Osteopathic Medicine

A quick history of Osteopathic Medicine

What does "somatic dysfunction" mean?

What is a D.O.?

Briefly, D.O. stands for Doctor of Osteopathic Medicine. 

D.O.’s, like their allopathic (M.D.) counterparts, are licensed to practice the full scope of medicine including the ability to order diagnostic testing, prescribe medications and perform surgery. In addition to the standard medical school curriculum, however, D.O.’s receive additional training in Osteopathic philosophy (emphasizing a holistic approach to our patients) and in Osteopathic manipulative therapy (OMT).

Philosophical differences aside, many people simply think of Osteopathic physicians as a combination of an M.D. and a chiropractor (D.C.) - allowing for "one-stop shopping" in today’s medical marketplace.

For an excellent discussion on this topic, please check out the American Osteopathic Association's web page at: http://www.am-osteo-assn.org/Consumers/whatdo.htm. Also check out this YouTube video from the Osteopathic Physicians and Surgeons of California here.

A quick history of Osteopathic Medicine

(The following is an excerpt of one of my postings from the Microsoft Network Healthcare Professionals Forum BBS, in response to how Osteopathic physicians differ from Chiropractors.)

Osteopathic Medicine was developed by an M.D., Dr. Andrew Taylor Still, who practiced as an itinerant (traveling) physician in the latter half of the 19th century. You have to remember what traditional medicine was like back in those days - not particularly good (try some arsenic for that sore throat?!!), particularly in the rural communities. 

As the result of an epidemic of spinal meningitis, Dr. Still lost some family members. Feeling helpless as he watched them die, he became determined to improve the practice of medicine of his day and went about re-studying anatomy and physiology. (This is a very polite way of saying that he dug up Indian graves and dissected/studied the bodies.) What he concluded, after a time, was that there were certain inherent principles among them being the concepts that the body has the ability to heal itself, structure and function are inter-related, and that what affects one part of the body affects others as well, due to the various interconnections provided by the neurovascular system. 

Still had noted that certain manipulations seemed to effect healthful changes in his patients and he included these in his therapeutic armamentarium. (Now he was not the first guy to ever perform manipulation, nor did he ever claim to. Manipulation has been around for 2000+ years, dating back to Chinese medicine; You may also recall that there were also "lightening bone setters" in England in the 1600's.) He also found palpation a valuable adjunct to his diagnostic skills as well, due to viscerosomatic and other reflexes.

When Dr. Still tried to teach what he had discovered to his medical/allopathic colleagues, they laughed him off as a quack. Yet, his medicine was sound (all physicians today recognize the aforementioned concepts). Faced with a disbelieving medical community, he decided to start his own school of medicine, teaching his newly elucidated principles. He had to quickly come up with a name, and decided upon the term "osteopathy" (a confusing misnomer by today's standards). The first school, the American School of Osteopathy, was founded in Kirksville, Missouri around 1892, and graduates were conferred the D.O. (Doctor of Osteopathy) degree.

Still continued to practice medicine and teach at Kirksville. During these early years, it has been recorded that a gentleman by the name of Palmer visited Still and spent a little bit of time with him. The next thing anyone knew, Palmer was back up in Iowa where he "discovered" chiropractic.

So, what's the difference between Osteopathic and Chiropractic medicine? Over the subsequent years, Still and the growing D.O. community integrated the Osteopathic principles and practices into their practice of medicine. That is, they would still use drugs or perform surgery if needed, but their general maxims were "Above all, do no harm." and "Keep it pure." In other words, D.O.'s were not defined by manipulation, rather, they were defined by their philosophy and manipulation/palpation happened to be a "really good tool" that was used. (In all honesty, D.O.'s didn't all agree that they wanted to do this; they were spurred on to do this by changes that were going on within the allopathic community, the Flexner Report on medical schools, etc.) D.C.'s, on the other hand, limited their practices strictly to manipulation, and did not teach "materia medicae" (essentially, medical therapeutics) in their schools at the time.

OK, back to the 1990's: Is there any difference between manipulation between a D.O. and a D.C.? Probably not. There are many different ways to mobilize joints and which technique is selected is more likely based upon the skill and comfort of the practitioner, not to mention the size/shape of the patient. I have chiropractic friends (who recently entered D.O. school incidentally) who would adjust me when I would need it using techniques very similar to mine.

How much manipulation training do D.O.'s receive? I can't quote the exact number of hours but they were a lot. In addition to our regular traditional medical school classes (anatomy, biochemistry, pharmacology, etc.), we would have at least one hour of Osteopathic Principles and Practices each day, for each semester that we were in classes. So generally, we spent longer times in school each day, in comparison to our M.D. colleagues.

