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The Somatic Connection  |   July 2006
The Somatic Connection
Article Information
The Somatic Connection   |   July 2006
The Somatic Connection
The Journal of the American Osteopathic Association, July 2006, Vol. 106, 381-383. doi:
The Journal of the American Osteopathic Association, July 2006, Vol. 106, 381-383. doi:
Osteopathic Manipulative Treatment and Acupuncture Provide Therapeutic Benefit to Children With Spastic Cerebral Palsy
Twenty-four of every 10,000 children born in the United States have cerebral palsy. The illness is caused by injury or trauma to the central nervous system during the brain's most rapid stage of development—prior to or shortly after birth. Although the injury or trauma is static and the resulting motor dysfunction is nonprogressive, the peripheral manifestations, especially in ambulation and speech, are far from static. Swallowing difficulties are progressive in some cases of cerebral palsy, while incontinence and epilepsy accompany many others. There are anecdotal reports of patients with cerebral palsy benefiting from osteopathic manipulative treatment (OMT) in the United States and acupuncture in East Asia. 
A pilot study was performed to evaluate the effectiveness of OMT and acupuncture as supplemental therapies for children with spastic cerebral palsy. From a pool of 5000 patients in Tucson, Ariz, 50 children were randomly selected to receive OMT or acupuncture or to be in a group of wait-list controls. The children ranged in age from 11 months to 12 years. Two children were younger than 24 months, and 39 were older than 4 years. At the time of enrollment, 20 children (58%) were classified as level 4 or 5 (the most severe levels of cerebral palsy) on the Gross Motor Functional Classification System. 
Twenty-three children were randomized to receive OMT; 19 to receive acupuncture; and 8 to receive combination therapy. Nineteen others served as wait-list controls. The period for each treatment arm and for the control arm was 24 weeks. 
In administering OMT, osteopathic physicians used the techniques of craniosacral and myofascial release. The acupuncturist used a combination of scalp, body, and auricular techniques bilaterally. Parents were asked to describe any changes they noticed in the children and to mark their perceptions of their children's levels of muscle stiffness and happiness on two visual log scales, each 100 mm in length. 
Two of the 17 parents of children in the control arm reported improvements (in children's mood) while their children were in this arm. All 17 of these parents reported improvements in their children after the children had completed treatment/therapy in the OMT group or acupuncture group. After all 50 children had completed treatment/therapy, all but two of the parents reported improvements. The most frequently noted area of improvement was the use of children's legs or hands, which was reported for 14 (61%) children in the OMT group; 13 (68%) in the acupuncture group; and 5 (71%) in the combination therapy group. An increase in restful sleep was the next most frequently reported improvement. Many parents of children in each of the four groups recorded a decrease in muscle stiffness on the visual logs. Children's level of happiness, as recorded on the logs, improved to a greater extent in the OMT group than in the acupuncture, combination therapy, or control groups. 
These results indicate that both OMT and acupuncture have beneficial results in children with spastic cerebral palsy. However, because a large proportion of the children in this study were severely disabled and relatively old, they may not have been optimal candidates to represent the population of children with cerebral palsy. — FJR 
Duncan B, Barton L, Edmonds D, Blashill BM. Clin Pediatr. 2004;43:349 –353.  
Long-term Follow-up of Patients With Low Back Pain May Reflect Psychological Distress
Low back pain is viewed as a largely self-limited problem with a favorable prognosis. However, this opinion is based mostly on patient outcomes evaluated within 12 months of presentation. A different pattern may emerge if the natural history of low back pain is considered in the context of a patient's lifetime. Low back pain may then be seen as a recurring phenomenon with varying degrees of pain and/or disability. Psychological and psychosocial factors may play an important role in the transition from acute to chronic low back pain. 
Two hundred fifty-two patients who were treated for low back pain at osteopathic manipulation clinics in the United Kingdom were evaluated over an average 4-year follow-up period. Clinical and psychosocial data were obtained at baseline. Mailed Roland Disability Questionnaires (which include assessments of pain intensity on a scale of 0 to 24) collected self-reported outcomes of pain, disability, symptom recurrence, and care seeking. Each patient received an average of 6.6 osteopathic manipulation sessions, in addition to encouragement and advice to remain active and avoid excessive rest. There was no attempt to assess or provide therapy for psychosocial factors. 
Of the 151 patients who had responded to the mailed surveys at 4 year follow-up, 119 (79%) reported having additional low back pain after 12 months. The likelihood of persistence of pain was related to the duration of symptoms prior to consultation for the index event. Four variables were identified as predictors of symptom recurrence: (1) longer duration of presenting symptoms; (2) presence of leg pain; (3) higher fear-avoidance belief; and (4) heightened somatic concern. 
