The Yoga and Osteopathic Medicine Connection
*This post is also available in podcast form. Head on over to The Trip Lab (available on Spotify, Apple or wherever you get your podcasts) to listen.
I have been meaning to put together something like this for a while because I am a DO (instead of an MD). Many people may have seen the DO instead of MD after their doctor's name and don’t really understand what it means, so let me dive into that a little bit first.
What is a DO?
To become a doctor in the United States, a medical doctor I should say, you can either choose to become a DO or MD. DOs are doctors of osteopathic medicine while MDs are doctors of allopathic medicine. The main difference is that DOs learn osteopathic manipulative treatment (OMT) in medical school in addition to everything else that MDs learn. After medical school both MDs and DOs pursue residency in any specialty including surgery (fun fact, I actually started out my career in general surgery residency!), cardiology, family medicine, etc. I will dive into what OMT is in a little bit because this is what this post is about, but let me also briefly mention one more difference about medical school for DOs.
One of the core principles of osteopathic medicine is that we are trained to practice a whole-person approach to care that looks beyond symptoms and understands that everything is interconnected. This is essential when we use OMT (the hands on treatment I mentioned), but it also applies to every other aspect of medicine as well. We can better understand this by looking at the 4 tenets of osteopathic medicine which are as follows:
The human body is one dynamic unit of function.
The body possesses innate self-healing mechanisms.
Structure (anatomy) and function (physiology) are interrelated at all levels.
Treatment is based upon an understanding of these basic principles.
When we go through our body systems courses in medical school (ie gastrointestinal, reproductive, neurological, etc.) these principles are emphasized so that we can understand how each system works together. It is not that MDs don’t connect everything together, they certainly do, but this is just emphasized more during our training. An easy example to understand this better is to look at IUDs (intrauterine devices). An IUD is a form of birth control that goes in the uterus. We are educated that it is often a better form of birth control (in terms of side effects) because the hormones supposedly only act locally in the uterus (rather than systematically, or throughout the body, like birth control pills, the depo shot or the nexplanon which gets implanted in the arm). However, when we look at the inside of the uterus– it is a mucous membrane. Mucous membranes absorb things into the bloodstream (like how medications that dissolve under the tongue do). So with that understanding we know that there is going to be at least SOME absorption into the bloodstream. And this is certainly seen clinically when many women end up needing spironolactone for acne after getting an IUD.
But the point is… the body cannot be separated into parts or systems because everything is connected together (quite literally through our fascia or connective tissue– more on this later), but also through our blood vessels, nerves, muscles and bones. This understanding is why we can use OMT to treat so many things. Simply put, OMT (or osteopathic manipulative treatment) is a hands on treatment modality in which we manipulate body tissues to facilitate healing.
If your doctor is a DO instead of an MD, then they learned this tool in medical school. Not all DOs practice OMT after school, especially if they went into fields like ophthalmology or surgery. Just as all physicians (MD or DO) do not use every skill they learned in medical school because we specialize afterwards in residncy. I have done 100s of cesarean sections, but this is not something I do now. I could argue that every specialty could use OMT (even, and in fact, especially, surgery), but it does require you to keep up your skills. I found my OMT training particularly useful when I was doing general surgery because for one, it required a lot more training in anatomy and physiology. Two– there are many OMT treatments that are excellent for post-op patients like mesenteric release to stimulate the colon after surgery or rib cage treatments to prevent post-op atelectasis.
However, just like surgery or procedural fields, using OMT in practice requires practice and upkeep.
So let’s get into what OMT actually is.
Osteopathic Manipulative Treatment (OMT)
First we “diagnose” using our hands and actually palpating the body. When we do this, we are diagnosing “somatic dysfunction” of the tissues rather than diagnosing specific medical conditions like cancer, asthma, etc. Somatic dysfunction is a palpable change in the body framework (muscles, bones, connective tissue, lymph, etc.) that we can feel with our hands and then subsequently use our hands to manipulate the tissues to treat them. Most commonly we use OMT to treat musculoskeletal pain like low back pain or knee pain, but we can also treat the lymphatic system to improve flow for cancer or post-op patients and even treat more internal disorders that stem from nerve dysfunctions like headaches and gut issues.
