Role of Osteopathic Manipulation in the Treatment of Back Pain
By Georges Ramalanjaona, MD, DSc, FACEP, MBA, and Joseph J. Calabro, DO, FACOEP, FACEP
Acute low back pain is the most prevalent ailment and most frequent cause of disability for persons younger than age 45 in the United States: Back pain injuries comprise 33% of all national disability costs and 21% of all compensable work injuries.1 Eighty percent of people in developed Western societies suffer from one or more episodes of low back pain during their lifetime.
The current evidence for the effectiveness of osteopathic manipulation (OM) in the management of back pain is compelling and deserves a careful review.
Pathophysiology of Back Pain
Multiple theories have been advanced to explain the pathophysiology of back pain. Knowledge of four basic possible mechanisms involved in the production of back pain is important in understanding the role of OM in its treatment.2 They include:
- disc protrusion after injury of the annulus and stretching of the nerve root;
- scar tissue formation (or adhesion) between lamellae of the disc and capsule;
- muscle contractures controlling the joints; and
- deformation of the articular surfaces with restriction of movements.
Mechanism of Action
The accepted rationale usually given for the benefits of OM in the management of back pain includes:3
- correction of internal displacement of the disc fragments and reduction of a bulging disc (controversial);
- freeing of adhesions around a prolapsed disc;
- inhibition of transmission of nociceptive impulses;
- relaxation of tense muscle by sudden stretching; unbuckling motion segments that have undergone disproportionate displacements; and
- relaxation of entrapped synovial folds.
Osteopathic Techniques
OM manipulates muscles, tendons, and bones to promote blood flow through tissues. It consists of manual application of forces to the spinal structure to restore normal vertebral biomechanics and relieve pain. It utilizes a variety of techniques to alleviate back pain. A single OM session usually requires 2-6 minutes to perform.
The principal goal of OM is to relieve pain and improve function by normalizing movement and position. All osteopathic physicians are trained in OM during their residency program and are required to pass written examinations in OM before graduation from a college of osteopathic medicine, though the intensity and depth of training varies from one college to the next. OM is classified into soft-tissue techniques, articulation, and mobilization.4
Soft-tissue techniques stretch the skin and muscle tissues to promote their motion and elasticity, either as a specific therapeutic goal or in preparation for other procedures (e.g., strain-counter strain and the myofascial release).
Articulation consists of repetitive, oscillatory movements to break a restrictive barrier (capsule, ligaments, and paravertebral muscles). The goal is to improve range of movement by stretching connective tissue around a restricted joint (e.g., using high-velocity, low-amplitude [HVLA] manipulation).
Mobilization engages the restrictive barrier of the involved joint, followed by a HVLA manipulation. HVLA manipulation is the most frequently used OM technique and has the greatest potential for significant complications. The therapist, after identifying the dysfunctional segment, locks the inferior facets, thus eliminating spinal segmental motion except at the involved vertebrae. A sharp thrust is directed to the involved vertebrae in the direction of the limitation of movement. When the thrust is directed through the locked vertebral column, it is called indirect technique. If it is delivered directly to the spinal or transverse process of the involved vertebrae, it is called short-lever technique.
Although direct techniques provide significant pain relief compared to indirect manipulations, their use increases potential complications due to the high forces applied directly to the affected region. Thus, it is important to rule out any areas of fracture/dislocation prior to their use.
Clinical Studies
Controlled clinical trials comparing studies have been performed in an outpatient setting. Here, we summarize the most relevant and significant trials that provide level of evidence I on a scale of I to III for OM effectiveness in the treatment of back pain (see Table).
In a prospective, stratified controlled trial, Hadler et al studied the effect of OM vs. mobilization on 57 patients suffering from acute low back pain.5 Randomization was stratified into those who suffered back pain for less than two weeks (S1) and those who suffered back pain for 2-4 weeks (S2). Outcome was monitored by a self-administered survey questionnaire assessing functional impairment. The OM group in S2 showed statistically significant improvement (P < 0.02) in pain during the first two weeks (50% first week, 80% second week) compared to the mobilization group. The same finding was replicated in an open controlled trial assessing the effect of OM vs. back pain education in 95 patients with nonspecific back pain.6
In another randomized clinical trial of 256 patients with sub-acute neck/back pain (six weeks or more), Koes et al found no difference in effectiveness between OM and physiotherapy for the principal outcome measurement (severity of complaints, global perceived effects, and physical functioning) during a three-, six-, and 12-week short-term follow-up.7 However, the results of one-year follow-up of the same cohort of patients showed that OM produced a significant improvement in the main complaint (difference 0.9, 95% confidence interval [CI] 0.1-1.7) and in physical functioning (difference 0.9, 95% CI -0.1 to -1.3) vs. physiotherapy.8 Both OM and physiotherapy were clearly more significantly effective than placebo and general practitioner treatment after 12 months.
A recent landmark article by Andersson et al reported a 12-week randomized, double-blind, controlled trial of 178 patients from two outpatient clinics who suffered back pain for at least three weeks but less than six months.9 These patients were treated either with OM (n = 83) or with one or more standard medical therapies (n = 72). The authors found no statistically significant differences between the two groups in any primary outcome measure, including scores on the Roland Morris and Oswestry questionnaires (assessing loss of function due to back pain), visual analogue pain scale, range of motion, and straight leg raising. Furthermore, the OM group required significantly less medication (P < 0.001) and less physical therapy (P < 0.05) than the standard therapy group.
