There is an increasing interest in the concepts of osteopathic manipulative medicine by both the orthodox and complementary branches of health care. This is particularly true for those fields that deal with the various pain syndromes. During the past twenty to thirty years the usefulness, indications, contra-indications, and outcomes of manipulation within a patient management model have been scientifically investigated. Furthermore, studies have emerged that, on the level of physiologic mechanisms, may explain some of the effects of the application of manipulative techniques. Indeed, there is a growing body of knowledge that supports the use of manual medicine approaches. The major contribution of osteopathic manipulative medicine, in particular, is the provision of a rationally integrated approach, wherein the physician’s hands are used in the medical diagnostic work-up (the “structural examination”) as well as the treatment prescription for particular painful syndromes.
Osteopathic manipulative approaches may be utilized as a “stand-alone” measure while, in other circumstances, they may be part of comprehensive patient management having the major goal of improving or restoring a patient’s function.
The major contribution of osteopathic manipulative medicine in the current patient management model of pain is two-fold: (1) the diagnostic framework (specific examination techniques and routines)1 that helps define the mechanical and neurophysiologic components of painful syndromes—particularly those directly related to mechanical back pain, and (2) the functional approach to patient management by comprehensively addressing the patient’s functional level as well as their pain perception level.2 The goal is to determine the presence of a somatic dysfunction (ICD-9 code 739) at a segmental spinal level, as well as its effects on regional or global functional level.
What Is Osteopathic Manipulative Medicine?
Osteopathic manipulative medicine (OMM) is one of the various modalities in the broad field of manual medicine. It constitutes a medical discipline in which medical practitioners apply their hands skillfully in both the diagnostic and therapeutic management of painful neuro-musculoskeletal disorders and various diseases.3 The practice includes the use of the hands in a patient management process with specific maneuvers and instructions to achieve maximum, pain-free movement of the musculoskeletal (motor) system in postural balance.4 Other terms that refer to the osteopathic manipulation procedures include Osteopathic Manipulative Therapy (OMT) and osteopathic manipulation in general. Osteopathic manipulative medicine education in the United States is part of every osteopathic physician’s training during medical school. Furthermore, allopathic physicians (MDs) and dentists can learn various osteopathic techniques and approaches in continuing medical education courses within the post-graduate medical education context.
It is noted that—while the use of OMM is often viewed as a “natural” approach to various musculoskeletal pain syndromes —it can be utilized rationally within the context of patient management for a number of medical conditions.5 Within this context, the OMM can serve as (1) the initial primary treatment for pain or (2) as an adjunct treatment of the effects that somatic dysfunction(s) has upon overall function including circulation, neurophysiology,6 and the overall compensatory and adaptive changes that follow such initial somatic dysfunction—or as the result of other diseases.
Osteopathic manipulative medicine may expand and refine the differential diagnosis by giving consideration to the existence of somatic dysfunction(s) and treatment options by integrating functionally-based treatment options (e.g. various techniques, specific exercise instruction, postural considerations, etc.) into state-of-the-art pain management practices.
Osteopathic Manipulative Medicine and Low Back Pain
Low back pain represents one of the most taxing health problems in developed countries and is commonly treated in primary health care settings.7 Lower Back Pain (LBP) symptoms are the second leading cause of visits to all primary care physicians, and are the most common cause of visits to Osteopathic Physicians.8 It is estimated that 15-20% of Americans experience low back pain annually. At any given time, 2% of Americans are disabled due to back problems.9 The total annual cost of back pain in America has been estimated at $20-50 billion.9
The clinical management of LBP can be quite varied, both with respect to the diag-nostic and therapeutic approaches.7,10,11 Spine care has also changed dramatically with indications for surgical spine care giving way to a comprehensive patient management model that utilizes all aspects in a patient’s bio-psycho-social situation. With the knowledge that the majority of low back pain is mechanical in nature (up to 90%), it stands to reason that OMM is a useful tool in the diagnostic and therapeutic management of the various mechanical spinal disorders. New evidence of both the physiological mechanism and outcome levels has steadily grown through improved study design as has general interest in the field.
