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The Role of Osteopathic Medicine
American Osteopathic Association
Thursday, November 11, 1999


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What is Osteopathic Medicine?
What is a D.O.?
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Overview of the Issue:
Tyler Cymet, D.O., discussed the osteopathic approach to treating many different injuries and illnesses ranging from back pain to anxiety. This approach includes how osteopathic physicians (D.O.s) get to know their patients including their home and work environments when assessing their patients' overall health. The purpose of this discussion was to give participants an understanding of D.O.s' distinct philosophy of care that focuses on treating the whole person and not just a specific injury or illness.
Tyler Cymet, D.O., is an osteopathic internal medicine physician at Sinai Hospital of Baltimore. He also serves as director of the Osteopathic Medical Education Program in Internal Medicine at Johns Hopkins University and Sinai Hospital. In 1998, Dr. Cymet was named one of the best physicians in Baltimore by Baltimore Magazine.

Moderator: Good afternoon and welcome to Viewpoint with our guest, Dr. Tyler Cymet. Dr. Cymet, thank you for joining us, and please get us started by explaining what an osteopathic physician is.

Dr. Tyler Cymet: D.O.s, or Osteopathic Physicians, are doctors trained at medical schools in the United States that give the D.O. degree. Osteopathic Medicine is a philosophy of care. The philosophy has us focus on the person in front of us. We have to listen to the symptoms to search out the root causes of problems. Then we treat the people and not just the symptoms. D.O.s are trained to be general physicians/family physicians. While D.O.s can go ahead and specialize in any area they choose, they have to start out their professional careers with the orientation that a person is more than just the sum of their parts.

Kensington, MD: I'm confused about the differences between a D.O. and an M.D. As I understand it, a D.O. has exactly the same privileges at a hospital, for example, as an M.D. The training for both M.D.s and D.O.s is virtually the same, no?
So what are the differences? And why would someone go to school to become a D.O. rather than an M.D., especially if they are virtually the same?
Also, I understand that D.O.s originally practiced structural manipulation, somewhat like chiropractors, but do they still do this?

Dr. Tyler Cymet: D.O.s and M.D.s both practice medicine and care for people. Just like both Republicans and Democrats practice politics and just like priests and rabbis both take care of people's spiritual needs.
We just have a different philosophy.
The philosophy of osteopathic medicine initially focused on the musculoskeletal system as being a key to health and illness and all D.O.s are trained in manipulation.
The manipulation is different than a chiropractor does.

Alexandria, VA: Hello Dr. Cymet,
For the past six months, I have suffered from debilitating pain in my knees and surrounding tissues. This pain has caused me to change my entire life-- I cannot do the things I could before, and I am only 26 years old. My orthopedist originally suggested that is was patella-femoral syndrome, but after two rounds of physical therapy, prescription anti-inflammatories, and a lot of rest, I am not better. The doctors have told me I am totally "normal" -based on blood tests and an MRI- and that there is no reason for my pain. Needless to say I am very frustrated, but I am beginning to wonder if I should start over with a primary care D.O. since there is an emphasis on the whole body and the entire musculoskeletal system? Do you have any advice? Thank you!

Dr. Tyler Cymet: I am sorry to hear about your problems with the knee and leg pain. 26 years old is too young to have such debilitating symptoms.
An Osteopathic Physician would be well qualified to give you a second opinion.
Sometimes it takes time for a disease process to fully declare itself and the best doctor is the last doctor you see because the disease becomes more obvious. Keep working to help yourself get better.
If you want to find a D.O. in your area feel free to call the American Osteopathic Association at 1-800 621 1773.

Dunstable, England: What causes muscles to spasm and how can they be treated?

Dr. Tyler Cymet: Muscle spasm is a tightening or contraction of a muscle. It can happen for many reasons. It is important to know if the spasm is a result of diabetes, or thyroid disease.
It occurs in healthy people as well usually from exercise. 50 percent of marathoners have muscle spasm. In those people it is usually an imbalance in the chemicals in the blood, like pottasium that cause it.
As to why it happens, there are a lot of theories, none of which have been proven. The answer is probably different in different people. In the patients I see who are young and active it appears to be nervous system induced (alpha adrenergic).

