Most osteopaths are trained in pediatric care, and osteopathic manipulative treatment (OMT) is available for many pediatric conditions. The objective of this systematic review was to critically evaluate the effectiveness of OMT as a treatment of pediatric conditions.
Eleven databases were searched from their respective inceptions to November 2012. Only randomized clinical trials (RCTs) were included, if they tested OMT against any type of control in pediatric patients. Study quality was critically appraised by using the Cochrane criteria.
Seventeen trials met the inclusion criteria. Five RCTs were of high methodological quality. Of those, 1 favored OMT, whereas 4 revealed no effect compared with various control interventions. Replications by independent researchers were available for 2 conditions only, and both failed to confirm the findings of the previous studies. Seven RCTs suggested that OMT leads to a significantly greater reduction in the symptoms of asthma, congenital nasolacrimal duct obstruction (posttreatment), daily weight gain and length of hospital stay, dysfunctional voiding, infantile colic, otitis media, or postural asymmetry compared with various control interventions. Seven RCTs indicated that OMT had no effect on the symptoms of asthma, cerebral palsy, idiopathic scoliosis, obstructive apnea, otitis media, or temporomandibular disorders compared with various control interventions. Three RCTs did not perform between-group comparisons. The majority of the included RCTs did not report the incidence rates of adverse effects.
The evidence of the effectiveness of OMT for pediatric conditions remains unproven due to the paucity and low methodological quality of the primary studies.
Comments
Re:Use of Osteopathic Manipulative Treatment (OMT) for Pediatrics
I graduated from the Des Moines University of Osteopathic Medicine in 1965. I had a significant educational experience during those academic four study years to consider incorporating OMT across a broad range of clinical issues. During my internship year to follow at Zieger & Botsford Hospitals, Detroit and following Pediatric residency in the Detroit Osteopathic Hospital Corporation, I had many clinical opportunities to successfully consider and employ therapeutically OMT interventions while caring for adult and pediatric patients. After entering private clinical specialty practice I was able to successfully administer osteopathic interventions to clinical conditions arising from biomechanical injury, and especially in pulmonary issues including acute bronchial asthma, and other primarily pulmonary issues ie bronchial/pneumonitic. Interventions were taught to caring nursing and medical staff individuals, as well as adult family members. These OMT interventions were not seen by me as an exclusive alternative to perhaps more traditional therapeutic measures, but as a complementary, and at times solo intervention in the care of both ambulatory and hospitalized patients, neonatal, infant and pediatric /adolescent age groups. Regretfully I sense today in meeting with recent graduates that while some sense that it can assist care of their patients, but either that they have insufficient knowledge, or are disinclined to appear as a "non- traditional" physician and while they appear to endorse it's value on a one to one basis, these graduates infrequently provide OMT care interventions in the primary care or pediatric specialty care arenas, and that they may not have the opportunity to refer to Osteopathic physicians in their areas to offer this care.
Conflict of Interest:
None declared
Use of Osteopathic Manipulative Treatment (OMT) for Pediatrics
After reading "Osteopathic Manipulative Treatment for Pediatric Conditions: A Systematic Review"1 by Paul Posadzki, PhD; Myeong Soo Lee, PhD; and Edzard Ernst, MD, I am concerned by the authors' conclusion about the use of osteopathic manipulative treatment (OMT) in pediatrics.
The authors cite "low methodological quality and paucity of the primary studies" as factors in reaching their conclusion that the "effectiveness of OMT for pediatric conditions remains unproven" and "OMT cannot be regarded as an effective therapy for pediatric conditions, and osteopaths should not claim otherwise."
My concerns are twofold. One is that the selection of articles for review in this particular article is misleading, and second is the utilization of random controlled trials (RCTs) in systematic reviews (SRs) does not tell the whole story. The authors describe the differences between osteopathic physicians (DOs) trained in the United States and nonphysician osteopaths from other countries, but then combine RCTs from both traditions of health care without distinction. That the implementation of OMT may not be standardized in each country and therefore lead to inaccurate comparisons is not addressed in this SR. The authors point out that four of the RCTs were done by nonosteopaths as the lead authors, and they include two articles that are in abstract form only further raising questions about conclusions made in the SR.
DOs trained in the United States are fully licensed physicians whereas osteopaths are health care providers trained elsewhere who do not qualify for licensure for the unlimited practice of medicine. Since the scope of practice is different outside the United States, the findings about the application of OMT in other countries are not applicable when compared with the osteopathic medical care provided in the United States.
