Chiropractic Research Equals Osteopathic Research?
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To the Editor: The March 2006 issue of JAOA—The Journal of the American Osteopathic Association courageously addresses many contemporary issues confronting the osteopathic medical community. A new section debuting in that issue of the JAOA titled "The Somatic Connection" summarizes important recent research regarding the musculoskeletal system's role in health and disease (J Am Osteopath Assoc. 2006;106:118–119). The introduction to this section states, "`The Somatic Connection' highlights... research articles [that relate] to the tenets and principles of osteopathic medicine." However, in one of the articles summarized in "The Somatic Connection"—a review by Bronfort et al1 of manipulation in patients with low back or neck pain—most of the randomized controlled studies used to support the efficacy of manipulation are chiropractic in nature.
Only four of 31 trials of manipulation for patients with low back pain cited by Bronfort et al1 examine the efficacy of osteopathic manipulative treatment (OMT). The other trials are chiropractic manipulation studies. All 12 neck pain trials cited by Bronfort et al1 are chiropractic studies. The Bronfort et al1 review cites one OMT study on acute low back pain,2 two on chronic low back pain,3,4 and one on mixed chronic/acute low back pain.5 Interestingly, some of the conclusions drawn by Bronfort et al1 inaccurately reflect the conclusions in these OMT studies as originally published.
Bronfort et al1 refer to MacDonald and Bell2 as their single OMT study on acute low back pain. MacDonald and Bell2 concluded that OMT was superior to sham treatment in patients whose back pain lasted between 14 and 28 days. They found that OMT was not statistically superior in those individuals whose back pain lasted less than 14 days or in those whose back pain lasted more than 28 days.2 It should also be noted that the research by MacDonald and Bell2 was a pilot study that had only 13 patients in the OMT group. MacDonald and Bell2 admitted that their study had numerous limitations and was mainly valuable in yielding hypotheses for further testing—not in reaching clinically relevant conclusions. Nevertheless, Bronfort et al1 included this pilot study in their review.
A study by Burton et al3 was one of the two articles mentioned by Bronfort et al1 that examined the efficacy of OMT in patients with chronic low back pain. Burton et al3 compared OMT with chemonucleolysis in cases of symptomatic lumbar disc herniation. Although they concluded that there was no statistically significant difference in outcome between the two treatments after 1 year, they also noted that OMT did result in a small but statistically significant improvement in back pain and disability during the first 6 weeks of treatment.3 This encouraging finding of Burton et al3 differs from the findings of two chronic low back pain studies that included large sample sizes and placebo control groups,4–6 both of which Burton et al3 lacked.
The other OMT research article on chronic low back pain mentioned by Bronfort et al1 was by Gibson et al,4 who compared OMT with short-wave diathermy and placebo (detuned short-wave diathermy). Gibson et al4 concluded that neither OMT nor short-wave diathermy was superior to placebo treatment. Their results supported the 2003 Licciardone et al6 study that concluded, "There were no significant benefits with osteopathic manipulative treatment, as compared with sham manipulation." Yet, Bronfort et al1 state that there is moderate evidence that manipulation of the spine produces an effect similar to that of nonsteroidal anti-inflammatory drugs.
The one OMT research article on subacute low back pain cited by Bronfort et al1 was by Andersson et al,5 who concluded that OMT and standard medical care have similar clinical results in patients with subacute low back pain—though the OMT group in this study did use fewer medications than the standard care group. Bronfort et al1 use this study to support their conclusion that there is "a small but nonsignificant short-term benefit of SMT [spinal manipulative treatment] over standard medical care for pain."
If the goal of "The Somatic Connection" is to highlight research that relates to the principles of osteopathic medicine, does the JAOA endorse chiropractic manipulation as being as efficacious as OMT? If the answer to this question is "no," then the JAOA should consider systematically reviewing osteopathic studies in an objective and scientific manner in future editions of "The Somatic Connection." With this change, clinicians and osteopathic medical students will continue trusting the JAOA as the evidenced-based standard for osteopathic research.
References
1. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis [review]. Spine J.2004; 4:335 –356.
2. MacDonald RS, Bell CMJ. An open controlled assessment of osteopathic manipulation in nonspecific low-back pain. Spine. 1990;15:364 –370.
3. Burton AK, Tillotson KM, Cleary J. Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation. Eur Spine J.2000; 9:202 –207.