The majority of patients in the study sought ongoing care with their original osteopathic practitioners rather than general practitioners, physical therapists, or hospital consultants. There was a trend for patients' symptoms to be marginally worse after 4 years. 
This study suggests that a high proportion of patients undergoing manipulative therapy for low back pain are likely to have long-term symptoms and disability. The patients' Roland Disability Questionnaire scores at 4 years were statistically related to their baseline depressive symptoms and pain intensity levels. The nature of patients' pain-related behaviors and psychological distress—rather than just the nociceptive component of their pain—may determine long-term outcomes. Practitioners are therefore advised to incorporate treatment and follow-up strategies based on biopsychosocial principles. — FJR 
Burton AK, McClune TD, Clarke RD, Main CJ. Man Ther. 2004;9:30 –35.  
Psychosocial Differences are Important Determinants for Treatment Outcomes in Patients With Chronic Low Back Pain
Chronic low back pain has a high prevalence rate and considerable socioeconomic consequences in the industrialized world. The public would benefit from early identification and treatment of individuals at high risk for developing chronic low back pain. 
To determine the relative influences of sociodemographic and episode-specific factors on relieving intensity of low back pain and disability, Niemistö et al conducted a randomized controlled trial of 204 patients in Finland with chronic low back pain. Half (n=102) of the patients received a combination of “manipulative treatment” and physician consultation, while the other half (n=102) received consultation alone. At 1 year, each group was divided into two clusters based on changes in pain intensity and self-related levels of disability. One cluster included patients whose symptoms clearly decreased, and the other included those whose symptoms persisted. 
Severe affective distress predicted a poor outcome to manipulative treatment. Individuals who did not benefit from physician consultation included those who had taken more than 25 days of sick leave from work during the previous year, those with feelings of “poor life control,” and those with generalized somatic symptoms. 
By univariant analysis, the sociodemographic factors that best predicted poor recovery from pain and disability were an unmarried status and a high level of education. The strongest single predictive factor was a low to moderate level of back pain intensity, which was associated with a fivefold increase in the odds of persistence of symptoms. More than 25 days of sick leave attributed to low back pain during the previous year was associated with a threefold increase in the odds of a poor outcome in the entire study population and a sevenfold increase in the odds of a poor outcome for the consultation group alone. Severe affective distress was associated with an almost threefold increase in the odds of a poor outcome in the manipulation group. 
The authors found a direct correlation between two descriptive groups and minimal improvement in symptoms after outpatient approaches. One group included highly educated individuals with minimal to moderate symptoms. For this group, the authors recommended more informative outpatient consultation. The second group included individuals with a great amount of psychosocial burden, work absenteeism, and poor subjective expectations of future work ability. For this group, the authors recommended consultation, manual treatments, and interventions focusing on psychosocial distress. — FJR 
Niemistö L, Sarna S, Lahtinen-Suopanki T, Lindgren KA, Hurri H. J Rehabil Med. 2004;36:104 –109.  
Back Pain and Patient Care Preferences
Back pain is a common chronic condition in industrialized countries. Yet, little is known about the treatment preferences of patients with this health problem. 
In 1997, questionnaires were mailed to a random sample of 14,868 adults, aged 18 to 64 years, in four counties in England. Responses were received from 8889 of these individuals. The respondents noted any long-standing illnesses, disabilities, or infirmities on the questionnaires. They identified their conditions from a checklist of 15 common conditions, including back pain. The respondents also answered questions about their use of healthcare practitioners, both conventional and complementary. 
Back pain was the most commonly reported chronic condition, affecting 1377 (15.6%) of the respondents. More women than men and more manual workers than nonmanual workers reported having chronic back pain. Prevalence increased with age—back pain was reported by 8.5% of those aged 18 to 33 years; 15.5% of those aged 34 to 49 years; and 23.4% of those aged 50 to 64 years. 
Four hundred eight (4.6%) respondents reported having consultations with “practitioners of osteopathy or chiropractic” during the previous 3 months, while 430 (4.8%) reported consulting practitioners of physiotherapy. Some 45% of the “osteopathy/chiropractic consultations” were reported by people who also reported back pain. Approximately 31% of the physiotherapy consultations were reported by people with back pain. A greater proportion of respondents who consulted “osteopaths/chiropractors” were free of any long-standing illnesses, disabilities, or infirmities, compared with those who consulted physiotherapists. 
