Osteopathy

Manipulation Is Good Medicine

Many of Joyce Frye's patients don't realize she's not an M.D.--until she gets her hands on them.

Dr. Frye's staff calls her doctor. Her office is decked out with the usual medical equipment. Impressive-looking diplomas and licenses hang on the walls. "I suppose many of the people coming to see me for the first time don't know that I'm a D.O. rather than an M.D.--not that I make any attempt to hide it," says Dr. Frye, obstetrician/gynecologist and chairperson of the Gynecology Department at Presbyterian Medical Center as well as a clinical faculty member at Jefferson Medical College, both in Philadelphia.

Doctors of osteopathic medicine, D.O.'s, are fully qualified physicians. Like M.D.'s, they finish four years of medical school (at osteopathic medical colleges), complete residencies and take certifying exams. Like M.D.'s, they order x-rays, blood and other diagnostic tests, prescribe drugs and perform surgery. As a patient, you'd be hard-pressed to tell a D.O. from an M.D.

But there is a difference. D.O.'s have one tool at their disposal that most M.D.'s don't: hands-on osteopathic manipulation. Though all D.O.'s learn to manipulate bone, muscles and connective tissue, not all use manipulation after graduation. There was a time when osteopathic manipulation--something akin to chiropractic adjustment--wasn't as popular among D.O.'s. The demand, however, for alternatives to conventional medicine has reawakened interest in manipulation. By including it in a comprehensive treatment regimen, D.O.'s say manipulation is an effective complement to more mainstream therapies.

D.O.'s use manipulation to both diagnose and treat. Studies show that it can relieve back and neck pain and menstrual cramps. There's some evidence that manipulative techniques, alone or in combination with other therapies, can ease labor pain and delivery, relieve respiratory problems, soothe migraines and lower blood pressure. Osteopaths also use it to help relieve a wide array of other health problems, including premenstrual syndrome, pelvic pain, digestive trouble, ulcers, temporomandibular disorder, colds, sinus infections, carpal tunnel syndrome and fibromyalgia.

"There's a whole flock of benefits," says Robert C. Ward, D.O., professor of biomechanics and family medicine at Michigan State University College of Osteopathic Medicine in East Lansing.

Manipulation is a real boon to women during pregnancy. "During pregnancy, they can't take a lot of medication," explains Dr. Frye, who uses manipulation to treat expectant moms with sciatica, migraines, labor pain, joint pain and carpal tunnel syndrome. Before manipulating a new patient, she makes sure that the patient understands what manipulation and osteopathy are all about, she adds.

HISTORY AND PHILOSOPHY

Osteopathic medicine differs from conventional care in philosophy as well as practice. It was the inspiration of a nineteenth-century M.D. named Andrew Taylor Still. Disillusioned by traditional practice after two of his children died of spinal meningitis (despite state-of-the-art care), Dr. Still concluded that conventional medicine was missing something. The problem, he reasoned, was that it failed to recognize that health is as dependent on the soundness of the body's muscle and skeletal systems as it is on the body's vital organs.

Dr. Still went on to pioneer various manipulative techniques to correct musculoskeletal problems. And, on the heels of an unsuccessful attempt to convince mainstream medical schools to change their curricula, he opened the first osteopathic medical school in 1892. There are now 19 schools of osteopathy--from the Greek "osteo" or bone, and "pathy" meaning disease--in the United States alone. M.D.'s still outnumber D.O.'s--only 6 percent of physicians are osteopaths--but the popularity and ranks of osteopaths are growing.

HANDS-ON EXPERIENCE

At the Philadelphia College of Osteopathic Medicine, the nation's largest school of osteopathy, a group of first-year students is learning how to manipulate muscles, connective tissue, joints and bones.

While one student lies facedown on an examination table, her partner presses on her back, just above her sacroiliac joint (the joint between the tailbone and hipbone), then bends her leg at the knee and rocks the leg back and forth. With this technique, an osteopath can test the sacroiliac joint's range of motion. The results can be particularly helpful in diagnosing the source of low-back pain, since limited flexibility of the joint is often the culprit, says Alex Nicholas, D.O., who leads the class.

Using a variety of techniques, a D.O. can detect not only abnormalities in range of motion but also uncover structural irregularities and changes in tissue texture and tenderness, which are additional diagnostic clues.

Dr. Nicholas asks his students how they would treat a patient who has limited sacroiliac joint mobility. Two students demonstrate. While one lies on her side on the examination table, her partner presses her upper leg down toward the floor, while rotating her pelvis out toward the wall, guiding the joint through the full range of motion.

In addition to improving mobility, Dr. Nicholas says, manipulation eases muscle tension and helps correct structural misalignments caused by injury, stress, poor posture or lack of exercise.

The osteopathic manipulative techniques that D.O.'s use are usually gentle and well-tolerated. A number of them resemble techniques that chiropractors use. But osteopathic manipulation has a different focus.

