Essentials of Complementary and Alternative Medicine (June 1999)

PROSPECTS FOR THE FUTURE
The chiropractic profession has undergone an unprecedented growth in its public and professional acceptance. Today, the United States has over 55,000 
chiropractors, and nearly another 12,000 are enrolled in the nation's chiropractic colleges. Chiropractic research has contributed significantly to basic understanding 
of low back pain, cervical pain, and headache, and is involved in examining several other major health problems, including dysmenorrhea, carpal tunnel syndrome, 
and otitis media. Chiropractors have begun to enjoy staff privileges in hospital settings, and some colleges are again offering rotations through participating hospitals. 
Chiropractors participate on federal panels and organizations, such as the Office of Alternative Medicine of the National Institutes of Health. They have also been 
involved in programs, such as merit review for the Interdisciplinary Training Grants for Rural Health Care program run under the auspices of the Health Resources 
and Services Administration (HRSA) (M. Brand, personal communication, May 1995).
An area of great potential is in the growth of the chiropractic profession outside the United States. The World Federation of Chiropractic (WFC) has been invited to 
join the World Health Organization (DA. Chapman-Smith, personal communication, January 1997). The WFC represents the interests of chiropractic associations and 
chiropractors from a multitude of locations, including Ireland, Great Britain, France, Italy, Mexico, Japan, Taiwan, Norway, Sweden, Switzerland, and Finland, and this 
is by no means a complete list. Chiropractic has a growing presence outside its traditional stronghold in the United States. An example is the new RMIT:Japan Unit, a 
college based in Japan and coordinated through the Royal Melbourne Institute of Technology. The latter institute has its own chiropractic college.
Most chiropractic colleges are private, nonprofit institutions. Of the chiropractic colleges in the United States, only the University of Bridgeport College of Chiropractic 
has an institutional affiliation. The Canadian Memorial Chiropractic College is now investigating university affiliation. Two chiropractic colleges are becoming 
universities: Palmer University (through combining its Palmer and Palmer West colleges) and Life University (which now offers programs in addition to the chiropractic 
program). National College is investigating implementing master's degree programs (D. Wickes, personal communication, March 1997). Whether there will be a 
greater movement towards university affiliation remains to be seen, but it would be a welcome development.
Managed care offers its own set of challenges. The chiropractic profession would like to see the adoption of an “any willing provider” provision of health care reform, 
fearing that many gains might be lost if it is deprived of playing a role in the managed care networks under development, especially those that require a medical 
gatekeeper. This situation is in tremendous flux, and it remains to be seen how this will evolve. It is interesting to note that chiropractic-specific reimbursement codes 
have been developed.
Curriculum revision is occurring within the chiropractic institutions. Programs such as Los Angeles College of Chiropractic's  Advantage curriculum and National 
College of Chiropractic's Guided Discovery curriculum are exploring full-blown problem-based education. Other programs have made their own in-roads into 
curriculum revision, although not to the scale that these two institutions have.
The issue of whether chiropractic is primary care must be debated further. The vast majority of chiropractic practices involve spinal manipulation for musculoskeletal 
issues. In many situations, however, it is incontestable that chiropractors do render primary care. This is especially true in the rural setting, where the chiropractor 
may be the sole deliverer of health care for the community. Efforts are currently underway to develop collaborations between chiropractic physicians and Area Health 
Education Centers (AHECs). HRSA made special effort to include chiropractors as merit reviewers in the Interdisciplinary Training Grant for Rural Health Care 
program. The thinking was that because chiropractors now represent a significant force in health care, it would be smart to consider them in terms of answering 
shortages that exist in delivery of health care to medically underserved areas. There now stands a chance that approximately every 4 years another 10,000 
chiropractors will enter the work force; efforts must be made to do long-term planning to address national needs and trends.
