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.


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

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