Selected Podcast
What in the World is Neuromusculo-Skeletal Medicine
Dr. James Sullivan explains the difference between chiropractic medicine and musculoskeletal manipulation and if musculoskeletal manipulation is a good option for me.
Featured Speaker:
James Sullivan, DO-Family medicine and Neuromusculo-Skeletal Medicine boarded physician Southern New Hampshire Health
James C. Sullivan, DO, is a Family Medicine Boarded physician fellowship trained in Neuromusculo-skeletal Medicine. He graduated LMU- Debusk college of Osteopathic Medicine in 2014 and completed his residency training at Southampton Hospital’s Integrated Family Medicine and Neuromusculo-Skeletal Medicine program. Transcription:
What in the World is Neuromusculo-Skeletal Medicine
Evo Terra (Host): Have you ever heard of neuromusculoskeletal medicine? What would your reaction be if your primary care physician recommended a referral to a specialist with training in that particular modality? To help us both understand that better, my guest today is Dr. James Sullivan, D, a family medicine and neuromusculoskeletal medicine boarded physician. This is the Solution Health podcast from Solution Health. I'm Evo Terra. Dr. Sullivan, could you please explain the difference between chiropractic medicine and musculoskeletal manipulation?
James Sullivan, DO (Guest): Musculoskeletal manipulation first off is a treatment modality that is administered by a physician, and it does so with regards to all of the soft tissues, the fascia, the cranial mechanism. We have the ability to investigate and further prescribe pharmaceuticals if need be, use injections, basically a full doctor.
Host: What types of ailments and/or pain would you treat?
Dr. Sullivan: That’s probably too long of a list for this broadcast. I could tell you if there is a joint, any place two muscles meet that are butted up with cartilage where muscles attach to it, I can work there.
Host: Okay. Got it. When patients are seeking out treatment, when would they know that musculoskeletal manipulation is something that might be a good option for them?
Dr. Sullivan: That’s something of an ambiguous question because honestly, I don’t even know until I've examined somebody. It’s definitely a conversation to have with your physician. I'm very open to taking calls and messages from other physicians, and I've done so often. I've been a little bit surprised with what patients really don’t share with their primary care physician. In my opinion, I shouldn’t be the first to hear about anything. I foster a patient having a good relationship with their primary care doctor. They should definitely be involved in that decision-making process. As far as my role in things, sometimes neuromusculoskeletal medicine and osteopathic manipulation are an adjunct that can improve patient outcomes. Sometimes it takes center stage, and I'm good with either.
Host: So I think, if I hear you correctly in this, it’s speak with your primary care physician first, and they may suggest to you that musculoskeletal manipulation might be a good course of treatment. Do I have that right?
Dr. Sullivan: Yes.
Host: Okay. Great. So let’s say that I've done that. Walk through a little role playing here. If my primary care physician says, “Yes, you should go see Dr. Sullivan” or my local Dr. Sullivan as it might be, what can I expect? What’s a typical visit with a doctor like yourself?
Dr. Sullivan: The initial visit is typically going over a lot of history of robust trauma history. Not just that you were in a car accident in 1989 per se, but which side were you hit on? How fast were they going? Because it’s important in some instances to understand the full breadth of what happened to the body, to understand how it dealt with it, and what I might be dealing with looking at it from my end. Examining all the relevant imaging and things to go along with the problem, a very thorough physical exam looking at usually—you can never say always or never in medicine—but usually investigating any kind of nerve impingement to begin with, and then screening for any honest to goodness orthopedic injury or frank injury that may be involved. Only then can I really judge what should be done next, that is if I can employ osteopathic manipulation or if I need to do further imaging. If I think there's a frank injury, what steps should we take there? Does it require referral to see someone else? Can I do something about it in my office? All these things come into consideration from the first that I see someone.
