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Special Communication  |   November 2010
American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain
Author Notes
  • Michael A. Seffinger, DO, was the chair of the Clinical Guideline Subcommittee on Low Back Pain of the Bureau of Osteopathic Clinical Education and Research. He is also the vice-chair of the AOA Bureau of Osteopathic Clinical Education and Research. Additional subcommittee participants were Boyd R. 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. 
  • Address correspondence to Michael A. Seffinger, DO, Western University of Health Sciences College of Osteopathic Medicine of the Pacific, 309 E 2nd St, Pomona, CA 91766-1854. E-mail: mseffinger@westernu.edu 
Article Information
Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment / Pain Management/Palliative Care / Low Back Pain
Special Communication   |   November 2010
American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain
The Journal of the American Osteopathic Association, November 2010, Vol. 110, 653-666. doi:10.7556/jaoa.2010.110.11.653
The Journal of the American Osteopathic Association, November 2010, Vol. 110, 653-666. doi:10.7556/jaoa.2010.110.11.653
Abstract

Background: Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement conventional treatment of musculoskeletal disorders, including those that cause low back pain. Osteopathic manipulative treatment is defined in the Glossary of Osteopathic Terminology as: “The therapeutic application of manually guided forces by an osteopathic physician (US Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction. OMT employs a variety of techniques.” 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.” Previous published guidelines have been based on literature reviews and meta-analyses of spinal manipulation for low back pain. They 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 for somatic dysfunction associated with low back pain by osteopathic physicians and osteopathic practitioners trained in osteopathic palpatory diagnosis and manipulative treatment.

Methods: Computerized bibliographic searches of MEDLINE, OLDMEDLINE, EMBASE, AMED, MANTIS, OSTMED (OSTMED.DR), 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 d statistic, and meta-analysis results were weighted by the inverse variance of individual comparisons. In addition to the overall meta-analysis, subgroup 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 subgroup meta-analyses.

Results: Osteopathic manipulative treatment significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 to -0.13; P=.001). Subgroup 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-, inter mediate-, and long-term follow-up.

Conclusions: Osteopathic manipulative treatment significantly reduces low back pain. The level of pain reduction is clinically important, greater than expected from placebo 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, and to assess the cost-effectiveness of OMT as a complementary treatment for low back pain.

Executive Summary
The American Osteopathic Association (AOA) recommends that osteopathic physicians use osteopathic manipulative treatment (OMT) in the care of patients with low back pain. Evidence from systematic reviews and meta-analyses of randomized clinical trials (Evidence Level 1a) supports this recommendation. 
The format used for this guideline is based on recommendations made in the following article: Shiffman RN, Shekelle P, Overhage JM, Slutsky J, Grimshaw J, Deshpande AM. Standardized reporting of clinical practice guidelines: a proposal from the Conference on Guideline Standardization. Ann Intern Med. 2003;1(39):493-498. 
1. Overview material: Provide a structured abstract that includes the guideline's release date, status (original, revised, updated), and print and electronic sources.  
Released June 2010. This Guideline is available through the AOA Web site and National Guideline Clearinghouse through the Agency for Healthcare Research and Quality. The guideline is partially based upon the following study: Licciardone JC, 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;6:43.1 
2. Focus: Describe the primary disease/condition and intervention/service/technology that the guideline addresses. Indicate any alternative preventive, diagnostic or therapeutic interventions that were considered during development.  
These guidelines are intended to assist osteopathic physicians in appropriate utilization of OMT for patients with low back pain. Other alternative preventive, diagnostic, and therapeutic interventions considered during development of these guidelines were those noted in the following published guidelines for physicians caring for patients with low back pain: 
  • Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society [published correction appears in Ann Intern Med. 2008;148(3):247-248]. Ann Intern Med. 2007; 147(7):478-91.
  • Low Back Pain or Sciatica in the Primary Care Setting. Washington, DC: VA/DoD Evidence-Based Clinical Practice Guideline Working Group, Veterans Health Administration, Department of Veterans Affairs, and Health Affairs, Department of Defense, November 1999. Office of Quality and Performance publication 10Q-CPG/LBP-99.
Background
Historically, low back pain has been the most common reason for visits to osteopathic physicians.2 More recent data from the Osteopathic Survey of Health Care in America have confirmed that a majority of patients visiting osteopathic physicians continue to seek treatment for musculoskeletal conditions.3,4 A distinctive element of low back care provided by osteopathic physicians is OMT. A comprehensive evaluation of spinal manipulation for low back pain undertaken by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) in the United States concluded that spinal manipulation can be helpful for patients with acute low back problems without radiculopathy when used within the first month of symptoms.5 Nevertheless, because most studies of spinal manipulation involve chiropractic or physical therapy,6 it is unclear if such studies adequately reflect the efficacy of OMT for low back pain. 
