Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis.

The short version

This systematic review and meta-analysis pooled 15 randomized trials with 1502 adults to test whether osteopathic manipulative treatment (OMT), a hands-on approach in which osteopaths choose techniques to suit each patient, improves pain and function in nonspecific low back pain (back pain with no specific underlying cause such as a fracture, tumor or infection). Low back pain is common, disabling and costly. The review counted only "authentic" osteopathic care, where practitioners used clinical judgment rather than one technique or a fixed protocol, and it analyzed pregnant and postpartum women separately. The authors searched seven databases and a trial register in October 2013 without language limits and also included unpublished grey literature, finding 307 records. Trials could compare OMT with sham treatment, usual care, physiotherapy or no treatment. Studies were independently reviewed with a standardized form, and only patient-reported outcomes were evaluated. Pain and functional status were pooled at about three months after treatment, and each trial was checked for risk of bias and graded for quality of evidence. In acute and chronic nonspecific low back pain, OMT lowered pain by 12.91 points on a 0-100 scale (95% CI -20.00 to -5.82) and improved function (SMD -0.36, -0.58 to -0.14), based on moderate-quality evidence. In chronic back pain alone, pain fell by 14.93 points (-25.18 to -4.68). In pregnancy, low-quality evidence showed pain reductions of 23.01 points (-44.13 to -1.88) and function gains (SMD -0.80), while moderate-quality evidence in postpartum women showed a 41.85-point pain reduction (-49.43 to -34.27) and an SMD of -1.78 for function. Effects were larger for pain than function and met the Cochrane threshold for clinical relevance. The largest trial, with 455 people, supplied only medians, so its values were estimated, and results were nearly identical with or without it. Only four of 15 trials reported adverse events, which were minor (stiffness, tiredness) with no treatment-related serious events. Heterogeneity was considerable. The authors conclude that OMT had clinically relevant effects on pain and functional status at three months posttreatment and recommend larger, high-quality trials with robust comparison groups. Limitations include small samples, different comparison groups, heterogeneity, no long-term measurement, blinding problems in every trial, and fewer than 400 participants in the pregnancy and postpartum comparisons. The authors also say future studies should report adverse events and describe the treatment approach clearly. The search ran in October 2013, so later trials are not included.

Key findings

• This systematic review combined 15 randomized trials with 1,502 adults to test osteopathic manipulative treatment (OMT, individualized hands-on osteopathic care) for nonspecific low back pain, meaning back pain without a specific underlying cause.
• About three months after treatment, OMT lowered pain by 12.91 points on a 0-100 scale (95% CI -20.00 to -5.82) and improved function (standardized mean difference -0.36), based on moderate-quality evidence.
• Larger effects were found in pregnant women (pain -23.01 points, low-quality evidence) and postpartum women (pain -41.85 points, moderate-quality evidence).
• Only four of the 15 trials reported adverse events, which were minor stiffness and tiredness or showed no treatment-related serious events.
• The trials were small, used different comparison treatments, were heterogeneous and had no long-term follow-up, so the authors call for larger high-quality trials.

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