Letters to the Editor  |   September 2013
Author Affiliations & Notes
  • John C. Licciardone, DO, MS, MBA
    The Osteopathic Research Center; Department of Medical Education, Texas College of Osteopathic Medicine; University of North Texas Health Science Center, Fort Worth
Article Information
Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment / Pain Management/Palliative Care / Low Back Pain
Letters to the Editor   |   September 2013
The Journal of the American Osteopathic Association, September 2013, Vol. 113, 661-662. doi:
The Journal of the American Osteopathic Association, September 2013, Vol. 113, 661-662. doi:
Leysen and colleagues1 make some interesting points and pose several provocative questions. They begin by noting that the recent report of favorable outcomes relating to chronic low back pain in the OSTEOPATHIC (OSTEOPAThic Health outcomes In Chronic low back pain) Trial used the acronym OMT to represent “osteopathic manual treatment” rather than “osteopathic manipulative treatment,”2 thereby raising (in their view) existential concerns relating to osteopathic identity. This conclusion appears to hinge on their observation that OMT consists of many manual techniques beyond “spinal manipulation,” which are largely unknown within the wider medical community. They assert that such manual techniques were not described in our report, although we indicated that the lumbosacral, iliac, and pubic regions were targeted for treatment with moderate-velocity, moderate-amplitude thrusts; high-velocity, low-amplitude thrusts; soft tissue techniques; myofascial release; counterstrain; and muscle energy.2 The latter 5 are among “the seven care modalities in osteopathic manual medicine.”3 
Leysen and colleagues' questions about the specificity of our OMT protocol betray their interest in the broader dichotomy of efficacy vs pragmatic trials. The OSTEOPATHIC Trial was designed to achieve a balance between these 2 approaches with the intent of maintaining scientific rigor while also informing clinical practice. Flexibility of the experimental intervention is one dimension in which the efficacy vs pragmatic dichotomy may be assessed.4 The OSTEOPATHIC Trial used an OMT protocol that has been described as “algorithmic.”5 This description means that OMT providers were trained in performing the diagnostic evaluation at each session and then delivering the 6 designated techniques within the targeted anatomical regions, but with the flexibility to avoid certain techniques when contraindicated or to add optional techniques (within time constraints) when indicated. Patients in the OSTEOPATHIC Trial had a high baseline prevalence of somatic dysfunction in the lumbar, sacral, pelvic, and innominate regions.6 Thus, rather than being a “black box,” our algorithmic multimodal OMT approach may have been responsible for the favorable results we achieved with OMT as compared with previous manual therapy studies that have often relied on unimodal manipulative approaches such as high-velocity, low-amplitude thrusts to achieve only marginal results.7 Interestingly, while the primary outcomes of the OSTEOPATHIC Trial immediately bolstered the evidence for treating patients with nonspecific chronic low back pain with OMT, other secondary analyses have identified reduction of serum tumor necrosis factor-α as a possible mediator of the observed OMT effects.5 
The heterogeneity of osteopathic education and training internationally and the disparate practice rights afforded to osteopathic licensees across national boundaries defy a uniform assessment of the challenges encountered by osteopaths abroad in dealing with such terms as “OMT,” “osteopathy,” and “osteopathic medicine.” Clearly, however, national differences exacerbate the confusion within the allopathic medical community about osteopathic terms and concepts. Nevertheless, a framework for the robust osteopathic vocabulary that Leysen and colleagues1 seek already exists in the Glossary of Osteopathic Terminology.3 The Glossary aims to standardize terminology based on a consensus within the osteopathic profession and to assist other professionals in understanding and making proper use of this terminology. 
Leysen P, Bombeke K, Remmen R. Osteopathic manual treatment and ultrasound therapy for chronic low back pain: an illustration of osteopathic semantic confusion [letter]. J Am Osteopath Assoc. 2013;113(9):660-661. [CrossRef] [PubMed]
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]
Educational Council on Osteopathic Principles. Glossary of Osteopathic Terminology. Chevy Chase, MD: American Association of Colleges of Osteopathic Medicine; 2011.
Glasgow RE. What does it mean to be pragmatic? pragmatic methods, measures, and models to facilitate research translation. Health Educ Behav. 2013;40(3):257-265. [CrossRef] [PubMed]
Licciardone JC, Kearns CM, Hodge LM, Bergamini MV. Associations of cytokine concentrations with key osteopathic lesions and clinical outcomes in patients with nonspecific chronic low back pain: results from the OSTEOPATHIC Trial. J Am Osteopath Assoc. 2012;112(9):596-605. [PubMed]
Licciardone JC, Kearns CM. Somatic dysfunction and its association with chronic low back pain, back-specific functioning, and general health: results from the OSTEOPATHIC Trial. J Am Osteopath Assoc. 2012;112(7):420-428. [PubMed]
Licciardone JC, Kearns CM, Minotti DE. Outcomes of osteopathic manual treatment for chronic low back pain according to baseline pain severity: results from the OSTEOPATHIC Trial [published online June 8, 2013]. Man Ther. doi:10.1016/j.math.2013.05.006.