J Am Osteopath Assoc. 2020 Dec 1;120(12):888-906. doi: 10.7556/jaoa.2020.128.
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.
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.
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.
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.
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.
慢性非癌性疼痛（CNCP）与残疾、生活质量（QOL）下降和无法重返工作（RTW）有关。整骨手法治疗（OMT）或整骨手法疗法（OMTh）越来越多地用于 CNCP 患者；然而，文献中现有的系统评价和荟萃分析在探索 OMTh 有效性方面存在重大局限性。
使用 Grading of Recommendations Assessment, Development, and Evaluation（GRADE）方法系统评估 OMTh 对 CNCP 患者有效性的证据质量，并通过对以前研究的汇总数据进行荟萃分析评估 OMTh 在 CNCP 患者中的疗效。
我们在 Ovid、MEDLINE、Embase、OSTMED.DR、EMCare、Allied and Complementary Medicine Database（AMED）、Physiotherapy Evidence Database（PEDro）和 Cochrane Central Register of Controlled Trials（CENTRAL）在线数据库中进行了搜索，以及评估 OMTh 对疼痛严重程度、残疾、QOL 或 RTW 结果的有效性的先前系统评价文章的参考文献。纳入标准包括随机对照试验方法、18 岁或以上的 CNCP 患者、使用经过验证的评估工具、将 OMTh 用作主动或联合干预以及存在对照组或比较组。我们根据 OMT 对照治疗和结果之间的同质性对研究进行了汇总。使用 Cochrane 偏倚风险工具评估偏倚风险，使用 GRADE 确定证据质量。
有 16 项随机对照试验（n=1158 名患者）符合数据提取标准。中等质量证据表明，OMTh 与标准护理相比，疼痛[标准化均数差（95%CI）=（-.37（-.58，-.17）]和残疾[-.28（-.46，-.10）]显著降低，生活质量[.67（.29，1.05）]显著提高。中等质量证据表明，OMTh 加运动与仅运动相比，疼痛严重程度[-1.25（-1.67，-.83）]和残疾[-1.15（-1.57，-.74）]显著降低。中等质量证据表明，与一般 OMTh 相比，内脏 OMTh 与疼痛严重程度[-.74（-1.09，-.39）]和残疾[-.52（-.91，-.13）]的降低显著相关。与物理治疗、加巴喷丁和 OMTh 加加巴喷丁相比，OMTh 对任何结果均无显著影响。OMTh 与标准护理在 12 周时并未显示 RTW 有显著改善，但在 OMTh 后 8 周时效果显著。
中等质量证据表明，OMTh 对 CNCP 患者有效。内脏 OMTh 与疼痛严重程度和残疾降低显著相关。需要更多高质量、大样本的随机对照试验来进一步探索 OMTh 在 CNCP 管理中的有效性。
