Osteopathic Manipulative Treatment
Osteopathic medicine originated as a 19th century alternative medical approach emphasizing the physical manipulation of the neuromusculoskeletal system. Today, doctors of osteopathic medicine study and practice the same types of medical and surgical techniques as their conventional MD colleagues with the addition of osteopathic manipulative treatment (OMT).
History of Osteopathic Manipulative Treatment
Osteopathic medicine was founded in 1874 by Andrew Taylor Still, a US physician. Physicians educated in this method were called doctors of osteopathy. Subsequently, however, schools of osteopathic medicine incorporated much of the same curriculum taught in conventional medical schools, while uniquely preserving training in OMT. Today, these physicians are now called doctors of osteopathic medicine (DO). The osteopathic medicine license is legally equivalent to that of MD. Like MDs, DOs complete 4 years of medical education followed by 3-8 years of graduate medical education.
Forms of Osteopathic Manipulative Treatment
Osteopathic medicine and chiropractic techniques overlap, but they are not identical. As a general rule, chiropractors focus most of their attention on the spine, while osteopathic physicians devote their efforts throughout the musculoskeletal system, including soft tissues and joints outside the spine.
There are several specific osteopathic techniques in wide use. Some of the more popular include:
High Velocity/Low Amplitude Technique (HVLA)
HVLA is used to release restrictions in the movement by applying a rapid, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint. It is also known as "thrust technique."
Muscle Energy Technique
In muscle energy technique, the patient voluntarily moves a body part from a precisely controlled position against a defined resistance by the osteopathic physician. The purpose is to progressively improve mobility of a joint.
Strain-counterstrain Technique (Jones Counterstrain)
Strain-counterstrain technique (Jones counterstrain) involves finding tender points and then passively manipulating associated joints until the tenderness decreases. Like muscle-energy work, strain-counterstrain progressively increases range of motion and, it is hoped, decreases muscle spasm and pain.
Myofascial release focuses on the fascial tissues that surround muscles. The practitioner palpates the fascial tissues, looking for a subtle sensation that indicates the tissues are ready to "unwind," and then helps the tissue to follow a pattern of spontaneous movement. This process is repeated over several sessions until a full release is achieved.
A small randomized trial with 63 patients compared two myofascial release techniques to a control group. Myofascial release treatments resulted in fewer headaches for the 4-week trial period compared to the control group.22
Venous insufficiency occurs when blood pools in the deep veins of the leg, stretching the vein wall and injuring its lining. Typically, the legs begin to feel heavy, swollen, achy, and tired. The addition of myofascial release to venous return therapy was associated with improved pain relief in a randomized trial of 65 post-menopausal women when compared to venous return therapy alone.24
Osteopathy in the Cranial Field
Osteopathy in the cranial field (sometime called cranial-sacral therapy) is a specialized technique based on the belief that the tissues surrounding the brain and spinal cord undergo a rhythmic pulsation. This “cranial rhythm” is supposed to cause subtle movements of the bones of the skull. A practitioner of cranial-sacral therapy is able to detect these rhythms and gently manipulate the bones in time with it. The existence of such cranial rhythms is controversial.11
What Is Osteopathic Manipulative Treatment Used For?
At the discretion of the DO, OMT is used as a key component of the management plan in conjunction with medications, surgery, education, and lifestyle counseling. OMT is primarily used to treat musculoskeletal pain conditions, such as back pain, shoulder pain, arthritis, and tension headaches. Some advocates of OMT believe that it has numerous other benefits, including:
What Is the Scientific Evidence for Osteopathic Manipulative Treatment?
There is little evidence as yet that OMT is helpful for the treatment of any medical condition. There are several possible reasons for this, but one is fundamental: Even with the best of intentions, it is difficult to properly ascertain the effectiveness of a hands-on therapy like OMT.
Only one form of study can truly prove that a treatment is effective—the double-blind, placebo-controlled trial. (For more information on why such studies are so crucial, see Why Does This Database Rely on Double-blind Studies?) However, it isn’t possible to fit OMT into a study design of this type. What could researchers use as a placebo OMT? And how could they make sure that both participants and practitioners would be kept in the dark regarding who is receiving real OMT and who is receiving fake OMT? The fact is, they can’t.
