Letters to the Editor  |   October 2010
Author Affiliations
  • Daniel K. Mangum, DO
    Advantage Medical Group, Portland, Oregon
Article Information
Evidence-Based Medicine / Osteopathic Manipulative Treatment / Pulmonary Disorders
Letters to the Editor   |   October 2010
The Journal of the American Osteopathic Association, October 2010, Vol. 110, 612-614. doi:
The Journal of the American Osteopathic Association, October 2010, Vol. 110, 612-614. doi:
The primary purpose of my letter1 in the June issue was to question the tenet proposed for our profession in an editorial by Felix J. Rogers, DO2 (ie, “the musculoskeletal system plays a primary role in health and disease”). Does the musculoskeletal system truly play a primary role in health and disease? I believe this proposed tenet is inaccurate, and that several other organ systems have better qualifications for association with the maintenance of health. 
Dr Capobianco enthusiastically supports, indirectly, the proposed tenet and the importance of the musculoskeletal (or neuromusculoskeletal) system in health maintenance. He claims to be certain that osteopathic manipulative treatment (OMT) is beneficial to patients with neuromuscular disorders, including cerebral palsy, multiple sclerosis, and numerous other medical problems. In addition, he notes that he uses prayer and nutrition advice in treatment, and he supports, at times, alternative therapies, such as detoxification and homeopathy. Certain “modern medications,” he adds, can help when necessary. 
I suggested a focused use of OMT for back pain.1 Dr Capobianco, by contrast, advocates an expansion of OMT use for numerous conditions listed in his letter, as well as for many other unlisted conditions. He is willing to survey OMT specialists to collect additional anecdotal reports. Although I welcome his response to my letter1 and this opportunity for dialogue, I am disturbed by the majority of opinions expressed by Dr Capobianco. 
I support the use of OMT as a valid treatment option for patients with musculoskeletal pain—though even for these conditions, there is no evidence that OMT is superior to other forms of care. The article cited by Dr Capobianco from the New England Journal of Medicine3 touting success of OMT is misleading, because the primary outcomes in that study were not any better for the OMT group than for the standard therapy group. 
I fear that the use of OMT for musculoskeletal pain is the only area of agreement that Dr Capobianco and I share. Our opinions diverge because Dr Capobianco supports anecdotal reports on the virtues of OMT, while I require evidence-based medicine—a term coined by Gordon Guyatt, MD, in 19904 and expanded upon in 1992.5 Evidencebased medicine should be the standard that the osteopathic medical profession and any other medical profession uses for support of treatments or development of guidelines for best care. There should be no debate on this point. 
Some evidence suggests benefits for the use of OMT for various illnesses, but the best evidence suggests that OMT fails. A.T. Still, MD, DO, claimed 100% success in the use of OMT to treat patients with asthma, for which he believed, as noted by Dr Capobianco, that “Osteopathy is king.”6 Asthma is listed by Dr Capobianco as one of the many conditions for which he has confidence in the effectiveness of OMT. Nevertheless, the best evidence to date suggests that the status of manipulation for asthma is less than regal. This evidence comes from The Cochrane Collaboration,7 an international, independent organization that provides excellent systematic reviews of evidence-based medicine. A Cochrane database review (consisting of 473 original citations and 3 randomized controlled trials) on the use of manual therapies for treating patients with asthma concluded that there is insufficient evidence to either support or refute such treatment.8 
Dr Capobianco outlines several other respiratory conditions—including chronic obstructive pulmonary disorder, coughs, colds, influenza, pleural effusions, and pneumonia—for which he expresses confidence in the use of OMT. He at least cites one published study in support of the use of OMT for pneumonia.9 Unfortunately, a Cochrane database review on physiotherapy for pneumonia—a review that included the cited OMT study9—does not support the use of manipulation for this condition.10 The review's summary concluded that manual therapies should not be recommended as routine adjunctive treatment for patients with pneumonia.10 
In fact, no firm evidence from randomized, reproducible studies can be cited as support for any claim made by Dr Capobianco. Moreover, various proposed mechanisms regarding how OMT might work in such medical problems as ulcerative colitis or various infections seem implausible and contrary to our modern understanding of human anatomy and physiology. 
Furthermore, I am frankly appalled that Dr Capobianco expands his support for alternative therapies where good evidence is completely nonexistent. For example, although Dr Capobianco lists homeopathy as an effective treatment, evidence definitively shows that this type of therapy does not work.11 A review group in the United Kingdom recently concluded that homeopathy does not produce results beyond the placebo effect and that explanations for why homeopathy would work are scientifically implausible.12 
Likewise, no evidence-based medicine exists to support claims for the use of detoxification or bioidentical hormone replacement—despite Dr Capobianco's claim that combining either of these therapies with OMT can make patient responses “more dramatic.” 
I remain convinced that we, as a profession, should distance ourselves from claims that OMT may prevent disease or modify illness when no reasonable physiologic explanation or proof can be offered. I would add that we withhold support of any alternative therapies and completely avoid anecdotal claims. Finally, the osteopathic medical profession should concentrate strictly on evidence-based medicine and proudly support the use of OMT for the treatment of patients with musculoskeletal pain. 
Mangum DK. Realigning the JAOA to sharpen our focus [letter]. J Am Osteopath Assoc. 2010: 110(6):320-321. Accessed August 21, 2010.
Rogers FJ. Realigning the JAOA to sharpen our focus [editorial]. J Am Osteopath Assoc. 2010; 110(11):577-578. Accessed August 21, 2010.
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 [published correction appears in N Engl J Med. 2000;342(11):817]. N Engl J Med. 1999;341(19):1426-1431. Accessed August 21, 2010.
Eddy DM. Practice policies: where do they come from? JAMA. 1990;263(9):1265 ,1269,1272.
Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992;268 (17): 2420-2425.
Still AT. Chapter VIII. In: Autobiography of Andrew T. Still. Kirksville, MO: Andrew Taylor Still; 1897. Accessed August 21, 2010.
About us. The Cochrane Collaboration Web site. Accessed August 21, 2010
Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev. April 18, 2005;(2):CD001002. Accessed August 21, 2010.
Noll DR, Shores JH, Gamber RG, Herron KM, Swift J Jr. Benefits of osteopathic manipulative treatment for hospitalized elderly patients with pneumonia. J Am Osteopath Assoc. 2000;100 (12):776-782. Accessed August 21, 2010.
Yang M, Yan Y, Yin X, et al. Chest physiotherapy for pneumonia in adults. Cochrane Database Syst Rev. February 17, 2010;(2):CD006338. Accessed August 21, 2010.
Goldacre B. Benefits and risks of homeopathy. Lancet. 2007;370(9600):1672-1673.
Science and Technology Committee: MPS urge government to withdraw NHS funding and MHRA licensing of homeopathy. United Kingdom Parliament Web site. February 22, 2010. Accessed August 21, 2010.