Osteopathic medicine as we know it begins with Andrew Taylor Still, M.D. (1828 – 1917), who introduced its concepts in 1874. Still’s basic idea — that the human body was much like a machine, one that would function well if all its parts were in proper mechanical relationship — was unique compared to the medical thinking of the time.
Doctor Still was a frontier doctor, and had trained like most physicians of his time – through apprenticeship, with some formal medical training added later. Still received a good deal of this apprenticeship training from his father, who was a physician as well as a minister in the Methodist Church. In addition to the private practice of medicine, Still also ran a farm and did mechanical work (he had received some formal schooling in mechanical engineering). Later in his career he served as a medical officer for the Union Army during the Civil war. He was also greatly influenced by the philosophy of Herbert Spencer. Still was particularly impressed with Spencer’s ability to explain the concepts of cause and effect, structure and function, the holistic nature of organisms, and the interrelatedness of parts.
Other life experiences eventually helped Still shape his philosophy of medicine. For example, as a youth he suffered from headaches, and though obviously not understanding it at the time, he discovered a method of treatment that he would later refer to as his first experience with the science of osteopathy. One day, when he was suffering from a headache, he got the idea to lower a rope swing to about 8 – 10 inches from the ground, threw a blanket over the rope and then laid down on the ground, using the rope swing as a pillow. He fell asleep, and later when he awoke he discovered that his headache was gone. Still later came to realize that, in treating his own headaches, he was doing something to alter the structural relationships of his body which somehow improved its function. Another major event that greatly influenced Still was an outbreak of spinal meningitis that occurred in 1864. Being a physician with all the medical knowledge of the time available to him proved to be of no value to Doctor Still. There simply was no treatment available to help him save the lives of three of his children. This loss caused him to become a driven man, searching for a better way to practice medicine. He dedicated himself to the study of the human body, and spent much of his time reviewing the elements of anatomy, physiology and chemistry. Believing that the human body contained with in it all the remedies it needed to maintain health, Still’s goal was to discover these remedies, and learn to utilize them to maximize the body’s self-healing capabilities.
Doctor Still gradually formulated the ideas that would become known as Osteopathy, or as currently termed, Osteopathic Medicine. He believed that all elements of a person’s body, mind and spirit had to be incorporated into the total care of that person. He believed that the body had self-regulatory and self-healing powers, that the body contained within it all the substances necessary for maintaining health. When the body was properly stimulated, Still believed that these substances would also assist in recovering from illness. He began to view the body as a machine – a machine that would function at its optimum level only when all its parts were in proper relationship to one another. Doctor Still no longer viewed disease as an outside agent somehow inflicting itself on the body. Rather, disease was the result of alterations in the structural relationships of the body parts that led to an inability of the body to resist or recover from illness.
Still applied this philosophy to his medical practice with great success, while continuing to prudently utilize the medical and surgical approaches available to him. As a result of his years of study, and the application of his ideas to his practice, he was able to leave us with a set of general principles that are still central to the contemporary practice of osteopathic medicine. His success led him to start the first osteopathic college, the American School os Osteopathy, in Kirksville, Missouri in 1892.
- The Unity of the Body
- Self-regulatory and Self-healing Systems
- The Relationship Between Structure and Function
- Rational Treatment Approach
The first of the major principles of osteopathic medicine is that the human body is a unit, an integrated organism in which no part functions independently. This regulation, coordination and integration of the body through multiple biological systems is often referred to as the principle of body unity. According to this principle, abnormalities in the structure or function of one part of the body may unfavorably influence other parts, and eventually, the body as a whole. Thus the body is viewed as an interrelated group of organ systems, each one dependent on the others, and each one compensating along with the others in order to meet the demands of the internal and external environments of the body.
Doctor Still believed that diseases affecting the viscera of the body would also affect the musculoskeletal system. Similarly, abnormalities in the structure or function of the musculoskeletal system could also adversely affect the viscera. Until Still’s time, treatment of disease was focused on individual organs or organ systems. Consideration was not given to the musculoskeletal system, which in itself comprises more than sixty percent of the body’s mass. Doctor Still recognized the importance of the musculoskeletal system and its relationship to health and disease, and added the treatment of this system to his use of traditional methods such as pharmaceutical agents and surgery.
