Osteopathic manipulative medicine

DEFINITION: Treatment through manipulation of soft tissues and joints outside the spine.

• PRINCIPAL PROPOSED USES: Back pain, enhancing recovery from surgery or serious illness, fibromyalgia, general health, musculoskeletal pain, neck pain
• OTHER PROPOSED USES: Asthma, general health, sinus infections, tendonitis

Overview

Osteopathy originated as a nineteenth-century alternative medical approach focusing on physical manipulation. Modern osteopathic physicians study and practice the same types of medical and surgical techniques as conventional medical doctors. Some of osteopathy’s original techniques still persist, however. Together, these techniques are called osteopathic manipulative medicine (OMM) or osteopathic manipulative treatment (OMT). OMM is less well known to the public than chiropractic spinal manipulation, but it has shown promise for many of the same conditions, such as back pain and tension headaches.

History of osteopathic manipulation. Osteopathic medicine was founded in 1874 by Andrew Taylor Still, an American physician. Physicians educated in this method were called doctors of osteopathy, or DOs. Subsequently, however, schools of osteopathic medicine became integrated with conventional medical schools, and today, the license of DO is legally equivalent to that of a medical doctor (MD). To become a DO, students complete four years of medical school, three to eight years (depending on specialization) of residencies and fellowships, and further hands-on training in osteopathic manipulative therapy.

Forms of osteopathic manipulation. Osteopathic and chiropractic techniques overlap, but they are not identical. As a general rule, chiropractors focus most of their attention on the spine, while osteopathic practitioners devote more of their efforts to the manipulation of soft tissues and joints outside the spine. Another general difference is that chiropractic spinal manipulation tends to make use of rapid, short movements (spinal manipulation, which is a high-velocity, low-amplitude technique), while OMM typically concentrates on gentle, larger movements (mobilization, which is a low-velocity, high-amplitude technique). Neither of these distinctions is absolute, and many chiropractic and osteopathic methods do not fit neatly into these categories.

There are several specific osteopathic techniques in wide use, many of which are named after their founders. Some of the more popular are the muscle energy technique, Jones counterstrain (also known as strain-counterstrain), myofascial release, and cranial-sacral therapy (formally known as osteopathy in the cranial field).

Muscle energy technique. The muscle energy technique involves bending a joint just up to the point where muscular resistance to movement begins (the barrier) and then holding the joint there while the patient gently resists. The pressure is maintained for a few seconds and then released. After a brief pause to allow the affected muscles to relax, the practitioner then moves the joint a little farther into the barrier, which will usually have shifted slightly toward improved mobility during the interval.

Strain-counterstrain technique. The strain-counterstrain technique (Jones counterstrain) involves finding tender points and then manipulating the joint connected to them to find a position where the tenderness decreases toward zero. Once this precise angle is found, it is held for ninety seconds and then released. Like muscle-energy work, strain-counterstrain progressively increases the range of motion and, it is hoped, decreases muscle spasms and pain.

Myofascial release. Myofascial release focuses on the fascial tissues that surround muscles. The practitioner first positions the painful area either at the edge of the barrier to movement or, alternatively, at the opposite extreme (the area of greatest comfort). Next, while the patient breathes slowly and easily, the practitioner palpates the fascial tissues, looking for a subtle sensation that indicates the tissues are ready to “unwind.” After receiving this indication, the practitioner then helps the tissue to follow a pattern of spontaneous movement. This process is repeated over several sessions until a full release is achieved. Myofascial release is said to be especially useful in pain conditions that have persisted for months or years.

Craniosacral therapy. Craniosacral therapy, more properly called cranial osteopathy (or cranial), is a specialized technique based on the scientifically unconfirmed belief that the tissues surrounding the brain and spinal cord undergo a rhythmic pulsation. This “cranial rhythm” is said to cause subtle movements of the bones of the skull. A practitioner of craniosacral therapy gently manipulates these bones in time with the rhythm (as determined by the practitioner’s awareness) to repair “cranial lesions.” This therapy is said to be helpful for numerous conditions ranging from headaches and sinus allergies to multiple sclerosis and asthma. However, many researchers have serious doubts that the cranial rhythm even exists.