0 The fact that in my practice, I have the ability to do anything a physician may do, but the chief reason that people come to see me—that people seek me out typically—is for my skill with my hands and my expertise in manual manipulation. So manual manipulation is safe to do. It has the ability to restore any joint to its normal resting position, it’s physiologic resting position, and undo any muscular compensation that may be affecting it to essentially short circuit the body’s spasm response. That can be used not only as a treatment, but also as a diagnostic. The diagnostic value is not to be understated. If I can remove somebody’s compensation and they still have pain or lord forbid pain gets worse then that may be cause to investigate further. That may be evidence that the body is in fact guarding against some type of a soft tissue injury. Oftentimes we go down a route of investigating following that. Essentially what somebody can expect on their first visit is a very long talk and a very thorough physical.
Host: Sure.
Dr. Sullivan: And perhaps a test treatment if it’s appropriate to do so.
Host: When you are doing a treatment—again, you're calling it manual manipulation—if it is in fact appropriate to do so for the secondary visit or perhaps beyond that. I guess the first question I have for it is when you're doing this manual manipulation, is that something that—Well, I'm just going to ask it. Does it hurt?
Dr. Sullivan: I’d have to say yes. My hands ache sometimes at the end of the day, but only if I've been doing yardwork recently. No, normally there’s no pain involved. Maybe a slight bit of discomfort. I always warn patients going forward from that first visit that they’re not allowed to sing my praises or curse my name for four full days because things will be in flux. Their body is going to be trying to readjust its normal resting tone to hang on to normal. It’s not going to be whatever it’s going to be for four full days. That’s part of the body’s process. These timelines aren’t really arbitrary. It’s something that we’ve come to note.
Host: So we should not expect immediate results from something. It takes a few days, as you say, to really notice the effects.
Dr. Sullivan: Some immediate results, but yes. It’s something that comes to fruition over the course of days.
Host: You said some immediate results. What sort of immediate results might be experienced?
Dr. Sullivan: I've had patients report right off the bat that wow, this seems less severe or it doesn’t hurt when I bend this way anymore. That’s just the start. At the same time, some patients will leave the office feeling great. They’ll tell me when I see them again, “Oh my god the next day I could barely move, but the day after that it was much better. I don’t know what in the world happened.” It’s all kind of part of the process.
Host: Sure. So if someone is having a conversation with their primary care doctor and the primary care physician says, “Maybe we need to refer you out to a musculoskeletal specialist,” like yourself, when is the right time for someone to have that conversation with their doctor? Does the doctor bring it up? Does the patient bring it up? Who’s responsible here?
Dr. Sullivan: It really can be a conversation that’s initiated by either party. Certainly, and I remember from my days as a primary care physician, sometimes I was teaching patients and sometimes I was learning from them. So if it’s something that your doctors never heard of and that you're interested in, bring it up. Let them do the research. Obviously let them be the steward of your healthcare and decide if that is what’s best and right. It’s a two-way conversation.
Host: Sure. So I'm trying to think back in the number of times I visit in my various primary care physicians over the last 52 years. I think I've been referred out to a chiropractor once or twice, but I don’t think at any time has a doctor suggested I go see someone that is a specialist in neuromusculoskeletal medicine. Or maybe they were, it’s just a different terminology now. What’s been your experience? Is something new?
Dr. Sullivan: The specialty of neuromusculoskeletal medicine was something that was really founded around 1995. It was—So DOs have learned manual manipulation for as long as DOs have been around. It was the cornerstone of the practice. So it’s been 130 odd years. The specialty of neuromusculoskeletal medicine was put out there, an idea to found a specialty to set apart those that are experts at manual manipulation. Not just a DO specialty…Any DO of any specialty can do manual manipulation. They have the right to practice if they feel confident in doing so. That specialty of neuromusculoskeletal medicine was put out there to help to distinguish those DOs who are experts in manual manipulation, and also impart them with a hybrid knowledge base. So we learn the clinical knowledge base of a sports medicine physician, we learn the clinical knowledge base of an orthopedist, and we learn a piece of the clinical knowledge base of neurosurgeons so that we can identify those things that we will eventually come across. It is an eventuality that you will come across something that needs to see them. That way we can get the patient to all the people that they need to see.
