Osteopathic Manipulative Medicine

Osteopathic Manipulation Longitudinal Educational Goals & Objectives

Osteopathic Manipulation is a basic tenet of Family Medicine at CMH. Because Osteopathic Manipulative Treatment (OMT) is a skill taught in medical school, this curriculum does not separate out residents by year of training. Rather, we have created a curriculum to validate resident skills by reinforcing principles with didactics and skills sessions and by providing opportunities to care for patients longitudinally in both the inpatient and outpatient settings. Lectures and hands-on sessions are designed to teach osteopathic philosophy, anatomy, and osteopathic manipulation techniques and reinforce the appropriate use of these procedures. The resident will become familiar with normal and dysfunctional anatomy and sympathetic and parasympathetic viscerosomatic reflexes and learn to identify clinical scenarios where Osteopathic Manipulative Treatment (OMT) is of benefit. Emphasis will be on the appropriate use of Osteopathic Principles and Practice (OPP) to enhance patient care and on dedication to lifelong learning of Osteopathic medicine. By working through this curriculum, residents will gain a thorough knowledge of the tenets of osteopathic philosophy and their practical application in the care of the whole patient.

Faculty will facilitate learning in the 6 core competencies as follows:

Patient Care and Procedural Skills

I. Residents must be able to provide compassionate, culturally-sensitive care that acknowledges patient apprehension concerning touch and palpatory diagnosis.

II. Residents must be able to recognize the entire clinical context and incorporate osteopathic principles to positively impact patient care in both the inpatient and outpatient setting. Residents should be able to

• incorporate the four tenets of OPP and use the relationship between structure and function to promote health
• identify patients who would benefit acutely from commonly used OMT techniques and recognize patients who have contraindications to OMT
• recognize patients who would benefit from longer term treatment with OMT for more chronic conditions

III. Residents will demonstrate the ability to take a focused history, incorporate information from the electronic medical record, and use OPP to perform competent physical, neurologic, and structural examinations. Residents should

• be familiar with normal anatomy and landmarks used in OMT
• understand patient tolerance and how it affects the level of aggressiveness of the OMT procedure used as well as identify signs of patient response
• be able to determine and alter a treatment plan based on comorbidities, analysis of diagnostic testing, patient response, any rebound reaction, and residual somatic dysfunction

IV. Residents will become familiar with multiple types of manipulation affecting different anatomic areas. Focus of the curriculum will be on learning the indications, contraindications, complications, limitations, and technique. Residents will spend hands on time in practicum sessions as well as time working with patients in their Continuity Clinics to become competent in their safe and effective use.

• Articulatory Techniques
• Autonomic Nervous System Balancing
• Balanced Ligamentous Tension
• Balanced Membranous Tension
• Chapman's reflexes
• Strain Counterstrain Technique with Jones’ Points
• Cranial Osteopathic Treatments
• Facilitated Positional Release
• Functional Techniques
• High Velocity Low Amplitude Techniques
• Inhibitory Pressure
• Lymphatic Techniques
• Muscle Energy
• Myofascial Release, Direct and Indirect
• Still Technique
• Visceral Somatic Reflexes

Medical Knowledge

I. Residents will demonstrate an understanding and application of OPP to treatment of the whole person rather than symptoms.

II. Residents will gain an understanding of how OMT procedures can complement or at times replace traditional therapies.

III. Residents will become skilled in the use of OMT to treat pain, particularly muscle pain, promote healing, and improve patient mobility.

IV. Residents should be able to incorporate OMT into a treatment plan for common primary care conditions, such as asthma, back and neck pain, carpal tunnel syndrome, menstrual pain, migraines, pneumonia and sinus disorders.

V. Residents should be familiar with techniques for special patient populations, such as children, elderly patients, and pregnant women.

VI. Residents will also develop an understanding of psychoneuroimmunology and the biopsychosocial model of thought, feeling, and disease of the body.

VII. Residents should be able to perform critical appraisals of literature related to OPP

Practice-Based Learning and Improvement

I. Residents should be able to access and incorporate current clinical practice guidelines and research where applicable to clinical decision making.

II. All residents should learn to function as part of a health care team to optimize patient care.

III. Residents should be able to critically appraise the literature and understand research methods and the application to clinical care.

