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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.
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
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
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.
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.
Financial Disclosure: Integrative Medicine Alert’s Executive Editor David Kiefer, MD; Peer Reviewer Suhani Bora, MD; AHC Media Executive Editor Leslie Coplin; Editor Jonathan Springston; and Editorial Group Manager Terrey L. Hatcher report no financial relationships relevant to this field of study.