Why aren’t larger numbers of osteopathic physicians using osteopathic manipulative treatment? Are osteopathic educators doing enough to educate students in OMT so that they use it in their practice? So that patients understand its value? Is there enough research to support its continuation in the world of evidence-based medicine? What is the profession without it?
Unfortunately, there are no easy answers to OMT’s challenges. But in an effort to scratch their surface and get us all scratching our heads to solve them, Still Magazine looks at osteopathic manipulation at ATSU. It’s a tale of two schools, but a singular dedication to the technique at the center of what it means to treat osteopathically.
Of course, any osteopathic physician worth his or her salt knows the underlying osteopathic philosophy and principles and incorporates them into their care of patients. “The philosophy is the most important dimension of the appeal,” says ATSUSchool of Osteopathic Medicine in Arizona Professor Hollis King, D.O., Ph.D.
It appealed to Austin Jones, D.O., ’08, who says that treating osteopathically means “to take every effort to remember and integrate the anatomical, functional, pathological, emotional, and spiritual components and their inter-related reality in every patient presentation.”
Although this approach is time-consuming, he adds, it becomes second nature, and when each patient interaction is approached with this distinct osteopathic filter, “it is more likely that OMT will be provided to the appropriate patient at the appropriate time – not as an after-thought or last resort, but as a natural therapeutic choice in the correct clinical setting.”
Agreed, says fellow alumnus Stephen Blood, D.O., ’68, who manages a successful practice solidly based in OMT. Giving each patient OMT is the equivalent of giving everyone a B12 shot, he says.
Still, there is no putting OMT on a shelf. It permeates Dr. Still’s teachings and lies at the very heart of the profession’s identity – if not among physicians themselves, then their patients, for whom OMT is a D.O.’s most distinguishing characteristic.
If you’ve been in an OMM lab at KCOM lately, it’s hard to imagine more could be done to educate students, considering there are no fewer than 13 physicians and fellows, as well as a model, to personally guide students through a variety of techniques.
In addition, students can watch a demonstration of techniques, as well as see key information, on four large video screens in each lab. But the screens are just one indication that times have changed for OMT education. Until the ’70s, “OMM was the technique class,” says OMM Chair Karen Snider, D.O. “Osteopathy was taught in all classes; OMT was just the technique. Now, we have to teach integration and technique in fewer hours than they were getting then.”
In fact, she says, “You probably wouldn’t see the difference between an M.D. and D.O. in terms of coursework. At Michigan State, M.D. and D.O. students are in most of the same classes during their first year. The only difference that year is that D.O. students have the OMT class.”
ATSU-SOMA Professor William Morris, D.O., says the goal of all allopathic and osteopathic medical schools across the country isn’t all that different: competence in medical topics so students pass the boards. “Now, how we go about that and how each physician practices,” he cautions, “is a different story.”
One factor affecting osteopathic education, says Jonathon Kirsch, D.O., director of Osteopathic Principles and Practice (OPP) at ATSU-SOMA, is that there is more content to learn in the first two years of an OPP curriculum, and fewer opportunities to implement each treatment and principle involved in the clinical years.
“When the profession started, everything was integrated from day one. Now, you have two years of OMM training, then students go into clinics, and it’s a challenge for them to utilize OMT. We teach our students to be competent in a lot of different techniques, then they go out and don’t always have the role models needed in the clinical realm to bring those skills into full clinical utilization in their future practice.”
SOMA is attempting to meet this challenge through its OPP seminar program, a series of requirements in OMM during the clinical years, as well as through a preceptor OMM faculty development program. Also potentially helpful to integration clinically is SOMA’s case presentation curriculum.
In the traditional model, “you’re telling students the answers before they even know what the questions are,” says Dr. Morris. “With the SOMA approach, you’re teaching them that this is the symptom, here’s why you need to know everything, and then you begin to expand that tree. So they always have a place to hang the information.”
From that sort of inductive thinking, he says, “the idea then is to integrate osteopathic thinking and treatment.” And that’s an education, he adds, for students as well as faculty, who, as medicine and education itself changes are asked to do more.
