What’s Wrong With Naturopathic Physical Medicine?
Historically, naturopaths always have employed physical medicine modalities (massage, manipulation, exercise, hydrotherapy). For example, both Lindlahr and Lust employed combinations of physical exercise, massage, osteopathy and chiropractic in their care of patients.1
In addition to specific physical medicine interventions, naturopathic practitioners have utilized general constitutional methods, both manual and hydrotherapeutic.2 Universal (General) Naturopathic Tonic Technique (UNTT or GNTT) is a generally applicable, non-specific, loosening/mobilizing sequence, developed in the early part of the 20th century by Frederick Collins, MD, ND, and described by Cordingly3 in 1924, in his book Principles and Practice of Naturopathy.
Modern validation for such non-specific manual interventions has emerged from osteopathic medicine. For example, Clark and McCombs4 have described a selection of basic physical medicine approaches (including positional release, muscle energy, myofascial release and other soft-tissue manipulation techniques, as well as – when indicated – high velocity thrust [adjustment] techniques) designed to support respiration, circulation (venous and lymphatic), ventilation and perfusion, in hospitalized patients in order to augment recovery following a surgery and/or disease.
They note that there are numerous examples where osteopathic manipulative treatment (OMT) has been shown to have a positive impact on the length of hospital stay for patients with a variety of diagnoses. They refer to studies by Stiles,5 Radjieski,6 Cantieri,7 Noll, et al,8,9 Sleszynski and Kelso,10 and others – all of which have demonstrated that recovery time from various conditions (pneumonia, for example) and situations (post-operative, for example) can be reduced and length of stay in the hospital minimized when combinations of manual modalities are used in patient care. It should be emphasized that although some of these physical methods have emerged from the osteopathic profession, most are used universally by physical medicine practitioners of all schools, including chiropractic, physical therapy and massage therapy.
The Biology of Physical Medicine Influences
Moving from the general constitutional approach to more specific manipulation interventions, a variety of general effects that relate to self-regulatory processes have been shown to result from aspects of physical medicine treatment.
A number of these recently have been summarised by Khalsa, et al.11 “There is increasing evidence that manual therapies may trigger a cascade of cellular, biomechanical, neural, and/or extracellular events, as the body adapts to the external stress. Collectively, reports of animal studies,12,13 case studies,14,15 and numerous clinical trials of chiropractic and physical therapy16-18 suggest that spinal manipulation can alter the activity of nearby mechanically-sensitive neurons,19,20 including those that function proprioceptively (which sense body position and muscle movements), in turn leading to responses by the central and autonomic nervous systems.21 These responses or alterations may, in turn, lead to observed changes in circulating levels of various neuropeptides and regulatory proteins. Whether this cascade is responsible for the reported clinical efficacy of manipulation for back and neck pain is unknown. Studies of massage-like stimulation in animals indicate that the treatment can stimulate pain-modulating systems working through the action of endogenous opioids.22 Massage-induced cardiovascular changes in animals also have been observed and found to be related to the action of the hormone oxytocin at the midbrain level.23-26However, although these preliminary studies are promising and suggest several hypotheses, the exact mechanisms of action for any treatment effects attributable to manual therapies are currently unknown.”
Although precise mechanisms remain unclear, there are strong indications that traditional osteopathic and chiropractic concepts are based on demonstrable physiological mechanisms. For example, the long-disputed concept that spinal restrictions (subluxations) can directly influence visceral function appears to be resolving, with support emerging from neuroscience involving both animal27-29 and human30-32 studies, validating what has been held to be clinically obvious by osteopathic and chiropractic professions for well over a century. Neuroscience research now appears to support a neurophysiologic rationale for the concept that aberrant stimulation of spinal or paraspinal structures might lead to segmentally organized reflex responses of the autonomic nervous system, which in turn, might influence visceral function.33
Further validation of the therapeutic value of such methods comes from the work of British osteopath Eyal Lederman, PhD,34 who has investigated the evidence for the usefulness of manual therapy in various settings, including:
- enhancement of local circulation and drainage;35,36
- reduction of swelling and improved washout of inflammatory chemicals;37,38
- assistance in normalization of trigger point myalgia;39
- modification of neural irritation caused by local oedema;40,41
- assistance in post-surgical recovery;42 and
- encouragement of optimal regeneration and repair, particularly during the remodelling phase of tissue recovery.43,44
Are Naturopaths Utilizing This Evidence?
