Osteopathic manipulative treatment: A systematic review and critical appraisal of comparative effectiveness and health economics research

Comments, suggestions, and criticisms of the Pragmatic Explanatory Continuum Indicator Summary-2 design tool: a citation analysis

INTRODUCTION

The pragmatic explanatory continuum indicator summary (PRECIS) tool, initially published in 2009 and revised in 2015, was created to assist trialists to align their design choices with the intended purpose of their randomised controlled trial (RCT): either to guide real-world decisions between alternative interventions (pragmatic) or to test hypotheses about intervention mechanisms by minimising sources of variation (explanatory). There have been many comments, suggestions, and criticisms of PRECIS-2. This summary will be used to facilitate the development of to the next revision, which is PRECIS-3.

METHODS

We used Web of Science to identify all publication types citing PRECIS-2, published between May 2015 and July 2023. Citations were eligible if they contained 'substantive' suggestions, comments, or criticism of the PRECIS-2 tool. We defined 'substantive' as comments explicitly referencing at least one PRECIS-2 domain or a concept directly linked to an existing or newly proposed domain. Two reviewers independently extracted comments, suggestions, and criticisms, noting their implications for the update. These were discussed among authors to achieve consensus on the interpretation of each comment and its implications for PRECIS-3.

RESULTS

The search yielded 885 publications, and after full-text review, 89 articles met the inclusion criteria. Comments pertained to new domains, changes in existing domains, or were relevant across several or all domains. Proposed new domains included assessment of the comparator arm and a domain to describe blinding. There were concerns about scoring eligibility and recruitment domains for cluster trials. Suggested areas for improvement across domains included the need for more scoring guidance for explanatory design choices.

DISCUSSION

Published comments recognise PRECIS-2's success in aiding trialists with pragmatic or explanatory design choices. Enhancing its implementation and widespread use will involve adding new domains, refining domain definitions, and addressing overall tool issues. This citation review offers valuable user feedback, pivotal for shaping the upcoming version of the PRECIS tool, PRECIS-3.

The Austrian Osteopathic Practitioners Estimates and RAtes (OPERA): A cross-sectional survey

INTRODUCTION

Since the previous survey of the osteopathic profession in Austria was almost a decade ago, an update was necessary. The Osteopathic Practitioners Estimates and RAtes (OPERA) project was developed as a Europe-based survey, whereby an updated profile of the profession not only provides new data for Austria, but also allows for a clear comparison with other European countries.

METHODS

A voluntary, online-based, closed-ended survey was distributed across Austria in the period between April and August 2020. The original English OPERA-questionnaire, composed of 52 questions in seven sections, was formally translated in German and adapted to the Austrian situation. Recruitment was performed through social-media and an e-based campaign.

RESULTS

The survey was completed by 338 individuals, of which 239 (71%) were female, and the median age was 40-49 years. Almost all respondents had preliminary healthcare training, mainly in physiotherapy (72%). The majority of respondents were self-employed (88%) and working as sole practitioners (54%). The median number of consultations per week was 21-25 and the majority of respondents scheduled 46-60 minutes for each consultation (69%). The most commonly used diagnostic techniques were: palpation of position/structure, palpation of tenderness and visual inspection. The most commonly used treatment techniques were cranial, visceral and articulatory/mobilisation techniques. The majority of patients estimated by respondents consulted an osteopath for musculoskeletal complaints mainly localised in the lumbar and cervical region. Although the majority of respondents experience a strong osteopathic identity, only a small proportion (17%) advertise themselves exclusively as osteopaths.

CONCLUSIONS

This study represents the first published document to determine the characteristics of the osteopathic practitioners in Austria using large, national data. It provides new information on where, how, and by whom osteopathic care is delivered. The information provided may contribute to the evidence used by stakeholders and policy makers for the future regulation of the profession in Austria.

Mechanisms Underlying Anti-Inflammatory and Anti-Cancer Properties of Stretching-A Review

Stretching is one of the popular elements in physiotherapy and rehabilitation. When correctly guided, it can help minimize or slow down the disabling effects of chronic health conditions. Most likely, the benefits are associated with reducing inflammation; recent studies demonstrate that this effect from stretching is not just systemic but also local. In this review, we present the current body of knowledge on the anti-inflammatory properties of stretching at a molecular level. A total of 22 papers, focusing on anti-inflammatory and anti-cancer properties of stretching, have been selected and reviewed. We show the regulation of oxidative stress, the expression of pro- and anti-inflammatory genes and mediators, and remodeling of the extracellular matrix, expressed by changes in collagen and matrix metalloproteinases levels, in tissues subjected to stretching. We point out that a better understanding of the anti-inflammatory properties of stretching may result in increasing its importance in treatment and recovery from diseases such as osteoarthritis, systemic sclerosis, and cancer.

Effectiveness of osteopathic interventions in patients with non-specific neck pain: A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis is to evaluate whether osteopathic manipulative interventions can reduce pain levels and enhance the functional status in patients with non-specific neck pain (NS-NP).

METHODS

A systematic review and meta-analysis was conducted following the 2020 PRISMA statement. Randomized controlled trials (RCTs) were searched in five databases, assessed through a standardized form, and evaluated using the "13 items Cochrane risk of bias (RoB) tool". Effect sizes (ES) were calculated post-treatment, and the quality of evidence was assessed through GRADE criteria.

RESULTS

Five articles were included in the review, and none of these was completely judged at low RoB. Four of these were included in the meta-analysis. Osteopathic interventions compared to no intervention/sham treatment showed statistically significant results for pain levels (ES = -1.57 [-2.50, -0.65]; P = 0.0008) and functional status (ES = -1.71 [-3.12, -0.31]; P = 0.02). The quality of evidence was "very low" for all the assessed outcomes. Other results were presented in a qualitative synthesis.