A recent meta-analysis of 23 randomized, controlled clinical trials showed stronger and more consistent effectiveness of OM in the treatment of low back pain than any other alternative treatment, including drugs, mobilization, and physiotherapy.10 OM displayed a significant overall effect size for 86% of outcome variables compared to alternative treatments. However, these findings were based on a limited number of true controls (or on placebo) and variable outcome measurements, so the usefulness of the meta-analysis is modest.
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Table |
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Recent clinical trials of osteopathic manipulation (OM) in treatment of low back pain |
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| Study | Condition | N | Treatment | Results |
| Hadler et al5 | acute | 54 | OM vs. mobilization | OM group improved short-term (P < 0.02) |
| MacDonald et al6 | acute | 95 | OM vs. education | OM group improved short term |
| Koes et al7 | sub-acute | 256 | OM vs. physiotherapy (PT) vs. drug therapy | OM and PT groups improved short term |
| Koes et al8 s | ub-acute | 256 | OM vs. PT vs. drug therapy | OM group significantly improved vs. PT group in long term |
| Andersson et al9 | sub-acute | 178 | OM vs. standard therapy | No difference between the two groups |
Adverse Effects
The most frequently reported complications of OM are vertebrobasilar accidents (one per 20,000 patients after cervical manipulation), followed by cauda equina syndrome and disc herniation.11 These same complications are seen in both OM and chiropractic manipulation (CM), with a slightly higher proportion of complications in CM. In general, these rare but serious adverse effects can be prevented by pre-manipulative evaluation and adherence to recognized techniques.
Contraindications and Precautions
Standard radiologic studies should be obtained in patients with a history of trauma to rule out fracture and dislocation. Absolute contraindications to OM include vertebral fractures/dislocation, infections, malignancy, spondylolisthesis, spondyloarthropathies (psoriasis, Reiter’s Syndrome), myelopathy, cauda equina syndrome, vertebral hypermobility (Marfan’s and Ehlers-Danlos syndrome), and anticoagulation therapy.12 Relative contraindications are pregnancy, radiculopathy, and vertebrobasilar artery insufficiency. The role of OM in the pediatric population has not been extensively studied; thus, the risk:benefit ratio cannot be determined.
Regulation and Reimbursement
Recent guidelines published by the Agency for Healthcare Research and Quality recommend the use of spinal manipulation (including OM) for the treatment of low back pain.13 OM can be used either as primary therapy or as an adjunct to other interventions.14 It usually is practiced by osteopathic physicians, and recently has obtained its own reimbursement rates.
Conclusion
OM is a safe and effective intervention for short-term pain relief and functional improvement of acute/sub-acute back pain in outpatient clinics.
Recommendation
Based on current data, OM is recommended as a reasonable adjunctive maneuver for the short-term symptomatic pain relief and functional improvement of musculoskeletal acute/sub-acute back pain in an outpatient clinic. Further clinical trials are needed to assess long-term effectiveness of OM (more than 24 weeks with at least eight sessions) in patients with back pain.
Dr. Ramalanjaona is Associate Chairman for Academic Affairs, and Dr. Calabro is Chairman and Associ-ate Professor, Department of Emergency Medicine, Seton Hall University, School of Graduate Medical Education, South Orange, NJ. Dr. Ramalanjaona also is Director of Research, Division of Emergency Medicine, St. Michael’s Hospital, Newark, NJ.
References
1. Pope MH, et al. Occupational Low Back Pain. New York: Preager; 1984.
2. Jayson M. Mechanisms underlying chronic back pain. BMJ 1994;309;681-682.
3. Curtis P, et al. Spinal manipulation: Does it work? Occup Med 1988;3:31-44.
4. Williams N. Managing back pain in general practice—is osteopathy the new paradigm? Br J Gen Pract 1997;47:653-655.
5. Hadler NM, et al. A benefit of spinal manipulation as adjunctive therapy for acute low back pain: A stratified controlled trial. Spine 1987;12:702-706.
6. MacDonald RS, Bell CM. An open controlled assessment of osteopathic manipulation in nonspecific low-back pain. Spine 1990;15:364-370.
7. Koes BW, et al. Spinal manipulation and mobilization for back and neck pain: A blinded review. BMJ 1991; 303:1298-1303.
8. Koes BW, et al. Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: Results of one year follow up. BMJ 1992;304:601-605.
9. Andersson GB, et al. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med 1999;341: 1426-1431.
10. Anderson R, et al. A meta-analysis of clinical trials of spinal manipulation. J Manipulative Physiol Ther 1992;15:181-194
11. Assendelft WJ, et al. Complications of spinal manipulation: A comprehensive review of the literature. J Fam Pract 1996;42:475-480.
12. Koss RW. Quality assurance monitoring of osteopathic manipulation treatment. J Am Osteopathic Assoc 1990;90:427-434.
13. Bigos S, et al. Acute low back pain problems in adults. Clinical practice guideline No.14. Rockville, MD: Agency for Healthcare Research and Quality; 1994: Publication No.95-0642.
14. Paul FA, Buser BR. Osteopathic manipulative treatment applications for the emergency department patient. J Am Osteopathic Assoc 1996;96:403-409.
Ramalanjaona G, Calabro JJ. Role of osteopathic manipulation in the treatment of low back pain. Altern Med Alert 2002;5:93-96.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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