Essentials of Complementary and Alternative Medicine (June 1999)

Table 16.1. Classification of Osteopathic Manipulative Treatment
D
IRECT
 T
ECHNIQUES
Thrust, or high-velocity, low-amplitude (HVLA) technique is an example of direct technique; HVLA technique has been a mainstay of osteopathic treatment since 
inception of the profession. The patient is placed in a position so that the joint is brought into its physiological restricted barrier to motion. The physician applies a 
small amount of force quickly, just enough to go beyond the restrictive barrier. Then, motion is reassessed. The expected result is improved function (i.e., motion). 
This is a passive treatment because the physician provides the force.
An example of thrust technique is a patient who presents with anterior chest wall pain. The most common etiology of this complaint is somatic dysfunction of the ribs. 
Assuming this is the diagnosis, the physician determines the barrier to rib head motion and after positioning the patient, gently and swiftly overcomes the barrier to 
motion. Besides improved motion, one expects immediate alleviation of pain.
Muscle energy technique is another example of direct treatment. This form, unlike thrust, is an active technique in that the patient helps provide the corrective force. 
An example is a patient who presents with acute lumbar pain. On examination, the practitioner finds that the L-5 vertebra rotates easier to the right than the left (i.e., 
rotated right) and sidebends easier to the left than the right (i.e., sidebent left). The patient is positioned, and the physician has the patient rotate to the right and 
sidebend to the left in the lumbar region against resistance applied by the doctor.
Cranial manipulation may also involve direct treatment. For example, if a neonate refuses to suckle, this problem may be caused by suboccipital compression 
secondary to labor and compressive forces of the birth canal. This in turn puts pressure on the involved cranial nerves, which decompression may relieve. The 
expected result is immediate improvement in suckling.
I
NDIRECT
 T
ECHNIQUES
Indirect techniques of manipulation involve taking the dysfunctional unit in a direction away from the restricted motion barrier until a state of balanced tension is 
obtained. Functional and indirect ligamentous balance technique uses these principles. For example, an athlete suffers a sprained ankle on the soccer field. Before 
any other intervention is done the physician cradles the proximal aspects of the tibia and fibula in one hand and grasps both malleolae in the other. He or she holds 
them in a state of balanced, ligamentous tension, feeling the release of the strain-sprain take place. When the tissues feel palpably normalized the physician retests 
motion. The usual result is immediate: alleviation of dysfunctional symptoms. In many cases, depending on severity, the athlete can immediately return to the game.
Strain-counterstrain is another form of indirect manipulation. A tenderpoint related to a specific somatic dysfunction is located. The ends of the muscle or muscles in 
which it occurs are approximated and held for about 90 seconds, at which point they are slowly released. At this point the muscle contraction and tenderpoint will be 
gone, and retesting of the joint motion reveals less dysfunction. An example is a patient with acute torticollis. The physician palpates the most tenderpoint along the 
anterior or posterior articular pillars in the cervical paraspinal musculature. Then the physician presses the point and asks the patient to quantify the pain (e.g., the 
most pain is equivalent to $1.00) Then he or she repositions the spine so that when he or she presses on the point again the patient tells the physician that 25¢ or 
less of the pain remains. The physician then holds the patient in this position for 90 seconds and then, without any help from the patient, brings the patient to a neutral 
position and firmly presses the point. Reevaluation of the specific joint dysfunction will reveal an improved range of motion and the patient will report significantly less 
pain. This form of manipulation is one of the best for the neophyte to begin with when starting to learn osteopathic manipulation because it involves only the most 
elementary type of palpation, is easily grasped, and produces excellent, longlasting results.
O
THER
 T
YPES OF
 OMT
There are many other types of osteopathic manipulation: Chapman's reflex points, fascial unwinding, fluid techniques, such as V-spread, energetic treatments, 
percussion hammer work of Robert Fulford, DO, embryologically based treatment of James Jealous, DO, indirect forms of cranial manipulation and the work of Rollin 
Becker, DO, John Upledger, DO, and others, to name but a few options.
TREATMENT EVALUATION
After treatment, the physician would expect to palpate increased range of motion as well as encounter more normalized function locally and systemically. Often the 
patient will report lessening of symptoms, especially pain, although occasionally things may actually seem worse initially. This initial worsening of symptoms 
represents a shifting and rebalancing of the system and usually passes without further intervention. Change is assessed using standard methods of evaluation as 
previously detailed. Patients must understand that the longer they have had the condition, the longer will it take for symptoms to resolve. Osteopathic treatment 
unleashes a homeostatic process that functions over days, weeks, and months, depending on the amount of dysfunction. The physician may hear from the patient that 
many more symptoms have resolved between the visits than what was reported immediately after treatment. Acute onset complaints may require relatively few visits 
for resolution compared to chronic ones. During each visit there is constant, multileveled evaluation going on. Based on this immediate feedback from the system, the 
various parameters of the ongoing treatment are established, reweighed, and accordingly altered. As always, the essential measurement of progress is normalization 

of function and improvement in symptoms on all levels.
