By Brian F. Degenhardt, DO
Reprinted with permission from: The Advisor, Vol. 21, #1 (Dec 2000)
As an osteopathic physician who integrates osteopathic manipulative medicine into his practice on a daily basis, I often spend a great deal of time explaining the role of this treatment modality in health care.
In his article on osteopathic medicine in this issue of The Advisor, Michael Kuchera, DO, FAAO, discussed the philosophy of osteopathic medicine, as well as how several of its basic tenets make this practice of medicine a distinctive form of health care in the United States. Applying this philosophy in the 21st Century is challenging, and requires a conscious commitment on the physician’s part to provide quality, personal care to patients. In this article, I will first comment on the importance of palpation or diagnostic touch, and manipulation or therapeutic touch, in patient care based on my clinical experiences in both office and hospital settings. Secondly, I will speak from my experience as a professor, commenting on the motivations that are important for a pre-medical student to consider when choosing a career in medicine, and particularly in osteopathic medicine.
Osteopathic manipulative medicine is the tool the D.O. uses to apply the osteopathic tenets outlined in Dr. Kuchera’s article. With an advanced understanding of the interrelationships between the body’s structure and function, and an understanding of how the body can be influenced by or can influence a human’s emotional or spiritual nature, the D.O. uses palpation and manipulation to provide patient specific care that promotes health and treats disease.
When a patient visits a D.O. for health care, that person is entering a partnership with the physician that may consider any aspect of his/her life. Because osteopathic physicians use a patient-centered approach to health care, they consistently take more aspects of the person’s life into account when outlining a treatment program or health goals.
As an example of how osteopathic physicians approach patient care and incorporate osteopathic manipulation, let me tell you about a young woman I treated earlier this year. This teenager had suffered severe stomach pains for several months. After being examined by an M.D. and given a tentative diagnosis of irritable bowel syndrome, the young woman was placed on medication. When the medication did not seem to bring any relief of symptoms, she was brought to me for examination and treatment. I began by taking a history and physical examination, just as any physician would do. Where my training as a D.O. made a difference for this young woman was first in the history. I helped her look at her lifestyle openly and critically so she could appreciate the healthy and less-than-healthy aspects to her daily routine. Then I conducted a structural examination using palpation, through which I determined that several areas of her body were not functioning optimally, and were being further aggravated by several stressful situations in her life. In this case, the stress was promoting muscles to be too tight and joints to not move well in the area that regulates or affects digestion (lower rib cage, abdomen and low back). These were also the areas she was experiencing pain on examination, even though she presented complaining primarily with abdominal pain. Using manipulation, I was able to begin to reduce some of the muscle tightness and joint restriction. Once the structural problems resolved, normal gastrointestinal function returned. It has been several months since I initially treated this young woman. She began to experience almost immediate relief of her symptoms with her first treatment, and was markedly improved after two sessions using osteopathic manipulative medicine. She currently sees an osteopathic physician near her home every four to six weeks as a preventative measure, and has been essentially symptom free without medication for six months.
As you can see from this case, osteopathic manipulative medicine offered an approach for this patient that was specific to her. Another patient with similar symptoms may have a different cause or different ways in which stress is manifested in the body, thus requiring a different, patient-specific treatment approach to resolve the problem. This particular patient responded very well to manipulative therapy. Such a response is common in our clinical experience using manipulation to treat a wide variety of conditions.
Often, when people hear about osteopathic manipulation, they compare it to chiropractic adjustments or massage therapy. In reality, osteopathic manipulation is different from both of these types of manual therapy for a number of reasons. One primary difference between osteopathic manipulation and other forms of therapy is that only the osteopathic physician has the training to apply the underlying philosophy of osteopathic health care with comprehensive medical training in all systems of the body, thus setting the stage for how manipulative medicine can be used with each patient.
This case illustrates how osteopathic physicians consider the whole person when making a diagnosis and developing a treatment plan rather than focusing solely on the symptom or disease process. Osteopathic physicians know that structure influences function, so they look for areas of the body where the structure may be altered and made more normal through manipulation in order to improve function to a particular body region, which then influences the entire body. Osteopathic physicians believe that the body has innate self-healing mechanisms that are key to restoring well-being and maintaining health, and that the physician’s job is to provide the proper supportive therapy or preventive measure to help the person return to health or to maintain health. Osteopathic physicians are trained that rational patient care is based on integration of these principles.
Osteopathic manipulation can be applied to every area of the body to help promote this self-healing process. Many people often assume that it is useful only for musculoskeletal complaints such as low back pain. As you saw in the patient case presented above, osteopathic manipulation may be used to treat a wide range of conditions.
When employing osteopathic manipulation, D.O.s use a variety of techniques that can be placed into some broader categories. Some of those categories include high velocity, low amplitude thrust techniques, which people generally associate with popping noises; muscle energy, where the physician uses techniques that requires the patient to contract his/her muscles in a very specific way to relieve muscle tightness and joint restriction; strain-counterstrain where the physician moves the patient into a position where localized painful spots are relieved; and myofascial release, where gentle forces are applied to by the physician’s hands to a region of the body to decrease neurologically mediated tightness to any structure of the body.
The use of palpation as a diagnostic tool is not limited in its usefulness in patient care. The use of manipulation, like any other component of a D.O.’s treatment options, i.e. medications, casting, surgery, delivery, is best utilized after appropriate diagnosis has been performed and an appropriate safety level for the patient has been determined. Since there are a variety of techniques, some being very gentle in nature, manipulation is generally indicated on some level for every patient. I am often asked to consult in the hospital to evaluate and treat newborns who had a difficult delivery, to treat post-trauma and post-surgical patients, and even to treat patients as they near death. Therapeutic touch has the ability to soothe and comfort patients, affecting them on physical, emotional and spiritual levels.
For the past 10 years, I have had the opportunity to participate in the training of osteopathic medical students, interns and residents. From this experience, it is apparent that to become a successful osteopathic physician, pre-medical students need to consider their motivation for becoming a physician, as well as the type of physician they wish to become. The osteopathic physician is challenged to become part of a patient’s life on a deeper level than other forms of care. To apply the osteopathic tenets in patient care, the physician must be willing to understand a patient, not just a symptom; to spend time interacting with patients to have an understanding of them on a personal level, their family, their hopes and their fears. Palpation provides a tool to better understand a patient through localizing areas that are poorly functioning and/or in pain. Some people are very comfortable with touching other people. Some people inherently, or through avocations such as playing instruments, cooking and carpentry, have a natural ability to develop manual diagnostic and therapeutic skills. Some people feel very uncomfortable getting physically close to other people. When a physician palpates a patient, the act naturally involves that the physician is simultaneously being touched as well. A fear of touching or being touched makes it very difficult for a physician to function in an osteopathic manner.
Helping a student to recognize their motivations, desires, strengths and weaknesses is very important in assisting them in making good career choices. Appreciating the unique characteristics of the osteopathic profession should help in directing premed students to apply to a system of medicine that best supports their motivations and skills.