Physiology and Theorized OMM Mechanism of Action
Once a particular loss of motion has been determined through the structural examination and contraindications have been excluded, manipulation can be applied to the hypomobile spinal motion segment(s). Manipulative techniques to address hypermobility should be carefully introduced, if at all, since the goal is to “strengthen” the joint.
A conceptual framework has been presented by Dvorak et al12 that explains one aspect of the physiologic effects of OMM upon a particular spinal segment and the various mechanoreceptors that, in turn, affect localized joint function (see Figures 1 and 2). Localized somatic dys-function affects motion characteristics at the segmental, as well as the regional and global levels, and potentially leads to adaptive and compensatory mechanical patterns that invoke abnormal functioning throughout.13
Figure 1. Flowchart illustrating normal, pain-free homeostasis of the vertebrae in the lower back (after Dvorak et al12).
Figure 2. Flow chart illustrating pain generators associated with mechanical low back disorders and the resulting corrective action utilizing OMM (after Dvorak et al12).
In addition to the infra-spinal effects of manipulation (e.g., at the articular and muscular levels), much interest has been given to the segmentally-related interactions at the level of the spinal cord.14
Degenhardt et al15 reported in 2007 that various nociceptive (e.g. pain) biomarkers were altered in response to osteopathic manipulative medicine treatment while the degree and duration of these changes were greater in subjects with chronic low back pain than in control subjects without the disorder.
In another recent study, it was found that a single spinal manipulation therapy (SMT) application to the thoracic spine lead to down-regulation of inflammatory-type responses as observed by a reduction of pro-inflammatory cytokine secretion
Researchers at the Neuroscience Research Institute of the State University of New York, College at Old Westbury, studied “Nitric Acid as a possible mechanism for understanding the therapeutic effects of Osteopathic Manipulative Medicine.”17 Their research “demonstrated that fluidic motions applied to vascular and nerve tissue (consistent with OMM) can cause a remarkable increase in Nitric Oxide (NO) concentration within the blood and vasculature. These findings, combined with the overwhelming amount of research into the beneficial effects of constitutive NO, provide a dynamic theoretical framework to explain the therapeutic effects of OMM.17
Tracey,18 while not expressly addressing manipulation per se, has presented interesting findings about the physiology and immunology of the cholinergic-inflammatory pathway. That might explain, at least in part, some of the effects associated with the introduction of manipulative intervention.
With the latest technologies and new investigative ideas, it may be possible to “connect the dots, that is to understand the biomechanical principles, neurophysiologic, humeral, and hitherto unknown pathways: all of them within one func-tional unit, the human body.”19 The key to the understanding of the mechanisms underlying OMM and their effects on a patient’s pain and functioning is to assume the “big view” that includes not only the peripheral, or localized tissue changes, but also the spinal cord level and higher, supra-spinal levels in one dynamic model.
Outcomes and Evidence-Based Medicine
It may come as a surprise that manual medicine approaches are actually some of the most studied interventions for low back pain and recent, well-conducted studies seem to support some of the successful claims forwarded by various proponents of manual medicine.
It is important to realize that while many healthcare professionals use a variety of diagnostic labels to affix a particular diagnostic term to a patient with low back pain, there exist, at present, no reliable and valid classification systems for most cases of non-specific (e.g., mechanical) low back pain.20
A growing number of published reports have investigated the effectiveness and cost considerations of spinal manipulative procedures. These studies typically do not make a distinction between “thrusting” maneuvers and the low-velocity mobilization techniques.21
A recent systematic review and meta analysis of randomized osteopathic manipulative trials concluded that osteopathic manipulative therapy significantly reduced lower back pain (LBP).22
Licciardone et al23 are currently conducting what is reported to be the largest randomized controlled trial involving OMM, with the goal of obtaining primary data on the efficacy of OMM for chronic low back pain.
In the November 1999 issue, the New England Journal of Medicine published a paper on osteopathic manipulation concluding that “while osteopathic manual care and standard medical care have similar clinical results in patients with sub-acute lower back pain (LBP), the use of medication is greater with standard care.”9 The conclusion went on to state that “given the known and potential serious adverse effects and costs of non-steroidal anti-inflammatory drug therapy, the achievement of equal outcome in regard to pain relief, function, and satisfaction, with less use of medication and physical therapy, suggests an important benefit of osteopathic manipulative treatment.”
