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Special Communication  |   May 2005
Advancing a Traditional View of Osteopathic Medicine Through Clinical Practice
Author Notes
  • From Downriver Cardiology Consultants in Trenton, Mich. 
  • Address correspondence to Felix J. Rogers, DO, Downriver Cardiology Consultants, 2205 Riverside Dr, Trenton, MI 48183-2101.E-mail: fjrogers@aol.com 
Article Information
Endocrinology / Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment / Preventive Medicine / Professional Issues / Diabetes / OMT in the Laboratory
Special Communication   |   May 2005
Advancing a Traditional View of Osteopathic Medicine Through Clinical Practice
The Journal of the American Osteopathic Association, May 2005, Vol. 105, 255-259. doi:10.7556/jaoa.2005.105.5.255
The Journal of the American Osteopathic Association, May 2005, Vol. 105, 255-259. doi:10.7556/jaoa.2005.105.5.255
The lack of a clear definition of osteopathic medicine and a unifying identity for osteopathic physicians has been labeled “the paradox of osteopathy.”1 In an editorial that was published in conjunction with the hallmark 1999 report of original research in The New England Journal of Medicine on the use of osteopathic manipulative treatment (OMT) for low back pain,2 Joel D. Howell, MD, PhD,1 challenged the osteopathic medical profession to define its reputed “distinctiveness.” 
In his editorial, Howell suggested that the direction that would prove most fruitful and “robust” to the profession in supporting its claims of uniqueness would be a demonstration of the value of therapy that is distinctly osteopathic. Howell predicted that “[t]he long-term survival of osteopathic medicine [would] depend on its ability to define itself as distinct from and yet still equivalent to allopathic medicine.”1 He further asserted that a complete defense of the uniqueness of osteopathic medicine should “be articulated not in theoretical terms,” but through treatment outcomes data.1 
In the February 2002 issue of JAOA—Journal of the American Osteopathic Association, several colleagues and I3 proposed a new set of osteopathic tenets and principles for patient care with the hope of promoting discussion and generating additional approaches to defining the distinctiveness of osteopathic medicine. 
Since that time, three articles have been published in The Journal,46 each describing components of the practice of osteopathic medicine that differ from that of our allopathic colleagues. Only one of these articles mentioned the use of OMT,6 and none documented the benefits of OMT using clinical outcomes data. 
Also since 2002, there have also been two new books on osteopathic medicine published.7,8 One of these books is a scholarly report that builds on previous analysis of osteopathic medicine7; the other is a proposal for the application of field theory to define osteopathic medicine.8 
I would suggest that all such discussions on the identity and defining features of the osteopathic medical profession could be grouped into three basic schools of thought: 
  • Fundamentalist—Osteopathic manipulative treatment is both necessary and sufficient for the definition of osteopathic medicine.
  • Traditional—The tenets and principles of osteopathic medicine—first described in 1922 (Figure 1 and Figure 2) and later revised in 1953 (Figure 3) and subsequently in 2002 (Figure 4)—build on early definitions of the practice of osteopathic medicine and are updated to represent the practice patterns of osteopathic physicians, professional publications, and the curricula of medical schools.3,911
  • Progressive—Proposals for the future direction of osteopathic medicine that might be personal formulations and are usually not based on the history of the profession or practice patterns. These proposals are based on theoretical concerns (eg, unified field theory for healthcare, the “divisions of man”).
The fundamentalist view of osteopathy is the one chosen by many osteopathic physicians—and it is frequently invoked by those outside the profession as osteopathy's defining element.1 The reality is that the practice of osteopathic medicine has always been much more than the use of OMT. In fact, The Journal has published survey-based study results indicating that a relatively small number of osteopathic physicians use OMT to treat their patients.12,13 
The traditional viewpoint builds on major position papers and authoritative statements issued within the osteopathic medical profession over the past 80 years. However, proponents of this approach (myself included) must readily admit that such documents,3,14 however well intentioned, have not generated a national dialogue nor been widely adopted within the profession. 
