Clinical Integration of Osteopathic Manipulative Medicine (OMM)

Family Medicine – Low

Authors: Jocelyn Young OMSIII, Patricia Kooyman DO, Sheldon C. Yao DO

Intro: Lower back pain has a substantial impact on lifestyle and quality of life. It is the second most common symptom related reason for clinical visits in the United States.1,2,3 Up to 84% of adults have at some point in their lives.1,4 The total cost of low back pain in the US exceeds $100 billion per year.5 While the long term outcome of low back pain is generally favorable, most patients were still experiencing low back pain, for which they did not seek care, one year after the initial episode.6

Differential diagnosis:

 The differential diagnosis for lower back pain is broad and can be broadly grouped into two categories: mechanical and systemic  Mechanical o Degenerative disc disease o Lumbar strain/sprain o o o o o  Systemic o Neoplastic o Infectious (vertebral osteomyelitis) o Inflammatory (ankylosing )  Imaging: o Plain radiographs are indicated if there has been no improvement after 4‐6 weeks and are used to rule out tumor, infection, instability, , and spondylolisthesis o Imaging is indicated at less than 4 weeks if any of the following is present: . Progressive neurological findings . Constitutional symptoms . History of traumatic onset . History of malignancy . Age < 50 years old . Infectious risks . Osteoporosis o CT or MRI imaging is considered after 12 weeks of persistent low back pain

Clinical pearls and diagnostic tools:

 Clues that suggest underlying systemic disease: o History of cancer o Unexplained weight loss o Duration of pain greater than 1 month o Nighttime pain o Pain that is not relieved when lying down o Incontinence  Evaluate three primary concerns when taking the patient’s history: o Is there evidence of systemic disease? o Is there evidence of neurologic compromise? o Is there social or psychological distress that may contribute to chronic, disabling pain?  Important pieces of the physical exam include: o Inspection of the back and posture o Range of motion o Palpation of the spine o Straight leg raise test o Neurologic assessment of L5 and S1 nerve roots o Evaluation for malignancy when the history strongly suggests systemic disease  When to refer: o Cauda equina syndrome o Suspected spinal cord compression o Progressive or severe neurological deficit

Osteopathic Manipulative Medicine (OMM) Integration: While medications such as NSAIDs and muscle relaxants are considered the first line treatment for low back pain (LBP), OMM is also considered as an effective treatment modality. There is statistical evidence which shows that OMM treatment can reduce low back pain when compared to a placebo or a non‐treated control.7,8 In 2010, the American Osteopathic Association’s Clinical Guidelines Subcommittee on Low Back Pain conducted a meta‐ analysis of six randomly controlled blinded studies involving OMM and low back pain in ambulatory care settings. The authors of this review concluded that treatment with OMM significantly reduced low back pain (LBP) during the short‐term (P=.01), intermediate‐term (P<.001) and long‐term (P=.03) follow up periods.7 In addition, obesity is considered a risk factor for low back pain and OMM treatment in this specific patient population has been looked at. There results found that OMM combined with specific exercises was significantly more effective in reducing pain than those specific exercises alone (p<.05).9

Osteopathic Structural Examination: Due to the large number of possible causes of low back pain, the somatic dysfunctions that could be found are widespread. An osteopathic structural exam should be performed and any somatic dysfunctions present should be identified. In the majority of the studies in which the authors analyzed the use of OMM for patients with low back pain, treatment was individualized for the patient.

Possible treatment options:

 Myofascial of the thoracic and/or lumbar spine  Muscle energy for pelvic and sacral dysfunctions  FPR for sacral motion restriction  Counterstrain for the piriformis, psoas, lumbar process tenderpoints  Counterstrain for the pelvic and sacral tenderpoints

Related evidence‐based medicine (EBM) articles:

 Clinical Guideline Subcommittee on Low Back Pain; American Osteopathic Association. American Osteopathic Association guidelines for osteopathic manipulative treatment (OMT) for patients with low back pain. J Am Osteopath Assoc. 2010 Nov;110(11):653‐66.  Liccardone J, 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; 4: 6‐43.  Vismara L, Cimolin V, Menegoni F, et al. Osteopathic manipulative treatment in obese patients with chronic low back pain: a pilot study. Man Ther. 2012; 17(5): 454‐455.

Citations for paper:

1. Deyo RA, Tsui‐Wu YJ. Descriptive epidemiology of low‐back pain and its related medical care in the United States. Spine. 1987; 12(3): 264‐268. 2. Freburger JK, Holmes GM, Agans RP, et al. The Rising Prevalence of Chronic Low Back Pain. Arch Intern Med. 2009;169(3):251‐258. 3. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the US workforce. JAMA 2003;290 (18) 2443‐ 2454 4. Cassidy JD, Carroll LJ, Cote P. The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine. 1998; 23(17): 1860‐1866. 5. Katz JN. Lumbar disc disorders and low‐back pain: socioeconomic factors and consequences. J Bone Joing Surg Am. 2006; 88 Suppl 2:21‐24. 6. Croft PR, Macfarlane GJ, Papageorgiou AC, et al. Outcome of low back pain in general practice: a prospective study. BMJ 1998; 316(7141): 1356‐1359. 7. Clinical Guideline Subcommittee on Low Back Pain; American Osteopathic Association. American Osteopathic Association guidelines for osteopathic manipulative treatment (OMT) for patients with low back pain. J Am Osteopath Assoc 2010 Nov;110(11):653‐66. 8. Liccardone J, 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; 4: 6‐43. 9. Vismara L, Cimolin V, Menegoni F, et al. Osteopathic manipulative treatment in obese patients with chronic low back pain: a pilot study. Man Ther. 2012; 17(5): 454‐455.