In the analyses of individual variables involving all respondents, six “lifestyle and health politics” factors were predictive of osteopathic or chiropractic use: (1) “not currently smoking tobacco at least once a day,” (2) “engaging in any physical activity/exercise for at least 30 minutes more than once a week on the average,” (3) “wanting to take more exercise,” (4) “worrying about the global environment some of the time or more often,” (5) “wanting to be involved in helping to make local NHS [National Health Service] decisions,” and (6) alcohol consumption. 
This study indicated that nonmanual workers with back pain in England are twice as likely to use osteopathic or chiropractic services than are manual workers with back pain. The great majority of osteopathic and chiropractic consultations in United Kingdom are private. Thus, this conclusion suggests that individuals in United Kingdom who can afford private treatment tend to choose osteopathic or chiropractic services over physiotherapy services. — FJR 
Ong CK, Doll H, Bodeker G, Stewart-Brown S. Health Soc Care Community.. (2004). ;12:265 –273.  
Practitioners of Spinal Manipulation are Unlikely to be Aware of Short-term Adverse Effects in Patients
Scientific investigations evaluating the safety of spinal manipulative therapy and treatment have been limited. Previous reports suggest that severe adverse effects—primarily involving the neck (cerebrovascular accident), midback (rib fractures), and lumbar spine (cauda equina lesions)—have low incidence rates. Relatively minor adverse effects may be common, but their incidence rates have not been quantified. 
Fifty-nine randomly invited, registered practitioners of spinal manipulation in Belgium (21 chiropractors, 20 manual physiotherapists, 18 “osteopaths”) participated in a study of adverse effects by Cagnie et al. Each practitioner received 15 questionnaires to distribute to 15 new, consecutive patients at each patient's first manipulative therapy/treatment session. On the questionnaire, patients recorded their risk factors and any adverse effects experienced within 48 hours of therapy/treatment. The practitioners likewise completed a questionnaire describing each patient's medical diagnosis, the region treated, and the type and number of manipulative interventions used. 
Fifty-one (86%) of the practitioners returned their questionnaires. Each practitioner distributed an average of 12.5 questionnaires to his or her patients, representing a total of 639 patients. Of these, 465 (73%) patients returned their questionnaires. 
The results of these questionnaires revealed that about 29% of the patients received 3 or more manipulative interventions, 38% received 2 interventions, and 33% received 1 intervention. Of the 930 recorded interventions, about 39% treated the cervical spine; 26%, the thoracic spine; 24%, the lumbar spine; and 12%, the sacroiliac. 
Two hundred eighty-three patients (61%) reported at least one postmanipulative adverse reaction. The most common reactions were headache (20%), stiffness (20%), aggravation of complaints (15%), and radiating discomfort and fatigue (each 12%). Most of these reactions began within 4 hours of therapy/treatment and disappeared within the next 24 hours. Women were more likely than men to report adverse effects (P<.001). Multivariant analysis showed that upper cervical manipulation, the use of medication, and patient sex and age were independent predictors of headache after spinal manipulation. 
These results indicated that reactions to spinal manipulation may be relatively common but are mostly benign and of short duration. It is important to identify those patients who are most susceptible to adverse effects in order to inform them of the potential risks of therapy/treatment. — FJR  
Cagnie B, Vinck E, Beernaert A, Cambier D. Man Ther. 2004;9:151 –156.  
 “The Somatic Connection” highlights and summarizes important contributions to the growing body of literature on the musculoskeletal system's role in health and disease. This section of JAOA—The Journal of the American Osteopathic Association strives to chronicle the significant increase in published research on manipulative methods in the United States and the renewed interest in manual medicine internationally, especially in Europe.
 
 Designed to inform osteopathic physicians about significant musculoskeletal research being published in journals other than the JAOA, “The Somatic Connection” gives special attention to research articles directly related to the tenets and principles of osteopathic medicine.
 
 Some research articles featured in “The Somatic Connection” may focus on tests of the efficacy of manipulative methods in a variety of clinical situations. Other articles may focus on other aspects of the musculoskeletal system, including the mechanism of chronic pain and interventions other than spinal manipulation.
 
 To identify research articles to feature, the editors of “The Somatic Connection” search multiple electronic databases and assess articles for their scientific validity. Readers are encouraged to submit scientific reports for consideration to the following editors of “The Somatic Connection”: JAOA Associate Editor Felix J. Rogers, DO (fjrogers@aol.com), or Michael A. Seffinger, DO (mseffinger@westernu.edu).