Osteopathic Manipulative Medicine (OMM) for Lower Back Pain
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
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.16