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The DO | Patient Care | Art of Healing

Strengthening the evidence base for osteopathic manipulative medicine

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John C. Licciardone, DO (right), is the principal investigator of the largest randomized controlled trial ever conducted on the effects of osteopathic manipulative treatment. (Photo courtesy of Dr. Licciardone)

“To know all of a bone in its entirety would close both ends of an eternity.”
—Andrew Taylor Still, MD, DO

In his bold questioning of assumptions and relentless pursuit of knowledge, Andrew Taylor Still, MD, DO, embodied the quest for truth that underlies all scientific research, observes Barbara Ross-Lee, DO, the vice president for health sciences and medical affairs at the New York Institute of Technology in Old Westbury.

“By any measure, A.T. Still was the osteopathic medical profession’s first researcher,” wrote Michael M. Patterson, PhD, in an editorial in the 100th volume of JAOA—The Journal of the American Osteopathic Association, published in April 2000. “His powers of observation and keen clinical insight led to many diagnostic and therapeutic discoveries that are relevant today.”

The second in a series, this article looks at the evidence base for osteopathic manipulative medicine and research currently under way. The first article presents an overview of evidence-based medicine and its application at the point of care.

A passion for inquiry propelled many of the profession’s early pioneers. During the second and third decades of the 20th century, Arthur G. Hildreth, DO, researched the effects of osteopathic manipulative treatment on mentally ill patients at the Still-Hilldreth Sanitorium in Macon, Mo., publishing statistical results on patient recovery rates in a 1929 issue of the American School of Osteopathy’s Journal of Osteopathy. Considered osteopathic medicine’s most renowned investigator of that era, Louisa M. Burns, DO, led the A.T. Still Research Institute in Chicago and then in Los Angeles from 1915 to 1936 and later ran a research laboratory at the former College of Osteopathic Physicians and Surgeons in Los Angeles. Dr. Burns conducted hundreds of studies on the effects of somatic dysfunction on skeletal muscle and visceral functions and wrote dozens of published articles and five books.

Consistently receiving funding from the National Institutes of Health, Irvin M. Korr, PhD, became the profession’s most celebrated researcher of the mid-20th century. Chairing the physiology department at the Kirksville College of Osteopathic Medicine from 1945 to 1975, he investigated the neurophysiological disturbances associated with somatic dysfunction.

Despite dating back more than 100 years, the osteopathic medical profession’s research endeavors failed to gain lasting, professionwide momentum, however. With its long struggle for parity and for public awareness and current focus on reimbursement, the profession as a whole has not consistently made research on osteopathic manipulative medicine a priority, notes Michael A. Seffinger, DO, the president of the American Academy of Osteopathy (AAO) and the vice chairman of the AOA Bureau of Osteopathic Clinical Education and Research.

“We do not have a research culture in our profession,” asserts William Thomas Crow, DO, the director of the integrated residency program in family medicine and neuromusculoskeletal medicine at Florida Hospital East Orlando. While prominent allopathic medical schools emphasize research, osteopathic medical schools for the most part focus on producing well-trained primary care physicians, Dr. Crow says.

But the federal government’s demand for scientific evidence in health care is compelling the profession to shift gears. “The push for evidence-based medicine is forcing us to do what we should have done before,” Dr. Ross-Lee says. “We don’t have enough research.”

In partnership with the Osteopathic Heritage Foundation, the AOA Council on Research provides up to $600,000 of funding annually for research projects. And this year, the annual AOA Research Conference focused entirely on the evidence base for osteopathic manipulative treatment. The AAO, in turn, has established a new foundation that has raised nearly $1 million to fund OMT research and disseminate research findings.

“Building our evidence base is crucial for us in gaining credibility as a profession,” says Hollis H. King, PhD, DO, who chaired the Research Conference that took place Oct. 31 to Nov. 1 during OMED 2011 in Orlando, Fla. “We have made significant progress, but more work needs to be done.”

Dr. King

Hollis H. King, PhD, DO (right), says that because fewer than a dozen individuals regularly conduct research on the efficacy of osteopathic manipulative treatment, it takes considerable time to build up the evidence base for OMT. (Photo courtesy of Dr. King)

Certain individuals and entities within the profession have remained committed to research, but they have received insufficient funding over the years, says Dr. Seffinger, an associate editor of the JAOA and the chairman of OMM at the Western University of Health Sciences College of Osteopathic Medicine of the Pacific in Pomona, Calif. Pilot studies, both experimental and observational, on many aspects of OMT have shown promise but have not yet added up to a rich repository of data, except for evidence that OMT alleviates low back pain and improves associated function, he notes. What’s more, today’s higher standards of research methodology have called into question results from the profession’s early forays into scientific investigation.