CONCLUSIONS

Osteopathic interventions could be effective for pain levels and functional status improvements in adults with NS-NP. However, these findings are affected by a very low quality of evidence. Therefore, further high-quality RCTs are necessary to improve the quality of evidence and generalize the results.

Osteopathic Manipulative Treatment and the Management of Headaches: A Scoping Review

Headaches have been studied and treated since nearly 7,000 BC because of their significant global impact. Current headache treatment modalities are various and have a wide variety of targets, but medications are the most common. Since conventional medical treatments have several side effects, alternative remedies such as osteopathic manipulative treatment (OMT) should be considered. OMT can assist in the management of various health conditions, such as low back pain, neck pain, and headaches. The purpose of this scoping review is to evaluate recent findings regarding the efficacy of OMT modalities in the management of headaches such as tension-type headaches (TTH) and migraines. This study was designed as a scoping review to gather evidence on the efficacy of OMT modalities in the management of headaches. Following PRISMA guidelines, four databases were used to search for articles published between 2010 and 2022 that reported the use of OMT and manual therapy for TTH and migraines. Databases used include Embase, PubMed, Medline, and Web of Science. The following keywords were used: treatment, therapy, Headache, migraine, craniosacral, muscle energy, myofascial release, trigger point, osteopathic, and manipulation. The initial search yielded 473 unique articles after removing duplicates. After screening based on the inclusion and exclusion criteria, and after further analysis, 15 articles were selected. Data reports of OMT and manual therapy efficacy and/or effectiveness in treating TTH and migraine were analyzed. Articles included were randomized control studies (13 of 15, 86.6%), one pilot study (one of 15, 6.7%), and one case series (one of 15, 6.7%), which were divided into TTH (nine of 15, 60%) and Migraine Headaches (six of 15, 40%). All articles reported significant headache improvement in at least one measurement. Of all treatments analyzed, single technique interventions (seven of 15, 47%) and multiple technique interventions (eight of 15, 53%) were identified. Among the techniques used, Myofascial Release was the most common (nine of 15, 60%). The articles presented provide evidence of the significant benefits of manual therapy. Because of the limitations of traditional medicine, OMT can be used either as an alternative or adjuvant therapy for headaches. Evidence suggests the positive impact it can provide on headache management, but the number of randomized control trials and population samples should be increased to support its recommendation. This demonstrates how different osteopathic techniques can provide therapeutic effects on TTH, MH, and potentially other types of headaches. A preference for myofascial release was observed, which can be due to the fast relief from the physiologic effect on tissue movement. This review study demonstrates the benefits OMT has on decreasing headache frequency, intensity, and duration in TTH and migraines. OMT has shown to be beneficial, especially for patients seeking alternative non-pharmaceutical and non-invasive treatments. Further studies are needed to evaluate the effects of different OMT techniques, and different combinations of treatments, on other types of headaches.

Alternative medicines worth researching? Citation analyses of acupuncture, chiropractic, homeopathy, and osteopathy 1996-2017

Some complementary and alternative medicines (CAM) are frequently criticised for being based on faith rather than scientific evidence. Despite this, researchers, academic departments, and institutes teach and investigate them. This article assesses whether the scholarship produced by four CAMs is valued by the academic community in terms of citations, and whether the level of citations received might be detrimental to academic authors' careers. Based on an analysis of acupuncture, chiropractic, homeopathy, and osteopathy journal articles indexed in Scopus 1996-2020, the results show that the prevalence of the four areas vary substantially internationally, with acupuncture eclipsing the others in East Asia but homeopathy being more common in India and Brazil. The main broad fields publishing these specialties are Medicine, Nursing, Health Professions, Veterinary Science, and Neuroscience. Whilst the research tends to be cited at a below average rate in most broad fields (n = 27) and years (1996-2017), acupuncture, chiropractic, and homeopathy are exceptions in some broad fields, including some core areas. Thus, studying these alternative medicines may not always lead to research that tends to be ignored in academia, even if many scientists disparage it. As a corollary, citation analysis cannot be relied on to give low scores to widely disparaged areas of scholarship.

Osteopathy in primary health care: partial results of continuing education experience and some initial outcomes

This paper presents partial results of a research-intervention, through training of PHC work teams. Initial consultation was made in a group by HC professionals, and the osteopath then performed the consultation. The socialization and training of practical knowledge and techniques of the osteopathic approach was done between consultations. Multiprofessional teams from three health centers from Florianópolis, southern Brazil, participated in the training, and the process was audio and videorecorded, along with a final interview. Data was analyzed using the Grounded Theory. Apprehending the osteopathic knowledge was a triggering tool for reflective processes about care. Faced with the efficiency and resolution of this approach in practice, participants showed a willingness to transform their acts of care of patients and also their self-care. The professionals argue that the common understanding about self-regulating mechanisms and the inclusion of the tissue mobility in their anamnesis, including the stimulation of endogenous mechanisms, contributed to less protocol-based care, more appropriate care for each case, better multidisciplinary team work, the rational use of additional tests, medication, and surgical procedures.

Osteopathic empirical research: a bibliometric analysis from 1966 to 2018

Background

Despite the increasing use of osteopathy, a manipulative complementary and alternative medicine therapy, in the general population, its efficacy continues to be debated. In this era of evidence-based practice, no studies have previously reviewed the scientific literature in the field to identify published knowledge, trends and gaps in empirical research. The aims of this bibliometric analysis are to describe characteristics of articles published on the efficacy of osteopathic interventions and to provide an overall portrait of their impacts in the scientific literature.

Methods

A bibliometric analysis approach was used. Articles were identified with searches using a combination of relevant MeSH terms and indexing keywords about osteopathy and research designs in MEDLINE and CINAHL databases. The following indicators were extracted: country of primary author, year of publication, journals, impact factor of the journal, number of citations, research design, participants’ age group, system/body part addressed, primary outcome, indexing keywords and types of techniques.