"Chiropractic concentrates more on the alignment of the bones," says William R. Loomis, D.O., an osteopathic physician in Spokane, Washington, and former president of the American Association of Orthopedic Medicine. "Osteopaths think that's important, but they think the soft tissues and connective tissues around the bones are extremely important."

Osteopathy focuses on the holistic concepts that emphasize the interplay among the body's many systems. The musculoskeletal system--all of it--gets as much attention as the cardiorespiratory system, the digestive system and all the rest.

"The idea is to have the musculoskeletal system working as efficiently as it can, thereby reducing the body's energy requirements, which in turn will reduce the workload on the heart and lungs," says Edward Isaacs, M.D., a Richmond, Virginia, neurologist and one of a small but growing number of medical doctors who are learning osteopathic manipulative techniques and incorporating these into their practices.

Improvements in musculoskeletal health can have all sorts of beneficial effects, practitioners say. Correcting pelvic misalignments, for example, can help alleviate severe menstrual cramps.

"The uterus doesn't just float in the abdomen; it's suspended by ligaments connecting it to the pelvic bones," explains John McPartland, D.O., an osteopathic physician in private practice in Middlebury, Vermont. "And if the pelvic bones are out of alignment, that puts pressure on the ligaments, which puts pressure on the uterus."

Since migraine headaches often start as tension headaches, Dr. McPartland says, relieving muscle tension can offer relief to browbeaten migraine sufferers.

For those with asthma, techniques that restore flexibility and strength to the chest muscles can make breathing easier. Why? If the diaphragm is more flexible, the patient can breathe more deeply, explains Dr. Ward.

For heart disease patients, the same techniques can help alleviate fluid-retention problems, since the motion of the diaphragm helps pump blood and lymphatic fluid through the body, Dr. Isaacs says.

DOMINO EFFECT

Manipulation seems to improve both circulation and nervous-system health in more subtle ways as well, easing other symptoms.

Among other things, it improves circulation by easing muscle tension. When muscles tense, they constrict both blood vessels and lymphatic channels, special vessels that channel excess fluid from tissues into the bloodstream. This limits the flow of blood and lymphatic fluid to surrounding tissues.

Because inadequate blood supply causes pain, manipulation helps relieve the pain by improving blood circulation, says Charles Steiner, D.O., adjunct professor of biomedical engineering at Rutgers University in New Brunswick, New Jersey. And because lymph helps clear dead cells and invading germs from the body, manipulation improves the body's ability to fight infection by enabling lymph to flow more freely, says Dr. Ward.

Animal studies suggest that manipulation may offer a variety of other benefits because it also has something of a calming effect on the autonomic nervous system, which governs involuntary functions like digestion, circulation and respiration. And various autonomic nerve pathways link the heart, intestines, stomach and other vital organs with the spine and brain.

Manipulating the section of the neck or back where the nerves to a particular organ join the spine seems to calm both the nerves and the organ they control, says Dr. Loomis. Consequently, manipulating the spot just beneath the shoulder blades, where the nerves controlling the dilation of blood vessels join the spine, seems to relax the nerves, thereby relaxing the muscles of the blood vessel walls and lowering blood pressure.

THE SCIENTIFIC EVIDENCE

To date, the best documented benefit of osteopathic manipulation is relief from neck and back pain.

A few scientific studies have found that manipulation helps take the edge off labor pain, speed labor and ease menstrual cramps as well. In a small-scale study, researchers at the University of Osteopathic Medicine in Des Moines, Iowa, found that manipulation performed within 12 hours of the start of menstruation relieved cramps and accompanying back pain for the duration of that period.

Other studies have found that manipulation can also help lower high blood pressure, alleviate breathing problems and decrease frequency of heart rhythm abnormalities. But studies examining manipulation's success in treating specific health problems are few and far between, says Philip Greenman, D.O., associate dean and professor in the Department of Osteopathic Manipulative Medicine at Michigan State University College of Osteopathic Medicine in East Lansing. And with good reason. Osteopathy has long taken a holistic view--focusing on overall health promotion rather than treatment of specific diseases and viewing manipulation as one element of a multi-therapy approach to care.

"It's this difference in philosophy that separates osteopathic medicine from mainstream orthodox medicine, and it's in this context that the profession uses manipulation," says Dr. Greenman. "Manipulation is not viewed as something good for a specific disease but as something good for promoting overall health. And most scientific studies look at the effects on this or that particular disease."

IF YOU GO

If you decide to see a D.O., remember that manipulation is just one of the tools that she'll use to diagnose and treat. In coordination with medical treatment, she may recommend changes in diet and exercise habits, prescribe at-home stretching and strengthening exercises and offer advice on dealing with stress.

She may also prescribe drugs or recommend surgery. By including manipulation in treatment, though, your D.O. may be able to lower the dose of medication that you're taking.

Unfortunately, manipulation seems to work better for some people than for others. Try three to five treatments before deciding whether it's helping you, suggests Dr. Loomis.

If it is, the frequency with which you'll need to schedule sessions will depend on what's ailing you. Some conditions clear up after just a couple of treatments. Others require follow-up sessions every month or two.