J Osteopath Med 2022; 122(1): 21–29

Musculoskeletal Medicine and Pain Original Article

John C. Licciardone*, DO, MS, MBA

Preventing progression from chronic to

widespread pain and its impact on health-related
quality of life: a historical cohort study of
osteopathic medical care
https://doi.org/10.1515/jom-2021-0105 for Chronic Low Back Pain recommended by the National
Received April 5, 2021; accepted August 2, 2021; Institutes of Health. Participants who reported “not being
published online September 23, 2021
bothered at all” by widespread pain during each encounter
were classified as not having widespread pain, whereas
Abstract
those who were bothered “a little” or “a lot” at any quar-
Context: It is generally acknowledged that osteopathic terly encounter were classified as having widespread pain.
physicians take a holistic approach to patient care. This The severity of widespread pain was measured by sum-
style may help prevent the progression of painful muscu- ming participant responses at each encounter. The Patient-
loskeletal conditions, particularly if combined with oste- Reported Outcomes Measurement Information System was
opathic manipulative treatment (OMT). used at each encounter to measure health-related quality-
Objectives: The study aimed to determine if osteopathic of-life (HRQOL) scores for physical function, anxiety,
medical care lowers the risk of progression from localized depression, fatigue, sleep disturbance, participation in
chronic low back pain to widespread pain and lessens the social roles and activities, and pain interference with
impact of pain on health-related quality of life. activities.
Methods: A historical cohort study was conducted within Results: A total of 462 participants were studied, including
the Pain Registry for Epidemiological, Clinical, and Inter- 101 (21.9%) in the osteopathic medical care group and 73
ventional Studies and Innovation (PRECISION Pain (15.8%) who used OMT. The mean age of participants at
Research Registry) using data acquired from April 2016 baseline was 52.7 ± 13.2 years (range, 22–79 years) and 336
through March 2021. Registry participants aged 21–79 years (72.7%) were female. A lower period prevalence rate of
with chronic low back pain at the baseline encounter were widespread pain was observed in the osteopathic medical
potentially eligible for inclusion if they had a treating care group (OR, 0.47; 95% CI, 0.27–0.81; p=0.006) and in
physician, completed all four quarterly follow-up en- the OMT group (OR, 0.40; 95% CI, 0.21–0.75; p=0.004),
counters, and did not report physician crossover at the although the latter finding did not persist after adjustment
final 12-month encounter. Eligible participants were clas- for potential confounders. The osteopathic medical care
sified according to the type of physician provider at base- and OMT groups both reported lower widespread pain
severity. The osteopathic medical care group also re-
line and thereby into osteopathic or allopathic medical
ported better age- and sex-adjusted outcomes for each of
care groups. Participants were also classified according to
the seven HRQOL dimensions throughout the study. The
prior use of OMT at the final encounter. Widespread pain
OMT group reported better outcomes in five of the HRQOL
was measured at baseline and each quarterly encounter to
dimensions.
determine the period prevalence rate of widespread pain
Conclusions: This study supports the view that osteo-
and its severity over 12 months using the Minimum Dataset
pathic physicians practice a holistic approach to medical
care that manifests itself through a lower risk of progres-
sion from chronic low back pain to widespread pain, lower
*Corresponding author: John C. Licciardone, DO, MS, MBA, Regents widespread pain severity, and lesser deficits in HRQOL.
Professor, Osteopathic Research Center and the Department of Family Similar findings were generally associated with OMT use.
Medicine, University of North Texas Health Science Center-Texas
College of Osteopathic Medicine, 3500 Camp Bowie Boulevard, Fort Keywords: chronic low back pain; fibromyalgia; health-
Worth, TX 76107, USA, E-mail: [email protected] related quality of life; historical cohort study; osteopathic
Open Access. © 2021 John C. Licciardone, published by De Gruyter. This work is licensed under the Creative Commons Attribution 4.0
International License.
22 Licciardone: Preventing progression to widespread pain