USES OF OSTEOPATHIC MANIPULATIVE TREATMENT
Because osteopathic treatment promotes homeostatic balancing and normalized function for the entire system, most pathological states may benefit to some degree 
from this approach. However, certain conditions in particular lend themselves to an osteopathic approach.
Indications
M
USCULOSKELETAL
 C
ONDITIONS
Osteopathic manipulation is often the treatment of choice for musculoskeletal conditions, particularly those involving trauma to the soft tissues, sprains and strains, 
range of motion restrictions, pain, impingement of nerves, and related areas. Most busy osteopathic practices see many patients with complaints of lumbar and 
cervical pain, both chronic and acute, localized and radiating. Some of this pain is caused by somatic dysfunction and some is secondary to nerve impingement, either 
discogenic or further along the route of the nerve. Manipulation is indicated in most of these situations with a few exceptions, one being in which extensive surgery 
has been performed and the effects of massive scar tissue impede osteopathic efforts and in emergencies, such as sudden loss of bowel and bladder function. 
However, even postsurgical cases often derive benefits arising from improved systemic function. Another key factor as with any approach is that of patient 
compliance. Reinjury of any kind must strictly be avoided.
Extremity pain, such as thoracic outlet syndrome, certain types of carpal tunnel syndrome in which repetitive motion reinjury can be avoided for a while, frozen 
shoulders, shoulder pain, and hip, knee, ankle and many types of foot pain seem to respond well.
Headaches of many kinds, with the exception of classical migraines (especially in their full-blown state), lend themselves to osteopathic treatment, as do sinusitis, 
temporomandibular joint dysfunctions, and closed-head injuries (with proper surgical consultation, of course).
C
HILDHOOD
 C
ONDITIONS AND
 P
REGNANCY
Although more research is needed, children with otitis media who have undergone many trials of antibiotic treatment with the infections always returning seem to 
respond well to OMT (
24
). The infections disappear, and the patients often avoid further antibiotics and tubes. In addition, the author has seen excellent response in 
patients with acute and chronic vertigo. In both of these conditions, cranial manipulation is useful.
Children diagnosed with attention deficit disorder and hyperactivity often benefit from an osteopathic cranial approach, as do many patients labeled developmentally 
delayed (
25
, 
26
 and 
27
).
Pregnant women respond especially well to gentle osteopathic treatment. It provides them with a relatively low pain pregnancy and is excellent physiological and 
anatomical preparation for delivery (
28
). Because most neonatal problems (e.g., colic, respiratory and upper respiratory problems, failure to suckle) can be treated in 
one to two visits, the author usually recommends mothers to bring in their newborn with these conditions. Issues such as plagiocephaly (i.e., misshapen heads) are 
best dealt with as early as possible and respond to direct cranial molding techniques.
H
YPERSYMPATHETIC
 S
YNDROMES
, R
ESPIRATORY
 D
ISORDERS
, 
AND
 O
THER
 C
ONDITIONS
One of the most valuable uses of OMT is in dealing with frank hypersympathetic syndromes, such as ileus. Until recently, standing orders were common at most 
osteopathic hospitals for preoperative and postoperative OMT for many surgical patients to prevent ileus. A clinical study demonstrating the value of such treatment 
for prevention of ileus was conducted at the osteopathic hospital in Waterville, Maine (
29
).
Although there are few formal studies conducted, I have found a number of conditions that are frequently helped with OMT. OMT is often helpful, for example, in 
respiratory disorders, such as asthma, pneumonia, and pulmonary sarcoidosis. Some data were collected on this in the 1918 influenza epidemic, which was in the 
preantibiotic era. American osteopathic clinics and hospitals reported a mortality rate of 0.25% for flu and 10% for the sequela of pneumonia compared with the 
allopathic rates of 9.8 to 27% for flu and 26 to 73% for the sequela of pneumonia at that time. Even now with antibiotics, OMT helps respiratory function in these 
conditions and can be a useful adjunct treatment (
30
, 
31
 and 
32
).
Other conditions that I have found responsive to osteopathic treatment include radiation fibrosis, hepatitis, mononucleosis, anterior chest wall pain, angina, 
amblyopia, neuritis, Bell's palsy, epilepsy with an unknown focal source, and whiplash.
There are also many conditions in which OMT may be a useful adjunct. Some of these are dental equilibration, swallowing disorders, tinnitus, stabilization of 
arrhythmias, infertility of unknown cause, gastroesophageal reflux, colitis, and stroke rehabilitation. OMT can also be helpful with the pain of cancer.
