Academic Integrative Health Fellow, University of Wisconsin, Department of Family Medicine and Community Health, Madison
Dr. Dubey reports no financial relationships relevant to this field of study.
SUMMARY POINTS
- Several randomized, controlled trials and meta-analyses support the efficacy of osteopathic manipulative treatment (OMT) for the treatment of acute, chronic, and pregnancy-related low back pain.
- OMT has been studied in a wide range of other conditions, but so far, compelling evidence to support consistent efficacy is lacking.
- Despite the lack of robust demonstrated efficacy, the low cost and low risk of harm associated with OMT makes it an attractive integrative treatment option for trial in a variety of clinical scenarios.
SYNOPSIS: Authors of a recent literature review found compelling evidence that osteopathic manipulative treatment is effective for treating low back pain, but not for other conditions.
SOURCE: Slattengren AH, Nissly T, Blustin J, et al. Best uses of osteopathic manipulation. J Fam Pract 2017;66:743-747.
Slattengren et al recently published a literature review of the current evidence base for osteopathic manipulative treatment (OMT).1 They concluded that although evidence is compelling for treating low back pain, it was insufficient to change clinical practice for other conditions. OMT is a hands-on method of diagnosis and treatment taught to osteopathic physicians as part of a comprehensive medical education. The founder of osteopathic medicine, Andrew Taylor Still, MD (1828-1917), eschewed the dangerous medical practices of his day and instead favored structural manipulation as a method to correct aberrant physiology. Osteopathic practice is grounded in the following fundamental principles: Each person is a unit of body, mind, and spirit; structure and function are reciprocally interrelated; the body has a capacity for self-regulation and self-healing; and rational treatment is based on these principles.2 These principles emphasize the inherently holistic and integrative nature of the osteopathic philosophy.
As a form of manual medicine, OMT has evolved over the ensuing years and now includes more than 50 specific techniques for addressing somatic dysfunction, which is defined as “the impaired or altered function of the somatic system, including articulatory, myofascial, or skeletal structures, as well as related vascular, neurologic, and lymphatic elements.”2 OMT practitioners diagnose somatic dysfunction using the TART mnemonic — finding areas of Tissue texture change, Asymmetry, Restriction of motion, and/or Tenderness. Somatic dysfunction may exist secondarily to organic pathology or as a primary functional disturbance of otherwise normal anatomy. OMT may be used in either case, typically in an adjunctive fashion in the former or as primary treatment in the latter.2
Evidence for Low Back Pain
As Slattengren et al noted, small sample size and other methodological flaws historically have limited osteopathic clinical research, but recently, more robust randomized, controlled trials (RCTs) and meta-analyses have found favorable results for OMT, especially in the case of low back pain. Slattengren et al did not report their review methodology, but they discussed four meta-analyses and three RCTs, all of which demonstrated efficacy of OMT for low back pain.
The American College of Physicians now includes spinal manipulation (which overlaps with certain OMT techniques) as a first-line treatment option in its practice guidelines for low back pain.3 Additionally, Slattengren et al presented a 2014 meta-analysis of 15 RCTs that found patients receiving OMT had significant pain relief and functional improvement compared to controls;4 a 2005 meta-analysis of six RCTs that reported improved pain scores from OMT vs. controls;5 and a 2013 randomized trial comparing OMT to therapeutic ultrasound that found that OMT decreased usage of pain medications.6 Regarding low back pain in pregnancy, Slattengren et al presented two RCTs and a Cochrane review supporting the efficacy of OMT.7,8,9
Evidence for Other Conditions
Slattengren et al also discussed existing evidence for other conditions, including acute neck pain, headaches, postoperative status, pneumonia, and irritable bowel syndrome. They noted that “available data are not sufficiently significant to compel a change in clinical practice,” citing limitations of existing studies such as small sample size, lack of reproducibility, poor methodology, and/or questionable clinical significance.
Acute Neck Pain. The authors summarized a 2005 RCT that compared OMT to intramuscular (IM) ketorolac. In this study, although the ketorolac dose may have been inadequate (30 mg IM), the response to OMT was significantly greater.10 However, they noted that uncertainty regarding the clinical significance of the treatment effect limits the strength of these study results.
Headache. Slattengren et al briefly summarized two RCTs, one in which the addition of OMT to medications decreased migraine frequency compared to medication alone and sham OMT plus medication, and another in which OMT combined with progressive muscle relaxation decreased frequency of tension headaches as compared to progressive muscle relaxation alone.11,12 However, both studies had limitations, including small sample sizes, questionable clinical significance of treatment effect, and lack of repeated results in other trials.