The progressive viewpoint, most recently articulated by McGovern and McGovern,8 is a statement of philosophy and theory that is intended to provide a new paradigm and direction for osteopathic medicine. 
Figure 1.
The 1922 consensus statement on the osteopathic view of the cell as published by the A.T. Still Research Institute in Text Book of the Principles of Osteopathy.9
Figure 1.
The 1922 consensus statement on the osteopathic view of the cell as published by the A.T. Still Research Institute in Text Book of the Principles of Osteopathy.9
An identity for osteopathic medicine is not going to be achieved through discussion or argument among fundamentalist, traditional, or progressive groups. Even if it could, the dominance of one school of thought would not establish the identity nor justify the existence of osteopathic medicine to the outside world: the federal and state governments, insurance carriers, the medical and scientific communities at large, and most importantly, our patients. 
The distinctiveness of osteopathic medicine will be clear when defined by advances in medical education and scientific publication, but the profession will only meet the litmus test of a reformation of medicine if it can demonstrate treatment outcomes in the important public health issues of today's world. Two areas of activity must be pursued: research and clinical practice. 
Osteopathic Research
The Osteopathic Research Center (ORC) at the University of North Texas Health Science Center at Fort Worth—Texas College of Osteopathic Medicine is a new focal point for research on OMT (see http://www.unthsc.edu/orc/default.asp). 
This center—which was launched in December 2001 after receiving a seed grant from the American Osteopathic Association, the American Osteopathic Foundation, and the American Association of Colleges of Osteopathic Medicine—is in the preliminary stages of developing a focused research program to test the efficacy of OMT in patients with pneumonia, back pain from pregnancy, osteoarthritis, and coronary artery disease. 
The ORC has made tremendous strides in the past three and a half years and deserves widespread support within the profession. At the same time, however, advocates for the advancement and acceleration of research in osteopathic medicine must note that the ORC is the first osteopathic research site of its kind and is attached to but one of the profession's 20 colleges (on 22 campuses) of osteopathic medicine. 
Public Health Issues and Osteopathic Medicine
The original impetus for the establishment of osteopathic medicine was to be a reformation of the practice of medicine in the late 19th century. In a society that was primarily agrarian, it is likely that musculoskeletal disorders played a much larger role in healthcare at that time than they do presently. 
Cardiovascular disease (including diseases of the heart, hypertension, stroke, and peripheral vascular disease), cancer, and diabetes account for nearly two of every three deaths in the United States today, however—close to 1.5 million people in 2001.15 These diseases undermine health, shorten life expectancy, and cause enormous suffering and disability, also inflicting great economic cost on families and the nation as a whole. Much of this disease burden could be avoided if there were a systematic application of what is already known about preventing the onset and progression of these conditions. 
By addressing the causes of cardiovascular disease, cancer, and diabetes—and by improving the systems used to detect and treat early-stage disease (ie, when current interventions are most effective)—considerable reduction in disability and premature mortality could be achieved.16 
Despite incontrovertible evidence supporting the medical and economic benefits of prevention and early detection, current disease-control efforts are underfunded and fragmented. As healthcare costs skyrocket, the national investment in all prevention efforts was estimated at less than 3% of the total annual healthcare expenditures.17 
Figure 2.
The 1922 consensus statement on the osteopathic view of the human body as published by the A.T. Still Research Institute in Text Book of the Principles of Osteopathy.9
Figure 2.
The 1922 consensus statement on the osteopathic view of the human body as published by the A.T. Still Research Institute in Text Book of the Principles of Osteopathy.9
Figure 3.
