Osteopathic Manipulative Treatment: Much More Than Simply a “Hands-on” Phenomenon

To the Editor:

In his recent editorial, Michael M. Patterson, PhD, associate editor of JAOA—The Journal of the American Osteopathic Association, contends that the time has come to rethink the role of touch in osteopathic medical practice, particularly as it relates to osteopathic manipulative treatment (OMT).¹ He asks, “Is touch a peripheral factor in OMT, or does it play a more important role in the effectiveness of OMT?” He then argues that touch is one of the “active ingredients” of OMT. As support for this position, he cites our North Texas Clinical Trial results,² claiming that “a touch sham therapy can be as effective as an active OMT.” However, there are 2 important factors that must be addressed to put this claim in proper perspective.

First, the sham OMT protocol used in the North Texas Clinical Trial included more than just a touch sham therapy.² In addition to light touch, range-of-motion activities and simulated OMT techniques were provided with this intervention. This comprehensive sham OMT protocol has now been adopted by others as a model for the delivery of sham manipulative techniques.³ Another methodologic feature of the North Texas Clinical Trial was that both the active and the sham OMT protocols were delivered by third- and fourth-year osteopathic medical students rather than by experienced osteopathic physicians. Thus, it is unclear if the non-superiority of OMT to sham OMT in the study would have been generalizable to OMT provided by more seasoned clinicians.

Second, the OSTEOPAThic Health outcomes In Chronic low back pain (OSTEOPATHIC) Trial⁴ was designed to overcome limitations of the North Texas Clinical Trial by increasing sample size and statistical power and by using predominantly licensed osteopathic physicians to provide OMT. The trial included a sham OMT protocol that was similar to that used in the North Texas Clinical Trial. Recent evidence from the OSTEOPATHIC Trial now clearly demonstrates that OMT is superior to sham OMT in reducing pain levels by 50% or more in patients with chronic low back pain.⁵ The results, which were statistically significant, were also clinically relevant according to guidelines established by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials⁶ and the Cochrane Back Review Group.⁷ Thus, because OMT provided substantially more low back pain relief than sham OMT, the specific effect of touch must have been correspondingly small in patients with chronic low back pain. Hence, these new data clearly refute Dr Patterson's contention that a touch sham therapy can be as effective as active OMT.

Nevertheless, the building of effective patient-physician relationships is integral to the practice of patient-centered medicine. The adjunctive use of OMT by osteopathic physicians to help manage a variety of musculoskeletal conditions and visceral disorders has long been a hallmark of the osteopathic approach to patient care. Indeed, osteopathic physicians often cite such “hands-on” care as an important difference in practice style compared with that of allopathic physicians.⁸ Many would argue that OMT training facilitates hands-on medical care and fosters better patient-physician relationships, even if OMT is not used during a patient encounter.

With an increased dependence on diagnostic tests and procedures in contemporary medicine, there is concern that physicians are abandoning their use of touch in interacting with and examining patients. Encouraging greater use of touch to enhance patient-physician relationships, improve diagnostic accuracy, and identify somatic dysfunction is certainly a worthwhile endeavor. However, the purported benefits of touch should not be extrapolated beyond the available data. At present, best evidence indicates that the effects of OMT are attributable to much more than simply a hands-on phenomenon. Why would we expect otherwise given the time and effort that are devoted to teaching OMT in our colleges of osteopathic medicine?