Stephanie Montrose, Mark Vogel, Kimberly R. Barber | Year 2021

Use of osteopathic manipulative treatment for low back pain patients with and without pain medication history

Pathology:

Low back pain

Type of study:

Pragmatic non randomized pilot study

Date of publication of the study’:

2021/Jan/29

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Purpose of the study

  • Objective: to evaluate the efficacy of OMT on low back pain in relation to medication consumption
  • Measured outcomes:
    • Primary: evaluation of pain through the Keele STarT back questionnaire and of function (sleep, standing, sitting, sex life, traveling and social life) through a modified version of the Oswestry Disability Index questionnaire
    • Secondary: evaluation of pain medication consumption (in particular, muscle relaxants and opioids)

Participants

  • Number: 36 people (25 female and 11 male)
  • Criteria of inclusion: patients in a medical ambulatory clinic or volunteers recruited through mailing/flyering, age 18-75 years, no OMT received in the 3 months prior to recruitment, a diagnosis of low back pain, low back pain for at least 6 months
  • Criteria of exclusion: OMT, chiropractic or steroids in the 3 months preceding the recruitment, metastatic cancer or pregnancy
  • Group of study: 2 groups obtained on the basis of low back pain medication prescription
    • Group 1: OMT, 26 people (18 female and 8 male, mean age 45.5 years)
      • in case of opioid use, people would be excluded from the study. However, none of them made use of opioids
    • Group 2: pharmacologic treatment with OMT, 10 people (7 female and 3 male, mean age 47.7 years)
    • At the beginning of the study, function evaluated through Oswestry Disability Index questionnaire was better in the OMT group

Interventions and evaluations

  • At each outpatient visit, evaluation of pain through Keele STarT back questionnaire and function through a modified version of the Oswestry Disability Index questionnaire
    • for the OMT group, two moments were considered for the analysis, ie, the beginning and the end of the study
    • for the pharmacologic treatment with OMT group, three moments were considered for the analysis, ie, the beginning of the study, after the beginning (once the OMT was added) and at the end of the study
  • Evaluation of pain medication consumption (type, dosage and frequency)
  • Various sessions of OMT over a year depending on the participants’ needs evaluated by the physician performing the OMT
    • participants in the pharmacologic treatment group, began to receive OMT after 3 months from when they had started taking medications, in order to reach the ideal pharmacological dose for pain control. For these participants the OMT lasted 9 months
  • OMT: counterstrain, myofascial release, muscle energy and high-velocity low amplitude techniques according to the somatic dysfunction detected during the palpatory examination
  • Pharmacologic treatment
  • OMT performed by 10 different physicians

Results

  • Primary outcomes: in the group with OMT alone, both pain and function improved in a statistically significant manner at the end of the study period (with an average of about 5 sessions of OMT).
    In the group with pharmacological treatment and OMT (an average of about 4 OMT sessions), there was no improvement in either pain or function between the start of the study and after 3 months of drug therapy alone. In contrast, both pain and function improved statistically significantly at the end of the study, and then after 9 months of medication combined with OMT. At the end of the study the improvements obtained in both groups resulted comparable to each other.
  • Secondary outcomes: With regard to the medication consumption, all patients taking muscle relaxants assumed cyclobenzaprine. Starting with 5 people taking this drug at the beginning of the study, only 2 were still taking it by the end of it. In addition, at the end of the study no participant would take hydrocodone any more.

Discussion

OMT proved to be capable of positively affecting pain and function in case of low back pain. The result it obtained, both alone and together with pharmacologic therapy, was comparable, taking under account that in the first group it favored the transition from a severe disability to a moderate one, while in the second group the transition was from a disability at the level of impairment to a severe one. In addition, although not significant (probably because of the small sample) there was a decrease in medication use after the application of OMT.

More studies are needed to evaluate more specifically the medications used, as the present study focused mainly on the use of opioids which, however, were only used by 1 participant. Therefore, the use of other classes of analgesic drugs should be considered more carefully. Finally, although costly and difficult to implement, it would be interesting to carry out studies comparing OMT and sham treatment in the long term.

The review of Osteopedia

By Marco Chiera

Strengths: good introduction on the importance of evaluating the effectiveness of OMT in case of pharmacological prescription; good description of the evaluation tests used; one of the few long-term studies (1 year). Although the two groups started with different functionalities, they still had the same improvement: therefore, the OMT seems able to have a positive impact independently from the initial condition.

Limits: small and numerically unbalanced sample; as indicated by the authors, more attention needs to be paid to the different medications used by the participants, as it cannot be excluded that people in the group with OMT alone also took paracetamol or other analgesics not considered here. Small note: there is a misprint in a diagram which does not allow to properly understand the improvement occurred in the group with pharmacologic treatment.

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