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Somatic, semantic distinctions: DOs try to come to terms with manual therapists

The third installment in The DO’s scope-of-practice series, this article focuses on the osteopathic medical profession’s relationships with nonphysicians who perform manual therapy and MDs who practice manual medicine. The first article in the series examined the increasing scope of practice of naturopathic doctors, while the second article concentrated on nurse practitioners.

A licensed acupuncturist and physical therapist in New York boasts of having expertise in “osteopathic physical therapy” and “advanced, post-graduate training” from the Michigan State University College of Osteopathic Medicine (MSUCOM) in East Lansing.

Dr. Johnson

A critic of the indiscriminate instruction of non-DOs in “osteopathic techniques,” Virginia M. Johnson, DO (top right), serves as a table trainer during an osteopathic manipulative medicine lab for DOs at a meeting of the Los Angeles County Osteopathic Medical Association. (Photo courtesy of Dr. Johnson)

Another PT, licensed in Pennsylvania, touts herself as an “osteopathic physical therapist” (PDF) on her online résumé and claims to have a “certificate in osteopathy” from the Osteopathic College of Ontario (Canada) and the Osteopathic Health and Wellness Institute in Wilmington, Del.

Two licensed massage therapists in Oregon promote “osteopathic manual therapy” on their website and vaunt having studied a range of “osteopathic techniques” under U.S.-trained DOs.

“By what right do these individuals use the term osteopathic?” asks Virginia M. Johnson, DO, the president of the Los Angeles County Osteopathic Medical Association.

Such examples call into question why members of the osteopathic medical profession would instruct non-DOs in the techniques of osteopathic manipulative medicine. “Why do some legitimate DOs believe they can teach our techniques outside the context of a full medical educational background and full ethical and legal responsibility in patient care?” probes Dr. Johnson, who practices neuromusculoskeletal medicine in Santa Monica, Calif.

Like Dr. Johnson, a number of osteopathic physicians decry the hands-on instruction of manual therapists in osteopathic principles and practice as a hazard both to patients and the profession. But some DOs contend that teaching others OPP increases acceptance of osteopathic medicine and improves public health.

Impinging on osteopathic physicians’ sense of professional identity, the debate over teaching OPP to non-DOs raises questions about the distinctiveness of osteopathic manipulative treatment. The issue is further complicated by the profession’s growing collaboration with other health professionals—foreign-trained osteopaths abroad and MDs, chiropractors and physical therapists in the United States.

Whom can DOs teach?

Osteopathic physicians who practice OMM typically regard non-DO practitioners of manual therapy as having entirely different training requirements, perspectives and patient outcomes, yet many DOs and osteopathic medical organizations teach manual therapy techniques and osteopathic philosophy to non-DOs. Though controversial, this is within the ethical guidelines of both the AOA and the American Academy of Osteopathy (AAO) as long as those being trained are learning techniques consistent with their scope of practice, says AAO President Richard A. Feely, DO.

Approved by the AOA House of Delegates in 2002, the AOA and the AAO’s joint position paper on teaching manual therapy encourages the free dissemination of osteopathic philosophy to other health professionals so that they can better coordinate care with and make referrals to DOs. (In July 2010, the House referred back to the submitter a resolution to reassess this position paper.)

But Michael P. Burruano, DO, for one, would like his profession to halt what he believes is the wholesale training of nonphysicians in OMT techniques—even though the term osteopathic manipulative treatment is reserved for U.S.-trained DOs. “As a profession, we have been shooting ourselves in the foot,” insists Dr. Burruano, who practices neuromusculoskeletal medicine in Brewster, N.Y.

Dr. Johnson calls attention to U.S. citizens who are studying nonmedical osteopathy—as opposed to osteopathic medicine—in Canada and other foreign countries and returning to the United States to practice essentially as unlicensed osteopaths, though some of these practitioners may be licensed physical therapists or massage therapists operating outside of their scope of practice. “Some of my patients come to me with untreated, progressing medical conditions—not to mention injuries sustained—after paying out of pocket to see such ‘osteopaths,’ unaware of the differences between these practitioners and DOs. The confusion and the danger to the public are the real issues.”