Although the professional bodies that represent osteopaths, chiropractors, and physiotherapists in the United Kingdom developed a spinal manipulation package consisting of three common manual elements for the UK Back pain Exercise And Manipulation (UK BEAM) trial,7 there are no data on the comparability of profession-specific outcomes.8,9 It is well known that OMT comprises a diversity of techniques.10 These OMT techniques are not adequately represented by the UK BEAM trial package. Professional differences in spinal manipulation are more pronounced in research studies, in which chiropractors have focused almost exclusively on high-velocity, low-amplitude techniques.11 For example, a major trial of chiropractic manipulation as adjunctive treatment for childhood asthma used a high-velocity, low-amplitude thrust as the active treatment.12 The simulated treatment provided in the sham manipulation arm of this chiropractic trial, which ostensibly was used to provide no therapeutic effect, bore a marked similarity to OMT.11,13 
Because differences in professional background and training lend themselves to diverse manipulation approaches, clinicians have been warned about generalizing the findings of systematic reviews to practice.14 In addition to professional differences in the manual techniques themselves, osteopathic physicians in the United States, unlike allopathic physicians or chiropractors, can treat this condition simultaneously using both conventional primary care approaches and complementary spinal manipulation. This represents a unique philosophical approach in the treatment of patients with low back pain. Consequently, there is a need for empirical data that specifically address the efficacy of OMT for conditions such as low back pain.15 
These guidelines are based on a systematic review of the literature on OMT for patients with low back pain and a meta-analysis of all randomized controlled trials of OMT for patients with low back pain in ambulatory settings. 
3. Goal: Describe the goal that following the guideline is expected to achieve, including the rationale for development of a guideline on this topic.  
The goal of these guidelines is to enable osteopathic physicians, as well as other physicians, other health professionals, and third party payers, to understand the evidence underlying recommendations for appropriate utilization of OMT, which is not detailed in the current sets of guidelines developed by other physicians. The AOA does not believe it is appropriate for other professionals to create guidelines for utilization of OMT because it is not a procedure or approach used by those physicians. It is, however, the purview and duty of the American Osteopathic Association to inform its members and the public about the appropriate utilization of OMT. 
4. Users/setting: Describe the intended users of the guideline (eg, provider types, patients) and the settings in which the guideline is intended to be used.  
These guidelines are to be used by osteopathic physicians in application of OMT to patients with low back pain in the ambulatory setting. 
Methods
5. Target population: Describe the patient population eligible for guideline recommendations and list any exclusion criteria.  
Patients with low back pain of musculoskeletal origin are eligible for guideline recommendations. Patients with visceral disease conditions that refer pain to the low back are excluded from these guidelines. Other conditions of exclusion are when the following are the identified source of the low back pain: vertebral fracture; vertebral joint dislocation; muscle tears or lacerations; spinal or vertebral joint ligament rupture; inflammation of intervertebral disks, spinal zygapophyseal facets joints, muscles, or fascia; skin lacerations; sacroiliitis; ankylosing spondylitis; or masses in or from the low back structures that are the source of the pain. Exclusion from this guideline does not imply that OMT is contraindicated in these conditions. 
6. Developer: Identify the organization(s) responsible for guideline development and the names/credentials/potential conflicts of interest of individuals involved in the guideline's development.  
The AOA, Bureau of Osteopathic Clinical Education and Research, Clinical Guideline Subcommittee on Low Back Pain: Michael A. Seffinger, DO (chair); Boyd R. 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; Monte E. Troutman, DO. 
7. Funding source/sponsor: Identify the funding source/sponsor and describe its role in developing and/or reporting the guideline. Disclose potential conflict of interest.  
This project was funded by the AOA. A subcommittee under the direction of Michael Seffinger, DO, vice-chair of the AOA Bureau of Osteopathic Clinical Education and Research, was convened to explore the issue and make recommendations to the AOA Board of Trustees and the AOA House of Delegates, with input from the AOA Bureau of Osteopathic Specialists, AOA Bureau of Scientific Affairs and Public Health, AOA Bureau on Socioeconomic Affairs, American Academy of Osteopathy, American College of Osteopathic Family Physicians, American College of Osteopathic Internists, and the AOA Council on Research. Upon approval of these recommendations, the AOA Board of Trustees submitted them to the National Guideline Clearinghouse for public record and access. As the guidelines were developed based on the peer-reviewed scientific literature, no conflict of interest is claimed by the developers. A well-rounded, objective perspective is presented. Any views from an osteopathic perspective that is not supported by the scientific literature is stated and clearly identified so the reader is able to discern any potential for bias. 