4. Gibson T, Grahame R, Harkness J, Woo P, Blagrave P, Hills R. Controlled comparison of short-wave diathermy treatment with osteopathic treatment in non-specific low back pain. Lancet.1985 :1:1258 –1261.
5. Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med.1999; 341:1426 –1431.
6. Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, Winn W, et al. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine.2003; 28:1355 –1362.
Oklahoma State University College of Osteopathic Medicine Tulsa, Okla(GREG P. HANSEN, OMS IV)
Only four of 31 trials of manipulation for patients with low back pain cited by Bronfort et al1 examine the efficacy of osteopathic manipulative treatment (OMT). The other trials are chiropractic manipulation studies. All 12 neck pain trials cited by Bronfort et al1 are chiropractic studies. The Bronfort et al1 review cites one OMT study on acute low back pain,2 two on chronic low back pain,3,4 and one on mixed chronic/acute low back pain.5 Interestingly, some of the conclusions drawn by Bronfort et al1 inaccurately reflect the conclusions in these OMT studies as originally published.
Bronfort et al1 refer to MacDonald and Bell2 as their single OMT study on acute low back pain. MacDonald and Bell2 concluded that OMT was superior to sham treatment in patients whose back pain lasted between 14 and 28 days. They found that OMT was not statistically superior in those individuals whose back pain lasted less than 14 days or in those whose back pain lasted more than 28 days.2 It should also be noted that the research by MacDonald and Bell2 was a pilot study that had only 13 patients in the OMT group. MacDonald and Bell2 admitted that their study had numerous limitations and was mainly valuable in yielding hypotheses for further testing—not in reaching clinically relevant conclusions. Nevertheless, Bronfort et al1 included this pilot study in their review.
A study by Burton et al3 was one of the two articles mentioned by Bronfort et al1 that examined the efficacy of OMT in patients with chronic low back pain. Burton et al3 compared OMT with chemonucleolysis in cases of symptomatic lumbar disc herniation. Although they concluded that there was no statistically significant difference in outcome between the two treatments after 1 year, they also noted that OMT did result in a small but statistically significant improvement in back pain and disability during the first 6 weeks of treatment.3 This encouraging finding of Burton et al3 differs from the findings of two chronic low back pain studies that included large sample sizes and placebo control groups,4–6 both of which Burton et al3 lacked.
The other OMT research article on chronic low back pain mentioned by Bronfort et al1 was by Gibson et al,4 who compared OMT with short-wave diathermy and placebo (detuned short-wave diathermy). Gibson et al4 concluded that neither OMT nor short-wave diathermy was superior to placebo treatment. Their results supported the 2003 Licciardone et al6 study that concluded, "There were no significant benefits with osteopathic manipulative treatment, as compared with sham manipulation." Yet, Bronfort et al1 state that there is moderate evidence that manipulation of the spine produces an effect similar to that of nonsteroidal anti-inflammatory drugs.
The one OMT research article on subacute low back pain cited by Bronfort et al1 was by Andersson et al,5 who concluded that OMT and standard medical care have similar clinical results in patients with subacute low back pain—though the OMT group in this study did use fewer medications than the standard care group. Bronfort et al1 use this study to support their conclusion that there is "a small but nonsignificant short-term benefit of SMT [spinal manipulative treatment] over standard medical care for pain."
If the goal of "The Somatic Connection" is to highlight research that relates to the principles of osteopathic medicine, does the JAOA endorse chiropractic manipulation as being as efficacious as OMT? If the answer to this question is "no," then the JAOA should consider systematically reviewing osteopathic studies in an objective and scientific manner in future editions of "The Somatic Connection." With this change, clinicians and osteopathic medical students will continue trusting the JAOA as the evidenced-based standard for osteopathic research.
References
1. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis [review]. Spine J.2004; 4:335 –356.
2. MacDonald RS, Bell CMJ. An open controlled assessment of osteopathic manipulation in nonspecific low-back pain. Spine. 1990;15:364 –370.
3. Burton AK, Tillotson KM, Cleary J. Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation. Eur Spine J.2000; 9:202 –207.
4. Gibson T, Grahame R, Harkness J, Woo P, Blagrave P, Hills R. Controlled comparison of short-wave diathermy treatment with osteopathic treatment in non-specific low back pain. Lancet.1985 :1:1258 –1261.
5. Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med.1999; 341:1426 –1431.
6. Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, Winn W, et al. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine.2003; 28:1355 –1362.
Oklahoma State University College of Osteopathic Medicine Tulsa, Okla(GREG P. HANSEN, OMS IV)