Dr. Johnson points out that some U.S.-trained osteopathic physicians are exacerbating this problem by teaching in Canadian and other international osteopathy schools that don’t meet the high standards for nonmedical osteopathy advanced by the Osteopathic International Alliance. Some foreign osteopathy schools provide training that is “minimal and incomplete if not outright unscientific,” she says.

Especially worrisome to both Dr. Johnson, the treasurer of The Cranial Academy, and Dr. Burruano, a former president of the Sutherland Cranial Teaching Foundation, has been the proliferation of craniosacral therapists in the United States. Trained by The Upledger Institute in Palm Beach Gardens, Fla., which John E. Upledger, DO, founded in 1985, these individuals include chiropractors, physical therapists, massage therapists and other nonphysicians. Cranial techniques, which require years of training and practice to perform well, can cause serious harm to patients when misapplied by practitioners who have limited experience and perspective, assert Drs. Burruano and Johnson.

But those who train manual therapists in OPP often feel a closer kinship with non-DOs who are enthusiastic about osteopathic philosophy and techniques than with DOs who don’t appreciate OMT, let alone provide it, notes Todd A. Bezilla, DO, an OMM specialist in Wilmington. “The osteopathic medical profession has strayed too far from A.T. Still’s vision,” says Dr. Bezilla, the director of education and curriculum development for the Canadian Academy of Osteopathy and Holistic Health Sciences, a school in Hamilton, Ontario. “Like Dr. Still, I see osteopathy as a powerful tool that diminishes the need for medical interventions, such as medications and surgery, while most DOs nowadays practice like they are MDs.”

13 Responses

  1. Joe on Jan. 8, 2011, 7:13 a.m.

    While the profession should look at working with the AMA to define the role of MD’s who do manual medicine, including techniques of OMT, I am fine with our non-DO colleagues performing OMT as long as they are trained by competent U.S. trained DOs. I think it leads to more acceptance of OMT and the profession of DOs when others can do OMT and see it’s results first-hand. I didn’t use to take that position. I originally thought it should only be DOs and we should hold OMT to ourselves. Now that I’ve seen non-DOs perform it and ask for help with it, I see how training them can be helpful. It’s also too busy to always be able to do OMT on all your patients that need it, so it’s also nice to be able to refer to someone who can do it as well. I would be fine with creating terminology and/or CPT codes that are consistent with OMT, but for non-DOs.

  2. J on Jan. 8, 2011, 11:09 a.m.

    As a 3rd year DO student I really see no problem with teaching non-DOs OMT. I learned all the OMT I ever need to learn in the first two years of school and I haven’t looked back. It’s not hard, it’s not dangerous, and with simple instruction the few relative contraindications can be taught to anybody. Honestly, most of us students couldn’t care less about being a “DO”, we just want to be doctors and the “drama” about this issue is quite laughable and almost pathetic. It even embarrasses me a little. If someone wants to help another human out and they think that OMT can help, by all means, teach the guy OMT. We are here to help patients. Not be greedy, selfish and childlike behind the cloak of “professional identity.” I think that is a bunch of bull. All of the opposition I have received from my MD preceptors is because of this exclusionary attitude that our leadership continues to display. If we really think OMT is such a great thing, why don’t we let MD students into our residencies and teach them OMT – like I said, it isn’t hard to learn – and then they could help that many more patients and the AOA could control who can say they have legitimately received OMT training.

  3. Zachary Comeaux DO on Jan. 10, 2011, 8:23 a.m.

    Article well reported with a representative scope of opinion.

    Two points:
    1) The non-DO in America performing “osteopathy” would be a non-threat if there were sufficient DO’s competently pracicing OMT as a distinctive osteopathic approach. Although OMT does not make medicine osteopathic, it is a critically important and underused element in diagnosis and treatment.
    2) As the article cites, all non-American DO’s are not the same cut. With anticipation of the WHO benchmarks, and the activity of OIA and WOHO, the climate of competency has shifted in many countries. Many are well trained, legal, and practicing within their recognized scope of practice.

