Editorial  |   November 2010
How the AOA Established the First National Guidelines for OMT
Author Notes
  • Dr Seffinger is currently the vice chair of the AOA Bureau of Osteopathic Clinical Education and Research and president-elect of the American Academy of Osteopathy, as well as a member of the AOA Joint Committee on Quality Payments and the JAOA Editorial Advisory Board. 
  • 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: 
Article Information
Osteopathic Manipulative Treatment
Editorial   |   November 2010
How the AOA Established the First National Guidelines for OMT
The Journal of the American Osteopathic Association, November 2010, Vol. 110, 636-637. doi:
The Journal of the American Osteopathic Association, November 2010, Vol. 110, 636-637. doi:
Twenty-five years ago, when I was a student at the Michigan State University College of Osteopathic Medicine in East Lansing, Robert C. Ward, DO, and other members of the Educational Council of Osteopathic Principles (ECOP) challenged me and several other osteopathic medical students to search the scientific literature for evidence supporting osteopathic medicine's philosophical approach to patient care. I found that osteopathic philosophy and its tenets are well founded upon the sciences of anatomy and physiology, as well as upon patient outcome studies. I also found that contemporary science supported many of the approaches Andrew Taylor Still, MD, DO, and his students proposed for a variety of dysfunctions and diseases. 
The Council of Deans charged ECOP to develop a standard evidence-based osteopathic curriculum for use as a guide and template for all colleges of osteopathic medicine. I helped develop that document from 1984 to 1986. By the time I graduated in 1988, ECOP, which is a council of the American Association of Colleges of Osteopathic Medicine (AACOM), had developed a well-referenced, evidence-based outline for a standard core curriculum for osteopathic principles and practice (OPP). In using the curriculum, osteopathic medical schools identified themselves as uniquely osteopathic, and their graduates carried the osteopathic philosophy with them to each patient encounter. 
The core curriculum led to the development of the American Osteopathic Association's standard textbook Foundations for Osteopathic Medicine,1 of which I have been a section editor from its beginning. Now in its third edition, the textbook is a multidisciplinary, comprehensive, peer-reviewed, evidence-based, state-of-the-art reference, through out which resonates the osteopathic philosophy, including the AOA-endorsed tenets of osteopathic medicine.2 Foundations' third edition is a synergy of the profession's scientific foundations and its art of practice, and it is based on a health-oriented philosophy that will guide generations of medical students and physicians in providing patient-centered osteopathic medical care throughout the world. 
From 1995, when the first Foundations was in the works, through 2008, I taught evidence-based manual medicine courses for allopathic physicians at the American Academy of Family Physicians' annual scientific assembly. These courses led to the development of an evidence-based manual medicine textbook that I cowrote with Raymond J. Hruby, DO, FAAO, in 2007.3 
With Felix J. Rogers, DO, I launched “The Somatic Connection” column in JAOA—The Journal of the American Osteopathic Association in 2006 to help readers keep abreast of the burgeoning evidence-based national and international literature relevant to OPP, especially osteopathic manipulative treatment (OMT). 
Needless to say, I have been keeping up to date on the world's scientific literature regarding OMT and other aspects of OPP. 
Lack of Awareness of Osteopathic Medical Studies
In all of these roles, I was dismayed time and again whenever I came across a clinical trial, review article, or clinical guideline (typically developed by an expert panel of physicians, chiropractors, physical therapists, or PhDs) and inevitably the document included no mention of research related to osteopathic medicine, despite the fact it existed. 
To combat this oversight, 8 years ago, Thomas Glonek, PhD, of the Louisa Burns Osteopathic Research Committee of the American Academy of Osteopathy (AAO), led the charge to ensure that the National Library of Medicine used ECOP's Glossary of Osteopathic Terminology4 to enable the MEDLINE and PubMed search engines to locate published osteopathic medical research. In addition, with the AOA's and AACOM's blessings, the Edward Via Virginia College of Osteopathic Medicine in Blacksburg relaunched the OSTMED database of osteopathic medical research literature, expanding it to include digital scans of articles and renaming it OSTMED.DR. 
Thereafter, I expected the trend to change. I thought that researchers outside the osteopathic medical profession would no longer use the excuse that they could not find our literature by using our keywords in databases and search engines. Unfortunately, the behavior of leaving out osteopathic medical studies from national guidelines, systematic reviews, and meta-analyses continued. In my experiences and in those of my colleagues, this exclusion hindered DOs from getting paid for OMT because claims reviewers would reason, “There is no literature supporting the use of OMT in that type of patient for that reason.” Even osteopathic physicians did not know that we had evidence-based literature to support our claims that OMT was indicated and efficacious. 
