Osteopathic Manipulative Treatment for Chronic Low Back Pain—Reply

In Reply As correctly pointed out by Licciardone, our study¹ involved nonphysician osteopathic practitioners and represented practice settings in France. According to French usage, osteopathic manipulative treatment (OMT) can be delivered by health and nonhealth professionals. In 2021, this latter category represented 21 000 (60%) of 35 000 osteopathic practitioners in France, and this proportion likely differs from international contexts. Licciardone suggested that these differences may have influenced our outcomes. However, despite design and contextual differences, data from the OSTEOPATHIC Trial, conducted by Licciardone and colleagues² in the Dallas–Fort Worth area of Texas, were consistent with ours regarding activity limitations, and that trial showed no clinically relevant differences between OMT (N = 230) and sham OMT (N = 225) at 3 months in patients with chronic lower back pain (LBP). Licciardone suggested we could have used another set of outcomes instead of our activity limitations, pain intensity, and health-related quality of life outcomes, but these domains are consistent with the core outcome set for clinical trials of nonspecific LBP.³ Licciardone also raised concerns about our inclusion of patients with subacute LBP, given that they may spontaneously improve. First, patients with subacute LBP are at higher risk of chronic LBP than patients with acute LBP. International guidelines consistently highlight differences between management of persistent and acute LBP.⁴ Second, even though our recruitment was open to patients with subacute LBP, only patients with chronic LBP (minimum LBP duration of 0.5 years) actually participated.¹