Narragansett, RI: What is prolotherapy? What signs and symptoms
would lead a physician to attempt prolotherapy? Is it effective in the sacroiliac joint? How many injections are appropriate? Can you refer me to scientific studies of prolotherapy in medical journals? How can I find a doctor in my area -DO or MD- who is experienced with prolotherapy?

Dr. Tyler Cymet: I don't do prolotherapy myself, but have sent some patients for that treatment. Prolotherapy is when a physician injects a saline (salt water) solution into a ligament. It is meant to stretch out the ligament and cause a local irritation so that the body works to correct the problem. People who have had chronic foot pain have seen some benefit, but I am not familiar with the medical literature on this procedure and would refer you to a specialist. The American College of Osteopathic Pain Management and Sclerotherapy may be of assistance. Their number is 302-996-0300

Bethesda, Maryland: Do you recommend osteopathy for the treatment of panic attacks? What specifically would an osteopath do to deal with this problem?

Dr. Tyler Cymet: Panic attacks are anxiety taken to an extreme. There are many ways to treat panic attacks starting from identifying the cause to medication.
I suggest seeing an osteopathic physician to work with you and see what type of relaxation techniques you may need to help, and if further interventions may also be needed.

Arlington VA: Is there osteopathic treatment that can aid a person recovering from back surgery?

I had back surgery about 6 months ago -anterior disectomy-. A neurosurgeon removed and replaced two discs at C-5 and C6. Since the surgery, I continue to have some pain, numbness and burning sensation in my lower back and right leg. I believe my pain and discomfort to be mostly nerve related.

Dr. Tyler Cymet: Osteopathic Manipulative Therapy can be used as an adjunct to help in recovery after back surgery.
It is important to relearn basic body mechanics, as in how to lift up objects, how to sit without stressing out certain parts of your back, and how to stand without putting all the pressure on one part of the back.
OMT or Osteopathic Manipulative Therapy, is used to help expand the motion that you are capable of doing after surgery.

Springfield, VA: I am having pain in my neck and down my left arm. I have had a CAT Scan and was told that I have bone spurs. Besides pain medication, what are my other alternatives? I am under the care of a GP, should I be seeing a specialist? If so, what type?

Dr. Tyler Cymet: Bone spurs can impinge on nerves and cause symptoms distant from where the problem is.
Bone spurs also help a physician to predict where the problem came from, if there are certain behaviors or activities that may have worsened the problem, and also how long and what you need to do to get better.
Besides pain medication a person would need to do what they did that put pressure on that part of the body and lead to the problem. Biomechanics is the study of how a body moves and where problems develop.
Many D.O.s do teach "back school" to teach people how to releive these symmptoms.

Hartford, Ct: My aunt is 86 yrs old and she has osteporosis. She has two compression fractures of the spine and is in constant pain. She is on a patch pain medication to try and help her manager her pain, however she is in constant pain and wonders why she is even living. She is losing her will to live because the quality of her life is so pain filled. Is there any hope for her?

Dr. Tyler Cymet:
Osteoporosis is when a person's bones thin out. This typically happens after menopause. Usual prevention is vitamin D and calcium supplements for women starting in their 40s. You can get these vitamins from foods, and being out in the sun. The best protection for the bones are weight bearing exercise like aerobics, walking, jogging.
Once a person has osteoporosis then it is too late to start the weight bearing exercise. Osteoporosis is defined as a density screen of -2.5, or being very different from the average women in regard to thickness/heaviness of the bones.
I would talk to my doctor about estrogen replacement first, if it is an option. Otherwise there are medicines, nasal sprays, and injectable medications that can be used to treat this problem and prevent hips and wrists from breaking.
Once the bones have thinned out, it is tough to get them built up.