John C. Licciardone, DO, the executive director of the Osteopathic Research Center on the campus of the University of North Texas Health Science Center—Texas College of Osteopathic Medicine in Fort Worth, gathered articles on clinical trials that assessed the efficacy of OMT in reducing low back pain and conducted a systematic review and meta-analysis.5 Dr Licciardone's study, published in 2005, indicated that research existed to support our claims of the efficacy of OMT. However, other researchers still ignored our literature. 
For example, a 2007 guideline6 for the evaluation and treatment of patients with low back pain developed by the American College of Physicians and the American Pain Society cited no clinical trials using OMT in patients with low back pain or even Dr Licciardone's systematic review and meta-analysis.5 
Development of the OMT Guidelines
After open forums held during the AOA's and the AAO's conventions, the AAO Board of Trustees determined that national guidelines for osteopathic physicians were in order, and it submitted a resolution to the AOA House of Delegates (Resolution 297 [A/2006]—“Practice Guidelines for Osteopathic Manipulative Treatment [OMT]”). The resolution was approved as AOA policy by the House in July 2006, and the AOA Bureau of Osteopathic Clinical Education and Research (BOCER) was charged with carrying out the policy. The bureau determined at its May 2007 meeting that it would focus on developing practice guidelines for low back pain because studies with the best evidence (Grade 1a) support using OMT for this purpose. The bureau formed a Clinical Guideline Subcommittee on Low Back Pain with eight members to develop the guidelines and obtained funding for the subcommittee's meetings from the A.T. Still Osteopathic Foundation and Research Institute. 
As BOCER's chair at the time, I was charged with directing the subcommittee 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, the AOA Bureau of Scientific Affairs and Public Health, the AOA Bureau on Socioeconomic Affairs, the AOA Council on Research, the AAO, the American College of Osteopathic Family Physicians, and the American College of Osteopathic Internists. 
With the help of subcommittee members Boyd R, Buser, DO; John C. Licciardone, DO; James A. Lipton, DO, FAAO; John K. Lynch, DO, MPH; Michael M. Patterson, PhD; Richard Snow, DO, MPH; and Monte E. Troutman, DO, I spearheaded a national effort to draft evidence-based guidelines that would meet the following objectives: 
  • assess the efficacy of OMT for somatic dysfunction associated with low back pain, with the treatment being administered by US-trained osteopathic physicians and foreign osteopathic practitioners trained in osteopathic palpatory diagnosis and manipulative treatment
  • assist osteopathic physicians in the appropriate use of OMT for patients with low back pain
  • enable osteopathic physicians—as well as other physicians, other health professionals, and third-party payers—to understand the evidence underlying recommendations for appro priate use of OMT, which is not detailed in the sets of guidelines developed by other physicians
In other words, these guidelines were to focus on the use of OMT on patients with somatic dysfunction and low back pain so that DOs and the world at large would know that OMT is efficacious as proved by rigorous scientific investigations. In addition, the evidence in the guidelines would support third-party payers reimbursing DOs for providing OMT to treat patients for low back pain. 
The guidelines drafted by the subcommittee were vetted by various other organizations and then approved by the AOA Board of Trustees. The AOA then submitted the guidelines to the National Guideline Clearinghouse at the federal Agency for Healthcare Research and Quality. The clearinghouse accepted the guidelines and posted an abstract to the guidelines on June 4, 2010, on the National Guideline Clearinghouse's Web site as Guideline Summary NGC:007504 ( The abstract includes a hyperlink to the entire guidelines document, which is posted on the AOA's Web site ( Beginning on page 653 of this issue, these guidelines are reproduced for JAOA readers. 
This document is the first national guidelines created by the AOA. I hope these guidelines will not be the last. 
Ward RC, ed. Foundations for Osteopathic Medicine. Philadelphia, PA: Lippincott Williams;1997 .
Tenets of osteopathic medicine. American Osteopathic Association Web site. Accessed November 17, 2010.
Seffinger MA, Hruby RJ. Evidence-Based Manual Medicine: A Problem-Oriented Approach. Philadelphia, PA: Saunders Elsevier;2007 .
Glossary of Osteopathic Terminology. Chevy Chase, MD: American Association of Colleges of Osteopathic Medicine; 2009. Accessed November 10, 2010.
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 .
Chou R, Qassem A, Snow V, et al; for the Clinical Efficacy Assessment Subcommittee on the American College of Physicians and the 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. Ann Intern Med. 2007;147(7):478-491.