8. Evidence collection: Describe the methods used to search the scientific literature, including the range of dates and databases searched, and criteria applied to filter the retrieved evidence.  
A search of the English-language literature was performed through 2006 to identify reports of randomized controlled trials of OMT. Based on the systematic review by Licciardone et al,1 we searched MEDLINE, OLDMEDLINE, EMBASE, AMED, MANTIS, OSTMED (OSTMED.DR), CINAHL, EMBASE, and the Cochrane Central Register of Controlled Trials. The search strategies for these databases are presented in Appendix 1.1 We also searched Alt Health Watch, SciSearch, ClinicalTrials.gov, and CRISP. Additionally, reports were sought from relevant reviews or meta-analyses of spinal manipulation,10,16-33 manual searches of reference citations in the reviewed literature sources, systematic manual searches of key osteopathic journals, and consultation with other osteopathic investigators for identification of other reports of OMT trials. 
Terminology used in the study is defined in Appendix 2. 
Selection
The search bibliographies and relevant reports were reviewed by a series of trained reviewers to identify randomized controlled trials involving OMT in human subjects. To validly assess the efficacy of OMT in primary care, eligibility was limited to randomized controlled trials of OMT that included blinded assessment of low back pain in ambulatory settings. Trials that involved manipulation under anesthesia, industrial settings, or hospitalized patients were not included. Because there is potential confusion regarding the type of manipulation performed in some trials,34 the reported methods in each trial were carefully reviewed to assess eligibility for the meta-analysis. Consequently, 7 studies known or purported to involve OMT for low back pain were reviewed and excluded for not meeting eligibility criteria.35-41 A subsequent source42 indicated that an osteopathic manipulation technique was used in the Irvine study.43 
Although several of the 6 included OMT trials were identified in multiple bibliographic databases, 543-47 were identified through MEDLINE. The Cleary48 trial was identified exclusively through the Cochrane Central Register of Controlled Trials. Another identified an OMT trial that involved treatment of spinal pain, including neck pain, upper back pain, lower back pain, and combinations thereof, did not present anatomic site specific data for review.49 The doctoral dissertation that served as the basis for this research and publication was successfully acquired in March 2007; however, this document did not provide the low back–specific data necessary for meta-analysis. 
Data Extraction
Each eligible trial was independently evaluated by two reviewers to abstract data on methodologic characteristics, OMT and control treatments, and low back pain outcomes. Conflicting data were resolved by consensus. 
9. Recommendation grading criteria: Describe the criteria used to rate the quality of evidence that supports the recommendations and the system for describing the strength of the recommendations.  
Recommendation strength communicates the importance of adherence to a recommendation and is based on both the quality of the evidence and the magnitude of anticipated benefits or harms. 
Quantitative Data Synthesis
10. Method for synthesizing evidence: Describe how evidence was used to create recommendations, eg, evidence tables, meta-analysis, decision analysis.  
We used the effect size, computed as Cohen d statistic, to report all trial results.50 A negative effect size represented a greater decrease in pain among OMT subjects relative to control treatment subjects. Dichotomous pain measures were transformed to effect sizes by first computing the relevant P value and then determining the effect size and 95% confidence interval (CI) that would obtain under the assumption of a two-tailed t test for measuring the standardized mean difference between OMT and control treatments in the relevant number of subjects.50 The meta-analysis results were weighted by the inverse variance for each OMT vs control treatment comparison. The Q statistic was used to test the homogeneity of trials included in each analysis.51 The overall meta-analysis included the 8 OMT vs control treatment comparisons. Four of the 6 trials, involving 6 of the 8 OMT vs control treatment comparisons, each reported 3 contrasts.43,44,46,47 The median contrast was used to represent the pain outcome for each of these 6 comparisons (the median contrast refers to the intermediate effect size among the 3 reported pain outcomes for a given OMT vs control treatment comparison). These median contrasts were then combined with the lone contrasts reported in each of the 2 remaining OMT vs control treatment comparisons.45,48 Based on the similarity among trials, a fixed effects model initially was used to perform meta-analysis and the results were then compared with those of a random-effects model. A series of sensitivity analyses were then performed. 