Because of these problems, all studies of OMT fall short of optimum design. Many have compared OMT against no treatment. However, studies of that type cannot provide reliable evidence about the efficacy of a treatment: If a benefit is seen, there is no way to determine whether it was a result of OMT specifically or just attention generally. (Attention alone will almost always produce some reported benefit.)
More meaningful trials used fake osteopathy for the control group. Such studies are single-blind because the practitioner is aware of applying phony treatment. However, this design can introduce potential bias in the form of subtle unconscious communication between practitioner and patient.
Still other studies have simply involved giving people OMT and seeing if they improve. These trials are particularly meaningless; it has long since been proven that both participants and examining physicians will think, at least, that they observe improvement in people given a treatment, whether or not the treatment does anything on its own; such studies are not reported here.
Given these caveats, the following is a summary of what science knows about the effects of OMT.
Possible Effects of Osteopathic Manipulative Treatment
Most studies of OMT have involved its potential use for various pain conditions.
In a study of 183 people with neck pain, use of osteopathic methods provided greater benefits than standard physical therapy or general medical care.12 Participants receiving OMT showed faster recovery and experienced fewer days off work. OMT appeared to be less expensive overall than the other two approaches; however, researchers strictly limited the allowed OMT sessions, making direct cost comparisons questionable. Another study evaluated a rather ambitious combined therapy for the treatment of chronic pain resulting from whiplash injury (craniosacral therapy along with Rosen Bodywork and Gestalt psychotherapy).13 The results failed to find this assembly of treatments more effective than no treatment.
In a 14-week, single-blind study of 29 elderly people with shoulder pain, real OMT proved more effective than placebo OMT.1 Although participants in both groups improved, those in the treated group showed relatively greater increase in range of motion in the shoulder. And, in a larger study of 150 adults with shoulder complaints, researchers found that adding manipulative therapy to usual care improved shoulder and neck pain at 12 weeks.18
In a small randomized, placebo-controlled trial researchers used oscillating-energy manual therapy, an osteopathic technique based on the principle of craniosacral therapy, to treat 23 subjects with chronic tendonitis of the elbow (tennis elbow or lateral epicondylitis). Subjects in the treatment group showed significant improvement in grip strength, pain intensity, function, and activity limitation due to pain. These results however, are limited by the small size of the study and the fact that the therapist delivering the treatment could not be blinded.17
Twenty-four women with fibromyalgia were divided into five groups: standard care, standard care plus OMT, standard care plus an educational approach, standard care plus moist heat, and standard care plus moist heat and OMT.2 The results indicate that OMT plus standard care is better than standard care alone, and that OMT is more effective than less specific treatments, such as moist heat or general education. However, because this was not a blinded study (participants knew which group they were in), the results can’t be taken as reliable. In another study, 93 women (average age 53) with fibromyalgia were randomized to receive sham treatment or craniosacral therapy (one-hour sessions twice a week for 20 weeks).19 The women in the craniosacral therapy group experienced a decrease in pain at 20 weeks, which persisted for at least one year. In another randomized trial, 94 people with fibromyalgia received either myofascial release or sham therapy for 40 sessions (20 weeks).21 At the 6-month follow-up, the people in the treatment group reported less pain and more physical ability. But, only some of these results lasted until the 1-year follow-up.
A study of 28 people with tension headaches compared one session of OMT against two forms of sham treatment and found evidence that real treatment provided a greater improvement in headache pain.3
A small randomized controlled trial with 63 patients compared two myofascial release techniques to a control group. Myofascial release treatments resulted in fewer headaches for the 4-week trial period compared to the control group.22 Similar results were found in a randomized trial including 62 people with tension headache. The twice-weekly myofascial head and neck massages were associated with fewer headaches when compared to an ultrasound or waitlist.26
OMT was tested for the prevention of migraines. Though they are both referred to as headaches, tension headaches and migraines have different trgigers. OMT is a reasonable treatment for tension headaches since it is associated with musculoskeletal tension but migraine causes are more often associated with changes in nervous system or chemical changes. However, in a randomized trial of 105 adults with chronic migraines (average 22.5 headaches per month), OMT with medication was associated with a significant reduction in rescue medication, migraine days per month, severity of pain, and functional disabilitycompared to sham OMT with medication and a control group taking medication only. Patients had eight 30-minute sessions using a combination techniques.27
OMT has shown some promise for the treatment of back pain,4,5 including a randomized trial of 455 patients. The trial assessed the effects of 6 OMT sessions over 8 weeks compared to sham treatments. At 12 weeks, OMT was associated with moderate or substantial pain reduction compared to sham OMT. OMT also reduced the use of prescription pain medications.25
However, one of the best-designed trials failed to find it a superior alternative to conventional medical care. In this 12-week study of 178 people, OMT proved no more effective than standard treatment for back pain.6 Another study, this one enrolling 199 people and following them for 6 months, failed to find OMT more effective than fake OMT.14 This study also included a no-treatment group; both real and fake OMT were more effective than no treatment.