Results

A total of 389 articles met the inclusion criteria. The number of empirical studies doubled every 5 years, with the United States, Italy, Spain, and United Kingdom being the most productive countries. Twenty-three articles were cited over 100 times. Articles were published in 103 different indexed journals, but more than half (53.7%) of articles were published in one of three osteopathy-focused readership journals. Randomized control trials (n = 145; 37.3%) and case reports (n = 142; 36.5%) were the most common research designs. A total of 187 (48.1%) studies examined the effects of osteopathic interventions using a combination of techniques that belonged to two or all of the classic fields of osteopathic interventions (musculoskeletal, cranial, and visceral).

Conclusion

The number of osteopathy empirical studies increased significantly from 1980 to 2014. The productivity appears to be very much in sync with practice development and innovations; however, the articles were mainly published in osteopathic journals targeting a limited, disciplinary-focused readership.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-021-03366-3.

The effect of osteopathic medicine on pain in musicians with nonspecific chronic neck pain: a randomized controlled trial

Background:

Nonspecific chronic neck pain (cNP) is common in adult violinists and violists and is often treated with osteopathic medicine (OM), although the effectiveness of this treatment has not been determined to date. This study aimed to evaluate the effectiveness and safety of OM in adult violinists and violists with cNP.

Methods:

In a two-armed randomized controlled single-center open trial, adult violinists and violists, including music students, with cNP (⩾12 weeks) were randomized to either five individualized OM sessions (OM group) or to no intervention (control group, CG) in the outpatient clinic for integrative medicine, Charité - Universitätsmedizin Berlin, Germany. All patients received a musicians’ medicine consultation and paracetamol on demand. The primary outcome parameter was the neck pain intensity on a visual analog scale (VAS, 0–100 mm, 0 = no pain, 100 = worst imaginable pain) after 12 weeks. Secondary outcomes included neck pain disability (Neck Disability Index, NDI, 0–100%) after 12 weeks. The last follow-up visit was after 52 weeks. Statistical analysis included analysis of covariance adjusted for respective baseline value.

Results:

Altogether, 62 outpatients were included [OM group (n = 28), CG (n = 34); 81% female; mean age, 41.6 ± 11.1 years; mean baseline neck pain, 55.9 ± 11.6 mm]. After 12 weeks, OM was associated with an improvement in the OM group versus the CG in neck pain on the VAS [14.6 mm (95% confidence interval 8.0; 21.2) versus 40.8 mm (34.7; 46.9), p < 0.001, Cohen’s d = 1.4], and neck pain disability as determined by the NDI [8.8% (6.7; 10.8) versus 17.2% (15.3; 19.1), p < 0.001]. Some improvements were maintained until 52 weeks of follow-up. No serious adverse events were observed.

Conclusions:

The results of this study suggest that OM might be effective in reducing pain intensity in adult violinists and violists with nonspecific cNP. Further studies should investigate the efficacy of OM in comparison with a sham procedure and with other effective therapy methods in high-quality multicenter trials.

Trial registration:

WHO Trial Registration https://apps.who.int/trialsearch/NoAccess.aspx?aspxerrorpath=/trialsearch/Trial2.aspx by German Clinical Trials Register DRKS00009258, Universal Trial Number (UTN): U1111-1173-5943.

What Makes an Osteopathic Treatment Effective From a Patient's Perspective: A Descriptive Phenomenological Study

OBJECTIVES

This study aimed to describe patients' perspectives on their experience in osteopathic treatment, to contribute toward developing interpretative models on effectiveness.

METHODS

A descriptive phenomenological approach was used. The data were collected through a semistructured interview. To capture the variability of the phenomenon, a purposive sample of 12 participants with previous experience of osteopathic care was selected. The data analysis was carried out in an inductive way, and it was parallel to the recruitment to continuously monitor the data saturation.

RESULTS

Data saturation was reached with 12 participants (female = 9; male = 3). Participants' age ranged from 27 to 82 years old (mean: 55.25 ± 17.15; median: 59; kurtosis: -0.82). Participants had different reasons for consultation. The analysis showed 1 overarching theme, "Osteopathy is a path of awareness," 3 themes, and 12 categories. Themes were: (1) "The experience of pain produces awareness of the need for care," (2) "Osteopathy is a journey to be shared over time," and (3) "The effectiveness of the osteopathic treatment is the discovery of the person's unity by experience."

CONCLUSION

Participants affirm that osteopathy is a path of awareness that starts from an experience of pain; leads them to contact an osteopath; and ends with their experience of the unity of body, mind, and spirit.

Does Osteopathic Manipulative Treatment Induce Autonomic Changes in Healthy Participants? A Thermal Imaging Study

Osteopathic manipulative treatment (OMT) has been demonstrated to be an effective therapy in several clinical conditions and age groups. Despite the clinical effectiveness, lack of robust data in terms of neurobiological, specifically autonomic, mechanisms of action is observed. Preliminary studies showed a parasympathetic effect leading to a trophotropic effect of OMT. However, these data are limited to heart rate variability (HRV) analysis. In order to study further the role of OMT on the autonomic nervous system, a cross-over randomized controlled trial RCT has been designed to test the effect of osteopathic treatment compared to sham therapy on a range of autonomic parameters. Thermal images, HRV and skin conductance data were collected on a sample of healthy adults. The study design consisted of two sessions (OMT and SHAM), 1 treatment per week, lasting 35 min each, composed of 5 min of baseline, 25 min of treatment, and 5 min of post-touch. During the baseline and the post-treatment, participants received no touch. Thirty-seven participants (aged 27 ± 5 years old, male ratio 40%) completed the study. Multivariate analysis showed a significant parasympathetic effect of group as well as of epoch on thermographic data of the nose (estimate 0.38; 95% CI 0.12–0.63; p < 0.01), left (0.17; 0.06–0.27; <0.001) and right (0.16; 0.07–0.24; <0.001) perioral as well as on the forehead (0.07; 0.01–0.12; <0.01) regions but not for the chin (0.08; −0.02 to 0.18; 0.13). Consistent with a parasympathetic effect, analyses demonstrated a difference between OMT and sham groups on the nuHF (p < 0.001) and DFA-a1 (p < 0.01) as well as on skin conductance (<0.01). The present research supports the hypothesis that a single session of OMT as compared to sham induces autonomic consequences in healthy non-symptomatic adults. Clinicaltrial.gov identifier: NCT03888456, https://clinicaltrials.gov/ct2/show/NCT03888456.