First, to address the possibility of bias by using the median contrasts method, analyses were repeated using the best-case and worst-case scenarios for the 6 relevant OMT vs control treatment comparisons. 43,44,46,47 Second, to address the possibility of bias by including comparisons involving the same OMT group vs 2 different control treatment groups in 2 trials,44,47 analyses were repeated using only 1 OMT vs control treatment comparison for each of these trials. Each of the 4 possible combinations of contrasts was analyzed. Third, the analysis was repeated after excluding the Cleary48 trial. Finally, an analysis was performed using all 20 low back pain contrasts. 
Similar analyses were performed after stratifying trials according to control treatment, country where the trial was performed, and duration of follow-up. There were 43 analyses performed, including the overall meta-analysis, 7 subgroup meta-analyses, and 35 sensitivity analyses. Meta-analysis was performed only when there were at least 3 contrasts available for data synthesis. Database management and analyses were performed using the Comprehensive Meta-Analysis software package (version 1.0.23; Biostat Inc, Englewood, New Jersey). 
Results
Overall Analyses
A total of 525 subjects with low back pain were randomized in the eligible trials. There was a highly significant reduction in pain associated with OMT (effect size, -0.30; 95% CI, -0.47 to -0.13; P=.001). The Q statistic was nonsignificant, thus supporting the assumption of homogeneity among trials. Using a random-effects model, the results were virtually identical to those observed with a fixed-effects model. There were 729 (36 × 12) possible combinations of contrasts for analysis based on 3 contrasts for each of 6 OMT vs control treatment comparisons43,44,46,47 and 1 contrast for each of the 2 remaining OMT vs control treatment comparisons.45,48 The efficacy of OMT for low back pain was supported in both the best-case (effect size, -0.37; 95% CI, -0.55 to -0.20; P<.001) and worst-case (effect size, -0.18; 95% CI, -0.35 - 0.00; P=.046) scenarios. Similarly, when each trial was limited to 1 OMT vs control treatment comparison, OMT was found to be efficacious in each of the 4 analyses. OMT also demonstrated significantly greater low back pain reduction than control treatment in analyses with the Cleary48 trial excluded and with all 20 contrasts included. 
Subgroup Analyses
There was a significant reduction in low back pain associated with OMT in trials vs active treatment or placebo control (effect size, -0.26; 95% CI, -0.48 to -0.05; P=.02), independent of fixed-effects or random-effects model specification. There were 243 (35 × 11) possible contrast combinations based on 3 contrasts for each of 5 OMT vs control treatment comparisons43,44,46,47 and 1 contrast for another remaining OMT vs control treatment comparison.48 Both the best-case and worst-case scenarios demonstrated a greater reduction in pain with OMT than active treatment or placebo control, although the worst-case results did not achieve statistical significance. Osteopathic manipulative treatment was found to significantly reduce pain in the remaining analyses that limited OMT vs active treatment or placebo control comparisons to 1 per trial, excluded the Cleary48 trial, and included all 16 contrasts. The OMT vs no treatment control comparisons were observed in trials in which all subjects received usual low back care in addition to their allocated treatment (ie, OMT and usual care vs only usual care).45,48 For these trials, the all-contrasts model (ie, the only model with sufficient contrasts for data synthesis) demonstrated a highly significant reduction in pain with OMT. Trials in both the United Kingdom (effect size, -0.29; 95% CI, -0.58 to 0.00; P=.050) and the United States (effect size, -0.31; 95% CI, -0.52 to -0.10; P=.004) demonstrated significant reductions in low back pain. In the sensitivity analyses, effects sizes were generally of comparable magnitude in both countries, though results in US trials consistently achieved statistical significance as a consequence of the larger sample sizes in these trials. 
There were significant reductions in low back pain associated with OMT during the short-term (effect size, -0.28; 95% CI, -0.51 to -0.06; P=.01), intermediate-term (effect size, -0.33; 95% CI, - 0.51 to -0.15; P<.001), and long-term (effect size, -0.40; 95% CI, -0.74 to -0.05; P=.03) follow-up periods. Sensitivity analyses for temporal outcomes demonstrated that intermediate-term results consistently achieved statistical significance, generally because of the greater number of subjects in these analyses. 
