Osteopathic Manipulation Overview

Osteopathy originated as a 19th century alternative medical approach focusing on physical manipulation. Today, osteopathic physicians study and practice the same types of medical and surgical techniques as conventional medical doctors. Some of osteopathy's original techniques still persist, however; these, taken together, are called osteopathic manipulation (OM). OM is less well-known to the public than chiropractic spinal manipulation , but it has shown promise for many of the same conditions, such as back pain and tension headaches.

Osteopathic medicine was founded in 1874 by Andrew Taylor Still, a US physician. Physicians educated in this method were called doctors of osteopathy, or DOs. Subsequently, however, schools of osteopathic medicine became integrated with conventional medical schools, and today the license of DO is legally equivalent to that of M.D.

Osteopathic and chiropractic techniques overlap, but they are not identical. As a general rule, chiropractors focus most of their attention on the spine, while osteopathic practitioners devote more of the their efforts to the manipulation of soft tissues and joints outside the spine. Another general difference is that chiropractic spinal manipulation tends to make use of rapid short movements (spinal manipulation, which is a high-velocity, low-amplitude technique), while OM typically concentrates on gentle, larger movements (mobilization, which is a low-velocity, high-amplitude technique). But neither of these distinctions is absolute, and many chiropractic and osteopathic methods do not fit neatly into these categories.

There are several specific osteopathic techniques in wide use, many of which are named after their founders. Some of the more popular are Greenman muscle-energy, Jones counterstrain (also known as strain-counterstrain), myofascial release, and cranial-sacral therapy (formally known as osteopathy in the cranial field).

Greenman Muscle-energy Technique

Greenman muscle-energy technique involves bending a joint just up to the point where muscular resistance to movement begins (“the barrier”), and then holding it there while the patient gently resists. The pressure is maintained for a few seconds and then released. After a brief pause to allow the affected muscles to relax, the practitioner then moves the joint a little farther into the barrier, which will usually have shifted slightly toward improved mobility during the interval.

Strain-counterstrain Technique (Jones Counterstrain)

Strain-counterstrain technique (Jones counterstrain) involves finding tender points and then manipulating the joint connected to them in order to find a position where the tenderness decreases toward zero. Once this precise angle is found, it is held for 90 seconds and then released. Like muscle-energy work, strain-counterstrain progressively increases range of motion and, it is hoped, decreases muscle spasm and pain.

Myofascial Release

Myofascial release focuses on the fascial tissues that surround muscles. The practitioner first positions the painful area either at the edge of the barrier to movement or, alternatively, at the opposite extreme (the area of greatest comfort). Next, while the patient breathes slowly and easily, the practitioner palpates the fascial tissues, looking for a subtle sensation that indicates the tissues are ready to “unwind.” After receiving this indication, the practitioner then helps the tissue to follow a pattern of spontaneous movement. This process is repeated over several sessions until a full release is achieved. Myofascial release is said to be especially useful in pain conditions that have persisted for months or years.

Cranial-sacral Therapy

Cranial-sacral therapy, more properly called cranial osteopathy (or just cranial for short), is a very specialized technique based on the scientifically unconfirmed 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 gently manipulates these bones in time with the rhythm (as determined by the practitioner’s awareness), in order to repair “cranial lesions.” This therapy is said to be helpful for numerous conditions ranging from headaches and sinus allergies to multiple sclerosis and asthma. However, many researchers have serious doubts that the cranial rhythm even exists. ¹

There is little evidence as yet that osteopathic manipulation 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 OM.

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 OM into a study design of this type. What could researchers use as a placebo OM? And how could they make sure that both participants and practitioners would be kept in the dark regarding who is receiving real OM and who is receiving fake OM? The fact is, they can’t.

Because of these problems, all studies of OM fall short of optimum design. Many have compared OM 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 OM 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 OM 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 OM.

Possible Effects of OM

Most studies of OM 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. ² Participants receiving OM showed faster recovery and experienced fewer days off work. OM appeared to be less expensive overall than the other two approaches; however, researchers strictly limited the allowed OM 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). ³ 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 OM proved more effective than placebo OM. ⁴ 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. ⁵ 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. ⁶ In another study, 24 women with fibromyalgia were divided into five groups: standard care, standard care plus OM, standard care plus an educational approach, standard care plus moist heat, and standard care plus moist heat and OM. ⁷ The results indicate that OM plus standard care is better than standard care alone, and that OM 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.

