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Pump it up: osteopathic manipulation and influenza

First, my bias. I work in Portland and we have medical students, residents, and faculty who are DOs (Doctor of Osteopathy). Before he moved on to be a hospitalist my primary physician was a DO. From my experience there is no difference between an MD and a DO. In my world they are interchangeable. There are many more qualified applicants for medical education than positions in MD programs and some opt for a DO education. Osteopathy has a dark side.
As best I can determine from my colleagues, learning osteopathic manipulation (OM) is the price they pay to obtain an otherwise standard medical education. I have yet to see OM offered by any of my DO colleagues. It may be they know better than to offer such a modality around me given my ranty propensity for all things SCAM.

The literature would suggest that OM is left behind by most DOs upon graduation. DOs are not proud of their OM, and rarely invite them ‘round to dinner. It will be interesting to see if OM fades over time in DO school as the old time true believers die off and are supplanted by a generation of DOs trained with more traditional medical education.

OM, the small pseudoscientific aspect of DO medical school education, is a form of massage and manipulation invented in the 19th century with no basis in reality. OM postulates

the existence of a myofascial continuity – a tissue layer that interlinks all parts of the body. By manipulating the bones and muscles of a patient a practitioner is supposed to be able to diagnose and treat and variety of systemic human ailments.

Studies into the efficacy of OM find it to be ineffective for any process aside from low back pain (is there anything that does not help low back pain?), not surprising for a therapeutic intervention detached from reality. My purpose with this entry is not to review OM per se, which may be a good topic someday, but to focus on a specific application of OM.

Despite OM fading in the US, that does not mean there are not true believers; all nonsense has its die-hard proponents and OM is no exception, yielding peculiar publications. An example I ran across: The 2012–2013 influenza epidemic and the role of osteopathic manipulative medicine.

It caught my interest. How could a ritualistic massage and muscle manipulation have any effect of a virus that is multiplying in and destroying respiratory epithelial cells? Can they do OM on the lining of the lung? And if so, how do they get into the airway to do it? Inquiring minds want to know the rationale behind such a goofy intervention for a viral infection of the lung. Routine readers of the blog know I am very much a Bayesian/prior plausibility kind of guy. It is inconceivable to me that OM could have any effect on of influenza.

There remains a great need for a “something more” to be done to deal with this highly contagious viral infection—and that “something” is embodied by what osteopathic medicine has offered in the past: a distinctive care that helped the world manage the Spanish influenza pandemic of 1918-1919, nearly 100 years ago. Then as now, osteopathic physicians were in a unique position, armed with osteopathic manipulative treatment (OMT). Modern osteopathic physicians use OMT in conjunction with vaccination, antiviral treatment, and chemoprophylaxis to turn the tide against this devastating, highly contagious pathogen.

Weird, huh? Give a list of reality based interventions to decrease infection risk and therapy (hygiene, vaccination, medications) then toss in some useless pseudoscience. Interesting how a mind can hold two contradictory ideas at the same time: simultaneously suggesting reality- and fantasy-based medicine.

One of the themes of this blog and one of the topics that I have an evolving interest in is how we know what is true and the standards we use to determine reality. My time in the SBM world has greatly heighten my awareness as to how horrendous we are at interpreting the effectiveness of medical interventions and how iffy much of the medical literature is.

What is the basis of using OM for the treatment of influenza? For that you have to go back to a time when all medical treatments were little better than using stone knives and bearskins, the turn of the century. It was a time when most of medicine was, by the standards of today, worthless, dangerous or both. Most of the focus of this entry will be on the original papers, which had better be pretty damn impressive to suggest OM is a reasonable adjunct to standard influenza care. Spoiler. It isn’t.

The source was the 1918–1919 influenza pandemic where:

osteopaths had a substantial impact on patient care: according to Smith, patients who received conventional (i.e., allopathic) medical treatment had a death rate 40 times higher than those who received osteopathic care.

Standard care at the time had a case fatality rate of about 2.5%, although they give more impressive mortality rates in the paper.

Whoa. Really? It did? That would be amazing if true. Let’s go to the video tape. Or the scanned pdfs.

The original reference from 1919 is a fun read, the transcription of a talk full of the pomp and verbosity common in the time. I am writing the final draft of this essay during breaks at the national ID meeting, where I have spent the last few days mostly having Powerpoint slides read to me. We could use some 19th century pomp and verbosity to enliven the sessions.

The reproduction is poor with a lot of bleed-through. I think it says, and this is the methods part of the presentation:

As you know, a letter containing a blank questionnaire on Influenza and Pneumonias was sent last November to all practicing osteopathic physicians in the United States and Canada. Strict and emphasized instructions were given to report only definitive and well developed cases and to report all such, together with all fatalities.

That’s it. I cannot locate what the strict and emphasized instructions were. Very little real data is given. Nowhere do they mention what specific osteopathic treatment was used, there was more of a focus on what was not done: no aspirin, no narcotics.

The data was equally minimalistic. In the original paper it was reported that 2,445 osteopaths answered the questionnaire and reported treating 110,220 cases of influenza with 257 deaths, 1/4 of one percent. They also reported 6,248 cases of pneumonia with 655 deaths.

The paper was presented in July 1919, only about 7 months after the end of the epidemic. A damn impressive turnaround time to send out almost 2,500 letters, have them filled out, returned, read and analyzed. I would so love to see those letters. It seems a wee bit suspicious to me. Anyone have the originals?

A further illuminating feature of these reports revealed that fact that few persons contracted influenza who, just preceding and at the time of the epidemic, had been having more or less regulate osteopathic manipulative treatment.

