Low Back Pain and Osteopathic Manipulative Medicine: A Trend in Pain Management
Low back pain (LBP) is one of the most prevalent musculoskeletal conditions in the United States. It is primarily responsible for more than 20 million ambulatory care visits, and costs $100 billion annually in the United States.1,2 LBP is also the most common reason adults seek complementary and alternative medicine,3 including the use of manual therapy practitioners. Osteopathic physicians in the United States are trained and licensed to provide both standard medical care and osteopathic manipulative treatment. This unique dual perspective bridges the gap between “conventional medicine” and “complementary and alternative medicine” and helps explain the high levels of ambulatory medical care provided by osteopathic physicians for patients with LBP.1
The contemporary view of LBP is that it is a chronic condition as opposed to a self-limiting condition and should be treated and managed as a lifelong process.4 As much as 95% of LBP is described as mechanical in nature, meaning that the underlying cause is an anatomic or functional abnormality, rather than an inflammatory disease, malignant neoplasm, or the manifestation of visceral disease.5 Often, chronic pain pathways involving allodynia develop as changing gene expression allows receptors to become active in the spinal cord, resulting in what is called “spinal cord learning.”6,7 In such cases, the patient may present with persistent pain.
Therefore, it stands to reason that manual medicine is a useful tool in the diagnosis and therapeutic management of the various mechanical spinal disorders.2 Osteopathic manipulative medicine (OMM) is one of the various modalities in the broad field of manual medicine. Other terms that refer to osteopathic manipulative procedures include osteopathic manipulative therapy or osteopathic manipulative treatment (OMT). Osteopathic physicians in the United States are trained in OMM during medical school.
Osteopathic physicians conduct osteopathic structural examinations, applying palpation skills that provide clues to the underlying mechanism(s) of injury by focusing on symmetry/asymmetry and tissue changes. Palpation diagnostics and insights lead to further questions, examinations, and tests to identify structural factors associated with specific pain generators or impediments in structure and function that may interfere with self-healing mechanisms. The examination findings lead the physician to explore functional demand issues associated with potential mechanisms of repeated injury or of cumulative microtrauma resulting from postural, habitual, or occupational ergonomic stressors.8
Management of persistent LBP cannot have a simple focus or be treated with a one-size-fits-all treatment plan. OMM/OMT is part of a multimodal treatment plan that embraces body unity principles and integrates palpation and OMM/OMT procedures into each patient’s treatment prescription. OMM/OMT treatment goals depend on each individual’s unique pain presentation, the suspected pathways involved, and the regions diagnosed with somatic dysfunction.
Common treatments used to address LBP include high-velocity, low-amplitude thrusts; moderate-velocity, moderate-amplitude thrusts; soft tissue stretching; kneading and pressure; myofascial stretching and release; and positional treatment of myofascial tender points. In addition, patients can provide isometric muscle activation against the physician’s unyielding and equal counterforce to address dysfunction in the lumbosacral, iliac, and pubic regions.9
Degenhardt et al reported that OMM/OMT causes changes in the release of endogenous pain biomarkers, such as opioids (endorphins and endocannabinoids) and serotonin, with involvement of serotoninergic and noradrenergic descending tracts.10 A similar mechanism of action also has been proposed for the anti-hyperalgesia effect produced by joint manipulation.11 Moreover, OMM/OMT results in an increase in the concentration of circulating endogenous opioids, which allows for improved antinociception and analgesia.12 Therefore, a possible explanation for the efficacy of the treatment is an enhancement of the action of opioids.
Arienti et al found that OMM/OMT is a feasible approach for the relief of chronic pain related to osteoarthritis and/or inflammatory conditions; adding OMM/OMT to standard treatment with pharmaceutical agents yielded significantly better pain relief in patients with both nociceptive and neuropathic pain.13 In addition, Licciardone et al showed that OMM/OMT is efficacious for short-term pain relief when used to complement other treatments for LBP, including nonprescription drugs and complementary and alternative medicine therapies.14 They also showed that pain reductions observed with OMM/OMT have been associated with decreased need for rescue medication. According to the study, a total of 31 (13%) OMT patients compared with 46 (20%) patients who received a sham OMT reported using prescription drugs for low back pain during the study.14 Furthermore, Prinsen et al found that patients who had OMM/OMT for LBP used less analgesic medication.15
Licciardone showed that patients treated with OMM/OMT had decreased pain, as well as an increase in specific back functioning, which was consistent with recovery from chronic LBP.16 They also demonstrated that not only was there significant pain reduction in individuals with LBP receiving OMT, but also that the effects of OMT had benefit beyond the first year of treatment.17
Licciardone also found that LBP visits provided by primary care physicians in the United States were often suboptimal; medical management appears to overuse surgery relative to more conservative treatments (eg, counseling, nonnarcotic analgesics, other drug therapies, and OMT).18
The American Osteopathic Association (AOA) published a Special Communication in 2010 titled “American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain.” The purpose of this published study was to assess the efficacy of OMM/OMT for somatic dysfunction associated with LBP by osteopathic physicians and osteopathic practitioners trained in osteopathic palpation, diagnosis, and treatment.19 The group concluded that OMM/OMT significantly reduced LBP and has not demonstrated harm in any clinical trials to date.
In 2016, the AOA published an additional Special Communication on “American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients with Low Back Pain” to update the AOA guidelines for practicing osteopathic physicians using OMM/OMT.20 This review of the literature highlights the work of Franke et al21 on nonspecific acute and chronic LBP, for which OMM/OMT significantly improved pain and functional status.20 In addition, the review provides evidence suggesting that OMM/OMT also results in improvements in pain and functional status in pregnant and postpartum patients with nonspecific LBP.20