ByunghHo J. K., JungHoon, A., HeeCheol, C.,
DongYun, K., TaeYeong, Kim., BumChul, Y. (2015)
Rehabilitation with Osteopathic Manipulative Treatment (OMT) After Lumbar Disc Surgery: A Randomised, Controlled Pilot Study
, IJOM: 18;
- Low back pain is a worldwide health problem with
a lifetime prevalence rate of 80% and can affect daily physical activity (1.).
- Lumbar disc pain accounts for less than 5-10% of
lower back pain (LBP) and is one of the most common reasons for lumbar spine
- Lumbar discectomy is one of the most commonly
performed operations for lower back pain to relieve nerve root pain and reduce
- The most common unsatisfactory complaints
complications observed in patients following lumbar discectomy are;
- Continued post operative physical disability
affecting daily activities.
- Residual lower back pain and leg pain (3.).
Post surgical intervention has been
considered important to reduce post surgical physical complications and
increase the success rate for patients post surgery.
This study performed a pilot study comparing Osteopathic
Manipulative Treatment (OMT) with
exercise following lumbar disc surgery to assess the feasibility for a future randomised
- 48 patients who met the eligibility criteria and
wanted to participate in the study were interviewed and screened by two
- The study was a randomised controlled pilot
study and conducted at a major metropolitan spine surgery hospital where all
participants underwent lumbar microdiscectomy.
- Two research spinal surgeons registered in Korea
and a research osteopath registered in the UK conducted patient recruitment and
- The study protocol was approved by the
institutional review board of the University of Korea, and all participants
provided written informed consent.
- Patients between 20 and 65 years of age who had
lower back pain and referred leg pain resulting from a herniated lumbar disc
and underwent lumbar microdiscectomy were identified by hospital nurses.
Patient Exclusion Criteria:
- A requirement of revision surgery or other forms
of combined surgery.
- A refusal to participate
- Contraindication for participation including
pregnancy, metastatic disease, or a mental disorder.
- Of the 48 patients, 15 were excluded and the
remaining 33 were randomly allocated to either the OMT group or the exercise
- 33 patients who had underwent lumbar
microdiscectomy by 2 neurosurgeons at the spine surgery hospital returned to
the hospital 2 to 3 weeks after surgery for baseline measurements and the first
- Each participant was randomly assigned to one of
two intervention groups; either exercise programme or an OMT group.
- The allocations were conducted using simple
- Both intervention programmes (Exercise and OMT) consisted of eight individual sessions which were performed twice a week for 4
weeks. Each session was 30 minutes and all patients in both groups were
prescribed supplementary anti inflammatory medication, analgesics and a muscle
relaxant by surgeons.
Rehabilitation & Techniques Used:
- All patients underwent physical assessment
before each intervention.
- The same practitioner applied a combination of
techniques in the standardised protocol for the OMT but the intensity and
sequence of the techniques were modified for each patient depending on their
tolerance to treatment and other post-operative physical conditions.
- The protocol did not include spinal high-velocity,
low-amplitude thrust (HVLAT) manipulation of the lumbar segments where the
surgery was performed.
- The focus of the OMT protocol was to reduce
biomechanical overload on the lumbar spine by functionally improving the motion
of adjacent spinal segments or joints including the thoracic and cervical
segments and the sacroiliac joint.
- The protocol included techniques applied to
myofascial structures to reduce post-operative physical tension and stiffness
generated in the body.
- Each OMT intervention was performed by two
osteopathic students under the supervision of a qualified osteopath.
- Each treatment process was documented and
reviewed by a research osteopath and surgeon.
- Overall, 8 exercise sessions were conducted over
a course of 4 weeks.
- The aim of the exercise programme was to improve
spinal mobility and stabilise the lumbar segments.
- For the first week, practitioners focused on
stretching exercises for the back and abdominal muscles with the patient in the
- For the 2nd and 3rd week,
practitioners focused on isometric strengthening exercises for the back and hip
extensors with the patient in the prone position or sitting on a gym ball.
- In the final 4th week, the intensity
of the previous exercises was increased and back stability exercises were
performed using a pilates exercise apparatus.
- Outcome measures were assessed after 2 and 3
weeks post surgery and post-intervention.
- A post-intervention evaluation was conducted 7
to 8 weeks post surgery which was otherwise a week after the final
- Primary outcome measures were evaluated for post-operative
disability and residual pain in the legs and lower back.
- Outcome measure questionnaires used were the
Rolande Morris Disability Questionnaire (RMQ) with a 24-point scale and the
Visual Analogue Scale (VAS) with 0 indicating ‘no pain’ and 100 indicating ‘the
- Secondary outcomes included lumbar range of
motion (ROM), use of medication, and patient satisfaction.
- The lumbar spine ROM at which the patients could
move without pain was measured with a double inclinometer by a physiotherapist
who was not involved in any intervention.
- The number of supplemental medications taken per
week was used to assess medication consumption.
- Patients were also asked to fill in a self-grading
questionnaire to evaluate their satisfaction for their rehabilitation
intervention which indicated ‘dissatisfaction’, ‘moderate satisfaction’ and
- Patients were asked whether they would recommend
the rehabilitation intervention they received to a family member or friend with
a similar condition.
- The Shapiroe Wilk test was used to assess
normality of distribution of the data. Medians are shown for the range of
movement found in lumbar spine extension and left side-bending, and for the
number of times medication was used.