Ultrasound Shear Wave Elastography to Assess Tissue Mechanical Properties in Somatic Dysfunction: A Feasibility Study

CONTEXT

Diagnosis of somatic dysfunction is based on subjective palpatory osteopathic assessments. This subjectivity has posed a challenge for researchers in studying osteopathic medicine. The development and use of radiological imaging techniques to objectively confirm or quantify muscle tissue stiffness associated with somatic dysfunction could be of benefit in osteopathic clinical practice, training, and further research.

OBJECTIVES

To investigate the feasibility of ultrasound shear wave elastography (SWE) to quantify muscle tissue stiffness in somatic dysfunction before and after osteopathic manipulative treatment (OMT).

METHODS

In this prospective study, we assessed lumbar spine somatic dysfunction in 20 adult patients before and after a single OMT session using standard osteopathic palpatory assessments by osteopathic physician faculty members in the Department of Osteopathic Principle and Practice at Rocky Vista University College of Osteopathic Medicine (Utah campus). Shear wave velocity (SWV, m/s) was measured in lumbar paraspinal muscle tissue using a commercial ultrasonography scanner on all participants immediately before and after OMT. In this study, OMT techniques targeted the iliocostalis lumborum and included the articulatory technique, balanced ligamentous tension, facilitated positional release, high-velocity, low-amplitude technique, muscle energy, myofascial release, and the Still technique at the discretion of the osteopathic physician. The difference in SWV between muscle tissues with and without dysfunction, and differences in SWV of dysfunctional tissue before and after OMT were examined using unpaired and paired t tests, as appropriate. The correlation between SWV measurements and osteopathic assessments was examined by the Spearman rank correlation. Intra- and interobserver reliability was analyzed using intraclass correlation coefficient.

RESULTS

The difference in SWV between muscle tissues with and without somatic dysfunction was significant before OMT (mean [SD], 1.93 [0.44] vs 1.69 [0.19]; P=.03) and was not significant after OMT (mean [SD], 1.69 [0.19] vs 1.53 [0.31]; P=.05). The difference in SWV in the same tissue with somatic dysfunction before and after OMT was significant (mean [SD], 1.93 [0.44] vs 1.52 [0.3]; P<.001). The SWV value highly correlated with manual osteopathic assessments (r=0.72). Intra- and interobserver reliability for performing SWE in somatic dysfunction was good (intraclass correlation coefficient >0.80).

CONCLUSIONS

The results of this study show that ultrasound SWE can objectively assess muscle tissue stiffness for diagnosis of somatic dysfunctions and for muscle tissue stiffness changes after OMT.

Osteopathic Manipulation in the Management of Chronic Pain: Current Perspectives

Chronic pain is a common condition that often interferes with work or other activities. Guidelines support the use of non-pharmacological treatments, such as spinal manipulation, in patients with chronic pain. Osteopathic physicians in the United States are uniquely positioned to manage chronic pain because their professional philosophy embraces the biopsychosocial model and they are trained in the use of osteopathic manipulative treatment (OMT) to complement conventional medical care. This narrative review provides current perspectives on the osteopathic approach to chronic pain management, including evidence for the efficacy of OMT based on systematic searches of the biomedical literature and the ClinicalTrials.gov database. Men, persons with low levels of education, and non-White and Hispanic patients are significantly less likely to have received OMT during their lifetime. Patients with low back and neck pain are most likely to be treated with OMT, and osteopathic manipulative medicine specialty physicians and family medicine physicians most often use OMT. However, many osteopathic physicians report using OMT infrequently. Although OMT is considered safe, based on millions of patient encounters over more than a century, there is limited evidence on its efficacy in treating chronic pain. The lone exception involves chronic low back pain, wherein there is evidence from systematic reviews, a large clinical trial, and observational studies. There is lesser evidence to support cost effectiveness and patient satisfaction associated with OMT for chronic pain. The only clinical practice guideline established by the American Osteopathic Association recommends that OMT should be used to treat chronic low back pain in patients with somatic dysfunction. Given the philosophy of osteopathic medicine, universal training of osteopathic physicians to use OMT, and national guidelines supporting non-pharmacological treatments for chronic pain, it is unclear why OMT use is reported to be remarkably low in physician surveys.

The Spanish Osteopathic Practitioners Estimates and RAtes (OPERA) study: A cross-sectional survey

Background

Despite the growth of the osteopathic profession in Spain in the last few years, reliable information regarding professional profile and prevalence is still lacking. The Osteopathic Practitioners Estimates and RAtes (OPERA) project was developed as a European-based survey dedicated to profiling the osteopathic profession across Europe. The present study aims to describe the characteristics of osteopathic practitioners, their professional profile and the features of their clinical practice.

Methods

A voluntary, validated online-based survey was distributed across Spain between January and May 2018. The survey, composed of 54 questions and 5 sections, was formally translated from English to Spanish and adapted from the original version. Because there is not a unique representative osteopathic professional body in Spain, a dedicated website was created for this study, and participation was encouraged through both specific agreements with national registers/associations and an e-based campaign.