Let’s remember again that everything is connected… so oftentimes even visceral or internal conditions will manifest more superficially in the body that we can feel. Let me give you an example looking at gut dysfunction (constipation, diarrhea, irritable bowel disease, etc.). All nerves in the body come from the spinal cord. The gut nerves, specifically, stem from the thoracic and lumbar regions of the spinal cord (the mid and low back). When there is dysfunction in the gut, the body tries to repair itself by changing the nerve signaling. On the other hand, in some cases impaired nerve signaling can also be the CAUSE of gut dysfunction. We can FEEL when these nerves are not functioning properly. The spinal cord might be slightly misaligned, or there will be tight connective tissues or muscles surrounding the spinal cord. The body can tell us when something is wrong. A dysfunction in one place will cause dysfunction in the surrounding tissues (through inflammation, tightening, etc.) and eventually move throughout the body. With OMT, we treat this dysfunction that we feel, allowing the muscles, bones and connective tissue to free up… which then allows the nerves and blood flow to free up and gut dysfunction improves. Whether the dysfunction in the gut caused the body to change the way the nerves function… or it was dysfunction in the spinal cord that impaired the nerves to cause gut dysfunction… treating the spinal cord will help. Now, this dysfunction we palpate cannot differentiate between specific colon diseases, it just tells us generally that there could be a dysfunction in the gut. A good physician will also look at all the potential causes of the gut dysfunction and treat with medications, supplements, surgery, etc. to get to the true root cause. OMT is just one tool in the toolbox to treat our patients.
Autonomic Nervous System
One more quick real life example that I have to share. The director of osteopathic medicine at my medical school is a very skilled OMT practitioner. One day, he was demonstrating techniques on a student and felt that the connective tissue all over his body just seemed off. Worried about something more than just chronic pain, he advised the student to go in for testing… and sure enough this student had malignant cancer with metastasis throughout his body. Unfortunately this was diagnosed too late and this student passed while in medical school. A sad story to be sure, but one that exemplifies the power of hands on diagnosis.
OMT Techniques
Now let’s look at some of the treatment techniques we use in OMT. All of them involve using our hands to subtly manipulate the body to free up the dysfunction that we feel. Getting OMT done will often feel like a massage, chiropractic adjustment or physical therapy. While there is overlap between these hands on treatment modalities, the goal of OMT is slightly different. Our goal is to treat the specific dysfunctions we feel in order to allow the body to heal itself afterwards.
One technique that I use most frequently is called myofascial release. This involves putting pressure on specific places of the muscles and fascia (connective tissue) in order to increase blood flow to that tissue. This one is where we start to see the yoga connection (we are getting there, I promise!). The idea is that if you can release a point of tension, then blood flow will improve and the muscles and connective tissues will start to heal themselves in the coming days to weeks. I LOVE this one for the IT band– a sneaky cause of low back pain, hip pain and knee pain.
Next let’s talk about muscle energy and counterstrain because the physiology of how these work is pretty cool. Counterstrain involves finding a “tender point” (that will be palpably tight and also be tender to touch) and then subsequently shortening the muscle by manipulating the body in such a way that the muscle is completely at ease. When the muscle is held at ease for a period of time, the tissue relaxes and the pain resolves (and immediately, I might add). Now, HOW does this work? Well our muscles have proprioceptive and pain receptors. When something is wrong, pain signals are sent to the brain. By shortening the muscle completely around a center of tension, the proprioceptive receptors “reset” and turn off the pain signals going to the brain. We are essentially tricking the muscle into a state of “nothing is wrong'' so it can release, increase blood flow and then the real healing happens afterwards. Muscle energy works in a similar way but instead of the doctor passively putting the muscle into a position of ease, we stretch the muscle and then have our patients press against our force so the muscle can see that it is allowed to contract without danger.
The Connection Between Pain and Muscle Contraction
The Yoga Connection
NOW let's bring this all to yoga. Yoga is, in a sense, a form of “self OMT.” The postures created in a yoga practice mirror many OMT techniques. Some poses (or asanas) activate muscles, but not to the point of full flexion – similar to how the muscle energy OMT treatment requires the patient to activate muscles against the doctor’s resistance, but not to the point of complete muscle contraction. On the other hand, more passive yin poses like supine spinal twist (jathara parivartanasana) or sleepng pigeon pose (eka pada rajakapotasana) puts some muscles in a position of stretch and others a position of ease. This both stretches some ligaments while shortening others, and with the help of a good yoga teacher, full release can happen. We can liken these poses to OMT techniques like balanced ligamentous tension (BLT) or facilitated positional release (FPR).