A much smaller study reportedly found that muscle energy technique enhances recovery from back pain, but this study does not appear to have used a meaningful placebo treatment.15
Researchers analyzed 4 studies investigating the benefits of manual therapy (including massage therapy, joint mobilization, and manipulation) for osteoarthritis of the hip or knee.20 The results were inconclusive. Although one of the studies (involving 68 people) did find that massage therapy helped to improve pain and function, it was compared to no intervention rather than another treatment or a placebo.
Some studies have evaluated the potential benefits of OMT for speeding healing in people recovering from surgery or serious illness. The best of these studies compared OMT against light touch in 58 elderly people hospitalized for pneumonia.7 The results indicate that use of osteopathy aided recovery.
In a much less meaningful study, OMT was compared to no treatment in people recovering from knee or hip surgery.8 While the people receiving OMT recovered more quickly, these results mean very little, since, as noted above, any form of attention should be expected to produce greater apparent benefits than no attention.
A weak study suggests that OMT might also be helpful for people hospitalized with pancreatitis.9
A small study found some evidence that OMT might be helpful for childhood asthma.16
OMT showed improvement in 6-minute walk test distance in a small randomized trial of 20 patients with stable chronic obstructive pulmonary disease. Distance in patients in the OMT group improved on average by 72.5 meters compared to 23.7 meters for patients in the sham OMT group.23
Finding a Qualified Practitioner of Osteopathic Manipulative Treatment
At the current rate of growth, it is estimated that more than 100,000 DOs will be in active medical practice by the year 2020. Many DOs who use OMT have been certified by the American Osteopathic Board of Neuromusculoskeletal Medicine. Osteopathic family physicians are the highest utilizers of OMT. People can find a DO by searching online at sites like the http://www.osteopathic.org/Pages/default.aspx or the http://www.academyofosteopathy.org/.
Be aware that some health practitioners may use the terms osteopathy or osteopath but are not licensed osteopathic physicians. Some areas outside of the United States also have osteopath training that does not include MD training. Look for the terms Osteopathic Physician or DO and ask your doctor or practitioner about their training before beginning treatments.
Safety of Osteopathic Manipulative Treatment
Most forms of OMT, because of their gentle nature, are believed to be quite safe. However, mild short-term, self-limited discomfort may occur immediately following treatment.10 Rarely has there been a report of serious injury as a result of OMT.
1. Knebl JA, Shores JH, Gamber RG, et al. Improving functional ability in the elderly via the Spencer technique, an osteopathic manipulative treatment: a randomized, controlled trial. J Am Osteopath Assoc. 2002;102:387-396.
2. Gamber RG, Shores JH, Russo DP, et al. Osteopathic manipulative treatment in conjunction with medication relieves pain associated with fibromyalgia syndrome: results of a randomized clinical pilot project. J Am Osteopath Assoc. 2002;102:321-325.
3. Hoyt WH, Shaffer F, Bard DA, et al. Osteopathic manipulation in the treatment of muscle-contraction headache. J Am Osteopath Assoc. 1979;78:322-325.
4. Newswanger DL, Patel AT, Ogle A. Osteopathic medicine in the treatment of low back pain. Am Fam Physician. 2000;62:2414-2415.
5. Koes BW, Assendelft WJ, van der Heijden GJ, et al. Spinal manipulation for low back pain. An updated systematic review of randomized clinical trials. Spine. 1996;21:2860-2873.
6. Andersson GBJ, Lucente T, Davis AM, et al. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med. 1999;341:1426-1431.
7. Noll DR, Shores JH, Gamber RG, et al. Benefits of osteopathic manipulative treatment for hospitalized elderly patients with pneumonia. J Am Osteopath Assoc. 2000;100:776-782.
8. Jarski RW, Loniewski EG, Williams J, et al. The effectiveness of osteopathic manipulative treatment as complementary therapy following surgery: a prospective, match-controlled outcome study. Altern Ther Health Med. 2000;6:77-81.