    Z. Comeaux DO
    Professor of OPP, WVSOM
    President, World Osteopathic Health Organization

  4. Theodore Jordan, DO on Jan. 10, 2011, 11:55 a.m.

    The fact is that “osteopathy” is flourishing around the world, both in countries where it is regulated, and in countries without regulation. There are certainly places, like England, where the standard of eduction is high and very respectable, However, two years ago, a french D.O. told me that osteopathy was not regulated in France, and there were over 40 (forty) osteopathic “schools” in Paris alone; the educational standards must be horrible in many instances. And so the story goes, that in many countries on every continent, anyone who wants to open an osteopathic school, and/or advertise his/her self as an osteopath can do so with with neither training nor acceptable standards. The number of D.O.s around the world is increasing at a staggering rate, while the average standard of care provided by them, I would argue, is dropping. This has significant repercussions to the american, fully licensed D.O. in an ever global economy. There is no easy answer to all of this except that we should pay closer attention as to how the words “osteopath” and “osteopathic” are used and misused around the world. Moreover, we must be proactive in how our profession sets its course for the future.

  5. Ted Findlay, DO on Jan. 10, 2011, 5:43 p.m.

    I read with interest the article “Somatic, semantic distinctions: DO’s try to come to terms with manual therapists” posted on Jan. 7
    The discussion of appropriate usage of osteopathic titles and restrictions around the use of such titles is of great interest and importance for our membership.
    I noted Dr. Todd Bazilla’s comment that he wished to “play a role in raising osteopathic training standards – in Canada and, ultimately, around the world.”
    In response, I would like to point out that both the Canadian and American Osteopathic Associations have formal policy statements to the effect that the use of osteopathic designations by non-physicians is not appropriate in our two countries. Additionally, the educational standards and accreditation of the A.O.A. are recognized by the Federation of Medical Regulatory Authorities of Canada as meeting the standards for physician registration across Canada.
    I don’t think we need to seek different osteopathic training standards in Canada, I believe that the ones that exist are just fine, thank you anyway for your offer of assistance.
    Sincerely,
    Ted Findlay, DO
    President
    Canadian Osteopathic Association

  6. MARTIN J PORCELLI,D.O. on Jan. 11, 2011, 2:24 p.m.

    D.O. OMT STAYS WITH D.O.S WE HAVE THE 1800 HRS. AND CLINICAL TRAINING TO APPLY THIS TO A COMPLEX SYSTEM. OMT IS A MEDICINE AND A PHILOSOPHY AND A D.O NEEDS TO RX ONLY. READERS ALL HAVE EXCELLENT PTS. D.O. KNOWLEDGE STAYS WITH D.O.S…DO NOT DILUTE A POWERFUL FORMULA…DO NOT LOSE OUR DISTICTIVENESS….DO NOT LOSE OUR UNIQUENESS…DO NOT LOSE OUR IDENTITY OF 135 YRS. DO NOT ERODE OUR FORWARD STRIDES OF THE PA DECADES…

  7. Carolyn Schierhorn on Jan. 11, 2011, 3:30 p.m.

    Dr. Findlay, as the author of the “Somatic, Semantic Distinctions” article, I’d like to respond to your comments. In the indirect quote from Dr. Bezilla, I should have said “osteopathy training standards” rather than “osteopathic training standards.” Dr. Bezilla and my article were referring to the nonmedical osteopathy practiced and taught in Canada and elsewhere. I apologize for not mentioning that fully licensed, U.S.-trained osteopathic physicians practice in Canada . I thought that would confuse the issue since my article is about nonphysicians (physical therapists, rolfers and the like) who take classes in Canadian and other nonmedical osteopathy schools and return to the United States to practice as “osteopaths.”

