The Elephant in the Room: Does OMT Have Proved Benefit?

To the Editor:

I would like to congratulate John C. Licciardone, DO, MS, et al on another high-quality study, “A Randomized Controlled Trial of Osteopathic Manipulative Treatment Following Knee or Hip Arthroplasty,” evaluating the efficacy of osteopathic manipulative treatment (OMT) (J Am Osteopath Assoc. 2004;104:193-202). The results of this randomized controlled trial indicate that OMT in the setting of postoperative knee arthroplasty is ineffective. Further, on one outcome measure, OMT actually decreased rehabilitative efficiency.

This study is an important contribution to osteopathic medicine's knowledge base. It has findings similar to those of Dr Licciardone and colleagues' earlier study that showed no added benefit of OMT over sham treatment for chronic low back pain.¹ The earlier study, also a randomized controlled trial, was published in a predominantly allopathic medical journal and has not been openly discussed in the osteopathic medical literature.

In the last paragraph of his article, Dr Licciardone and colleagues state what many osteopathic physicians have come to believe: Healthy patients derive more benefit from OMT than those who are ill or injured. This seems intuitive and supports the hypothesis that OMT has a minimal effect. Such an effect may be all that is needed for people who are healthy; people with injury or illness, however, are not as likely to receive significant benefit from OMT. Moreover, one could argue that when OMT does have an effect, it is little more than the classic placebo effect. It certainly offers some Pygmalion effect; however, which occurs when a persistently held belief becomes a perceived reality

This begs the question of why members of the osteopathic medical profession continue to teach an outdated and ineffective system of healthcare to undergraduate osteopathic medical students.

It is important that osteopathic medical students know the history of osteopathic medicine and the ideas that A. T. Still, MD, DO, professed. But Still lived in the preantibiotic and presurgical era. His findings, though important at that time, are of little more than historic interest today. He did the best with what he had. Likewise, practitioners such as Christian Friedrich Samuel Hahnemann, MD, the founder of homeopathy, did the best with what they had as well. But under the scrutiny of the scientific method, such antiquated practices as homeopathy and magnetic healing have fallen by the wayside.² It seems that OMT will and should follow homeopathy, magnetic healing, chiropractic, and other outdated practices into the pages of medical history.

I received an excellent undergraduate medical education and am proud to be a DO, but I cannot continue to support an antiquated system of healthcare that is based on anecdote or, in some cases, pseudoscience. As a medical school student, I was taught to critically analyze problems and practice evidence-based medicine. When it came to courses in osteopathic principles and practices, however, my peers and I were asked to put aside our critical, evidence-based medical skills and accept the tenets of OMT on faith. When we questioned such esoteric practices as craniosacral therapy and energy field therapy, we were told that “we needed to believe.” Likewise, when less than 5% of the class “felt” the craniosacral rhythm, the rest of the class was derided for a lack of faith—to the point that ejection from the medical school was threatened. When we complained that some students were using barbeque strikers to stimulate invisible “energy fields,” we were told that in time, we would come to understand and believe.

In osteopathic medical school, OMT courses were so steeped in history, tradition, and anecdote that a question included on a final examination asked the name of the mascot of the American School of Osteopathy in 1906, a query without any clinical relevance whatsoever. When my classmates and I inquired into the science of OMT, we were given copies of studies that were little more than statements of faith published in the Journal of the American Osteopathic Association more than 50 years ago. As Mark Twain wrote in his book, Following the Equator, “Faith is believing what you know ain't so.”

How can the osteopathic medical profession deliberately seek the brightest college graduates to become osteopathic physicians and at the same time, ask those students to believe in and practice modes of therapy that have little or no proved effect? Likewise, how can osteopathic physicians, with a straight face, ask those students to believe that the fused bones of the skull move in a magic rhythm that mainstream researchers have never been able to document?^3-6 (Perhaps the findings of these researchers would be different if they had “faith.”) How can we ask students to believe that the body has an energy field that cannot be seen or objectively measured or ask students to believe that providing myofascial release will cause the tissues to “remember” the trauma that caused their injury? This is what we were taught; it did not make sense then and makes even less sense now.

Therefore, I express my congratulations to Dr Licciardone and his colleagues. I hope they continue to ask and answer the hard questions. The testament to osteopathic medicine as a profession will be whether it responds to accumulating scientific evidence and modifies its practices accordingly or simply reverts to a call for faith. Osteopathic medicine has found a niche in modern medicine, not one of a medical specialty that practices OMT, but as a medical specialty that produces well-rounded primary care physicians. The future of osteopathic medicine is bright. But, the future is in the continued graduation of competent and compassionate primary care physicians and not in the historic dogma of OMT.

Response

John C. Licciardone

Department of Family Medicine University of North Texas Health Science Center at Fort Worth—Texas College of Osteopathic Medicine

Dr Bledsoe's letter raises important questions that deserve comment and discussion within the osteopathic medical community. Osteopathic medical education and practice, particularly with regard to osteopathic manipulative treatment (OMT), must be based on rigorous, evidence-based findings. Beyond the methodologic challenges in conducting OMT research, most, if not all, clinical trials of OMT to date have not been sufficiently powered to demonstrate small to moderate treatment effects. Many osteopathic physicians are currently conducting research that will contribute to a growing body of knowledge that attempts to rectify this situation.

The original teachings of Andrew Taylor Still, MD, DO, suggest that the body has the capacity to maintain health and that OMT may be useful in augmenting that capacity by preventing or treating disease. Osteopathic manipulative treatment may be viewed through the prism of preventive medicine by examining the three levels of prevention within the natural history of disease.²

Not surprisingly, the benefits of OMT are likely to vary according to the patient's disease and the stage at which OMT is administered in the disease's natural history. This variance in benefit explains why OMT may be useful for patients who have acute low back pain, ³ but may not be as useful for the patient who has late-stage knee osteoarthritis that requires total joint replacement.⁴ To suggest that OMT has minimal effect because it is more beneficial in healthy patients (ie, in the early, or even subclinical stage of disease) is fallacious. Certainly, the effects of many primary and secondary preventive measures in clinical practice would not be classified as minimal.

Evidence also exists to suggest that the benefits of OMT for patients with chronic low back pain are substantially greater than can be attributed to a placebo effect. Additional analyses, not reported in our published paper,⁵ found that effect sizes for pain outcomes in the usual care plus OMT group versus the usual care group to be –0.77 (95% confidence interval [CI], –1.36 to –0.17) after 1 month of treatment; –1.05 (95% CI, –1.69 to –0.41) after 3 months; and –0.75 (95% CI, –1.40 to –0.11) after 6 months. A comprehensive review of placebos used in clinical trials involving pain outcomes reported a pooled effect size of only –0.27 (95% CI, –0.40 to –0.15).⁶ Thus, pain reduction with OMT in our trial was three to four times greater than expected, based on effects historically attributed to placebos.

Last, it is true that a greater proportion of osteopathic physicians than allopathic physicians enter primary care specialties. Nevertheless, OMT has been identified as the aspect of osteopathic medicine that best reflects its uniqueness.⁷ Demonstrating the efficacy of OMT will ensure the long-term survival of osteopathic medicine by establishing it as distinct from and yet equivalent to allopathic medicine.⁷ Thus, as encouraged by Dr Bledsoe, we will continue to ask and answer the difficult questions regarding OMT. We hope that others also will continue to join in the osteopathic clinical research enterprise. The future of osteopathic medicine may well depend on such efforts.