Thomasville, GA: As my children get older and weigh 40lbs, I find it harder and harder to
constantly lift them. What age should parents begin to reduce the child's
dependency on being lifted... to save our backs?

Dr. Tyler Cymet: It is hard to give you an individual answer without seeing you personally. The answer isn't a single age or weight limit. It depends on how big/strong the parent is to begin with.
One way to prevent problems from lifting children is to lift them right. You don't want to bend over too much to pick up a child because that straightens out your spine too much. When a person straightens out their spine, the pressure from lifting gets focused on one small area of the vertebrae, and can lead to deterioration of the area between the vertebrae.
If it hurts---don't do it. It doesn't matter how old, or how much they beg to be picked up.

Grand Lake, Colo,: What are the differences in
Lupus and Fibromyalgia?
Is one disease often mis-
diagnosed for the other?

Dr. Tyler Cymet: There is a big difference between lupus and fibromyalgia. We know what lupus is, we don't have as much information about fibromyalgia.
Lupus is when a person develops antibodies to their own organs, and skin. It is classically identified by the rash over the cheeks and the bridge of the nose. Although not everyone with lupus will get this rash. Lupus effects the skin, kidneys, arteries, and brain. We know how to monitor lupus and have good treatments.
Fibromyalgia is a syndrome or collection of symptoms. Physicians (D.O.s and M.D.s) still do not know where the main disease process is in fibromyalgia. We fight about whether the main disease is a muscle, nerve, or in the brain.
The diagnosis of fibromylagia is based on clinical findings made by a physician.

Clearwater, FL: Our new insurance carrier lists several D.O. physicians. I do not know anything about osteopathy and am unsure about choosing a D.O. for my primary care physician. Can you provide any information that would help me in making that decision?

Dr. Tyler Cymet: D.O.s are trained as primary care physicians and look to treat people and not just symptoms.
If you want a physician with this kind of philosophy a D.O. would be a good choice.
The most important thing is that you know your doctor, trust them and have a good relationship with them so that you can be honest and work together to help get you to your optimal level of health.
D.O.s are good at this.

Toledo, Ohio: Do M.D.s and D.O.s use the same methods in dealing with an osteopathic problem? If a person has such a problem, would it be better to get treatment from an D.O. rather than an M.D.?

Dr. Tyler Cymet: You cannot change a person's anatomy and philosophy, and we learn the same basic sciences.
DO's do train in manipulation, which is the therapeutic application of a force to effect a change in the body.
M.D.s do not learn manipulation or nutrition. In the M.D. medical school where I teach the students get one hour in four years on manipulation. In the D.O. schools it is at least four hours a week for two years.
An M.D. would have to refer a patient to another physician or other specialist for manipulation. A D.O. is trained to do it themselves.
So, yes, A D.O. is better for treating many problems. Particularly musculoskeletal pain, low back pain, but not limited to those areas.

Washington, D.C.: What treatment would you recommend for patients with stress-related anxiety, and what are the implications of long-term anxiety?

Dr. Tyler Cymet: Anxiety effects the whole body. It has good aspects as well as bad. Without anxiety some people would not get out of bed in the morning.
Anxiety becomes a problem when it is so severe that it interferes with normal functioning and takes over thoughts and action to a detrimental level.
It is important to know what kind of social support a person has, what their interests are, how they deal with their anxiety and why and when the anxiety becomes a problem.
Also, sometimes anxiety can tell us when we are doing too much and need a break.
I do suggest working with someone to help identify the sources of anxiety, and ways of treating it.
Treatment ranges from relaxation techniques such as breathing exercises, to biofeedback, all the way to antianxiety medications.

Washington, DC: Can an osteopath offer me new treatment or a new perspective on my scoliosis? My back is periodically "looked at" by my primary care physician. About 5 years ago I went through a course of physical therapy which I found to be very unhelpful. What would an osteopath do?