Host: It sounds like quite the blending of different modalities together.
Dr. Sullivan: Yes. I really found that in most health systems and the healthcare field, it really is the missing piece of the puzzle for things that just…Extremes of back pain that you really don’t see anything on an MRI and they really don’t know what to do. So it’s musculoskeletal. Take ibuprofen, take muscle relaxers, and go rest in bed. If it’s musculoskeletal, it belongs to me. It makes me wish that the neuromusculoskeletal medicine specialty wasn’t such a rare commodity to come across as it does seem to be.
Host: Why do you think that is? Why do you think the specialty is so rare?
Dr. Sullivan: It goes all the way back to osteopathic medical school. Every last student in osteopathic medical school has to learn manual manipulation, has to learn the basics. How to feel if something is off, and four basic techniques that are the tenants of what we’re tested on in order to graduate. Many of us don’t come to utilize it within the scope of our practice. Many of us will never see it again after medical school. There's a percentage of a medical school class really. I graduated in a class of 150. Out of 150 of us, there were maybe 10 that were any good at all with their hands. Out of that 10, maybe three of us went on into a specialty that utilizes that in an expert manner. I'm speaking of neuromusculoskeletal medicine and some physiatry programs also foster that osteopathic component as a feature of that program. It’s a little bit of a self-selecting bias. You must have the interest, you must have the skill, and there has to be a program out there that will accept people. That’s the other side of things. Out of as many hopefuls that approach these fellowship programs to learn neuromusculoskeletal medicine, it’s a pretty tough selection process. It’s not a guarantee. Then you go to the boarding process, the actual testing of people is completed, a board accredited program. It is a fact that about 50% of those tested will fail one or more parts of the board. 50%. That is holding a high standard.
Host: Definitely so. Well Dr. Sullivan, this has been quite the fascinating conversation. Thank you for your time.
Dr. Sullivan: You're welcome. Anytime.
Host: Again, that was Dr. James Sullivan, DO, a family medicine and neuromusculoskeletal medicine boarded physician. To learn more about neuromusculoskeletal medicine and other innovative models of care, please visit solutionhealth.org. Thank you for listening to this episode of the Solution Health podcast. I am Evo Terra.
What in the World is Neuromusculo-Skeletal Medicine
Evo Terra (Host): Have you ever heard of neuromusculoskeletal medicine? What would your reaction be if your primary care physician recommended a referral to a specialist with training in that particular modality? To help us both understand that better, my guest today is Dr. James Sullivan, D, a family medicine and neuromusculoskeletal medicine boarded physician. This is the Solution Health podcast from Solution Health. I'm Evo Terra. Dr. Sullivan, could you please explain the difference between chiropractic medicine and musculoskeletal manipulation?
James Sullivan, DO (Guest): Musculoskeletal manipulation first off is a treatment modality that is administered by a physician, and it does so with regards to all of the soft tissues, the fascia, the cranial mechanism. We have the ability to investigate and further prescribe pharmaceuticals if need be, use injections, basically a full doctor.
Host: What types of ailments and/or pain would you treat?
Dr. Sullivan: That’s probably too long of a list for this broadcast. I could tell you if there is a joint, any place two muscles meet that are butted up with cartilage where muscles attach to it, I can work there.
Host: Okay. Got it. When patients are seeking out treatment, when would they know that musculoskeletal manipulation is something that might be a good option for them?
Dr. Sullivan: That’s something of an ambiguous question because honestly, I don’t even know until I've examined somebody. It’s definitely a conversation to have with your physician. I'm very open to taking calls and messages from other physicians, and I've done so often. I've been a little bit surprised with what patients really don’t share with their primary care physician. In my opinion, I shouldn’t be the first to hear about anything. I foster a patient having a good relationship with their primary care doctor. They should definitely be involved in that decision-making process. As far as my role in things, sometimes neuromusculoskeletal medicine and osteopathic manipulation are an adjunct that can improve patient outcomes. Sometimes it takes center stage, and I'm good with either.
