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Dubious Aspects of Osteopathy

Stephen Barrett, M.D.

Osteopathic physicians (DOs) are the legal and professional equivalents of medical doctors. Although most offer competent care, the percentages involved in chelation therapy, clinical ecology, orthomolecular therapy, homeopathy, ayurvedic medicine, and several other dubious practices appear to be higher among osteopaths than among medical doctors. I have concluded this by inspecting the membership directories of groups that promote these practices and/or by comparing the relative percentages of MDs and DOs. listed in the Alternative Medicine Yellow Pages [1] and HealthWorld Online's Professional Referral Network. The most widespread dubious treatment among DOs appears to be cranial therapy, an osteopathic offshoot described below.

Cultist Roots

Andrew Taylor Still, MD (1828-1917) originally expressed the principles of osteopathy in 1874, when medical science was in its infancy. A medical doctor, Still believed that diseases were caused by mechanical interference with nerve and blood supply and were curable by manipulation of "deranged, displaced bones, nerves, muscles -- removing all obstructions -- thereby setting the machinery of life moving." His autobiography states that he could "shake a child and stop scarlet fever, croup, diphtheria, and cure whooping cough in three days by a wring of its neck." [2]

Still was antagonistic toward the drug practices of his day and regarded surgery as a last resort. Rejected as a cultist by organized medicine, he founded the first osteopathic medical school in Kirksville, Missouri, in 1892.

As medical science developed, osteopathy gradually incorporated all its theories and practices [3]. Today, except for additional emphasis on musculoskeletal diagnosis and treatment, the scope of osteopathy is identical to that of medicine. The percentage of practitioners who use osteopathic manipulative treatment (OMT) and the extent to which they use it have been falling steadily.

Osteopathy Today

There are 19 accredited colleges of osteopathic medicine and about 40,000 osteopathic practitioners in the United States [3]. Admission to osteopathic school requires three years of preprofessional college work, but almost all of those enrolled have a baccalaureate or higher degree. The doctor of osteopathy (DO) degree requires more than 5,000 hours of training over four academic years. The faculties of osteopathic colleges are about evenly divided between doctors of osteopathy and holders of PhD degrees, with a few medical doctors at some colleges. Graduation is followed by a one-year rotating internship at an approved teaching hospital. A majority of osteopaths enter family practice. Specialization requires two to six additional years of residency training, depending on the specialty. The American Osteopathic Association (AOA) recognizes more than 60 specialties and subspecialties. AOA membership is required for specialty certification, which forces some practitioners to belong to the AOA even though they do not approve of the organization's policies. Since 1985, osteopathic physicians have been able to obtain residency training at medical hospitals, and the majority have done so. Since 1993, DOs who completed osteopathic residencies have also been eligible to join the American Academy of Family Practice, which had previously been restricted to MDs or DOs with training at accredited medical residencies [4].

Osteopathic physicians are licensed to practice in all states. The admission standards and educational quality are a bit lower at osteopathic schools than they are at medical schools. I say this because the required and average grade-point averages (GPAs) and the Medical College Admission Test (MCAT) scores of students entering osteopathic schools are lower than those of entering medical students [5,6] -- and the average number of full-time faculty members is nearly ten times as high at medical schools (714 vs. 73 in 1994) [6]. However, as with medical graduates, the quality of individual graduates depends on how bright they are, how hard they work, and what training they get after graduation. Those who diligently apply themselves can emerge as competent.

In January 1995, a one-page questionnaire was mailed to 2,000 randomly selected osteopathic family physicians who were members of the American College of Osteopathic Physicians. About half returned usable responses. Of these, 6.2% said they treated more than half of their patients with OMT, 39.6% said they used it on 25% or fewer of their patients, and 32.1% said they used OMT on fewer than 5% of their patients. The study also found that the more recent the date of graduation from osteopathic school, the lower the reported use [7].

AOA Hype

Many observers believe that osteopathy and medicine should merge. But osteopathic organizations prefer to retain a separate identity and have exaggerated the minor differences between osteopathy and medicine in their marketing. According to a 1987 AOA brochure, for example: (1) osteopathy is the only branch of mainstream medicine that follows the Hippocratic approach, (2) the body's musculoskeletal system is central to the patient's well-being, and (3) OMT is a proven technique for many hands-on diagnoses and often can provide an alternative to drugs and surgery [8]. A 1991 brochure falsely claimed that OMT encourages the body's natural tendency toward good health and that combining it with all other medical procedures enables DOs to provide "the most comprehensive treatment available." [9] Such statements are consistent with a 1992 AOA resolution that defines osteopathy as:

A system of medical care with a philosophy that combines the needs of the patient with current practice of medicine, surgery, and obstetrics and emphasis on the interrelationships between structure and function and an appreciation of the body's ability to heal itself [10].