  8. The DO | Misuse of osteopathic in nonphysician titles a setback for profession in Canada on Feb. 17, 2011, 2:31 p.m.

    [...] regard to Carolyn Schierhorn’s timely article posted on Jan. 7, “Somatic, Semantic Distinctions: DOs Try to Come to Terms With Manual Therapists”, we executive members of the Canadian Osteopathic Association (COA) would like to contribute the [...]

  9. Dave Abend, D.O. on April 13, 2011, 5:15 p.m.

    Look, I’ve been inpractice > 20years, am board-certified in 2 specialties-Family Practice and NMM/OMM and have been proude to practice my integrative and unique hands-on skills to the best of my ability and can back up my credibility.

    I’m proud to say that I attended Dr. Burrano’s Cranial course and can see all of the above points, but it’s safe to say without being supercilious, that unless a practitioner has truly ‘stepped’ in my shoes and had the intensive all-inclusive and well-rounded clinical experience that I/we have as practicing clinicians in the US, then all they are are limited practitioners attempting to act as someone else, practicing OMM wthout a license. It’s plain to see, They have practice and board exams and guidelines here for a reason. Try and pass the NMM/OMM full, not just the written, board and you’ll see what I mean-THEN put it into clinical practice.

    As my father, also double -boarded, 1st in FP, then in Radiology has said, ” The masses are asses “-it rings true here.

    Go through medical school and residency/ies and undergo the same rigorous sleep-deprived, stressful ‘hazing’ I did and I’ll be proud to call you a ‘colleague’.

    Dr. Upledger at least graduated from KCOM, but I suspect got a taste of the money and went way too far.

    Personally, I think we should let all the Non-medical acupuncturists, massage therapists, physical therapists who think they are more ‘expert’ at this than they really are, and PA’s and NP’s chiropractors as well as manicurists and reiki artists, etc. staff the ER at our local hospitals without ANY physican supervision and each other for about an hour before the public freaks out and gets shocked into reality that they are really not ‘doctors’.

    Let the responses begin.

  10. Otis on Aug. 22, 2011, 6:46 p.m.

    Dr Abend,

    You’re a FP doctor; I would have to ask how many true emergencies have you really handled and how frequently?
    How many full arrests have you run on your own, if any, without staff there to do everything for you? How many babies have you delivered? Any breech or twins? How about shootings, stabbings, rapes, poisonings, pin-in MVC’s, major wrecks with 20 cars or more, train derailment, electrocution, drowning, child/elderly abuse cases have you personally handled? Did you go to Katrina and handle the chaos there or did you stay at home and watch it on TV?
    How many chest needle decompression’s have you preformed when it meant life or death? How many intubations have you done? Surgical cric? You’re a general practice doctor, I’d like for you to put yourself in the same ER scenario you suggested these other practitioners be placed and see how long you last alone. Emergency medicine is a specialty just like OMT. Comparing them is like comparing apples and oranges.

    I have done all the above and then some. I have NO desire to be a doctor. I have worked with many doctors that are not emergency doctors and they cannot manage an emergency. It’s just not their area of practice.

    Very few DO’s practice the beautiful art of true osteopathy, and I for one think it is a shame. The body is smarter than you or I will ever be and only the tissue knows what it needs to restore balance. The rule of the artery is supreme, and function effects structure and structure effects function always. Understanding the cranial sacral system, visceral and parietal system and how all three are connected is imperative. The art of listening WITHOUT EGO and TRULY understanding anatomy is dying in the American doctor’s culture. I see it every day.

    Osteopaths from Europe and Canada are far superior with their OMT skills than any US DO I have encountered. I travel to Europe and Canada to study and receive treatments because I cannot get what I need or want here in the USA, which is a shame! Our US based medical school system is a broken system. Those that want to be doctors should be doctors and those that want to be osteopaths should be osteopaths. Not go to DO school because that’s the only one they were accepted to. It’s tainting osteopathy as a whole and it’s losing its credibility.