Contraindications
OMT is not recommended in certain conditions. Examples are cancer, nutritional problems, emotional problems, continuing repetitive trauma, or conditions of a 
psychosocial etiology.
With the exception of thrust technique, there are few contraindications (
33
). Obviously in muscle energy, an active technique, the patient must be able to follow 
commands adequately. Contraindications to thrust include fractures at the site of thrust, increase of pain or neurological symptoms while positioning the patient, 
severe rheumatoid arthritis, and metastatic cancer at the site of the thrust. Relative contraindications include carotid bruits in cervical thrust, advanced osteoporosis, 
acute spasms, and advanced mechanical motion restrictions (e.g., in certain types of arthritis).
ORGANIZATION
Training
American osteopathic physicians follow a parallel track with their allopathic medical colleagues in training. They have identical premedical course and testing 
requirements. Osteopath applicants must work with the American Association of Colleges of Osteopathic Medicine (AACOM) application service by applying to any of 
the 19 American osteopathic medical schools. The four-year osteopathic curriculum is equivalent to that of the allopathic medical school, except that the osteopathic 
student is required to take additional coursework in osteopathic principles and practice. Traditionally there is greater emphasis on understanding certain aspects of 
the basic sciences, such as anatomy, and later integrating that learning into the clinical setting than is commonly found in conventional allopathic medical schools.
After graduation as a doctor of osteopathy (DO) and before beginning postgraduate specialty training, DOs must do a one-year internship in an approved osteopathic 
clinical teaching institution. This hospital internship is roughly equivalent to the MD transitional year; the physician spends three months doing surgery and then 
several months in internal medicine, pediatrics, obstetrics, and so forth. This assures hands-on skills and exposure to all areas of practice in an osteopathic 
atmosphere. After the internship year, the physician is encouraged to complete a multiyear specialty or subspecialty residency. Presently, DOs are eligible for 
admission to all residencies in all specialties and subspecialties of medicine and surgery in all American MD and DO teaching hospitals. After this, additional 
fellowship training is available. Postgraduate training is also available in osteopathic manipulation.
Licensure and Certification
The National Board of Osteopathic Medical Examiners administers a three-part, six-day exam which, except for its specifically osteopathic component, mirrors its MD 
counterpart exam. These and other exams qualify DO's for licensure as full-practice physicians and surgeons in all 50 states. As a result of their advanced specialty 
training in residencies and fellowships, DOs are also eligible to sit for all AOA and AMA certifying examinations. They may and do serve on the staff of any allopathic 
or osteopathic hospital. They are also eligible to serve as fully commissioned medical officers in the armed forces, public health service, and other government 

programs.
Professional Societies
The central unifying organization in the United States is the American Osteopathic Association. The AOA has numerous component subsections and societies that are 
concerned with local affairs (e.g., state societies), specialty colleges (e.g.,. anesthesiology), research (e.g., National Osteopathic Foundation), and philanthropic 
groups. One group that has been around since the 1930s, the American Academy of Osteopathy, is concerned with furthering the teaching and development of 
osteopathic manipulation and principles. It also has numerous component societies for special interests in this area (e.g., Cranial Academy). There also exists a 
National Osteopathic Museum in Kirksville, Missouri, home to the first osteopathic school.
Osteopathic physicians are licensed by the states in which they practice. Approximately 17 states have specific boards just for DOs. The rest of the states and 
territories use composite and MD boards to license DOs (
34
).
Reimbursement Status and Relations with Conventional Medicine
American DOs are considered identical to MDs as far as third-party and government reimbursement for their services is concerned. There are specific ICD-9 codes for 
somatic dysfunction as well as the Physician's Current Procedural Terminology (CPT) codes specific for osteopathic manipulation done by a licensed physician (
35
). 
As of 1997, there were 129 hospitals accredited by the AOA. Many of these sponsored internship, residency, and fellowship postdoctoral specialty and subspecialty 
training (
36
).
The profession's relationship with the medical profession is at present cordial. For most of the profession's history, however, and as recently as the early 1960s, 
conventional mainstream medicine waged a steady campaign to weaken the osteopathic profession. In 1962, for example, the California affiliate of the AMA in league 
with the national organization got the legislature to pass a provision outlawing the licensing of DOs in that state. As a result, the osteopathic profession lost over 30 
osteopathic hospitals, which were taken over by MDs. The College of Osteopathic Physicians and Surgeons (founded 1901) was also taken over and became the 
University of California School of Medicine at Irvine. In 1974, the California State Supreme Court declared the 1962 law a violation of the antitrust amendment, but the 
damage had been done. This example is only one of many ways in which mainstream medicine has treated the osteopathic profession over the years (
37
, 
38
).
PROSPECTS FOR THE FUTURE
Ironically, the AMA News published an article which noted that as of the last few years it is actually more competitive to get into a DO school than an MD school (
39
). 