A growing number of people within the chiropractic profession would argue that chiropractic medicine is no longer complementary and alternative medicine but now 
mainstream.
C
HAPTER
 R
EFERENCES
1.
Langworthy SM, Smith OG, Paxson MC. A textbook of modernized chiropractic. Cedar Rapids, IA: American School of Chiropractic, 1906.
2.
Palmer DD. The chiropractor's adjuster: a textbook of the science, art and philosophy of chiropractic for students and practitioners. Portland, OR: Portland Printing House, 1910.
3.
Palmer DD. The chiropractor. Los Angeles: Beacon Light Publishing Co., 1914.
4.
Palmer BJ. The science of chiropractic: its principles and philosophies. Davenport, IA: Palmer School of Chiropractic, 1917.
5.
Carver W. Carver's chiropractic analysis of chiropractic principles as applied to pathology, relatology, symptomatology, and diagnosis. Oklahoma City, OK: Warden-Elbright Printing Co., 1909.
6.
Forster AL. Principles and practice of spinal adjustment: For the use of students and practitioners. Chicago: National College of Chiropractic, 1915.
7.
Howard JF. Encyclopedia of chiropractic (the Howard system). Chicago: National College of Chiropractic, 1912.
8.
Beiderman F. Fundamentals of chiropractic from the standpoint of a medical doctor. Germany: Haug Verlag, 1959.
9.
Illi FWH. The vertebral column: life line of the body. Chicago: National College of Chiropractic, 1951.
10.
Homewood AE. Neurodynamics of the vertebral subluxation. Thornhill, Ontario: self-published, 1962.
11.
Janse J, Hauser H, Wells BF. Chiropractic principles and technic, 2nd ed. Chicago: National College of Chiropractic, 1947.
12.
Gaucher-Peslherbe PL. Chiropractic: early concepts in their historical setting. Lombard, IL: National College of Chiropractic, 1993:228–261.
13.
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Communicative Disorders and Stroke (NINCDS). Bethesda, MD: DHEW Pub. No. (NIH76–998).
14.
Haldeman S. Modern developments in the principles and practice of chiropractic. New York: Appleton-Century-Croft, 1980.
15.
Wardwell W. Chiropractic. History and evolution of a new profession. St. Louis: Mosby Year Book, 1992.
16.
Yochum TR, Rowe L. Essentials of skeletal radiology. Baltimore: Williams & Wilkins, 1987.
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Leach R. The chiropractic theories, 3rd ed. Baltimore: Williams & Wilkins, 1995.
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Cox JM. Low back pain: Mechanism, diagnosis and treatment. 5th ed. Baltimore: Williams & Wilkins, 1990.
19.
Lawrence DJ, ed. Fundamentals of chiropractic diagnosis and management. Baltimore: Williams & Wilkins, 1987.
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Foreman S, Croft A. Whiplash injuries, 3rd ed. Baltimore: Williams & Wilkins, 1995.
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Gatterman M. Foundations of chiropractic: subluxation. St. Louis: Mosby Year Book, 1996.
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Gibbons R. Evolution of chiropractic. In: Haldeman S. Modern developments in the principles and practice of chiropractic. New York: Appleton-Century-Croft, 1980.
23.
Beideman RP. Seeking the rationale alternative: the National College of Chiropractic 1906 to 1982. Arch J Assoc Hist Chiropr 1983;3:17–23.
24.
Gibbons RW. Go to jail for Chiro. J Chiropr Humanities 1994;4:61–71.
25.
Flexner A. Medical education in the United States and Canada. New York: Carnegie Foundation for the Advancement of Teaching, 1910.
26.
National College of Chiropractic. Profile of the Practice of Chiropractic. Lombard, IL: National College of Chiropractic, 1989.
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Bergmann TF. Chiropractic technique. In: McNamee KP, ed. The chiropractic college directory: 1994–95. Los Angeles: KM Enterprises, 1994.
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Bergmann TF, Peterson D, Lawrence DJ. Chiropractic technique. New York: Churchill Livingstone, 1993.
29.
Gillet H, Liekens M. Belgium chiropractic research notes. Davenport, IA: Palmer College of Chiropractic, 1951.
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Gatterman MI, Vernon H. Development of chiropractic nomenclature through consensus. J Manipulative Physiol Ther 1994;17:302–309.
31.
Shekelle PG, Adams AH, Chassin MR, et al. The appropriateness of spinal manipulation for low back pain. Santa Monica: RAND, 1991.
32.
Koes BW, Bouter LM, Mameran van H, et al. Randomized clinical trial of manual therapy and physiotherapy for persistent back and neck complaints: results of one year follow up. Br Med J 
1992;304:601–605.
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Meade TW, Dyer S, Browne W, et al. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1431–1437.
34.
Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical practice guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and 