A 1994 AOA resolution describes osteopathy as "a complete system of health care and as such is much more holistic than medicine in the classic sense." [10].

The American Osteopathic Association's web site glorifies Andrew Still and asserts that osteopathic medicine has a unique philosophy of care because "DOs take a whole-person approach to care and don't just focus on a diseased or injured part." I consider it outrageous to imply that osteopathic physicians are the only ones who regard their patients as individuals or who provide comprehensive care or pay attention to disease prevention. Another AOA web document states:

Osteopathic physicians frequently assess impaired mobility of the musculoskeletal system as that system encompasses the entire body and is intimately related to the organ systems and to the nervous system. Using anatomical relationships between the musculoskeletal and these organ systems, osteopathic physicians diagnose and treat all organ systems [11].

This statement strikes me as the same sort of baloney chiropractors use to suggest that somehow their attention to the spine will have positive effects on all body processes. Spinal manipulation may produce pain relief in properly selected cases of low back pain. However, OMT has no proven effect on people's general health.

Chelation Therapy

Chelation therapy is a series of intravenous infusions containing EDTA and various other substances. Proponents claim it is effective against atherosclerosis and many other serious health problems. However, no controlled trial has shown that chelation therapy can help any of them. Chelation therapy with EDTA is one of several legitimate methods for treating cases of lead poisoning, but the protocol differs from that used inappropriately for other conditions. To its credit, the AOA has adopted a negative position statement on chelation therapy:

WHEREAS, chelation therapy utilizing calcium disodium edetateis currently labeled by the Food and Drug Administration and recognized by most physicians as medically acceptable only in the management of acute or chronic heavy metal poisoning; now, therefore, be it

RESOLVED, that pending the results of thorough, properly controlled studies, the American Osteopathic Association does not endorse chelation therapy as useful for other than its currently approved and medically accepted uses. Adopted 1985, revised and reaffirmed, 1990, 1995 [10].

The 1998 member referral list of the American College for Advancement of Medicine (ACAM) , the principal group promoting chelation therapy, identifies about 400 MD members and 121 DO members who list chelation therapy as a specialty. These numbers strongly suggest that the percentage of osteopathic physicians doing chelation therapy is about four or five times as high as the percentage of medical doctors doing it. Curiously, AOA President Ronald A. Esper, DO, of Erie, Pennsylvania, is an ACAM member and does chelation therapy.

Cranial Therapy

Practitioners of "cranial osteopathy," "craniosacral therapy," "cranial therapy," and similar methods claim that the skull bones can be manipulated to relieve pain (especially of the jaw joint) and remedy many other ailments. They also claim that a rhythm exists in the flow of the fluid that surrounds the brain and spinal cord and that diseases can be diagnosed by detecting aberrations in this rhythm and corrected by manipulating the skull. Most practitioners are osteopaths, massage therapists, chiropractors, dentists, or physical therapists.

Cranial osteopathy's originator was osteopath William G. Sutherland, who published his first article on this subject in the early 1930s. Today's leading proponent is John Upledger, DO, who operates the Upledger Institute of Palm Beach Gardens. Florida. An institute brochure states:

CranioSacral Therapy is a gentle, noninvasive manipulative technique. Seldom does the therapist apply pressure that exceeds five grams or the equivalent weight of a nickel. Examination is done by testing for movement in various parts of the system. Often, when movement testing is completed, the restriction has been removed and the system is able to self-correct [12].

Another Upledger brochure states:

The rhythm of the craniosacral system can be detected in much the same way as the rhythms of the cardiovascular and respiratory systems. But unlike those body systems, both evaluation and correction of the craniosacral system can be accomplished through palpation.
CranioSacral Therapy is used for a myriad of health problems, including headaches, neck and back pain, TMJ dysfunction, chronic fatigue, motor-coordination difficulties, eye problems, endogenous depression, hyperactivity, attention deficit disorder, central nervous system disorders, and many other conditions [13].

The theory underlying craniosacral therapy is erroneous because the bones of the skull fuse during infancy and cerebrospinal fluid does not have a palpable rhythm. Nor do I believe that "the rhythms of the craniosacral system can be felt as clearly as the rhythms of the cardiovascular and respiratory systems," as is claimed by another Upledger Institute brochure [14]. The brain does pulsate, but this is exclusively related to the cardiovascular system [15]. In a recent study, three physical therapists who examined the same 12 patients diagnosed significantly different "craniosacral rates," which is the expected outcome of measuring a nonexistent phenomenon [16]. At least 15 of the 88 items listed in the October 1996 American Osteopathic Association's list of "Osteopathic Literature in Print" were written by Sutherland, Upledger, or others who appear to advocate cranial therapy [17].