Comment
Efficacy of OMT
The overall results clearly demonstrate a statistically significant reduction in low back pain with OMT. Subgroup meta-analyses to control for moderator variables demonstrated that OMT significantly reduced low back pain vs active treatment or placebo control and vs no treatment control. If it is assumed, as shown in a review,52 that the effect size is -0.27 for placebo control vs no treatment in trials involving continuous measures for pain, then the results of our study are highly congruent (ie, effect size for OMT vs no treatment [-0.53] = effect size for OMT vs active treatment or placebo control [-0.26] + effect size for placebo control vs no treatment [-0.27]). It has been suggested that the therapeutic benefits of spinal manipulation are largely due to placebo effects.53 A preponderance of results from our sensitivity analyses supports the efficacy of OMT vs active treatment or placebo control and therefore indicates that low back pain reduction with OMT is attributable to the manipulation techniques, not merely placebo effects. Also, as indicated above, OMT vs no treatment control demonstrated pain reductions twice as great as previously observed in clinical trials of placebo vs no treatment control.52 
The clinical significance of our findings is readily evident when compared with nonsteroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors. A recent meta-analysis of the efficacy of these drugs included 23 randomized placebo-controlled trials for osteoarthritic knee pain, representing more than 10,000 subjects, and measured pain outcomes up to 3 months following randomization.54 This study found an overall effect size of -0.32 (95% CI, -0.24 to -0.39) and effect size of -0.23 (95% CI, -0.16 to -0.31) when drug non-responders were not excluded from the analyses. Thus, our effect size of -0.26 (95% CI, -0.48 to - 0.05) for OMT in trials vs active treatment or placebo control suggests that OMT provides an analgesic effect comparable to nonsteroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors. Unlike the meta-analysis of nonsteroidal anti-inflammatory drugs,54 however, Licciardone et al47 found that OMT also significantly reduced pain during the 3- to 12-month period following randomization. Thus, OMT for low back pain may eliminate or reduce the need for drugs that can have serious adverse effects.45 
Because osteopathic physicians provide OMT to complement conventional treatment for low back pain, they tend to avoid substantial additional costs that would otherwise be incurred by referring patients to chiropractors or other practitioners.55 With regard to back pain, osteopathic physicians make fewer referrals to other physicians and admit a lower percentage of patients to hospitals than allopathic physicians,2 while also treating back pain episodes with substantially fewer visits than chiropractors.56 Although osteopathic family physicians are less likely to order radiographs or prescribe nonsteroidal anti-inflammatory drugs, aspirin, muscle relaxants, sedatives, and narcotic analgesics for low back pain than their allopathic counterparts, osteopathic physicians have a substantially higher proportion of patients returning for follow-up back care than allopathic physicians.57 In the United Kingdom, where general practitioners may refer patients with spinal pain to osteopaths for manipulation, it has been shown that OMT improved physical and psychological outcomes at little extra cost.49 
11. Prerelease review: Describe how the guideline developer reviewed and/or tested the guidelines prior to release.  
Guidelines were reviewed by the AOA Board of Trustees, Bureau of Osteopathic Specialists, Bureau of Osteopathic Clinical Education and Research, Council on Research, Bureau of Scientific Affairs and Public Health, Bureau of Socioeconomic Affairs, Department of Quality and Research, American College of Osteopathic Family Physicians, American Academy of Osteopathy, American College of Osteopathic Internists, and the AOA House of Delegates. 
12. Update plan: State whether or not there is a plan to update the guideline and, if applicable, an expiration date for this version of the guideline.  
The guidelines will be updated every 5 years. 
13. Definitions: Define unfamiliar terms and those critical to correct application of the guideline that might be subject to misinterpretation.  
Osteopathic manipulative treatment referred specifically to manual treatment provided by osteopathic physicians, or other physicians who had demonstrated training and proficiency in OMT, such as those practitioners in Europe who may have undertaken osteopathic conversion programs. 
14. Recommendations and rationale: State the recommended action precisely and the specific circumstances under which to perform it. Justify each recommendation by describing the linkage between the recommendation and its supporting evidence. Indicate the quality of evidence and the recommendation strength, based on the criteria described in 9.  
Based on this meta-analysis (evidence level 1a—see Figure 1) of randomized controlled trials on OMT for patients with low back pain, it is recommended that OMT be utilized by osteopathic physicians for musculoskeletal causes of low back pain, ie, to treat patients with the diagnoses of somatic dysfunctions related to the low back pain. Subgroup meta-analyses to control for moderator variables demonstrated that OMT significantly reduced low back pain vs active treatment or placebo control and vs no treatment control. 
Figure 1.
Levels of evidence. Source: Adapted from Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 3rd ed. London, England: BMJ Publishing Group; 2005.
