| Physical Healing Methods
All the biomechanical therapies--grouped here as "physical healing methods"--are
based on the understanding that dysfunction of any discrete body part
often affects secondarily the function of other discrete, not necessarily
directly connected, body parts, both in close proximity and at a distance.
The various manual medicines have developed theories and processes that
treat these secondary dysfunctions through a variety of methods that manipulate
the soft tissues or realign the body parts. Overcoming these misalignments
and manipulating soft tissues bring the individual parts back to optimal
function and return the body to health. Osteopathic Medicine One of the
earliest systems of health care in the United States to use manual healing
methods was osteopathic medicine. To its practitioners and to much of
the public, the manual healing methods of osteopathic medicine are mainstream
processes, but some people consider them ~alternative. The principles
and philosophy of osteopathy integrate health and illness, emphasizing
four major areas: • Structure and function are interdependent. Furthermore,
behavior is an intermingled complex in which psychosocial influences can
affect both anatomy (structure) and physiology (function). All these relationships
are fundamentally designed to work in harmony. • The body has the ability
to heal itself, and the role of the osteopathic physician is to enhance
the healing process as much as possible. • Diseases, impairments, and
disabilities arise from disruptions of the normal interactions of anatomy,
physiology, and behavior. • Appropriate treatment is based on the ability
to understand, diagnose, and treat--by ~whatever methods are available--including
manually applied procedures. When hands-on procedures are used to identify
somatic dysfunction (see the glossary), the practitioner then determines
whether the pattern of somatic dysfunction that is observed can be related
to any visceral (that is, related to the internal body organs), neuromusculoskeletal,
or--occasionally--behavioral dysfunction. History and context. American
osteopathic medicine was begun by Andrew Taylor Still (1828-1917). Still
was a physician of his period, trained mainly through apprenticeships.
It is said that he attended a medical school in Kansas City, MO, for one
semester but found it boring and irrelevant (Gevitz, 1980). As a result
of many adverse experiences with then contemporary medical practices,
including the death of several family members from untreatable meningitis
and pneumonia, Still began a personal search for improved methods to treat
diseases and restore health (Gevitz, 1980; Schiotz, 1958). This empirical
approach continues to be used by many osteopathic physicians.~Development
and use of osteopathically oriented manipulative skills began around the
time of Still's search (Carlson, 1975; Gevitz, 1980), but how he developed
his system that combined "lightning bone setting" with the magnetic healing
concepts of Mesmer is not clear (Hood, 1871). It seems likely that his
knowledge (of manipulation) was derived from simply observing the work
of another practitioner in the field. However he learned these methods,
Still soon afterwards made an important discovery, namely, that the sudden
flexion and extension procedures peculiar to the spinal area were not
limited to orthopedic problems; furthermore, they constituted a more reliable
means of healing than simply rubbing the spine (Gevitz, 1980). Whatever
the circumstances, Still began his new health profession in 1874, before
beginning his use of manipulation, which he was reported to use somewhat
later in that decade (Gevitz, 1980). After advertising and working as
both a magnetic healer and a lightning bone setter, he began writing about
his ideas (Still, 1899). Ultimately, he founded his first school, the
~American School of Osteopathy, in 1892 at Kirksville, MO, to improve
on existing surgical and obstetrical practices. The original emphasis
was on observing the relationship between structure and function. He incorporated
assumptions that manual restoration of normal anatomic relationships leads
to physiological improvements. This reasoning included by definition a
spectrum not only of health issues but of specific recommendations for
disease and obstetrical interventions. Some examples from osteopathic
literature include discussions dealing with labor and delivery, postoperative
ileus (bowel) paralysis, asthma, otitis media (middle ear infection),
hypertension, coronary artery disease, back pain, neck pain, diabetes,
trauma of all kinds, migraine headache, and stress-related illnesses (Downing,
1935; Kuchera and Kuchera, 1990; Sleszynski and Kelso, 1993). Osteopathy
spread to England in the 1920s when John Littlejohn emigrated from Chicago
to London, establishing the British School of Osteopathy, the first of
several such schools. The expansion continued as continental European
practitioners studied at the British schools in the 1930s and 1940s. ~Historically,
many currently popular manual medical techniques--with the exceptions
of "energy" techniques, massage, and high-velocity maneuvers (Hood, 1871)--originated
within American osteopathy and spread elsewhere. Among those techniques
are manual methods applied in other medically oriented systems and also
activities of alternative health care providers. Examples include muscle
energy and postisometric relaxation concepts, which were originally developed
and codified by Fred Mitchell, Sr. and Paul Kimberly; fascial-myofascial
release and visceral techniques, developed by A.T. Still and others, including
Charles Neidner; cranial-craniosacral techniques, William G. Sutherland
(Sutherland, 1990); strain and counterstrain, Lawrence Jones; and thoracic
pump and lymphatic techniques, A.T. Still, Gordon Zink, and several contemporaries.