A study of 28 people with tension headaches compared one session of OM against two forms of sham treatment and found evidence that real treatment provided a greater improvement in headache pain. ⁸ Although OM has shown some promise for the treatment of back pain , ⁹ 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, OM proved no more effective than standard treatment for back pain. ¹⁰ Another study, this one enrolling 199 people and following them for 6 months, failed to find OM more effective than fake OM. ¹¹ This study also included a no-treatment group; both real and fake OM 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. ¹²

Some studies have evaluated the potential benefits of OM for speeding healing in people recovering from surgery or serious illness. The best of these studies compared OM against light touch in 58 elderly people hospitalized for pneumonia. ¹³ The results indicate that use of osteopathy aided recovery.

In a much less meaningful study, OM was compared to no treatment in people recovering from knee or hip surgery. ¹⁴ While the people receiving OM 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 similarly weak study suggests that OM might also be helpful for people hospitalized with pancreatitis . ¹⁵ A small study found some evidence that OM might be helpful for childhood asthma . ¹⁶

Although there are many licensed doctors of osteopathy (DOs), most practice conventional medicine and do not specialize in OM. Some do, and many of those have been certified by the American Osteopathic Board of Neuromusculoskeletal Medicine.

In addition, many physical therapists and massage therapists use some osteopathic techniques, with variable amounts of training.

1. Hartman SE, Norton JM. Craniosacral therapy is not medicine. Phys Ther. 2002;82:1146-1147.
2. 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.
3. 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.
4. Knebl JA, Shores JH, Gamber RG, Gray WT, Herron KM. Improving functional ability in the elderly via the Spencer technique, an osteopathic manipulative treatment: a randomized, controlled trial. J Am Osteopath Assoc. 102(7):387-96.
5. Bergman GJ, Winters JC, Groenier KH, Meyboom-de Jong B, Postema K, van der Heijden GJ. 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. 33(2):96-101.
6. Nourbakhsh MR, Fearon FJ. The effect of oscillating-energy manual therapy on lateral epicondylitis: a randomized, placebo-control, double-blinded study. J Hand Ther. 21(1):4-13; quiz 14.
7. Gamber RG, Shores JH, Russo DP, Jimenez C, Rubin BR. Osteopathic manipulative treatment in conjunction with medication relieves pain associated with fibromyalgia syndrome: results of a randomized clinical pilot project. J Am Osteopath Assoc. 102(6):321-5.
8. Hoyt WH, Shaffer F, Bard DA, Benesler JS, Blankenhorn GD, Gray JH, Hartman WT, Hughes LC. Osteopathic manipulation in the treatment of muscle-contraction headache. J Am Osteopath Assoc. 78(5):322-5.
9. Newswanger DL, Patel AT, Ogle A. Osteopathic medicine in the treatment of low back pain. Am Fam Physician. 62(11):2414-5.
10. 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.
11. Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, Winn W, Swift J Jr. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine (Phila Pa 1976). 28(13):1355-62.
12. 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. 33(9):502-12.
13. Noll DR, Shores JH, Gamber RG, Herron KM, Swift J Jr. Benefits of osteopathic manipulative treatment for hospitalized elderly patients with pneumonia. J Am Osteopath Assoc. 100(12):776-82.
14. Jarski RW, Loniewski EG, Williams J, Bahu A, Shafinia S, Gibbs K, Muller M. The effectiveness of osteopathic manipulative treatment as complementary therapy following surgery: a prospective, match-controlled outcome study. Altern Ther Health Med. 6(5):77-81.
15. Radjieski JM, Lumley MA, Cantieri MS. Effect of osteopathic manipulative treatment of length of stay for pancreatitis: a randomized pilot study. J Am Osteopath Assoc. 98(5):264-72.
16. Guiney PA, Chou R, Vianna A, Lovenheim J. Effects of osteopathic manipulative treatment on pediatric patients with asthma: a randomized controlled trial. J Am Osteopath Assoc. 105(1):7-12.