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The DO | In Training | OMS Spotlight

Confessions of an OMM skeptic, or How I learned to stop worrying and love OMT

I have a confession to make. Before my first clinical rotation in it, I was an osteopathic manipulative medicine skeptic.

I had spent two years learning in school about Fryette mechanics; cranial motion; high-velocity, low-amplitude (HVLA) techniques; and myriad related topics. My professors shared astonishing anecdotal stories and studies supporting the efficacy of OMM. My classmates and I practiced what we learned in lecture in our clinical labs.

This was all fantastic, but I still wondered if OMM actually worked. I found certain concepts, such as cranial and counterstrain, particularly hard to believe. While muscle energy, HVLA and soft tissue all made sense to me, these other two really puzzled me. The bones of the head move? There is a rhythmic impulse that I can feel? I can move your arm in this certain position and hold it there for 90 seconds and your pain will be gone? Really?

Hagemen

“The look of relief over the man’s face was incredible.”
Hageman

Sometimes it’s a little difficult to comprehend things you haven’t yet experienced. I read about the effectiveness of some techniques but hadn’t yet performed them and seen the results firsthand. In our osteopathic manipulative treatment labs, we practiced on each other. For the most part we are relatively young, healthy medical students. We don’t have a ton of somatic dysfunction. Maybe a small kyphosis after sitting in the library for twelve hours a day, but nothing like the dysfunctions of the chronically ill or those with severe musculoskeletal issues.

I had doubts that what worked for my healthy classmates would work well for a patient with chronic arthritis or irritable bowel syndrome, and I wasn’t sure if my OMM rotation would change anything.

Real-world exposure

But when I walked into the third-floor office for my first clinical rotation, I tried to keep an open mind. The Orlando, Fla., clinic was large, with about 15 exam rooms, each with its own blue OMT table. OMM was this clinic’s main focus, and its attendings, neuromusculoskeletal medicine fellows, and family medicine residents were booked solid from 9 a.m. to 5 p.m. They were always busy because they got results, I learned, and their patients kept coming back.

So many of the cases I saw illustrated what I had only read about in textbooks, and seeing real improvement in patients is what convinced me that OMM really worked.

I remember one patient, a 55-year-old man, who came in with chronic back pain of 35 years that a chiropractor had relieved numerous times in the past. However, he had seen his chiropractor six times in the past two months with no relief, and the chiropractor told him there was nothing else he could do. The patient drove an hour to see us. His initial complaint was low back pain, and a sensation of veering to the side when he walked. He had been out of work for a month because of the pain and discomfort. We learned that he had been in a motorcycle accident at the age of 16 and had dislocated his left hip. A thorough structural exam revealed a three-quarter-inch leg-length inequality that was not amenable to a number of our techniques—it was “stuck.” He had been compensating for this inequality for the last 30-plus years.

We removed some other dysfunctions and prescribed a heel lift for the short leg. A month later, his back pain and his mood were much better, and he was back to work. We did not “cure” him, but we did greatly improve his quality of life.

Another patient could find no relief for her regular, disabling migraines. Whenever she had one she would visit the office, and the attending would perform cranial. Within a few minutes, her pain level would decrease, she said. Although she still needed prophylactic medication, I could see the benefit of these techniques.

There was also a patient who had a history of severe necrotizing fasciitis of his lower leg, which had disfigured it badly, causing contractures and pain. He said the only thing that helped was OMT, in particular soft-tissue and lymphatic techniques.

And one time, an attending diagnosed a woman’s mechanism of injury just by observing her posture while sitting on the examination table. With no prior history he was able to deduce that she had been stopped at a red light and was rear-ended while her foot was on the brake pedal (crazy, I know).

And this was just the outpatient clinic. The physicians and I also performed daily inpatient rounds. We treated patients from age 11 to 89—many even requested OMT. In one case, a patient was admitted for severe chest pain, and everything in his workup was negative. His physician consulted the OMM department. Our attending examined the man and found a severely dysfunctional right posterior rib. He asked me to grab a hard compression board to place under the patient. He then performed a double-arm supine technique, which put the rib back into its correct place. The look of relief over the man’s face was incredible.

These experiences have carried over into how I think about treating patients and even into my personal life. I’ve fixed my wife’s superior pelvic shear that she developed while training for a marathon. I’ve treated my sister when she came down with pneumonia. I’ve even treated a patient with a clear-cut history of a cervicogenic headache in the emergency room.