In spite of recent increased interest in holistic approaches to patient care, there is still a common tendency among physicians to isolate illness within a certain organ or system in the body. The osteopathic physician, however, is trained to recognize that when the body is sick, it is sick all over. A specific organ or system may become the prime focus of illness, but the effects of that illness can be felt in some degree throughout the entire body.
In a similar fashion, when responding to an illness, the specific organ or system does not operate alone. The entire body, by way of the circulatory, nervous, endocrine and immune systems, is brought into action in a concerted effort to overcome the body-wide effects of the illness. Only when the whole body has returned to its normal balance has the alleviation of illness truly been achieved.
Still’s concept of holism, however, went beyond the idea of the human body as a unit and included a holism of body, mind and spirit. Doctor Still strongly believed that all pertinent aspects of the human being (physical, mental, emotional, spiritual, psychological, environmental, and others) had to be taken into consideration when the physician was faced with a patient needing treatment. Thus, for A. T. Still, holism was more than an open-mindedness to other forms of diagnosis and treatment. Rather, it was an approach to the patient that required the physician to consider the totality of the human being when diagnosing illness or planning treatment.
The second major principle of osteopathic medicine is that the body has an inherent capacity to maintain its own health and to heal itself. By extension, this principle implies that there must be adequate circulation to and from all tissues of the body, and there must be proper nervous system function in order to coordinate the actions of all of the body’s organs and systems.
Still believed that the body contained within itself all that it needed to either be healthy, or, if ill, all that it needed to overcome the illness and return to a healthy state. The job of the osteopathic physician was to help the body utilize its own self-healing mechanisms to overcome disease and maintain health.
Physicians in the mid to late 1800’s understood that the immune system functioned to provide for natural and acquired immunity, to help maintain wellness, to assist in the repair of damaged tissues, and to help the body compensate for irreparable damage. In spite of limited scientific proof at the time, Doctor Still grasped the complex interaction of the nervous, endocrine and immune systems in providing a mechanism for the body to maintain its own health and to self-heal. He saw the duty of the osteopathic physician as one of assisting the body in this endeavor. He understood that the body did not simply exist in a state of health or illness, but was engaged in an ongoing struggle with the demands of its external and internal environments. The body constantly attempts to resist, neutralize or overcome the various stresses to which it is exposed. The degree to which the body is successful in these attempts determines its state of health. If the body can handle stressors without excessive demand on itself, then it remains healthy. However, if some discord within the body or a force in the external environment obstructs its adaptability, then disease and illness can occur.
The third basic osteopathic principle is that structure and function are interrelated, that the musculoskeletal system can reflect changes in and can produce changes in other body systems. Doctor Still placed great importance on the role of the musculoskeletal system in health and disease. The interrelationship between structure and function is one of the most unique aspects of osteopathic medicine.
Still considered the human body to be a machine. He knew that a machine’s parts had to be assembled in the proper order for the machine to operate effectively. If the machine was not functioning properly, the parts had to be adjusted until it did. Still decided that the human body could work the same way. He saw that the musculoskeletal system (bones, muscles, ligaments and connective tissues) was the largest collective system of the body, making up 60 percent or more of the body’s mass. Through careful study and experimentation, he was able to associate abnormalities in the structural system of the body with signs and symptoms of various diseases. He developed manipulative methods (now known as osteopathic manipulative treatment) to remove these structural abnormalities to alleviate the patient’s illness. These experiences led Still to believe that diseases, as we commonly think of them, were really the result bodily malfunctions, not the cause of them. Often that bodily malfunction was an abnormality in the musculoskeletal system, which decreased the ability of the nervous and/or circulatory systems to function properly. Osteopathic physicians refer to these abnormal areas in the musculoskeletal system as “somatic dysfunctions”, defined as “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.” These are palpable areas, in the spinal muscles, that can be associated with organ diseases as well as common musculoskeletal problems.
A. T. Still’s recognition that the musculoskeletal system has an important role in health and disease was a revolutionary concept. His discovery that the use of manipulative methods could assist the patient in recovering from illness, often with little or no use of drugs or surgery, is one of his most important contributions to the practice of medicine. Using this knowledge of the interrelationship of structure and function, and the techniques of osteopathic manipulation, the DO has knowledge of a unique system of diagnosis and treatment. This approach alone can often assist patients in recovering from illness. At other times, it allows for recovery with little or no medication, and in some cases may help the patient to avoid surgery.
