Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials

Abstract

Background: Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement their conventional treatment of musculoskeletal disorders. Previous reviews and meta-analyses of spinal manipulation for low back pain have not specifically addressed OMT and generally have focused on spinal manipulation as an alternative to conventional treatment. The purpose of this study was to assess the efficacy of OMT as a complementary treatment for low back pain.

Methods: Computerized bibliographic searches of MEDLINE, EMBASE, MANTIS, OSTMED, and the Cochrane Central Register of Controlled Trials were supplemented with additional database and manual searches of the literature. Six trials, involving eight OMT vs control treatment comparisons, were included because they were randomized controlled trials of OMT that involved blinded assessment of low back pain in ambulatory settings. Data on trial methodology, OMT and control treatments, and low back pain outcomes were abstracted by two independent reviewers. Effect sizes were computed using Cohen's d statistic and meta-analysis results were weighted by the inverse variance of individual comparisons. In addition to the overall meta-analysis, stratified meta-analyses were performed according to control treatment, country where the trial was conducted, and duration of follow-up. Sensitivity analyses were performed for both the overall and stratified meta-analyses.

Results: Overall, OMT significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 - -0.13; P = .001). Stratified analyses demonstrated significant pain reductions in trials of OMT vs active treatment or placebo control and OMT vs no treatment control. There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States. Significant pain reductions were also observed during short-, intermediate-, and long-term follow-up.

Conclusion: OMT significantly reduces low back pain. The level of pain reduction is greater than expected from placebo effects alone and persists for at least three months. Additional research is warranted to elucidate mechanistically how OMT exerts its effects, to determine if OMT benefits are long lasting, and to assess the cost-effectiveness of OMT as a complementary treatment for low back pain.

Figure 1

Flowchart of trials.

Figure 2

Effect size for low back pain. CI denotes confidence interval; OMT, osteopathic manipulative treatment. Overall effect size, -0.30; 95% CI, -0.47 – -0.13; P = .001.

Figure 3

Summary of meta-analysis results. A denotes all-contrasts model; B, best-case scenario model; C, Cleary [47] trial excluded model; M, median contrasts model; NT, no treatment control; OMT, osteopathic manipulative treatment; W, worst-case scenario model. 1, 2, 3, and 4 indicate alternative models restricted to one OMT vs control treatment comparison per trial. A diamond indicates the inclusion of the relevant contrast or observation of the stated result. Sensitivity analyses are shaded in gray. Results are presented for each of the 43 analyses, including the overall meta-analysis, seven stratified meta-analyses, and 35 sensitivity analyses.