(Most of these techniques are described briefly in the "Osteopathic Education"
section.) In many instances, contemporary practices of these methods throughout
the world are extensions and refinements of original osteopathic concepts.
Other systems, such as chiropractic, Swedish massage, Cyriax (Great Britain),
Mennell (Great Britain), Lewit (Czech Republic), Dvorak (Switzerland),
and several German systems also have influenced ~current practices, both
in the United States and elsewhere. Two current osteopathically based
examples are advances in myofascial release and fascial unwinding maneuvers
and in "energy"-based practices arising from basic cranial concepts, codified
by both Sutherland and Harold Magoun, Sr. (Magoun, 1976; Sutherland, 1990).
Demographics. As of 1993, this country had more than 32,000 American-educated
and licensed doctors of osteopathy (D.O.s), some in every State. They
perform all aspects of medical care, including all specialties and family
practice. Sixteen colleges and schools graduate approximately 1,500 D.O.s
annually. While graduates make up about 5 percent of the country's physician
population, the profession is responsible for approximately 10 percent
of total health care delivery in the United States. More than 60 percent
of osteopathic physicians are involved in primary care areas--family medicine,
pediatrics, internal medicine, and obstetrics-gynecology (Annual Directory,
1993). Many osteopathic physicians from a variety of disciplines regularly
incorporate structural diagnosis of abnormalities of musculoskeletal function
and manual medical treatments in their ~day-to-day activities.1 Ironically,
because of current attitudes among third-party payers toward physician
use of manual medicine, many are not paid for these services. Much of
the reluctance to pay is based on a lack of adequately funded research,
particularly relating to outcome measures. From an osteopathic perspective,
what is considered "alternative" by most of the medical and research establishment
is mainstream for the average D.O. (Gevitz, 1980; Grad, 1979; Schiotz,
1958). Osteopathic education. Basic American osteopathic education (Gershenow,
1985) includes substantial emphasis on osteopathic philosophy and principles
including extensive manually oriented training designed to develop manual
medicine diagnosis and treatment skills. The profession generally refers
to the latter as structural diagnosis and manipulative treatment. These
skills have been used by osteopathic physicians for more than 100 years
in a context of total patient care. The Education Council on Osteopathic
Principles, representing the 16 osteopathic colleges, is currently contributing
to osteopathic education through three principal projects: the 1982 ~publication
of an updated glossary of osteopathic terminology; development of a core
curriculum for osteopathic principles; and development of state-of-the-art
textbook chapters highlighting the uses of palpatory diagnosis (use of
touch) and manipulative treatment in multiple clinical disciplines. Basic
palpation and structural diagnosis and treatment skills are emphasized
in preclinical American osteopathic education, and eight major manual
medical methods are taught in osteopathic colleges. These eight methods
are as follows: 1. Soft-tissue techniques that enhance muscle relaxation
and circulation of body fluids. 2. Isometric and isotonic techniques (often
referred to as muscle energy or postisometric relaxation) that focus primarily
on restoring physiological movements to altered joint mechanics. 3. Articulatory
techniques (also called joint play and manipulation without impulse) that
~emphasize restoration of intrinsic joint mobility. 4. High-velocity,
low-amplitude techniques (also called manipulation with impulse), designed
to restore the symmetry of the movements associated with the vertebral
joints. 5. Myofascial release techniques (also called fascial release
techniques) that use combinations of so-called direct and indirect methods
(see the glossary) to modify problems of individual and interactively
related muscle groups and surrounding or covering (myofascial) tissues.