Take Dr. Snider for instance. As department chair, her role is fourfold: performing research, teaching, carrying out administrative duties, and seeing patients – in addition to serving on committees and supporting student groups. Her goal in those endeavors, she says, “is to create truly osteopathic physicians – physicians who are able to integrate OMM into whatever specialty they are in, not just primary care. We’ve lost that, and I’d like to see it come back.”
In an effort to do just that, she focuses on completing research and getting it published, teaching students not only OMT but how to integrate OMM into their practice, and seeing patients so that she understands when – and when not – to use OMT in a clinical setting. She also works with licensing boards to make sure they are uniquely osteopathic.
With that kind of schedule, it’s no wonder she doesn’t have time to focus on every issue – such as the perennial conundrum of how to expose students to OMT in their third and fourth years. “The No. 1 reason our students don’t use manipulation is because they do not see it used during their third and fourth years of training or during their residencies. Whether they’re training with M.D.s or not, if they’re not seeing it, they’re not going to do it,” she says. “I can’t make the trainers use it, and I don’t know who can.”
Fellow professor Dr. Morris may not be able to make trainers use it, but he developed a plan while serving as founding chair of the department of Osteopathic Manipulative Medicine at Touro College of Osteopathic Medicine in Harlem, N.Y., that offers ideas toward that end.
In his “Connect the Dots” program, he strives to give students the confidence and skills to present the option of OMT to a physician naïve of osteopathic medicine. His message: “You can always do something!” The foundation, scope, and desire of the program, he says, was to get students not only to do something and try OMT but also “to make the case that you can change physiology in terms the rest of medicine will understand.”
The problem, he says, is that although schools do a good job of training students in the first two years, “there are not enough D.O.s who actually practice manual medicine to supervise the next step. There are maybe 100 of us in all 30 schools who are teaching it every week for most of the first two years. What happens after that is the students go out on rotation in hospitals or doctors’ offices, and the presence of osteopathic physicians who use the full complement of osteopathic tools isn’t there.”
Students, he says, see a lot of physicians who are disease-oriented, and very few who practice OMT. “If they’re not requested to do OMT, many students are going to duck. That’s the nature of the process. You’re asked to do way too much in too little time. If somebody gives you the opportunity to take a break for five minutes, you’re going to take it just to catch your breath.”
Any number of students at any number of schools will tell you it’s not unusual for students to finish their second year of classes and not see another technique until graduation, he says. “We’re graduating 4,000 people each year, and there’s just not enough osteopathically practicing physicians to provide that sort of care.”
Another challenge, says Drs. Kirsch and Snider, are the students themselves. “The biggest obstacle we see here in the first and second years is that some students just aren’t interested,” Dr. Snider says. “They sit and text on their phones. For the student who’s not interested, there’s not much you can do. You teach to those who are.”
Of course, not only do you need students willing to consider the full continuum of care, but faculty to support their education. Faculty who also carry the load for research in a medical community no longer content to rely on anecdotes and faith, but one increasingly focused on cold, hard facts.
Research and evidence-based medicine
a.k.a. time, people, money, space
“I often hear this comment that there’s no research supporting manipulation, and that’s just wrong,” says Dr. Snider. “It just may not be labeled as osteopathic.”
Osteopathy “does not have a monopoly on manual medicine,” she says. “To say that research done by a chiropractor or P.T. or D.O. are somehow different is not realistic. You need to look at manual medicine studies that are cross discipline. There’s tons of manual medicine research. Tons. Rib raising is rib raising no matter who does it.”
Dr. Kirsch agrees. “It’s important that we do our own osteopathic research, but it’s important not to ignore the research of other groups looking at manipulation. There are a lot of potential opportunities for collaboration or application. It’s not to say that manipulation is manipulation, but if you do something to the musculoskeletal system and it makes a change, does it matter what you call it?”
Whether that’s a philosophical or practical question, the profession will have to decide. Where the rubber hits the road, says John Heard, Ph.D., vice president of research, grants, and information systems, is that if D.O.s can’t demonstrate some validity to what they do they’re not going to get reimbursed for it, may not be able to perform some aspects of OMT if following the evidencebased medicine model, and in the worst case scenario may cease to exist.
“Although anecdotal evidence is strong across the board,” he says, “We’ve got to prove it.”
There are several reasons for urgency. “More research is being done because the culture of medicine is requiring more research in all areas, not just manipulation,” Dr. Snider says.