Results

A total of 517 osteopaths participated in the study, of which 310 were male (60%). The majority of respondents were aged between 30–39 years (53%) and 98% had an academic degree, mainly in physiotherapy. Eighty-five per cent of the respondents completed a minimum of four-year part-time course in osteopathy. Eighty-nine per cent of the participants were self-employed. Fifty-eight per cent of them own their clinic, and 40% declared to work as sole practitioner. Thirty-one per cent see an average of 21 to 30 patients per week for 46–60 minutes each. The most commonly used diagnostic techniques are movement assessment, palpation of structures/position and assessment of tenderness and trigger points. Regarding treatment modalities, articulatory/mobilisation techniques followed by visceral techniques and progressive inhibition of neuromuscular structures is often to always used. The majority of patients estimated by the respondents sought osteopathic treatment for musculoskeletal problems mainly localised on the lumbar and cervical region. The majority of respondents manifest a robust professional identity and a collective desire to be regulated as a healthcare profession.

Conclusions

This study represents the first published document to determine the characteristics of the osteopathic practitioners in Spain using large, national data. To date, it represents the most informative document related to the osteopathic community in Spain. It brings new information on where, how, and by whom osteopathy is practised in the country. The information provided could potentially influence the development of the profession in Spain.

The importance of decision intent within descriptions of pragmatic trials

OBJECTIVE

It is now more than 50 years since the concepts of explanatory and pragmatic attitudes toward trials were first discussed by Schwartz and Lellouch in their influential 1967 paper. Since then, there has been increasing focus on design aspects that may be consistent with more pragmatic attitudes within clinical trials, and a number of tools developed to assist investigators prospectively think about their trial design. Researchers have subsequently expressed interest in using these tools retrospectively to characterize trials as pragmatic or explanatory.

RESULTS

We suggest that recent attempts to retrospectively dichotomize trials solely on the basis of quantitative scoring of trial design features are flawed. Instead, we argue that there is a need to consider both the intent and design when assessing the degree of pragmatism within a trial.

CONCLUSION

The practical implication of our suggestion for trial reporting is that investigators should explicitly state the intent of the trial through a clear articulation of the decision that they hope will be informed by the trial results. This should be coupled with a completed PRagmatic-Explanatory Continuum Indicator Summary 2 assessment (or similar) with an explanation of study design choices to appropriately assess whether the study design is consistent with the study intent. We believe this will assist reviewers and knowledge users in making assessments of trials.

Effects of Osteopathic Manual Therapy on Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease: A Randomized Cross-Over Study

Osteopathic manual therapy (OMT) may reduce hyperinflation in patients with chronic obstructive pulmonary disease (COPD) by improving breathing mechanics. The aim of the study was to evaluate the immediate effects of OMT on hyperinflation in stable COPD patients with forced expired volume in 1 s (FEV₁) <50% predicted. Nineteen COPD patients of the median age 68 (IQR 63-72) years and the median FEV₁ 39.8 (IQR 33.4-46.6) % predicted were enrolled into the study. For the first session, patients were randomly assigned to either OMT or sham therapy. During the second session, the two groups of patients were crossed over. Pulmonary function and dyspnea were compared before and after both procedures. Neither pulmonary function nor dyspnea differed significantly before and after OMT or sham procedures. However, 36.7% and 47.4% patients achieved the minimally important difference for residual volume (RV) reduction after both OMT and sham therapy, respectively. Responders to OMT had a greater median (IQR) baseline sense of dyspnea compared to non-responders, assessed on a visual analog scale, of 7.0 (4.5-7.0) vs. 3.0 (0.0-5.0), p = 0.040, respectively. Although OMT did not have an immediate effect on hyperinflation or dyspnea, a subgroup experienced a reduction in RV following OMT and sham therapy. Future studies are needed to identify the characteristics of responders.

Comparative Effectiveness of Chuna Manipulative Therapy for Non-Acute Lower Back Pain: A Multi-Center, Pragmatic, Randomized Controlled Trial

Current evidence on the effectiveness and safety of Chuna manipulative therapy (CMT) for managing non-acute lower back pain (LBP) is insufficient. We investigated the comparative effectiveness and safety of CMT, a Korean style of manipulation, plus usual care (UC) compared to UC alone for non-acute LBP. We conducted a parallel, two-armed, multi-centered, assessor blinded, pragmatic, randomized controlled trial at four major Korean medical hospitals. Overall, 194 patients were randomly allocated to either CMT plus UC (n = 97) or UC alone (n = 97), for six weeks of treatment and six months follow-up. The primary outcome was measured using the numerical rating scale (NRS) of LBP intensity at 7 weeks. Secondary outcomes included NRS of leg pain, Oswestry Disability Index (ODI) for functional disability, patient global impression of change (PGIC) scale, and safety. A total of 194 patients were included in the intention-to-treat analysis, and 174 patients provided complete data for the primary outcome. At 7 weeks, clinically significant differences between groups were observed in the NRS of LBP (CMT + UC: -3.02 ± 1.72, UC: -1.36 ± 1.75, p < 0.001), ODI scores (CMT + UC: -5.65 ± 4.29, UC: -3.72 ± 4.63, p = 0.003), NRS of leg pain (CMT + UC: -2.00 ± 2.33, UC: -0.44 ± 1.86, p < 0.0001), and PGIC (CMT + UC: -0.28 ± 0.85, UC: 0.01 ± 0.66, p = 0.0119). Mild to moderate safety concerns were reported in 21 subjects. CMT plus UC showed higher effectiveness compared to UC alone in patients with non-acute LBP in reducing LBP and leg pain and in improving function with good safety results using a powered sample size and including mid-term follow-up.

Ultrasound Shear Wave Elastography to Assess Osteopathic Manipulative Treatment on the Iliocostalis Lumborum Muscle: A Feasibility Study

OBJECTIVES

To investigate the feasibility of ultrasound shear wave elastography (SWE) in assessing iliocostalis lumborum muscle changes after osteopathic manipulative treatment (OMT).

