Osteopathic Manual Treatment for Pain Severity, Functional Improvement, and Return to Work in Patients With Chronic Pain
Open accessAbstract
Context: Chronic non-cancer pain (CNCP) is associated with disability, poor quality of life (QOL), and failure to return to work (RTW). Osteopathic manipulative treatment (OMT) or osteopathic manual therapy (OMTh) are increasingly offered to patients with CNCP; however, the existing systematic reviews and meta-analyses in the literature that explore the effectiveness of OMTh have major limitations. Objective: To systematically evaluate the quality of evidence documenting the effectiveness of OMTh for patients with CNCP using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and to evaluate the efficacy of OMTh in patients with CNCP through a meta-analysis of pooled data from previous studies. Methods: We searched online the databases Ovid, MEDLINE, Embase, OSTMED.DR, EMCare, Allied and Complementary Medicine Database (AMED), Physiotherapy Evidence Database (PEDro), and Cochrane Central Register of Controlled Trials (CENTRAL), as well as the bibliographic references of previous systematic review articles evaluating OMTh for pain severity, disability, QOL, or RTW outcomes. Eligibility included randomized controlled trials methodology, CNCP patients 18 years or older, use of previously validated assessment tools, use of OMTh as an active or combination intervention, and presence of a control or comparison group. We pooled studies based on the homogeneity between OMT comparator treatment and outcomes. Risk of bias was assessed with the Cochrane risk of bias tool and the quality of evidence was determined with GRADE. Results: Sixteen randomized controlled trials (n=1158 patients) were eligible for data extraction. Moderate quality evidence showed that OMTh vs. standard care was significantly associated with a reduction in pain [standardized mean difference (95% CI)=[−.37 (−.58, −.17)] and disability [−.28 (−.46, −.10)], as well as improved QOL [.67 (.29, 1.05)]. Moderate quality evidence showed that OMTh plus exercise vs. exercise only was significantly associated with reduction in pain severity [−1.25 (−1.67, −.83)] and disability [−1.15 (−1.57, −.74)]. Moderate quality evidence showed that using visceral OMTh vs. general OMTh was significantly associated with reduction in pain severity [−.74 (−1.09, −.39)] and disability [−.52 (−.91, −.13)]. In comparison to physiotherapy, gabapentin, and OMTh plus gabapentin, OMTh did not show any significant effect for any of the outcomes. OMTh vs. standard care did not show significant improvement in RTW at 12 weeks, although the effect was significant at 8 weeks after OMTh. Conclusion: Moderate quality evidence suggests that OMTh is effective for CNCP patients. There was a significant association between visceral OMTh and reduced pain severity and disability. More robust, high-quality randomized controlled trials with larger sample sizes are required to further explore the effectiveness of the OMTh in the management of CNCP.
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In Rehman and colleagues, another pooled analysis including two trials with 486 participants revealed efficacy of OMT versus standard care in improving disability, with a large effect size, moderate quality of evidence, and no heterogeneity.
“Moreover, another pooled analysis including two trials with 486 participants revealed the efficacy of OMT versus standard care in improving disability (large ES, moderate quality of evidence and no heterogeneity).”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredIn Rehman and colleagues, a pooled analysis of two trials with 210 participants found that OMT versus standard care improved quality of life, with a medium effect, moderate quality of evidence, and no heterogeneity.
“Similarly, the pooled analysis of the other two trials with 210 participants found that OMT versus standard care improved the quality of life (medium effect, moderate quality of evidence and no heterogeneity).”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
The Quality of life section reports that two studies found improved quality of life with OMTh versus standard care (SMD 0.67), with moderate-quality evidence, but their pooled sample was 120 participants, not 210. Table 4 lists low inconsistency for this outcome; it does not establish the claimed absence of heterogeneity. (LLM, conf=0.92)
Experimental — accuracy not yet measuredIn Rehman and colleagues, the authors using a modified version of the Handbook of Cochrane with six domains reported high risk of bias, with high-risk domains including patient blinding (100%), care provider blinding (100%), outcome assessor blinding (57%), random sequence generation (29%), participant allocation concealment (29%), and dropout >20% (43%).