The standard of practice of osteopathic medicine in the United States insures public safety through adherence to the highest standards of medical practice for all patients including the use of OMT in pediatrics. Furthermore, while typical of SRs, this SR gives an incomplete picture of the status of OMT in pediatrics, especially to the lay public. There is research at levels of evidence below RCTs on the evidence pyramid, such as cohort studies and case-controlled studies, and there is abundant clinical practice experience supporting the benefit of OMT in pediatrics by DOs in the United States.
The one redeeming value of this SR, in my opinion, is that it does point out several research design issues that need to be accounted for in future research publications on OMT in general and pediatrics in particular, including the description of the OMT protocol and the reporting of adverse events or side effects. With this in mind, editors of The Journal of the American Osteopathic Association recognize the need to advance the osteopathic medical profession through new research initiatives, which continues to progress.2
Sincerely,
Hollis H. King, DO, PhD The Journal of the American Osteopathic Association Editorial Advisory Board Member
REFERENCES 1. Posadzki P, Lee MS, Ernst E. Osteopathic manipulative treatment for pediatric conditions: a systematic review. Pediatrics 2013; 132(1): 140- 52. 2. Seffinger, M. Advancing osteopathic medicine through research. Journal of the American Osteopathic Association 2012; 112(9):589-90.
Conflict of Interest:
None declared
Osteopathic Manipulative Treatment (OMT) for Pediatrics
We wish to thank Drs. Posadzki, Lee and Ernst for conducting a broad analysis of international osteopathic research addressing a number of pediatric conditions.1 Authors cited a number of methodological limitations in the studies reviewed, such as inadequate effect size and randomization, and concluded that the effectiveness of osteopathic manipulative treatment (OMT) for pediatric conditions remains unproven. The importance of conducting high quality research is essential, and this review provides further motivation for the osteopathic research community to investigate the effectiveness of OMT in a more rigorous fashion.
Growth within the osteopathic profession has been steady. The number of licensed Doctors of Osteopathic Medicine (D.O.) in the United States is now 63,045 (7.2% of all licensed physicians).2 Last year, 803 D.O. pediatric resident physicians participated in ACGME training programs, representing 9.7% of all pediatric resident trainees in the United States.3 With this growth comes concern about the quality and quantity of research required to demonstrate the effectiveness of OMT. Many leaders within the osteopathic profession have articulated a need to increase research efforts and initiatives.4 In response to this call for more robust research, a number of recent research initiatives have been developed.
Posadzki, Lee, and Ernest exposed a previously recognized deficiency in osteopathic research. However, we believe their methodology was limited, and therefore, the conclusion was overstated. First, the sample was too heterogeneous to make any meaningful comparisons or conclusions. Of the 17 studies included in the final review, 15 different clinical conditions were investigated, and each study involved a different combination of OMT modalities.1 It is important to understand that OMT is not one form of treatment, but rather a collection of hundreds of treatment modalities. Investigating a constellation of treatment modalities and their effect on a constellation of pediatric conditions is therefore not practical or appropriate. A corollary investigation would be a systematic review of oral medication treatments for pediatric conditions, which too would be exceedingly broad for a meaningful analysis. Second, while the described literature review seemed well described, it is likely that a few significant studies were overlooked. Perhaps involving a D.O. in the systematic review process would address this limitation. Third, authors neglected to consider variation between clinical researchers. Significant differences exist in how osteopathic practitioners learn, use and incorporate OMT in the care of patients around the world.5 Eight different countries were represented in the sample of seventeen.1 Because osteopathic practitioners from different countries are trained and licensed differently, the use and application of OMT is likely not standardized. Comparing findings of research conducted in eight different countries is therefore not likely to be practical or meaningful.
We congratulate authors for emphasizing the need for increasing research related to OMT and pediatrics. However, we believe their analysis was incomplete and their conclusion was premature and overstated. The pediatric osteopathic community has recognized a need to conduct high quality clinically-oriented research, and with reinvigorated efforts, we look forward to providing evidence of the effectiveness of OMT for pediatric conditions.
References
1.Posadzki P, Lee MS, Ernst E. Osteopathic manipulative treatment for pediatric conditions: a systematic review. Pediatrics. 2013;132(1):140 -52
2.Young A, Chaudhry H, Thomas JV, Dugan M. A Census of Actively Licensed Physicians in the United States, 2012. J Med Reg. 2013;99(2):11- 24.
3.Brotherton SE, Etzel SI. Graduate medical education, 2011-2012. JAMA. 2012;308(21):2264-79
4.Seffinger MA. Advancing osteopathic medicine through research. J Am Osteopath Assoc. 2012;112(9):589-90
5.Qureshi Y, Kursienski AM. Commentary on the globalization of osteopathic medicine. Osteopathic Family Physician. 2010; 2(3): 72-76
Conflict of Interest:
None declared