The actual data to support the preventative effects of OM? Nothing. His assertion. Color me unimpressed (mauve-y shade of pinky russet is the color of unimpressed, if you must know).

Most of the report goes on to castigate the powers that be for not including DOs as part of the medical response to the pandemic despite their superior medical treatments and noting that DOs did not make any of their patients drug addicts. It is quite an indignant screed, worthy of the blogosphere but short on supporting data.

The paper, while interesting, is of no value what so ever for supporting the use of OM for influenza: no microbiologic diagnosis, no case definition, no case control, and huge opportunity for reporting bias that renders the information totally unreliable. But a fun rant does not a reliable intervention make. I would love to see the original questionnaires and look at the data. We have to take the word of the author who, from the tone of the paper, has a real ax to grind in the promotion of DO/OM treatment.

Although anti-medication in tone, it is of interest that they were of the opinion that:

In 1918-1919, aspirin…played the same harmful role as was played by antipyrin and ?? a generation earlier.

How much of the death in the US from influenza was due to inadvertent aspirin overdose is an interesting question:

In 1918, the US Surgeon General, the US Navy, and the Journal of the American Medical Association recommended use of aspirin just before the October death spike. It has been suggested that aspirin overdose lead to significant pulmonary edema and death in the US. If these recommendations were followed, and if pulmonary edema occurred in 3% of persons, [a significant proportion of the deaths may be attributable to aspirin.]

A curious hypothesis, although the virus was quite capable of killing without the benefit of medical care and aspirin.

It is an interesting question as to whether it was DO care or the avoidance of MD care and aspirin, if it occurred, that resulted in an improved survival rate. The fact that most SCAMs do nothing would be a benefit in a time when medicine inflicted aggressive nonsense upon the ill. More likely is biased reporting by an author railing against “medical bigotry and medical politics.”

Even if OM care was responsible for a decreased death rate, and I would be skeptical based on the methods and data reporting, it is more likely a result of what DO did not do (standard care) than what they did (OM).

The author of the 1937 paper referring to the 1919 report credits:

the lymphatic pump technique, which has become popular in the last few years is a procedure of definite value in the treatment of influenza.

What proportion of patients actually received the ‘lymphatic pump technique’ cannot be discovered, as it is not mentioned in the original 1919 paper what exactly the DO interventions consisted of.

As best as can be determined, there is no information in the original reports to suggest that any conclusions can be made about any specific osteopathic intervention for influenza as no specific intervention is mentioned (must less the use of any lymphatic pump).

The fact that there is no mention of a lymphatic pump as the intervention that led to such a dramatic decline in mortality doesn’t stop the technique as being touted for the treatment of influenza:

Should we face additional waves of new influenza infections in the coming year, the use of the gentle lymphatic treatment techniques and medications such as oseltamivir will likely help pre- vent many persons from getting the influenza-related complications that took so many lives during the Spanish influenza pandemic of 1918-1919.

and

Retrospective data gathered by the American Osteopathic Association shortly after the 1918–1919 influenza pandemic have suggested that osteopathic physicians (DOs), using their distinctive osteopathic manipulative treatment (OMT) methods, observed significantly lower morbidity and mortality among their patients as compared to those treated by allopathic physicians (MDs) with standard medical care available at the time. In light of the limited prevention and treatment options available, it seems logical that a preparedness plan for the treatment of avian influenza should include these OMT procedures, provided by DOs and other healthcare workers capable of being trained to perform these therapeutic interventions.

I love their understatement about the validity of the original data:

These were not controlled studies. The data is retrospective and some conclusions cannot be well drawn from such information.

How about no conclusions can be drawn? I grow even more of a mauv-y shade of pinkish russet by the paragraph. It doesn’t prevent the author from declaring

OMT proved to be a critical factor in the success of osteopathic physicians treating influenza patients during the pandemic of 1918

They suggest a variety of pumps that are supposed to boost the immune system (zero prior plausibility for that concept) and increase lymph flow (maybe, but I can’t see that lymph flow would be of any value in and of itself and the short term increase in lymph flow, if it does occur with OM, would be brief and of an inconsequential amount given the duration of the intervention relative to the 24–7 illness like influenza. A pump would be like adding a lit match to increase the burn rate of a forest fire).

The various pumps are described look to me like a series of massages, some of which look like they are designed to give influenza to the practitioner. I wonder how a patient with flu, intractable cough, high fevers and severe myalgia would lie still to let this be done.

It is often interesting to go back to the original literature and see if the paper actually says what people say it does. I learned as a fellow that papers are often ink blots and people see in them what they think should be there rather than what actually is there. Confirmation bias can show up in the damnedest places.

A reading of the primary literature for OM and influenza does not lead to great confidence in the intervention for influenza nor do the papers actually say what the proponents suggest they do. I become Shaltanac’s joopleberry shrub.

As we head into the influenza season, stick with realty-based interventions. Wash your hands, avoid the spew of coughers, harder than you might think, get the vaccine and be replete in your vitamin D. I think it is safe to say you can pass on osteopathic manipulation.

Posted in: Chiropractic, Clinical Trials, History, Science and Medicine

Leave a Comment (65) ↓

65 thoughts on “Pump it up: osteopathic manipulation and influenza

  1. AnObservingParty says:

    My primary is a DO, a wonderful physician who encourages research and follows a science-based practice model. Like the DOs you described, he cringes at the reputation OM has wraught. I think next time I see him I’ll bring up this article and then we’ll have a hearty laugh.