manipulative treatment; osteopathic medicine; pain (PRECISION Pain Research Registry). The registry was established at
research registry; patient-centered care; widespread pain. the University of North Texas Health Science Center in 2016 and
transitioned to a digital research platform in 2019, thereby facilitating
remote screening and data collection on chronic low back pain
Low back pain has been a common reason for patients to management and outcomes from participants throughout the 48
visit osteopathic physicians in the United States [1, 2]. The contiguous states and District of Columbia. Potential participants in
first systematic review and meta-analysis of the effect of this historical cohort study must have completed their baseline
osteopathic manipulative treatment (OMT) on low back encounter and all four quarterly follow-up encounters during the
period from April 2016 through March 2021. Registry procedures were
pain [3] initially led to the only clinical practice guideline
approved by the North Texas Regional Institutional Review Board
issued by the American Osteopathic Association, which
(protocol 2015-169) and all enrollees provided written informed
recommended that OMT be used in patients with low consent.
back pain when somatic dysfunction is the cause of or a Registry participants must range from 21 to 79 years of age at
contributing factor in its presentation [4]. An updated enrollment and be able to complete case report forms in English, either
guideline [5], based on a subsequent systematic review independently or with assistance from registry staff. This study was
limited to registry participants with chronic low back pain according
and meta-analysis [6], similarly recommends the use of
to the RTF diagnostic criteria, which require that participants report
OMT in patients with low back pain. The OSTEOPATHIC having low back pain for at least the past 3–6 months, and with a
Trial has shown that simple targeting strategies may be frequency of at least one-half of the days over the past six months [11].
used to identify patients with chronic low back pain who Participants without a treating physician for low back pain, who had
are likely to achieve substantial improvement with OMT not yet completed the 12-month follow-up encounter, who had missed
quarterly encounters, or with physician crossover were excluded. The
[7], and that patients may experience a chronic pain re-
latter consisted of participants who were treated by an osteopathic
covery with OMT [8].
physician at enrollment and then by an allopathic physician at
The dual tenets of a holistic approach to medical care 12 months, or vice-versa.
and use of OMT have been widely regarded as potentially
supporting the distinctiveness of osteopathic medicine [9].
Exposure to osteopathic or allopathic medical care
However, a recent joint statement from the American
Medical Association in conjunction with the American
The type of medical care received was determined by participant
Osteopathic Association further bolsters this claim of
response on the baseline encounter item that asked about the type of
distinctiveness [10]. This statement emphasized that oste- physician who treats their low back pain (i.e., osteopathic or allo-
opathic medicine is a distinctive branch of medical practice pathic physician). The use of OMT was estimated using the medical
in the United States that involves a “whole-person” care group and another case report form item that asked about prior
approach to care, including the use of OMT to treat pain in use of spinal manipulation for chronic low back pain at the final
encounter. A trichotomous variable was derived from these two el-
such areas as the low back, neck, shoulders, and knees.
ements. Participants who reported never using spinal manipulation
The National Institutes of Health Task Force on were considered to have never used OMT (OMT=0), regardless of their
Research Standards for Chronic Low Back Pain (RTF) has medical care group. Participants who reported prior use of spinal
recommended considering widespread pain a key comor- manipulation were considered to have possibly used OMT (OMT=1),
bid condition in patients with chronic low back pain [11]. if they were in the allopathic medical care group. For example, it is
possible that such participants may have received OMT from an
Given the holistic approach of osteopathic physicians,
osteopathic manipulative medicine specialist during the study
including potential use of OMT, it is reasonable to
period. The latter often restrict their practices to providing OMT as a
hypothesize that they are well positioned to prevent the complement to primary care provided by other physicians. However,
transition from chronic low back pain to widespread pain other health care professionals, such as chiropractors, may also
and its impact on health-related quality of life (HRQOL). provide such complementary spinal manipulation. Participants who
The purpose of this study was to test this hypothesis using reported prior use of spinal manipulation were considered to have
used OMT (OMT=2) if they were in the osteopathic medical care
data from a pain research registry.
group.