In addition, “Students now are more scientifically oriented than they were 100 years ago, and they want to take less on faith,” adds Dr. Kirsch.
Just as important, says Dr. King, SOMA’s second-year OPP course director, is “students likely will be asked on rotation, ‘Where’s the research supporting this?’”
In response, SOMA has instituted the use of physiologic demonstrations in its OPP labs that show physiologic change in response to manipulation of the musculoskeletal system.
Brian Degenhardt, D.O., director of ATSU’s Still Research Institute (SRI), assistant vice president for osteopathic research, and former OMM chair at KCOM, also is working to prove OMT’s validity and says that research is critical to its survival.
“I have seen numerous cases where manipulative treatment has been extremely successful in improving people’s lives. Unfortunately, the use of OMT is still quite limited, so getting the resources and the interest for a broader group of clinicians to provide this type of care is going to require research to really define the impact of OMT. There are conditions where OMT can be quite useful; there are others that it probably has no impact whatsoever. Until those conditions are defined, incorporation of OMT for society just won’t be achieved.”
Like the challenges to education, the challenges to research are many: establishing objective and reliable measures that demonstrate OMT skills meet an acceptable level of reliability, the profession’s culture of service as opposed to research, what some suggest is a bias against osteopathic research by research publications, and a lack of funding, space, time, researchers, and sustained focus.
Because osteopathic schools tend to be smaller, with a fraction of the faculty found at many allopathic schools, and because the culture is one focused on patient care, research simply hasn’t been a priority until now, Dr. Heard says. The bias in publishing osteopathic research, he says, is also natural. “If you have results from an allopathic physician and an osteopathic physician, and you have the option of printing either one, you will publish the one that will affect more people.”
Contributing to the dearth of published research into OMT is the fact that the majority of such research was conducted in the ’50s and ’60s and is not considered valid by modern standards, explains Dr. Snider, who says that a large amount of osteopathic research has never been published because the culture in osteopathic medical schools doesn’t “push” publication.
“It will change as schools change their priorities,” she says. “Osteopathic schools have always put students as No. 1 – and they should. But they have to place more emphasis on research if they want it published, because it takes a lot of time.”
Time, says Dr. Degenhardt, is the primary challenge. Research requires a sustained focus by researchers who don’t need to spend time refining their skills to complete a definitive study, he says. Because this is often the case, “So far, most, if not all of the work of osteopathic research has been preliminary or pilot studies.”
Modern osteopathic research, being performed at ATSU and a handful of osteopathic schools in Texas, Ohio, and Pennsylvania, centers on three areas, he says: establishing objective and reliable measures, looking at underlying mechanisms for manual techniques that examine outcomes and clinical efficacies, and performing observational studies on the current use of OMT.
The Still Research Institute, he says, leads the broadest and most consistent research taking place today. Since its creation in 2001, it has transitioned from purely osteopathic research to a disablement model, which includes osteopathic medicine and allows the SRI to support the majority of university research activities–cross-discipline.
“We have made significant strides in demonstrating reliability of the diagnostic procedures associated with OMT, which hasbeen a significant problem for decades,” Dr. Degenhardt says. “Research certainly has increased in the amount and rigor at ATSU, and we’re pursuing ongoing research directions, which is critical in advancing the science of any discipline.”
In the past 10 years, ATSU researchers have published 114 abstracts or articles. Prior to that, “the modern clinical research endeavor at ATSU was essentially non-existent,” Dr. Heard says. “The other thing that’s happening now that didn’t occur before is that basic scientists are collaborating with clinical researchers. In the past, again, there was virtually no collaborative research between basic scientists and clinicians.”
That’s because “clinical time uses up everything they have,” Dr. Heard says. “Between academic responsibilities and clinical practice, they don’t have time.” In fact, “clinical research is one of those areas that has sort of died off nationwide.”
His wish list includes “more space, more money to do the research, and more people to support it,” In short, Dr. Heard says there aren’t enough trained researchers because there’s no formal mechanism to train them, they can earn more in healthcare delivery, internal funds are dependent on the stock market, and federal funding “has gotten so tight that if you don’t already have the results, you’re not going to get funding, especially in an area that isn’t mainstream.”