  2. Jann Bellamy says:

    Chiropractors are making the same claim, substituting routine “preventative care” (chiropractic “adjustments”) for osteopathic manipulation:

    “We recommend the approach that was so successful during the pandemic [OF 1917-1918]; routine preventative care and if symptomatic, an intensive course of care with supportive nutrition, homeopathics, herbs and or other types of therapies,”

    http://www.nydailynews.com/news/national/chiropractors-buck-trend-warning-flu-shots-article-1.1241886

    1. AnObservingParty says:

      I question what part of treatment during that particular pandemic they thought was successful, as the latest estimates point to it killing around 100 million people. Success!

      One difference, is at least the old-school DOs are citing mostly SBM with the one example of woo. That’s all woo.

    2. theroguechiropractor says:

      We’ve had chiros here in Australia trying to claim the Flu Pandemic and better mortality rates.
      If chiropractic cured flu and stopped people from dying from it, I’m sure there’d be a Nobel Prize for it somewhere, but the judges are rigged ya see…. ;-)

  3. Montressor says:

    First, my bias. Whenever I read the word “Portland,” I assume its the one in Maine, near where I live.

    I’ll be heading there soon to get my annual influenza vaccination. I doubt I’ll run into any Doctors of Osteopathy while I’m there. Just sayin’.

    1. windriven says:

      Maine? I thought she was sunk off Havana in the late 19th century.

      1. Montressor says:

        We don’t like to talk about that.

    2. WilliamLawrenceUtridge says:

      THERE’S A PORTLAND IN MAINE!?!?!?

      My grasp of geography is terrible. For the longest time I thought Illinois was a city in Minnesota.

      1. Montressor says:

        You’re close. It’s actually in <a href="http://is.gd/EGnEj6"Texas.

      2. Nashira says:

        @WLU, concerning geography:

        At work, I regularly see bills come in from Pike County Memorial Hospital. It’s on Georgia Street, in Louisiana, MO.

  4. windriven says:

    ” Interesting how a mind can hold two contradictory ideas at the same time: simultaneously suggesting reality and fantasy based medicine.”

    Isn’t that part of the differential diagnosis for schizophrenia?

    * * *

    ” the use of the gentle lymphatic treatment techniques and medications such as oseltamivir”

    Translation: prescribe Tamiflu and sing the Largo al Factotum from The Barber of Seville while shaking a brown bag full of the bones of small mammals. Knocks the edge off influenza almost every time.

    * * *

    Sam Sheppard was a D.O. Sheppard, a Bay Village, OH physician, was the model for the character Richard Kimball in the television series, The Fugitive. After serving forever and a day for the brutal murder of his wife, he went on to career as a big time wrestler. Yes, that kind of wrestler. But he was never the governor of Minnesota.

    There’s your useless bit of information for the day.

  5. goodnightirene says:

    I’m just on my way to get my flu shot, but thought I’d mention that a few DO’s (youngish ones) advertise around here in the Co-op’s magazine (a hive of SCAM). They offer the woo parts of Osteopathy with great pride. None are affiliated with any of the well known medical institutions that make up most of Wisconsin’s health care system. They have small, “independent” practices and tend not to get involved with insurance.

    Not only is there a Portland in Wisconsin, but an Oregon as well! (I always laugh when they say OR-AH-GONE–Dr C will get this!)

    1. Thor says:

      It’s the same here in Sonoma County, CA, where osteopathy can be the height of woo, leaving many less educated woomeisters in the dust. With a DO degree comes authority and power. which can make them even more dangerous than your run-of-the-mill crank. I, for one, am looking forward to a comprehensive treatise of osteopathy on SBM.

      1. agitato says:

        Me too! I don’t know much about the DO brand of medicine so I visited the American Association of Osteopathic Colleges website (www.aacom.org/) ‎and read a digital pamphlet called ‘A Brief Guide to Osteopathic Medicine, For Students, By Students’. The whole pamphlet was most enlightening, especially Chapter 3 called ‘Breaking Down Osteopathic Manipulative Medicine’. However, I thought it was quite troubling from a Science Based Medicine perspective.

  6. PB says:

    Mark is right – the vast majority of current DO students (and I’m one of them, though I’m especially critical as I’m also getting a PhD) really sees OMM as primarily a historical quirk that really should be de-emphasized.

    At best, IMHO, getting training in it gives us familiarity with being “close” to patients (people you won’t necessarily know well). Of course, this is by no means going to make you a better physician.

    My friends (primarily other DO/PhD students) and I really have a hard time reconciling our training in OMM with our scientific training as well as the American Osteopathic Association’s hellbent-ness on validating OMM, scientifically – rather than putting forward more efforts to advance SBM.

    Personally, it’s my hope that with the current talks between the AOA and ACGME (governing bodies of DO and MD residencies, respectively) related to more freely allowing DOs to enter MD residencies – and vice versa – will eventually lead to a dissolution of the two separate professions and creation of a single medical body. This probably won’t happen for a while, though. :-/

  7. William says:

    @Mark Crislip
    Why don’t you ask your DO friends why they don’t change the name of their profession as they are not really doctors of osteopathy but of medicine. While you’re at it why don’t you ask your friends if any of them were any good at doing OM. Those DOs that decry OM never learned the skills and really just wanted to a medical doctor just like you.

    1. windriven says:

      “Those DOs that decry OM never learned the skills”

      Do you have some proof of this or is this just idle speculation?

      1. William says:

        @windriven
        Of course I don’t mean DOs didn’t “learn the skills” , they had to take the coursework.
        Until they graduated. Do I need to post a bunch of references showing decreased use of OMT? Most want to be identical to MDs . Too bad.

