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OMT) for Patients with Low Back Pain

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OMT) for Patients with Low Back Pain SPECIAL COMMUNICATION American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain Clinical Guideline Subcommittee on Low Back Pain Background: Osteopathic manipulative treatment (OMT) tional database and manual searches of the literature. Six is a distinctive modality commonly used by osteopathic trials, involving eight OMT vs control treatment compar - physicians to complement conventional treatment of mus - isons, were included because they were randomized con - culoskeletal disorders, including those that cause low back trolled trials of OMT that involved blinded assessment of pain. Osteopathic manipulative treatment is defined in low back pain in ambulatory settings. Data on trial method - the Glossary of Osteopathic Terminology as: “The therapeutic ology, OMT and control treatments, and low back pain application of manually guided forces by an osteopathic outcomes were abstracted by two independent reviewers. physician (US Usage) to improve physiologic function Effect sizes were computed using Cohen d statistic, and and/or support homeostasis that has been altered by meta-analysis results were weighted by the inverse variance somatic dysfunction. OMT employs a variety of tech - of individual comparisons. In addition to the overall meta- niques.” Somatic dysfunction is defined as: “Impaired or analysis, subgroup meta-analyses were performed altered function of related components of the somatic according to control treatment, country where the trial (body framework) system: skeletal, arthrodial and myofas - was conducted, and duration of follow-up. Sensitivity cial structures, and their related vascular, lymphatic, and analyses were performed for both the overall and sub - neural elements. Somatic dysfunction is treatable using group meta-analyses. osteopathic manipulative treatment.” Previous published Results: Osteopathic manipulative treatment significantly guidelines have been based on literature reviews and meta- reduced low back pain (effect size, -0.30; 95% confidence analyses of spinal manipulation for low back pain. They interval, -0.47 to -0.13; P=.001). Subgroup analyses demon - have not specifically addressed OMT and generally have strated significant pain reductions in trials of OMT vs focused on spinal manipulation as an alternative to con - active treatment or placebo control and OMT vs no treat - ventional treatment. The purpose of this study was to ment control. There were significant pain reductions with assess the efficacy of OMT for somatic dysfunction asso - OMT regardless of whether trials were performed in the ciated with low back pain by osteopathic physicians and United Kingdom or the United States. Significant pain osteopathic practitioners trained in osteopathic palpatory reductions were also observed during short-, inter mediate -, diagnosis and manipulative treatment. and long-term follow-up. Methods: Computerized bibliographic searches of MED - Conclusions: Osteopathic manipulative treatment signif - LINE, OLDMEDLINE, EMBASE, AMED, MANTIS, icantly reduces low back pain. The level of pain reduction OSTMED (OSTMED.DR), and the Cochrane Central Reg - is clinically important, greater than expected from placebo ister of Controlled Trials were supplemented with addi - effects alone, and may persist through the first year of treatment. Additional research is warranted to elucidate mechanistically how OMT exerts its effects, to determine if OMT benefits extend beyond the first year of treatment, Michael A. Seffinger, DO, was the chair of the Clinical Guideline Subcommittee and to assess the cost-effectiveness of OMT as a comple - on Low Back Pain of the Bureau of Osteopathic Clinical Education and mentary treatment for low back pain. Research. He is also the vice-chair of the AOA Bureau of Osteopathic Clinical Education and Research. Additional subcommittee participants were Boyd R. J Am Osteopath Assoc . 2010;110(11):653-666 Buser, DO; John C. Licciardone, DO, MBA; James A. Lipton, DO, FAAO; John K. Lynch, DO, MPH; Michael M. Patterson, PhD; Richard Snow, DO, MPH; and Monte E. Troutman, DO. Funding for these guidelines was provided by the American Osteopathic Association. Editor’s Note: To enhance the readability of this special fea - These guidelines were first published to the National Guidelines Clear - inghouse and the AOA Web site in June 2010. ture to JAOA—The Journal of the American Osteopathic Financial Disclosures : None reported. Association , these guidelines have been edited for grammar Address correspondence to Michael A. Seffinger, DO, Western Univer - and basic JAOA style. The content of this contribution has not sity of Health Sciences College of Osteopathic Medicine of the Pacific, 309 E been modified. 