Outcome measures
Methods
Registry participants responded to the widespread pain item included
in the Minimum Dataset for Chronic Low Back Pain recommended by
Study design and participant inclusion criteria
the RTF [11] at the baseline encounter and at each of four quarterly
follow-up encounters over 12 months. This item, which asked partici-
Study participants were recruited through the Pain Registry for pants about the bothersomeness of widespread pain during the past
Epidemiological, Clinical, and Interventional Studies and Innovation four weeks, was used to measure the period prevalence rate of
 Licciardone: Preventing progression to widespread pain 23

widespread pain. The latter was considered to have occurred if a female. The medical care groups were comparable on many
participant reported being bothered “a little” or “a lot” by widespread sociodemographic and clinical characteristics at the time of
pain at any encounter. An ordinal variable was also used to measure
registry enrollment (Table 1). Prior use of spinal manipulation
widespread pain severity by assigning the following values to each
response option at each encounter: “not bothered at all,” 0; “bothered a was more often reported in the osteopathic medical care
little,” 1; and “bothered a lot,” 2. Thus, this measure potentially ranged group (68.3%) than in the allopathic medical care group
from 0 (no widespread pain) to 10 (most severe widespread pain). (44.0%) (p<0.001). Other less highly significant group dif-
The Patient-Reported Outcomes Measurement Information ferences involved educational level, cigarette smoking status,
System with 29 items (PROMIS-29) [12] was used to measure seven
heart disease, and use of acupuncture. Osteopathic manip-
dimensions of HRQOL: physical function, anxiety, depression,
ulative treatment was used by 73 (15.8%) participants,
fatigue, sleep disturbance, participation in social roles and activ-
ities, and pain interference with activities. Responses for each possibly used by 179 (38.7%) participants, and never used by
dimension were transformed to standardized scores that are normed 210 (45.5%) participants.
according to the United States general population, wherein the mean The period prevalence rate of widespread pain was 77
is 50 and SD is 10 on each scale. Higher scores represent worse (76.2%) for participants in the osteopathic medical care
HRQOL on each scale except physical function and participation
group, as compared with 315 (87.3%) for participants in the
in social roles and activities.
allopathic medical care group (OR, 0.47; 95% CI, 0.27–0.81;
p=0.006). The lower prevalence of widespread pain in the
Statistical analysis
osteopathic medical care group persisted after adjustment
for age, sex, and the other potential confounders (OR, 0.48;
Sociodemographic characteristics, history of low back pain and co-
morbid medical conditions, and treatments for low back pain were 95% CI, 0.26–0.90; p=0.02). The period prevalence rate of
used to describe the participants, including the mean ± SD for widespread pain was 52 (71.2%) for participants who used
continuous variables and the number (%) for categorical variables. OMT, 159 (88.8%) for participants who possibly used OMT,
Contingency table methods were used to compute the crude odds ratio and 181 (86.2%) for participants who never used OMT.
(OR) and 95% confidence interval (CI) for the period prevalence rate of
There was a lower risk of widespread pain in the group that
widespread pain over 12 months in the osteopathic medical care group
vs. the allopathic medical care group. Multiple logistic regression
used OMT vs. the group that never used OMT as a control
was used to adjust the OR and 95% CI for age, sex, race, ethnicity, group (OR, 0.40; 95% CI, 0.21–0.75; p=0.004), but not in
education, cigarette smoking status, history of comorbid conditions the group that possibly used OMT (OR, 1.27; 95% CI, 0.69–
(herniated disc, sciatica, osteoarthritis, osteoporosis, hypertension, 2.34; p=0.43). The lower prevalence of widespread pain in
heart disease, diabetes mellitus, asthma, and depression), and previous the group that used OMT did not persist after adjustment
low back surgery. Similar analyses were repeated to measure and
for potential confounders (OR, 0.59; 95% CI, 0.27–1.26;
compare the period prevalence rates of widespread pain in the three OMT
use groups. Non-parametric statistics were used to analyze data for the p=0.17).
widespread pain severity score because it was not normally distributed. The osteopathic medical care group reported lower
These included the Mann-Whitney test for comparison of the osteopathic widespread pain severity than the allopathic medical care
and allopathic medical care groups and the Kruskal-Wallis test for group (median, 2; interquartile range, 0–4 vs. median, 3;
comparison of the OMT use groups. Repeated measures analysis of
interquartile range, 0–5) (p=0.008) (Figure 2). Corre-
variance was used to compare the medical care and OMT use groups on
each of the seven dimensions of HRQOL over 12 months, including
spondingly, the group that used OMT reported lower pain
adjustment for age and sex. As the clinical importance of significant severity (median, 2; interquartile range, 0–5.5) than the
between-group differences in the HRQOL dimensions may not be intui- groups that possibly used OMT (median, 4; interquartile
tively obvious, they were further measured with Cohen’s d statistic for range, 2–7) and never used OMT (median, 4.5; interquartile
effect size [13]. Effect sizes greater than 0.20 were considered clinically range, 2–6) (p=0.02).
important. Data management and statistical analyses were performed
The osteopathic medical care group reported better
with the IBM SPSS Statistics software package (Version 25). Two-sided
tests and significance thresholds of p≤0.05 were used for all statistical age- and sex-adjusted outcomes for each of the seven
analyses. dimensions of HRQOL throughout the study (Figure 3).
The group differences in age- and sex-adjusted main ef-
fects were: mean, 3.29; 95% CI, 1.66–4.92 (p<0.001;
Results d=0.37) for physical function; mean, 2.78; 95% CI, 0.50–
5.06 (p=0.02; d=0.22) for anxiety; mean, 2.94; 95% CI,
A total of 462 registry participants met the eligibility criteria, 0.74–5.15 (p=0.009; d=0.24) for depression; mean, 2.36;
including 101 (21.9%) in the osteopathic medical care group 95% CI, 0.02–4.71 (p=0.048; d=0.18) for fatigue; mean,
(Figure 1). The mean age of participants at baseline was 2.96; 95% CI, 1.10–4.81 (p=0.002; d=0.29) for sleep
52.7 ± 13.2 years (range, 22–79 years) and 336 (72.7%) were disturbance; mean, 3.77; 95% CI, 1.72–5.82 (p<0.001;
24 Licciardone: Preventing progression to widespread pain