Uses and Applications

Osteopathic manipulation is primarily used to treat musculoskeletal pain conditions, such as back pain, shoulder pain, and tension headaches. OMM is often said to be specifically effective for conditions that have persisted for some time, as opposed to chiropractic spinal manipulation, which, according to this view, is most effective for treatment of injuries that have occurred recently. However, few meaningful scientific trials support this belief.

Some OMM advocates believe it has numerous additional benefits, including the enhancement of overall health and well-being. With more than forty treatment and therapy techniques, OMM offers therapeutic methods to target the musculoskeletal, digestive, nervous, and immune systems. However, many of these treatments lack scientific evidence of their effectiveness.

Scientific Evidence

There is little evidence that osteopathic manipulation is helpful for the treatment of any medical condition. There are several possible reasons for this, but one is fundamental: Even with the best intentions, it is difficult to properly ascertain the effectiveness of a hands-on therapy like OMM.

Only one form of study can truly prove that a treatment is effective: the double-blind, placebo-controlled trial. However, it is not possible to fit OMM into a study design of this type.

Because of these problems, all studies of OMM fall short of optimum design. Many have compared OMM with no treatment. However, studies of that type cannot provide reliable evidence about the efficacy of a treatment: if a benefit is seen, there is no way to determine whether it was a result of OMM specifically or just attention generally. (Attention alone will almost always produce some reported benefit.)

More meaningful trials used fake osteopathy for the control group. Such studies are single-blind because the practitioner is aware of applying phony treatment. However, this design can introduce potential bias in the form of subtle unconscious communication between practitioner and patient.

Other studies have involved giving people OMM and seeing if they improve. These trials are particularly meaningless; it has long since been proven that both participants and examining physicians will think, at minimum, that they observe improvement in people given a treatment, whether or not the treatment does anything on its own; such studies are not reported here. Given these caveats, the following is a summary of what science knows about the effects of OMM.

Possible effects of OMM. Most studies of OMM have involved its potential use for various pain conditions. In a study of 183 people with neck pain, the use of osteopathic methods provided greater benefits than standard physical therapy or general medical care. Participants receiving osteopathic manipulation treatments showed faster recovery and experienced fewer days off work. OMM appeared to be less expensive overall than the other two approaches; however, researchers strictly limited the allowed OMM sessions, making direct cost comparisons questionable. Another study evaluated a rather ambitious combined therapy for the treatment of chronic pain caused by whiplash injury (craniosacral therapy with Rosen bodywork and Gestalt psychotherapy). The results failed to find this assembly of treatments more effective than no treatment.

In a fourteen-week, single-blind study of twenty-nine older persons with shoulder pain, real OMM proved more effective than placebo OMM. Although participants in both groups improved, those in the treated group showed a relatively greater increase in the range of motion in the shoulder. In a larger study of 150 adults with shoulder complaints, researchers found that adding manipulative therapy to usual care improved shoulder and neck pain at twelve weeks.

In a small randomized, placebo-controlled trial, researchers used oscillating-energy manual therapy, an osteopathic technique based on the principle of craniosacral therapy, to treat twenty-three persons with chronic tendonitis of the elbow (tennis elbow or lateral epicondylitis). Persons in the treatment group showed significant improvement in grip strength, pain intensity, function, and activity limitation because of pain. These results, however, are limited by the small size of the study and the fact that the therapist delivering the treatment could not be “blinded.”

In another study, twenty-four women with fibromyalgia were divided into five groups: standard care, standard care plus OMM, standard care plus an educational approach, standard care plus moist heat, and standard care plus moist heat and OMM. The results indicate that OMM plus standard care is better than standard care alone and that OMM is more effective than less specific treatments, such as moist heat or general education. However, because this was not a blinded study (participants knew which group they were in), the results cannot be taken as reliable.

