Letters to the Editor  |   September 2013
Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: An Illustration of Osteopathic Semantic Confusion
Author Affiliations & Notes
  • Peter Leysen, MD
    University of Antwerp, Belgium; Mr Leysen completed the educational program of the International Academy of Osteopathy
  • Katrien Bombeke, MD, PhD
    University of Antwerp, Belgium
  • Roy Remmen, MD, PhD
    Department of Primary and Interdisciplinary Care, Division of General Practice, University of Antwerp, Belgium
Article Information
Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment / Pain Management/Palliative Care / Low Back Pain
Letters to the Editor   |   September 2013
Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: An Illustration of Osteopathic Semantic Confusion
The Journal of the American Osteopathic Association, September 2013, Vol. 113, 660-661. doi:
The Journal of the American Osteopathic Association, September 2013, Vol. 113, 660-661. doi:
To the Editor: 
A recent randomized controlled trial by Licciardone et al1 reported on the beneficial effect of osteopathic manual treatment (OMT) in chronic low back pain. This keen study should excite the medical world's interest, not only for the results in favor of OMT but also for some existential—with regard to OMT—philosophical considerations that it raises. After all, what is OMT? It is striking that in this study1 the abbreviation OMT is used for “osteopathic manual treatment,” differing from the usual term “osteopathic manipulative treatment.”3 We would like to point out that this seemingly small change reflects a larger identity problem peculiar to osteopathic medicine. 
In our search for a description of OMT as studied in interventional research and as pooled in systematic reviews,2,3 we noticed that besides spinal manipulation, OMT can cover various sets of techniques that are widely unknown in the health care world: soft tissue techniques, Strain-Counterstrain, muscle energy techniques, cranial osteopathic manipulative treatment, etc. Despite this global lack of knowledge of OMT, Licciardone et al1 did not clearly define it in their study. The different interpretations of OMT across studies raises the following fundamental questions: Is OMT the equivalent or rather a subset of osteopathic medicine? And what has been studied? A technique, a set of individually tailored techniques, or the application of an unexplicited theoretical osteopathic concept? In the study,1 Licciardone et al started the treatments with a standard diagnostic evaluation, but the step from findings to treatment plan, as well as the applied techniques and approached body structures, cannot be retrieved. Were tissue stretches limited to muscles? Did the physicians apply visceral techniques in the pelvic or abdominal region? 
To our understanding, OMT is seen as a black box. In other words, it is seen as a subset of osteopathic medicine that contains “typical” osteopathic techniques that are applied according to a “typical” osteopathic way of reasoning, and that reasoning is difficult to disentangle on the basis of existing literature. If this deduction is correct, osteopathic medicine is probably widely misunderstood. 
Let's illustrate this misunderstanding with recent evolutions in Belgium, a small country in Europe where legislation is being adapted to regulate nonconventional medicine. A Belgian health technology assessment report4 from 2010 was published regarding the evidence base of osteopathic medicine. The researchers, who are experts in literature research but who were not familiar with nonconventional medicine, pooled studies with vertebral manipulation as intervention, regardless of whether the intervention was defined as “high velocity low amplitude” (HVLA) or “osteopathic manipulative treatment” (OMT). These researchers thus reduced osteopathic medicine to a treatment method of spinal manipulations and described its limited evidence base. They probably did not know that OMT contains a wide range of techniques not limited to HVLA techniques. Moreover, judging on the efficacy of spinal manipulation, the report did not discriminate between manipulation applied by manual therapists, chiropractors, and osteopaths or osteopathic physicians. Yet the conclusions of this report4 are key in the debate of the regulation of osteopathic medicine in Belgium as nonconventional manual therapy. 
In an attempt to better understand the true nature of osteopathic medicine, we looked at the educational programs of the Belgian schools of osteopathy.4 According to a document of the World Health Organization to streamline osteopathic education worldwide,5 most Belgian schools offer osteopathy in the cranial, visceral, and parietal (musculoskeletal) field. So does the biggest and most widespread institution for osteopathic education in Europe, The International Academy of Osteopathy, which has locations across the globe. By contrast, the only Belgian university that offers education in osteopathy (Université Libre de Bruxelles) limits its program to the parietal field, a part that is excluded from the education program at The Sutherland College of Osteopathic Medicine. With such different curricula, it is difficult to understand how students at all of these institutions will be registered the same way, as osteopaths. In our opinion, these major disparities in osteopathic education reflect the same identity confusion as seen in the literature about OMT. 
To better study, understand, and regulate osteopathic medicine, we need a robust osteopathic vocabulary that clearly describes osteopathic techniques and concepts. This vocabulary must be commonly accepted by the osteopathic world and consistently used in education, research, and practice. It would be a significant step to a better understanding of a treatment method that—at least in Belgium—is not appreciated or even tolerated by the medical community, despite all of the local and international struggles for the status of an autonomous medical profession. 
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. [CrossRef] [PubMed]
Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials [published online August 6, 2005]. BMC Musculoskelet Disord. 2005;6:43. [CrossRef] [PubMed]
Posadzki P, Ernst E. Osteopathy for musculoskeletal pain patients: a systematic review of randomized controlled trials [published online November 6, 2010]. Clin Rheumatol. 2011;30(2):285-291. [CrossRef] [PubMed]
De Gendt T, Desomer A, Goossens Met al. Stand van zaken voor de osteopathie en de chiropraxie in België. Brussel: Federaal Kenniscentrum voor de Gezondheidszorg (KCE); 2010. Contract No.: D/2010/10.273/91. Accessed August 2, 2013.
Benchmarks for Training in Traditional/Complementary and Alternative Medicine: Benchmarks for Training in Osteopathy. Geneva, Switzerland: World Health Organization; 2010. Accessed August 2, 2013.