Figure 1.
Levels of evidence. Source: Adapted from Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 3rd ed. London, England: BMJ Publishing Group; 2005.
15. Potential benefits and harms: Describe anticipated benefits and potential risks associated with implementation of guideline recommendations.  
Potential benefits include but are not limited to improved care for patients seeing osteopathic physicians or practitioners for somatic dysfunctions causing low back pain. Harms have not been identified in randomized clinical trials on OMT for patients with low back pain. Osteopathic manipulative treatment for somatic dysfunction has not demonstrated harm in any clinical trials to date. 
16. Patient preferences: Describe the role of patient preferences when a recommendation involves a substantial element of personal choice or values.  
Patients have a choice of provider and services when they suffer from low back pain. Osteopathic manipulative treatment offers another option for care for low back pain from somatic dysfunction and can be provided by osteopathic physicians. It is utilized as an adjunct or complementary to conventional or alternative methods of treatment. 
17. Algorithm: Provide (when appropriate) a graphical description of the stages and decisions in clinical care described by the guideline.  
Once a patient with low back pain is diagnosed with somatic dysfunction as the cause, or contributing factor, of the low back pain, OMT should be utilized by the osteopathic physician (Figure 2). The diagnosis of somatic dysfunction entails a focal or complete history and physical examination, including an osteopathic structural examination that provides evidence of asymmetrical anatomic landmarks, restriction or altered range of joint motion, and palpatory abnormalities of soft tissues. Osteopathic manipulative treatment for somatic dysfunction is utilized after other potential causes of low back pain are ruled out or considered improbable by the treating physician (ie, vertebral fracture; vertebral joint dislocation; muscle tears or lacerations; spinal or vertebral joint ligament rupture; inflammation of intervertebral disks, spinal zygapophyseal facets joints, muscles or fascia; skin lacerations; sacroiliitis; ankylosing spondylitis; masses in or from the low back structures; or organic [visceral] disease referring pain to the back or causing low back muscle spasms). 
Figure 2.
Algorithm for osteopathic manipulative treatment (OMT) for low back pain (LBP) decision making. Source: Adapted from: Nelson KE. The manipulative prescription. In: Nelson KE, Glonek T, eds. Somatic Dysfunction in Osteopathic Family Medicine. Baltimore, MD: Lippincott Williams & Wilkins; 2007:27-32.
Figure 2.
Algorithm for osteopathic manipulative treatment (OMT) for low back pain (LBP) decision making. Source: Adapted from: Nelson KE. The manipulative prescription. In: Nelson KE, Glonek T, eds. Somatic Dysfunction in Osteopathic Family Medicine. Baltimore, MD: Lippincott Williams & Wilkins; 2007:27-32.
18. Implementation considerations: Describe anticipated barriers to application of the recommendations. Provide reference to any auxiliary documents for providers or patients that are intended to facilitate implementation. Suggest review criteria for measuring changes in care when the guideline is implemented.  
One of the barriers to application of the recommendations cited by osteopathic physicians has been poor reimbursement for OMT.58 However, Medicare has reimbursed osteopathic physicians for this procedure (ICD-9 code: 98926-9) for more than 30 years. Many osteopathic physicians apparently do not utilize OMT in clinical practice because of a number of barriers, including time constraints, lack of confidence, loss of skill over time from disuse, and inadequate office space.58 Some specialists (ie, pathologists and radiologists) do not use OMT as it is not applicable to their duties within their specialty. The AOA believes patients with low back pain should be treated with OMT given the high level of evidence that supports its efficacy. Changes in care when this guideline is implemented will be determined by physician and patient surveys, billing and coding practice patterns among osteopathic physicians, data gathered from osteopathic physicians via the AOA's Clinical Assessment Program, and other registry data gathering tools currently being developed by researchers. 