Host: So I think, if I hear you correctly in this, it’s speak with your primary care physician first, and they may suggest to you that musculoskeletal manipulation might be a good course of treatment. Do I have that right?
Dr. Sullivan: Yes.
Host: Okay. Great. So let’s say that I've done that. Walk through a little role playing here. If my primary care physician says, “Yes, you should go see Dr. Sullivan” or my local Dr. Sullivan as it might be, what can I expect? What’s a typical visit with a doctor like yourself?
Dr. Sullivan: The initial visit is typically going over a lot of history of robust trauma history. Not just that you were in a car accident in 1989 per se, but which side were you hit on? How fast were they going? Because it’s important in some instances to understand the full breadth of what happened to the body, to understand how it dealt with it, and what I might be dealing with looking at it from my end. Examining all the relevant imaging and things to go along with the problem, a very thorough physical exam looking at usually—you can never say always or never in medicine—but usually investigating any kind of nerve impingement to begin with, and then screening for any honest to goodness orthopedic injury or frank injury that may be involved. Only then can I really judge what should be done next, that is if I can employ osteopathic manipulation or if I need to do further imaging. If I think there's a frank injury, what steps should we take there? Does it require referral to see someone else? Can I do something about it in my office? All these things come into consideration from the first that I see someone.
0 The fact that in my practice, I have the ability to do anything a physician may do, but the chief reason that people come to see me—that people seek me out typically—is for my skill with my hands and my expertise in manual manipulation. So manual manipulation is safe to do. It has the ability to restore any joint to its normal resting position, it’s physiologic resting position, and undo any muscular compensation that may be affecting it to essentially short circuit the body’s spasm response. That can be used not only as a treatment, but also as a diagnostic. The diagnostic value is not to be understated. If I can remove somebody’s compensation and they still have pain or lord forbid pain gets worse then that may be cause to investigate further. That may be evidence that the body is in fact guarding against some type of a soft tissue injury. Oftentimes we go down a route of investigating following that. Essentially what somebody can expect on their first visit is a very long talk and a very thorough physical.
Host: Sure.
Dr. Sullivan: And perhaps a test treatment if it’s appropriate to do so.
Host: When you are doing a treatment—again, you're calling it manual manipulation—if it is in fact appropriate to do so for the secondary visit or perhaps beyond that. I guess the first question I have for it is when you're doing this manual manipulation, is that something that—Well, I'm just going to ask it. Does it hurt?
Dr. Sullivan: I’d have to say yes. My hands ache sometimes at the end of the day, but only if I've been doing yardwork recently. No, normally there’s no pain involved. Maybe a slight bit of discomfort. I always warn patients going forward from that first visit that they’re not allowed to sing my praises or curse my name for four full days because things will be in flux. Their body is going to be trying to readjust its normal resting tone to hang on to normal. It’s not going to be whatever it’s going to be for four full days. That’s part of the body’s process. These timelines aren’t really arbitrary. It’s something that we’ve come to note.
Host: So we should not expect immediate results from something. It takes a few days, as you say, to really notice the effects.
Dr. Sullivan: Some immediate results, but yes. It’s something that comes to fruition over the course of days.
Host: You said some immediate results. What sort of immediate results might be experienced?
Dr. Sullivan: I've had patients report right off the bat that wow, this seems less severe or it doesn’t hurt when I bend this way anymore. That’s just the start. At the same time, some patients will leave the office feeling great. They’ll tell me when I see them again, “Oh my god the next day I could barely move, but the day after that it was much better. I don’t know what in the world happened.” It’s all kind of part of the process.
Host: Sure. So if someone is having a conversation with their primary care doctor and the primary care physician says, “Maybe we need to refer you out to a musculoskeletal specialist,” like yourself, when is the right time for someone to have that conversation with their doctor? Does the doctor bring it up? Does the patient bring it up? Who’s responsible here?