What about holistic medicine? Do M.D.'s practice holistic medicine? As I noted, the concepts of structure and function being inter-related, etc. have all been pretty much accepted by the medical community nowadays, but whether or not most M.D.'s actually think about this is another matter. Philosophically, Osteopathy can be considered more closely aligned historically with Chinese medicine, which took a holistic approach. Allopaths (M.D.'s) philosophy stems way back to ancient Egypt where they used to have individual gods for different things. Body parts were sort of compartmentalized - there may have been a god to care for extremities, another for chest, etc.. This type of thinking does not lend itself as well to a holistic approach. The result today: the majority of D.O.'s practice primary care medicine and the majority of M.D.'s specialize.    

What does "somatic dysfunction" mean?

[The following article was published in the San Diego Workers' Compensation Forum Newsletter.  Osteopathic physicians frequently use the term "somatic dysfunction" to describe certain musculoskeletal diagnoses. This article was designed to explain this term to insurance adjusters and other Workers' Comp professionals.]

Diagnosis:  Neck sprain/strain (Somatic dysfunction: cervicothoracic junction)

Patient B: 20 year-old female visiting nurse slipped while descending staircase at a clients home. Managed to catch herself with the railing as she fell backwards, hence she did not actually strike the ground. No pain at the time, but within an hour or so, begins to feel sharp pain in the middle of the back associated with painful deep inspirations.

Diagnosis:  Thoracic sprain/strain (Somatic dysfunctions: thoracolumbar junction and ribs)

Patient C: 35 year-old male construction worker bent forward to pick up a jackhammer that had been lying in a hole. Thought he felt a "tweak"/popping sensation as he stood up, but didn’t hurt. Next day, he begins experiencing aching in right side of his low back and finds he has some restricted movement in the region. No changes in his genitourinary or gastrointestinal systems, nor does he complain of radicular symptoms.

Diagnosis:  Low back sprain/strain (Somatic dysfunction: lumbosacral region)

You know what a sprain/strain means – the patient did not sustain any bony injuries such as a fracture, i.e. a "soft-tissue" injury. But what about these "somatic dysfunction" diagnoses – is this doc trying to pad his bill?

No, in fact a Doctor of Osteopathic Medicine (D.O.) uses this term in an attempt to be more specific regarding their diagnoses. A sprain refers to a stretch-type injury of a ligament, whereas a strain refers to muscles and tendons. In the above mentioned examples, neither one of these mechanisms is responsible for the patients’ complaints. Rather, a mechanical restriction occurs first, which is usually followed by a reflex increase in muscle tone/spasm.

Allopathic physicians refer to this as "facet syndromes;" Chiropractors refer to them as subluxations. To osteopathic physicians, somatic dysfunction refers to impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic and neural elements.

Recall the fact that humans are machines containing an internal skeletal supporting structure. The vertebral column contains 3 regional curves (cervical, thoracic, and lumbar), that can be easily visualized from the side. These curves are important because they help to cushion the discs and spinal cord from excessive or unexpected forces.

Sidebending a spine in its neutral posture (i.e. with curves intact) is generally well-tolerated and without ill-effects as the individual vertebral segments accommodate to the movement, as a group, and return back to their neutral postures once the movement is completed.

On the other hand, let’s say that there is a loss of normal curvature in a region when sidebending is attempted. The spinal mechanics are different. Rather than behaving as a group, a single vertebral segment must "give in" to allow for the segments above and below it to sidebend. [Try this simple experiment: fold an 8" x 11" piece of paper in half (so that it becomes 4" x 11"). Grasp the folded edge using the thumbs of both hands and attempt to bend the "spine" of the paper. You’ll observe that the paper must "kink" in order to promote bending.]

Incidentally, this "kink" doesn’t have to cause pain right away. In fact, the reflex mechanisms that kick in may not induce discomforts until 1-3 days later. Why the inspiratory rib discomforts seen with thoracic problems? This is because the rib heads articulate with the thoracic vertebral segments. If a particular segment is restricted in its motion, the adjacent rib will be affected, as well. Hence, a rib that is prevented from its normal inspiratory excursion causes pain (that often originates from the back and radiates anteriorly around the chest).

Finally, why bother using the term at all – isn’t sprain/strain still good enough for coding purposes? The reason has to do with a procedure called Osteopathic Manipulative Therapy (OMT). If a D.O. performs OMT as part of his/her overall treatment plan, a diagnosis of the appropriate regional somatic dysfunction needs to be included in order to support the need for this particular treatment modality (e.g. one wouldn’t code a laceration repair without a diagnosis of a laceration!).

Therefore, in summary, D.O.’s may list both the allopathic and osteopathic diagnoses as part of their assessments. The former to provide a sense of what is going on with the patient using conventional terminology, the latter to address billing documentation concerns.