Figure 1: Flow of participants through the

study.

d=0.34) for participation in social roles and activities; and mean, 3.05; 95% CI, 0.57–5.53 (p=0.02; d=0.29) for
mean, 3.16; 95% CI, 1.36–4.96 (p=0.001; d=0.32) for pain depression; mean, 1.60; 95% CI, −1.01 to 4.22 (p=0.23;
interference with activities. These group differences were d=0.14) for fatigue; mean, 2.89; 95% CI, 0.81–4.97
clinically important for all HRQOL dimensions except (p=0.007; d=0.33) for sleep disturbance; mean, 3.90; 95%
fatigue. CI, 1.62–6.19 (p=0.001; d=0.40) for participation in social
The use of OMT was associated with better age- and roles and activities; and mean, 3.71; 95% CI, 1.69–5.73
sex-adjusted outcomes for all HRQOL dimensions except (p<0.001; d=0.43) for pain interference with activities.
fatigue (Figure 4). The group differences in age- and sex- These group differences were statistically significant and
adjusted main effects for participants who used OMT vs. clinically important for all HRQOL dimensions except fa-
those who never used OMT were: mean, 4.31; 95% CI, tigue. The group that possibly used OMT did not report
2.48–6.14 (p<0.001; d=0.56) for physical function; mean, better age- and sex-adjusted outcomes on any of the
3.42; 95% CI, 0.86–5.99 (p=0.009; d=0.32) for anxiety; HRQOL dimensions.
 Licciardone: Preventing progression to widespread pain 25

Table : Baseline participant characteristics by medical care group Table : (continued)