No opportunity wasted

Some medical students and physicians are leery of OMM because they’ve heard horror stories about trying to bill for it, but this wasn’t my experience in my rotation. I learned that if an exam shows evidence of somatic dysfunction, a physician can treat, code and bill for it in just a few minutes. To learn more about this, speak to your attending physician. [Editor’s note: Members can also contact the AOA’s Practice Management department for help with billing and coding.] Payment is based on locale, but at my clinic, treating one or two regions of the body netted the physician an extra $32. Nine to 10 regions would be an extra $75. Over time this will add up.

If you’re getting ready to embark on your third-year rotations, I suggest you try to leave any biases you have behind. Take advantage of your OMT rotation and absorb as much as you can. Be hands-on and practice. That’s what you’re there for. If there’s something you don’t remember, look it up. I use “5-minute” consult books, and you can also download smartphone applications. The app OMM Guide by James Lamberg (free!) has OMM techniques, guidelines on the osteopathic medical assessment and more. Developed by the American College of Osteopathic Family Physicians, DO OMT ($9.99) has 120-plus step-by-step videos illustrating various techniques.

If you have weaknesses, focus on them now because this is where you will refine your techniques. Once your rotation is done, apply what you’ve learned to other rotations. Use your visceral techniques in surgery or your lumbosacral techniques for obstetrics. Explain and demonstrate to your MD preceptors and counterparts what you’d like to do if they seem apprehensive. You can pull up some of the good studies and evidence-based guidelines that are out there. Get as much experience as possible and find your own anecdotal evidence, or work with your preceptor and get a study started.

Learning OMM has forever changed the way I think about and practice medicine, and I hope other skeptics read my story and decide to give OMM a chance. It is yet another layer of care you can provide to your patients, and they will love it.

Kevin D. Hageman, OMS III, attends the Georgia Campus-Philadelphia College of Osteopathic Medicine in Suwanee.

thedo@osteopathic.org

16 Responses

  1. Lindsey Newman-Dufresne on April 25, 2013, 5:39 p.m.

    Great post!

  2. erik on April 25, 2013, 11:48 p.m.

    Concise, thought provoking, and straight from the heart. Love it…wise words for future students

  3. Dr Hochman on April 26, 2013, 7:46 a.m.

    It’s great to see that there are Osteopathic medical students that continue to learn and appreciate the techniques that I was taught by some of the Philadelphia greats years ago. Doctors like Nick Nicholas, his son, Dr. Heilig and others taught us the value of OMM/OMT and many of continue to value this today. While I do not use OMT in my radiation oncology practice, I did when I was a GP and ER doc many years ago and my friends and family know I can still help them. I still believe that the basic principles of evaluation of the patient from the Osteopathic point of view are a valuable everyday tool for those of us that are so trained. If you are in a practice where OMM/OMT can serve your patients, you do them a disservice to miss out on that opportunity!

  4. S. P. Radjenovich D.O. on April 26, 2013, 10:19 a.m.

    Great article, I attended KCOM (now A.T. Still University) and graduated class of ’74. I have used OMM both in my office practice and in the ER. Patients are very pleased with the improvement in their pain,an explanation as to the cause,and in many cases a discusson on how to prevent it from happening in the future.Keep on learning! S.P.Radjenovich D.O.

  5. Scott Leggoe, DO on April 26, 2013, 10:40 a.m.

    Those patients sound vaguely familiar ;-)
    Glad we opened your eyes up to the world of OMM/NMM during your time here with us.
    We loved having you and keep promoting osteopathy wherever you go.

  6. Joe on April 26, 2013, 3:24 p.m.

    While I completely agree with the above comments, and the substance of this article, it is important to recognize the subtext of the piece. OMS Hageman talked about his skepticism of OMT anecdotes. His skepticism was only overcome by developing his own foundation of anecdotal evidence. A reluctance or inability to scientifically quantify the therapeutic benefits of many OMT modalities is a real obstacle to OMM as a mainstream treatment that all competent practitioners (not just DOs) can use.

  7. Jenny on April 26, 2013, 5:25 p.m.

    Great article. I was wondering if you would be willing to share the name of the clinic? I go to LECOM in Bradenton, Florida and am currently setting up my thurs year rotations. I’ve been looking in Orlando and this clinic and its OMM experience sounds amazing. (I am as well a but skeptical after only treating healthy medical students). You can email me at hillje13@gmail.com if you have a chance. Thank you!