A graphical depiction of the “four general principles from which are derived an etiological concept, a philosophy and a therapeutic technic (sic) that are distinctive,” as described in 1953 by the Special Committee on Osteopathic Principles and Osteopathic Technic (sic), Kirksville College of Osteopathy and Surgery.10 In this illustration, Da Vinci's Vitruvian Man represents the patient. The authors of the 1953 principles10 also noted that these four principles are “not the only features of osteopathic diagnosis and treatment,” however, detailing each element as follows: “(1) The body is a unit, (2) The body possesses self-regulatory mechanisms, (3) Structure and function are reciprocally inter-related, and (4) Rational therapy is based upon an understanding of body unity, self-regulatory mechanisms, and the inter-relationship of structure and function.”
Figure 3.
A graphical depiction of the “four general principles from which are derived an etiological concept, a philosophy and a therapeutic technic (sic) that are distinctive,” as described in 1953 by the Special Committee on Osteopathic Principles and Osteopathic Technic (sic), Kirksville College of Osteopathy and Surgery.10 In this illustration, Da Vinci's Vitruvian Man represents the patient. The authors of the 1953 principles10 also noted that these four principles are “not the only features of osteopathic diagnosis and treatment,” however, detailing each element as follows: “(1) The body is a unit, (2) The body possesses self-regulatory mechanisms, (3) Structure and function are reciprocally inter-related, and (4) Rational therapy is based upon an understanding of body unity, self-regulatory mechanisms, and the inter-relationship of structure and function.”
The American Heart Association, American Diabetes Association, and the American Cancer Society developed a Web site (see http://www.everydaychoices.org) that recommends four key strategies for the prevention of disease: 
  • Eat right,
  • Get active,
  • Don't smoke, and
  • See your doctor.
Cancer, cardiovascular disease, and diabetes mellitus share common risk factors. Healthy eating, avoidance of weight gain, obesity, and tobacco (including second-hand smoke), and regular physical activity have substantial benefits in primary and secondary prevention of these public health problems. 
The Nurse's Health Study18 demonstrated that 82% of all myocardial infarctions in women can be attributed to lifestyle. It is further demonstrated that 91% of all cases of type 2 diabetes mellitus are the result of lifestyle.19 It is clear that there is considerable overlap in terms of risk. 
Among cancer deaths in the United States, 20% to 60% are attributable to diet.20 Physical activity reduces the risk of breast and colon cancer, and it may reduce the risk of several other types of cancer.21,22 Obesity is associated with increased risk of cancer at numerous sites. Diabetes has recently been shown to be associated with increased risk for cancer in a cohort of 1.3 million people with a low rate of obesity.23 As a general statement, medical professionals might counsel patients that 80% to 90% of cases of diabetes mellitus, heart disease, and cancer are caused by lifestyle. 
Appropriate screening and follow-up treatment by physicians can have a major impact in the prevention or reduction of disease burden in the remaining 10% to 20% of patients. For example, a person might be fit, eat properly, and avoid tobacco, but have hypertension and hypercholesterolemia. There are effective treatments for both of these conditions. In other words, nearly every heart attack, most cases of type 2 diabetes mellitus, and most deaths from cancer can be prevented. 
There were two key features of the 2002 Proposed Tenets (Figure 4)3: (1) an emphasis on the primary role of the musculoskeletal system in health and disease, (2) an elaboration of osteopathic principles for patient care that calls for patients to be the focus of healthcare and for physicians and their patients to recognize that each patient has primary responsibility for his or her own health. 
An effective treatment program incorporates evidence-based guidelines, optimizes the patient's natural healing capacity, addresses the primary cause of disease, and emphasizes health maintenance and disease prevention. These are essential elements of an osteopathic approach to the major public health problems of our time. 
The musculoskeletal system plays a surprisingly large role in major public health problems, but it is necessary for osteopathic physicians to expand our perspective beyond a focus on OMT to include exercise and function of the skeletal muscle itself. 
Exercise is often overlooked as an approach to major public health problems because of our national preoccupation with technology and more glamorous approaches. 