        1. Windriven says:

          I’m curious why you believe the declining use of OM is ‘too bad’ absent evidence of therapeutic benefit? I expect you to say something along the lines of ‘in my experience’ but I’m equally certain that you understand the confirmation bias that accompanies anecdotal observations.

    2. bluedevilRA says:

      William, couldn’t disagree more. I performed well on almost all of my clinical competencies in OM. I wouldn’t say I’m great by any means, but I didn’t fail :) I use some of the gentler techniques on my friends from time to time. And some of my friends use techniques on me because honestly, why turn down a free massage? I have zero intention of ever charging for OM when I become a physician because it is not evidence based. In fact, most of it runs counter to the evidence (see Dr. Hall’s article on cranial). If people want to do acupuncture, OM or whatever because it “feels good” then that is fine by me. I just don’t approve of attaching health benefits to OM (or any other CAM modality) when the evidence does not demonstrate it. I never had much drive to learn it either, which might explain why you think your OM-hating fellow students are bad it. I wanted to be a physician–MD, DO, doesn’t make a difference.

  8. bluedevilRA says:

    Dr. Crislip, thank you for tackling this subject! This is definitely something the osteopathic community clings too. Are you blogging from IDweek?

    1. Mark A Crislip says:

      Yep.

  9. RobRN says:

    OR-AH-GONE?

    Don’t you know it’s ORY-GUN!

  10. mousethatroared says:

    I’ve had a couple of DOs – Rheumatologist and one who specializes in non-surgical muscle/skeletal pain. I don’t see alot of difference between them and my regular MDs. Neither offered me a flu shot, but I think only because that’s my internist’s domain. Never been offered OM by either or anything that I would consider CAM.

    When I was a kid (a loooong time ago) our family doctor was a DO he used OM on me a couple of times for chronic headaches. It always feels good getting your neck cracked, but it wasn’t very effective – long term. He wasn’t a very good doctor generally, regardless of the OM.

  11. Rork says:

    Stone knives and bear skins both work incredibly well at certain tasks (cutting, and keeping you warm). Entertainment I watch is often in great need of reality-check-man.

    I’ve met less-than-wooless DOs that don’t work in hospitals, though not performing OM that I know. However, at my university hospital (Ann Arbor) I don’t know any DOs. Why is that? (The ones I know all do research, else I wouldn’t know them.) Is it a sign of likely-to-be less suited to perform science than MD?

  12. Mika says:

    As an interesting side note I might add that in Finland (and in Europe in general, I would guess, or at least in the Nordic countries) Osteopaths are not equal to Medical Doctors, but they are purely a similar profession to physiotherapists. It’s also funny to read OMT as “osteopathic”, since the term around here has been taken by physiotherapists who have Orthopedic Manual Therapy ie. OMT. :-)

    1. Ocellicyst says:

      The US is one of the only countries to offer FULL medical training to osteopathic students. In many european countries, the DOs just learn OMM. They are literally OMM specialists while American DOs are able to practice anywhere. I think I have read articles about how you can practice (most) anywhere as a DO with full medical privileges as long as you supply sufficient evidence of your training. They have to pass separate license testing, as well.

      The one thing I will always take with me from school, though, is palpatory skills. People underestimate how much less unpleasant a visit to the doctor can be if he can palpate really well — joint injections especially.

  13. windriven says:

    @Mika

    “[I]n Finland Osteopaths are not equal to Medical Doctors”

    Interesting. I have become convinced in recent years that many DOs are about as well trained as MDs. Perhaps that is not the same in Europe.

    Finland ranks slightly ahead of the US in health outcomes and does it for $3251 per person while the US spends $8233 to achieve similar results. Do you know, is the Finnish model similar to the Swedish?

    1. WilliamLawrenceUtridge says:

      It’s like that in Canada too – osteopaths didn’t professionalize and medicalize like they did in the US. I think the US might even be unique in their DOs becoming MDs with a bit of a different history. Everywhere else, they still craaaaaayyyyyzeeeee.

  14. Calli Arcale says:

    I’ve been treated twice by DOs. One was an opthamologist, who looked at a problem with my eye and prescribed conservative treatment (which worked). The other was an obstetrician, who ended up being the OB on call the day I delivered my second child. As I’d had a previous c-section and this child was breech, my GP didn’t get to do the delivery, and instead assisted on the c-section. The DO did the procedure, and did a great job. I had no complications, and recovery was a breeze. Neither even mentioned manipulation. My husband’s GP is a DO, who lists manipulation as a special area of interest; since hubby was a frequent visitor to chiropractors, I figured this guy might give him a path to less chiropractic manipulation. Which ended up being the case! For his persistent back pain, he didn’t perform any manipulation at all, but instead sent hubby in for physical therapy, which made a marked difference in his back. He no longer suffers from back pain.

  15. bluedevilRA says:

    Some important points of clarification: only DOs trained in the United States at 4 year accredited schools of medicine are allowed to practice medicine. The European system has something related but quite dissimilar called Diplomate of Osteopathy (also DOs) but this is not a doctorate (I believe it is 2 years of training). As mentioned above, they are similar to physical therapists and can only perform manipulation. They are not licensed to prescribed medications or perform surgery. This creates a lot of unfortunate confusion when American-trained DOs try to practice abroad. This confusion also led to the American Osteopathic Association adopting “osteopathic physician” and “osteopathic medicine” as the official terms to describe the field in the US. “Osteopathy” generally applies to the Diplomates of Osteopathy.