METHODS

Using a linear array ultrasound transducer (4-9 MHz), we prospectively measured the shear wave velocity (SWV) of bilateral iliocostalis lumborum muscles in 20 patients with low back somatic dysfunction and in 9 age-matched healthy volunteers. The SWV was measured in muscle relaxation and contraction in all participants and immediately before and after OMT in patients. We developed a muscle SWV rate [SWV_contraction - SWV_relaxation )/SWV_relaxation ] and an SWV improvement index [(SWV_pre-OMT - SWV_post-OMT )/SWV_pre-OMT ] for quantifying muscle contractibility and changes in muscle stiffness after OMT. Statistical analyses included an unpaired t test to analyze the difference in the muscle SWV between muscle relaxation and contraction and between somatic dysfunction and nonsomatic dysfunction in patients and healthy volunteers, a paired t test to examine the difference in the SWV and SWV rate before and after OMT, the intraclass correlation coefficient to test intraobserver and interobserver reliability, and Spearman rank correlation to analyze the correlation of changes in the SWV with manual osteopathic assessments.

RESULTS

The mean ages of the patients with low back somatic dysfunction and the healthy volunteers were 28 and 26 years, respectively. The muscle SWV significantly differed between somatic dysfunction and nonsomatic dysfunction in patients and healthy volunteers, between muscle relaxation and contraction, and before and after OMT (P < .001). The SWV improvement index moderately correlated with manual osteopathic assessments (r = 0.68). The interobserver and intraobserver reliability for performing SWE was good (intraclass correlation coefficient, >0.8).

CONCLUSIONS

Our results suggest that SWE is feasible for quantifying the change in muscle stiffness and contractibility after OMT.

Economic evaluation of community acquired pneumonia management strategies: A systematic review of literature

BACKGROUND

Community-acquired pneumonia (CAP) is a major cause of mortality and morbidity worldwide. Efficient use of resources is fundamental for best use of money among the available and novel treatment options for the management of pneumonia. The objective of this study was to systematically review the economic analysis of management strategies of pneumonia.

METHODS

A systematic search was performed using Academic Search Complete, MEDLINE, EconLit, Global health, MEDLINE complete and Embase databases using specific subject headings or key words in May 2018 without restricting publication year. All search results were recorded and any type of economic evaluation for management of CAP was included for detailed review. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used for quality appraisal.

RESULTS

Nineteen studies met the inclusion criteria; ten studies were trial based, five conducted analysis using model based techniques and the rest of the studies were either based on observational, record review or pre-post intervention studies. Most of the studies conducted cost-effectiveness analysis (n = 15) and compared different combinations of antimicrobials. Most were based on developed countries (n = 17), considered adult age groups (n = 16) and used a provider perspective (n = 14). Nine studies reported dominant alternatives (lower cost with higher benefit). Sensitivity analysis was performed by the majority of studies (n = 15). Fourteen studies were assessed as either being excellent, very good or good quality, with no relationship found between publication year and study quality. Methodological variation, type of microbial used, perspective, costs and outcome measures limit the compatibility among the results of the included studies.

CONCLUSION

Economic evaluation of interventions for management of CAP to date supports cost-effectiveness of studied interventions. However, evidence relates largely to antimicrobials choice in older populations in developed countries. Parallel economic evaluation of different management strategies of CAP is recommended for both developed and developing countries to support rigorous and robust comparative economic analysis within health care systems. PROSPERO registration no: CRD42018097174.

Efficacy of osteopathic treatment in patients with stable moderate-to-severe chronic obstructive pulmonary disease: a randomized controlled pilot study

Background This randomized controlled pilot study evaluated the efficacy of osteopathic treatment in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) assessed using spirometry, COPD Assessment Test (CAT) and six minutes walking test (6MWT). The main goals were to improve the quality of life of patients with stable moderate-to-severe COPD, and to revise the parameters of the assessment tests, such as spirometry and 6MWT. Methods The study comprised several phases and patients were divided into two groups: group A (controls) received conventional pharmacological treatment with Indacaterol-Glycopyrronium and, while group B (OMT group) received both traditional therapy and osteopathic manipulative treatment (OMT) at different stages of the study. The osteopathic approach focused on maxillary sinus, vertebral-pleural ligaments, phrenic nerves, ribs, pleura, lungs, bronchi, subclavian muscles, and trapezoid and conoid ligaments. Results Overall, 32 patients were randomized and treated. Patients of the OMT group got better improvements in all tests compared to the control group: spirometry: FVC (p<0.5411), total FEV1 (p<0.5061); CAT: OMT (p<0.0005) - controls (p<0.188) 6MWT OMT (p<0.0038) - controls (p<0.5326). The clinical results collected in phase (T3) confirm those obtained in the first sessions; the results of CAT questionnaire (p<0.0005) and 6MWT (p<O, OO38) highlighted score improvements of patients treated with osteopathy compared to patients in the other group. Conclusions The results showed that the patients with COPD who received the conventional pharmacological treatment in association with the OMT therapy demonstrated a good response to the osteopathic treatment, thus leading to significant improvements in their health and wellbeing, and a better daily functioning.

An investigation of Australian osteopaths' attitudes, skills and utilisation of evidence-based practice: a national cross-sectional survey

Background

Osteopaths are an integral member of the health care team, playing a pivotal role in the provision of care for patients with musculoskeletal disorders. Osteopaths, like other health care providers, are under increasing pressure to deliver evidence-based health care and to improve patient outcomes. However, the extent to which osteopaths engage in evidence-based practice (EBP), particularly in Australia, is not well understood. This study therefore set out to investigate the attitudes, skills and use of EBP, and perceived barriers and enablers of EBP uptake, among osteopaths practicing in Australia.

Methods

National cross-sectional survey of Australian registered osteopaths. Eligible participants were invited by email and other digital media recruitment strategies to complete the online Evidence-Based Practice Attitude and Utilisation Survey (EBASE).

