When I talked with Ben Greene for his Osteopathic Manipulative Medicine (OMM) Podcast a few weeks ago, we got into a conversation about whether OMM is a procedure or a process, and it has been on my mind since. OMM is a field in Osteopathic Medicine, and it is my specialty. It has been both a vehicle and destination for me to learn the process of helping patients get from illness to health.
When I talked with Ben about my work in the research field of validating physical exam findings, I said it helped me to see the inherent subjectivism in physical diagnosis, which is a keystone of OMM. Osteopathic Manipulative Treatment (OMT) is taught as a procedure one performs to treat the diagnosis of Somatic Dysfunction. I also learned and performed many procedures for other diagnoses in surgery, obstetrics, emergency medicine, etc. I think of them as different than performing OMT. What is different is the key to why I see OMM as a process and not a procedure.
Let’s take the procedure for putting in a central line. There is an indication (need for access) followed by a series of steps that are done the same way every time. The prep, the creation of a sterile field, and the setup of the needed equipment. Then, each time you do the procedure, you identify the structure you wish to access and proceed to use the same equipment, technique, order of steps or sequence, finally using an accepted method of confirming that you have done what you intended and can use the access to monitor, give fluids, whatever the purpose of the action intended. Once a procedure has moved into the mainstream as an ideal way to accomplish a goal, all surgeons in training are taught how to do it that way. Variation from the norm is not encouraged or necessary.
How is OMM different? The answer goes back to a fundamental difference in philosophy between Osteopathy and Medicine that was a prominent point of contention at the beginning of our profession. The Founder of Osteopathic Medicine lived in the 1800s, and his name was Andrew Taylor Still. In A. T. Still: From The Dry Bone to the Living Man, a biography of A.T. Still by John Lewis, published 10 years ago, much is said about our founder’s conception of the “Osteopathic Lesion.”That term has been replaced by Somatic Dysfunction today. It has fired my imagination over these few weeks of reading. His conception was not the way we today think of a structural lesion. It was a more dynamic and fluid concept of an outwardly discernible manifestation of an internal derangement within the patients’ body. It was an inclusive definition encompassing all the elements we use when we define Somatic Dysfunction today (impaired or altered function of one or more components of the musculoskeletal system (skeletal, ligamentous, myofascial) and its related neural, vascular and lymphatic components) But he saw more deeply that the emotional, mental, and spiritual elements involved in the context of a patient’s life were literally a palpable and discernible finding that manifested in the body as well. The answer was to be found in the patient’s body, the abnormal alteration in anatomy that caused a dysfunction of the natural ability of the body to heal itself.
He was also ahead of his time in his conception of cause and effect, which he spoke of frequently. What I found fascinating was that he did not see it simply as a linear function, such as “If this happens, then that will occur,” but saw it as a two-way street, more like an infinite set of contingencies far too complex to line up in a “this causes that” kind of way. He had the consciousness to perceive what we today refer to as the butterfly effect, the oft heard analogy in systems and chaos theory (def: property of chaotic systems (such as the atmosphere) by which small changes in initial conditions can lead to large-scale and unpredictable variation in the future state of the system). His focus on cause was the most intense thing about him; he searched for understanding of cause his whole life. He considered disease an effect and was strongly influenced by Virchow’s concept of terrain, the state of a person which makes them vulnerable to disease. Hence, his focus was on the vitality and life force, nerve and blood supply and return from an affected area in the person being treated. He looked for the altered terrain within people that got in the way of their ability to manifest health. He did not teach a specific technique or procedure to fix it when you found it, either. The method of restoring the body to normal depended on the nature of the lesion.
I genuinely enjoyed learning more about this remarkable man; his curiosity and courage to forge new pathways in medical practice inspires me today. My job as an “Osteopath” is fun, creative, and never boring. Each day brings different people with different problems to work on, puzzles to solve. The most important thing about the process is the listening and seeing with all my faculties. As I hear their words, see how they move, and feel their tissues, my consciousness is honed on finding what is needed for them to move toward healing. The treatment part of a visit using the hands as well as my presence and use of words follows from the understanding of what I am seeing, feeling, and hearing. I work to bring the body into more coherence, make the connections, improve the relationships between the parts. I rarely treat the somatic dysfunction I find the same way I did on the other patients of that day; the way I do it depends upon the patient’s body habitus, my sense of what layer or layers the dysfunction is manifesting in, and a host of other variables that are specific for that day. Patients often comment on the fact I never do things the same way from visit to visit, and I challenge myself to find new ways of treating any somatic dysfunction I find that is most appropriate for that time and place.
So, when I say it is a process, it is for me involving several elements:
What I see, hear, and find with my hands on that day, and how their body is responding to the questions I ask it with the movements I take them through.
Where the patient is in the context of the illness they have; how far along in the healing process affects what I choose to do at that point in the journey.1. How much involvement the patient has in their own healing; I work to involve them more and more as they get better.
The clarity I have with what I am perceiving influences how I perform the OMM treatment; if I am not seeing clearly, I keep asking questions (not necessarily just with words but also with my listening hands) until I get a clearer picture.
The way I use my hands to bring improvement in function will be different based on the patient, so OMT is patient-centric rather than procedure specific.
Therefore, for me OMM is an ongoing conversation with the patient, a dialogue between all the aspects of my being and all the aspects of their being. I use what I know, the skills I have, and I bring all of myself fully focused to the interaction. An admirable aspect of A.T. Still was that he was humble and perceived his work as an agent in the service of healing. I participate with the patient in a process that is first and foremost a partnership in the service of healing. I use all the faculties available to me, including intuition and openness to changing course should circumstances lead us in a different direction.
These are some of the reasons I see OMM as both a lens and a tool that assists patients in the process of healing. It is so much bigger than moving some body part around!
DNG January 2022