OMT Competency and Complications
To the editor,
Zachary Comeau makes the point,[1] perhaps too delicately, that "if the current trend in developing the WHO guidelines for health care workers unfolds showing tiered competencies and credentials for the three categories of Osteopathy, our model [ the U.S. one] may be viewed as deficient compared to both our physician and non-physician counterparts abroad." Yes, yes, American Osteopathic students are responsible for a far broader and deeper field of study that includes all of allopathic medicine, a courageous attempt that may overcome the obvious informational bulimia involved, but what of the comparable skills that make us and them osteopathically unique? The German physicians apparently take some 600 hours of postgraduate training in osteopathic philosophy and technique to gain that extra professional degree; the non-physician English and French programs require 1200 hours, 2400 hours or more of osteopathic training. The American programs? Well, AACOM or COCA hasn't settled on any one number just yet, but the American Association of Colleges of Osteopathic Medicine reports an "average number of OPP contact hours (lecture and lab) of 211, with a range from 160 to 304".[2] Osteopathic students at Kirksville-COM in the 1950's were required to accumulate a log of 500 osteopathic manipulative cases in each of their third and fourth years prior to graduation.[3]
There have been no shortages of committees and recommendations, from "integrating OMM into basic science and all clinical lectures", to stressing "the role of OMM in optimizing systems function, not just for alleviation of motion restriction or pain", but where the rubber meets the road, the degree of comfort with osteopathic skills as self assessed by graduating osteopathic medical students has shown a gradual but steady decline over an extended period of time after the second year.[4], [5], [6] Nowhere, in our opinion, is this more acute than at the postgraduate Training level.[7]
So, it was sad to find out that the West Virginia School of Osteopathy,[8] and quite possibly the New York College of Osteopathic Medicine[9] have discontinued undergraduate teaching of High Velocity Low Amplitude osteopathic technique to the cervical spine. And yet, the AOA Position Paper on Osteopathic Manipulative Treatment of the Cervical Spine states that "all modalities of osteopathic manipulative treatment of the cervical spine, including High Velocity/Low Amplitude, should continue to be taught at all levels of education, and that osteopathic physicians should continue to offer this form of treatment to their patients."[10] Why are certain academnicians not heeding the recommendations of the AOA?
The concern of these teachers and osteopathic schools, is that osteopathic treatment, specifically HVLA, might cause a vertebral or cervical artery dissection; but some would avoid a particular combination of positions altogether, even though muscle energy technique might supply an even greater torque force than artfully applied HVLA.
136 pedestrians were killed in NYC last year, lawfully walking on the streets. For a population of 9,000,000 that is a risk of 1 in 10,000. Should you recommend that persons avoid walking on the streets of NYC, or that all forms of vehicles be banned?
In Haldeman's case series of 64 patients over 16 years, the oldest was 53 y.o. Should the contraindication not extend to those over 53? 4/64 of Haldeman's cases presented with vertigo, one with tinnitus. Will you refer all patients with those symptoms for MRA prior to checking a Dix-Halpike test and treatment with Epley maneuver ? 92% of his cases presented with head or cervical spine complaints, 25% with severe, sudden onset of head and neck pain.[11] Are you going to refer the first group for neurological evaluation, or just the second group? Cases consisted of 41 (64%) females and 23 (36% males).[12] You could cut your risk in half by simply not treating women.
In 39/61 cases the type of manipulation used was defineable; In 51% (or 20) the primary movement was rotation. Traction was used in 5% and non-force techniques were used in 3% – Cranial osteopathic physicians take note.
Will I tell you what your absolute risk for treatment of any kind is? No, no you will have to read the papers and decide for yourself.[13], [14], [15], [16], [17] Students who are anxious to begin with, learning a whole slew of new techniques and paradigms, daring to take up the mantle of physician and healer need a balanced presentation. Limiting students' access practically, or virtually by instilling fear is not the best way to develop Osteopathic thinking physicians. Would you recommend we stop teaching D.O. students pharmacology because hundreds of thousands are directly injured or killed by their use each year?