  11. Dr. Julie on Oct. 7, 2012, 9:46 p.m.

    Dear Otis,
    Reading your response made me smile. Thank you for making me believe there are people out there who really do get it! I agree that so many medical students use DO schools for the wrong reasons. I graduated from a US DO school because I wanted to practice OMM and FP from a holistic perspective. I have been happily and proudly practicing for 20 years! Most importantly, I am sorry you have not been able to find a caring osteopathic physician within the US. It is a real shame when an ideal patient, one who actually knows about an osteopathic physician and is in touch with his body, is unable to connect with a doctor.

  12. Chris Jurak, MS, PT on Jan. 20, 2013, 8:54 p.m.

    Interesting article; the take-home message, as far as I read it between the lines, seems to have less to do with standards of care than with, as the Chinese put it, “protecting one’s rice bowl”.,
    To start, in interests of full-disclosure: I am a PT; I have studied osteopathic manual techniques in pretty much a “piecemeal” approach over the years, picking up different things from different people over the years (Jones Institute, MIchigan State teachers including Hruby and Mitchell Jr., cranial from Upledger, 2 years at a Canadian DOMP program, and, believe it or not, even got through Frymann’s basic cranial course, lol); but I practice from an integrated perspective, meaning that if someone has a bad back, I am looking at the entire body (obviously w focus on neuromusculoskeletal & connective tissue systems as that’s my scope of practice) for answers, not just the lumbar spine;
    that said, I am not an osteopath; while I state in promotional materials that I utilize osteopathic manual techniques and employ an osteopathic approach (which are true statements) I don’t advertise myself as being an osteopath or practicing osteopathy; I don’t need to – I’m a licensed PT, and that is more than enough in terms of legitimacy.

    As to the article: While I appreciate the argument that OMT is only one aspect of being an Osteopath, and that in order to truly practice Osteopathy one needs must be able to diagnose and treat at the level of a physician, let’s look at the reality of the situation.