6. Functional techniques that emphasize treatment of restrictive patterns
in joint, myofascial, and neural systems, using "ease," "bind," "sensing,"
and "motor" hands (see the glossary) as proprioceptive (see the glossary)
diagnostic concepts. 7. Strain and counterstrain techniques, designed
to locate sore places at specific sites on the body, tender points that
relate to specific patterns of abnormal joint movement. The ~points are
"turned off" by moving the body or limb to a treatment position that quiets
painful feedback. The position is held for 90 seconds. Reevaluation typically
reveals improvement in movement and a decrease in local pain. 8. Cranial
techniques (also called craniosacral techniques) that highlight the manual
ability to assess and release tensions associated with subtle, reciprocating
cranial (head) and sacral (tailbone) oscillations. These movements are
thought to arise from a complex combination of dural (covering) and ligamentous
(fibrous connecting tissue) relationships in the spinal network. Adams
and Heisey have documented movement of cranial bones in studies using
cats. They found cerebrospinal fluid waves having various frequencies
and amplitudes (Adams et al., 1992; Heisey and Adams, 1993). Opportunities
for research in this area abound. A number of continuously evolving diagnostic
and treatment systems that are osteopathically oriented and manually based
incorporate various of these eight manual techniques. Some systems are
meant to stand on their own, while others are integrated to a greater
or lesser ~extent with medically (i.e., allopathically) oriented decisionmaking.
Postdoctoral training, certification, and fellowship status in manual
medicine are available to American osteopathic graduates, approximately
35 postdoctoral positions are available each year. Programs last 1 to
4 years. One-year fellowships are available for D.O.s and M.D.s who have
finished a previously approved residency. Standalone 2-year programs leading
to manual medicine certification are available in several colleges. Interdisciplinary
3-and 4-year programs that combine some of the many specialties and subspecialties
are also available. The most popular are combinations of manual medicine
with either family practice or physical medicine and rehabilitation. Total
patient care. Osteopathic physicians are involved in all aspects of total
patient care (Northup, 1966), including structural diagnosis and manipulative
treatment. Manipulative treatment is commonly used, especially by osteopathic
family physicians, as adjunctive care for systemic illness and for various
neuromusculoskeletal problems, such as low back, head, and neck pain.
In this context, a wide variety of hands-on and--in some situations--"energy"
~applications are used in a range of disciplines, including family practice,
pediatrics, geriatrics, physical medicine, surgery of all kinds, physical
medicine and rehabilitation, neurology, rheumatology, pulmonology, and
sometimes behavioral medicine and psychiatry. A few disciplines have conducted
research using manual methods (Reynolds et al., 1993; Sleszynski and Kelso,
1993), but many questions remain. Research base. Since its inception,
the osteopathic profession has maintained and pursued active research
in many areas. This work has usually been published in the Journal of
the American Osteopathic Association, which until recently was not listed
in Index Medicus. Present activities designing research tend to be directed
toward evaluating (1) long-term effects of somatic dysfunctions and facilitated
segments in disease states and (2) the outcome resulting from the use
of manipulative treatment. An extensive body of work supports a physiological
basis for using osteopathic techniques in both musculoskeletal and nonmusculoskeletal
problems. Of particular interest are studies dealing with~ • interactions
between internal body organs and neuromuscular structures, • alterations
in reflex thresholds, • reliability of physician palpatory skills (inter-rater
reliability studies), and • effects of manipulative treatments on disease
processes and a variety of physiological functions. Early work performed
by Louisa Burns demonstrated that spinal strain has adverse effects on
both functional and motor neuron levels (Burns, 1917). Later work by Denslow
and Korr demonstrated long-lasting, highly individual patterns of spinal
hyperexcitability associated with neuromuscular and various visceral dysfunctions.
This research led to the concept of the "facilitated segment" (fig. 1;
also see "facilitation" in the glossary), which has been associated with
a variety of clinical problems (Denslow et al., 1947; Korr, 1947, 1955).
The concept of the facilitated segment is that repeated stimulation produces
~hyperactive responses, resulting in improper functioning of some body
part. By considering function along with structure, osteopathic theory
has included conjecture on the role of the body's communication systems--nervous,
circulatory, and endocrine--in initiating somatic dysfunction and causing
additional responses in the body. Some early research (Northup, 1970)
supports this supposition with regard to reflexes having a role in mediating
both the origin of somatic dysfunctions and the effects of manipulative
treatment. Osteopathic medicine needs continuing basic research on the
role of the nervous system in establishing and maintaining somatic dysfunctions
and effecting interactions with the rest of the body. Figure 1 demonstrates
potential effects of repeated facilitation; that is, inducing a hyperactive
response, leading to somatic dysfunction. The term facilitation is usually
used to describe enhancement or reinforcement of otherwise subthreshold
neuronal activities that stimulate effector units to inappropriately carry
out whatever action they are programmed to do. Examples of effector sites
are muscle bundles, muscle groups, viscera, and other neural units ~and
networks. Osteopathic treatment is designed to raise these stimulus thresholds
so that the stimulatory event is less likely to occur. More recent examples
of osteopathic research include a preliminary assessment of the effectiveness
of manipulative treatment for paresthesias (abnormal sensations) with
peripheral nerve involvement (Larson et al., 1980) and thermographic studies
of skin temperature in patients receiving manipulative treatment for peripheral
nerve problems (Kappler and Kelso, 1984; Larson, 1984). Thermography was
selected as a promising method to study segmental facilitation of sympathetic
nerves without invading the body (as would be required if needle electrodes
were used). Initial studies have been complicated, however, by the number
of variables affecting skin-level circulation, including circulatory patterns,
local influences, and local shunting. If methods can be developed to identify
the effects of these variables, then thermography may prove useful for
detecting changes in the sympathetic nervous system that affect skin-level
circulation. Other current clinical research projects that examine the
effects of manual treatments have ~researched their effects on postoperative
pulmonary flow rates (Sleszinski and Kelso, 1993), pain management (Zhu
et al., 1993), and electromyographic changes associated with manual treatments.