Results

A total of 332 osteopaths completed the survey. The demographic characteristics of respondents were generally consistent with the characteristics of the Australian osteopathy workforce. The respondents were mostly favourable of EBP, with the majority agreeing or strongly agreeing that EBP assists in making decisions about patient care (86.7%) and improves the quality of patient care (75.6%). While most respondents (88.3%) had some training in EBP, most reported a moderate level of perceived skill in EBP. The majority of respondents engaged infrequently (0–5 times) in EBP activities within the last month, and most indicated that a very small or small proportion of their clinical practice was based on clinical research evidence. Leading barriers to the uptake of EBP were lack of time and lack of clinical evidence in osteopathy. Key enablers of EBP uptake were access to the internet and online databases at work, and access to full-text articles and EBP education materials.

Conclusions

Osteopaths participating in the survey were largely supportive of evidence-based practice, yet engaged infrequently in EBP activities. An important next step in this research is to identify suitable strategies that effectively improve EBP uptake in osteopathy, and perchance, improve patient outcomes.

Attitudes, skills and use of evidence-based practice among UK osteopaths: a national cross-sectional survey

BACKGROUND

Evidence-based practice (EBP) is a clinical decision-making framework that supports quality improvement in healthcare. While osteopaths are key providers of musculoskeletal healthcare, the extent to which osteopaths engage in EBP is unclear. Thus, the aim of this cross-sectional study was to investigate UK osteopaths' attitudes, skills and use of EBP, and perceived barriers and facilitators of EBP uptake.

METHODS

UK-registered osteopaths were invited to complete the Evidence-Based Practice Attitude and Utilisation Survey (EBASE) online.

RESULTS

Of the 5200 registered osteopaths in the UK, 9.9% (517/5200) responded to the invitation, and 7.2% (375/5200) completed the EBASE (< 20% incomplete answers). The demographic characteristics of the survey sample were largely similar to those of the UK osteopathy workforce. The osteopaths reported overall positive attitudes towards EBP, with most agreeing that EBP improves the quality of patient care (69.3%) and is necessary for osteopathy practice (76.5%). The majority reported moderate-level skills in EBP, and most (80.8%) were interested in improving these skills. Participating osteopaths typically engaged in EBP activities 1-5 times over the last month. Barriers to EBP uptake included a lack of time and clinical evidence in osteopathy. Main facilitators of EBP included having access to online databases, internet at work, full-text articles, and EBP education materials.

CONCLUSIONS

UK osteopaths were generally supportive of evidence-based practice, had moderate-level skills in EBP and engaged in EBP activities infrequently. The development of effective interventions that improve osteopaths' skills and the incorporation of EBP into clinical practice should be the focus of future research.

Osteopathic care for spinal complaints: A systematic literature review

The aim of the current study was to evaluate the literature examining the impact of osteopathic care for spinal complaints. The bibliographic databases Medline (Pubmed), Web of Science, Embase, and PEDro were searched. In addition, a number of grey literature sources were searched. Only randomized controlled trials conducted in high-income Western countries were considered. Two authors independently screened the titles and abstracts. Primary outcomes included ‘pain’ and ‘functional status’, while secondary outcomes included ‘medication use’ and ‘health status’. It was examined if differences existed related to the treatment protocol and geography (European vs. US studies). Study quality was assessed using the risk of bias tool of the Cochrane Back Review Group. Nineteen studies were included and qualitatively synthesized. Nine studies were from the US, followed by Germany with seven studies. The majority of studies (n = 13) focused on low back pain. In general, mixed findings related to the impact of osteopathic care on primary and secondary outcomes were observed. For the primary outcomes, a clear distinction between US and European studies was found, in favor of the latter ones. Studies were characterized by substantial methodological differences in sample sizes, number of treatments, control groups, and follow-up. In conclusion, there is some evidence suggesting that osteopathic care may be effective for people suffering from spinal complaints. Further studies with larger study samples and assessment of long-term impact are required to further increase the evidence-based knowledge of the potential of osteopathic care for individuals suffering from spinal complaints.

A workforce survey of Australian osteopathy: analysis of a nationally-representative sample of osteopaths from the Osteopathy Research and Innovation Network (ORION) project

Background

Limited information is available regarding the profile and clinical practice characteristics of the osteopathy workforce in Australia. This paper reports such information by analysing data from a nationally-representative sample of Australian osteopaths.

Methods

Data was obtained from a workforce survey of Australian osteopathy, investigating the characteristics of the practitioner, their practice, clinical management features and perceptions regarding research. The survey questionnaire was distributed to all registered osteopaths across Australia in 2016 as part of the Osteopathy Research and Innovation Network (ORION) project.

Results

A total of 992 Australian osteopaths participated in this study representing a response rate of 49.1%. The average age of the participants was 38.0 years with 58.1% being female and the majority holding a Bachelor or higher degree qualification related to the osteopathy professional. Approximately 80.0% of the osteopaths were practicing in an urban area, with most osteopaths working in multi-practitioner locations, having referral relationships with a range of health care practitioners, managing patients a number of musculoskeletal disorders, and providing multi-model treatment options.

Conclusions

A total of 3.9 million patients were estimated to consult with osteopaths every year and an average of approximate 3.0 million hours were spent delivering osteopathy services per year. Further research is required to provide rich, in-depth examination regarding a range of osteopathy workforce issues which will help ensure safe, effective patient care to all receiving and providing treatments as part of the broader Australian health system.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3158-y) contains supplementary material, which is available to authorized users.

The perceptions and experiences of osteopathic treatment among cancer patients in palliative care: a qualitative study

PURPOSE

This research aimed to explore the perceptions and experiences of cancer patients receiving osteopathic treatment as a complementary therapy when it is used in addition to conventional treatment for cancer pain.

METHODS

This qualitative study employed semi structured interviews of cancer patients in a palliative care unit in Lyon, France, who received treatment from an osteopath alongside their conventional cancer treatment. We analysed data using grounded theory and qualitative methods.