(n=).
Characteristic Osteo- Allopathic
Characteristic Osteo- Allopathic pathic medical
pathic medical medical care
medical care care
care
n= n=
n= n=
No. % No. % p-
No. % No. % p- Value
Value
Current use of drug therapy for low back pain
Age, year (mean, SD) . . . . . Nonsteroidal anti-inflammatory  .  . .
Female sex  .  . . drugs
Race . Opioids  .  . .
White  .  .
*Body mass index (BMI) was not available for six participants.
Black  .  .
Asian  .  .
American Indian/Alaska Native  .  .
Native Hawaiian/Pacific  .  .
Islander Discussion
Hispanic ethnicity  .  . .
Educational level .
Less than college degree  .  . This study found that the groups who received osteopathic
Bachelor or master degree  .  . medical care and who used OMT were both less likely to
Professional or doctoral degree  .  . progress from chronic low back pain to widespread pain
Ever lost work for one or more months due to low back pain over the course of 12 months. Accordingly, both of these
 .  . .
groups also reported lower widespread pain severity. These
Ever applied for or received disability or workers’ compensation
benefits due to low back pain
findings align with the view that osteopathic physicians
 .  . . provide a more holistic approach to medical care,
Ever involved in a legal claim related to low back pain including use of OMT when indicated for low back pain [9].
 .  . . In providing medical care for patients with chronic low
Cigarette smoking status . back pain, osteopathic physicians may assess and treat
Never or former smoker  .  .
such patients more comprehensively rather than focusing
Current smoker  .  .
BMI, kg/m (mean, SD)* . . . . . only on pain within a limited anatomical location, thereby
Medical conditions ever diagnosed lowering the risk of widespread pain progression and its
Herniated disc  .  . . impact on HRQOL. Indeed, it has been argued that osteo-
Sciatica  .  . . pathic tenets and principles for pain management pre-
Osteoarthritis  .  . .
ceded the widely accepted and heuristic biopsychosocial
Osteoporosis  .  . .
Hypertension  .  . .
approach [14]. Proponents of the latter approach now
Heart disease  .  . . recognize the importance of the physician-patient rela-
Diabetes mellitus  .  . . tionship in offering empathy, encouragement, and hope
Asthma  .  . . for patients with chronic pain [15].
Depression  .  . . The study findings also support the American Osteo-
History of low back surgery .
pathic Association guideline for OMT for patients with low
Yes, one surgery  .  .
Yes, more than one surgery  .  . back pain [5]. Therein, it is recommended that osteopathic
No  .  . physicians assess patients to determine if somatic
Ever use of non-pharmacological treatments for low back pain dysfunction is the cause or a contributing factor in the
Exercise therapy  .  . . presentation of low back pain. If somatic dysfunction is the
Yoga  .  . .
cause of low back pain, then OMT should be used to
Massage therapy  .  . .
Spinal manipulation  .  . <.
address its impact on the body framework system,
Acupuncture  .  . . including any skeletal, arthrodial, and myofascial struc-
Cognitive behavioral therapy  .  . . tures that may be affected, and their related vascular,
26 Licciardone: Preventing progression to widespread pain

Figure 2: Widespread pain severity according to group. Group comparisons involve the medical care group (A) and whether osteopathic
manipulative treatment (OMT) was used (B). The severity score represents the sum of participant responses at five quarterly encounters from
baseline through the 12-month follow-up. Higher scores represent more severe widespread pain. A score of 0 indicates that widespread pain
was not reported during the study.