2nd St, Pomona, CA 91766-1854. E-mail: [email protected] Clinical Guideline Subcommittee on Low Back Pain • Special Communication JAOA • Vol 110 • No 11 • November 2010 • 653 SPECIAL COMMUNICATION Executive Summary Office of Quality and Performance publication 10Q- The American Osteopathic Association (AOA) recom - CPG/LBP-99. mends that osteopathic physicians use osteopathic manip - ulative treatment (OMT) in the care of patients with low Background back pain. Evidence from systematic reviews and meta- Historically, low back pain has been the most common analyses of randomized clinical trials (Evidence Level 1a) reason for visits to osteopathic physicians. 2 More recent data supports this recommendation. from the Osteopathic Survey of Health Care in America The format used for this guideline is based on recom - have confirmed that a majority of patients visiting osteo - mendations made in the following article: Shiffman RN, pathic physicians continue to seek treatment for muscu - Shekelle P, Overhage JM, Slutsky J, Grimshaw J, Desh - loskeletal conditions. 3,4 A distinctive element of low back pande AM. Standardized reporting of clinical practice care provided by osteopathic physicians is OMT. A com - guidelines: a proposal from the Conference on Guideline prehensive evaluation of spinal manipulation for low back Standardization. Ann Intern Med . 2003;1(39):493-498. pain undertaken by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy 1. Overview material: Provide a structured abstract that includes and Research) in the United States concluded that spinal the guideline’s release date, status (original, revised, updated), and manipulation can be helpful for patients with acute low print and electronic sources. back problems without radiculopathy when used within Released June 2010. This Guideline is available through the first month of symptoms. 5 Nevertheless, because most the AOA Web site and National Guideline Clearinghouse studies of spinal manipulation involve chiropractic or through the Agency for Healthcare Research and Quality. physical therapy, 6 it is unclear if such studies adequately The guideline is partially based upon the following study: reflect the efficacy of OMT for low back pain. Licciardone JC, Brimhall AK, King LN. Osteopathic manip - Although the professional bodies that represent ulative treatment for low back pain: a systematic review osteopaths, chiropractors, and physiotherapists in the and meta-analysis of randomized controlled trials. BMC United Kingdom developed a spinal manipulation package Musculoskelet Disord . 2005;6:43. 1 consisting of three common manual elements for the UK Back pain Exercise And Manipulation (UK BEAM) trial, 7 2. Focus: Describe the primary disease/condition and interven - there are no data on the comparability of profession-spe - tion/service/technology that the guideline addresses. Indicate cific outcomes. 8,9 It is well known that OMT comprises a any alternative preventive, diagnostic or therapeutic interventions diversity of techniques. 10 These OMT techniques are not that were considered during development. adequately represented by the UK BEAM trial package. These guidelines are intended to assist osteopathic physi - Professional differences in spinal manipulation are more cians in appropriate utilization of OMT for patients with pronounced in research studies, in which chiropractors low back pain. Other alternative preventive, diagnostic, have focused almost exclusively on high-velocity, low- and therapeutic interventions considered during devel - amplitude techniques. 11 For example, a major trial of chi - opment of these guidelines were those noted in the fol - ropractic manipulation as adjunctive treatment for child - lowing published guidelines for physicians caring for hood asthma used a high-velocity, low-amplitude thrust as patients with low back pain: the active treatment. 12 The simulated treatment provided in the sham manipulation arm of this chiropractic trial, ◾ Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, which ostensibly was used to provide no therapeutic effect, Shekelle P, Owens DK; Clinical Efficacy Assessment bore a marked similarity to OMT. 11,13 Subcommittee of the American College of Physicians, Because differences in professional background and American College of Physicians, American Pain Society training lend themselves to diverse manipulation Low Back Pain Guidelines Panel. Diagnosis and treat - approaches, clinicians have been warned about generalizing ment of low back pain: a joint clinical practice guideline the findings of systematic reviews to practice. 14 In addition from the American College of Physicians and the Amer - to professional differences in the manual techniques them
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