Based on various international clinical guidelines for low back pain, spinal manipulation for the relief of acute low back pain is being recommended. Koes et al20 conclude that a patient with chronic low back pain is likely to obtain benefit from spinal manipulation. The UK Back Pain Exercise and Manipulation (UK BEAM) Study, the largest randomized trial of back pain interventions ever completed, concluded that spinal manipulation “provides significant relief,” and that this approach is “often more cost effective than conventional approaches to managing lower back pain.”24
The Osteopathic Manipulation Prescription
After the physician has evaluated the patient using the standard medical approach and “red flags” (e.g., sinister pathology) have been ruled out, the structural functional osteopathic examination is undertaken. The usual sequence is that of a screening examination to quickly determine gross postural abnormalities, followed by a regional scanning examination, and, finally, an evaluation of the spine and joints of the extremities at a specific segmental level. The sequence typically follows that of the “look-feel-move” approach. This inspection is followed by palpation and, subsequently, motion testing.
Once a specific segmental diagnosis of somatic dysfunction is established, consideration is given to any adaptive or compensatory/over-compensatory changes that may have resulted from the segmental somatic dysfunction. This is of particular interest in chronic situations where it is often difficult to determine what “came first.”
The therapeutic objectives in the treatment of spinal disorders is to improve function within the entire patient context and include the following:
- promote rest for the affected autonomic structures
- diminish muscle spasm
- diminish inflammation
- improve tissue fluid drainage
- reduce symptomatic pain
- increase muscle strength
- increase range of motion
- increase endurance
- increase functional and physical work capacity
- modify work and home environment
- modify social environment
- provide treatment adapted to the psychological aspects of the problem
Together, the patient and physician determine relevant functionally-based goals and outcomes. Once the therapeutic objectives have been clearly established, consideration is given to specific treatment approaches or techniques available. It is important to note that the choice of the particular treatment technique is to be tailored according to the patient’s age, functional level, co-existing comorbidities, and acceptance of the use of such techniques. Some patients are unable to tolerate the “high-velocity, low amplitude thrusting” techniques, as in the direct manipulative technique, “the thrust”—especially elderly persons with known osteoporosis, fractures, or other contraindications.
It is beyond the scope of this article to describe the individual techniques, and so the interested reader is referred to the standard texts on OMM. An overview of the various Osteopathic Manipulative Techniques includes the following:25
- Balanced ligamentous tension
- Chapman’s reflexes
- Facilitated postural release
- Fascial ligamentous release
- High velocity-low amplitude thrust
- Integrated neuromuscular release and myofascial release
- Muscle energy
- Myofascial trigger point
- Osteopathy in the cranial field
- Progressive inhibition of neuromuscular structures
- Strain and counter-strain
Treatment Intensity, Frequency, and Duration
No “hard and fast” guidelines currently exist that would prescribe the “appropriate amount” or frequency of osteopathic manipulative treatments. A rational approach was that presented by Gilliar et al13 and Mein.25 The recommended treatment is to be no more than twice a week for the first three to four weeks, followed by once every two weeks for one to two months, and then monthly for two to three months.
While there may be treatment sessions required on an episodic basis, not much information exists in the current literature regarding claimed advantages of “preventive regularly ongoing treatment regimens.” However, as with all clinical practice, if the goals that are established can be reached within a rational, transparent medical approach, then such individualized treatments should not be trumped by potentially restrictive “guidelines”—especially given the complex nature of the treatment of pain in general, and low back pain in particular.
Summary and Epilogue
OMM can be useful tool—either as a primary or an adjunct—in the diagnostic and therapeutic management of various mechanical low back disorders. Pain management using OMM for a particular patient should employ an individualized and personally tailored program with the primary goal being to improve function and minimize pain.
- 1. Isaacs ER and Bookhout MR. Bourdillon’s Spinal Manipulation, 6th Edition. Butterworth and Heinemann. Boston. 2002. p 38. 2. Dvorak J, Dvorak V, Gilliar W, Schneider W, Spring H, and Tritschler T. Musculoskeletal Medicine: Diagnosis and Treatment. Thieme. 2007. pp 145-147.