Research, Public Health Service, U.S. Department of Health and Human Services. December, 1994.
35.
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1986;9:27–31.
36.
Gatterman M. Contraindications and complications of spinal manipulative therapy. ACA J Chiro 1981;18:S75–S86.
37.
Gatterman M. 
Chapter 4
: Complications of and contraindications to spinal manipulative therapy. In: Gatterman M, ed. Chiropractic management of spine-related disorders. Baltimore: Williams 
& Wilkins, 1990:55–69.
38.
Hawk C, Dusio ME. A survey of 492 U.S. chiropractors on primary care and prevention-related issues. J Manipulative Physiol Ther 1995;18:57–64.
39.
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McNamee KP, ed. The chiropractic college directory: 1994–95. Los Angeles: KM Enterprises, 1994.
41.
Wilk CA et al. vs. AMA et al. Complaint 76C3777 filed October 12 in the United States District Court for the Northern District of Illinois, Eastern Division.

CHAPTER 16. O
STEOPATHY
Essentials of Complementary and Alternative Medicine
CHAPTER 16. O
STEOPATHY
Harold Goodman
Background
 
Definition
 
Founder
 
History and Development
 
Key Published Works and References
Principal Concepts
Provider-Patient Assessment
The Structural Examination
 
General Considerations
 
Observation and Palpation
 
Additional Approaches to the Structural Examination
Disease Classification: Taxonomy in Osteopathy
Determinants of Treatment
Therapy and Outcomes
 
Osteopathic Manipulative Treatment
 
Basic Treatment Approaches
Treatment Evaluation
Uses of Osteopathic Manipulative Treatment
 