    Second point, as Dr. Crislip pointed out, the data are quite clear. Depending on the study, OM use rates are around 5%. None of the DOs I have worked with practice OM except for the very few who did a residency in it and then dedicated their practice to it. They practice OM, energy medicine, homeopathy, etc. Your typical DO these days functions more or less like an MD. The two often work side by side in hospitals and the patients never notice the difference. When I get asked by people what a DO is, I respond “basically an MD with some extra training in the musculoskeletal system.”

  16. Peavy says:

    Back in the dark ages I worked at an Osteopathic hospital. When I interviewed, I asked about the difference between an osteopath and an allopath. The main thrust was a more whole person / holistic / conservative treatment first emphasis. Manipulation was mentioned, but without any hint it would have any use but for orthopedic / musculoskeletal issues.

    Not one DO of my personal acquaintance has suggested manipulation for anything but musculoskeletal issues. No one has claimed they could treat, ameliorate or cure flu, other infectious disease, or chronic conditions like diabetes or heart failure with manipulation.

    I’ve had a DO as my primary for twenty years and have seen a manipulation specialist for what (thankfully) turned out to be muscle pulls not spinal injury. My experience was good diagnostics, then manipulation as PT / range of motion with instruction on ROM, strengthening exercises, and future prevention.

    My prescription was conservative: similar work on my own and moderate, short term OTC anti-inflammatory medication. There was a follow-up appointment made before I left and a follow-up phone call received the day after I’d been seen for diagnosis, to ensure my situation had remained stable.

    In my town DOs practice in all hospitals and are in the residency programs as well. It seems like a higher percentage of the DOs are in Internal / Family / General practice, but I have absolutely no numbers to support that.

  17. Chris Hickie says:

    When I got my flu shot a few weeks ago, I did rub my arm afterwards a few times. Does that count as OM or lymphatic pumping?

    1. mousethatroared says:

      I heard that moving about vigorously may help prevent local pain after an injection….so I try to put on the Clash and thrash about at bit. Any truth to that?

      …Damn Manhattans are strong. Sorry for any typos.

      1. Mark A Crislip says:

        No worries. Don’t tell Gorski, but that is exactly how I write my posts.

      2. Chris Hickie says:

        Was that “should I pump or should I OM now?”

  18. Gemman Aster says:

    I am quite confused with this ‘DO’ topic. If they are trained and accredited to the same standards as a true doctor, why do any potential medical students choose the ‘DO’ route and not study a standard medical degree? Is there some kind of funding advantage or easier acceptance?

    I am British and over here an osteopath is a fairly rare breed of quack. At best they offer their services on a private basis and advertise alongside the likes of aromatherapists or especially massage therapists – which they tend to be looked on as a glorified version. Certainly they NEVER attempt to portray themselves as real doctors and are legally barred from doing so. As the vast majority of British people access their healthcare through the NHS, this tends to make it very hard for CAM artists to hoodwink patients at a primary care level. Sometimes however physiotherapists try to sneak in various forms of bullshit like acupuncture. That said their is a regulatory body for osteopaths, the ‘General Osteopathic Council’ and any who wish to advertise to or practice on the public must be members.

    1. William says:

      Gee Thanks Gemman for telling us what we already know. Ta!

    2. Chris says:

      The DO in the USA is completely different than what they are in the UK. Apparently the American osteopaths decided to get change their schools and comply with real medicine. So they actually pass the same medical boards as MDs.

      In the USA, and apparently only in the USA, there really is not much different between an MD or DO. Except perhaps the DO would be better at giving massages.

  19. Rob Cordes, DO says:

    Gemman, to answer your question a lot of US students appply to both MD and DO programs. Some will only apply to one or the other for reasons such as liking the “DO philosophy” of being a primary care physician first and treating the “whole person” or not wanting to have to potentially deal with the “what is a DO and how are they different?” questions or any possible future prejudice against DO’s (see Quackwatch for instance).

    Personally I applied to both and went to the school were I was accepted.
    I did like learning OM and since my school only gave 1 hour lecture and 1 hour lab per week I need to learn it better on my own. Doing so meant finding faculty willing to give students extra time and also a classmate who was a D.C.

    An interesting thing I was told by one of our faculty that he could stop acute asthma attacks with OM ( high velocity / low applitude ex crunching) the thoracic spine. So while doing a general practice rotation as an MS3 I tried it a few times and based on auscultory findings and patients subjective responce it did well.
    As a DO intern I tried it on a few patients and on two of them did pre /post peak flows. One imporved and one worsened both on PF and ausculation. The one who worsened was a smoker.
    In spite of asking I could never get a staff / attending physician help me set up any kind of study even just a full PFT pre / post.

    Chris, rubbing for arm after a flu vaccine counts as “soft tissue” manipulation so I guess wiggling my nose after my flu vaccine counts too .

    1. theroguechiropractor says:

      Rob,
      Interesting anecdote, as the only studies I’ve seen with thoracic manipulation and asthma indicate that while there may be subjective benefits following treatment, objectively (VO2 max, FEV) they do worse.
      Have you seen the Engal paper on COPD and chiropractic (manipulation/mobilisation) out of Australia?

  20. RobRN says:

    Interesting comments here… I recall when I applied (unsuccessfully) to medical schools in the early 1970s that DO schools still had a sort of stigma of “not as good as an MD”. I think part of my uninformed decision at the time not to apply to DO schools was the influence of the pre-med advisor at my university. He had advised pre-med students since the 1930s and I think now that he had a biased opinion of DOs. His attitude was “If you REALLY want to be a DO INSTEAD of an MD… go ahead and apply.” I served with quite a number of DOs for years in the military service and have had contact with many in civilian practice. Having some background in healthcare quality analysis, I can anecdotally state that I saw no disproportionate quality of care issues with DOs and I never observed them practice any sort of osteopathic manipulation.