lymphatic, and neural elements [16]. If somatic dysfunction participants had missing encounters during the 12 months
is only a contributing factor to low back pain, then an ex- of follow-up, thereby requiring exclusion from the study.
amination for the primary cause should be undertaken so The remaining participants reported complete data, thus
that it may be treated accordingly. obviating the need for imputation of missing data. Partic-
The lower risk of widespread pain observed in the ipants with physician crossover were excluded to derive
groups receiving osteopathic medical care and using OMT more specific estimates of the treatment effects for each of
over 12 months was associated with benefits in HRQOL. It is the medical care groups.
noteworthy that these benefits were observed in all seven The study was limited by using standard case report
dimensions of HRQOL except fatigue. These included forms that did not include validated research instruments
benefits relating to anxiety, depression, and sleep distur- for widespread pain. The latter may be considered an early
bance, which are not generally assessed in studies of or mild stage of fibromyalgia [18]. Clinical criteria for fi-
musculoskeletal disorders, including those specifically bromyalgia have been established and modified over the
involving OMT. Previous research has shown that patients past three decades, including the development of patient
treated by osteopathic physicians report greater physician self-report instruments for research purposes [19–21]. Such
empathy and better interpersonal manner than patients instruments are not deployed in the registry to avoid an
treated by allopathic physicians, as well as better outcomes onerous participant reporting burden at each encounter.
relating to back-related functioning [17]. The present The simple participant self-report item on widespread pain
findings for anxiety, depression, and sleep disturbance in the Minimum Dataset for Chronic Low Back Pain used
further support the view that osteopathic physicians take a herein has shown promise as a sensitive measure of the
holistic approach that transcends merely focusing on the early manifestations of fibromyalgia [22]; however, it has
musculoskeletal aspects of chronic low back pain that are limited specificity. Consequently, the registry recently
more likely to impact such HRQOL dimensions as physical began collecting participant data on fibromyalgia as a co-
function, participation in social roles and activities, and morbid condition using a new item on its case report forms.
pain interference with activities. However, there were an insufficient number of participants
This study has several strengths that should be noted. who completed this new item to perform meaningful ana-
It was conducted within a pain research registry involving lyses in the present study. Similarly, there were too few
a digital research platform that enabled remote data participants who were entirely free of widespread pain at
acquisition throughout the 48 contiguous states and Dis- the baseline encounter to assemble a suitable inception
trict of Columbia using a series of validated research in- cohort to measure the incidence rate of widespread pain.
struments relating to chronic low back pain, including The period prevalence rate was thus used as an alternative
several recommended by the RTF [11]. Only 6.7% of registry measure of risk.
 Licciardone: Preventing progression to widespread pain 27

Figure 3: Health-related quality-of-life outcomes according to medical care group. Group comparisons involve physical function (A), anxiety
(B), depression (C), fatigue (D), sleep disturbance (E), participation in social roles and activities (F), and pain interference with activities (G).
The scores for these dimensions on the Patient-Reported Outcomes Measurement Information System with 29 items were transformed and
standardized using the Unites States general population, wherein the mean is 50 and standard deviation is 10. Higher scores represent worse
outcomes on each dimension except physical function and participation in social roles and activities. Error bars represent 95% confidence
intervals.
28 Licciardone: Preventing progression to widespread pain

Figure 4: Health-related quality-of-life outcomes according to osteopathic manipulative treatment (OMT) group. Group comparisons involve
physical function (A), anxiety (B), depression (C), fatigue (D), sleep disturbance (E), participation in social roles and activities (F), and pain
interference with activities (G). The scores for these dimensions on the Patient-Reported Outcomes Measurement Information System with 29
items were transformed and standardized using the Unites States general population, wherein the mean is 50 and standard deviation is 10.
Higher scores represent worse outcomes on each dimension except physical function and participation in social roles and activities. Error bars
represent 95% confidence intervals. Pairwise comparisons of participants who used and never used OMT are further presented in the text.
 Licciardone: Preventing progression to widespread pain 29