RESULTS

We interviewed 16 patients. The themes identified through the analysis included a low awareness of osteopathy among the population and an accompanying high level of misconceptions. The benefits of osteopathy were described as more than just the manual treatments with participants valuing osteopathy as a holistic, meditative, and non-pharmaceutical approach. Participants also described the osteopathic treatments as assisting with a range of cancer-related health complaints such as pain, fatigue, and sleep problems. Offering osteopathic treatment at an accessible location at low or no cost were identified by participants as enablers to the continued use of osteopathy.

CONCLUSIONS

The findings of this study provides preliminary data which suggests, when delivered alongside existing medical care, osteopathy may have health benefits for patients with complex conditions such as cancer.

Profile of osteopathic practice in Spain: results from a standardized data collection study

Background

There is limited research regarding patients’ profiles and consumer attitudes and habits of osteopathy in Spain. The purpose of this study was to profile patients who regularly receive osteopathic care in Spain using an internationally developed standardized data collection tool.

Method

During the period between April 2014 and December 2015, a UK-developed standardized data collection tool was distributed to Spanish osteopaths who voluntarily agreed to participate in this cross-sectional study.

Results

Thirty-six osteopaths participated in this study and returned a total of 314 completed datasets. Of 314 patients, 61% were women and 39% were men, with a mean age of 40 years (SD 17.02 years, range 0 to 83 years). Forty-four percent were full-time salaried workers, and in 78% of cases, receiving osteopathic treatment was the patient’s own choice. Chronic spinal pain presentations were the most frequent reasons for consultation. Seventy-five percent of patients presented with a coexisting condition, mainly gastrointestinal disorders and headaches. The main treatment approach consisted of mobilization techniques, followed by soft tissue, cranial and high velocity thrust techniques. Improvement or resolution of the complaint was experienced by 93% of patients after a small number of sessions. Adverse events were minor and occurred in 7% of all cases.

Conclusion

This is the first study carried out in Spain analyzing the profile of patients who receive osteopathic care. The typical patient who receives osteopathic care in Spain is middle-aged, presents mainly with chronic spinal pain, and voluntarily seeks osteopathic treatment. Osteopathic treatment produces a significant improvement in the majority of cases with a low rate of minor adverse events reported.

Electronic supplementary material

The online version of this article (10.1186/s12906-018-2190-0) contains supplementary material, which is available to authorized users.

Reliability of diagnosis and clinical efficacy of visceral osteopathy: a systematic review

Background

In 2010, the World Health Organization published benchmarks for training in osteopathy in which osteopathic visceral techniques are included. The purpose of this study was to identify and critically appraise the scientific literature concerning the reliability of diagnosis and the clinical efficacy of techniques used in visceral osteopathy.

Methods

Databases MEDLINE, OSTMED.DR, the Cochrane Library, Osteopathic Research Web, Google Scholar, Journal of American Osteopathic Association (JAOA) website, International Journal of Osteopathic Medicine (IJOM) website, and the catalog of Académie d’ostéopathie de France website were searched through December 2017. Only inter-rater reliability studies including at least two raters or the intra-rater reliability studies including at least two assessments by the same rater were included. For efficacy studies, only randomized-controlled-trials (RCT) or crossover studies on unhealthy subjects (any condition, duration and outcome) were included. Risk of bias was determined using a modified version of the quality appraisal tool for studies of diagnostic reliability (QAREL) in reliability studies. For the efficacy studies, the Cochrane risk of bias tool was used to assess their methodological design. Two authors performed data extraction and analysis.

Results

Eight reliability studies and six efficacy studies were included. The analysis of reliability studies shows that the diagnostic techniques used in visceral osteopathy are unreliable. Regarding efficacy studies, the least biased study shows no significant difference for the main outcome. The main risks of bias found in the included studies were due to the absence of blinding of the examiners, an unsuitable statistical method or an absence of primary study outcome.

Conclusions

The results of the systematic review lead us to conclude that well-conducted and sound evidence on the reliability and the efficacy of techniques in visceral osteopathy is absent.

Trial registration

The review is registered PROSPERO 12th of December 2016. Registration number is CRD4201605286.

Electronic supplementary material

The online version of this article (10.1186/s12906-018-2098-8) contains supplementary material, which is available to authorized users.

The Australian Complementary Medicine Workforce: A Profile of 1,306 Practitioners from the PRACI Study

OBJECTIVES

This study aims to describe the Australian complementary medicine (CM) workforce, including practice and professional characteristics.

DESIGN

National cross-sectional survey.

SETTINGS/LOCATION

Australia.

SUBJECTS

Any individual who self-identified as a practitioner qualified in any one of 14 CM professions and working in any state or territory of Australia was eligible to participate in the survey.

INTERVENTIONS

A 19-item online survey was developed following a review of existing CM workforce data and in alignment with other CM workforce survey projects in progress at the time. The survey items were presented under three main constructs: demographic characteristics, professional characteristics, and practice characteristics.

STATISTICAL ANALYSIS

Descriptive statistical analysis, including frequencies and percentages, of multiple choice survey items was used. Open response items were analyzed to determine the mean, standard deviation (SD), minimum, and maximum. The demographic data were evaluated for representativeness based on previously reported CM workforce figures.

RESULTS

The survey was completed by 1306 CM practitioners and was found to be nationally representative compared with the most recent registrant data from the Chinese Medicine Board of Australia. Participants primarily practiced in the most populous Australian states and worked in at least one urban clinical location. Most participants held an Advanced Diploma qualification or lower, obtained their qualification ten more years ago, and practiced in a clinical environment alongside at least one other practitioner from another health profession. Participants reported diverse clinical practice specialties and occupational roles. Per week, participants worked an average of 3.7 days and treated 23.6 clients.

CONCLUSIONS

The results from this survey of practitioners from most complementary professions in Australia provide new insights into the national complementary medicine workforce. Further exploration of the CM workforce is warranted to inform all who provide patient care and develop health policy for better patient and public health outcomes.