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 = 1,158 patients) were eligible for data extraction. Moderate quality evidence showed that OMTh versus standard care was significantly associated with a reduction in pain (standardized mean difference (95% CI)) (-0.37 (-0.58 to -0.17)) and disability (-0.28 (-0.46 to -0.10)), as well as improved QOL (0.67 (0.29 to 1.05)). Moderate quality evidence showed that OMTh plus exercise versus exercise only was significantly associated with reduction in pain severity (-1.25 (-1.67 to -0.83)) and disability (-1.15 (-1.57 to -0.74)). Moderate quality evidence showed that using visceral OMTh versus general OMTh was significantly associated with reduction in pain severity (-0.74 (-1.09 to -0.39)) and disability (-0.52 (-0.91 to -0.13)). In comparison to physiotherapy, gabapentin, and OMTh plus gabapentin, OMTh did not show any significant effect for any of the outcomes. OMTh versus 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.
Reprinted from JAOA, The Journal of the American Osteopathic Association. Copyright American Osteopathic Association. Permission given with the consent of the American Osteopathic Association.

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