Marti-Salvador M, Hidalgo-Moreno L, Domenech-Fernandez J, et al. Osteopathic Manipulative Treatment Including Specific Diaphragm Techniques Improves Pain and Disability in Chronic Nonspecific Low Back Pain: A Randomized Trial. Arch Phys Med Rehabil. 2018 Sep;99(9):1720-1729. doi: 10.1016/j.apmr.2018.04.022. Epub 2018 May 19. (Original study)

OBJECTIVE: To investigate the effects of an osteopathic manipulative treatment (OMT), which includes a diaphragm intervention compared to the same OMT with a sham diaphragm intervention in chronic nonspecific low back pain (NS-CLBP).

DESIGN: Parallel group randomized controlled trial.

SETTING: Private and institutional health centers.

PARTICIPANTS: Participants (N=66) (18-60y) with a diagnosis of NS-CLBP lasting at least 3 months.

INTERVENTIONS: Participants were randomized to receive either an OMT protocol including specific diaphragm techniques (n=33) or the same OMT protocol with a sham diaphragm intervention (n=33), conducted in 5 sessions provided during 4 weeks.

MAIN OUTCOME MEASURES: The primary outcomes were pain (evaluated with the Short-Form McGill Pain Questionnaire [SF-MPQ] and the visual analog scale [VAS]) and disability (assessed with the Roland-Morris Questionnaire [RMQ] and the Oswestry Disability Index [ODI]). Secondary outcomes were fear-avoidance beliefs, level of anxiety and depression, and pain catastrophization. All outcome measures were evaluated at baseline, at week 4, and at week 12.

RESULTS: A statistically significant reduction was observed in the experimental group compared to the sham group in all variables assessed at week 4 and at week 12 (SF-MPQ [mean difference -6.2; 95% confidence interval, -8.6 to -3.8]; VAS [mean difference -2.7; 95% confidence interval, -3.6 to -1.8]; RMQ [mean difference -3.8; 95% confidence interval, -5.4 to -2.2]; ODI [mean difference -10.6; 95% confidence interval, -14.9 to 6.3]). Moreover, improvements in pain and disability were clinically relevant.

CONCLUSIONS: An OMT protocol that includes diaphragm techniques produces significant and clinically relevant improvements in pain and disability in patients with NS-CLBP compared to the same OMT protocol using sham diaphragm techniques.

Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Physician 4 / 7
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Comments from MORE raters

Physician rater

This is of interest to physical therapists and other manual practitioners. It's a fairly complicated protocol. The effect size was very large for this type of intervention. I would certainly want to see this study replicated before advising implementation of this protocol in practice.

Physician rater

There's more to pain management in cases of non-specific chronic pain than simply medications.

Physician rater

When I refer someone for physiotherapy, it´s the rehab doctor or the physiotherapist the one who decides what therapy is best. Therefore, it should be better known to Physiotherapists than to Primary Care doctors.

Physician rater

Small study groups and co-interventions not controlled and only short-term follow-up. However, most important is that the rationale with the treatment method and low-back pain is missing.

Rehab Clinician (OT/PT) rater

I was put off reading the whole article due the naivety of the introduction, including the following phrases: "in relation to mechanical low back pain," "difficult to diagnose," wide range of aetiologies," "often associated with respiratory disorders." The osteopathic model delivered within a private care model is not useful as a model for delivery of publicly funded and evaluated care for MLBP.

Rehab Clinician (OT/PT) rater

It's interesting to see OMT being investigated by other disciplines (PT). While the results of this randomised intervention appear to have utility, I am inclined to consider that the study does not adequately rebut results attributable to, or influenced by chance, bias or confounding. The apparent absence of a valid comparable control and blinding are a significant concern.

Rehab Clinician (OT/PT) rater

It makes a great deal of sense that dysfunction of the diaphragm is closely linked with NS-CLBP but I am not sure how many of us actively treat the diaphragm when treating LBP. The article is very interesting. I wish there was a better description of the techniques they used so that it was easier to reproduce them. It is worth your time to read it.

Rehab Clinician (OT/PT) rater

This is a well described techniques with diagrams.
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