1,2 
Appendix 1
Computerized database search strategies. A literature search for all patient-oriented research involving osteopathic manipulative treatment was conducted in the following databases: MEDLINE, OLDMEDLINE, OSTMED, AMED, MANTIS, CINAHL, EMBASE, and Cochrane Center Register of Controlled Trials. The following thesis and dissertation databases and Web sites were searched: Osteopathic Research Web, WorldCat Dissertations and Theses, and Digital Dissertation Abstracts, Canadian College of Osteopathy Research Titles, and the International Academy of Osteopathy. Abbreviations: MeSH, medical subject heading; OMT, osteopathic manipulative treatment. Source: Licciardone JC et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;6:43.1
Computerized database search strategies. A literature search for all patient-oriented research involving osteopathic manipulative treatment was conducted in the following databases: MEDLINE, OLDMEDLINE, OSTMED, AMED, MANTIS, CINAHL, EMBASE, and Cochrane Center Register of Controlled Trials. The following thesis and dissertation databases and Web sites were searched: Osteopathic Research Web, WorldCat Dissertations and Theses, and Digital Dissertation Abstracts, Canadian College of Osteopathy Research Titles, and the International Academy of Osteopathy. Abbreviations: MeSH, medical subject heading; OMT, osteopathic manipulative treatment. Source: Licciardone JC et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;6:43.1 Computerized database search strategies. A literature search for all patient-oriented research involving osteopathic manipulative treatment was conducted in the following databases: MEDLINE, OLDMEDLINE, OSTMED, AMED, MANTIS, CINAHL, EMBASE, and Cochrane Center Register of Controlled Trials. The following thesis and dissertation databases and Web sites were searched: Osteopathic Research Web, WorldCat Dissertations and Theses, and Digital Dissertation Abstracts, Canadian College of Osteopathy Research Titles, and the International Academy of Osteopathy. Abbreviations: MeSH, medical subject heading; OMT, osteopathic manipulative treatment. Source: Licciardone JC et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;6:43.1
Appendix 1
Computerized database search strategies. A literature search for all patient-oriented research involving osteopathic manipulative treatment was conducted in the following databases: MEDLINE, OLDMEDLINE, OSTMED, AMED, MANTIS, CINAHL, EMBASE, and Cochrane Center Register of Controlled Trials. The following thesis and dissertation databases and Web sites were searched: Osteopathic Research Web, WorldCat Dissertations and Theses, and Digital Dissertation Abstracts, Canadian College of Osteopathy Research Titles, and the International Academy of Osteopathy. Abbreviations: MeSH, medical subject heading; OMT, osteopathic manipulative treatment. Source: Licciardone JC et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;6:43.1
Computerized database search strategies. A literature search for all patient-oriented research involving osteopathic manipulative treatment was conducted in the following databases: MEDLINE, OLDMEDLINE, OSTMED, AMED, MANTIS, CINAHL, EMBASE, and Cochrane Center Register of Controlled Trials. The following thesis and dissertation databases and Web sites were searched: Osteopathic Research Web, WorldCat Dissertations and Theses, and Digital Dissertation Abstracts, Canadian College of Osteopathy Research Titles, and the International Academy of Osteopathy. Abbreviations: MeSH, medical subject heading; OMT, osteopathic manipulative treatment. Source: Licciardone JC et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;6:43.1 Computerized database search strategies. A literature search for all patient-oriented research involving osteopathic manipulative treatment was conducted in the following databases: MEDLINE, OLDMEDLINE, OSTMED, AMED, MANTIS, CINAHL, EMBASE, and Cochrane Center Register of Controlled Trials. The following thesis and dissertation databases and Web sites were searched: Osteopathic Research Web, WorldCat Dissertations and Theses, and Digital Dissertation Abstracts, Canadian College of Osteopathy Research Titles, and the International Academy of Osteopathy. Abbreviations: MeSH, medical subject heading; OMT, osteopathic manipulative treatment. Source: Licciardone JC et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;6:43.1 ×
Appendix 2
Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved.
Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved. Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved. Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved.
Appendix 2
Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved.
Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved. Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved. Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved. ×
 These guidelines were first published to the National Guidelines Clearinghouse and the AOA Web site in June 2010.
 
 Financial Disclosures: None reported.
 
 Editor's Note: To enhance the readability of this special feature to JAOA—The Journal of the American Osteopathic Association, these guidelines have been edited for grammar and basic JAOA style. The content of this contribution has not been modified.
 
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Figure 1.
Levels of evidence. Source: Adapted from Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 3rd ed. London, England: BMJ Publishing Group; 2005.
Figure 1.
Levels of evidence. Source: Adapted from Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 3rd ed. London, England: BMJ Publishing Group; 2005.
Figure 2.
Algorithm for osteopathic manipulative treatment (OMT) for low back pain (LBP) decision making. Source: Adapted from: Nelson KE. The manipulative prescription. In: Nelson KE, Glonek T, eds. Somatic Dysfunction in Osteopathic Family Medicine. Baltimore, MD: Lippincott Williams & Wilkins; 2007:27-32.
Figure 2.
