Osteopathic Manipulation Outcomes

[abcd]

I am looking for comments about the success or failures of osteopathic manipulation, especially from those who have some experience in its practice, or those who have observed significant outcomes. Everyone knows that there is a lack of research on the field due to its difficult nature to do such. But is everything explained by research? Please, let us know about certain techniques that have been especially helpful or futile (ie HVLA, ME, MFR, etc.)

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[doublelle]

Are you referring to simply spinal manipulation? If so, I do not practice it (yet), but I have it done to me quite frequently. I have an awful back and one vertebrae that "goes out" all the time. It sends shooting pain down my arm and prevents me from catching deep breaths. A DO where I work will just pop it back in and I am fine for another few weeks. Yes, I have had X rays done and other tests to find out what is going on with it. The only thing they can figure is that tight muscles pull it out. I have also had to have my lower back manipulated because I am a runner and tend to screw alot of things up in the pelvic region. I completely believe in the manipulation simply because it works for me.

 

[JoeDoc]

Most of the research on manipulation has been done by chiropractors, so you may want to check out a multidiscilinary peer reviewed journal like Journal of Manipulative and Physiological Therapeutics. The majority of the articles I've read have investigated HVLA. I'm not familiar with any large osteopathic studies but most DO research is published in JAOA.

 

[ewagner]

Blinded and randomized studies are nonexistant. There are really very few good studies out there for sham vs. manipulation or manipulation vs. thera ex vs. combination vs. bed rest. That is a BIG problem. Lack of control and long term outcomes are missing.
Outcome studies in the purist sense of the word are just not out there (total visits, total cost, functional outcome, with 6 mos and 1 year follow ups)! Just not there.

Sure, there are some studies that may be around in some chiropractic and osteopathic literature, but there are defined sampling problems and like I said earlier, control problems.

I have run across a few in the Journal of Orthopedic and Sport Physical Therapy as well as the Journal of Physical Therapy (both peer reviewed and university based research)and some poorer studies in Journal of Manipulative Medicine.

Sure JAOA has some stuff...but if it is negative or the Null Hypothesis was proven true, it is surpressed from publication.

Oh, yes, I ran across some favorable reviews in a recent Journal of Emergency Medicine I think (maybe it was Internal Medicine).

But if you are gonna look for articles, you should really only look from peer reviewed sources that are of University caliber...and please read with a critical eye.


[This message has been edited by ewagner (edited 07-15-2000).]

 

[abcd]

Getting off of the topic of research (although it is very important and necessary), who has seen it work or not work?

 

[ewagner]

I have seen it work for particular cases, such an acute postural problem, but I have also seen that same problem aided by other means.
OMT in the realm of the pelvis seems to give relief if the OMT is followed by stabilization exercises or postural alterations. It seems to work well in pregnancy in conjunction with exercise.
It doesn't seem to work with chronic problems based in repetative movement disorders...or should I say, other things seem to show better and quicker results leaving the question "would it have gotten better in due time regardless?"

I have seen HVLA work particularly well in select cervical spine problems...but the problem returns if the cause is not treated (ie posture, movement, muscular imbalance).
During particular low impact trauma of the ribs, HVLA on the ribs is uniquely suited.

MFR techniques are useful in the head and are excellent for TMJ disorders with the addition of exercise and change of habits.
Muscle energy techniques are great for stretching and are called PNF contract relax in PT and ATC circles.

As with anything it has its place, and there is of course considerable placebo affect going on. The question of what is really going on has yet to be precisely answered and what affects this has in the long term has also not been answered.

Maybe that will help.

 

[abcd]

ewagner: thanks for your intelligent reply. I tend to agree with you. We need to grab a beer in Brookside like we talked about.

 

[ewagner]

OK...so who is it?
I've asked alot of people to drink beer with me in Brookside!

hmmmmmm

 

[DO2003]

I have seen manipulation work. I am an MS-I, and of course here at school, we work on each other when we need it (and in assigned labs). BUT before shrugging this off... we at have had a two week preceptorship this summer, and I actually treated low back pain succesfully using the simplest of techniques! How much was placebo and how much was real, well, having experienced it, I think that there is some of both, but I definately think that there is significant benefit to the manipulative treatment.

That said, even faculty here have admitted that some studies show that after 8 weeks of traditional (allopathic) medicinal therapy vs. 8 weeks of Osteopathic Manipulative Therapy, there was no significant difference in the cure rate for chronic low back pain. So, for patients who don't like drugs and want an immediate though temporary relief, OMM does work. On the other hand, for the patient who doesn't want to be cracked, folded, or rolled, drugs work just as well. As a DO, you have 2 methods to acheive the same result with about the same efficacy.