Those teachers who advocate minimizing teaching of HVLA need to look quietly into their own hearts to see whether their fear of inadequacy in that technique is being transferred to a more generic and far less realistic fear of risk to patients. The risk for a patient presenting with an evolving cervical artery dissection is not significantly less for a physician practicing only Osteopathy in the Cranial Field than it is for one practicing a more eclectic approach. Cranial osteopathy was not taught to undergraduates for almost 40 years because certain academnicians who were unskilled at it thought it was voodoo. Today, a new generation of unskilled or fearful academics say HVLA is too dangerous to teach. The world will and must move away from a disease model to a more preventive, dare we say "Osteopathic" model. Let us not abdicate the full teaching of this tried and true technique at this critical juncture.
Digging on,
John H. Juhl, D.O.
Gary L.Ostrow, D.O.
Mikhail Gleyzer, M.D., D.O.
William F. Morris, D.O.
Denise K. Burns, D.O.
Amy Davison, D.O.
Contact person:
John H. Juhl, D.O.
drjuhl@drjuhl.com
(212) 838-8265
[1] Comeau Zachary, United States Osteopathic Education; The challenge of Globalization, The AAO Journal, V18 #3, Sept 2008, p 11-15.
[2] 2003-4 Annual Survey, American Association of Osteopathic Colleges of Osteopathic Medicine.
[3] Stookey James R, Andrew Taylor Still Memorial Address: Lessons from Mecca, The DO, September 2000, p 58-63.
[4] Gamber Russell G, Gish EE, Herron KM, Student perception of osteopathic manipulative treatment after completing a manipulative medicine rotation, JAOA, July 2001;V 101 # 7; p 395-400.
[5] Jones John M, Presidential Address, The AAO Journal, Summer 2000, p. 9-12.
[6] Acunto Brian, Careless abandonment of osteopathic identity or lask of instillation in medical school?, JAOA letters, Dec 2001; V 101 # 12: p 698-9.
[7] Essig-Beatty David R, Klebba GE, La Pointe NR, Miller ED, Strong RE, Decline in structural examination compliance in the hospital medical record with advanced training, JAOA, Spet 2001;V 101 # 9: p 501-8.
[8] Conversation, WVCOM OMM staff, 4-29-09.
[9] NYCOM Lab Worksheet on Cervical Diagnosis Review and Cervical FPR “CAVEAT: For cervical spine evaluation and treatment, one should NOT extend, sidebend and rotate the cervical spine simultaneously, in order to avoid vertebral artery compromise.”
[10] AOA Position paper on Osteopathic Manipulative Treatment of the Cervical Spine, www.do-online.org.
[11] Haldeman Scott, Kohlbeck FJ, McGregor Marion, Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy, a review of 64 cases… SPINE, 2002; v 27 # 1, P49-55.
[12] Haldeman Scott, Kohlbeck FJ, McGregor Marion, Stroke, cerebral artery dissection, and cervical spine manipulation therapy, J Neurol, 2002;249: 1098-1104.
[13] Jamieson Dara G, Lean, Lanky, Smoky, Headachy: At risk for Cervical Artery Dissection? Neurology Alert, April 2009.
[14] Rubenstein Sidney M, Peerdeman SM, et.al., A Systemic review of the risk factors for cervical artery dissection, Stroke, 2005;36:1575-1580. Further, Letters to the editor, Stroke, p 2340-43.
[15] Kerry, Roger, Taylor, Alan J, Mitchell, Jeanette, McCarthy, Chris, Cervical arterial dysfunction and manual therapy: a critical literature review to inform professional practice, Manual Therapy,2008, doi:10.1016/j.math.2007.10.006.
[16] Gibbons Peter, Tehan Philip, HVLA thrust techniques: What are the risks?, Int Journal of Osteopathic Medicine 9, 2006, p4-12.
[17] Leon-Sanchez Andres, Cuetter Albert, Ferrer Gustavo, Cervical Spine manipulation: An Alternative Medical procedure with Potenetially fatal Complications, Southern Medical Journal, Feb 2007;v 100 # 2, p 201-203.