Chronic Low Back Pain (CLBP) is pain that is located between the costal margin and buttocks and has persisted for longer than 3 months. Patients suffer physical disabilities and psychological distress concurrently with the pain . The condition has a high incidence and prevalence. International back pain researcher Gordon Waddell  described CLBP as a 21st century epidemic. In 2007, 13.8% of Australian population (2,846,400) stated they had a back pain/problem, and/or a disc disorder . These disorders are categorised as musculoskeletal conditions, and in 2004–05, musculoskeletal conditions were more prevalent than any other of the National Health Priority Areas (NHPAs), with 31% of Australians suffering from one or more of these conditions . Arthritis and musculoskeletal conditions were also responsible for the main disabling condition in more than one in three Australians with a disability , and were a major area of health expenditure in 2001–02, with around $4.6 billion spent on the conditions.
Non-specific low back pain is described in a recent review of national guidelines  as a diagnosis of exclusion, where pain caused by a suspected or confirmed serious pathology (‘red flag’ conditions such as tumour, infection or fracture) or presenting as a radicular syndrome have been ruled out . The review states that some guidelines, e.g. the Australian and New Zealand guidelines, do not distinguish between non-specific low back pain and radicular syndrome.
Osteopathic Medicine is a medical system of diagnosis and therapy based on a set of overarching principles that give osteopathic medicine a holistic basis for its practice . It is practiced worldwide, predominantly in developed western nations, and the practice varies from full medical scope in the US to allied/adjunctive health in the UK, Australia and New Zealand amongst others. A major foundation of osteopathic medicine worldwide is an evaluation of the somatic tissues for signs of dysfunction which is treated with a broad range of manual therapies and adjunctive care.
Osteopaths manage a range of patients depending on the jurisdiction and scope of practice. Because of utilising the holistic diagnostic model and a broad range of manual techniques, Osteopathic Manipulative Treatment (OMT) cannot be confined to a single intervention. Osteopathic medicine is one of the registered professions legally allowed to use Spinal Manipulative Therapy (SMT), defined as manual loading of the spine using short or long leverage methods , and SMT as a single modality has been heavily researched [7, 8]. John Licciardone, principal author of the only systematic review of OMT in chronic low back pain and a senior clinical academic, warns that OMT is not chiropractic or simple SMT, but a complex intervention based on a multi-factorial diagnostic work up .
The results of a sample of 2238 patients presenting to 255 Australian osteopathic practices  demonstrate that chronic low back pain is a common presenting problem to these practices, and that the interventions are multi-dimensional. The most common primary presenting symptom was pain located in the lumbar spine (27.3%), and 51.2% of the primary presenting complaints were classified as chronic. The osteopathic intervention on this subset of patients was predominantly soft tissue techniques (78% received this modality), joint articulation (65%), muscle energy (58%), high velocity manipulation (synonymous with SMT) (55%) and exercise advice (42%) .
The results of a pilot study surveying 342 osteopathic practices in the United Kingdom that collected data on 1630 patients  demonstrated that pain located in the lower back was the most common presenting symptom (36%), and that 37.7% of patients presenting had chronic complaints. The most common osteopathic interventions for these patients were soft tissue techniques (78% received this modality), joint articulation (72.7%), high velocity manipulation (37.7%) and education (35.8%).
There is a need to evaluate the effectiveness of this service to these patients using rigorous research that can be applied to practice. A comparative review of the clinical trial literature of SMT or massage or osteopathy in the treatment of low back pain reveals an evidence base for SMT and massage, both modalities in use by osteopaths, but a lack of research into whole osteopathic practice as demonstrated in the survey data mentioned. A Cochrane review of SMT in low back pain concluded that despite over 800 publications addressing this issue, evidence for the effect on low back pain is equivocal . The Cochrane review of 13 clinical trials of massage found that there is evidence that it may be beneficial for subacute and chronic low back pain in conjunction with exercise . A systematic review and meta-analysis of osteopathic clinical trials up to 2003  concluded that patients had significant improvements from osteopathic intervention, but that many of the results are from trials with small numbers and the intervention is often a single modality or technique.
The question that arises is what is the clinical trial evidence for the osteopathic intervention in CNSLBP, and does the research translate into clinical practice by testing the intervention as it is applied in the everyday practice? Osteopathic intervention for this study is defined specifically as manual intervention and lifestyle advice applied by an osteopath which would be considered by the osteopathic community to be consistent with osteopathic practice. An updated systematic review is warranted to include more recent studies, to apply a rigorous risk of bias assessment, and also to examine the evidence of authentic multidimensional osteopathic intervention, and not simply extrapolating from single modality evidence.
This current Systematic Review of clinical research into osteopathic intervention in chronic non-specific low back pain aims to focus on the quality of the evidence and its applicability to practice. Factors underpinning this objective are: to focus on a study condition that commonly presents to this professional group, to use a rigorous mainstream assessment of quality, and finally to review studies that reflect what is known of authentic osteopathic practice.