Osteopathic Intervention in Chronic Low Back Pain
Osteopathic Intervention in Chronic Low Back Pain
These findings clarify the current state of research on the effect of the osteopathic intervention in the treatment of chronic non-specific lower back pain in adults. This condition in the adult population has been identified as one of the most prevalent presentations to osteopathic clinicians; and as such, needs to be seen as a key research priority for the osteopathic profession. The results of this review suggest that there is a paucity of quality clinical trials that assess the effectiveness of osteopathic medicine intervention in this condition in the adult population, with only two trials included. These suggest that OMT appeared similar to sham intervention, and exercise and physiotherapy.
This review differs in its conclusions from the previous Systematic Review of 2003, which concluded there was a positive effect from OMT in patients with low back pain. There were a number of trials included in the 2003 review that were not included in the current one for a number or reasons. The Hoehler, Gibson and Andersson trials did not fit the criteria of testing only chronic low back pain, the Burton trial did not fit the criteria of testing non-specific low back pain and the Cleary trial did not specify the type of back pain.
One of the difficulties of research in osteopathic medicine where there are only a small number of intervention trials is the lack of consistency in the methodology used. The lack of consensus on what is appropriate methodology remains a substantive barrier to understanding the role of osteopathic medicine in chronic non-specific lower back pain, which forms a major presentation to osteopathic clinical practice. The benefit of consistent methodology is the capacity to better compare clinical trials and where appropriate to use meta-analysis to provide a statistical assessment of a number of smaller homogenous clinical trials grouped together. Failure to develop an effective methodological consensus may leave this question of the effectiveness of osteopathic medicine in non-specific lower back pain unanswered.
A number of the methodological issues have been discussed by researchers in the field. These include: the problem of blinding the subject and the treatment provider to the intervention, the subjects' knowledge and perceptions of the intervention, and the difficulty of control in trials of manual therapy, particularly the credibility of sham treatment. Although both included studies were considered to have a low risk of bias according to the Cochrane Back Review Group, both had methodological weakness in blinding of participants and patient compliance, which appear to be common issues in trials of manual therapy interventions. Licciardone and Russo point out that the influence of a number of non-specific treatment effects on clinical outcomes present a major challenge to raising the evidence base of OMT and constructing appropriate clinical trials.
Another methodological issue that arises from this Systematic Review is whether the Randomised Clinical Trial that aims to test efficacy suits a complex intervention like osteopathic medicine in a multifactorial condition like chronic non-specific LBP. The emergence of comparative effectiveness research, including the pragmatic trial approach, may point the way to solving the difficulties that researchers have had in meeting the requirements of Evidence Based Medicine and the hierarchy that places Systematic Reviews of rigorous RCTs at its pinnacle.
As in any systematic review, it is possible that there are clinical trials that were not found in the search process. The aim of focussing strictly on CNSLBP limited the number of studies, as many had mixed back pain populations. The requirement of having an authentic osteopathic intervention, which was based on studies of practice in Australia and the United Kingdom, may limit the generalizability of these findings to other jurisdictions.
Discussion
Summary of Evidence
These findings clarify the current state of research on the effect of the osteopathic intervention in the treatment of chronic non-specific lower back pain in adults. This condition in the adult population has been identified as one of the most prevalent presentations to osteopathic clinicians; and as such, needs to be seen as a key research priority for the osteopathic profession. The results of this review suggest that there is a paucity of quality clinical trials that assess the effectiveness of osteopathic medicine intervention in this condition in the adult population, with only two trials included. These suggest that OMT appeared similar to sham intervention, and exercise and physiotherapy.
This review differs in its conclusions from the previous Systematic Review of 2003, which concluded there was a positive effect from OMT in patients with low back pain. There were a number of trials included in the 2003 review that were not included in the current one for a number or reasons. The Hoehler, Gibson and Andersson trials did not fit the criteria of testing only chronic low back pain, the Burton trial did not fit the criteria of testing non-specific low back pain and the Cleary trial did not specify the type of back pain.
One of the difficulties of research in osteopathic medicine where there are only a small number of intervention trials is the lack of consistency in the methodology used. The lack of consensus on what is appropriate methodology remains a substantive barrier to understanding the role of osteopathic medicine in chronic non-specific lower back pain, which forms a major presentation to osteopathic clinical practice. The benefit of consistent methodology is the capacity to better compare clinical trials and where appropriate to use meta-analysis to provide a statistical assessment of a number of smaller homogenous clinical trials grouped together. Failure to develop an effective methodological consensus may leave this question of the effectiveness of osteopathic medicine in non-specific lower back pain unanswered.
A number of the methodological issues have been discussed by researchers in the field. These include: the problem of blinding the subject and the treatment provider to the intervention, the subjects' knowledge and perceptions of the intervention, and the difficulty of control in trials of manual therapy, particularly the credibility of sham treatment. Although both included studies were considered to have a low risk of bias according to the Cochrane Back Review Group, both had methodological weakness in blinding of participants and patient compliance, which appear to be common issues in trials of manual therapy interventions. Licciardone and Russo point out that the influence of a number of non-specific treatment effects on clinical outcomes present a major challenge to raising the evidence base of OMT and constructing appropriate clinical trials.
Another methodological issue that arises from this Systematic Review is whether the Randomised Clinical Trial that aims to test efficacy suits a complex intervention like osteopathic medicine in a multifactorial condition like chronic non-specific LBP. The emergence of comparative effectiveness research, including the pragmatic trial approach, may point the way to solving the difficulties that researchers have had in meeting the requirements of Evidence Based Medicine and the hierarchy that places Systematic Reviews of rigorous RCTs at its pinnacle.
Limitations
As in any systematic review, it is possible that there are clinical trials that were not found in the search process. The aim of focussing strictly on CNSLBP limited the number of studies, as many had mixed back pain populations. The requirement of having an authentic osteopathic intervention, which was based on studies of practice in Australia and the United Kingdom, may limit the generalizability of these findings to other jurisdictions.
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