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Letters to the Editor  |   May 2011
Response
Author Affiliations
  • Michael M. Patterson, PhD
    Retired Professor, Nova Southeastern University College of Osteopathic Medicine, Ft Lauderdale, Florida; Associate Editor, JAOA—The Journal of the American Osteopathic Association
Article Information
Osteopathic Manipulative Treatment
Letters to the Editor   |   May 2011
Response
The Journal of the American Osteopathic Association, May 2011, Vol. 111, 347-348. doi:10.7556/jaoa.2011.111.5.347
The Journal of the American Osteopathic Association, May 2011, Vol. 111, 347-348. doi:10.7556/jaoa.2011.111.5.347
I appreciate Dr Kirsch's comments on the concept of technique studies vs treatment studies. I certainly agree that to be a study of osteopathic manipulative treatment (OMT), the treatment must stem from a full physical and structural examination. It was with this requirement in mind that I wrote the editorial comment to which Dr Kirsch refers1 and on which I have recently further elucidated.2 
It is important to recognize that technique studies are not OMT studies. A technique study covers only a specific subset of the procedures used during OMT. In my editor's message,1 I tried to make it clear that both researchers and consumers of the research must understand this difference. Technique studies ask very different questions than do full OMT studies. Technique studies also have limitations as to how they can be generalized to the practice of OMT, for some of the reasons expressed by Dr Kirsch. The distinction made in the editor's message1 was meant to highlight these limitations so that technique studies would not be confused with full OMT studies. 
Dr Kirsch argues that technique studies do not involve a physical and structural examination. However, although some technique studies may not involve a full physical and structural examination, most such studies do involve examinations of at least the areas to be treated, as well as some form of medical history of the patient. Again, these studies are not meant to be OMT studies and must not be held out as such. 
Two of the hallmarks of scientific research are that studies be conducted according to a protocol and that studies be reproducible. When a protocol is established for a study, choices must be made as to what can and what cannot be done during the study. These choices are necessary for reproducibility, both within the study (ie, from patient to patient) and for replication in other studies. With each choice made, certain doors are closed. 
Selection of study participants is one such choice. Participants are included in a study only after meeting certain inclusion and exclusion criteria. Such criteria are used in all clinical studies, including full OMT studies. One could make the argument that all studies that have inclusion and exclusion criteria are not conducted according to osteopathic principles, because OMT is useable on essentially all patients. However, even the landmark study by Andersson et al3 comparing osteopathic care with standard care for patients with low back pain had such limiting criteria in its protocol. Without such criteria, a study would not produce useable data and, indeed, it would not even be a “study” but rather an observational exercise. 
In any scientific study, the more controlled the protocol and the less the variability, the more one can conclude about the connection between the variable being studied and the outcome (ie, the cause and the effect). With less variability, fewer patients need to be enrolled to have a chance at yielding a positive result (if such a result exists). Thus, the best studies are those that have well-defined protocols and as little variability as possible. 
Technique studies are attempts to test certain aspects of manipulative treatment—not to test OMT. How the results of these studies relate to OMT can be debated and, of course, there is always the potential problem of generalizing the results too freely. However, as previously pointed out, all studies (both technique and treatment) have limitations on generalizability to practice because of the need for study protocols. 
As to concerns about reimbursement, there is a danger that if studies are not clearly specified as technique studies, they could be taken as representative of OMT as a whole. This danger is exactly why the distinction between technique and treatment—and the limitations of any technique or treatment study—must be made clear. However, an even greater danger is that we will not properly examine OMT through either study type, thereby losing the distinctiveness of osteopathic medical practice because of failure to demonstrate its beneficial effects. 
Dr Kirsch's analogy of breaking down OMT into parts for study is similar to separating out the ingredients of a therapeutic herb. Although in some herbal remedies there may be interactions among ingredients that are necessary for the total effect, in many other herbal remedies, a single “active” (ie, most dramatically effective) ingredient has been found. A few examples of such herbal remedies are quinine, atropine, and curare. These substances were all initially used in their whole forms as herbal remedies before the major, active ingredient in each was isolated, purified, and processed into an important medication. 
Osteopathic manipulative treatment obviously consists of many components—such as touch, patient-physician interactions, and specific movements—all of which combine to produce the final result. Although it is important to examine the efficacy of the total treatment, it is also important to study the effects of the individual components so that the total effect can be fully understood. 
Both treatment and technique studies are necessary if we are to maintain the uniqueness of osteopathic medicine. The distinctions between these 2 study types and the limitations of each must be clearly recognized and spelled out. 
I agree with Dr Kirsch's quotation of Dr Korr, that “[i]t is essential... that assessments of effectiveness of OMT be of OMT as it is practiced.”4 However, technique studies are not studies of OMT, but only parts of it. By clearly recognizing this distinction, technique studies can be effective in helping to understand the totality of osteopathic practice according to osteopathic philosophy and, in that way, help to maintain the distinctiveness of osteopathic medicine. 
I wish to acknowledge and thank William Brooks, DO, and Hollis H. King, DO, PhD, for their helpful comments on my draft of this response. 
Patterson MM. “Techniques” versus “treatment” in osteopathic manipulation (editor's message). J Am Osteopathic Assoc. 2002;102(7):375 .
Patterson MM. Foundations for osteopathic medical research. In: Chila A, ed. Foundations of Osteopathic Medicine. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:1021-1038.
Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med. 1999;341(19):1426-1431.
Korr IM. Osteopathic research: the needed paradigm shift. J Am Osteopath Assoc. 1991;91(2):156-171.