Fewer than a dozen individuals regularly conduct primary research on OMT, says Dr. King, the osteopathic residency director for a dually accredited program at the University of Wisconsin School of Medicine and Public Health in Madison. With only a small cadre of dedicated researchers, strengthening the evidence base takes considerable time, he notes.

3 Responses

  1. Plato E. Varidin, DO on Dec. 2, 2011, 5:18 p.m.

    If OMM were employed to patients on a regular quarterly basis, we would not have the diseases we have today.A quote that we have been using for years. OMM is more than just for back pain, it is an immune booster, our greatest protector, of diseases of visceral organs. Our patients on whom we have been using OMM as above, have been living quality lives well into their nineties. Ask for the report, written in two parts, that was submitted to the AOA, [John B. Crosby JD and to the entire AOA Board], authored by B. Warren Smith, DO., and Plato E. Varidin, DO. We presented it to the entire board on October 29, 2011. We do not object publishing any or all of its content.

  2. Jed Downs, MD, MPH on July 18, 2012, 11:27 p.m.

    Osteopathy was originally developed as an alternate way to promote health and facilitate recovery. History suggests that the survival rates from the 1918 influenza pandemic were much better for patients managed with osteopathy. In the days of PEEP and respirators, it is unknown if such efficacy could still be demonstrated.
    So much is being learned about the science of fascia, the importance of the extra cellular matrix on the organization of cells, mechanotransduction, tensegrity structure of the body at multiple levels, effects that are likely integrally related to osteopathic treatment effects. The basic science is being developed which should support the clinical work and provide biological plausibility to treatment. e.g. http://www.sacralmusings.com/video/video/show?id=921165%3AVideo%3A113681&xgs=1&xg_source=msg_share_video, Mina Bissell’s TED talk on the impact of the ECM on the development of cancer.
    From the standpoint of reimbursement, clearly demonstrating efficacy of OMM is critical, for the purposes of integrity as practitioners the EBM of osteopathy is needed. OMM lacks reliable funding sources. There is no medical device maker, no pharmaceutical manufacturer with a corporate interest in the success of OMM. That may be the biggest hurdle facing EBM research in osteopathy.
    In my mind the next biggest hurdle is study design. I like the idea of a blind assessor as described on page 2, but the blind assessor has to commit to staying blind. A good historian should be able to separate SHAM treatment from true treatment. I cannot imagine being able to sustain the same quality of doctor patient relationship if I were expected to provide sham treatment instead of the real deal.
    Another challenge is trying to limit the treatment to a protocol. Back pain may be secondary to multiple causes e.g. DJD/DDD, mechanical somatic dysfunctions of the lumbar spine or sacrum, The sacral restriction might be secondary to compaction of C0/C1 or elsewhere in the cranium, ptosis of a kidney, scarring and adhesions from a hysterectomy, appendectomy, or past diverticulitis etc. Protocol driven treatment plans are not going to be able to distinguish themselves adequately if a symptom is treated by rote. The skilled practitioner really needs to be given free rein to treat what they find to be the most significant dysfunctions. The next obvious problem is how does one standardize the practitioner, what kind of rho values can be established, are all practitioners expected to use the same treatment techniques. Each practitioner develops their individual tool box a further complication when it comes to analysis.
    I appreciate and respect the efforts of the researchers in question because the analysis of osteopathy is pretty damn hard.

  3. Chris Jurak, MS, PT on Jan. 21, 2013, 7:56 a.m.

    In regards to the above letter by Dr. Downs, I believe that he has hit the nail on the head; much of the power of manual therapy, be it osteopathic or otherwise, is operator skill – not only in terms of applying it, but in selecting the type (e.g. – direct v indirect), sequence, location, and frequency/amplitude/duration. As such, despite the desire on the part of many to apply MT exclusively via relatively-objective algorithms (the PT profession is going gaga over this approach of late), there is an almost necessarilly subjective component to MT’s application that is predicated upon the operator’s ability to interract with a complex system in a way that doesn’t always follow a linear flow chart approach (especially in light of a tensegrity-based model of connective tissue). As such, this sort of thing can be fiendishly difficult to construct a double-blind RCT around; it’s one thing to test inter-operator reliability of identifying counterstrain tender points, it’s another matter entirely to generate a standardized protocol for actually treating someone with it. High-quality anecdotal single-subect pre-post treatment case studies are certainly useful, but unfortunately don’t satisfy the current EBM trend. RCT’s that are constructed to minimize subjective variables might succeed to the point of eliminating aspects of MT’s application that rob it of some of its most powerful aspects. It’s a challenge for certain…

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