American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain

Abstract

Background: Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement conventional management of musculoskeletal disorders, including those that cause low back pain (LBP). Osteopathic manipulative treatment is defined in the Glossary of Osteopathic Terminology as "The therapeutic application of manually guided forces by an osteopathic physician (U.S. Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction. OMT employs a variety of techniques" (eAppendix). Somatic dysfunction is defined as "Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment." These guidelines update the AOA guidelines for osteopathic physicians to utilize OMT for patients with nonspecific acute or chronic LBP published in 2010 on the National Guideline Clearinghouse.1 METHODS: This update process commenced with literature searches that included electronic databases, personal contact with key researchers of OMT and low back pain, and Internet search engines. Early in the process, the Task Force on the Low Back Pain Clinical Practice Guidelines discovered the 2014 systematic literature review conducted by Franke et al2; this study serves as the basis for this updated guideline and further builds upon the literature used to support the previous guidelines. Findings from other eligible studies published after the search parameters of the Franke et al systematic review were also incorporated.

Results: The authors of the systematic review identified 307 studies. Thirty-one were evaluated and 16 were excluded. Of the 15 studies included in the review, 6 were retrieved from Germany, 5 from the United States, 2 from the United Kingdom, and 2 from Italy. Two additional studies published after the Franke et al review were also included. Osteopathic manipulative treatment significantly reduces pain and improves functional status in patients, including pregnant and postpartum women, with nonspecific acute and chronic LBP. Franke et al found that in acute and chronic nonspecific LBP, moderate-quality evidence suggested that OMT had a significant effect on pain relief (mean difference [MD], -12.91; 95% CI, -20.00 to -5.82) and functional status (standard mean difference [SMD], -0.36; 95% CI, -0.58 to -0.14). More specifically, in chronic nonspecific LBP, the evidence suggested a significant difference in favor of OMT regarding pain (MD, -14.93; 95% CI, -25.18 to -4.68) and functional status (SMD, -0.32; 95% CI, -0.58 to -0.07). When examining nonspecific LBP in pregnancy, low-quality evidence suggested a significant difference in favor of OMT for pain (MD, -23.01; 95% CI, -44.13 to -1.88) and functional status (SMD, -0.80; 95% CI, -1.36 to -0.23). Conversely for nonspecific LBP postpartum, Franke et al found that moderate-quality evidence suggested a significant difference in favor of OMT for pain (MD, -41.85; 95% CI, -49.43 to -34.27) and functional status (SMD, -1.78; 95% CI, -2.21 to -1.35).2 CONCLUSION: The conclusions of Franke et al further strengthen the findings that OMT reduces LBP. In a 2005 systematic review conducted by Licciardone et al3 and the basis of the LBP guidelines published in 2010, it was determined that OMT reduces pain more than expected from placebo effects alone, and these results had the potential to last beyond the first year of treatment. Franke et al specifically stated that clinically relevant effects of OMT were found for reducing pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women 3 months after treatment. Larger randomized controlled trials with robust comparison groups are needed to further validate the effects of OMT on LBP. In addition, more research is needed to understand the mechanics of OMT and its short- and long-term effects, as well as the cost-effectiveness of such treatment.