“The methodological quality of the included studies was performed by the authors using a modified version of the Handbook of Cochrane33 where only six domains were considered (random sequence generation, allocation concealment, blinding of participants, healthcare provider, outcome assessors and dropout rates). According to this modified version, the quality of the RCTs was reported by the authors”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredIn Rehman and colleagues, a pooled analysis including 6 RCTs with 728 participants found efficacy of OMT versus standard care in reducing pain severity, with a small effect size, moderate quality of evidence, and low heterogeneity.
“A pooled analysis, including 6 RCTs with 728 participants (six comparators), found the efficacy of OMT versus standard care in reducing pain severity (small ES, moderate quality of evidence and low level of heterogeneity).”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
The Pooled Analysis section reports six studies comparing OMTh with standard care and a significant reduction in pain severity, with a small standardized effect (−0.37) and moderate-quality evidence. The Strengths and Limitations section describes low heterogeneity. The participant count is incorrect: the Pooled Analysis and Table 4 both report 710, not 728; page numbers are unavailable in our copy. (LLM, conf=0.92)
Experimental — accuracy not yet measuredTwo of the nine systematic reviews registered a protocol before beginning the study.
“Two of the nine SRs registered a protocol before beginning the study.27 29”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
The Methods section says this review’s protocol was registered with PROSPERO. It does not establish that registration occurred before the study began, and this source alone does not substantiate the count of two among nine reviews. (LLM, conf=0.83)
Experimental — accuracy not yet measured
The lack of solid evidence stems from a small sample size, the presence of conflicting results, and high heterogeneity in participants, outcome measures, interventions, and comparison interventions.
“The lack of solid evidence stems from a small sample size,26 28–32 the presence of conflicting results24 30 31 and a high heterogeneity in participants,25 31 outcomes measures,31 32 interventions25–27 31 and comparison interventions.25–27 32”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
The Strengths and Limitations section (page unavailable) identifies small sample sizes as a limitation and says that pooling studies by similar interventions and comparators reduced heterogeneity. The paper also discusses variation in outcomes, but it reports low heterogeneity in its own pooled analyses; it does not establish that high heterogeneity across every listed category caused the lack of solid evidence. (LLM, conf=0.85)
Experimental — accuracy not yet measuredThe systematic review by Rehman and colleagues identified 16 RCTs, but the overview considered pooled analyses in which trials were only performed by osteopaths.
“The SR by Rehman and colleagues29 evaluated the efficacy of osteopathic interventions performed by manual therapists in chronic non-cancer pain. Sixteen RCTs were identified; however, we considered pooled analyses in which the trials were only performed by osteopaths”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
All systematic reviews evaluated the risk of bias of the included studies.
“All SRs24–32 evaluated the RoB of the included studies”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
Eight systematic reviews performed an appropriate literature search.
“Eight SRs performed an appropriate literature search,25–32”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
Five systematic reviews carried out a meta-analysis and used appropriate methods for the statistical combination of findings.
“five SRs25–29 carried out a meta-analysis and used appropriate methods for the statistical combination of findings.”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
Reduced heterogeneity was found when the RCTs were pooled considering interventions and comparators.
“Notably, reduced heterogeneity was found when the RCTs were pooled considering interventions and comparators.29”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
Eight systematic reviews accounted for the risk of bias when interpreting and discussing the results of the systematic review.
“Eight SRs25–32 accounted for the RoB when interpreting and discussing the results of the SR.”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
Domain 15 (publication bias assessment) was rated as not applicable for all systematic reviews due to lack of a meta-analysis or inclusion in the meta-analysis of fewer than 10 trials.
“Finally, domain 15 (publication bias assessment) was rated as not applicable for all the SRs due to lack of a meta-analysis24 30–32 or the inclusion in the meta-analysis of fewer than 10 trials.25–29”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
The overall traffic light evidence for the outcomes of each condition in Rehman and colleagues was assessed to be yellow.