So, the evidence for the use of a variety of soft-tissue and joint manipulation methods in patient care – even of the severely ill individual – is powerful and impossible to refute.
It might, therefore, be anticipated that, with training in these well-validated methods and modalities, as well as a scope of practice that allows their use, NDs would be offering a physical medicine aspect of care to all, or even most, of their patients. Unfortunately, the evidence is that many are not, and what has been dubbed “green allopathy” (botanical, nutritional, homeopathic methods) is so dominant in naturopathic medicine that the physical medicine dimension is being either overlooked or avoided – and this trend starts with inadequate training of the physical medicine dimension – despite the heroic efforts of those involved in this training. Quite simply, it appears that not sufficient curriculum hours are offered to what can be seen to be the Cinderella of naturopathic care. But, is there evidence for this assertion?
The figures listed below represent what was being taught at leading U.S. colleges of naturopathic medicine within the last 10 years:45
- the total number of hours devoted to physical medicine was 224 for lab and 55 for lectures (less than 10 percent of the total curriculum);
- the total number for palpation was 36 lab hours (none at some colleges);
- the total number for hydrotherapy was 18 lab and 10 lecture hours;
- the total number for orthopedic diagnosis was 36 lab hours;
- the total number for physiotherapy was 36 lab hours: electrical, sound, light, heat, cold, laser and mechanical therapeutics (the minimum requirements to sit for the physiotherapy part of the national chiropractic licensure exam is 120 lab and 60 lecture hours);
- the total number for exercise therapies was 18 lab and nine lecture hours; and
- the total number for manipulative therapies was 90 lab and 36 lecture hours (with topics such as lumbopelvic manipulation comprising two hours positional release, two hours sacro-tuberous ligament release [adapted from Logan], four hours muscle energy technique and 10 hours HVLA).
It is difficult to see how anyone graduating from such training (unless previously or subsequently trained as a DC, DO, PT or advanced LMT) could be described as skilled in the use of manual and manipulation techniques. Nevertheless, in a recent survey of licensed Canadian NDs,46 there was a strong indication that core manipulation skills were, in the opinions of the responders, perfectly adequate. When asked about the degree of thoroughness with which training had been offered in particular physical medicine modalities, more than 300 responders to the survey made the observations seen in Table 1.
How Does This Translate Into Practice?
This same survey of naturopathic practices in Canada, involving NDs trained both in that country and the U.S., confirms that despite having been (in their opinions) adequately trained, there is a decline in the clinical use of what should be a key facet of naturopathic patient care (see Table 2).
The evidence is that despite very high scores on perceived quality of training, neither massage or manipulation are offered to almost 50 percent of patients seen by naturopathic practitioners in Canada (and by implication, the U.S.).
Why Is This Important?
The reasons include:
- Physical medicine has been a part of naturopathy from the outset, but is being relegated to a poor relation in modern ND training and practice for reasons that make little clinical or political sense, but which relate to an overcrowded curriculum. The solution may be to lengthen the time spent training.
- As has been demonstrated in the evidence offered earlier in this article, structural and biomechanical features are critical to function, therefore dysfunction, and are far beyond the obvious areas of joint and spinal pain.
- Constitutional approaches (physical medicine or hydrotherapeutic) are in complete accord with naturopathic concepts.
Unless the trend towards “green allopathy” and downgrading of physical medicine therapeutics is reversed, naturopathy is in danger of losing its single most important feature – its comprehensive, whole person perspective.
