Book Review  |   February 2009
Evidence-Based Manual Medicine: A Problem-Oriented Approach
Author Affiliations
  • David C. Mason, DO
    Department of Osteopathic Manipulative, Medicine, Associate Professor of Osteopathic Manipulative, Medicine and Family Medicine, University of Medicine and Dentistry, of New Jersey-School of Osteopathic Medicine, Stratford
    Acting Chair
Article Information
Book Review   |   February 2009
Evidence-Based Manual Medicine: A Problem-Oriented Approach
The Journal of the American Osteopathic Association, February 2009, Vol. 109, 103-104. doi:
The Journal of the American Osteopathic Association, February 2009, Vol. 109, 103-104. doi:
The osteopathic medical profession has a great need for more evidence-based medicine. Our researchers are working to produce quality randomized controlled trials and systematic reviews. 
Evidence-Based Manual Medicine: A Problem-Oriented Approach, by Michael A. Seffinger, DO, and Raymond J. Hruby, DO, is a timely compilation of up-to-date evidence-based findings in diagnostic and treatment approaches to manual medicine. 
Dr Seffinger is an associate professor and the acting chair for the Department of Osteopathic Manipulative Medicine (OMM) at Western University of Health Sciences College of Osteopathic Medicine of the Pacific in Pomona, Calif. Dr Hruby is a professor and past chair in the same department. Both authors are renowned authorities on OMM who have many years of experience teaching manual medicine to family practitioners through didactics and workshops. In fact, the American Academy of Family Physicians selected these authors to educate its members about manual medicine. Both authors serve in leadership roles for JAOA—The Journal of the American Osteopathic Association, with Dr Seffinger as a member of the editorial advisory board and section editor for “The Somatic Connection” and Dr Hruby as a member of the editorial board. 
The text by Drs Seffinger and Hruby is enhanced by a generous number of superb illustrations by William A. Kuchera, DO, professor emeritus at A.T. Still University-Kirksville (Mo) College of Osteopathic Medicine, as well as by numerous photographs. 
Evidence-Based Manual Medicine is divided into 12 chapters. The first chapter is a brief overview of the text, describing the authors' motivations and the manuscript's development. 
Chapter 2, “Somatic Dysfunction Mechanisms,” begins with a review of relevant physiologic mechanisms encountered in patient care, followed by the most complete—yet concise—review of biomechanical principles of spinal motion and somatic dysfunction currently available in print. 
The next chapter, “Manual Diagnostic Procedures Overview,” is a valuable review of manual diagnostic testing procedures that should be used for a complete biomechanical examination of a patient. A DVD-ROM that accompanies the text includes video clips of many of the components of the biomechanical screening examination, providing a useful addition to this section of the book. 
Chapter 4, “Treatment Procedures Overview,” describes the treatment modalities noted through the remainder of the book. 
For the remaining seven chapters, the book shifts focus, devoting itself to several specific and commonly encountered clinical topics: “Mechanical Low Back Pain,” “Mechanical Neck and Upper Back Pain,” “Cervicogenic Headache,” “Temporomandibular Joint Dysfunction,” “Shoulder Pain and Dysfunction,” “Carpal Tunnel Syndrome,” and “Ankle Sprain.” 
Each clinical chapter carefully guides the reader through the relevant background epidemiology, functional anatomy, and differential diagnosis. The patient history and physical examination portion is likewise comprehensive, providing articulate instructions for manual diagnostic testing. 
The most unique portions of this text are the evidence-based reviews, which address potential risks and benefits of manual treatment and include practice recommendations. 
For example, the chapter on neck and upper back pain outlines risks vs benefits using tables—one that outlines the evidence in support of manual therapy for this patient population, and another devoted to contraindications for this treatment modality. 
One potentially confusing aspect of Evidence-Based Manual Medicine is inconsistent use of terminology. In some descriptions of diagnostic and treatment techniques, the authors use directional restriction nomenclature; while at other times, they opt for standard ease-of-motion nomenclature. For example, the caption for Figure 5.52 reads, “Sidelying lumbar articulatory technique: restricted extension,” while the caption for Figure 5.53, on the same page, reads, “Seated lumbar muscle energy technique: L1 through L5: neutral, sidebent right, and rotated left.” 
However, the reader can overcome any confusion caused by this minor language inconsistency by referring to the clearly written, easy-to-follow stepwise instructions of technique—provided that he or she has some familiarity with manual medicine, barrier concepts, and direct and indirect techniques of osteopathic manipulative treatment (OMT). 
The DVD-ROM that accompanies the book contains video clips of evaluation and treatment techniques described in the “Mechanical Low Back Pain” and “Mechanical Neck and Upper Back Pain” chapters. These video clips, which are professionally presented, are narrated in real time and highlight important sections of each chapter. The reader/viewer is left wishing for a multimedia option for the remaining chapters of Evidence-Based Manual Medicine. 
Reflecting the reality of our profession, a few of the clinical chapters are short on the evidentiary support of particular applications for manual medicine. For example, the chapter on ankle sprain points to one trial in the emergency department setting that demonstrated reduction in pain and edema, as well as increased range of motion, after a single session of OMT. However, no other studies are discussed in this regard. At the conclusion of each clinical chapter, the authors attempt to entice readers and would-be researchers by making thoughtful recommendations for future evidence-based research endeavors. 
True to the holistic approach that is the hallmark of patient care for osteopathic physicians, each clinical chapter includes photographs of exercises and complete stepwise descriptions, which are very well done. Many of these exercises are also featured on the book's DVD-ROM and are presented as PDF (Adobe portable document format) documents, which allows physicians to print them out when needed for patient education handouts. 
The final chapter in the book, “Manual Medicine Coding,” is devoted to billing and coding systems used for OMM procedures. This important chapter covers the basics and gives good suggestions for pursuing follow-up questions with payers. This type of information should be incorporated into more resources and, even here, could have benefited from more elaborate detail. 
Evidence-Based Manual Medicine will benefit the primary care practitioner who seeks to incorporate OMM into the treatment of patients who have common musculoskeletal complaints. This book will also be useful for primary care residents and their residency directors to supplement attempts at meeting the core competency requirements for OMT. 
Furthermore, directors of third- and fourth-year clinical courses in OMM will find this text valuable for beginning to fill a void in the education of osteopathic medical students who are transitioning their classroom-based knowledge of OMM into the clinical environment. 
As evidence slowly mounts in support of manual medicine, the authors will surely be encouraged to broaden the scope of this book in subsequent editions. Evidence-Based Manual Medicine represents a brilliant concept, and this refined first effort is much appreciated. 
 By Michael A. Seffinger, DO, and Raymond J. Hruby, DO. 323 pp, $82.95. ISBN: 978-1-4160-2384-5. Philadelphia, Pa: Saunders-Elsevier; 2007.
 Editor's Note: Corrections to this article were published in the July 2009 issue of JAOA—The Journal of the American Osteopathic Association (2009;109:388). The corrections have been incorporated in this online version of the article, which was posted December 2009. An explanation of these changes is available at: