When to consider osteopathic manipulation

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Applied Evidence

When to consider osteopathic manipulation

J Fam Pract. 2010 May;59(5):E5-E8

By

Jeremy Reed, DO

Sarah Cole, DO

Patients with low back pain, headache, and neck pain can benefit from this approach.

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References

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5. McPartland JM, Giuffrida A, King J, et al. Cannabimimetic effects of osteopathic manipulative treatment. J Am Osteopath Assoc. 2005;105:283-291.

6. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.

7. Low back pain, adult (guideline). Institute for Clinical Systems Improvement. November 2008. Available at: http://www.icsi.org/guidelines_and_more/gl_os_prot/ musculo-skeletal/low_back_pain/low_back_pain__adult_5. html. Accessed April 8, 2010.

8. Johnson SM, Kurtz ME. Conditions and diagnoses for which osteopathic primary care physicians and specialists use osteopathic manipulative treatment. J Am Osteopath Assoc. 2002;102:527-532.

9. Licciardone J, Brimhall A, King L. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskel Dis. 2005;6:43-55.

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11. Licciardone J, Stoll ST, Fulda KG, et al. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine. 2003;28:1355-1362.

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PRACTICE RECOMMENDATIONS

• Consider osteopathic manipulation for low back pain that has not responded to customary care, and other musculoskeletal pain such as headache or neck pain. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

A patient of yours has nonspecific back pain that fails to improve with the usual self-care measures. He asks you whether osteopathic manipulation might help. Would you be prepared to discuss the relevant clinical evidence?

For a patient such as this, expert guidelines do recommend referral for osteopathic spinal manipulation, which, if performed by a qualified physician, may be efficacious and cost effective. Limited data show that osteopathic manipulation may also be effective for nonspinal disorders.

We conducted a systematic review of the evidence for osteopathic manipulative treatment (OMT) as applied to several conditions. Specifically, we searched PubMed for English language articles published between 1970 and December 2007, using the keywords osteopathy, osteopathic medicine, osteopathic manipulation, spinal manipulation, and somatic dysfunction. Our findings follow.

How OMT contributes to wellness

Osteopathic manipulative procedures are based on the premise that the neuromuscular system is vital to maintaining homeostasis. Changes in the musculoskeletal system can affect other organs (somatovisceral reflex), and visceral pathology can manifest as abnormalities in musculoskeletal tissue texture and articular motion (viscerosomatic reflex).¹ These musculoskeletal changes are diagnosed as somatic dysfunction and are assigned International Statistical Classification of Diseases and Related Health Problems (ICD-9) codes corresponding to the area of the body in which these changes are palpated.² Similarly, OMT therapeutic procedures are assigned Evaluation and Management (E&M) codes corresponding to the number of body areas treated.

OMT comprises more than 100 different techniques used to treat somatic dysfunction. Some techniques are similar to those used by chiropractors and physical or massage therapists; others are unique to osteopathically trained physicians.

OMT has multiple physiologic effects. Mechanically, OMT causes articular release, freeing joint motion. Neuromuscularly, OMT generates afferent input into the dorsal root ganglion, diminishing motor neuron discharge and relaxing muscle fibers.³ Vascularly, OMT may increase nitric oxide concentration in the blood, promoting vasodilatation and increasing blood flow to peripheral vascular tissue.⁴ Neurochemically, OMT can transiently increase serum levels of anandamide, stimulating cannabinoid receptors in the brain.⁵

What the evidence says about OMT for back pain

Joint clinical practice guidelines issued in 2007 by the American College of Physicians and the American Pain Society give a weak recommendation based on moderate-quality evidence that manipulation is an appropriate nonpharmacologic modality for treating nonspecific acute and chronic low back pain that fails to improve with self-care.⁶

The Institute for Clinical Systems Improvement guidelines for back pain, updated in 2008, recommend referral to a spine therapy professional for manipulative treatment of nonspecific low back pain that has failed to improve with self-care after 2 weeks, or for a patient experiencing incapacitating pain. The guidelines suggest that referred patients usually demonstrate improvement within 3 to 4 visits and typically require no more than 6 visits.⁷

DO family practitioners appear to use OMT more often for pain in the back than for pain in other areas of the body.⁸ Although a large number of randomized controlled trials (RCTs) have examined the role of spinal manipulation for adults with back pain, regardless of the type of practitioner, fewer trials have focused on manipulation specifically performed by osteopathically trained physicians.

FAST TRACK

OMT led to a 30% reduction in back pain compared with several control therapies, which included NSAIDs and home exercises.

Pain reduction is significant. A meta-analysis was conducted on 8 RCTs involving patients with back pain of at least 3 weeks’ duration, with 318 patients assigned to receive OMT vs 231 controls. Subjects in the OMT group received a variable number of OMT sessions over a given time frame per study protocol, while subjects in the control group were allowed to pursue standard care for back pain, including nonsteroidal anti-inflammatory agents (NSAIDs), muscle relaxants, narcotics, physical therapy, and home exercises. The authors found a significant (30%) overall reduction in pain rating in the OMT group compared with various control therapies at 4 and 12 weeks’ follow-up (95% confidence interval [CI], -0.47 to -0.13; P=.001).⁹

Another study randomized 155 patients with subacute low back pain to receive standard care or standard care plus 8 sessions of OMT over 2 months. At follow-up, both groups had similar pain ratings on a visual analog scale, but participants in the OMT group required significantly less NSAIDs, muscle relaxants, and physical therapy.¹⁰