  8. Joey on May 3, 2013, 1:10 p.m.

    There’s no real research in this field at all. Sorry. Let me see a study showing before and after spinous process locations via imaging. Or have docs palpate and back it up with ct/MRI/us. Then conduct 10-20 of these studies.

  9. Di Ke on May 3, 2013, 1:23 p.m.

    I would also qualify as an OMT skeptic. I don’t claim that OMT is totally ineffective, but I wonder how many of the claims about what OMT can do are overstated. More importantly, I wonder how much of the patient’s relief is due to OMT and not the placebo effect. In this regard I would say that Joe and Joey are on the right track. I have read a number of OMT research articles and find the research designs in many to be quite poor; these articles conclude that OMT is the decisive factor (of course), and yet the experimental design does not support such a definitive statement.

    Personally, I would like to see stronger research in this area. Better research designs showing that the efficacy is truly due to OMT and research indicating what aspects of the OMT treatment catalyze the relief are sorely needed.

    Skepticism aside, I appreciated this article and look forward to trying OMT during my upcoming third-year rotations to see for myself how effective the techniques are on people with true dysfunctions.

  10. Emily on May 3, 2013, 2:14 p.m.

    Loved this article! I am currently an OMS I, and we are in the middle of learning cranial techniques. I suffer from chronic headaches, and I benefited from some of these techiques just last week from an OMS II. It is easy to be skeptical of these techniques when we first learn them because we aren’t yet very good and we are working on healthy patients. Glad to hear that you gained confidence in the validity of OMM in practice!

  11. OMS1 on May 3, 2013, 2:24 p.m.

    Anecdote is not the plural of data. This is a concept that most of my OMS-1 class seems to struggle with (along with our entire OMM department) despite the number of EBM lectures we’re given. Sigh….

  12. SDJA on May 3, 2013, 3:23 p.m.

    To OMT skeptics and lovers,

    You simply cannot argue with success- whether there is or is not scientific background that defines the fine physiologic properties of the medication/treatment. If it works, and the pt feels happy and can go about their life feeling better, in many cases, then I too am pleased.

    -SDJA

  13. Beryl G Chickerella MS RN on May 3, 2013, 3:51 p.m.

    It is wonderful to see young DOs loving the OMM practice. Many nurses like myself wish that this modality were used more. Keep up the good work,and spreading the word!

  14. OMS1 on May 3, 2013, 4:36 p.m.

    SDJA- you certainly can argue with success! More specifically the billing of it. If we’re billing for a service that is no more than a placebo then it is unethical at best and more akin to fraud. It also destroys our reputation in the medical community. If something works as well as many physicians claim OMM does then it should be very easy to prove with some simple research studies that include a control group, a sham (placebo) group, and a treatment group.

  15. CKK on May 5, 2013, 10:20 p.m.

    As a graduated OMM predoctoral fellow I can say that yes more research is needed. However saying if it works it would be easy to prove is not correct. There are many issues with performing research on any physical modality that make performing valid research much more complicated than with a pharmeceutical agent. Also the drug companies have a financial stake in the research they perform whereas OMT tends to lower the use of pharmeceutical agents and so funding the research is a bigger challenge. However, remember that research only answers the question asked. “Failed to prove” doesn’t mean works or doesn’t work…it means failed to prove. OMM either works or it doesn’t. I suspect it does because no sham could have endured the last 100 years of application. Does this mean I think all techniques or operators or patients are equal? Of course not. The problem with 1st and 2nd year education of OMT is that when med students practice on one another they are treating essentially normal subjects. Treating actual conditions successfully isn’t seen until 3rd or 4th year and that is dependent on having practitioners who know what they are doing. That is not true in all rotations. So it is only natural (and actually positive) that there are skeptics. But this isn’t a religion. We don’t need believers. I don’t “believe” in OMT. I use it as a modality for the benefit of my patients with good effect. I don’t have time to waste and so if it didn’t work so well I would do something else. OMT for me is like ordering physical therapy for a patient. Some come back and say it didn’t help. Should I begin believing physical therapy doesn’t work? Or consider all of the reasons why…wrong dx, poor compliance, operator error, more time (dosing) needed.

  16. My GA-PCOM - Confessions of an OMM Skeptic on May 8, 2013, 5:22 p.m.

    […] Please check out his article here as it hits close to home, and very close to campus! […]

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