  21. Peebs says:

    With regard to Gemman’s comment, I have met only one Osteopath in the UK but have trained in the Medical Branch of the Royal Navy so have a fairly good background of Anatomy, Physiology and a more than basic knowledge of diagnostics.

    Said Osteopath went into a rant about how he was as qualified as a General Practitioner and had trained as much so felt he should be given the title ‘Doctor’.

    Having worked extensively with real doctors and – what we call physiotherapists – in the field of sports medicine and general diagnostics his arrogance was breathtaking.

    So I asked him him how he would recognise a Chicken Pox rash and where the sphincter of Oddi is.

    One very basic visual diagnosis and, admittedly, one fairly obscure anatomy question. He failed both and then started giving me sh*t, telling me I was trying to catch him out (I was and I did).

    I may have caught him on a bad day and realise this is but anecdote but it did give me an idea of their aims and training.

  22. Eclair says:

    Most of the pulmonologists in the group I used to go to for asthma treatment (before they dropped my insurance) were DOs. No manipulation was ever mentioned, and I always get my flu shots.

    1. Newcoaster says:

      As WLU points out, DO=MD only in the USA. Here in Canada they are still mostly British trained and mostly quacks. They mostly don’t seem to be as bad as chiropractors or naturopaths et al, and many just work as glorified physiotherapists but get to call themselves doctor.

      When I first moved to the small town where I now practise it was before I really knew (& or cared) much about woo and I did make referrals upon request to a local DO who was, and still is (though he must be nearly 80) beloved as a miracle worker for back pain. It was only after the first few consult letters came back that I realised everyone was diagnosed with “myofascial dysfunction ” and he used “muscle energy release” on all of them no matter what their specific complaint.

      However he did also teach them some techniques to prevent back pain, didn’t bring them infor repeated treatments like the chiros, and never made claims for treating medical diseases. So he seems mostly harmless, probably helps most of his patients, and he doesn’t order a bunch of useless X-rays or request that I do, so I still do send the occasional back pain his way if a patient makes the request. He’s the only one I will refer to. There a few others I town who work out of “wellness centres” who are clearly into the woo in a big way.

      1. Birdy says:

        There are many Canadian students who have gone to US DO schools because they are easier to get into than Canadian schools and Canada-friendly US MD programs. It’s a common recommendation for premeds with less than competitive, but not terrible, grades and MCAT.

        As of now, I believe that two provinces (BC and I think one other) consider US DOs as equal to US/Canadan MDs in the match, which is pretty recent I think, and there’s at least one group of Canadian students studying in US DO schools pushing for full recognition in all provinces.

        But, given that we have thousands of Canadians with MDs from international (excluding US) schools who also want that same recognition, I don’t think the DOs will be allowed access to residency positions before MDs from places like the UK.

        1. Newcoaster says:

          I’m in BC and that’s news to me but I can’t say I’ve followed the issue that closely. However as you point out I think the priority for residency programs should be given to Canadians who did their training in foreign medical schools ahead of those who went to US Osteopathic schools

          And, since there aren’t enough positions for those *IMG’s already I doubt we’ll be seeing any DO getting an MD any time soon. My clinic is currently trying to recruit an IMG and there are numerous government hoops to jump through as it is.

          *International Medical Graduate

          1. Birdy says:

            Some of those foreign med schools advertise quite aggressively on the basis of the doctor shortage and how it will be so ‘easy’ to come back home to a promising career. I’m only in my second year of undergrad right now and somehow ended up on ad lists so I keep getting pamphlets from foreign schools.

            They , of course, don’t mention the intense difficulty getting back into the country and that there’s already thousands in limbo with an MD but no residency. I’ve heard it said there are now more Canadians studying medicine abroad than within Canada, so it’s going to get even worse for IMGs I expect, even without the DOs getting recognition.

            Good luck in your recruiting!

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    1. WilliamLawrenceUtridge says:

      Another spambot.

  24. WScott says:

    “My purpose with this entry is not to review OM per se, which may be a good topic someday…”
    Yes, please!
    [anecdote alert] My wife gets OM quarterly to help with complications from scoliosis, and it seems to be quite effective. In fact in her case it’s the *only* thing we’ve found that seems to help. I’ve gotten OM myself occasionally when my back goes out, and again it seems very effective – certainly better than chiropractic and, at least with our particular DO, with far less woo. (He’s certainly never tried to sell it as a cure for the flu!) But now you’ve got me wondering. Is the problem that OM doesn’t actually work for musculoskeletal issues, or just that it’s being oversold as a way to treat non- musculoskeletal problems?

    1. Amanda says:

      It really depending on the country/jurisdiction whether they recognize a DO as equivalent to an MD. In the US, a DO=MD and a DO requires the same training (eg residency, fellowship) as an MD, and can work in any field. Most Canadian provinces accept the US DO degree as equivalent to an MD degree, as well as many other countries, and DOs are usually allowed a full scope of practice just like an MD.

      I’m a Canadian and was doing my undergrad at University of Michigan, planning to go to med school, and I was considering MSU-COM (Michigan State University College of Osteopathic Medicine). I would have been able to complete the DO degree, residency, write my boards, then come back to Canada to practice if I wanted to. I had planned to go into surgery, and would have left the OMT in the dust. (Unfortunately my plans were sidetracked when I developed spinal problems

      The confusion comes in when people can’t discern between “osteopathic medicine” or an “osteopathic doctor” and an “osteopath” or “osteopathy.” Basically, if you have the DO degree, you have the same training as an MD (with the additional OMT, which many DOs drop and leave behind). DO degree = medical professional; any other osteopathic diploma/degree = quack.

