What is osteopathic manipulation?

Overview

Osteopathy originated as a nineteenth-century alternative
medical approach focusing on physical manipulation. Today, osteopathic physicians
study and practice the same types of medical and surgical techniques as
conventional medical doctors. Some of osteopathy’s original techniques still
persist, however. Taken together, these techniques are called osteopathic
manipulation (OM). OM is less well known to the public than chiropractic spinal
manipulation, but it has shown promise for many of the same conditions, such as
back pain and tension headaches.

History of osteopathic manipulation. Osteopathic
medicine was founded in 1874 by Andrew Taylor
Still, an American physician. Physicians educated in this
method were called doctors of osteopathy, or D.O.’s. Subsequently, however,
schools of osteopathic medicine became integrated with conventional medical
schools, and today the license of D.O. is legally equivalent to that of medical
doctor (M.D.).

Forms of osteopathic manipulation. Osteopathic and
chiropractic techniques overlap, but they are not identical.
As a general rule, chiropractors focus most of their attention on the spine, while
osteopathic practitioners devote more of the their efforts to the manipulation of
soft tissues and joints outside the spine. Another general difference is that
chiropractic spinal manipulation tends to make use of rapid short movements
(spinal manipulation, which is a high-velocity, low-amplitude technique), while OM
typically concentrates on gentle, larger movements (mobilization, which is a
low-velocity, high-amplitude technique). Neither of these distinctions is
absolute, and many chiropractic and osteopathic methods do not fit neatly into
these categories.

There are several specific osteopathic techniques in wide use, many of which are
named after their founders. Some of the more popular are muscle energy technique,
Jones counterstrain (also known as strain-counterstrain), myofascial release, and
cranial-sacral therapy (formally known as osteopathy in the cranial field).

Muscle energy technique. The muscle energy technique involves
bending a joint just up to the point where muscular resistance to movement begins
(the barrier), and then holding the joint there while the patient gently resists.
The pressure is maintained for a few seconds and then released. After a brief
pause to allow the affected muscles to relax, the practitioner then moves the
joint a little farther into the barrier, which will usually have shifted slightly
toward improved mobility during the interval.

Strain-counterstrain technique. The strain-counterstrain
technique (Jones counterstrain) involves finding tender points and then
manipulating the joint connected to them to find a position where the tenderness
decreases toward zero. Once this precise angle is found, it is held for ninety
seconds and then released. Like muscle-energy work, strain-counterstrain
progressively increases range of motion and, it is hoped, decreases muscle spasm
and pain.

Myofascial release. Myofascial release focuses on the fascial
tissues that surround muscles. The practitioner first positions the painful area
either at the edge of the barrier to movement or, alternatively, at the opposite
extreme (the area of greatest comfort). Next, while the patient breathes slowly
and easily, the practitioner palpates the fascial tissues, looking for a subtle
sensation that indicates the tissues are ready to “unwind.” After receiving this
indication, the practitioner then helps the tissue to follow a pattern of
spontaneous movement. This process is repeated over several sessions until a full
release is achieved. Myofascial release is said to be especially useful in pain
conditions that have persisted for months or years.

Cranialsacral therapy. Cranialsacral therapy, more properly
called cranial osteopathy (or cranial), is a specialized technique based on the
scientifically unconfirmed belief that the tissues surrounding the brain and
spinal cord undergo a rhythmic pulsation. This “cranial rhythm” is said to cause
subtle movements of the bones of the skull. A practitioner of cranialsacral
therapy gently manipulates these bones in time with the rhythm (as determined by
the practitioner’s awareness) to repair “cranial lesions.” This therapy is said to
be helpful for numerous conditions ranging from headaches and sinus allergies to
multiple sclerosis and asthma. However, many researchers have serious doubts that
the cranial rhythm even exists.

Uses and Applications

Osteopathic manipulation is primarily used to treat musculoskeletal pain conditions, such as back pain, shoulder pain, and tension headaches. OM is often said to be specifically effective for conditions that have persisted for some time, as opposed to chiropractic spinal manipulation, which, according to this view, is most effective for treatment of injuries that have occurred recently. However, there is no meaningful scientific support for this belief. Some advocates of OM believe that it has numerous additional benefits, including the enhancement of overall health and well-being.

Scientific Evidence

There is little evidence that osteopathic manipulation is helpful for the treatment of any medical condition. There are several possible reasons for this, but one is fundamental: Even with the best of intentions, it is difficult to properly ascertain the effectiveness of a hands-on therapy like OM.

Only one form of study can truly prove that a treatment is effective: the
double-blind,
placebo-controlled trial. However, it is not possible to fit
OM into a study design of this type.

Because of these problems, all studies of OM fall short of optimum design. Many have compared OM with no treatment. However, studies of that type cannot provide reliable evidence about the efficacy of a treatment: If a benefit is seen, there is no way to determine whether it was a result of OM specifically or just attention generally. (Attention alone will almost always produce some reported benefit.)

More meaningful trials used fake osteopathy for the control group. Such studies are single-blind because the practitioner is aware of applying phony treatment. However, this design can introduce potential bias in the form of subtle unconscious communication between practitioner and patient.

