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?
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.
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.