 

[Maire]

For what it's worth - when I was interviewing at UHS this spring, my husband had had a horrible muscle spasm in his shoulder for a week. He'd been to the doctor and on muscle relaxants, and nothing helped. The interviewees were given a demonstration of OMT techniques, one of which was for a muscle spasm. I watched carefully, and that night I tried it on my husband. It took 90 seconds, the spasm was gone, and never returned.
My husband is a complete skeptic, and did not believe this was going to work. Since he often gets muscle spasms, he is now very excited about me going to osteopathic school!

 

[abcd]

How about cranial? Any comments?

 

[RockyMan]

abcd:

First of all, I?d like to ask what kind of ?evidence? you?re looking for? In your first post you seemed to want to talk about experimental evidence, but then later you seemed to be looking more for individual anecdotes.

If you want a string full of testimonials-- the anecdotal, subjective experiences of medical students, in separate or combined roles as either patients, students or practitioners-- that?s fine with me, but not especially useful, I think. What I mean is that we may be encouraged or appalled by the claims that are posted in response to your request, but in the end they are NOT ?significant outcomes? that prove anything about the effectiveness of ?osteopathic? manipulation. They are just anecdotes, testimonials. If you want to figure out whether there are any ?significant outcomes? with treatment you have to do modern scientific medical studies. Do them or refer to them.

Testimonials are all over the place. They?re great, the staff of social life, but they don?t prove anything about what?s really happening in health or disease or medicine. My brother?s ex-wife believes that eating fish makes you smarter, it?s ?brain food?-- that?s a testimonial. She thinks it is true from her experience, and she believes it just as much as she believes that the earth revolves around the sun. The Christian Scientists have file cabinets full of detailed claims, dating back for over a century, that nearly every illness and trauma imaginable has been cured by direct divine intervention in response to prayers. Testimonials? Yes. A mechanism for medical progress? Of course not.

Anyway, that?s what I think, and I?m pretty hard core about it. So is just about everyone else who has had to make a living by doing research and figuring out how the human body and mind really work, and what really makes pts more healthy.

I agree somewhat w/ ewagner about the poor quality of the ?osteopathic literature? i.e., the studies published in JAOA et al. I?ve read fewer articles from the chiropractic journals, but I haven?t been impressed with them either. But I still think we DO students should talk about what?s really been studied. If we end up tearing apart 95% of the published articles in osteopathic-sponsored journals, that?s still a good thing-- heaven knows, someone has to clear out the underbrush at some point.

So if you?re interested in discussing the scientific evidence for effectiveness of osteopathic treatments, well, yes, I?d love to talk. We can start with last year?s study in NEJM on back pain, or whatever anyone wants, I?m game. How about cranial osteopathic manipulation? Personally, after two years of DO school, I think cranial manipulation, at least for adults, is pretty much quackery through and through.


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Question Authority & Overturn Dogma

 

[drusso]

Here are some recent basic science and clinical abstracts related to OMM. I think our profession needs to continue to produce high quality relevant research in physical and manipulative modalities:

TITLE: Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation [In Process Citation]
AUTHORS: Burton AK; Tillotson KM; Cleary J
AUTHOR AFFILIATION: Spinal Research Unit, University of Huddersfield, UK.
SOURCE: Eur Spine J 2000 Jun;9(3):202-7
[MEDLINE record in process]
CITATION IDS: PMID: 10905437 UI: 20361372
ABSTRACT: This single-blind randomised clinical trial compared osteopathic manipulative treatment with chemonucleolysis (used as a control of known efficacy) for symptomatic lumbar disc herniation. Forty patients with sciatica due to this diagnosis (confirmed by imaging) were treated either by chemonucleolysis or manipulation. Outcomes (leg pain, back pain and self-reported disability) were measured at 2 weeks, 6 weeks and 12 months. The mean values for all outcomes improved in both groups. By 12 months, there was no statistically significant difference in outcome between the treatments, but manipulation produced a statistically significant greater improvement for back pain and disability in the first few weeks. A similar number from both groups required additional orthopaedic intervention; there were no serious complications. Crude cost analysis suggested an overall financial advantage from manipulation. Because osteopathic manipulation produced a 12-month outcome that was equivalent to chemonucleolysis, it can be considered as an option for the treatment of symptomatic lumbar disc herniation, at least in the absence of clear indications for surgery. Further study into the value of manipulation at a more acute stage is warranted.