The fourth basic principle of osteopathic medicine is that rational treatment is based upon integration of the first three principles into the total care of the patient. Thus treatment is based on the principles of body unity, self-regulatory and self-healing mechanisms, the somatic component of disease, the interrelationship between structure and function, and the appropriate use of manipulative treatment.
What an osteopathic physician does for a patient (aside from the use of osteopathic manipulative treatment) is often not different from what any physician might do when faced with a similar situation. What is different about the osteopathic physician is how he or she thinks about health and disease. The difference is found in the previously described philosophical concepts and principles of osteopathic medicine.
THE OSTEOPATHIC VIEW OF HEALTH AND DISEASE
When the human being is viewed in light of osteopathic principles the perception of the health-disease continuum changes. Osteopathic principles allow the physician to consider all aspects of the patient, not just the symptoms. The osteopathic physician sees the integrated nature of the various organ systems and body’s capabilities for self-regulation and self-healing. These principles acknowledge the importance of the musculoskeletal system and its role in health and disease.
The body, through its own regulatory mechanisms, constantly attempts to maintain itself in a state of health. At the same time, the body is subjected to various stressors which threaten this healthy state. These stressors may come from various sources and may include biological, behavioral, social, spiritual and environmental factors. The presence of somatic dysfunction may also interfere with the body’s ability to maintain health and resist illness.
Under normal circumstances, the body’s own self-regulatory and self-healing mechanisms are able to counteract these stressors and thus maintain health. However, should stressors accumulate to the point where these mechanisms are overwhelmed, the body’s inherent tendency toward health is weakened. Continuation of this process over time leads to the signs and symptoms of illness. The osteopathic physician recognizes that these signs and symptoms are not the illness itself, but are only the outward signs of the illness. The illness is the result of the stressors’ impact on the body’s systems. Treatment must be directed toward the stressors, as symptomatic treatment alone will not guarantee the restoration of health.
At this stage, external resources are needed to help the patient recover from the illness. The osteopathic physician can assist the patient by helping to reduce or eliminate the stressors, including somatic dysfunction. When this is achieved the body’s self-regulatory and self-healing capacities can regain their normal function, and the body can be restored to health. The body’s inherent regulatory mechanisms are then able, once again, to maintain this healthy condition. Thus the osteopathic physician does not view himself or herself as a “healer”, but as one who works with the patient to facilitate that patient’s inherent tendency toward health.
How does the osteopathic physician apply OPP in the care of patients? Remember that we define osteopathic medicine as a complete system of medical care with a philosophy that combines the needs of the patient with the current practice of medicine, surgery, and obstetrics; that emphasizes the interrelationship between structure and function; and that has an appreciation of the body’s ability to heal itself. Based on this definition, osteopathic medicine defines a distinctive set of tenets which osteopathic physicians use to formulate their approach to patient care. These tenets are:
- A person is the product of dynamic interaction between body, mind, and spirit
- An inherent property of this dynamic interaction is the capacity of the individual for the maintenance of health and recovery from disease
- Many forces, both intrinsic and extrinsic to the person, can challenge this inherent capacity and contribute to the onset of illness
- The musculoskeletal system significantly influences the individual’s ability to restore this inherent capacity and therefore to resist disease processes
From these tenets the osteopathic physician derives certain principles for patient care. These principles state that 1) the patient is the focus for healthcare; 2) the patient has the primary responsibility for his or her health; and 3) an effective treatment program for patient care is founded on the above-mentioned tenets.
Thus the osteopathic physician uses a health-oriented and patient-centered philosophy to implement the principles of osteopathic medicine in the care of the patient. The osteopathic physician’s goals are to:
- Seek out and address the root cause(s) of disease using available evidence-based approaches
- Optimize the patient’s self-regulating and self-healing capacities
- Provide an individualized patient management plan that includes emphasis on health promotion and disease prevention
- Include palpatory diagnosis and osteopathic manipulative treatment to address the somatic component of disease the extent that it influences the well-being of the patient
On a practical level, the osteopathic physician may organize osteopathic philosophy and principles according to a conceptual framework organized into five areas, often referred to as five models, for consideration. , These models are: mechanical, neurologic, respiratory-circulatory, metabolic-nutritional and biopsychosocial. Each model allows the osteopathic physician to consider:
- How the elements of the particular model are affecting, or being affected by, the patient’s condition by contributing to the overall level of demand on the patient
- Treatment options applicable to the particular model, including osteopathic manipulative treatment (OMT)
- Patient education and preventive measures relative to the specific model
The Mechanical Model
This model deals with factors that alter posture, motion and gait. These factors include altered joint relationships, muscle imbalances (hyper- and hypotonicity), and abnormal fascial tensions. These somatic dysfunctions can cause or contribute to adverse neurologic and circulatory functions. The energy demands of the body’s attempt to cope with abnormal mechanical stresses can be part of the overall load contributing to arterial hypertension. The goal of treatment within this model is the restoration of free motion within the body’s musculoskeletal system elements. A wide range of osteopathic manipulative treatment (OMT) techniques can assist in alleviating these stressors. These OMT techniques include: high velocity-low amplitude, muscle energy, articular and functional techniques, among others.