- The categorical data was analysed using the
chi-square test or Fisher’s exact test to account for baseline variations.
- The Student‘s t-test or the Manne Whitney U test
was applied to compare the differences between the groups. SPSS statistical
software (Version 12.0, SPSS Inc., Chicago, IL) was used for the analyses.
Two-sided tests and a significance level of 0.05 were used for all statistical
- Subjects Of the 48 patients deemed eligible for
inclusion, 33 (69%) were enrolled and randomly allocated to either the OMT or
- There were no significant differences in
baseline characteristics and baseline measures between the two groups.
- The primary reason for non-enrolment was lack of
interest in participation. Of the enrolled patients, 6% were lost to follow-up
at the primary study endpoint (2 of 33, 1 in each group). All 33 patients who
were randomly assigned to a group were analysed on an intention-to-treat basis.
Primary Outcome Results
- Primary outcomes OMT and the exercise programme
improved all primary outcomes.
- Post-surgical physical disability questionnaire results
showed that patients improved more after OMT rehabilitation than the exercise
- Residual leg pain after the lumbar discectomy
decreased in the OMT group with a 53% reduction compared to the exercise group
which had a 17% reduction.
- Residual lower back pain also decreased in both
interventions with a 37% reduction in the OMT group and a 10% reduction in the
Secondary Outcome Results
Table Of Results
- An overall improvement was found in the lumbar
spine active ROM with patients being able to move without pain in both the OMT group and
- Patients in the groups required less frequent
use of medication with an 87% reduction in the OMT and 73% in the exercise.
- Patients in both groups responded that they
were highly satisfied with the post-operative rehabilitation and answered that
they would recommend the post-operative rehabilitation to a family member or a
friend undergoing spinal surgery.
- No side effects or complications from any
intervention were reported.
- In this pilot study, we showed the feasibility
of OMT for post-operative rehabilitation after lumbar disc surgery compared to
an exercise programme.
- The early post-operative physical disability and
residual pain in the lower back and legs were reduced by both rehabilitation
- These two post-operative cares also improved the
active range of motion of the lumbar spine and were shown to be a safe approach
without side effects and high satisfaction.
- To the author’s knowledge, this is the first
pragmatic, randomised, controlled pilot trial to assess the feasibility of OMT
for post-operative rehabilitation after lumbar disc surgery.
- The present pilot study also showed the
applicability of the combination of lumbar disc surgery and OMT rehabilitation
in a pragmatic setting where the medical professionals including spinal
surgeons, physiotherapists, nurses and an osteopath were involved in the study
& Critical Analysis
Summary Follow Up:
- It is
difficult to determine whether the post-operative outcomes of OMT
rehabilitation can be maintained long-termly because of a short follow-up
- However, the information regarding the
short-term beneficial effect of the early applied rehabilitation would be
important because the main expectations of patients undergoing lumbar
microdiscectomy are early return to work or normal daily activities after disc
is a patient-centred system of healthcare with individualised diagnosis and
treatment. The manipulative techniques are only part of a philosophy of care.
- The unavailability of fully trained
osteopath but osteopathic students to perform OMT intervention was also a study
- However, the intensity, sequence and selection
of the treatment techniques were individualised to each patient depending on
their physical conditions such as tolerance to treatment on the day of the
intervention within the standardised OMT protocol.
- The research osteopath who was fully trained and
registered and surgeon reviewed the each assessment for the treatment and
supervised the OMT rehabilitation when required.
Lack of Blinding:
- The lack
of blinding was also a methodological weakness. In the pragmatic study,
however, it was not possible to prevent the patients from knowing the
explained the type of rehabilitation being used upon inquiry. In particular, the
patients allocated to the OMT group were not familiar with osteopathic
Lack of Placebo
- Since the lack of a placebo control group, the
study result is limited to determine whether the post-operative outcomes were
improved by the interventions themselves or whether they were related to other
aspects of the interventions.
- Factors such as time spent with patients or
frequency of patient’s visits may represent placebo effects.
- However, it was not desirable to use a sham
treatment or no treatment because of ethical considerations concerning loss of
chance for patients to improve the early post-operative outcomes.
- In addition, it is difficult to develop an OMT
placebo at a pragmatic setting.
- The results presented in this pilot trial
comparing OMT with exercise will be valuable because the exercise programme we
applied in the study has proven to be more effective rehabilitation to improve
early post-operative disability and pain than no treatment, or other types of
interventions such as self-homecare or programmes focusing on behaviour
timing and intensity of the rehabilitation, found that an intensive programme
starting immediately after lumbar discectomy had better short-term outcomes
such as pain reduction and increased range of lumbar motion than less active
- This was further confirmed by experimental
studies showing that vigorous exercise started 4 to 5 weeks postoperatively
reduced physical disability and residual pain after lumbar disc surgery.
- Findings from the present study are limited but
support the feasibility for a future definitive trial.
- The future well-designed, adequately powered
trial will require a larger sample size and long term follow-up periods to
confirm the effect of OMT rehabilitation.
- The use
of fully trained and experienced osteopaths for the intervention should be
considered in future research assessing the post-operative effect of OMT.
- The postoperative pain and its associated
physical disability were more reduced in OMT, which required less use of
medication; therefore a cost effectiveness analysis should be performed.
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