Still other studies have simply involved giving people OM and seeing if they improve. These trials are particularly meaningless; it has long since been proven that both participants and examining physicians will think, at minimum, that they observe improvement in people given a treatment, whether or not the treatment does anything on its own; such studies are not reported here. Given these caveats, the following is a summary of what science knows about the effects of OM.

Possible effects of OM. Most studies of OM have involved its potential use for various pain conditions. In a study of 183 people with neck pain, the use of osteopathic methods provided greater benefits than standard physical therapy or general medical care. Participants receiving OM showed faster recovery and experienced fewer days off work. OM appeared to be less expensive overall than the other two approaches; however, researchers strictly limited the allowed OM sessions, making direct cost comparisons questionable. Another study evaluated a rather ambitious combined therapy for the treatment of chronic pain caused by whiplash injury (craniosacral therapy with Rosen bodywork and Gestalt psychotherapy). The results failed to find this assembly of treatments more effective than no treatment.

In a fourteen-week, single-blind study of twenty-nine elderly persons with shoulder pain, real OM proved more effective than placebo OM. Although participants in both groups improved, those in the treated group showed relatively greater increase in range of motion in the shoulder. In a larger study of 150 adults with shoulder complaints, researchers found that adding manipulative therapy to usual care improved shoulder and neck pain at twelve weeks.

In a small randomized, placebo-controlled trial, researchers used oscillating-energy manual therapy, an osteopathic technique based on the principle of craniosacral therapy, to treat twenty-three persons with chronic tendonitis of the elbow (tennis elbow or lateral epicondylitis). Persons in the treatment group showed significant improvement in grip strength, pain intensity, function, and activity limitation because of pain. These results, however, are limited by the small size of the study and the fact that the therapist delivering the treatment could not be “blinded.”

In another study, twenty-four women with fibromyalgia were divided into five groups: standard care, standard care plus OM, standard care plus an educational approach, standard care plus moist heat, and standard care plus moist heat and OM. The results indicate that OM plus standard care is better than standard care alone and that OM is more effective than less specific treatments, such as moist heat or general education. However, because this was not a blinded study (participants knew which group they were in), the results cannot be taken as reliable.

A study of twenty-eight people with tension headaches compared one session of OM with two forms of sham treatment. The study found evidence that real treatment provided a greater improvement in headache pain.

Although OM has shown some promise for the treatment of back pain, one of the best-designed trials failed to find it a superior alternative to conventional medical care. In this twelve-week study of 178 people, OM proved no more effective than standard treatment for back pain. Another study, this one enrolling 199 people and following them for six months, failed to find OM more effective than fake OM. This study also included a no-treatment group; both real and fake OM were more effective than no treatment. A much smaller study reportedly found that muscle energy technique enhances recovery from back pain, but this study does not appear to have used a meaningful placebo treatment.

Some studies have evaluated the potential benefits of OM for speeding healing in people recovering from surgery or serious illness. The best of these studies compared OM with light touch in fifty-eight elderly people hospitalized for pneumonia. The results indicate that the use of osteopathy aided recovery.

In a much less meaningful study, OM was compared to no treatment in people recovering from knee or hip surgery. While the people receiving OM recovered more quickly, these results mean very little, because any form of attention should be expected to produce greater apparent benefits than no attention. A similarly weak study suggests that OM might also be helpful for people hospitalized with pancreatitis. A small study found some evidence that OM might be helpful for childhood asthma.

Choosing a Practitioner

Although there are many licensed doctors of osteopathy, most practice conventional medicine and do not specialize in OM. Some do, and many have been certified by the American Osteopathic Board of Neuromusculoskeletal Medicine. In addition, many physical therapists and massage therapists use some osteopathic techniques, with variable amounts of training.

Safety Issues

Most forms of OM, because of their gentle nature, are believed to be quite safe. However, mild short-term pain may occur immediately following treatment. In addition, some osteopathic practitioners use the high-velocity thrusts common to chiropractic and might, therefore, introduce some slight safety risks.

Bibliography

Bergman, G. J., et al. “Manipulative Therapy in Addition to Usual Care for Patients with Shoulder Complaints.” Journal of Manipulative and Physiological Therapeutics 33 (2010): 96-101.

Gamber, R. G., et al. “Osteopathic Manipulative Treatment in Conjunction with Medication Relieves Pain Associated with Fibromyalgia Syndrome.” Journal of the American Osteopathic Association 102 (2002): 321-325.

Guiney, P. A., et al. “Effects of Osteopathic Manipulative Treatment on Pediatric Patients with Asthma.” Journal of the American Osteopathic Association 105 (2005): 7-12.

Licciardone, J. C., et al. “Osteopathic Manipulative Treatment for Chronic Low Back Pain.” Spine 28 (2003): 1355-1362.

Ventegodt, S., et al. “A Combination of Gestalt Therapy, Rosen Body Work, and Cranio Sacral Therapy Did Not Help in Chronic Whiplash-Associated Disorders.” Scientific World Journal 4 (2005): 1055-1068.

Wilson, E., et al. “Muscle Energy Technique in Patients with Acute Low Back Pain.” Journal of Orthopaedic and Sports Physical Therapy 33 (2003): 502-512.