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Letters to the Editor  |   May 2011
Are Clinical Protocols for Osteopathic Manipulative Procedures Truly “Osteopathic”?
Jonathon R. Kirsch, DO
Author Affiliations
  • Jonathon R. Kirsch, DO
    American Osteopathic Association Board Certified in Neuromusculoskeletal Medicine/Osteopathic Manipulative Medicine; Director, Osteopathic Principles and Practice, A.T. Still University of Health Sciences-School of Osteopathic Medicine in Arizona, Mesa
Article Information
Osteopathic Manipulative Treatment / Professional Issues
Letters to the Editor   |   May 2011
Are Clinical Protocols for Osteopathic Manipulative Procedures Truly “Osteopathic”?
The Journal of the American Osteopathic Association, May 2011, Vol. 111, 322-347. doi:https://doi.org/10.7556/jaoa.2011.111.5.322
The Journal of the American Osteopathic Association, May 2011, Vol. 111, 322-347. doi:https://doi.org/10.7556/jaoa.2011.111.5.322
To the Editor:  
Clinical protocols for osteopathic manipulative treatment (OMT) procedures have been used in “technique” studies to examine the effects of specific procedures. Such studies, writes Michael M. Patterson, PhD,1 are “useful in instances where there may be reason to suspect that a specific manipulative technique would change a particular condition.” I would like to raise a concern regarding whether these technique studies, which are not based on medical histories or physical examinations, are ideal in terms of supporting osteopathic concepts and the practice of distinctive osteopathic medicine. In my opinion, in technique studies based on protocols for OMT procedures, manipulations are not delivered in a manner consistent with osteopathic principles, and there may be unforeseen consequences of such research—whether findings for the procedures are positive or negative. 
Dr Patterson2 has explained that “there are basically two types of studies of osteopathic manipulation: (1) technique studies... and (2) studies of osteopathic manipulative treatment.” In a technique study, a specific OM procedure is studied for its effects on a target problem. By contrast, in a study of OMT, the full range of OMT procedures are available, and the application of a specific technique depends on a thorough physical examination of the patient by the osteopathic physician. 
Osteopathic manipulative treatment is defined as the “therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction.”3 American Osteopathic Association (AOA) protocols for the use of OMT state that the “diagnosis must be specific.”4 Once a diagnosis is made, the osteopathic physician “determine(s) the appropriate techniques and treatment.” Furthermore, an evaluation and management service code requires a “history, examination, and medical decision making,” all of which must be documented in the medical record.4 Thus, by definition, OMT is directed toward removing the somatic dysfunctions that are inhibiting the body's function and self-healing mechanisms. When treatment in a clinical technique study is not based on the findings of a patient's medical history and physical examination, how can we be practicing osteopathic medicine or be studying the effects of a truly osteopathic manipulative procedure? 
In the present letter, I examine each of the tenets of osteopathic medicine5 as they relate to standardized clinical protocols for OMT procedures. 
  1. The body is a unit; the person is a unit of body, mind, and spirit.
    The first part of this tenet notes that the body is a unit, meaning that the body's structure and systems function together as a unit. Structure and function interact and are unified through myriad relationships and mechanisms, and in some cases, the real source of the patient's problem is anatomically distant from the area prompting the complaint. Although there are many parts to the body, “the osteopathic physician refrains from selecting any part above the whole.”6
    How can a technique study adequately address specific somatic dysfunctions that are inhibiting the body's ability to function when those dysfunctions are not included in the protocol used in the study—or when the dysfunctions are not even located in the area of complaint?
  2. The body is capable of self-regulation, self-healing, and health maintenance.
    Irvin M. Korr, PhD,7 discusses this tenet as recognizing the inherent healing power of the body as well as the body's ability to maintain homeostasis and to defend itself from outside challenges through immunity. Dr Korr terms this combination of abilities the “internal healthcare system.”7 Certain OMT protocols support these self-healing mechanisms through the use of manipulative procedures that correct somatic dysfunction or assist the autonomic or lymphatic systems.
    However, an OMT protocol may not address the areas of the somatic dysfunctions—whether primary or secondary—that are most inhibiting to the patient's self-regulatory mechanisms. For example, in lymphatic OMT procedures, treatment “should begin with the removal of all restrictions resulting from tissue hypertonicity that may be affecting lymph flow.”8 Without the guidance of a medical history and physical examination of the patient, how can the osteopathic physician direct treatment specific to that patient?