If vibration is applied to muscles near the spine or these paraspinal
muscles contract voluntarily, weakened electrical potentials are observed
in the cerebrum, the main part of the human brain. This finding suggests
that muscle spindle receptors are responsible for providing signals that
cause the early components of magnetically evoked brain potentials. The
brain's evoked potentials return to normal amplitude (1) when the muscle
spasm subsides after a period of time and (2) after spinal manipulative
therapy is applied (Zhu et al., 1993). Additional research on the interaction
of visceral and somatic structures (Eble, 1960) has supported clinical
findings that palpation of neuromuscular structures can help identify
visceral disturbances (Johnston, 1992; Kelso et al., 1980) and that manual
procedures can help restore both visceral and neuromuscular (somatic)
functions (Buerger and Greenman, 1985; Korr, 1978; Northup, 1970). The
latter include situations involving low back pain (Hoehler et al., 1981),
neurological development in children (Frymann et al., 1992), carpal ~tunnel
syndrome (Sucher, 1993), postoperative collapsed lung (Sleszynski and
Kelso, 1993), and burning pain in an extremity (Levine, 1991). Moreover,
in some preliminary observations with cadavers, Reynolds and Ward (Ward,
1994) found that palpatory diagnoses tended to correlate with radiographic
and autopsy data. One example of the diagnostic potential of osteopathic
palpation is the studies of Johnston and colleagues (Johnston et al.,
1980, 1982b), comparing subjects with normal and high blood pressure.
A significant number of the hypertensive patients were shown to have a
stable pattern of musculoskeletal findings in the cervicothoracic spinal
region. This finding suggests that osteopathic diagnoses could contribute
to identifying internal difficulties. Another issue that osteopathic researchers
have addressed is the accuracy of their examinations of patients before
and after manipulative treatment, including whether such observations
are consistent among a group of osteopathic physicians. Several studies
(Beal et al., 1980, 1982; Johnston, 1982a; Johnston et al., 1982a, 1982c,
1983; McConnell et al., 1980) have been conducted in which osteopathic
physicians working independently have ~used a mutually agreed-upon test
procedure. These studies of inter-rater reliability look for correlations
in the observations of two or more independent raters. Results suggest
that when there is prior training or agreement on which tests to use and
what is clinically significant with respect to findings, inter-rater agreement
can be achieved consistently. This ability to reach agreement becomes
particularly important as the basis for establishing a method of setting
up controlled clinical trials to determine the success of manipulative
treatments. Virtually all osteopathically oriented research has been funded
from the private sector, mainly through the bureau of research of the
American Osteopathic Association. The largest grant to date, $400,000,
is for evaluating outcomes associated with the use of manipulation for
back pain in a Chicago health maintenance organization population. This
is a 3-year prospective study conducted by two osteopathic physicians
specializing in musculoskeletal medicine. Patients having acute back pain
with and without sciatica (pain radiating downward into the leg) are randomized
into the project so that some receive manipulative care while others receive
"standard" medical care. Clinical outcomes are evaluated by ~uninvolved
clinicians. Preliminary data are expected in late 1994. Barriers and key
issues. Historically, Federal research initiatives relevant to osteopathic
medicine (for example, from the National Institute of Neurological Disorders
and Stroke at the National Institutes of Health (NIH) or from the Centers
for Disease Control and Prevention) have been controlled by traditionally
defined disciplines and their expert panels. Manual-methods research panels
are not among them, and the result is a lack of genuine peer review capability.
