Applied Evidence

Best uses of osteopathic manipulation

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Osteopathic manipulative treatment helps patients with lower back pain. The evidence for its effectiveness with headaches and IBS, however, is less compelling.


› Recommend osteopathic manipulative treatment to your patients with low back pain, as those who receive OMT have decreased pain, improved function, and use less medication. B

› Consider OMT as an adjunctive modality to decrease back-specific dysfunction in the third trimester of pregnancy. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series



Interest in osteopathy continues to rise in this country. Currently, more than 20% of medical students in the United States are training to be osteopathic physicians.1 In addition, the 2007 National Health Interview Survey found that spinal manipulation was among the most common complementary and alternative medicine (CAM) therapies used; with 8.6% of US adults reporting that they used it within the previous 12 months.2

With the growing number of DOs and the high utilization of osteopathic manipulative treatment (OMT), it is important for all physicians to understand the role OMT can play in the treatment of conditions ranging from low back pain to irritable bowel syndrome so that patients may be offered, or referred for, the treatment when appropriate.

To clarify when OMT may be most beneficial, we performed a literature review. Our findings are summarized here. But first, a word about osteopathic medicine and what OMT entails.

Osteopathic physicians view the body as a whole

According to the American Osteopathic Association, “the osteopathic philosophy of medicine sees an interrelated unity in all systems of the body, with each working with the other to heal in times of illness."3 This “whole-person approach to medicine” focuses on looking beyond symptoms alone to understand how lifestyle and environmental factors impact well-being.

As part of their education, DOs receive special training in the musculoskeletal system and in OMT. OMT is the process by which DOs use their hands to diagnose illness and injury and then mobilize a patient’s joints and soft tissues using techniques that include muscle activation, stretching, joint articulation, and gentle pressure to encourage the body’s natural tendency to heal itself.

These patients with low back pain will likely benefit

In the past, studies with small sample sizes, blinding issues, differing controls, and subjective outcome measurements have marred research efforts to demonstrate the effectiveness of OMT. More recently, researchers have attempted to minimize these issues, particularly when evaluating the efficacy of OMT for low back pain.

Meta-analyses show decreased pain and improved function in patients who received osteopathic manipulative treatment for low back pain.

In addition to increasing sample size, studies have compared OMT to usual care, to sham manipulation, and more recently to other manual modalities including ultrasound to equalize the subjective effects of interventions.4 With improved study designs, there has been increased awareness of the effectiveness of spinal manipulation by organizations that develop guidelines for the care of patients with low back pain. The most recent clinical practice guideline from the American College of Physicians includes spinal manipulation as a treatment modality that should be considered by clinicians for patients who have acute, subacute, or chronic low back pain.5

Chronic nonspecific low back pain. Looking at OMT vs other interventions for chronic nonspecific low back pain, a 2014 meta-analysis found moderate quality evidence for clinically relevant effects of OMT on low back pain and function. In 6 studies that evaluated 769 patients with chronic nonspecific low back pain, there was a significant difference in pain—equivalent to a 1.5-point improvement (mean difference [MD]= -14.93; 95% confidence interval [CI], -25.18 to -4.68)—in favor of OMT compared with controls, as measured on a 10-point visual analogue scale (VAS).6 In all of the studies in this meta-analysis, the treating examiner used clinical judgment to determine which manipulation techniques would be most appropriate for each patient—an approach that best represents "real-world" osteopathic practice.6

Acute and chronic nonspecific low back pain. Similarly, in the same 2014 meta-analysis, 1141 participants with acute and chronic nonspecific low back pain in 10 studies had the equivalent of 1.3 points more pain relief with OMT compared with controls (MD= -12.91; 95% CI, -20.00 to -5.82). The authors used the standardized mean difference (SMD), which is the difference in means divided by the standard deviation, to interpret the magnitude of difference in function between participants who received OMT and those in the control groups. Further, 1046 participants with acute and chronic nonspecific low back pain in 9 studies had a small improvement in functional status using the Roland-Morris Disability Questionnaire (RMDQ) or Oswestry-Disability Index (SMD= -0.36; 95% CI, -0.58 to -0.14).6

A 2005 meta-analysis that evaluated 6 randomized controlled trials (RCTs) involving 549 patients with low back pain found that 318 patients who received OMT had significantly less low back pain compared with 231 controls (effect size= -0.30; 95% CI, -0.47 to -0.13; P=.001).7 Although significant, an effect size of this magnitude is characterized as small.8

Other benefits of OMT include increased patient satisfaction, fewer meds

A randomized double-blind, sham-controlled study involving 455 patients with chronic low back pain compared outcomes of OMT to sham OMT applied in 6 treatment sessions over 8 weeks.9 Intention-to-treat analysis was performed to measure moderate and substantial improvements in low back pain at Week 12 (≥30% and ≥50% pain reductions from baseline, respectively). Based on the Cochrane Back Review Group criteria for effect sizes, response ratios were calculated to determine if the differences seen were considered clinically relevant.10

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