To address a few of these challenges, the SRI has adopted a new initiative to develop practice-based research networks (PBRN) for physicians who are interested in research but whose primary focus is patient care. These individual physicians, spread out across the country, report on outcomes in their practices to uncover what types of OMT are being used, on whom, and with what results. Within the network, they also may pick a problem to research and develop a protocol they will implement to generate data.
“We have over 100 years of anecdotal recording about the efficacy of OMT,” says Dr. Degenhardt, “and what the PBRN can do is really determine what shows the most value at this time in the 21st century regarding the use of OMT for various conditions. That can help us focus on what areas to do further research and on those that have the greatest potential impact.”
For Dr. Degenhardt, it’s one project at a time, and success is the only option. “If you don’t sustain the research and infrastructure, the training for researchers, and a research direction,” he says, “the profession will not have an impact on modern medicine.”
To date, some of ATSU researchers’ most definitive studies include MOPSE (Multicenter Osteopathic Pneumonia Study in the Elderly), published this year, in which the research team found a trend that OMT reduced patients’ hospital stays by one day and reduced mortality and adverse events; and a 2003 JAOA article in which Dr. King was able to show that treating women during pregnancy results in fewer problems with pregnancy, labor, and delivery, and fewer pre-term deliveries.
The evidence base of musculoskeletal disorders has a lot of solid evidence, Dr. King says. “We have a systematic review and analysis that meets any standard for chronic low back pain. It’s about as good as you can get.” He also sees promising research into the viscera-somatic reflex.
And with four manuscripts in the pipeline and eight current research projects ranging from assessing techniques that affect the autonomic nervous system to a survey on physician attitudes toward billing and coding for counterstrain, Dr. Snider, too, soon will be adding more to the body of OMT knowledge.
The problem is that “no one is a slam dunk,” says Dr. King. “But if you look at all the research together, it’s fair to conclude that OMT does have physiologic benefit.”
Playing devil’s advocate is Dr. Blood, who isn’t waiting for a slam dunk. He sees proof of OMT’s benefit every day.
“I’m a fee-for-service doc, and if I don’t treat patients so they get better, they don’t come back. To me, that’s worth a lot more than justifying it all by research and not getting the job done. The patient doesn’t care whether we have research or not.”
People never stop seeking
Dr. Blood is lucky and skilled enough to experience on a near daily basis what many of those interviewed describe as transformative experiences – experiences where OMT changes lives, both for the doctor or student doctor and the patient.
“When you watch a student in the second or third month of classes, and their partner gets up and goes, ‘Wow, that really does feel different,’ and the student realizes they made a difference, it’s powerful,” says Dr. Morris. “It’s even more powerful when they do it with a real patient. I could not pay amounts of money for what that student doctor is feeling with his ability to change somebody else’s life and make it better.”
In Dr. Blood’s practice, it’s what keeps patients coming back for more. “I convert doubters,” he says. “Patients come in not knowing anything and walk out disciples. That’s what everybody should have.”
If OMT had an evangelist, it would be Dr. Blood, who promises not miracles but relief to patients via a bustling practice in Alexandria, Va., where he performs about 100 treatments each week and devotes at least 20 percent of his practice to children and infants. “It’s the most satisfying and important thing I do on this Earth,” he says.
One satisfied patient is Randy Kendrick, wife of Ken Kendrick, part owner of the National Baseball League’s Arizona Diamondbacks. Kendrick herself has been treated by Dr. Blood, in addition to several members of her family, including daughter Catie, a twin. When she was born, Catie’s head was twisted down on her chest, and she lacked the sucking response. After four or five minutes with SOMA Associate Professor Deborah Heath, D.O., she took to the bottle.
“I couldn’t help but think,” Kendrick says, “how many people might go through the same thing and never know about such a simple treatment.”
Kendrick once again sought OMT when Catie, at 1, dragged her left leg when crawling. After a visit to Dr. Blood, she immediately crawled across the table and began walking within two weeks. “You can’t fake that kind of stuff,” she says. “I was completely blown away.”
In kindergarten, Catie’s jaw and teeth were at an angle, and once again Kendrick took her to Dr. Blood, this time for a couple of months. Once again, he corrected the misalignment.