Indications
 
Contraindications
Organization
 
Training
 
Licensure and Certification
 
Professional Societies
 
Reimbursement Status and Relations with Conventional Medicine
Prospects for the Future
Chapter References
BACKGROUND
Definition
Osteopathy, or osteopathic medicine, may be defined as a complete system of health care that teaches and practices according to the following tenets (
1
):
1. The body is a unit.
2. The body has its own self-protecting and self-regulating mechanisms.
3. Structure and function are reciprocally interrelated.
4. Treatment proceeds from the first three principles.
As a primary care practitioner, the osteopathic physician uses any and all therapeutic and diagnostic approaches that best support these principles and most 
effectively, gently, and functionally promote local and systemic homeostasis.
Founder
Andrew Taylor Still, MD (1828–1917), the father of osteopathy, was an allopathic physician and Civil War surgeon who practiced in the midwestern United States 
during the nineteenth century. After many years of practice and clinical observation, he concluded that what was called health care was mostly fixated on disease and 
that medicine per se consisted of the suppression of symptoms and little else. He was galvanized into action by the death of several of his children to spinal 
meningitis. He thought that the enlightened mind of humans could certainly come up with something better than what passed for medicine. He believed that by 
diligently observing nature and, specifically, the living anatomy and physiology of humans, some guidance might be gleaned. Over the years he evolved a system of 
diagnosis and treatment, which he announced to the world in 1874 as osteopathy.  Osteo, the Greek word for bone, emphasized the new approach to physical and 
nonphysical structure.
History and Development
Dr. Still saw his work as a reformation of medicine, surgery, and midwifery (obstetrics) and as an expansion of the traditional medical–surgical model (
2
). It was never 
his intention to start a new profession. He believed that over time logical, rational men and women would accept his contributions for the overall betterment of society. 
Instead he was hounded by the medical community, driven out of Kansas where he practiced, and ended up in Kirksville, Missouri. In 1892 in Kirksville, he founded 
the first school of osteopathy, the American School of Osteopathy. This school, which was empowered by the state to award the MD degree, instead issued a new 
degree, the doctor of osteopathy (DO), which distinguished its graduates from the medical profession and insured professional and legal autonomy. A major emphasis 
in the osteopathic curriculum was a mastery of the basic sciences, especially anatomy (which he called the alpha and omega of osteopathy), as well as applied 
physiology. Dr. Still also emphasized the mastery of osteopathic philosophy, which he believed was his major contribution to the discipline. Specific manipulative 
technique was not initially taught. Dr. Still believed that, based on a thorough background in applied basic science, a well-supported diagnosis, and reasonable skill, 
any osteopathic physician could devise a treatment for any specific condition. However, within a few years,  technique, as osteopathic treatment was termed, became 
an established part of the nascent curriculum. Dr. Still saw osteopathy and medicine as diametrically opposed and loudly denounced attempts to integrate the two 
approaches. Traditional osteopathy continued to grow (by the time of Dr. Still's death in 1917, there were 5000 DOs). But by the 1940s, when early antibiotics were 
introduced, the previously drugless profession of osteopathy began to embrace pharmacology and a symptom-oriented medical model.
Although there has always been a small, active minority embracing and attempting to implement classical osteopathic approaches, the majority of osteopathic 
graduates and the professional osteopathic colleges have adopted the allopathic model with little training in traditional osteopathic principles. However, within the last 
few years the trend has begun to reverse; more and more younger osteopaths show interest in Dr. Still's original teachings and observations. For example, the 
Undergraduate American Academy of Osteopathy, which was almost moribund in the early 1980s, is quite vibrant today. Most of these practitioners participate in the 
American Academy of Osteopathy and its subsections, such as the Cranial Academy. Over the years, entirely new territories have been developed in the art and 
science of osteopathy. Some examples are the cranial concept (
3
); the embryological approach (best exemplified by the work of James Jealous, DO, of the New 
England College of Osteopathic Medicine); the use of the percussion hammer (as exemplified by the teachings of Robert Fulford, DO, for over 15 years); and fluid- 
and energetic-based approaches to osteopathy.
Key Published Works and References
The history of the profession is chronicled in two books. The first book, by E. R. Booth (
2
), covers the profession up to the 1920s, whereas the second book, by 
Norman Gevitz (
4
), covers the profession up to the 1970s. The Gevitz book is written by someone outside the profession and is thought by some osteopaths to 
contain historical inaccuracies and major omissions of key aspects of osteopathic history.
The literature of osteopathy is available in both monographic and journal form. Unfortunately, much of the classical literature is out of print. However, many of the 
classics in osteopathy are being republished by the American Academy of Osteopathy and by Health Resources Press. Dr. Still published four books, including  The 