- 3. Ibid ref 2. Dvorak et al; pp 1-2.
- 4. Dvorak J, Dvorak V, and Schneider W. (eds). Manual Medicine. Springer Verlag. 1984.
- 5. Nelson KE and Glonek T. (eds). Somatic Dysfunction in Osteopathic Family Medicine. Lippincott Williams and Wilkins. 2007. p v.
- 6. Ibid ref 5. Nelson and Glonek T; p 1.
- 7. Koes BW, van Tulder MW, and Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006. 332: 1430-1434.
- 8. Cypress BK. Characteristics of Physician Visits for Back Symptoms: A National Perspective. Am J Public Health. 1983. pp 389-395.
- 9. Andersson GBJ, Lucente T, Davis AM, et al. A Comparison of Osteopathic Spinal Manipulation with Standard Care for Patients with Low Back Pain. The New England Journal of Medicine. November 1999. Vol. 341: 1426-1431.
- 10. Cherkin DC, Deyo RA, Wheeler K, and Ciol M. Physician variation in diagnostic testing for low back pain: who you see is what you get. Arthritis Rheum. 1994. 37: 15-22.
- 11. Cherkin DC, Deyo RA, Loeser JD, Bush T, and Waddell G. Ann international comparison of back surgery rates. Spine. 1994. 19: 1201-1206.
- 12. Dvorak J, Dvorak V, Gilliar W, Schneider W, Spring H, Tritschler T. Musculoskeletal Medicine: Diagnosis and Treatment. Thieme. 2008. pp 131-135.
- 13. Gilliar WG and Anderson W. Normal and Abnormal Vertebral Motion: A Practical Approach. Physical Medicine and Rehabilitation: State of the Art Reviews. 1998. 14(1): 5-25.
- 14. Gilliar WG, Kuchera M, and Giulianetti D. Neurologic Basis of Manual Medicine. Physical Medicine and Rehabilitation Clinics of North America. 1996. 7(4): 693-714
- 15. Degenhardt BF, Darmani NA, and Johnson JC. Role of Osteopathic Manipulative Treatment in altering pain biomarkers: a pilot study. JAOA. 2007. 107: 387-400.
- 16. Teodorcyk-Injeyan JA, Injeyan HS, and Ruegg R. Spinal manipulative therapy reduces inflammatory cytokines but not stubstance P production in normal subjects. J Manipulative Physiol Ther. 2006. 29(1): 14-21.
- 17. Salamon E, Zhu W, and Stefano GB. Nitric Oxide as a Possible Mechanism for understanding the therapeutic effects of Osteopathic Manipulative Medicine. Int J Mol Med. Sept 2004. 14(3): 443-449.
- 18. Tracey KJ. Physiology and immunology of the cholinergic anti-inflammatory pathway. J Clin Invest. 2007. 117: 289-296.
- 19. Ibid ref 2. Dvorak et al; pp 81-98.
- 20. Koes BW, van Tulder MW, and Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006. 332: 1430-1434.
- 21. Ibid ref 2. Dvorak et al; pp 167-168.
- 22. Licciardone JC, Brimhall AK, and King LN. Osteopathic Manipulative Treatment for Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. BMC Musculoskeletal Disorders. 2005. 6: 43.
- 23. Licciardone JC, King HH, Hensel KL, and Williams DG. Osteopathic Health Outcomes in Chronic Low Back Pain: the Osteopathic Trial. Osteopathic Medicine and Primary Care. 2008. Available at www.om-pc.com/content/2/15/ Accessed 8/25/2008.
- 24. UK Back pain Exercise and Manipulation (UK BEAM) trial – national randomised trial of physical treatments for back pain in primary care: objectives, design and interventions [ISRCTN32683578]. BMC Health Serv Res. Published online August 2003. Available at: www.pubmedcentral.nih.gov/article render.fcgi?artid=194218. Accessed 8/20/08.
- 25. Ibid ref 12. Dvorak et al. 2008.
- 26. Mein E. Low Back Pain and Manual Medicine – A look at the Literature. Physical Medicine and Rehabilitation Clinics of North America. 7 (4) Nov. 1996. 715-729