Although stories such as Catie’s immediate and transformative care are the most amazing examples of OMT’s effectiveness, immediate recovery often isn’t the norm, says Dr. Snider. Most patients, she says, are in pain because of things they do every day and can’t be “fixed” until they stop doing those things. Until then, OMT helps.
For Kendrick, who is worried OMT is being forgotten, the technique “is what makes osteopathic medicine different,” she says. If she had one message to convey to the profession, it’s: “Stop being ashamed of it. There’s something to it, something beneficial,” she says. “I think it’s an incredible life-saver, and it bothers me that it gets short-shrift.”
Kendrick may illustrate one of the most powerful challenges, not only to OMT but the profession itself: public perception.
“It’s been a problem for D.O.s for a long time,” Dr. Kirsch says. “In the beginning, I think it was pretty clear what we did. Part of the issue is that you usually don’t get OMT when you go to a D.O. I think if you always got it, more people would know what a D.O. is, but you don’t and there’s a disconnect there that’s been created by our profession. We have to be the ones who will address it if it’s going to change.”
To drive home the point, he paraphrases medical historian Norm Gevitz, who recently visited ATSU’s Arizona campus. “The profession has tried to be as much like M.D.s as possible,” he quotes, “to the detriment of its distinctiveness.”
According to Dr. Blood, whose father, Harold, graduated from KCOM in 1939 and practiced medicine for more than 50 years, manipulation was what made D.O.s separate and different from general practitioners of the day and that we once again will see a return to the hands with the advent of super bugs, epidemics, and viruses resistant to medication, as well as a public interest in natural therapies. Harkening Dr. Morris’ advice to “Do something!” he says, “You study, you practice, and even if you’re still not comfortable, you can still make people feel better.”
The public, he says, never stops seeking. And that’s another reason he sees hope for OMT, which for many patients falls under the increasingly popular category of complementary medicine and which has been recognized by NCCAM, the National Center for Complementary and Alternative Medicine. Although only 6 percent of NCCAM’s budget goes to manual therapy research, such funding has provided research support for the SRI and other osteopathic researchers.
Another group supporting OMT is the American Academy of Osteopathy (AAO), of which Dr. King is a past president. The AAO, with a stable membership of about 2,000 OMT specialists, and more than 6,000 student members, educates and advocates for OMT and supports its research.
Richard Feely, D.O., ’78, is the current president and says OMT isn’t being lost, but it’s not growing as fast as he would like. Currently, the AAO is awaiting word regarding a five-year grant to create the Center of Osteopathic Medical Education, which would support research and train physicians in manipulation and education. It also is working with the American Osteopathic Association (AOA) to identify physicians with the potential to teach, as well as to configure OMT codes, which set a relative value on OMT and therefore affect reimbursement.
Although reimbursement is a challenge to OMT’s financial viability, Dr. Kirsch doesn’t see it as insurmountable. The real challenge, he says, is technology. In particular, he would like to see a push to incorporate osteopathic structural examination elements in electronic medical records, and in fact has created such software that he would like to use in a grant situation.
“We have to make a decision as a profession that we’re not going to be left behind,” he says. “If we can get structural exam findings into EMR systems nationally, with a federally mandated system potentially coming down the pike, we have a good chance of increasing its utilization. Right now, it’s like the chicken and the egg. It’s not out there, so it’s tough to get out there.”
Even still, osteopathic medicine, with its focus on health and life rather than death and disease, is flourishing, Dr. Feely says. “We’re just outstripping our expertise. We’re the keepers of the flame, and we need to light as many as we can.”
Just how many lights there are is hard to pin down. According to a study by the AOA, 85 percent of D.O.s in its membership use manipulation; however, only 20 percent used OMT on more than half of their patients.
Still, there’s hope, says ATSU faculty and alumni. “Once you get it, and you know in your heart it works and it’s the truth, your commitment won’t be shaken,” Dr. Blood says. “If you practice medicine like this, you’re not looking for more patients, you’re looking for more partners.”
5 things alumni can do to support OMT research
1. Become a member of a practice-based research network
2. Stay well-informed on what current research is showing
3. Participate in CMEs and educational opportunities by the SRI
4. Consider funding an endowment for students interested in research
5. Communicate the science of OMT to patients so there is an ongoing desire for this type of care, which will drive research in this area