Postoperative Care. They summarized one retrospective study that analyzed the effect of OMT on 17 of 55 patients after abdominal surgery. The treatment group had a significantly shorter time to flatus and a significantly shorter mean length of stay than the non-treatment group.13 However, since this study was retrospective, there was risk of selection bias.
Pneumonia. The authors reviewed a 2010 RCT and a 2013 Cochrane Review, both of which looked at OMT as adjunctive treatment in adults hospitalized with pneumonia. In the RCT, there was no significant effect of OMT in the intention-to-treat analysis, but in the RCT protocol analysis and Cochrane review, OMT reduced length of stay and duration of intravenous antibiotics.14,15
Irritable Bowel Syndrome. Slattengren et al reviewed both a crossover study (n = 31) and an RCT (n = 30). In both studies, OMT significantly improved symptoms,16,17 but the authors noted major limitations of both studies, including self-reported symptoms and small sample sizes.
COMMENTARY
Slattengren et al presented a succinct and practical summary of the state of osteopathic clinical research in the era of evidence-based medicine. However, the review had some concerning characteristics, which limit its usefulness in guiding clinical practice, including lack of transparency regarding review methodology, incompleteness in presentation of existing data, and absence of ECHO assessment (Efficacy, Cost, Harms, and patient Opinions) in consideration of application to practice.
Unfortunately, the authors did not report their methods regarding study selection or analysis. Results reporting was limited to synopsis of specific studies and did not include the total number of articles reviewed nor the number of studies omitted. For instance, in addition to the conditions reviewed by the authors, OMT has been studied in many other conditions, including but not limited to: asthma,18 chronic obstructive pulmonary disease,19 balance in the elderly,20 chronic pelvic pain,21 recurrent otitis media,22 neonatal prematurity,23 concussion,24,25 and infantile colic.26 It is not clear why the authors chose to omit a discussion of these data.
When engaging patients in shared decision-making, physicians should keep in mind the ECHO mnemonic as they consider potential treatment options.27 As the authors noted, while robust data on the efficacy of OMT for many conditions may be lacking, the cost efficiency, low risk of harm, and, in many cases, favorable patient opinion may sufficiently compel the integrative provider to incorporate a trial of OMT into a treatment plan for a variety of diagnoses.
In terms of cost to the patient and the healthcare system, OMT appears to be well positioned. Medicare and many private insurers reimburse for OMT, leaving patients with manageable copays. This stands in contrast to many integrative therapies for which patients often must pay out of pocket. Furthermore, if a surgery or medication adverse event can be avoided, OMT may save the healthcare system money, as well. Although more research is needed on the effect of OMT on cost of care, existing studies support the intervention as cost-neutral or cost-saving.28,29
Regarding potential for harm, the incidence of serious adverse events after OMT is rare.30 In a recent analysis of more than 1,800 OMT encounters, no serious adverse events were reported. However, it should be noted that the incidence of mild adverse events, such as increased pain or discomfort, was 2.5%.31
Patient opinion and preference also must be considered. Typically, patients favorably perceive treatment options that may allow them to avoid surgery and costly or potentially harmful medications. Furthermore, although many pharmaceutical or surgical procedures target downstream pathology, OMT is an inherently upstream intervention and may be better received by patients desiring to address the root cause of their symptomatology.
Overall, OMT is a safe, low-cost, noninvasive treatment option for a wide variety of conditions. There is now mainstream acceptance of its demonstrated efficacy for low back pain. For other conditions, robust evidence is lacking, but a trial of OMT still may be discussed with patients as a potential treatment option, especially if the service is readily available and patient preference is favorable.
REFERENCES
- Slattengren AH, Nissly T, Blustin J, et al. Best uses of osteopathic manipulation. J Fam Pract 2017;66:743-747.
- Chila A. Foundations for Osteopathic Medicine. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2011: 3-21.
- Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2017;166:514-530.
- Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: A systematic review and meta-analysis. BMC Musculoskelet Disord 2014;15:286.
- Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative treatment for low back pain: A systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2005;6:43.
- Licciardone JC, Minotti DE, Gatchel RJ, et al. Osteopathic manual treatment and ultrasound therapy for chronic low back pain: A randomized controlled trial. Ann Fam Med 2013;11:122-129.
- Licciardone JC, Aryal S. Prevention of progressive back-specific dysfunction during pregnancy: An assessment of osteopathic manual treatment based on Cochrane Back Review Group criteria. J Am Osteopath Assoc 2013;113:728-736.