IV. Residents should be able to reflect systematically upon their own clinical practice ofnosteopathy and understand and integrate evidence-based OPP into patient care to improve outcomes

V. All residents should respond with positive changes to feedback from members of the health care team.

Interpersonal and Communication Skills

I. Residents must document the Osteopathic musculoskeletal examination in a standardized format.

II. Residents must also develop interpersonal and communication skills (verbal and nonverbal, including touch) to educate and counsel patients regarding OPP and a patient-centered approach to holistic care.

III. Residents should be able to educate other health care professionals on the Osteopathic approach to care and demonstrate leadership skills to coordinate a multidisciplinary approach to patient care.

Professionalism

I. Residents must demonstrate a commitment and self-directed approach to lifelong learning of Osteopathic medicine.

II. All residents must demonstrate strong commitment to carrying out professional responsibilities as reflected in their conduct, ethical behavior, attire, interactions with colleagues and community, and devotion to patient care.

III. Residents should be sensitive to conflicts of interest between the needs of patients and pressures from society, community, and the health care industry.

IV. Residents should recognize and respect the role gender, age, culture, race, religion, disabilities, national origin, socioeconomic status, and sexual orientation may play in a patient’s perception of touch within the context of OPP.

V. Residents should treat the terminally ill with compassion in management of pain, palliative care, appropriate touch, and preparation for death.

VI. Residents should learn to use time efficiently in the clinic and on rounds to allow time to practice OMT.

VII. Upper level residents should be able to provide constructive criticism and feedback to more junior residents during hands on practicums and when providing supervision of patient care.

System-Based Practice

I. Residents must have a basic understanding of how OMT affects the cost and quality of patient care and advocate for their patients’ needs within the system.

II. Residents must be able to discuss OMT as a complementary or alternative therapy to traditional care strategies, taking into account the other medical, social, economic, and psychological factors affecting the patient’s choices regarding their care.

III. Residents should understand the impact of insurance status on patient access to OMT.

Teaching Methods

I. Residents are required to review the video modules available from American College of Osteopathic Family Physicians.

II. Residents have scheduled hand-on practicums with peers monthly.

III. Residents will provide supervised OMT treatments to their patients both in their Continuity Clinics and within the context of their inpatient and outpatient clinical rotations.

• Residents will initially be directly observed with patients, to facilitate the acquisition of excellent history taking, exam skills, and the appropriate use of OMT.
• As residents become more proficient, they will interact more independently with patients and present cases to faculty. Proficiency is determined by the OMM attending physician, not by numbers of OMT procedures logged. Proficiency will be assessed in the following four categories: medicine/surgery/outpatient, obstetrics, pediatrics/neonates, and critical care.
  • Initial emphasis will be on identification of patients who can benefit from OMT and the use of appropriate techniques.
  • Focus will be on medical decision-making and treatment, and residents will work with supervising physicians to finalize an OMT care plan.
  • Residents will assume increased responsibility for independently incorporating osteopathic concepts into patient management.

IV. Conferences

• Osteopathic Manipulative Medicine (OMM) conference

V. Independent study

• Journal and textbook reading
  • Seffinger, M.A. (2019). Foundations of Osteopathic Medicine: Philosophy, Science, Clinical Applications, and Research. Lippincott Williams & Wilkins.
  • Nicholas, A. S., & Nicholas, E. A. (2015). Atlas of osteopathic techniques. Lippincott Williams & Wilkins.
  • Nelson, K. E., & Glonek, T. (Eds.). (2014). Somatic dysfunction in osteopathic family medicine. Lippincott Williams & Wilkins.
• Additional reading as recommended by attending physician
  • ACOFP Video Procedures Online (available through the Program Director)
  • Scholar Teacher

Evaluation

I. Individual attending and peer verbal feedback during hands-on sessions

Curriculum Structure

I. Residents attend OMM conferences covering a variety of topics. Conferences typically occur once per month. Introductory topics, such as the general approach to the hospitalized patient, will be repeated for each intern class.

• In the session, residents will have a didactic session followed by open discussion and a hands-on practicum. Discussion will focus on patient presentation, appropriate indications for OMT, contraindications, and development and execution of a treatment plan.
• Case-based learning is most effective. Nightly reading/study should be based on patients seen during the day.
• When seeing outpatient consults referred from another provider, the resident should understand the question asked and provide a concise answer.

II. Residents should notify the attending physician promptly if they cannot attend an OMM session at the assigned time.

III. Residents may be asked to do focused literature searches or presentations during the course of the sessions.

IV. All educational sessions and direct patient care will occur within the bounds of resident work hours as per ACGME requirements.