Then, my FAVORITE technique (to do for patients with OMT and also in yoga instruction) is called articulatory technique. In this technique, the physician applies a repetitive rocking motion to a joint or restricted area to open it up. I use this most commonly on the sacroiliac joints (SI joints). The nerves that exit the sacrum innervate the pelvis and genitourinary organs. Dysfunctions here are common with menstrual cramps, pelvic floor dysfunction, urinary dysfunction, hip pain and low back pain. To do this technique you have the patient lie prone (on their stomach) and place your hand in a fist position on the sacrum. You then gently rock back and forth to release the ligaments and open up nerve flow. This is also great for pregnant patients with low back pain or round ligament pain. For them, you would have them lay on their backs (supine) with your hand in the same position on the sacrum, but this time it would be underneath them. This is ideal so they don’t have to lay on their belly, and there also is the added bonus of the pressure of the patient's weight on top of the hand offers even more release. You can do this in yoga by laying on your back, placing a yoga block under your sacrum and then bringing your knees to your chest (or even in a happy baby position). Then you gently rock side to side on the yoga block… and let me tell you, this feels PHENOMENAL (and does wonders for menstrual cramps). The same technique can be applied a little higher on the low back as well. For a deeper release in this area (the lumbar spine), place the yoga block just lateral (or to the side of) the spine and either rock back and forth or lay still. In this area (the low back or lumbar area) you are treating both the quadratus lumborum muscle AND the lumbar spine. The nerves that exit here innervate the lower GI tract so this is excellent for constipation.
Other than the actual yoga poses (or asanas), we can find similarities between yoga and OMT when we look at the breath. One of the ways that yoga can be differentiated from other forms of movement or exercise is that we connect our practice to the breath– either flowing one breath to one movement, or utilizing the breath to deepen postures or enter a meditative state. Many OMT techniques can be augmented like this as well through what we call “respiratory assist”. We will have patients inhale deeply which opens up many areas like the rib cage, thoracic spine and diaphragm… followed by a deep exhale during which we augment contraction of whatever technique we are doing.
An even more interesting connection with the breath is looking at the ujjayi breath (or ocean breath). This type of breathing is central to most yoga practices and is done by constricting the back of the throat as you deeply (and audibly) inhale and exhale. I teach this to students by telling them to imagine you are fogging up a window or a pair of glasses. When you constrict the back of the throat while breathing, you are actually activating the vagus nerve– the biggest parasympathetic nerve in the body. The vagus nerve exits the skull right next to where that constriction of the throat happens, so the vibration you create with constriction during breathing actually activates it. Parasympathetic nerves control the “rest and digest” side of our autonomic nervous system. So by augmenting these nerves we create an immediate relaxation response in the body– calming the nerves and lowering the heart rate and blood pressure in real time. Many OMT techniques involve manipulating tissues around nerves so that they can function properly. Specifically cranial and cervical (neck) OMT utilizes manipulating the tissues in such a way that activates the vagus nerve to both treat headaches and full body tension.
How The Ujjayi Breath Stimulates the Vagus Nerve
Last, to round out the autonomic nervous system connection, we can look at the flow state that yoga puts us in. The dynamic sequences of vinyasa flows have us connect one breath to one movement to calm the mind and bring our focus solely to the body and the breath. This flow state makes it almost impossible to have sympathetic (“fight or flight” response) activation— one of the many reasons yoga has been shown to be a treatment for stress or high blood pressure.
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All in all, we see that everything is connected– the mind, body and spirit. This philosophy is what intrigues me so much about osteopathic medicine and integrative medicine. A deep understanding of the mind-body connection has unlimited potential to treat not only pain, but also disorders that stem from abnormalities in the autonomic nervous system, lymphatic system and more. I always tell my patients, pain actually IS “all in your head.” That doesn’t mean it isn’t real, it certainly is… but the reason we feel pain is because the body is sending signals to the brain. If we listen close enough, the body will tell us what is wrong. I will never forget in medical school when we were told that 90% of a diagnosis can be made from the history and physical exam alone. Labs and imaging are just there to confirm suspicions. The problem is that most doctors do not listen… partly because our flawed medical system does not allow the proper time to do so as we are given minimal face to face time with each patient. My hope is that as the integrative and holistic health movement is on the rise, this will change. People are fed up with doctors who do not listen and just prescribe a pill for whatever ailment they are presenting with. And as they should be. So I will end with this: take the time to listen to your body, and find a physician who will do the same.