However, a recent report24 demonstrated that a 12-month program of regular physical exercise resulted in superior event-free survival and exercise capacity at lower costs when compared with angioplasty and stent in a group of patients with stable coronary artery disease and severe (at least 75%) coronary artery stenosis. The benefits of cardiac rehabilitation exercise have also been documented in the management of patients with coronary artery disease and heart failure,25,26 but rehabilitation continues to be underutilized throughout the country.25,27 
Large-scale epidemiologic studies in subjects with and without cardiovascular disease demonstrate that low aerobic exercise capacity is a stronger predictor of mortality than other established risk factors.2831 In patients with type 2 diabetes mellitus, low aerobic capacity is associated with reduced expression of genes involved in oxidative phosphorylation.32 In insulin-resistant elderly patients, there is a 40% reduction in mitochondrial oxidative and phosphorylation activity largely attributable to impaired skeletal muscle glucose metabolism.33 
Petersen et al34 defined impaired mitochondrial activity in the insulin-resistant offspring of patients with type 2 diabetes mellitus and helped to advance medical understanding of the causation of type 2 diabetes mellitus. The authors hypothesized that insulin resistance occurs in the skeletal muscle and is associated with dysregulation of intramyocellular fatty acid metabolism, possibly because of an inherited defect in mitochondrial oxidative phosphorylation.34 
The key feature of the Petersen et al study was that the subjects were healthy, young, and lean, but physically inactive and insulin-resistant.34 Insulin resistance is believed to represent the precursor of type 2 diabetes mellitus, perhaps by as much as 10 or 20 years. The typical bioenergetic properties of the mitochondria in type 2 diabetes mellitus are also present in obesity.35 
Figure 4.
The 2002 proposed tenets of osteopathic medicine and principles for patient care published in the February 2002 issue of JAOA—Journal of the American Osteopathic Association.3
Figure 4.
The 2002 proposed tenets of osteopathic medicine and principles for patient care published in the February 2002 issue of JAOA—Journal of the American Osteopathic Association.3
In an editorial that accompanied the work of Petersen et al, Taylor links physical inactivity, adiposity, and this mitochondrial defect.36 Physical exercise increases mitochondrial gene expression and oxidative capacity. However, new questions unfold: 
  • Do obese, inactive people who retain normal glucose tolerance lack susceptibility to this abnormality in mitochondrial function?
  • What is the dose-response relationship between the exercise-induced stimulation of mitochondrial activity in the prevention of diabetes mellitus?
The osteopathic profession is well equipped for the comprehensive prevention and treatment of cardiovascular disease, diabetes mellitus, and cancer. Osteopathic physicians have offered patient-centered care for more than a century. By tradition, they have emphasized prevention and the role of the musculoskeletal system. 
Apart from the three major categories of disease described above, there are other important health issues for which the 2002 Proposed Tenets (Figure 4)3 are well matched. These include back and neck pain, degenerative musculoskeletal conditions, falls and subsequent fractures, sports medicine, respiratory disease, and pain management. As part of our emphasis on the musculoskeletal system, osteopathic medicine offers the diagnostic and therapeutic modalities of palpatory diagnosis and manipulative treatment. 
As research programs, like the ones currently underway at the ORC, begin to explore the potentially unique contributions the osteopathic approach can offer in the face of these public health problems, all osteopathic physicians, irrespective of specialty, can demonstrate the importance of the 2002 Proposed Tenets.3 
Advocacy
It is reasonable to assume that the major forces that shape life in the United States will continue to include the pharmaceutical and entertainment industries. Which group will promote lifestyle change—especially exercise and diet as interventions—to prevent the major public health problems of today's world? 
I would suggest that an appropriate advocacy position for the osteopathic profession would be encouraging and promoting such changes among our patients. I would further suggest that this area would be a reasonable, timely, and effective area of emphasis for a profession historically interested in the musculoskeletal system and nonpharmacologic approaches to disease. 
Indeed, such a fundamental reorientation would do much to reestablish osteopathic medicine as a robust participant in the healthcare industry today. 