TITLE: The effects of manually applied intermittent pulsation pressure to rat ventral thorax on lymph transport [In Process Citation]
AUTHORS: Dery MA; Yonuschot G; Winterson BJ
AUTHOR AFFILIATION: Department of Osteopathic Manipulative Medicine, University of New England, Biddeford, Maine, USA.
SOURCE: Lymphology 2000 Jun;33(2):58-61
[MEDLINE record in process]
CITATION IDS: PMID: 10897471 UI: 20355662
ABSTRACT: The present study evaluated the effects of tissue massage on a part of the body remote from the region of lymph uptake into the initial lymphatics. Lymph uptake was assessed with a fluorescent probe placed in a potential space of the lower extremity of anesthetized female Sprague-Dawley rats. Tail blood was assayed at intervals over 15 hours for fluorescence. A total of 63 animals were utilized (treatment = 32 and control = 31). The manipulated group received lymph flow enhancing treatment (LFET) five minutes per rat per hour until they were aroused. The control group were left lying prone in cages until a blood sample was taken. The LFET procedure was bilateral finger pressure applied to the lower ribs of a supine rat followed immediately by a light tap to the sternum. These maneuvers were repeated for 5 minutes. The rate of appearance of fluorescent probe was greater during the first nine hours of the experiment in the treatment group than in the controls but not at hours 12 and 15. This study demonstrates that mechanical pressure to body regions physically distant from the location of lymph formation enhances lymph uptake.

TITLE: Manual therapy for asthma.
AUTHORS: Hondras MA; Linde K; Jones AP
AUTHOR AFFILIATION: Western States Chiropractic College, 2900 NE 132nd Avenue, Portland, Oregon 97230-3099, USA. [email protected]
SOURCE: Cochrane Database Syst Rev 2000;(2):CD001002
CITATION IDS: PMID: 10796578 UI: 20257668
ABSTRACT: BACKGROUND: A variety of manual therapies with similar postulated biologic mechanisms of action are commonly used to treat patients with asthma. Manual therapy practitioners are also varied, including physiotherapists, respiratory therapists, chiropractic and osteopathic physicians. A systematic review across disciplines is warranted. OBJECTIVES: To evaluate the evidence for the effects of manual therapies for treatment of patients with bronchial asthma. SEARCH STRATEGY: Trials were searched in computerized general (EMBASE, CINAHL and MEDLINE) and specialized databases (Cochrane Complementary Medicine Field, Cochrane Rehabilitation Field, ICL, and MANTIS). In addition, bibliographies from included studies were assessed, and authors of known studies were contacted for additional information about published and unpublished trials. Date of most recent search: December 1998. SELECTION CRITERIA: Trials were included if they: (1) were randomised; (2) included asthmatic children or adults; (3) examined one or more types of manual therapy; and (4) included clinical outcomes. DATA COLLECTION AND ANALYSIS: All three reviewers independently extracted data and assessed trial quality using a standard form. MAIN RESULTS: From an initial 316 unique citations, 48 full text articles were retrieved and evaluated, which resulted in nine citations to five RCTs (290 patients) suitable for inclusion. Trials could not be pooled statistically because studies that addressed similar interventions used disparate patient groups or outcomes. The methodological quality of one of two trials examining chiropractic manipulation was good and neither trial found significant differences between chiropractic spinal manipulation and a sham manoeuvre on any of the outcomes measured. Quality of the remaining three trials was poor. One small trial compared massage therapy with a relaxation control group and found significant differences in many of the lung function measures obtained. However, this trial had poor reporting characteristics and the data have yet to be confirmed. One small trial compared chest physiotherapy to placebo and one small trial compared footzone therapy to a no treatment control. Neither trial found differences in lung function between groups. REVIEWER'S CONCLUSIONS: There is insufficient evidence to support the use of manual therapies for patients with asthma. There is a need to conduct adequately-sized RCTs that examine the effects of manual therapies on clinically relevant outcomes. Future trials should maintain observer blinding for outcome assessments, and report on the costs of care and adverse events. Currently, there is insufficient evidence to support or refute the use of manual therapy for patients with asthma.