    First of, let’s not kid ourselves: as a PT, I can safely, effectively, efficiently, legally and ethically utilize most osteopathic manual modalities (counterstrain, muscle energy, balanced ligamentous tension and manipulation / thrust) within the scope of my practice, and can employ aspects of the rest (cranial and visceral techniques) in certain cases, without having to go to medical school in order to be properly inculcated in the so-called principles of osteopathy. Not only can I use them, but the fact is that I should be using them, because by using them (appropriately), I can have a better chance of helping patients get better (which, ultimately, is what the real point of this all is, as opposed to what is really nothing more than a juvenile turf war between PT’s, DC’s and DO’s); the argument that Osteopathy is more than just OMT may sound good, but ultimately, it’s really the defining characteristic that sets DO’s apart from MD’s, and one does NOT need to be a physician in order to utilize them safely and effectively.
    Second, PT’s are trained in medical model, and frankly I resent the statement made in the article that by using OMT-based techniques or taking an “osteopathic” approach (meaning looking at the body as a functional unit instead of at just one part at a time) we will miss a serious pathology, mis-diagnose, etc.; as part of our training, which currently takes 3 full-time years of post-BA study, we are taught how to appropriately screen for pathologies that are outside of our scope of practice and to refer a patient we shouldn’t be treating to a physician (“when in doubt, refer out!”). I have never treated a patient I shouldn’t have been treating just because I thought that I could handle them using OMT, nor have I caused any patient injury using the osteopathic techniques I have learned by using them unsafely (including thrust); in fact have helped numerous patients who have been through the mill in the standard PT-style practices (don’t get me started on trashing my own profession – I have plenty to say about that as well!), and who also have been to DO’s doing OMT and have gotten better results than they did – figure that one out…which brings me to my next point:
    Third, let’s face it – most DO’s are NOT doing OMT; and of those who are who are, a fair number do it less effectively than they ought to be doing it; for example, my wife is an MD (OB/GYN), but she’s also a French trained DO (2700 hours of pure OMT); she practices at a hospital where the residents are DO’s. Most residents she encounters have minimal interest in OMT, and for those that do, when she asks them questions about principles / philosophy of Osteopathy, most are clueless; in fact, she was told by one grad that they learned that “when someone has neck pain, we just treat the neck” (she also has a lot of negative things to say about their medical training as well – altho she trained in former USSR, and thinks that many US physicians are clinically inferior to the standard she was trained to…)
    Fourth – if the DO profession wants to protect the integrity of OMT, they should follow the example of Michigan State (Greenman, et. al. – btw, ALL of the exercises that Greenman shows in his book were created by a PT – should I argue that because he’s not a PT and doesn’t practice philosophically as a PT, he shouldn’t be using them? I mean, c’mon…); if there is an interest on the part of, say, PT’s, then the best thing to do would be for the AAO/AOA to sponsor an approved series of coursework that teaches PT the principles of osteopathy as applied to their scope of practice, and techniques within that range – meaning that I don’t need to use OMT to treat “bloody flux”, but I can certainly use it to fix someone’s chronic low back pain. This way, the AOA maintains quality control of what is being taught by DO’s to PT’s; also, it should certify those PT’s who pass the course – this would not only improve quality control, but would obviate the need for PT’s to go to Canada or the UK to get osteopathic certifications; and by maintaining a certification program to separate out those PT’s who have been trained according to that program from those who have not, it can take a stance against those not certified with more credibility. And it would go a long way at dealing with the alleged confusion on the part of patients as to who is legitimately practicing OMT in this country. Clearly people like Greenman, Hruby and Mitchell (all of whom are well respected in the DO community) get this already – the rest of the profession should follow suit.
    The bottom line is that osteopathic manual techniques work amazingly well, and in my experience far outclass all other manual therapy approaches currently taught. I personally get consistently positive results using them, and as such have been able to help far more people than I would have using other approaches. If the ultimately goal is to help as many patients as possible, then logically the more PT’s practicing “OMT” (or whatever u want to call it so as not to encroach on proprietary terminology) effectively, the better; instead of wasting time arguing semantics and using circuitous rationalizations to protect it’s “identity”, the osteopathic profession should get itself in gear and create a national certification program for PT’s (and MD’s) as I outlined above. Until that happens, until the AOA takes a proactive leadership role in the dissemination of osteopathic manual practice in a responsible manner, the John Upledger’s (RIP) of the world will have a field day teaching anyone who shows up on their doorsteps, and PT’s will just go get the information they want the same way we have been doing.
    I know I have taken a strong tone in the above, but I firmly believe that the current state of affairs ultimately does a disservice to patients who are not getting access to the most effective form of manual treatment available, and that is due to the recalcitrance of the DO profession to engage the issue in a manner that serves the common good whilst maintaining the qualitative integrity of their manual modalities when in the hands of alternate professions. I sincerely hope that this can change, as it will ultimately be of benefit to patients if it occurs.

  13. Tanya Eberhardt on Aug. 19, 2013, 8:02 a.m.

    If Osteopathy in itself was an internationally regulated profession, we would not be having this conversation. Let’s get it regulated in the US, requiring a bachelors of science and a doctoral degree, just like the PTs. We can easily distinct DOs practicing OMT or OMM and MDs practicing OPP from Osteopaths that only have a manual practice. I have a Bachelors of Science degree in exercise in sports sciences, with a focus in applied exercise physiology and kinesiology. I have studied human movement and manual therapy in depth. I am a licensed massage therapist, a registered yoga teacher and a nationally certified bodyworker with NCTMB. I have published countless articles on stretching, yoga, myofascial release, the myofascial system, anatomy and bodywork. However, I have not fulfilled my terminal degree, because the degree I want to pursue a Doctoral degree in Osteopathy is not offered in the US. Therefore, I am forced to go outside the US to successfully finish my goals. Still, my desired profession is not recognized in the US and therefore I am more limited in my scope of practice as a massage therapist than if I was a regulated Osteopath. This means I am less able by law to help my clients, who I cannot call patients. My desire to master Andrew Still’s techniques radiates like a beaming ray of sunlight. I am extremely passionate about the health of the myofascial system and am a founding member of the Fascia Research Society. I in every way want to get involved with research and know I can make a difference in people’s lives. Let me.

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