“The OTLE for the outcomes of each condition was assessed to be yellow.”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
The Quality of Evidence section says the review used GRADE, and Strengths and Limitations describes its overall GRADE assessment as moderate. A search for OTLE, traffic-light ratings, and yellow found no passage assigning a yellow rating to the outcomes of each condition. The copy therefore does not verify the attributed assessment. (LLM, conf=0.72)
Experimental — accuracy not yet measuredAdverse events were not considered by the Rehman and colleagues systematic review authors.
“Adverse events were not considered by the SR authors.”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
The Strengths and Limitations section (page unavailable) identifies pain, function, quality of life, and return to work as the review’s focus, but does not say whether the authors considered adverse events. Searches for “adverse,” “adverse events,” and safety found no decisive passage; omission alone does not establish that they were not considered. (LLM, conf=0.67)
Experimental — accuracy not yet measuredAccording to the critical domain established in Shea et al, seven systematic reviews were rated low quality and two were rated critically low quality.
“According to the critical domain established in Shea et al,12 seven25–29 31 32 and two SRs 24 30 were rated as low and critically low quality, respectively.”
From Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews (2022) · cites this paper as [29]
The Quality of Evidence section describes a GRADE assessment of evidence from trials, not quality ratings of systematic reviews using Shea et al’s critical domains. The Strengths and Limitations section calls this review’s GRADE assessment moderate, but does not report seven reviews rated low and two rated critically low. Searches for those ratings and Shea’s critical domains found no supporting passage in our copy. (LLM, conf=0.75)
Experimental — accuracy not yet measured
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Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews
Bagagiolo, D., Rosa, D., & Borrelli, F. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-053468 · Cited by 104 · see citing works
“25 26 28 31 32 All SRs 24–32 evaluated the RoB of the included studies and five SRs 25–29 carried out a meta-analysis and used appropriate methods for the statistical combination of findings.”
BackgroundMethodInfluentialOsteopathy and Mental Health: An Embodied, Predictive, and Interoceptive Framework
Bohlen, L., Shaw, R., Cerritelli, F., & Esteves, J. E. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.767005 · Cited by 51 · see citing works
Bohlen, L., Schwarze, J., Richter, J., Gietl, B., Lazarov, C., Kopyakova, A., Brandl, A., & Schmidt, T. (2022) · Scientific Reports · doi:10.1038/s41598-022-20452-9 · Cited by 22 · see citing works
Mamud-Meroni, L., Tarcaya, G. E., Carrasco‐Uribarren, A., Rossettini, G., Flores-Cortés, M., & Ceballos‐Laita, L. (2025) · Biomedicines · doi:10.3390/biomedicines13020392 · Cited by 10 · see citing works
An overview of systematic reviews on the efficacy and safety of osteopathic techniques
Zipp, C., Semlitsch, T., Tögel, G., Krenn, C., Loder, C., Jeitler, K., & Siebenhofer, A. (2025) · Journal of Bodywork and Movement Therapies · doi:10.1016/j.jbmt.2025.03.018 · Cited by 10 · see citing works
Ceballos‐Laita, L., Jiménez‐del‐Barrio, S., Carrasco‐Uribarren, A., Medrano-de-la-Fuente, R., Robles-Pérez, R., & Ernst, E. (2024) · Diseases · doi:10.3390/diseases12110287 · Cited by 8 · see citing works