Dr. Sullivan: It really can be a conversation that’s initiated by either party. Certainly, and I remember from my days as a primary care physician, sometimes I was teaching patients and sometimes I was learning from them. So if it’s something that your doctors never heard of and that you're interested in, bring it up. Let them do the research. Obviously let them be the steward of your healthcare and decide if that is what’s best and right. It’s a two-way conversation.
Host: Sure. So I'm trying to think back in the number of times I visit in my various primary care physicians over the last 52 years. I think I've been referred out to a chiropractor once or twice, but I don’t think at any time has a doctor suggested I go see someone that is a specialist in neuromusculoskeletal medicine. Or maybe they were, it’s just a different terminology now. What’s been your experience? Is something new?
Dr. Sullivan: The specialty of neuromusculoskeletal medicine was something that was really founded around 1995. It was—So DOs have learned manual manipulation for as long as DOs have been around. It was the cornerstone of the practice. So it’s been 130 odd years. The specialty of neuromusculoskeletal medicine was put out there, an idea to found a specialty to set apart those that are experts at manual manipulation. Not just a DO specialty…Any DO of any specialty can do manual manipulation. They have the right to practice if they feel confident in doing so. That specialty of neuromusculoskeletal medicine was put out there to help to distinguish those DOs who are experts in manual manipulation, and also impart them with a hybrid knowledge base. So we learn the clinical knowledge base of a sports medicine physician, we learn the clinical knowledge base of an orthopedist, and we learn a piece of the clinical knowledge base of neurosurgeons so that we can identify those things that we will eventually come across. It is an eventuality that you will come across something that needs to see them. That way we can get the patient to all the people that they need to see.
Host: It sounds like quite the blending of different modalities together.
Dr. Sullivan: Yes. I really found that in most health systems and the healthcare field, it really is the missing piece of the puzzle for things that just…Extremes of back pain that you really don’t see anything on an MRI and they really don’t know what to do. So it’s musculoskeletal. Take ibuprofen, take muscle relaxers, and go rest in bed. If it’s musculoskeletal, it belongs to me. It makes me wish that the neuromusculoskeletal medicine specialty wasn’t such a rare commodity to come across as it does seem to be.
Host: Why do you think that is? Why do you think the specialty is so rare?
Dr. Sullivan: It goes all the way back to osteopathic medical school. Every last student in osteopathic medical school has to learn manual manipulation, has to learn the basics. How to feel if something is off, and four basic techniques that are the tenants of what we’re tested on in order to graduate. Many of us don’t come to utilize it within the scope of our practice. Many of us will never see it again after medical school. There's a percentage of a medical school class really. I graduated in a class of 150. Out of 150 of us, there were maybe 10 that were any good at all with their hands. Out of that 10, maybe three of us went on into a specialty that utilizes that in an expert manner. I'm speaking of neuromusculoskeletal medicine and some physiatry programs also foster that osteopathic component as a feature of that program. It’s a little bit of a self-selecting bias. You must have the interest, you must have the skill, and there has to be a program out there that will accept people. That’s the other side of things. Out of as many hopefuls that approach these fellowship programs to learn neuromusculoskeletal medicine, it’s a pretty tough selection process. It’s not a guarantee. Then you go to the boarding process, the actual testing of people is completed, a board accredited program. It is a fact that about 50% of those tested will fail one or more parts of the board. 50%. That is holding a high standard.
Host: Definitely so. Well Dr. Sullivan, this has been quite the fascinating conversation. Thank you for your time.
Dr. Sullivan: You're welcome. Anytime.
Host: Again, that was Dr. James Sullivan, DO, a family medicine and neuromusculoskeletal medicine boarded physician. To learn more about neuromusculoskeletal medicine and other innovative models of care, please visit solutionhealth.org. Thank you for listening to this episode of the Solution Health podcast. I am Evo Terra.