      Wiki has a good page explaining DO education, training and mobility:

      http://en.wikipedia.org/wiki/Doctor_of_Osteopathic_Medicine

      1. WScott says:

        Thanks Amanda. But I wasn’t asking about DO qualifications. I’m asking specifically what the research says about the effectiveness of osteopathic manipulation for musculoskeletal problems?

        1. Ocellicyst says:

          There is actually quite a bit of back pain evidence, but that’s about it. I’ve wondered this myself. I can say that it does actually help with some minor aches and pains, but no one actually goes to the doctor for minor aches and pains. I can also say that I’m impressed with the “whole” body approach. At first it seemed to make me think “yeah, no duh”, but the further we go, the less obvious it really is. When you hurt your bones, it causes them to move in areas you wouldn’t always necessarily think to look.

  25. Jonathan Grice says:

    “They suggest a variety of pumps that are supposed to boost the immune system (zero prior plausibility for that concept) and increase lymph flow (maybe, but I can’t see that lymph flow would be of any value in and of itself and the short term increase in lymph flow, if it does occur with OM, would be brief and of an inconsequential amount given the duration of the intervention relative to the 24–7 illness like influenza. A pump would be like adding a lit match to increase the burn rate of a forest fire).”

    There is some research that show that lymphatic pump techniques do significantly increase lymphatic flow over hours after manual treatment. First, in animal models (rats and dogs) using cathetered thoracic or mesenteric lymphatic ducts http://www.ncbi.nlm.nih.gov/pubmed/21190489, and http://www.ncbi.nlm.nih.gov/pubmed/20583872. One unexpected outcome of the research to see if lymphatic flow was increased by manual techniques was that there was an observed increase in lymphocyte density within the lymph and a higher proportion of activated lymphocytes. The techniques also significantly alter the lymphatic content of the following: interleukin-2 (IL-2), IL-4, IL-6, IL-10, interferon-γ, tissue necrosis factor α, monocyte chemotactic protein-1 (MCP-1), keratinocyte chemoattractant, superoxide dismutase (SOD) and nitrotyrosine (NT).

    Subsequently, there has been research into the use manual techniques also work in pneumonia http://www.ncbi.nlm.nih.gov/pubmed/22977459. The lead author of this research is LM Hodge who in this article looks at possible physiological models of the mechanism of action http://www.ncbi.nlm.nih.gov/pubmed/21865405.

    The blogger is correct that the claims for the effectiveness of OM in the treatment of the 1918 flu epidemic is based on fragmentary evidence (read no evidence) and unscientific claims (a failing that seems to beset the history of osteopathy). However, there is enough evidence in papers above to suspect that lymphatic techniques can and could have had a role to play to prevent thoracic organ failure and pneumonia in serious influenza.

    The blogger is correct that the lack of scientific evidence for most osteopathic techniques is shameful, and that the evidence of the effectiveness of OM is at very best a mixed bag. The blogger is also correct that most US DOs are ashamed of OM as a modality. The problem for these DOs is that they share with the blogger either a disregard for or ignorance of the evidence of action and they believe as the blogger does, that OM is merely ritualistic massage.

    1. WilliamLawrenceUtridge says:

      Wouldn’t osteopathic manipulation be redundant to regular exercise?

      Plus, if it actually works, then there is tremendous beneift in actually researching it so it can be added to the regular medical quiver. Seems like this would be an area where careful controls to isolate the exact cause of improvements (if any) would be important.

  26. Jonathan Grice says:

    There is some research that show that lymphatic pump techniques do significantly increase lymphatic flow over hours after manual treatment. First, in animal models (rats and dogs) using cathetered thoracic or mesenteric lymphatic ducts http://www.ncbi.nlm.nih.gov/pubmed/21190489, and http://www.ncbi.nlm.nih.gov/pubmed/20583872. One unexpected outcome of the research to see if lymphatic flow was increased by manual techniques was that there was an observed increase in lymphocyte density within the lymph and a higher proportion of activated lymphocytes. The techniques also significantly alter the lymphatic content of the following: interleukin-2 (IL-2), IL-4, IL-6, IL-10, interferon-γ, tissue necrosis factor α, monocyte chemotactic protein-1 (MCP-1), keratinocyte chemoattractant, superoxide dismutase (SOD) and nitrotyrosine (NT).

    Subsequently, there has been research into the use manual techniques also work in pneumonia http://www.ncbi.nlm.nih.gov/pubmed/22977459. The lead author of this research is LM Hodge who in this article looks at possible physiological models of the mechanism of action http://www.ncbi.nlm.nih.gov/pubmed/21865405.

    The blogger is correct that the claims for the effectiveness of OM in the treatment of the 1918 flu epidemic is based on fragmentary evidence (read no evidence) and unscientific claims (a failing that seems to beset the history of osteopathy). However, there is enough evidence in papers above to suspect that lymphatic techniques can and could have had a role to play to prevent thoracic organ failure and pneumonia in serious influenza.

    The blogger is correct that the lack of scientific evidence for most osteopathic techniques is shameful, and that the evidence of the effectiveness of OM is at very best a mixed bag. The blogger is also correct that most US DOs are ashamed of OM as a modality. The problem for these DOs is that they share with the blogger either a disregard for or ignorance of the evidence of action and they believe as the blogger does, that OM is merely ritualistic massage.