Autobiography of A.T. Still, Philosophy of Osteopathy, and his final work, Osteopathy: Research and Practice (1910). From a clinical perspective, his most valuable 
work is The Philosophy and Mechanical Principles of Osteopathy (1902). Arthur Hildreth, a friend and student of Dr. Still, wrote and published an excellent biography, 
The Lengthening Shadow of Dr. Andrew Taylor Still. Other outstanding authors and leading figures in the profession include:
William Garner Sutherland, who discovered the cranial concept
Beryl Arbuckle, one of the most creative developers of the cranial concept and the leading authority on osteopathic pediatrics
Carl McConnell, a skilled, prolific writer on core concepts in osteopathy
F. P. Millard, the leading developer of the osteopathic approach to lymphatics
Rollin E. Becker, a student of Dr. Sutherland
Robert Fulford, a student of Drs. Sutherland and Arbuckle and developer of the percussion hammer
Some of these authors have only published in journals. In addition, there are a number of other recent authors, such as Kuchera, Greenman, Mitchell, Jones, and 
others represented in the bibliography.
The Journal of the American Osteopathic Association (JAOA, 1901 to present) has an excellent index up to the mid-1950s, after which much of the journal's index can 
be found in the Index Medicus. Two other excellent but unfortunately defunct journals are the  Journal of Osteopathy and Osteopathic Profession; the former ran from 
1892 to around 1967, was founded by Dr. Still, and contained articles by him and his original students. Several anthologies based on these and other osteopathic 
journals are available from Health Resources Press.
Overall, the best representation of osteopathic thought outside of the pre-1950 years of the  JAOA and the writings of Dr. Still can be found in the  Yearbooks of the 
American Academy of Osteopathy, a monograph that ran from 1938 to the late 1970s, after which issues have been released only sporadically.
PRINCIPAL CONCEPTS
Dr. Still often said that his major contribution to osteopathy was in the realm of ideas, principally in the elaboration of osteopathic philosophy, which he believed was 
an accurate reflection of the essential laws of nature applied to the human being.
The first principle of osteopathy is that the body is a unit and functions as such. Reductionistic attempts to view the body as a collection of disparate parts ignore the 
reality that this is not how the system actually functions. The next principle is that structure and function are reciprocally interrelated. This is a central underlying 
theme of all osteopathic work, which, in diagnosis and practice, distinguishes it from other health care systems. The form or structure (from the macroscopic to the 
microscopic level) of each living creature is a perfect reflection of its function. Osteopathic physicians believe that nature is deliberate in its evolutionary development. 
Dr. Still would often study human structures and ask, “Why, in order to best accomplish its function,  must this bone take the form that it does?” In this manner, the 
osteopathic physician can intimately understand the human biosystem. And, just as structure absolutely governs function, abnormal structure governs dysfunction.
Other basic principles of osteopathy are (
5
):
The body possesses self-regulatory mechanisms.
The body has the inherent capacity to defend and repair itself.
When normal adaptability is disrupted or when environmental changes overcome the body's capacity for self-maintenance, disease may ensue.
Movement of body fluids is essential to health.
The nervous system plays a crucial role in controlling the fluids of the body.
There are somatic components to disease that are not only manifestations of disease, but also are factors that contribute to maintenance of the diseased state.
These basic principles are, as applicable, elaborated on many levels because humans are viewed as simultaneously experiencing physical, emotional, mental, and 
spiritual realities. Dr. Still alluded to this in part when he presented his discovery of what he called the Law of Mind, Motion, and Matter. In this sense, motion in the 
patient is seen as a material manifestation of the effects of the underlying forces in the universe.
A consistent theme in osteopathy is to constantly support the system in its quest for homeostasis and normalized function. Osteopathy concentrates on health and not 
on the eradication of disease; it is a system that views the body as an ally and teacher, not as the enemy or simply a mass of tissues; and it is a system that embraces 
life and all of its manifestations as part of a greater, intelligent, self-generating, self-healing Unity.
PROVIDER-PATIENT ASSESSMENT
The purpose of osteopathic evaluation and patient assessment is to provide sufficient interaction with the patient to initiate the treatment phase.
The physician begins by observing the patient. This observation includes but is not limited to body habitus, dress, emotional state, posture, and anything else that 
may reflect the essential, underlying patterns of the patient as a unique individual. As the patient walks into the examination room (assuming he or she is ambulatory), 
the physician pays close attention to how he or she moves through space.
The history and physical examination are of crucial importance in osteopathy. They form the foundation for future clinical work and must be undertaken in a careful 
and thorough manner. The history covers the major medical parameters; specific information about prenatal, labor, and delivery history; and neonatal, pediatric, and 
adolescent physical and psychosocial history. Significant traumas and illnesses must also be elicited. The physician also must determine if the patient is right- or 
left-handed and if this was ever consciously or otherwise changed.
In eliciting the chief complaint as well as other complaints, the practitioner must accurately establish the onset of symptoms and specific history of any pathological 
development. It is especially important to understand the personal factors (e.g., family or personal crises, emotional traumas) that occurred in the patient's life within 
six months preceding and up to the complaint. This information may change the physician's understanding of the situation. Previous therapies of any nature must be 
elicited.