- Kirchfield F. Boyle W. Nature Doctors. Buckeye Naturopathic Press. East Palestine, Ohio, 1994.
- Boyle W. Lectures in Naturopathic Hydrotherapy. Buckeye Naturopathic Press. East Palestine, Ohio, 1988.
- Cordingley A. Principles and Practice of Naturopathy: A Compendium of Natural Healing. Bazan, Calif., 1925.
- Clark R. McCombs T. Post operative osteopathic manipulative protocol for delivery by students in an allopathic environment. American Academy Osteopathy Journal; 2006, 16(20):19-21.
- Stiles E. Somatic dysfunction in hospital practice. Osteopathic Annals, 1979:7(1) 35-38.
- Radjieski J. Lumley M. Cantieri M. Effect of osteopathic manipulative treatment on length of stay for pancreatitis: a randomized pilot study. Journal American Osteopathic Association 1998;(5):264-272.
- Cantieri M. Inpatient osteopathic manipulative treatment; impact on length of stay. American Academy of Osteopathy Journal 1997;(4): 25-29.
- Noll D. Shores J. Bryman P. et al. Adjunctive osteopathic manipulative treatment in the elderly hospitalized with pneumonia: a pilot study. Journal American Osteopathic Association 99(3):143-152.
- Noll D. Shores J. Gamber R. et al. Benefits of osteopathic manipulative treatments for hospitalized elderly patients with pneumonia. Journal American Osteopathic Association. 2000;(12):776-782.
- Sleszynski S. Kelso A. Comparison of thoracic manipulation with incentive spirometry in preventing postoperative atelectasis. Journal American Osteopathic Association 1993;(8):834-838.
- Khalsa P. Eberhart A. Cotler A. et al. The 2005 Conference on the Biology of Manual Therapies.Journal of Manipulative and Physiological Therapeutics 2006;29(5):341-346.
- Boal R. Gillette R. Central neuronal plasticity, low back pain and spinal manipulative therapy. J Manipulative Physiol Ther 2004;27:314-326.
- Pickar J. Wheeler J. Response of muscle proprioceptors to spinal manipulative-like loads in the anesthetized cat. J Manipulative Physiol Ther,2001;24: 2-11.
- Dishman J. et al. Evaluation of the effect of postural perturbation on motoneuronal activity following various methods of lumbar spinal manipulation. Spine J 2005:650-659.
- Mohammadian P. Gonsalves A. Tsai C., et al. Areas of capsaicin-induced secondary hyperalgesia and allodynia are reduced by a single chiropractic adjustment: a preliminary study. J Manipulative Physiol Ther, 2004;27:381-387.
- Buchmann J. Wende W. Kundt G. et al. 2005 Manual treatment effects to the upper cervical apophysial joints before, during, and after endotracheal anesthesia: a placebo-controlled comparison. Am J Phys Med Rehabil. 2005;84:251-257.
- Childs J. Fritz J. Flynn T. et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med2004;141:920-928.
- Hoiriis K. Pfleger B. McDuffie F. et al. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. J Manipulative PhysiolTher.2004;27:388-398.
- Bolton P. Reflex effects of vertebral subluxations: the peripheral nervous system. An update. J Manipulative Physiol Ther. 2000;23: 101-103.
- Pickar J. Neurophysiological effects of spinal manipulation. Spine J. 2002;2:357-371.
- Boal R. Gillette R. Central neuronal plasticity, low back pain and spinal manipulative therapy. J Manipulative Physiol Ther.2004;27:314-326.
- Lund I. Ge Y. Yu L. et al. Repeated massage-like stimulation induces long-term effects on nociception: contribution of oxytocinergic mechanisms. Eur J Neurosci. 2002;16:330-338.
- Kurosawa M. Lundeberg T. Agren G. et al. Massage-like stroking of the abdomen lowers blood pressure in anesthetized rats: influence of oxytocin. J Auton Nerv Syst. 1995;56:26-30.
