September 2007

Harvard Med to teach manipulation

Despite previous warnings that "osteopathic manipulation" may be associated with stroke and "should not replace other more proven treatments for potentially severe conditions," Harvard Medical School has begun offering a continuing education course in osteopathic manipulative treatment. The course is limited to MDs and DOs.

According to a course brochure distributed by the school, the three‑day course will cover such topics as "Vertebral Motion: Normal and Dysfunctional;" "Diagnosing Vertebral Dysfunction;" "Bony Landmark Identification and Palpation;" "ICD‑9 Codes and CPT Codes;" "Principles of Myofascial Release; Counterstrain;" "Postural Models/Functional Anatomy;" "Articulatory Technique;" "Thoracic Spine High Velocity, Low Amplitude Thrust Technique;" and "Somatic Dysfunction of the Lumbar Spine." The course includes a number of hands‑on workshops.

The school notes in the brochure: "Osteopathic manipulative treatment provides an alternative diagnostic and therapeutic tool for the physician. Learning osteopathic manipulative techniques allows for a more accurate diagnosis and provides an additional form of treatment. This course introduces clinicians to the field of osteopathic medicine and teaches them skills in multiple hands‑on workshops. Osteopathic manipulation is used to diagnose and treat most musculoskeletal conditions. Both patients and practitioners appreciate osteopathic manipulative techniques."

Although the brochure says the course "also encourages physicians to take more advanced courses in the future," it claims physicians will be enabled to "use osteopathic manipulative treatment to diagnose and treat patients, utilizing techniques taught at this course," stating that the three‑day training "integrates examination and osteopathic techniques to increase the accuracy of the physician's ability to diagnose and treat musculoskeletal disorders."

While this is not the first time that manipulative therapy has been taught to MDs, it is believed to be the first continuing education course sponsored by Harvard School of Medicine.

In 1996, the chiropractic profession was shocked to learn of a grant request submitted to the Department of Health and Human Services (DHHS) through the Public Health Service (PHS) entitled, "Manual Therapy in Primary Care of Low Back Pain."

The grant application was for a proposed project to train 25 primary care physicians to give spinal manipulations, and then actually manipulate 320 patients in their practices. Training would consist of "4 sessions in the first year" and "a small reference booklet ... for participants to use in their offices to reinforce training."

The proposal noted that the curriculum of the training program was to be under the overall direction of a medical doctor, an osteopath, and two chiropractors, Dr. John Triano and Dr. Geoffrey Bove.

Eventually, a grant was awarded and the study was conducted, led by Timothy S. Carey, MD, MPH, of the University of North Carolina. The researchers recruited and trained 33 primary care allopathic physicians in the basics of spinal manipulation for acute low back pain. They enrolled 295 patients in a randomized trial of therapies for low back pain in 31 physician's offices, comparing manual therapy with enhanced care (a similar number of visits, a specific explanation of the spinal problem, and a series of instructional pamphlets).

Patient follow up at two, four, and eight weeks found that clinical outcomes were similar between the two patient groups. Ninety percent of patients had returned to their previous level of functioning by eight weeks, and satisfaction was high in both groups.

The researchers concluded that training primary care physicians in manual therapy was feasible, but that the similarity of outcomes seen in the trial made it unlikely that it would become a major therapeutic tool for allopathic physicians. (Abstract, executive summary, and final report are available from National Technical Information Service, www.ntis.gov, accession no. PB2000‑101832.)

However, in the ensuing years, the popularity of the non‑invasive approach has made the medical community rethink its position on manipulation and many MDs are beginning to embrace it and incorporate osteopathic techniques into their own practices. The trend is a complete reversal of the medical profession's traditional attitude toward osteopathy and chiropractic.

On Jan. 26, 1923, The New York Times noted that Dr. Arthur F. Chase, the new president of the New York County Medical Society, was reported to have said in his inaugural address: "It is because the profession looks down upon manual therapy that an army of osteopaths and chiropractors has sprung up."

This superiority complex shaped many of the policies of the American Medical Association for decades. A 1951 article in Time magazine observed: "Many M.D.s persist in regarding osteopathy as little better than chiropractic, whose practitioners claim that illness springs from maladjustment of the spinal column. The American Medical Association still holds it unethical for an M.D. to refer his patients to an osteopath (unless the osteopath also happens to be an M.D.)."

In a legal struggle similar to chiropractic's 1976 Wilk vs. AMA, the American Osteopathic Association accused the American Medical Association of trying to create a monopoly on medicine by destroying osteopathy. Although the AMA was forced to stop some of its practices, it continued to use subtle (and not so subtle) means to suppress osteopathy. The way osteopaths chose to overcome this opposition by the medical profession was to become part of the medical profession, distancing itself from its original identity as an alternative to medicine.

As an article in the November 1997 issue of ACP Observer, published by the American College of Physicians, explained, "While osteopathic leaders emphasize osteopaths' unique identity, many osteopaths would rather not draw attention to their uniqueness. Many actually complete their training in allopathic residency programs, in effect turning away from osteopathic principles."

That article also quoted from an editorial for the Pennsylvania Journal of the American Osteopathic Association, in which Leonard Finkelstein, DO, president and CEO of the Philadelphia College of Osteopathic Medicine, wrote: "Too many (DOs) hid the fact that they were osteopathic physicians by putting 'Dr.' in front of their name instead of 'DO' behind it."

For years, the chiropractic profession has been struggling to decide how best to resist and combat the medical monopoly. Some want chiropractic to follow the lead of osteopathy and insinuate itself into the medical industry while others wish to retain chiropractic's unique identity and continue offering people a safe and effective alternative to the drug and surgery oriented medical fields.

"As the medical community begins co‑opting spinal manipulation and offering manipulative therapy, chiropractic has only one avenue left if it hopes to survive as an independent and autonomous profession," states Terry A Rondberg, DC, president of the World Chiropractic Alliance (WCA). "We have to emphasize the unique character, purpose and lexicon of chiropractic. We need to 'own' the concept of vertebral subluxation and manual adjusting to maximize health and wellness.

"Right now," he stresses, "everyone ‑‑ DOs, MDs, PTs, and every other health care provider ‑‑ wants to do spinal manipulation. Doctors of chiropractic are the only ones trained and licensed to correct subluxations and if we don't preserve that identity, we'll end up being tossed into the gumbo of 'medical' practitioners. If anyone thinks we'll fare better as subordinates to the medical authorities, they haven't learned from history."