A study of twenty-eight people with tension headaches compared one session of OMM with two forms of sham treatment. The study found evidence that real treatment provided a greater improvement in headache pain.

Although OMM has shown some promise for the treatment of back pain, one of the best-designed trials failed to find it a superior alternative to conventional medical care. In this twelve-week study of 178 people, OMM proved no more effective than standard treatment for back pain. Another study, which enrolled 199 people and followed them for six months, failed to find OMM more effective than fake OM. This study also included a no-treatment group; both real and fake OMM were more effective than no treatment. A much smaller study reportedly found that muscle energy technique enhances recovery from back pain, but this study does not appear to have used a meaningful placebo treatment.

One of the best-researched techniques in OMM is the lymphatic pumping technique (LPT), which increases the body's immune response to microbial infections. Practitioners massage and firmly manipulate specific areas of the body to open proximal lymphatic channels, which is intended to improve the efficacy of vaccines, support the work of antibiotics, and reduce recovery time from infections. Some studies have evaluated the potential benefits of LPT for speeding healing in people recovering from surgery or serious illness. The best studies compared OMM with light touch in fifty-eight older people hospitalized for pneumonia. The results indicate that the use of osteopathy aided recovery.

In a much less meaningful study, OMM was compared to no treatment in people recovering from knee or hip surgery. While the people receiving OMM recovered more quickly, these results mean very little because any form of attention should be expected to produce greater apparent benefits than no attention. A similarly weak study suggests that OMM might also be helpful for people hospitalized with pancreatitis. A small study found some evidence that OMM might be helpful for childhood asthma.

In a review of peer-reviewed articles from the first decades of the twenty-first century concerning OMM's impact on psychological conditions and mental health in individuals with chronic pain, fibromyalgia, and irritable bowel syndrome, manual techniques showed positive results. Though these studies lacked proper standards to reach reliable conclusions, the findings provided a foundation for further research into the psychological implications of OMM.

Choosing a Practitioner

Although there are many licensed doctors of osteopathy, most practice conventional medicine and do not specialize in OMM. Some do, and many have been certified by the American Osteopathic Board of Neuromusculoskeletal Medicine. In addition, many physical therapists and massage therapists use some osteopathic techniques with variable amounts of training.

Safety Issues

Most forms of OMM are gentle-natured, but, in the short-term, pain may occur immediately following treatment. Additionally, some osteopathic practitioners use the high-velocity thrusts common to chiropractic and might, therefore, introduce some slight safety risks.

Bibliography

Bergman, G. J., et al. “Manipulative Therapy in Addition to Usual Care for Patients with Shoulder Complaints.” Journal of Manipulative and Physiological Therapeutics, vol. 33, 2010, pp. 96-101.

Bowes, Michael R., et al. “Osteopathic Manipulative Medicine and Its Role in Psychiatry.” Cureus, vol. 15, no. 10, Oct. 2023. doi.org/10.7759/cureus.47045. Accessed 19 Nov. 2024.

Licciardone, J. C., et al. “Osteopathic Manipulative Treatment for Chronic Low Back Pain.” Spine, vol. 28, 2003, pp. 1355-62.

"Osteopathic Manipulative Medicine Explained." American Association of Colleges of Osteopathic Medicine, www.aacom.org/become-a-doctor/about-osteopathic-medicine/omm-explained. Accessed 20 Sept. 2024.

"Osteopathic Manipulation Treatment (OMT)." Cleveland Clinic, 18 Jan. 2021, my.clevelandclinic.org/health/treatments/9095-omt-osteopathic-manipulation-treatment. Accessed 20 Sept. 2024.

Roberts, Ashley, et al. “Osteopathic Manipulative Medicine: A Brief Review of the Hands-On Treatment Approaches and Their Therapeutic Uses.” Medicines, vol. 9, no. 5, 2022, p. 33. doi.org/10.3390/medicines9050033. Accessed 19 Nov. 2024.