1. Osteopathic Principles, Practice, and Manipulative Treatment

Overview

Osteopathic physicians must demonstrate knowledge of osteopathic principles and practice such that care of patients is approached from the distinct behavioral, philosophical, and procedural aspects of osteopathic medical practice related to the four tenets of osteopathic medicine: 1) the body is a unit; the person is a unit of body, mind, and spirit; 2) the body is capable of self-regulation, self-healing, and health maintenance; 3) structure and function are reciprocally interrelated; and 4) rational treatment is based on an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function. While osteopathic tenets are considered foundational to the other competency domains herein, this classification emphasizes the distinctive osteopathic foundation and approach to patient care, including osteopathic principles, the treatment of somatic dysfunction, and the use of osteopathic manipulative treatment (OMT). Osteopathic physicians must recognize, diagnose, and treat patients with somatic dysfunction using OMT in the clinical setting. The AACOM 2017 Glossary of Osteopathic Terminology defines OMT and somatic dysfunction as follows:

osteopathic manipulative treatment (OMT): 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.

somatic dysfunction: impaired or altered function of related components of the body framework system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements... Somatic dysfunction is treatable using osteopathic manipulative treatment.

Required Elements

1.1 Knowledge of Osteopathic Principles, Practice, and OMT

DEFINITION
The osteopathic physician must demonstrate an understanding of osteopathic principles and practice, including knowledge of the basic science, mechanisms of action, and physical findings of somatic dysfunction, and basic application of OMT.

MEASURED OUTCOMES
The osteopathic physician must:

• describe the concept of body unity and recognize its role in whole-person health care.
• describe the concept of interrelatedness of structure and function in the human body and how it guides physical examination for patient presentations, including biomechanical, respiratory, circulatory, neurologic, biopsychosocial, and metabolic structure-function relationships and their effect on the body’s self-regulating and self-healing capabilities.
• describe the reciprocal effects of dysfunction within the musculoskeletal system and dysfunction within the vascular, lymphatic, neurologic, and organ systems.
• describe how the human body’s self-healing and self-regulatory mechanisms affect treatment options.
• describe the scientific knowledge supporting the use of osteopathic principles, practice, and OMT, including the basic science of the mechanisms of OMT and of somatic dysfunction, and the current evidence base for the clinical application of OMT and the role of the osteopathic physician to facilitate health.
• name and define the types of physical examination findings that are consistent with somatic dysfunction.
• name, define, and describe the types of somatic dysfunction found within the 10 body regions, which are the head, cervical, thoracic, lumbar, sacral, pelvic, lower extremity, upper extremity, rib, and abdominal/visceral regions.
• describe the underlying mechanisms, signs, symptoms, and physical findings associated with viscerosomatic, somatovisceral, viscerovisceral, and somatosomatic reflexes.
• name and describe the diagnostic examination, initial positioning, monitoring, motion barriers, activating forces, therapeutic timing, repetition, and reassessments used in indirect and direct technique types of OMT, including the following: counterstrain; muscle energy; myofascial release; high velocity, low amplitude; soft tissue; lymphatic; osteopathic cranial manipulative medicine; articulatory; balanced ligamentous tension; ligamentous articular strain; facilitated positional release; Still; visceral; treatment of Chapman reflexes; and treatment of trigger points.
• identify the indications and contraindications of different OMT techniques.
• compare and contrast the relative value, advantages, and disadvantages of different OMT techniques.

1.2 Skills in Osteopathic Principles, Practice, and OMT

DEFINITION
The osteopathic physician must be able to apply osteopathic principles, including the use of OMT, to an appropriate patient care plan.

MEASURED OUTCOMES
The osteopathic physician must:

• incorporate osteopathic principles into problem solving in clinical settings.
• obtain medical, family, social, and cultural histories from or about the patient pertinent to the presenting complaint, with emphasis on assessing potential structure-function and mind-body-spirit relationship influences.
• perform an appropriate osteopathic structural examination before and reassessment after administration of OMT.
• diagnose somatic dysfunction within the 10 body regions (head, cervical, thoracic, lumbar, sacral, pelvic, lower extremity, upper extremity, rib, and abdominal/visceral), prioritize a differential diagnosis, and develop an appropriate care plan.
• perform effective indirect and direct technique types of OMT and associated elements, including diagnostic examination, initial positioning, monitoring, motion barriers, activating forces, therapeutic timing, repetition, and reassessment. The technique types of OMT include: counterstrain; muscle energy; myofascial release; high velocity, low amplitude thrust; soft tissue; lymphatic; osteopathic cranial manipulative medicine; articulatory; balanced ligamentous tension; ligamentous articular strain; facilitated positional release; Still; visceral; treatment of Chapman reflexes; and treatment of trigger points.
• provide for the safety and dignity of the patient while diagnosing somatic dysfunction and administering OMT.
• communicate principles of and demonstrate use of appropriate therapeutic and rehabilitative exercises, activity modification, and supportive and adaptive devices in the management of neuromusculoskeletal dysfunction and facilitation of health

1.3 Integration of Osteopathic Principles, Practice, and OMT Into Care

DEFINITION
The osteopathic physician must demonstrate sufficient depth of knowledge and skills to recognize, diagnose, and treat patients who have somatic dysfunctions, using OMT in the clinical setting.

MEASURED OUTCOMES
The osteopathic physician must:

• apply osteopathic principles and practice in health and disease to resolve complaints and concerns with which patients commonly present, giving particular emphasis on optimizing homeostasis and maximizing the patient’s comfort and health.
• advocate for the administration of OMT in appropriate clinical settings.
• identify viscerosomatic relationships and the role of the musculoskeletal system in the patient presentation by performing an osteopathic structural examination.
• demonstrate respect to patients of heterogeneous and diverse populations, including but not limited to diversity in ethnicity, culture, gender identity and/or sexual orientation, and religious beliefs, who may express the symptoms of their somatic and/or visceral dysfunctions in unique or unconventional ways.
• document diagnostic information to allow for appropriate coding for evaluation and management services and OMT.
• determine the limits of his/her knowledge and clinical skills and seek an appropriate referral in regard to the use of OMT or the application of osteopathic principles and practice.
• report and interpret epidemiologic data in patients with musculoskeletal dysfunction.
• integrate scientific knowledge supporting the use of osteopathic principles, practice, and OMT into the clinical evaluation and management of the patient.