This sociological fact of life has inhibited development and understanding
of the manual medicine field, even though public acceptance has been and
continues to be high throughout the world. Some major issues to be considered
in trying to improve osteopathic research opportunities are the following:
• Selecting appropriate patient populations in which to study the effects
of manual manipulation.~ • Arranging for knowledgeable peer review and
research guidance, including (1) ensuring that persons with osteopathic
experience serve on peer review panels (see also the "Peer Review" chapter)
and (2) determining appropriate procedures for measuring success of osteopathic
treatments. • Establishing whether previous inter-rater agreement studies
support the use of the inter-rater agreement method in osteopathic and
other kinds of research. • Making previous osteopathic research more accessible
(for example, the recent inclusion of the Journal of the American Osteopathic
Association in Index Medicus), which could educate other investigators
about osteopathic issues and possibly lead to collaborative research.
(See also the "Research Databases" chapter.) • Ensuring that osteopathic
clinician-researchers are part of any research team so that persons inexperienced
with osteopathic diagnosis and treatment do not conduct the work improperly.
Additional training in planning, conducting, evaluating, and reporting
clinical ~research should be made available to the osteopathic clinicians.
• Setting up a review process to integrate available information from
outside the osteopathic profession with osteopathically based research
on the structure-function relationship. Included would be research, for
example, on homeostasis; short-, intermediate-, and long-term responses
to different stressors; and adaptation to changes in internal and external
environment. Useful new research questions are likely to result. • Documenting
anecdotal observations of patients and osteopathic clinicians who treat
the somatic component of medical and health-related problems to tabulate
patient benefits that include relief from stress and improvement in function
and well-being. Attention should be paid to all patient health outcomes,
not just short-term benefits from manipulation; for example, reducing
health risks, improving health maintenance, and modifying adaptive responses
would be included. • Designing and conducting research to support or refute
the use of palpatory ~examination and manipulative treatment for the somatic
component of dysfunction and illness. Also researching the role of the
somatic system; identifying the nature and effects of somatic dysfunctions
and their incidence, prevalence, and effects on acute illness and long-term
health; and any changes in those effects resulting from treatment. • Developing
alternative research designs for safety and efficacy studies that do not
require blind controls for manual procedures. (See also the "Research
Methodologies" chapter.) There are both practical and ethical reasons
not to use blind controls for a hands-on procedure. One alternative is
to use naive patients who lack any expectation that the treatment will
be beneficial. • Developing and integrating cost-benefit research that
compares the use of palpatory examination and manipulative treatment with
mainstream health care and disease management procedures. Common examples
include headaches of all kinds, back pain, allergy, asthma, many orthopedic
problems, postoperative and posttraumatic effects of all kinds, and various
rheumatologic diseases.~Chiropractic Chiropractic science is concerned
with investigating the relationship between structure (primarily of the
spine) and function (primarily of the nervous system) of the human body
in order to restore and preserve health. Chiropractic medicine addresses
how to apply this knowledge to diagnose and treat structural dysfunctions
that affect the nervous system. Chiropractic philosophy and practice emphasize
four major points: • The human body has an innate self-healing ability
and seeks to maintain homeostasis (see the glossary), or balance. • The
nervous system is highly developed in humans and influences all other
systems in the body, thereby playing a significant role in health and
disease. • The presence of joint dysfunction and subluxation (see the
glossary) may interfere with ~the ability of the neuromusculoskeletal
system to act efficiently and may lead to or be a concomitant of disease.
• Treatment is based on the chiropractic physician's ability to diagnose
and treat existing pathologies and dysfunctions by appropriate manual
and physiological procedures. The chiropractic physician relies heavily
on hands-on procedures using touch (palpation) to determine both structural
and functional joint "dysrelationships." These hands-on procedures are
carried out alongside more traditional forms of diagnostic assessment.
By training and by law, chiropractic physicians use manual procedures
and interventions, not surgical or chemotherapeutic ones. History and
context. While manipulative medicine has been practiced for millennia,
the chiropractic profession is only now preparing for its centennial.
The profession was founded in the 1890s when Daniel David (D.D.) Palmer,
a grocer and magnetic healer, applied his knowledge of the nervous system
and manual therapies, thrusting on a thoracic vertebra to ~restore the
hearing of Harvey Lillard, a local janitor. While Palmer was not the first
to practice manual thrusting, he was the first to use the bony projections,
or processes, of the vertebrae (specifically, the spinous and transverse
processes) as levers for the manual contact. Within 2 years of this initial
discovery, Palmer had founded his Chiropractic School and Cure, while
at the same time developing the concept of subluxation, a type of partial
joint dislocation, as a causal factor in disease. For these reasons, D.D.
Palmer is known as the Founder.
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