The aim of this paper was to systematically evaluate the effectiveness of osteopathic manipulative treatment (OMT) for managing headaches associated with musculoskeletal dysfunction and to assess the associated harm outcomes.
In September 2023, the following databases were searched for randomized controlled trials (RCTs) of adult patients with headaches associated with musculoskeletal dysfunction who were treated with OMT: Allied and Complementary Medicine Database, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Excerpta Medica (EMBASE), Osteopathic Medicine Digital Library (OSTMED), Ovid Emcare, Ovid MEDLINE, Physiotherapy Evidence Database (PEDro), PsycINFO, and PubMed. The search terms included osteopathic manipulative medicine, manual therapy, osteopath, headache, concussion, and head injury. The studies had to compare OMT techniques (e.g., articulatory [ART]; high-velocity, low-amplitude [HVLA]; soft tissues [ST]) to another form of treatment or a different type of OMT technique. The primary outcomes included headache severity, headache frequency, disability associated with headaches, quality of life, and return to work (RTW); harm outcomes included all-cause dropout (ACD) rates, dropouts due to inefficacy, and adverse effects. The Cochrane Risk of Bias (ROB) tool was utilized to assess the ROB in the reviewed studies, and the quality of evidence was assessed utilizing the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Outcomes data were pooled for analysis and reported as standardized mean difference (SMD) and 95 % confidence interval (CI).
The searches identified 11,657 RCTs. After removing duplicates and screening titles and abstracts, 167 underwent full-text review, and 18 were included in our review. None of the reviewed RCTs met all of the Cochrane ROB criteria. Moderate-quality evidence indicated that combined ART-HVLA (SMD=−0.61, 95 % CI=−1.0 to −0.23) and ST HVLA-ART (SMD=−0.48, 95 % CI=−0.83 to −0.13) effectively reduced the severity of headache. Moderate-quality evidence also indicated that the combined techniques of ART-HVLA (SMD=−0.43, 95 % CI=−0.74 to −0.13) and ST-ART-HVLA (SMD=−0.62, 95 % CI=−0.89 to −0.35) effectively reduced the frequency of headaches. Moderate-quality evidence indicated that quality of life was improved with combined ART-HVLA (SMD=0.57, 95 % CI=0.14 to 0.99). Low-quality evidence indicated no significant associations of OMT with disability or harm outcomes (all p>0.26).
The authors concluded that our systematic review and meta-analysis suggested that a combination of multiple types of OMT techniques effectively reduced the frequency and severity of headaches and improved quality of life. However, high-quality RCTs with large sample sizes utilizing a variety of technique modalities and combinations of technique modalities are necessary to better evaluate the effectiveness of OMT for managing headaches.
I do not agree with these conclusions!
Here are some of my reasons:
- The authors claim to evaluate OMT for managing headaches associated with musculoskeletal dysfunction. Yet few of the trials were specifically aimed at this aim.
- Comparator treatment included sham manipulation, waitlist or no treatment, treatment as usual, a different type of OMT technique or protocol that was not the same as the experimental intervention, or any standard of care intervention, such as exercise therapy or medication. Most of these do not allow conclusions about specific effects of OMT.
- There was no attempt to control for placebo effects which might be significant in the case of OMT.
- In general, the methodological quality of the primary studies was low.
- There are too few studies to adequately assess the multitude of different OMT techniques.
- The fact that multiple forms of headache exist is not adequately addressed.
Yes, the authors try to be cautious in their conclusions and admit that the evidence is weak. Yet, I simply do not see enough compelling evidence to agree with them that the data are even suggestive of a positive effect.
Leave a Reply