9. Radjieski JM, Lumley MA, et al. Effect of osteopathic manipulative treatment on length of stay for pancreatitis: a randomized pilot study. J Am Osteopath Assoc. 1998;98:264-272.
10. Knebl JA, Shores JH, Gamber RG, et al. Improving functional ability in the elderly via the Spencer technique, an osteopathic manipulative treatment: a randomized, controlled trial. J Am Osteopath Assoc. 2002;102:387-396.
11. Hartman SE, Norton JM. Craniosacral therapy is not medicine. Phys Ther. 2002;82:1146-1147.
12. Korthals-de Bos IB, Hoving JL, van Tulder MW, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial [electronic version]. BMJ. 2003;326:911.
13. Ventegodt S, Merrick J, Andersen NJ, et al. A Combination of Gestalt Therapy, Rosen Body Work, and Cranio Sacral Therapy did not help in Chronic Whiplash-Associated Disorders (WAD) - Results of a Randomized Clinical Trial. ScientificWorldJournal. 2005;4:1055-1068.
14. Licciardone JC, Stoll ST, Fulda KG, et al. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine. 2003;28:1355-1362.
15. Wilson E, Payton O, Donegan-Shoaf L, Dec K. Muscle energy technique in patients with acute low back pain: a pilot clinical trial. J Orthop Sports Phys Ther. 2003;33:502-512.
16. Guiney PA, Chou R, Vianna A, et al. Effects of osteopathic manipulative treatment on pediatric patients with asthma: a randomized controlled trial. J Am Osteopath Assoc. 2005;105:7-12.
17. Nourbakhsh MR, Fearon FJ. The effect of oscillating-energy manual therapy on lateral epicondylitis: a randomized, placebo-control, double-blinded study. J Hand Ther. 2008;21:4-14.
18. Bergman GJ, Winters JC, Groenier KH, et al. Manipulative therapy in addition to usual care for patients with shoulder complaints: results of physical examination outcomes in a randomized controlled trial. J Manipulative Physiol Ther. 2010 Feb;33(2):96.
19. Castro-Sánchez AM, Matarán-Peñarrocha GA, Sánchez-Labraca N, et al. A randomized controlled trial investigating the effects of craniosacral therapy on pain and heart rate variability in fibromyalgia patients. Clin Rehabil. 2011;25(1):25-35.
20. French HP, Brennan A, White B, Cusack T. Manual therapy for osteoarthritis of the hip or knee - a systematic review. Man Ther. 2011;16(2):109-17.
21. Castro-Sánchez AM, Matarán-Peñarrocha GA, Arroyo-Morales M, Saavedra-Hernández M, Fernández-Sola C, Moreno-Lorenzo C. Effects of myofascial release techniques on pain, physical function, and postural stability in patients with fibromyalgia: a randomized controlled trial. Clin Rehabil. 2011;25(9):800-813
22. Ajimsha MS. Effectiveness of direct vs indirect technique myofascial release in the management of tension-type headache. J Bodyw Mov Ther 2011 Oct;15(4):431.
23. Zanotti E, Berardinelli P, Bizzarri C. Osteopathic manipulative treatment effectiveness in severe chronic obstructive pulmonary disease: a pilot study. Complement Ther Med. 2012;20(1-2):16-22.
24. Ramos-González E, Moreno-Lorenzo C, et al. Comparative study on the effectiveness of myofascial release manual therapy and physical therapy for venous insufficiency in postmenopausal women. Complement Ther Med. 2012 Oct;20(5):291-298.
25. Licciardone JC, Minotti DE, et al. Osteopathic manual treatment and ultrasound therapy for chronic low back pain: a randomized controlled trial. Am Fam Med 2013;11(2):122-129.
26. Moraska AF, Stenerson L, et al. Myofascial trigger point-focused head and neck massage for recurrent tension-type headache: A randomized, placebo-controlled clinical trial. Clin J Pain. 2015;31(2):159-168.
27. Cerritelli F, Ginevri L, Messi G, et al. Clinical effectiveness of osteopathic treatment in chronic migraine: 3-Armed randomized controlled trial. Complement Ther Med. 2015;23(2):149-156.
Last reviewed September 2014 by EBSCO CAM Review Board
Last Updated: 7/16/2015
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