Osteopathic web sites that espouse cranial therapy can be located by using Infoseek's Advanced Search with the top line set at "must contain the phrase cranial osteopathy" and the second line set as "must contain the name Sutherland." The most illuminating source I have found (which no longer appears to be posted) was The Cranial Letter, published quarterly by the Cranial Academy, a component society of the American Academy of Osteopathy,which is a practice affiliate of the AOA. The Summer 1993 issue stated that the Cranial Academy had 989 members. Other issues contained case reports stating that cranial therapy can cause knee pain to disappear within a week (Summer 1992), cure hives (Summer 1993), improve the mental condition of Down syndrome patients (May 1995), and correct crossed eyes (May 1996). The American Osteopathic Association's 1998 continuing education calendar listed a 40-hour cranial osteopathy course it cosponsored with the American Academy of Osteopath

The Bottom Line

I believe that the American Osteopathic Association is acting improperly by exaggerating the value of manipulative therapy and by failing to denounce cranial therapy. If you wish to select an osteopathic physician as your primary-care provider, your best bet is to seek one who: (1) has undergone residency training at a medical hospital; (2) does not assert that osteopaths have a unique philosophy or that manipulation offers general health benefits; (3) either does not use manipulation or uses it primarily to treat back pain; and (4) does not practice cranial therapy.

Reader Comment

An osteopathic student complained about my criticism of the misleading statements the AOA makes about OMT on its web site:

The AOA is not reflective of the majority of osteopathic physicians. To begin with, if one ever hopes to achieve a leadership position in the AOA, one must complete both an osteopathic internship and an osteopathic residency, this effectively eliminates somewhere around 70% of DOs (at least that's the figure tossed around this campus). The remaining 30% of DOs unfortunately includes those who make many questionable claims about OMT. It also includes many excellent physicians. The DOs who continue to make these claims are a very vocal minority; most of us become a little embarrassed when we read this sort of thing.

I replied:

I would suggest that you and your future colleagues who think that the AOA is making deceptive claims bring pressure on the AOA because it is the only publicly identified spokesperson you seem to have.

AOA Protests

On January 23, 1988, I received a letter from the AOA's law firm objecting to certain passages in a previous version of this article [18]. Since that time, I have clarified some of the points they raised and added additional information and references. I also invited the AOA to submit a letter for posting and further discussion. Through their attorney, they agreed to do so, but none has arrived so far.

References

1. Alternative Medicine Yellow Pages. Puyallup, Washington. Futurer Medicine Publishing, Inc., 1994.
2. Still AT. Autobiography -- with a history of the discovery and development of the science of osteopathy. Reprinted, New York, 1972, Arno Press and the New York Times.
3. Gevitz N. The D.O.'s: Osteopathic Medicine in America. Baltimore, 1982, The Johns Hopkins University Press.
4. Gugliemo WJ. Are D.O.s losing their unique identity? Medical Economics 75(8):201-213, 1998. (Clarification regarding AAFP membership published in Medical Economics 75(14):21, 1998.)
5. Doxey TT, Phillips RB. Comparison of entrance requirements for health care professions. Journal of Manipulative and Physiological Therapeutics 20:86­91, 1997.
6. Ross-Lee B, Wood DL. Osteopathic medical education. In Sirica CM, editor. Osteopathic Medicine, Past, Present and Future. New York, Josiah Macy Jr. Foundation, 1996, page 95.
7. Johnson SM et al. Variables influencing the use of osteopathic manipulative treatment in family practice. Journal of the American Osteopathic Association 97:80-87, 1997.
8. Osteopathic medicine: A distinctive branch of mainstream medical care. Undated brochure, distributed in 1987. Chicago: American Osteopathic Association
9. What is a D.O.? (Brochure) Chicago: American Osteopathic Association, 1991,
10. AOA Position Papers, Aug 1996. In AOA Yearbook and Directory. Chicago: American Osteopathic Association, Jan 1997, pages 565-588.
11. Position Paper on Osteopathic Manipulative Treatment (OMT) & Evaluation and Management services. Part II: The Standard of Care for Osteopathic Manipulation and the E&M Service. AOA web site, September 1998.
12. Discover CranioSacral Therapy. Undated flyer distributed in 1997 by the Upledger Institute.
13. Upledger CranioSacral Therapy I. Brochure for course, November 1997.
14. Workshop catalog, Upledger Institute, 1995.
15. Ferre JC and others. Cranial osteopathy, delusion or reality? Actualites Odonto-Stomatologiques 44:481-494, 1990.
16. Wirth-Pattullo V, Hayes KW. Interrater reliability of craniosacral rate measurements and their relationship with subjects' and examiners' heart and respiratory rate measurements. Physical Therapy 74:908-16, 1994.
17. Osteopathic literature in print, October 1996. In AOA Yearbook and Directory. Chicago: American Osteopathic Association, Jan 1997, pages 756-757.
18. Prober, JL. Letter to Dr. Stephen Barrett, January 23, 1998.
 

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