  3. Structure and function are reciprocally interrelated.
    This tenet addresses the interaction of the musculoskeletal system with the physiologic systems of the body. The tenet broadly states that the structure of the body affects its function, and the function of the body affects the structure. As noted by DiGiovanna et al,6 “As structure governs function, similarly, abnormal structure brings about dysfunction.” Clinical protocols for OMT procedures will certainly affect the musculoskeletal system. However, depending on the locations of the somatic dysfunctions, the main structural elements that are in need of change and that are affecting the patient's function most may be completely untouched by the protocol.
    In addition, if standardized amounts of force are stipulated by a given protocol, there may not be sufficient personalized application of force to correct a somatic dysfunction in a patient. For example, if 15 pounds of force were required to lift a section of ribs and affect change at the sympathetic chain ganglia of a patient, but the clinical protocol stipulated 5 pounds of force be used in the rib-raising procedure, then the technique would not be effective.
  4. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.
Clinical protocols for OMT procedures face a challenge in adhering to this tenet. By their very nature, standardized protocols are not able to meet the specific clinical needs of a patient because patients cannot be standardized. Protocols cannot fully address a patient's body unity because they are not based on the patient's physical examination or medical history. Protocols cannot fully address the structure-function tenet because they are not necessarily aimed at the key structural issues involved in each case. Protocols cannot fully assist the patient's self-healing mechanisms and abilities because they do not adequately address the structure and function of the body as a unit. 
Reimbursement Considerations
If clinical protocols do not represent truly osteopathic treatment, then technique studies using protocols for OMT procedures may not accurately reflect the efficacy of the procedures. Negative outcomes in technique studies may not be conclusive relative to the value of those same techniques when applied in the context of a visit to an osteopathic physician. Nevertheless, although the difference between technique studies and OMT studies has been discussed in the literature,2 it seems clear that results from technique studies are generally seen as reflective of the actual efficacy of those treatments when used in practice. If this perception occurs, then negative results in a technique study could create a negative impression regarding the efficacy of OMT and distinctive osteopathic practice, which could have insurance reimbursement ramifications. 
Furthermore, positive outcomes in technique studies may send the message that a medical diagnosis of somatic dysfunction is not necessary when applying an OMT procedure in the clinical setting. Osteopathic physicians billing for OMT routinely receive insurance statements denying evaluation and management codes, often accompanied by the explanation that a diagnosis is not necessary to deliver OMT. Research outcomes that inadvertently support this mistaken argument would seem to work against efforts made by our state and national associations to improve access to distinctive osteopathic healthcare. 
Conclusion
The application of standardized clinical protocols for OMT procedures may not be consistent with personalized treatment in osteopathic medicine that is customized for each patient and his or her specific dysfunctions. Breaking down each of the elements in the overall clinical approach to OMT may be akin to trying to separate out the ingredients of a therapeutic herb in order to discover which ingredient is the active one. By isolating individual OMT techniques from a comprehensive osteopathic approach, the techniques may cease to be osteopathic treatment at all. 
I agree with Dr Korr9 that “[i]t is essential... that assessments of effectiveness of OMT be of OMT as it is practiced, as an integral part of the total interaction between physician and patient, and not as an isolated, contrived, and standardized procedure.” In my view, only by studying truly osteopathic manipulative treatment—based on an understanding of the tenets of osteopathic medicine5 and directed by a patient's medical history and physical examination—do we have the opportunity to demonstrate, with evidence, the true power of the unique healthcare approach that we in osteopathic clinical practice see every day. 
Ward RC, ed. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003: 1173.
Patterson MM. “Techniques” versus “treatment” in osteopathic manipulation [editor's message]. J Am Osteopath Assoc. 2002;102(7):375 .
Glossary Review Committee for the Educational Council on Osteopathic Principles and the American Association of Colleges of Osteopathic Medicine. Glossary of Osteopathic Terminology. July 2006.
American Osteopathic Association Division of Socioeconomic Affairs. Protocols for Osteopathic Manipulative Treatment (OMT). Chicago, IL: American Osteopathic Association; July 1998.
Tenets of osteopathic medicine (consensus statement approved at annual meeting of American Osteopathic Association House of Delegates, July 2008). American Osteopathic Association Web site. http://www.osteopathic.org/index.cfm?PageID=ost_tenet. Accessed October 11, 2010.
DiGiovanna EL, Schiowitz S, Dowling DJ, eds. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:10-11.
Ward RC, ed. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003: 15.
Ward RC, ed. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003: 1062.
Korr IM. Osteopathic research: the needed paradigm shift. J Am Osteopath Assoc. 1991;91 (2):156-171.