Howell JD. The paradox of osteopathy. N Engl J Med. 1999;341:1465-1468. Extract available at: http://content.nejm.org/cgi/content/short/341/19/1465. Accessed May 25, 2005.
Anderson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain [published correction appears in N Engl J Med. 2000;342:817]. N Engl J Med. 1999;341:1426–1431. Available at: http://content.nejm.org/cgi/content/abstract/341/19/1426. Accessed May 23, 2005.
Rogers FJ, D'Alonzo GE Jr, Glover JC, Korr IM, Osborn GG, Patterson MM, et al Proposed tenets of osteopathic medicine and principles for patient care. J Am Osteopath Assoc. 2002;102:63–65. Available at: http://www.jaoa.org/cgi/reprint/102/2/63. Accessed May 25, 2005.
Carey TS, Motyka TM, Garrett JM, Keller RB. Do osteopathic physicians differ in patient interaction from allopathic physicians? An empirically derived approach. J Am Osteopath Assoc. 2003;103:303–318. Available at: http://www.jaoa.org/cgi/reprint/103/7/313 Accessed May 31, 2005.
Boulet JR, Gimpel JR, Errichetti AM, Meoli FG. Using National Medical Care Survey data to validate examination content on a performance-based clinical skills assessment for osteopathic physicians. J Am Osteopath Assoc. 2003;103:225–231. Available at: http://www.jaoa.org/cgi/reprint/103/5/225. Accessed May 31, 2005.
Sun C, Desai GJ, Pucci DS, Jew S. Musculoskeletal disorders: does the osteopathic medical profession demonstrate its unique and distinctive characteristics? J Am Osteopath Assoc. 2004;104:149–155. Available at: http://www.jaoa.org/cgi/content/full/104/4/149. Accessed May 31, 2005.
Gevitz N. The DOs. Osteopathic Medicine in America. 2nd ed. Baltimore, Md: The Johns Hopkins University Press; 2004.
McGovern J, McGovern R. Your Healer Within: A Unified Field Theory for Healthcare. Tuscon, Ariz: Fenestra Books;2003 .
Hulett GD. A Text Book of the Principles of Osteopathy. 5th ed. Pasadena, Calif: A.T. Still Research Institute; 1922.
Interpretation of osteopathic concept prepared by committee at Kirskville. Designed for use toward more effective teaching throughout curriculum. (report to Board of Trustees for Kirksville College of Osteopathy and Surgery, Morris Thompson, President, June 1952). J Osteopathy. 1953;60:7 .
Special Committee on Osteopathic Principles and Osteopathic Technic (sic), Kirksville College of Osteopathy and Surgery. An interpretation of the osteopathic concept. Tentative formulation of a teaching guide for faculty, hospital staff and student body. J Osteopathy. 1953;60:8-10.
Johnson SM, Kurtz ME, Kurtz JC. Variables influencing the use of osteopathic manipulative treatment in family practice [published correction appears in J Am Osteopath Assoc. 1997;97:202]. J Am Osteopath Assoc. 1997;97:80 –87.
Spaeth DG, Pheley AM. Use of osteopathic manipulative treatment by Ohio osteopathic physicians in various specialties. J Am Osteopath Assoc. 2003;103:16–26. Available at: http://www.jaoa.org/cgi/reprint/103/1/16. Accessed May 31, 2005.
Hayes OW, Greenman PE. Reprise on a theme: Osteopathic principles for the 21st century [editorial]. The DO. December1993;34:21 –28.
Anderson RN, Smith BL. Deaths: leading causes for 2002. Natl Vital Stat Rep. March 7, 2005;53:1–89. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_17.pdf. Accessed May 31, 2005.
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Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000;343:16–22. Abstract available at: http://content.nejm.org/cgi/content/abstract/343/1/16. Accessed May 31, 2005.