Fernandes, W. V. B., Politti, F., Rodríguez‐Blanco, C., Lucareli, P. R. G., Gomes, C. A. F. D. P., Corrêa, F. I., & Corrêa, J. C. F. (2023) · Journal of Bodywork and Movement Therapies · doi:10.1016/j.jbmt.2023.04.006 · Cited by 8 · see citing works
Rehman, Y., Kirsch, J., Wang, M. Y.-F., Ferguson, H., Bingham, J., Senger, B., Swogger, S. E., Johnston, R., & Snider, K. T. (2022) · Journal of Osteopathic Medicine · doi:10.1515/jom-2022-0119 · Cited by 8 · see citing works
Self-citationOsteopathic manipulation and its applicability in the emergency department: A narrative review
Pelletier, J., Capistrant, T., & Nordt, S. P. (2024) · The American Journal of Emergency Medicine · doi:10.1016/j.ajem.2024.07.050 · Cited by 7 · see citing works
Rehman, Y., Ferguson, H., Bozek, A., Blair, J., Allison, A., & Johnston, R. (2021) · Journal of Osteopathic Medicine · doi:10.1515/jom-2020-0240 · Cited by 5 · see citing works
Self-citationSoin, A., Gupta, M., Abd-Elsayed, A. A., Nashi, S. E., Escobar, A., Reynolds, D., Montes, G. C., Witte, R. J., & Peskin, E. (2025) · Cureus · doi:10.7759/cureus.98348 · Cited by 3 · see citing works
Rehman, Y., Kirsch, J., Wang, M. Y.-F., Johnston, R., Will, M., Gibson, E., Spencer, D., Garcia, C., & Snider, K. T. (2025) · Journal of Osteopathic Medicine · doi:10.1515/jom-2025-0075 · Cited by 2 · see citing works
Self-citationEin osteopathischer Ansatz für den ganzen Körper: Kompensationsstrategien
Jarvis, L. (2026) · Osteopathische Medizin · doi:10.1016/s1615-9071(26)00009-2 · Cited by 1 · see citing works
Franke, H. (2023) · Osteopathische Medizin · doi:10.1016/s1615-9071(23)00017-5 · Cited by 1 · see citing works
Franke, H. (2023) · DO - Deutsche Zeitschrift für Osteopathie · doi:10.1055/a-1996-6934
Lathish, K., Dutta, P., & Nikilesh, A. (2024) · International Journal of Science and Research (IJSR) · doi:10.21275/sr24504175512
The Role of Osteopathic Manipulative Treatment in Osteoarthritis: A Scoping Review
Stoll, V. K., Trube, J., Johnson, T. M., Darbhanga, J., & Mehra, R. S. (2024) · Cureus · doi:10.7759/cureus.74440
Joseph, C. R., Mintle, L. S., Hoegerl, C., Asher, D., Adams, K., Fugler, P. R., & McKinney, J. (2024) · International journal of osteopathic medicine · doi:10.1016/j.ijosm.2024.100743
Ein osteopathischer Ansatz für den ganzen Körper: Multiple Schmerz- und Stressstimuli
Jarvis, L. (2026) · Osteopathische Medizin · doi:10.1016/s1615-9071(26)00039-0
Ngo, A. L., Ho, T., Tadakamalla, R., Nguyen, U. T., & Serfin, J. (2026) · Journal of the American Osteopathic Academy of Orthopedics · doi:10.70709/3w5uzbikc
- Authors
- Rehman, Y., Ferguson, H., Bozek, A., Blair, J., Allison, A., & Johnston, R.
- Venue
- Journal of Osteopathic Medicine
- Publisher
- Walter de Gruyter GmbH
- Published
- 2020-09-17
- Volume
- 120
- Issue
- 12
- Pages
- 888-906
- ISSN
- 2702-3648 (ISSN-L)
- OpenAlex
- W3087145916
- Cited by
- 21
- References
- 66
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 5 · 2023: 4 · 2022: 3 · 2021: 2
- FWCI
- 0.30
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Osteopathic Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Cell Biology › Myofascial pain diagnosis and treatment
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Medical Practices and Rehabilitation
- Keywords
- chronic non-cancer pain, osteopathic manual therapy, osteopathic manipulative treatment, pain intensity, disability, quality of life, return to work, exercise therapy, visceral manipulation, physiotherapy, gabapentin, quality of evidence, GRADE, risk of bias, treatment effectiveness comparison, chronic low back pain, fibromyalgia, osteoarthritis, neck pain
- MeSH terms
- Analgesics, Opioid, Humans, Quality of Life, Manipulation, Osteopathic, Chronic Pain, Return to Work
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