    1. windriven says:

      @Jonathan Grice

      Pretty thin gruel, this. 3 of your 4 citations are by the same author, 2 of 4 are reviews not research, all are in extremely low impact journals and none seem to involve human subjects.

      OM has been around for 150 years. That ought to have been enough time to demonstrate substantial efficacy at something. OM may be largely discounted by US DOs but not so in the rest of the world. Do you have some solid data supporting OM having made a substantial contribution to human medical care in the last century?

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  28. Tom C. says:

    Ok. So I’m not an MD, or a DO. (although if I had to choose between becoming one or the other, I would lean towards a DO with an emphasis on OM) So now that I have declared a side in this “discussion” let me make a few points for you DO bashers to consider.

    If osteopathic care and other complimentary medical procedures including manual therapy techniques, massage, acupuncture, have no validity and don’t work, why are the populations of the western world in particular moving towards that type of care and away from traditional allopathic care? Could it have anything to do with the arrogance displayed here on these boards? The discounting of anecdotal evidence as having any validity in medicine? Some things as yet cannot be measured within the body (or outside the body!) and so how OM works (visceral and cranial work for example) is not particularly well understood though there are well thought out hypotheses for the mechanisms involved in these techniques.

    For those of you who refuse to use said techniques and have never seen or witnessed the very real physical responses they can achieve, or those of you who have never used the services of a DO who is highly skilled in OM and experienced the results for yourself, what right do you have to question their work or the theories behind their work?

    Most of you seem to come from the “I have a headache therefore my body must be short on aspirin” camp.

    Perhaps many of you should read more. May I recommend you read some Barral, for example, or Upledger, for a start.

    We all know there are DO’s, DC’s, AND MD’s who make medical claims beyond the scope of their practice and who are unscrupulous in the way they practice healthcare.
    But, I tire of reading articles such as this which are bent to disparage one type of healthcare to the benefit of another.

    Here’s a question for you allopathic folks…. Why is it that in the US, that receiving allopathic care in a hospital setting is the third leading cause of death(Either receiving in the US behind heart disease and cancer? Whatever happened to first, do no harm?

    That being said, if I am seriously ill, or I’ve just been in an auto accident, I won’t make the case to be taken to a massage therapist or a DO. I want to be in the care of an MD who is compassionate, open minded, and highly skilled. But for most aspects of my health care, I would gladly choose the former over the latter as I have never had a serious negative reaction from a skillfully applied massage or manipulation and the benefits I have received are real and often measurable.

    So get off you high horse, stop bashing things you obviously don’t understand or are unwilling to try and understand, and just do your job to the best of your ability.

    1. Harriet Hall says:

      1. Why are people using CAM? Many reasons, the least of which is our “arrogance.” Why do people still read horoscopes?
      2. Read some Upledger? I have read some Upledger. I was not impressed. See http://www.quackwatch.com/01QuackeryRelatedTopics/cranial2.html
      3. Some things can’t yet be measured, but that is almost certainly because they don’t exist. Physicists have succeeded in measuring incredibly tiny energies of all kinds; and for anything that has an effect on the material world, that effect can be measured.
      4. If those techniques showed “very real physical responses,” it should have been easy enough to demonstrate them in controlled studies that would have convinced the entire medical community.
      5. The “death by medicine” trope is refuted at http://www.sciencebasedmedicine.org/death-by-medicine/
      6. Yes, articles here are meant to disparage one type of healthcare (the kind that doesn’t work) to the benefit of another (the kind that works).
      7. We don’t discount anecdotal evidence as a source of hypotheses to be tested; we only discount it as the kind of evidence that can be used to guide treatment without proper testing. And the whole history of medicine justifies our approach.
      8. What right do we have to question things like cranial manipulation if we haven’t experienced it for ourselves? We have every right. Just as we have the right to question perpetual motion devices and revelations from mediums who claim to talk to the dead. Personal experience would only interfere with our ability to be objective.

    2. MadisonMD says:

      Ok. So I’m not an MD, or a DO. (although if I had to choose between becoming one or the other, I would lean towards a DO with an emphasis on OM)

      Might I suggest naturopathy school as a good fit? You don’t need as much education, grades, or critical thinking skills (actually the latter would be detrimental since graduation requires you to sit through several semesters of homeopathy without calling BS).

      That being said, if I am seriously ill, or I’ve just been in an auto accident, I won’t make the case to be taken to a massage therapist or a DO. I want to be in the care of an MD who is compassionate, open minded, and highly skilled.

      Good choice here. If you have an auto accident, cancer, heart disease, the flu choose science-based medicine. If however, you have a vague sense of unease, a touch of the nerves or even just more money than sense, then its just as well to choose the nonsense. (credit: M&W).

      Incidentally, you can get science-based medicine from either MD’s or DO’s which was the central thesis of the first 3 paragraphs of the blog post–now how did you miss it?

      1. windriven says:

        Don’t you just love these barking arses who recognize the power of science based medicine when their lives are on the line but judge quacks more capable of treating the mundane? Absolutely breathtaking.

      2. Andrey Pavlov says:

        @madison:

        I’m tempted to write a nice even handed science based smack down on Tom C. but am currently pressed for time.

        However, it should be noted that outside the US DO’s are just as quacky as naturopaths and chiropractors. It is unique in the US that they actually did what chiro’s claim to have tried to do and really should do to become legitimate – become science based. DO programs still have tiny vestiges of the OM quackery, but the vast majority is limited to more evidence based PT type stuff. But more importantly their approach to disease is evidence based – they often take the same board exams as we do and they do their graduate medical education side by side with us. Tom C. may well be from outside the US.

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