Algorithm for osteopathic manipulative treatment (OMT) for low back pain (LBP) decision making. Source: Adapted from: Nelson KE. The manipulative prescription. In: Nelson KE, Glonek T, eds. Somatic Dysfunction in Osteopathic Family Medicine. Baltimore, MD: Lippincott Williams & Wilkins; 2007:27-32.
Appendix 1
Computerized database search strategies. A literature search for all patient-oriented research involving osteopathic manipulative treatment was conducted in the following databases: MEDLINE, OLDMEDLINE, OSTMED, AMED, MANTIS, CINAHL, EMBASE, and Cochrane Center Register of Controlled Trials. The following thesis and dissertation databases and Web sites were searched: Osteopathic Research Web, WorldCat Dissertations and Theses, and Digital Dissertation Abstracts, Canadian College of Osteopathy Research Titles, and the International Academy of Osteopathy. Abbreviations: MeSH, medical subject heading; OMT, osteopathic manipulative treatment. Source: Licciardone JC et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;6:43.1
Computerized database search strategies. A literature search for all patient-oriented research involving osteopathic manipulative treatment was conducted in the following databases: MEDLINE, OLDMEDLINE, OSTMED, AMED, MANTIS, CINAHL, EMBASE, and Cochrane Center Register of Controlled Trials. The following thesis and dissertation databases and Web sites were searched: Osteopathic Research Web, WorldCat Dissertations and Theses, and Digital Dissertation Abstracts, Canadian College of Osteopathy Research Titles, and the International Academy of Osteopathy. Abbreviations: MeSH, medical subject heading; OMT, osteopathic manipulative treatment. Source: Licciardone JC et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;6:43.1 Computerized database search strategies. A literature search for all patient-oriented research involving osteopathic manipulative treatment was conducted in the following databases: MEDLINE, OLDMEDLINE, OSTMED, AMED, MANTIS, CINAHL, EMBASE, and Cochrane Center Register of Controlled Trials. The following thesis and dissertation databases and Web sites were searched: Osteopathic Research Web, WorldCat Dissertations and Theses, and Digital Dissertation Abstracts, Canadian College of Osteopathy Research Titles, and the International Academy of Osteopathy. Abbreviations: MeSH, medical subject heading; OMT, osteopathic manipulative treatment. Source: Licciardone JC et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;6:43.1
Appendix 1
Computerized database search strategies. A literature search for all patient-oriented research involving osteopathic manipulative treatment was conducted in the following databases: MEDLINE, OLDMEDLINE, OSTMED, AMED, MANTIS, CINAHL, EMBASE, and Cochrane Center Register of Controlled Trials. The following thesis and dissertation databases and Web sites were searched: Osteopathic Research Web, WorldCat Dissertations and Theses, and Digital Dissertation Abstracts, Canadian College of Osteopathy Research Titles, and the International Academy of Osteopathy. Abbreviations: MeSH, medical subject heading; OMT, osteopathic manipulative treatment. Source: Licciardone JC et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;6:43.1
Computerized database search strategies. A literature search for all patient-oriented research involving osteopathic manipulative treatment was conducted in the following databases: MEDLINE, OLDMEDLINE, OSTMED, AMED, MANTIS, CINAHL, EMBASE, and Cochrane Center Register of Controlled Trials. The following thesis and dissertation databases and Web sites were searched: Osteopathic Research Web, WorldCat Dissertations and Theses, and Digital Dissertation Abstracts, Canadian College of Osteopathy Research Titles, and the International Academy of Osteopathy. Abbreviations: MeSH, medical subject heading; OMT, osteopathic manipulative treatment. Source: Licciardone JC et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;6:43.1 Computerized database search strategies. A literature search for all patient-oriented research involving osteopathic manipulative treatment was conducted in the following databases: MEDLINE, OLDMEDLINE, OSTMED, AMED, MANTIS, CINAHL, EMBASE, and Cochrane Center Register of Controlled Trials. The following thesis and dissertation databases and Web sites were searched: Osteopathic Research Web, WorldCat Dissertations and Theses, and Digital Dissertation Abstracts, Canadian College of Osteopathy Research Titles, and the International Academy of Osteopathy. Abbreviations: MeSH, medical subject heading; OMT, osteopathic manipulative treatment. Source: Licciardone JC et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;6:43.1 ×
Appendix 2
Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved.
Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved. Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved. Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved.
Appendix 2
Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved.
Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved. Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved. Definitions of terms used. Source: Glossary of Osteopathic Terminology, Revised April 2009. Reprinted with permission from the American Association of Colleges of Osteopathic Medicine. All rights reserved. ×