- Kurosawa M. Lundeberg T. Agren G. et al. Massage-like stroking of the abdomen lowers blood pressure in anesthetized rats: influence of oxytocin. J Auton Nerv Sys.1995;56:26-30.
- Lund I. GeY. Yu L. et al. Repeated massage-like stimulation induces long-term effects on nociception: contribution of oxytocinergic mechanisms. Eur J Neurosci. 2002;16: 330-338.
- Wikstrom S. Gunnarsson T. Nordin C. Tactile stimulus and neurohormonal response: a pilot study. Int J Neurosci. 2003;113:787-793.
- Sato A. Swenson R. Sympathetic nervous system response to mechanical stress of the spinal column in rats. J Manipulative Physiol Ther. 1984;7:141-147.
- Budgell B. Sato A. Suzuki A. et al. Responses of adrenal function to stimulation of lumbar and thoracic interspinous tissues in the rat. Neurosci Res. 1997;28:33-40.
- Budgell B. Hotta H. Sato A. Reflex responses of bladder motility following stimulation of interspinous tissues in the anesthetized rat. J Manipulative Physiol Ther. 1998;21:593-599.
- Budgell B. Sato A. 1996, Modulations of autonomic functions by somatic nociceptive inputs. In: (9th ed.) Progress in Brain Research, Vol. 113, Elsevier, Amsterdam pp. 525-539.
- Fujimoto T. Budgell B. Uchida S. et al. Arterial tonometry in the measurement of the effects of innocuous mechanical stimulation of the neck on heart rate and blood pressure. J Autonom Nerv Syst. 1999;75: 109-115.
- Budgell B. Hotta H. Sato A. Spinovisceral reflexes evoked by noxious and innocuous stimulation of the lumbar spine. J Neuromuscul Syst. 1995;3:122-13.
- Budgell B. Reflex effects of subluxation: The autonomic nervous system. Journal of Manipulative and Physiological Therapeutics. 2000;23(2):104-106.
- Lederman E. 2005, Science and Practice of Manual Therapy (2nd edition) Churchill Livingstone, Edinburgh p277-293.
- Foldi M. Strossenreuther R. 2003, Foundations of Manual Lymph Drainage (3rd edition) Elsevier, Mosby, St.Louis.
- Hovind H. Nielsen S. 1974, Effect of massage on blood flow in skeletal muscle. Scandinavian J of Rehabilitation Medicine. 6:74-77.
- Wittlinger H. Wittlinger G. 1982, Textbook of Dr. Vodder’s manual lymph drainage, Vol 1: basic course, 3rd ed. Karl F Haug, Heidelberg.
- Tamir L. Hendel D. Neyman C. et al. Sequential foot compression reduces lower limb swelling and pain after total knee arthroplasty. Journal of Arthroplasty 1999;14(3):333-338.
- Larsson S. Bodegard L. Henrikssn K. et al. 1990, Chronic trapezius myalgia. Morphology and blood flow Acta Orth. Scandinavica 61(5):394-398.
- Hoyland J. Freemont A. Jayson M. Intervertebral foramen venous obstruction Spine, 1989;14(6):558-568.
- Rozmaryn L. Dovelle S. Rothman E. et al. 1998, Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome. Journal of Hand Therapy, 11(3):171-179.
- Cantieri MS. 1997, In-patient osteopathic manipulative treatment; impact on length of stay.American Academy of Osteopathy Journal, 7(4): 25-29.
- Williams P. Effect of intermittent stretch on immobilised muscle. Annals of Rheumatic Disease. 1988;47:1014-1016.
- Williams P. Catanese T. Lucey E. et al. 1988, The importance of stretch and contractile activity in the prevention of accumulation in muscle. Journal of Anatomy, 158:109-114.
- Personal communications with Physical Medicine department heads.
- Verhoef M. et al. 2006, The scope of naturopathic medicine in Canada: an emerging profession.Social Science & Medicine, 63(2):409-417.