Best uses of osteopathic manipulation

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Applied Evidence

Best uses of osteopathic manipulation

J Fam Pract. 2017 December;66(12):743-747

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References

1. American Association of Colleges of Osteopathic Medicine. What is osteopathic medicine? Available at: https://www.aacom.org/become-a-doctor/about-om. Accessed July 10, 2017.

2. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. 2008;12:1-23. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19361005. Accessed November 10, 2015.

3. American Osteopathic Association. What is osteopathic medicine? Available at: http://www.osteopathic.org/osteopathic-health/Pages/what-is-osteopathic-medicine.aspx. Accessed November 17, 2017.

4. Licciardone JC, Russo DP. Blinding Protocols, Treatment Credibility, and Expectancy: Methodologic Issues in Clinical Trials of Osteopathic Manipulative Treatment. J Am Osteopath Assoc. 2006;106:457-463.

5. 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.

6. 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.

7. 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.

8. Cohen J. Statistical Power Analysis for the Behavioral Sciences.82nd ed. Hillsdale NJ: Lawrence Erlbaum Associates; 1988.

9. 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.

10. Furlan AD, Pennick V, Bombardier C, et al, Editorial Board, Cochrane Back Review Group. 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine (Phila Pa 1976). 2009;34:1929-1941.

11. 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.

12. 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.e1-e9.

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14. 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.

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16. Anderson RE, Seniscal C. A comparison of selected osteopathic treatment and relaxation for tension-type headaches. Headache. 2006;46:1273-1280.

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Patients receiving OMT were more likely to achieve moderate (response ratio=1.38; 95% CI, 1.16-1.64; P<.001) and substantial (response ratio=1.41; 95% CI, 1.13-1.76; P=.002) improvements in low back pain at Week 12. The calculated number needed to treat (NNT) for moderate and significant improvement in pain at 12 weeks was 6 and 7, respectively. In addition, patients in the OMT group were more likely to be very satisfied with their care (P<.001) with an NNT of 5, and used fewer medications than did patients in the sham group during the 12 weeks of the study (use ratio=0.66; 95% CI, 0.43-1.00; P=.048; NNT=15).⁹

Pregnant women may benefit from OMT in the third trimester

A 2013 RCT involving 144 patients randomized to OMT, sham ultrasound, or usual obstetric care found that 68 patients (47%) experienced back-specific dysfunction during their third trimester of pregnancy (defined by a ≥2-point increase in the RMDQ).¹¹

OMT reduced the risk of back-specific dysfunction by 40% vs the ultrasound group (relative risk [RR]=0.6; 95% CI, 0.3-1; P=.046) and 60% vs the usual obstetric care group (RR=0.4; 95% CI, 0.2-0.7; P<.001). The corresponding NNTs were 5.1 (95% CI, 2.7-282.2) for the OMT group vs the ultrasound group and 2.5 (95% CI, 1.8-4.9) vs the usual care group. The outcomes of this study were not conclusive because the initial RMDQ score was 1.8 points worse for the OMT group than for the usual care group.¹¹

Subsequently, the PROMOTE (Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects) study involving 400 patients demonstrated that a standard OMT protocol was effective for decreasing pain and function deterioration compared with usual obstetric care.¹² However, results from the OMT group did not differ significantly from those of the ultrasound group, which were labeled as subtherapeutic in the study.¹²

The most recent Cochrane Review on low back pain in pregnancy noted that there was moderate quality evidence (due to study design limitations or imprecision) that OMT significantly reduced low back pain and function disability.¹³

OMT for other conditions? The evidence is limited

To date, studies on conditions other than low back pain have not demonstrated the same robust improvements in design as have those concerning low back pain (ie, larger sample sizes, comparisons to usual care and other treatments, etc.), and available data are not sufficiently significant to compel a change in clinical practice. Despite this, patients seek out, and receive, OMT as an alternative or adjunctive treatment for many conditions other than low back pain,² and family physicians should be aware of the current evidence for OMT in those conditions.

OMT for acute neck pain: A comparison with ketorolac

Researchers randomized 58 patients presenting to 3 emergency departments with neck pain of less than 3 weeks’ duration to receive either OMT or 30 mg IM ketorolac.¹⁴OMT techniques were provided at the discretion of the physician based on patient needs. Patients rated their pain intensity on an 11-point numerical scale at the time of presentation and one hour after treatment. Patients receiving ketorolac or OMT had significant reductions in pain intensity with improvements of 1.7 +/- 1.6 (95% CI, 1.1-2.3; P<.001) and 2.8 +/- 1.7 (95% CI, 2.1-3.4; P<.001), respectively.

Patients who received osteopathic manipulative treatment for low back pain used fewer medications.

Although the pain reduction changes were statistically significant in both groups, the improvements were small enough to question if they were functionally significant. Compared to those receiving ketorolac, those receiving OMT reported a significantly greater decrease in their pain intensity (2.8 vs 1.7; 95% CI, 0.2-1.9; P=.02), but it’s worth noting that the dose of ketorolac was half the recommended dose for moderate or severe pain.¹⁴

Patients may have more headache-free days with OMT

To assess the use of OMT to treat chronic migraine, researchers conducted a prospective, single-blind RCT in which 105 chronic migraine sufferers (average of 22.5 migraine days/month) were split into 3 treatment groups: OMT plus medications, sham OMT plus medications, and medications alone.¹⁵

OMT led to fewer days with migraines compared with the medication group (MD= -21.06; 95% CI, -23.19 to -18.92; P<.001) and sham OMT group (MD= -17.43; 95% CI, -19.57 to -15.29; P<.001), resulting in less functional disability (P<.001).¹⁵ Caution should be taken in interpreting the results of this small trial, however, as an effect of this size has not been replicated in other studies.

A small (N=29) single-blind RCT looked at progressive muscular relaxation with and without OMT for the treatment of tension headache. Patients who completed relaxation exercises plus 3 sessions of OMT experienced significantly more headache-free days (1.79 vs 0.21; P=.016).¹⁶ Despite this finding, headache intensity and headache diary ratings were not different between the 2 groups in this study.