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The Somatic Connection  |   July 2013
Osteopathic Manipulative Treatment Is Efficacious for Management of Chronic Low Back Pain
Author Affiliations
  • Michael A. Seffinger, DO
    Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, California
Article Information
The Somatic Connection   |   July 2013
Osteopathic Manipulative Treatment Is Efficacious for Management of Chronic Low Back Pain
The Journal of the American Osteopathic Association, July 2013, Vol. 113, 568-569. doi:10.7556/jaoa.2013.010
The Journal of the American Osteopathic Association, July 2013, Vol. 113, 568-569. doi:10.7556/jaoa.2013.010
Licciardone JC, Minotti DE, Gatchel RJ, Kearns CM, Singh KP. Osteopathic manual treatment and ultrasound therapy for chronic low back pain: a randomized controlled trial. Ann Fam Med. 2013;11(2):122-129.  
Each year in the United States, low back pain (LBP) is associated with more than 20 million ambulatory health care visits1 and $100 billion in related costs.2 During a 4-year period, researchers at the Osteopathic Research Center on the campus of the University of North Texas Health Science Center in Fort Worth, with Executive Director John C. Licciardone, DO, MS, MBA, as principal investigator, performed a landmark study (the OSTEOPAThic Health outcomes In Chronic low back pain [OSTEOPATHIC] Trial) assessing the efficacy of osteopathic manual treatment, or osteopathic manipulative treatment (OMT) as it is more commonly known, and ultrasound therapy (UST) in patients with chronic LBP. 
This randomized, double-blind, sham-controlled study enrolled 455 nonpregnant participants (171 men, 284 women; age range, 21-69 years) with LBP of at least 3 months' duration. Potential participants were excluded from the study if they met any of the following criteria: underlying spinal disease; low back surgery performed during the past year; receipt of workers' compensation benefits in the past 3 months; history of angina or congestive heart failure symptoms with minimal activity; history of stroke or transient ischemic attack; implanted biomedical devices; active bleeding or infection in the low back; corticosteroid use during the past month; use of manual therapy (OMT or manual therapy provided by chiropractors or physical therapists) or UST either in the past 3 months or more than 3 times in the past year. Potential participants who had signs of lumbar radiculopathy at physical examination were also excluded. 
Participants were randomly assigned to 1 of 4 main effect groups: OMT (n=230), sham OMT (n=225), UST (n=233), or sham UST (n=222). Each participant received 6 treatments (performed at weeks 0, 1, 2, 4, 6, and 8) consisting of OMT or sham OMT for 15 minutes, followed by UST or sham UST for 10 minutes. After standard osteopathic structural examination, somatic dysfunction in OMT group patients was managed in the lumbosacral, iliac, and pubic regions by using soft tissue; myofascial release; strain-counterstrain; muscle energy procedures; high-velocity, low-amplitude thrusts; and moderate-velocity, moderate-amplitude thrusts, followed by other osteopathic manipulative procedures administered as needed by the osteopathic physician providing the OMT. Sham OMT was described as “hand contact, active and passive range of motion, and techniques that simulated OMT but that used such maneuvers as light touch, improper patient positioning, purposely misdirected movements, and diminished physician force.” 
The same physician who applied the OMT or sham OMT intervention delivered UST or sham UST to 150 to 200 cm2 of the low back region after the initial intervention was completed. A Sonicator 730 (Mettler Electronics Corp) with a 10 cm2 applicator (intensity, 1.2 W/cm2; frequency, 1 MHz) was used to deliver UST, and sham UST was delivered in the same way but at a subtherapeutic intensity (0.1 W/cm2). 
The primary outcome measure was short-term pain relief, which was recorded at week 12 using a 100-mm visual analog scale and was compared with the measurement obtained before treatment. Consensus statement recommendations from the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) regarding moderate (pain reduction of 30% or more) and substantial (pain reduction of 50% or more) improvement were used to evaluate the primary outcome. Secondary outcome measures included back-specific functioning, general health, work disability caused by LBP, prescription drug use, satisfaction with back care, safety outcomes, and treatment adherence. These outcome measures were recorded at baseline and at weeks 4, 8, and 12 by using the Roland-Morris Disability Questionnaire, the Medical Outcomes Study Short Form-36 Health Survey general health scale, the number of work days lost because of LBP during the past 4 weeks, and a 5-point Likert scale for recording patient satisfaction with back care. 
Results favored OMT over sham OMT for moderate (P<.001) and substantial (P=.002) pain relief at 12 weeks. Of the secondary outcomes, only patient satisfaction (P<.001) and decreased frequency of use of prescription medications (P<.048) favored OMT over sham OMT. All other outcomes did not differentiate between OMT and sham OMT. No statistically significant interaction between OMT and UST was noted, and neither UST intervention was considered efficacious for pain relief. 
The results of this long-awaited and largest and most rigorously designed randomized clinical trial in osteopathic medical research history demonstrate that OMT is indeed efficacious in relieving chronic, nonspecific LBP related to somatic dysfunction. This study lends further support to the American Osteopathic Association's guidelines3 that recommend the use of OMT for patients with LBP. 
   “The Somatic Connection” highlights and summarizes important contributions to the growing body of literature on the musculoskeletal system's role in health and disease. This section of The Journal of the American Osteopathic Association (JAOA) strives to chronicle the substantial increase in published research on manipulative methods and treatments in the United States and the renewed interest in manual medicine internationally, especially in Europe.
 
   To submit scientific reports for possible inclusion in “The Somatic Connection,” readers are encouraged to contact JAOA Associate Editor Michael A. Seffinger, DO (mseffingerdo@osteopathic.org), or JAOA Editorial Advisory Board Member Hollis H. King, DO, PhD (hollis.king@fammed.wisc.edu).
 
References
Licciardone JC. The epidemiology and medical management of low back pain during ambulatory medical care visits in the United States. Osteopath Med Prim Care. 2008;2(1):11. [CrossRef] [PubMed]
Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006;88(suppl 2):21-24. [CrossRef] [PubMed]
Clinical Guideline Subcommittee on Low Back Pain. American Osteopathic Association guidelines for osteopathic manipulative treatment (OMT) for patients with low back pain. J Am Osteopath Assoc. 2010;110(11):653-666. [PubMed]