The Neurologic Model
The neurologic model deals with the effects of facilitated spinal cord segments and sustained symphaticotonia, resulting in viscerosomatic and somatovisceral reflex phenomena. Goals of treatment within this model include: restorating autonomic balance, alleviation of segmental facilitation, decreasing or eliminating abnormal afferent signaling, and relief of pain. Various OMT techniques can be used here, but some modalities that are thought to be especially effective within the neurological model include counterstrain and the treatment of Chapman reflex points.
The Respiratory-Circulatory Model
This model addresses altered respiratory mechanics which may predispose to congestive changes, decreased lymphatic flow, venous return and edema formation. These adverse changes can lead to insufficient oxygen and nutrient distribution to tissues, reduced venous and lymphatic return, impaired immune system function and insufficient removal of metabolic waste products from the body. The treatment goal within this model is to restore the body’s ability to adequately move air and fluids throughout its systems. Somatic dysfunctions relative to this model include altered rib cage mechanics and restricted motion of the thoracic diaphragm and other functional diaphragms of the body. Commonly used OMT modalities for this model include osteopathy in the cranial field, myofascial release and lymphatic pump techniques.
The Metabolic-Nutritional Model
The metabolic-nutritional model takes into consideration such things as dietary deficiencies and excesses, food allergies, the effect of toxins, and any other factors that may affect the self-regulatory and self-healing mechanisms of the body. Treatment goals for this model include promoting energy conservation by balancing the body’s energy expenditure and exchange, and enhancing immune system function. In this model a major emphasis is on such things as nutritional counseling, dietary advice, avoiding of obesity and encouraging exercise. Lymphatic pump techniques can be useful here, as they have been shown to positively affect the immune system.
The Biopsychosocial Model
In this model, we consider the psychological and social components of the patient’s health status. Some of these components include the patient’s spiritual outlook, social support system, ability to cope with stress, and ability to make healthy lifestyle choices. In particular, stress is a well known cause or contributor to hypertension. Thus, reduction of stress factors can contribute to the ultimate control of hypertension in some patients. The treatment goals for this model include optimizing the psychological and social components of the patient’s overall health. This might include teaching the patient strategies for stress reduction, helping the patient improve his or her abilities for social interaction, and helping the patient improve his or her spiritual outlook. OMT is not commonly a part of the treatment approach in this model, although some osteopathic physicians advocate the use of OMT to improve autonomic balance for these patients, thus secondarily helping to relieve stress on the body.
THE OSTEOPATHIC PROFESSION TODAY
- Colleges of osteopathic medicine are graduating more and more students each year. More than 4,200 new osteopathic physicians enter the workforce each year.
- The nation’s approximately 63,000 fully licensed osteopathic physicians practice the entire scope of modern medicine, bringing a patient-centered, holistic, hands-on approach to diagnosing and treating illness and injury.
- Today, more than 20 percent of medical students in the United States are training to be osteopathic physicians.
- Osteopathic physicians can choose any specialty, prescribe drugs, perform surgeries, and practice medicine anywhere in the United States.
- Osteopathic physicians bring the additional benefits of osteopathic manipulative techniques to diagnose and treat patients.
- Osteopathic physicians work in partnership with patients to help them achieve a high level of wellness by focusing on health education, injury prevention, and disease prevention
Osteopathic medicine distinguishes itself as a complete system of prevention, diagnosis and treatment based on a “whole person” approach. Its philosophy is based on the principles of the unity of the human body, the body’s ability to regulate and heal itself, the somatic component of disease, the interrelationship of structure and function, and the use of manipulative treatment in the total care of the patient.
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Page content contributed by: Raymond J. Hruby, DO, MS, FAAO
Copyright 2000, 2007, 2014 by Raymond J. Hruby, DO, MS, FAAO