TITLE: Inter-examiner and intra-examiner agreement for assessing sacroiliac anatomical landmarks using palpation and observation: pilot study.
AUTHORS: O'Haire C; Gibbons P
AUTHOR AFFILIATION: School of Health Sciences, Victoria University, Australia.
SOURCE: Man Ther 2000 Feb;5(1):13-20
CITATION IDS: PMID: 10688955 UI: 20157025
ABSTRACT: Despite the paucity of research into the reliability of static palpation, it is still employed extensively as a diagnostic tool by manual medicine practitioners. This study tested the inter- and intra-examiner agreement of ten senior osteopathic students using static palpation on ten asymptomatic subjects. Four assessments of the posterior superior iliac spine (PSIS), sacral sulcus (SS), and the sacral inferior lateral angle (SILA) on every subject by all examiners resulted in 1200 assessments in total. Kappa (Kg) yielded intra-examiner agreement that ranged between less-than-chance to substantial for the SILA (Kg=-0.05 to 0.69; mean Kg=0.21), and slight to moderate for the PSIS (Kg=0.07 to 0.58; mean Kg=0.33) and the SS (Kg=0.02 to Kg=0.60; mean Kg=0.24), with 50% significant beyond the 0.05 level. Inter-examiner agreement was slight (PSIS Kg=0.04; SILA Kg=0.08; SS Kg=0.07) and significant at the 0.01 level. Intra-examiner agreement was greater than inter-examiner agreement, which was consistent with existing palpation reliability studies. The poor reliability of clinical tests involving palpation may be partially explained by error in landmark location. Copyright 2000 Harcourt Publishers Ltd.

TITLE: Manual and manipulation techniques for rheumatic disease.
AUTHORS: Fiechtner JJ; Brodeur RR
AUTHOR AFFILIATION: Division of Rheumatology, Michigan State University, Colleges of Osteopathic and Human Medicine, East Lansing, USA.
SOURCE: Rheum Dis Clin North Am 2000 Feb;26(1):83-96, ix
CITATION IDS: PMID: 10680196 UI: 20144448
ABSTRACT: Manipulation is practiced primarily by chiropractors and osteopaths and is one of the most commonly utilized alternative treatments for rheumatic diseases. Low back pain and neck pain are the most frequently treated disorders, but manipulation is also used to treat a broad range of rheumatic diseases. Manipulation has been shown to decrease joint pain and normalize function. The mechanisms of action, however, are not well understood. Current theories propose an imbalance of muscle activity is a source of pain that manipulation can relieve through reflexive actions. Such muscle imbalances would exacerbate rheumatic and arthritic conditions, suggesting that manipulation may be an important therapy that is appropriate for early conservative care as part of a comprehensive treatment program.


ITLE: [Evaluation and critical review published in the European literature on osteopathic studies in the clinical field and in the area of fundamental research]
VERNACULAR TITLE: Evaluierung und kritische Bewertung von in der europaischen Literatur veroffentlichten, osteopathischen Studien im klinischen Bereich und im Bereich der Grundlagenforschung.
AUTHORS: Schwerla F; Hass-Degg K; Schwerla B
AUTHOR AFFILIATION: A.R.E.D.O.E. Deutschland, Gauting. [email protected]
SOURCE: Forsch Komplementarmed 1999 Dec;6(6):302-10
CITATION IDS: PMID: 10649001 UI: 20116111
ABSTRACT: OBJECTIVE: Identification of studies of osteopathic treatment in defined countries. Evaluation of methods and results of the studies and assessment of the available evidence concerning the effectiveness of osteopathy. STUDY DESIGN: Systematic review. Assessment of the quality of the studies, with respect to the osteopathic concept and current methodological criteria according to predefined keys. DATA SOURCES: Clinical trials and fundamental studies originating from Germany, England, Austria, The Netherlands, Scandinavia +/- published or unpublished. RESULTS: Out of a total of 30 studies retrieved, 9 reached the predetermined minimum number of points to be rated into quality categories. In 2 of these studies the osteopathic treatment was more effective than the control intervention (p < 0.05). CONCLUSIONS: No definitive conclusions about the effectiveness of osteopathy can be drawn so far because of the low number of evaluated studies. It seems necessary to scrutinize the relevance of osteopathy through further methodologically adequate studies. Additionally, criteria for evaluation are proposed which correspond to the highest international standards in order to ensure a valid (and commonly accepted) evaluation of the osteopathic literature. Copyright 1999 S. Karger GmbH, Freiburg

 

[RockyMan]

drusso: Thanks for the post. I'll see if our library has any of these articles. Often from the abstracts it's difficult to tell what exactly was done, how the data was analyzed, etc.