Dr. Tyler Cymet: Scoliosis is a serious chronic problem. It is important to follow up with a physician and have the rotation of the spine measured.
A D.O. can see if there are somatosomatic problems or problems from one group of muscles effecting another group of muscles.
If Somatic dysfunction is diagnosed then there are unique treatments that a D.O. can offer to make a person more comfortable.
The goal of care is to retain the ability to move as freely as possible and keep the spine as symmetrical as possible.
There are devices as well that may be of assistance.
The Levitor is one that comes to mind right away, but there are many.

Moderator: Do managed care plans cover D.O.s?

Dr. Tyler Cymet: You will find D.O.s in managed care plans in many different areas. The most common area is under primary care providers. Many specialists are D.O.s as well.
One common question that D.O.s and patients frequently ask managed care plans is whether or not manipulation is part of the primary care capitation that D.O.s receive for caring for a person.
Oftentimes you will see a seperate category for Manipulation where D.O.s are physicians who specialize in that area of medicine. In that case you would need a referral to see the DO who specializes in manipulative medicine.

Vienna, VA: I am a 36 year old former athlete with arthritis in the L3 position in my back. I am only left with biking and walking as options for excercise. Is there any hope for someone in this condition?

Dr. Tyler Cymet: At 36 you are not yet middle-aged. Technically that starts at 40. And you should still be able to heal up problems in the spine.
It takes 18-24 months for a vertabra to remodel. We usually give a person that long before thinking about surgery as an option of treatment-unless there are signs of a nerve being pinched.
But, if you can bike and walk then you should be healthy enough to reheal the L# vertebra. There are dietary supplements like glucosamine sulfate that can speed up healing, and exercises and behavioral changes that might be necaessary to protect the vertebra.

Groton, CT : Dr. Cymet:
What was your impression of the article-editorial in the Nov. 4th NEJM, regarding OMT and subacute lowback pain? As well, your thoughts regarding the editorial by Dr. Joel Howell.
Thank you.
Gary E. Raffel, D.O.

Dr. Tyler Cymet:
The November 4, 1999 edition of the New England Journal of Medicine published a randomized controlled trial of manipulation in sub-chronic low back pain. That is back pain that has been present more than three weeks but less than six months and found manipulation to be equally as effective as medication in relieving the pain and found it to be cheaper and probably having less problems and side effects than medicine.
In the November 1999, edition of Mayo Clinic Proceedings they recommend OMT(manipulation) for acute low back pain. That means back pain that has been present less than 4 weeks can be treated effectively with manipulation. The AHCPR, the government agency that comes out with consensus studies on medical topics, agrees with this evaluation of Osteopathic manipulation.
Manipulation works on freeing up motion. A person gets manipulation to allow for the body to work better by bringing back the potential to move in all directions freely and hopefully without much pain.
The editorial in the NEJM was at times amusing and annoying. Dr. Howell included an interesting short history of osteopathic medicine, but then fell into the argument that yeah, now you got some good proof in an allopathic journal that it works, but if it is so good, why don't I do it? I think that his question was good, but he should have attempted an answer.

Frankfurt am Main - Germany: I would like to know the negative side of osteopathic treatment. Which are the most common mistakes in this treatment that can cause big problems and pains to the patient?

Dr. Tyler Cymet: Every intervention that has an effect can have problems. One problem I have with providing osteopathic treatment is that people love it! And they want more. And I, being an internist need to be sure that I have a diagnosis that I am comfortable with and have made sure that there are no other problems in my patient.
I worry about missing the diagnosis of cancer, infection and fracture of a bone in people who have back pain. If I make a person feel better with the warmth of my hands, the relaxing of tight muscles, the freeing up of joints that were not able to work right before, they don't want any more tests done, just treatments.
Another problem that I have less frequently is muscle spasm. People with a new problem who have muscle tightness may not be able to relax their muscles enough to get treatments, or the treatments cause pain.
Pain is the most important symptom we see. It gets people to come to a doctor and motivates them to find root causes and answers for their problems. So again, I don't want people to be in pain, but am afraid to releive pain without being sure of where it came from and requestioning the source on a regular basis.

