Friday, September 26, 2008

A CAUTION TO BEING OVER-FACINATED BY OSTEOPATHIC SPINAL MANIPULATION

Introduction:

Of late we have seen many INDIAN physios especially young ones are getting fascinated by Osteopathic manipulative treatments. Study 3 discussed below just gives us an idea where osteopaths employ spinal manipulations.
A few CPD/paid seminar providers though moderate in their cost; are currently providing module courses on the same. I doubt many young physios even know when they slip from a physiotheputic domain to Osteopathic domain. No doubt techniques such as myofascial releases, MET are quite helpful but what about different spinal manipulations? Do they have any current scientific evidence to induct them in our day to day clinical practice?
Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement their conventional treatment of musculoskeletal disorders. Previous reviews and meta-analyses of spinal manipulation for low back pain have not specifically addressed OMT and generally have focused on spinal manipulation as an alternative to conventional treatment. The effectiveness of spinal manipulation as a treatment for back pain remains uncertain and controversial. This is because of methodological weakness in many of the published clinical trials and also because of markedly opposing interpretations of the primary data by different reviewers.

I have taken 6 recent reviews on this issue from PEDro & simplified them for the common physio readers. The last review is probably coinciding with my views.

Study1. HVLA spinal manipulation for symptomatic lumbar disk disease: a systematic review of the literature

Lisi AJ et al reviewed the evidence for high-velocity low-amplitude spinal manipulation (HVLASM) for symptomatic lumbar disk disease (SLDD). This review was published in Journal of Manipulative and Physiological Therapeutics 2005 Jul-Aug;28(6):429-442.

16 studies met the inclusion criteria, representing 203 total subjects. Of these, 172 subjects received HVLASM as active treatment, and 31 received other treatments as comparison subjects. Improvements in patient-based and physiological outcomes were reported among subjects receiving HVLASM

The conclusion of this study was:

1. There is limited evidence, and definitive conclusions on safety and effectiveness cannot be made.
2. HVLASM may be effective in the treatment of SLDD and does not support the hypothesis that HVLASM is inherently unsafe in SLDD cases.
3. However it was recommended that it is an area of research importance. More high-quality clinical trials are necessary.

Study 2: A systematic review of systematic reviews of spinal manipulation

Ernst E collated and evaluated the evidence from recent systematic reviews of clinical trials of spinal manipulation which was published in Journal of the Royal Society of Medicine 2006 Apr;99(4):192-196.

16 papers were included relating to the following conditions: back pain (n = 3), neck pain (n = 2), lower back pain and neck pain (n = 1), headache (n = 3), non-spinal pain (n = 1), primary and secondary dysmenorrhoea (n = 1), infantile colic (n = 1), asthma (n = 1), allergy (n = 1), cervicogenic dizziness (n = 1), and any medical problem (n = 1).

The conclusion of this study was:

1. These reviews were largely negative, except for back pain where spinal manipulation was considered superior to sham manipulation but not better than conventional treatments.
2. Collectively data do not demonstrate that spinal manipulation is an effective intervention for any condition.
3. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.
Study 3: Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials
Licciardone JC et al assessed the efficacy of OMT as a complementary treatment for low back pain published in BMC Musculoskeletal Disorders 2005 Aug 4;6(43):Epub.

6 trials, involving 8 OMT versus control treatment comparisons, were included because they were RCTs of OMT that involved blinded assessment of low back pain in ambulatory settings.

The conclusion of this study was:

1. Overall, OMT significantly reduced low back pain. There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States.
2. Significant pain reductions were also observed during short-, intermediate-, and long-term follow-up.
3. However the authors suggested additional research is warranted to clarify mechanistically how OMT exerts its effects.

Study 4. Distraction manipulation of the lumbar spine: a review of the literature

Lumbar distraction manipulation is a non-thrust mechanically assisted manual medicine technique with characteristics of manipulation, mobilization, and traction. It is used for a variety of lumbar conditions and chronic pelvic pain. The primary rationale for its use is on the basis of the biomechanical effects of axial spinal distraction.

Little data are available describing the in vivo effect of distraction when used in combination with flexion or other motions. Gay RE reviewed the literature concerning distraction manipulation of the lumbar spine, particularly regarding physiological effects, clinical efficacy, and safety.

30 articles were identified; 3 were uncontrolled or pilot studies, 3 were basic science studies, and 6 were case series. Most were case reports.

This study concluded:
1. Despite widespread use, the efficacy of distraction manipulation is not well established.
2. Further research is needed to establish the efficacy and safety of distraction manipulation and to explore biomechanical, neurological, and biochemical events that may be altered by this treatment.
Study 5. Chiropractic spinal manipulation treatment for back pain? A systematic review of randomised clinical trials

Back pain is a common condition for which chiropractic treatment is often recommended. Ernst & Canter
did a study to evaluate critically the evidence for or against the effectiveness of chiropractic spinal manipulation for back pain which was published in Physical Therapy Reviews 2003 Jun;8(2):85-91.
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Data sources ware only from RCTs of chiropractic spinal manipulation with patients suffering from back pain from 5 independent literature searches. The authors extracted data on trial design, methodological quality, sample size, patient characteristics, nature of intervention, outcome measures, follow-up and results.

The findings are as follows:

1. Twelve studies could be included. They related to all forms of back pain. Many trials had significant methodological shortcomings. Some degree of superiority of chiropractic spinal manipulation over control interventions was noted in 5 studies.
2. More recent trials and those with adequate follow-up periods tended to be negative.
3. So it was concluded that the effectiveness of chiropractic spinal manipulation is not supported by compelling evidence from the majority of randomised clinical trials.
A nail on the coffin: Sources of bias in reviews of spinal manipulation for back pain

Study 6:

Researchers have highly conflicting views whether spinal manipulation works or not. Canter PH et al have systematically assessed a representative sample of recent reviews on spinal manipulation for back pain. They have tried to find out “What are the sources of bias in reviews?”. Reviews were included in the analysis if they were published between 1993 and March 2004, were listed in PubMed with an abstract and categorised as a review or meta-analysis, and were written in English.

They found that:

1. 29 reviews met the inclusion criteria. 16 reached an overall positive conclusion, 7 a negative conclusion and 6 a neutral conclusion regarding therapeutic effectiveness.
2. This study indicated a strong association between authorship by osteopaths or chiropractors and low methodological quality and positive conclusion. (Overtly biased Osteopaths for their treatments)
3. It also concluded that, the outcomes of reviews of this subject are strongly influenced by both scientific rigor and profession of authors.
4. This study also suggested that effectiveness of spinal manipulation for back pain is less certain than many reviews suggest; most high quality reviews reach negative conclusions.
Full text may be available at: http://www.springerlink.com/openurl.asp?genre=journal&eissn=1613-7671

NB:
1. This review is not intended or targeted to any audience.
2. The opinion does not dissuade anybody to acquire the OMT skills.
3. This opinion certainly intends to reach those clinicians who invest time & labor to see smiles in his patients face.

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