practiced by those holding a Doctor of Osteopathic Medicine degree (D.O.). A doctor with a D.O. degree 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. Because 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 argue that the distinction between the two has blurred enough to render the lesser known D.O. degree obsolete. However, many osteopathic physicians contend that they strive for a more holistic, compassionate, 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 was once an issue for osteopathic practitioners. Today D.O.s often hold comparable prestige to M.D.s where they work side by side in the health care setting.
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.
There is no doubt that the American osteopathic medicine, as a progressive social movement, has had a significant influence on the practice of American medicine generally. Indeed, some US osteopathic medical schools have opened basic courses in osteopathic manual therapy for their M.D. cousins.
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 [5]. 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) [6]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, [7], [8]. 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 2005 the General Medical Council of Great Britain announced that U.S.-trained D.O.s would be accepted for full medical practice rights in the United Kingdom. This decision was an important departure from the United Kingdom's long-standing tradition of exclusively manual, or "traditional" osteopathy. [9]
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 UK graduates. Likewise, each country maintains a government-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 public 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 (as in Great Britain) US-trained osteopathic physicians have unlimited scope of medical practice.
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 focussed mainly on musculoskeletal conditions and treatment of some other conditions by manual means. Osteopaths in all four countries do not have prescribing rights, although the British 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[10]. 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.
Future Challenges
In the United States Osteopathic medicine has been criticized for including therapies such as cranial and cranio-sacral manipulation, and for having a greater tolerance for alternative medical practices. Osteopathic medical schools have been criticized for being less focused on research than allopathic schools, although this trend is changing. Critics also have pointed towards the lower GPA, 3.45 for osteopathic vs 3.63 for allopathic, and MCAT scores, an average of 24.6 for osteopathic vs 30.1 for allopathic, among enrollees. While the GPA and MCAT scores are lower, this may be due to the fact the osteopathic schools admit many non-traditional students who do not perform as well on the MCAT as younger students who are able to devote much of their time to studying. However, it is important to note that average MCAT and GPAs of osteopathic medical students are comparable to allopathic medical students who choose primary care residency programs.
Because the field of osteopathic medicine encompasses all conventional medical practices, it has been subject to the same criticisms. And, in other countries where Osteopathy does not encompass conventional medical practices, it is subject to the same criticisms levelled at many alternative medicine modalities.
See also
Further reading
- The DOs: Osteopathic Medicine in America, Norman Gevitz, 2004 (2nd Edition), paperback, 264 pages, The Johns Hopkins University Press, ISBN 0801878349 (An excellent review of the history and development of ostepathic medicine and medical education in the United States)
- Science in the Art of Osteopathy: Osteopathic Principles and Models, Caroline Stone, Nelson Thornes, 1999, paperback, 384 pages, ISBN 0748733280
- An Osteopathic Approach to Diagnosis and Treatment , Eileen DiGiovanna, Lippincott Williams and Wilkins, 2004, hardback, 600 pages, ISBN 0781742935
External links
U.S. Osteopathic Medical Schools
- Directory of Colleges of Osteopathic Medicine in the U.S.
- A.T. Still University of Health Sciences Kirksville College of Osteopathic Medicine
- Arizona College of Osteopathic Medicine of Midwestern University
- Chicago College of Osteopathic Medicine of Midwestern University
- Des Moines University College of Osteopathic Medicine
- Kansas City University of Medicine and Biosciences: College of Osteopathic Medicine
- Lake Erie College of Osteopathic Medicine
- Michigan State University College of Osteopathic Medicine
- New York College of Osteopathic Medicine of New York Institute of Technology
- Nova Southeastern University College of Osteopathic Medicine
- Ohio University College of Osteopathic Medicine
- Oklahoma State University Center for Health Sciences College of Osteopathic Medicine
- Philadelphia College of Osteopathic Medicine
- Pikeville College School of Osteopathic Medicine
- Touro University College of Osteopathic Medicine - California
- University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine
- University of New England College of Osteopathic Medicine
- University of North Texas Health Science Center at Fort Worth - Texas College of Osteopathic Medicine
- Edward Via Virginia College of Osteopathic Medicine
- West Virginia School of Osteopathic Medicine
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific
Apply to U.S. Osteopathic Medical Schools
Canadian Osteopathic College
U.K. Osteopathic Colleges
- British College of Osteopathic Medicine
- British School of Osteopathy
- College of Osteopaths
- European School of Osteopathy
- London School of Osteopathy
- LCOM / NESCOT
- Oxford Brookes University
Australian Osteopathic Colleges
New Zealand Osteopathic College
Osteopathic Associations & Regulatory Bodies
- American Osteopathic Association
- Student Osteopathic Medical Association (U.S. students)
- The American Association of Colleges of Osteopathic Medicine
- U.S. Osteopathic State & Regional Associations
- The (American) Council of Osteopathic Student Government Presidents
- International Osteopathic Alliance
- UK General Osteopathic Council website
- British Osteopathic Association website
- NZ Osteopathic Council website
- Osteopathic Society of NZ website
- Australian Osteopathic Association
- Chiropractic and Osteopathic College of Australasia
- Irish Osteopathic Society
- The Cranial Academy
- American Academy of Osteopathy
- The Sutherland Society for UK Cranial Osteopathy
- Israeli Osteopathic Association
Journals
- Journal of the American Osteopathic Association
- International Journal of Osteopathic Medicine
- Chiropractic & Osteopathy An online journal published by BioMed Central
Other Links
- The History of Osteopathic Medicine (American Osteopathic Association)
- The Osteopathic Center For Children
- Osteopathic Research Information - Vienna School of Osteopathy
- Supportive article on Cranial Osteopathy
- An article supportive of osteopathic medicine: The Paradox of Osteopathy
- Osteopathic medicine and back pain
- PubMed Literature Search (valuable search engine for articles on topic)
- Osteopathy: Art of Practicede:Osteopathie (Behandlungsform)
es:Osteopatía fr:Ostéopathie he:אוסטאופתיה ja:オステオパシー nl:Osteopathie