Merrick, New York: Dr. Cymet, I was recently diagnosed with type 2 diabetes. I am 39 years old and thin. What do you suggest for dealing with it. I am highly reactive and the sugar levels go below 40 when I do the slightest amount of exercise. I am not on any medication. Thank you.

Dr. Tyler Cymet: Diabetes is a disease where the body has trouble regulating the blood sugar levels. It may go too high and occasionally can yo yo up and down.
The most important thing a person can do is to know their own bodies, be aware of how they feel when their sugars are high or low.
Grazing or eating throughout the day becomes important so that the sugar doesn't go too low.
It is encouraging that you are able to stay off of medicine it means you are able to learn about diet and use foods for good effects on your body.
Low blood sugars usually cause a person to get jittery, sweaty and nauseaus.
High blood sugars cause a person to pee a lot, eat a lot, and drink a lot as well as being fatigued, lightheaded and a host of other symptoms.
Being able to differentiate between high and low blood sugar is an important thing to learn for people with this problem.

Rockville, MD: My husband has been battling back pain in excess of three years. Specifically on his left lower side. A "facet" problem, degenerating discs. It only really causes him pain and spasms when he rotates his upper body to the left -like swinging a golf club-. Unfortunately this is the thing he cares about most. He has had facet blockets; pidurals, etc. Now seeing a chiropractor for the last couple weeks. What are his chances of success and how long might it take?

Dr. Tyler Cymet: Without making changes in activities like sitting, walking and standing, it can take forever. Not all back pain has a reason to occur, but once it is there it is important to work on taking the stress off the area of problem. If it is a facet, the portion of the vertebrae that hinge on to another, it can be difficult.
There are medicines that releive swelling that occurs in the joint area, stretching before doing any specific exercises is also of benefit.
Manipulation may be of benefit in facet problems particularly if they have been longstanding and the muscles around the area tend to tighten up and then atrophy.
Healing is a long process and I generally give a person 2 years to heal up, before saying it is going to be a problem to get it completely behind them.

New Smyrna Beach, Fla.: Can you take Vioxx along with Atenolol and Plavix without harm?

Dr. Tyler Cymet: Vioxx is a cox-2 inhibitor, a fancy term for a drug that decreases swelling without the bad side effects that can lead to ulcers or other problems. There are currently two cox-2 inhibitors being used Vioxx and Celebrex and both are excellent medication.
You can take Vioxx with beta blockers like Atenolol without any problems. I have not seen any data on using Vioxx with Plavix, but do not see any problems-I would discuss this with your physician as well.

Statesboro, Georgia: Our daughter is a second year at Philadelphia College of Osteopathic Medicine. What has she got to look forward to with respect to workplace prejudice toward women in medicine, and toward osteopathic physicians in general. Will she have any trouble finding a job when she finishes her residency in about the year 2005?

Dr. Tyler Cymet: Medicine is a great profession. I spend my days learning about peoples pains and secrets and then have to do whatever I can to help them. I can't think of anything that could be as fun or rewarding as being a D.O.
Your daughter has an exciting world opening up to her. There will be a torrent of new therapies, gene therapies, new medications, and being based in a philosophy of treating people, caring for people and listening to people will make her in high demand no matter where she goes.
Any change is stressful, and in medicine we will have tons of change going on for years to come, but our job and goals are still the same, just different roads to get there.

Dr. Tyler Cymet: I want to thank for hosting this chat, and all of you for coming here with questions. There are D.O.s in all fifty states who would be happy to see you on an individual basis. The most important part of medicine is still the relationship you develop with your healthcare provider.
The American Osteopathic Association would be happy to help you find a D.O. in your area. You can call them at 1-800-621-1773 or write them at 142 East Ontario Street, Chicago, Illinois 60611

Moderator: Our thanks to all, especially Dr. Cymet and AOA.

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