- Hensel KL, Buchanan S, Brown SK, et al. Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects: The PROMOTE study. Am J Obstet Gynecol 2015;212:108.e101-109.
- Pennick V, Liddle SD. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev 2013:CD001139.
- McReynolds TM, Sheridan BJ. Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: A randomized clinical trial. J Am Osteopath Assoc 2005;105:57-68.
- Cerritelli F, Ginevri L, Messi G, et al. Clinical effectiveness of osteopathic treatment in chronic migraine: 3-armed randomized controlled trial. Complement Ther Med 2015;23:149-156.
- Anderson RE, Seniscal C. A comparison of selected osteopathic treatment and relaxation for tension-type headaches. Headache 2006;46:1273-1280.
- Baltazar GA, Betler MP, Akella K, et al. Effect of osteopathic manipulative treatment on incidence of postoperative ileus and hospital length of stay in general surgical patients. J Am Osteopath Assoc 2013;113:204-209.
- Noll DR, Degenhardt BF, Morley TF, et al. Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: A randomized controlled trial. Osteopath Med Prim Care 2010;4:2.
- Yang M, Yan Y, Yin X, et al. Chest physiotherapy for pneumonia in adults. Cochrane Database Syst Rev 2013(2):CD006338.
- Attali TV, Bouchoucha M, Benamouzig R. Treatment of refractory irritable bowel syndrome with visceral osteopathy: Short-term and long-term results of a randomized trial. J Dig Dis 2013;14:654-661.
- Florance BM, Frin G, Dainese R, et al. Osteopathy improves the severity of irritable bowel syndrome: A pilot randomized sham-controlled study. Eur J Gastroenterol Hepatol 2012;24:944-949.
- Guiney PA, Chou R, Vianna A, Lovenheim J. Effects of osteopathic manipulative treatment on pediatric patients with asthma: A randomized controlled trial. J Am Osteopath Assoc 2005;105:7-12.
- Engel RM, Vemulpad SR. Immediate effects of osteopathic manipulative treatment in elderly patients with chronic obstructive pulmonary disease. J Am Osteopath Assoc 2008;108:541-542.
- Lopez D, King HH, Knebl JA, et al. Effects of comprehensive osteopathic manipulative treatment on balance in elderly patients: A pilot study. J Am Osteopath Assoc 2011;111:382-388.
- Marx S, Cimniak U, Beckert R, et al. [Chronic prostatitis/chronic pelvic pain syndrome. Influence of osteopathic treatment — a randomized controlled study]. Urologe A 2009;48:1339-1345.
- Mills MV, Henley CE, Barnes LL, et al. The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media. Arch Pediatr Adolesc Med 2003;157:861-866.
- Lanaro D, Ruffini N, Manzotti A, Lista G. Osteopathic manipulative treatment showed reduction of length of stay and costs in preterm infants: A systematic review and meta-analysis. Medicine (Baltimore) 2017;96:e6408.
- Guernsey DT, Leder A, Yao S. Resolution of concussion symptoms after osteopathic manipulative treatment: A case report. J Am Osteopath Assoc 2016;116:e13-17.
- Chappell C, Dodge E, Dogbey GY. Assessing the immediate effect of osteopathic manipulation on sports related concussion symptoms. Osteopath Fam Phys 2015;7:30-35.
- Dobson D, Lucassen PL, Miller JJ, et al. Manipulative therapies for infantile colic. Cochrane Database Syst Rev 2012;12:CD004796.
- Rakel D. Integrative Medicine. 4th ed. Philadelphia: Elsevier; 2018.
- Gamber R, Holland S, Russo DP, et al. Cost-effective osteopathic manipulative medicine: A literature review of cost-effectiveness analyses for osteopathic manipulative treatment. J Am Osteopath Assoc 2005;105:357-367.
- Schabert E, Crow WT. Impact of osteopathic manipulative treatment on cost of care for patients with migraine headache: A retrospective review of patient records. J Am Osteopath Assoc 2009;109:403-407.
- Seffinger MA. The safety of osteopathic manipulative treatment (OMT). J Am Osteopath Assoc 2018;118:137-138.
- Degenhardt BF, Johnson JC, Brooks WJ, Norman L. Characterizing adverse events reported immediately after osteopathic manipulative treatment. J Am Osteopath Assoc 2018;118:141-149.
Authors of a recent literature review found compelling evidence that osteopathic manipulative treatment is effective for treating low back pain, but not for other conditions.
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