MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

The aim of this RCT was to investigate the effects of an osteopathic manipulative treatment (OMT) which includes a diaphragm intervention compared to the same OMT with a sham diaphragm intervention in chronic non-specific low back pain (NS-CLBP).

Participants (N=66) with a diagnosis of NS-CLBP lasting at least 3 months were randomized to receive either an OMT protocol including specific diaphragm techniques (n=33) or the same OMT protocol with a sham diaphragm intervention (n=33), conducted in 5 sessions provided during 4 weeks.

The primary outcomes were pain (evaluated with the Short-Form McGill Pain Questionnaire [SF-MPQ] and the visual analog scale [VAS]) and disability (assessed with the Roland-Morris Questionnaire [RMQ] and the Oswestry Disability Index [ODI]). Secondary outcomes were fear-avoidance beliefs, level of anxiety and depression, and pain catastrophization. All outcome measures were evaluated at baseline, at week 4, and at week 12.

A statistically significant reduction was observed in the experimental group compared to the sham group in all variables assessed at week 4 and at week 12. Moreover, improvements in pain and disability were clinically relevant.

The authors concluded that an OMT protocol that includes diaphragm techniques produces significant and clinically relevant improvements in pain and disability in patients with NS-CLBP compared to the same OMT protocol using sham diaphragm techniques.

This seems to be a rigorous study. The authors describe in detail their well-standardised interventions in the full text of their paper. This, of course, will be essential, if someone wants to repeat the trial.

I have but a few points to add:

  1. What I fail to understand is this: why the authors call the interventions osteopathic? The therapist was a physiotherapist and the techniques employed are, if I am not mistaken, as much physiotherapeutic as osteopathic.
  2. The findings of this trial are encouraging but almost seem a little too good to be true. They need, of course, to be independently replicated in a larger study.
  3. If that is done, I would suggest to check whether the blinding of the patient was successful. If not, there is a suspicion that the diaphragm technique works partly or mostly via a placebo effect.
  4. I would also try to make sure that the therapist cannot influence the results in any way, for instance, by verbal or non-verbal suggestions.
  5. Finally, I suggest to employ more than one therapist to increase generalisability.

Once all these hurdles are taken, we might indeed have made some significant progress in the manual therapy of NS-CLBP.

5 Responses to Osteopathy for chronic low back pain – progress at last?

  • Without access to the full text (which is paywalled), it’s unclear whether blinding was tested. The investigators could have asked patients which treatment arm they thought they were in, before the blind was broken. This is a valuable check which is usually ignored in most trials, so it’s safe to assume that was the case here.

  • Interesting as usual!
    My issues with cLBP (having it myself) is that though people say “my back hurts all the time” I suspect like me, it’s a move-able feast…I can go 3 mos (the study duration) mostly pain-free…and of course during interventions of any sort there may be concomitant changes in lifestyle and activities. And I have had many various interventions (heavy on manipulation) and most tend to do nothing or more likely are irritating.
    If the diaphragm-intervention is involving abdominal-hollowing/TrA or dedication to “braced-core” control, or eliminating the use of the diaphragm in core-control…then extensive instruction is necessary. So specific effects of exercise may also play the real role. Hodges, Jull and others have published extensively on this and their “impressive result” (one study showing a near 90% reduction over a year in low back flares vs the control) did not include “sorcery”, er…manipulation.

    • @ Michael,

      Are you still a physiotherapist? Are you for or against physiotherapy?

      Also, “the core” is not really that important for low back pain – see tweet below and search for the video titled below, could be informative for you

      Peter O’Sullivan
      Peter O’Sullivan
      @PeteOSullivanPT
      ·
      15h
      What is the cause of your pain? “it’s my weak core – but I have done Pilates for ever…so how could that be?” “ every physio has told me that!” We need to change the narrative of LBP.

      Video: Back pain – separating fact from fiction – Prof Peter O’Sullivan

  • EE wrote

    “What I fail to understand is this: why the authors call the interventions osteopathic? The therapist was a physiotherapist and the techniques employed are, if I am not mistaken, as much physiotherapeutic as osteopathic.”

    Osteopathics were addressing the diagragm from early on, and was most likely was a part of their approach in the addressing the 1918 flu epidemic.

    The APA wasnt formed until 1921 as a response to help polio victims as well as WW1 wounded soldiers.

    Therefore, historically, it’s an osteopathic technique.

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