Conclusions 8. Licciardone JC, Gatchel RJ, Aryal S. Recovery from chronic low
back pain after osteopathic manipulative treatment: a
randomized controlled trial. J Am Osteopath Assoc 2016;116:
The study findings reported herein support the claims that 144–55.
osteopathic physicians practice a more holistic approach to 9. Howell JD. The paradox of osteopathy. N Engl J Med 1999;341:
medical care. This was demonstrated through a lower risk 1465–8.
of progression from chronic low back pain to widespread 10. American Medical Association. AOA and AMA stand against
misrepresentation of osteopathic physicians; 2020.
pain, lower widespread pain severity, and lesser deficits in
https://www.ama-assn.org/press-center/ama-statements/aoa-
HRQOL in the groups that received osteopathic medical and-ama-stand-against-misrepresentation-osteopathic-
care and that used OMT. physicians [Accessed 23 Nov 2020].
11. Deyo RA, Dworkin SF, Amtmann D, Andersson G, Borenstein D,
Research funding: None reported. Carragee E, et al. Report of the NIH Task Force on research
standards for chronic low back pain. J Pain 2014;15:569–85.
Author contributions: The author has accepted responsibility
12. PROMIS Health Organization and PROMIS Cooperative Group.
for the content of this manuscript and approved its submission. Chicago, IL: PROMIS-29 Profile v2.0; 2013.
Competing interests: None reported. 13. McGough JJ, Faraone SV. Estimating the size of treatment effects:
Ethical approval: Registry procedures were approved by moving beyond p values. Psychiatry 2009;6:21–9.
the North Texas Regional Institutional Review Board 14. Minotti D, Licciardone JC, Kearns C, Gatchel RJ. Osteopathic
(protocol 2015-169). medicine: approach to pain management. Practical Pain Manag
2010;10:37–8.
Informed consent: All enrollees provided written informed
15. Ballantyne JC, Sullivan MD. Intensity of chronic pain–the wrong
consent. metric? N Engl J Med 2015;373:2098–9.
16. Giusti R. Glossary of osteopathic terminology. In: Seffinger MA,
Hruby R, Willard FH, Licciardone J, editors. Foundations of
References osteopathic medicine: philosophy, science, clinical applications,
and research, 4th ed. Philadelphia, PA: Wolters Kluwer; 2018:
1. Cypress BK. Characteristics of physician visits for back symptoms: 1563–94 pp.
a national perspective. Am J Publ Health 1983;73:389–95. 17. Licciardone JC, Schmitt ME, Aryal S. Osteopathic and allopathic
2. Licciardone JC. A national study of primary care provided by physician interpersonal manner, empathy, and communication
osteopathic physicians. J Am Osteopath Assoc 2015;115:704–13. style and clinical status of their patients: a pain registry-based
3. Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative study. J Am Osteopath Assoc 2019;119:499–510.
treatment for low back pain: a systematic review and meta- 18. Staud R. Chronic widespread pain and fibromyalgia: two sides of
analysis of randomized controlled trials. BMC Muscoskel Disord the same coin? Curr Rheumatol Rep 2009;11:433–6.
2005;6:43. 19. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C,
4. Clinical Guideline Subcommittee on Low Back Pain. American Goldenberg DL, et al. The American College of Rheumatology
Osteopathic Association guidelines for osteopathic manipulative 1990 criteria for the classification of fibromyalgia. Report of the
treatment (OMT) for patients with low back pain. J Am Osteopath Multicenter Criteria Committee. Arthritis Rheum 1990;33:
Assoc 2010;110:653–66. 160–72.
5. Task Force on the Low Back Pain Clinical Practice Guideline. 20. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz
American Osteopathic Association guidelines for osteopathic RS, et al. Fibromyalgia criteria and severity scales for clinical and
manipulative treatment (OMT) for patients with low back pain. J Am epidemiological studies: a modification of the ACR preliminary
Osteopath Assoc 2016;116:536–49. diagnostic criteria for fibromyalgia. J Rheumatol 2011;38:
6. Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment 1113–22.
for nonspecific low back pain: a systematic review and meta- 21. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz
analysis. BMC Muscoskel Disord 2014;15:286. RL, et al. 2016 revisions to the 2010/2011 fibromyalgia diagnostic
7. Licciardone JC, Gatchel RJ, Aryal S. Targeting patient subgroups criteria. Semin Arthritis Rheum 2016;46:319–29.
with chronic low back pain for osteopathic manipulative 22. Licciardone JC, Pandya V. Prevalence and impact of comorbid
treatment: responder analyses from a randomized controlled trial. widespread pain in adults with chronic low back pain: a registry-
J Am Osteopath Assoc 2016;116:156–68. based study. J Am Board Fam Med 2020;33:541–8.