This may be because of the American trend of people looking for fully licensed physicians with a holistic orientation and good primary care skills, both major aspects 
of osteopathy today. Currently almost 40,000 DOs, which is 5% of all fully licensed physicians in the United States, serve over 10% of the American population. This 
trend is increasing daily. Today there are 19 osteopathic schools, compared with the late 1960s when there were only 5. New osteopathic schools are being approved 
at a time when medical schools are being closed and consolidated. It appears that organizationally, the osteopathic profession is doing well. There also appear to be 
renewed efforts to recapture the uniquely osteopathic orientation that first distinguished the profession and without which it will in all probability not survive as a 
distinctive, separate stream in American health care. Thus, despite tremendous pressures to the contrary, Dr. Still's reported final words to “Keep it pure” are being 
adopted by an small but increasing minority within the American osteopathic profession.
C
HAPTER
 R
EFERENCES
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2.
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3.
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4.
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6.
Kuchera.op. cit. 113.
7.
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8.
Truhlar R. Dr. A.T. Still in the living. Cleveland: Private printing, 1950.
9.
Dowling DJ. Neurophysiologic mechanisms related to osteopathic diagnosis and treatment. In: Di Giovanna, Schiowitz S. An osteopathic approach to diagnosis and treatment. Philadelphia: JB 
Lippincott, 1991:12–19.
10.
Millard FP. Applied anatomy of the lymphatics. Kirksville, Mo: Journal Printing Co., 1922:22–27.
11.
Owens C. An endocrine interpretation of Chapman's reflexes. Chatanooga, TN: Private, 1937.
12.
Jones L. Strain and counterstrain. Newark, OH: American Academy of Osteopathy, 1981.
13.
Upledger J. The reproducibility of craniosacral examination findings: a statistical analysis. J Am Osteopath Assoc 1977;76:890–899.
14.
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Greenman P. Roentgen findings in the craniosacral mechanism. J Am Osteopath Assoc 1970;70:24–35.
16.
Michael DK, Retzlaff EW. A preliminary study of cranial bone movement in the squirrel monkey. J Am Osteopath Assoc 1975;74:866–869.
17.
Retzlaff EW, et al. Cranial bone mobility.J Am Osteopath Assoc 1975;74:869–873.
18.
Dunbar HS, et al. A study of the cerebrospinal fluid pulse wave. Arch Neurol 1966;14:624–630.
19.
Mitchell F Jr. The muscle energy manual. Vol 1. East Lansing, MI: MET Press, 1995.
20.
Fryette HH. Physiologic movements of the spine.J Am Osteopath Assoc 1918;18:1.
21.
Fryette HH. Principles of osteopathic technic. Kirksville, MO: Academy of Applied Osteopathy, 1954.
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American Osteopathic Association, Publications Dept., 142 E. Ontario St.,Chicago,Ill. 60611.
23.
Dowling DJ. Neurophysiologic mechanisms related to osteopathic diagnosis and treatment. In: Di Giovanna, Schiowitz S. An osteopathic approach to diagnosis and treatment. Philadelphia: JB 
Lippincott, 1991:12–19.
24.
Gintis B. AAO case study. Recurrent otitis media. AAOJ 1996;6:2:16.
25.
Agresti LM. Attention deficit disorder. The hyperactive child. Osteopathic Annals 1989;14:6–16.
26.
Frymann V, et al. Effect of osteopathic medical management on neurologic development in children.J Am Osteopath Assoc 1992;92:729–744.
27.
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Johnson K. An integrated approach for treating the OB patient: treating the five diaphragms of the body. Part I. AAOJ 1991;1:4:6.
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Stiles, E.G. Osteopathic manipulation in a hospital environment. J Am Osteopath Assoc 1976;76:243–258.
30.
Magoun H Sr. Practical osteopathic procedures. Belen, NM/Kirksville, MO: Journal Printing Co, 72–73.
31.
Anonymous. Osteopathy's epidemic record. Osteopathic Physician 1919;36:1.
32.
Smith RK. Influenza mortality, one hundred thousand cases; with death rate of one-fortieth of that officially reported under conventional medical treatment. J Am Osteopath Assoc 
1920;19:172–175.
33.
Kuchera. op. cit. 295–296.
34.
Citation 23 for address of AOA which publishes directory.
35.
AOA directory contains latest guideline. Address citation 23.
36.
Yearbook and directory of osteopathic physicians. 87th ed. Chicago, IL: American Osteopathic Association, 1996:665–669.
37.
Gevitz N.The D.O's. Baltmore: The Johns Hopkins University Press, 1982.99–136.
38.
Bartosh L. The history of osteopathy in California. Journal of the Osteopathic Physicians and Surgeons of California 1978;5:30–33.
39.
AMA News. May 10, 1993.

CHAPTER 17. N
ATUROPATHIC
 M
EDICINE
Essentials of Complementary and Alternative Medicine