Hu FB, Manson JE, Stampfer MJ, Colditz G, Liu S, Solomon CG, Willett WC. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med. 2001;345:790–797. Abstract available at: http://content.nejm.org/cgi/content/abstract/345/11/790. Accessed May 31, 2005.
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Colditz GA, Cannuscio CC, Frazier AL. Physical activity and reduced risk of colon cancer: implications for prevention [review]. Cancer Causes Control. 1997;8:649 –667.
Friedenreich CM, Courneya KS, Bryant HE. Influence of physical activity in different age and life periods on the risk of breast cancer. Epidemiology. 2001;12:604 –612.
Jee SH, Ohrr H, Sull JW, Yun JE, Ji M, Samet JM. Fasting serum glucose level and cancer risk in Korean men and women. JAMA. 2005;293:194 –202.
Hambrecht R, Walther C, Mobius-Winkler S, Gielen S, Linke A, Conradi K, et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation. 2004;109:1371–1378. Epub 2004 Mar 8. Available at: http://circ.ahajournals.org/cgi/content/full/109/11/1371. Accessed June 1, 2005.
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Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med. 2002;346:793–801. Abstract available at: http://content.nejm.org/cgi/content/abstract/346/11/793. Accessed June 1, 2005.
Kavanagh T, Mertens DJ, Hamm LF, Beyene J, Kennedy J, Corey P, et al. Peak oxygen intake and cardiac mortality in women referred for cardiac rehabilitation. J Am Coll Cardiol. 2003;42:2139 –2143.
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Figure 1.
The 1922 consensus statement on the osteopathic view of the cell as published by the A.T. Still Research Institute in Text Book of the Principles of Osteopathy.9
Figure 1.
The 1922 consensus statement on the osteopathic view of the cell as published by the A.T. Still Research Institute in Text Book of the Principles of Osteopathy.9
Figure 2.
The 1922 consensus statement on the osteopathic view of the human body as published by the A.T. Still Research Institute in Text Book of the Principles of Osteopathy.9
Figure 2.
The 1922 consensus statement on the osteopathic view of the human body as published by the A.T. Still Research Institute in Text Book of the Principles of Osteopathy.9
Figure 3.
A graphical depiction of the “four general principles from which are derived an etiological concept, a philosophy and a therapeutic technic (sic) that are distinctive,” as described in 1953 by the Special Committee on Osteopathic Principles and Osteopathic Technic (sic), Kirksville College of Osteopathy and Surgery.10 In this illustration, Da Vinci's Vitruvian Man represents the patient. The authors of the 1953 principles10 also noted that these four principles are “not the only features of osteopathic diagnosis and treatment,” however, detailing each element as follows: “(1) The body is a unit, (2) The body possesses self-regulatory mechanisms, (3) Structure and function are reciprocally inter-related, and (4) Rational therapy is based upon an understanding of body unity, self-regulatory mechanisms, and the inter-relationship of structure and function.”
Figure 3.
A graphical depiction of the “four general principles from which are derived an etiological concept, a philosophy and a therapeutic technic (sic) that are distinctive,” as described in 1953 by the Special Committee on Osteopathic Principles and Osteopathic Technic (sic), Kirksville College of Osteopathy and Surgery.10 In this illustration, Da Vinci's Vitruvian Man represents the patient. The authors of the 1953 principles10 also noted that these four principles are “not the only features of osteopathic diagnosis and treatment,” however, detailing each element as follows: “(1) The body is a unit, (2) The body possesses self-regulatory mechanisms, (3) Structure and function are reciprocally inter-related, and (4) Rational therapy is based upon an understanding of body unity, self-regulatory mechanisms, and the inter-relationship of structure and function.”
Figure 4.
The 2002 proposed tenets of osteopathic medicine and principles for patient care published in the February 2002 issue of JAOA—Journal of the American Osteopathic Association.3
Figure 4.
The 2002 proposed tenets of osteopathic medicine and principles for patient care published in the February 2002 issue of JAOA—Journal of the American Osteopathic Association.3