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The Somatic Connection  |   November 2008
The Somatic Connection
Article Information
The Somatic Connection   |   November 2008
The Somatic Connection
The Journal of the American Osteopathic Association, November 2008, Vol. 108, 631-633. doi:
The Journal of the American Osteopathic Association, November 2008, Vol. 108, 631-633. doi:
OMT's Effect on the Rule of the Artery
Osteopathic rhetoric claims that osteopathic manipulative therapy can improve blood flow, but no clinical studies have tested that hypothesis in patients with compromised blood flow, such as those with peripheral arterial disease (PAD). 
A group of physicians at the University of Perugia in Italy and a foreign-trained osteopath conducted a case-controlled pilot study to determine the effect of osteopathic manipulative therapy on PAD. In this power analysis–based study, 15 nonsmoking men with PAD elected to receive 6 months of osteopathic manipulative therapy. These subjects were matched with 15 similar patients (age, medical treatment) who did not receive manipulation. All subjects maintained their current treatment regimens (ie, aspirin, angiotensin-converting enzyme inhibitors, statins) throughout the study. 
At each session, the osteopath performed a structural examination to identify areas of somatic dysfunction, which was treated using one or more of the following techniques: craniosacral therapy; high-velocity, low amplitude; lymphatic pump; muscle energy; myofascial release; soft tissue; and strain/counterstrain. In the first 2 months, manipulation was provided for 30 minutes every 2 weeks. In the third month, patient response to manipulation was assessed and techniques were adjusted to improve responses. In the last 3 months, manipulation was applied every 3 weeks. Final assessments were made after the sixth month. Control subjects received laboratory and clinical assessment at the same study points after 30 minutes of rest. 
Compared with the control group at the end of the study, the treatment group had statistically significant increases in brachial flow–mediated vasodilation, ankle/brachial pressure index, treadmill testing, and the physical health component of quality-of-life measures (P<.05). Univariate analysis in the manipulation group revealed a negative correlation between changes in brachial flow–mediated vasodilation and IL-6 levels as well as a positive correlation between claudication pain time and physical function score. Only 3 patients complained of transient muscle tenderness, and no new pathologies or complications were reported. 
The authors conclude that despite the relatively few number of patients in the study, osteopathic manipulative therapy can significantly improve endothelial function and intermittent claudication—the hallmark symptom of PAD—and provide benefits in quality of life. However, the study has other limitations, including the lack of randomization, lack of placebo manipulation, and absence of protocol violation discussion. No difference existed between groups in total walk time, but there was a significant difference in time to claudication favoring the manipulation group. However, the first is likely to be a marker of functional status, and the second outcome measure is subjective. 
This study also raises the question: If osteopathic manipulative therapy affects brachial flow–mediated vasodilation, why aren't the effects more immediate than 6 months? Nevertheless, it is an intriguing article and should stimulate further investigations along these lines. —MAS 
Lombardini R et al [published online ahead of print September 27 , 2008]. Man Ther..  
Managing Musculoskeletal Pain
The global Bone and Joint Decade 2000-2010 initiative—which the American Osteopathic Association (AOA) recently rejoined—charged an international, interdisciplinary task force to develop recommendations for standards of care for patients with musculoskeletal pain. One glaring deficiency in the resulting guidelines, however, is the lack of any reference to osteopathic literature, evaluation for somatic dysfunction, or use of osteopathic manipulative treatment (OMT). This absence is particularly disconcerting considering that musculoskeletal pain is one of the most common conditions managed by osteopathic physicians. 
Despite this oversight, the guidelines recommend that “[a]ll aspects of the patient's life, from overall health to introduced risks, should be reassessed throughout treatment and recovery” and that “[t]he need for further visits should be discussed at each consultation.” These statements are in line with Protocols for Osteopathic Manipulative Treatment, an AOA document (available to AOA members at www.do-online.org), and the AOA-sponsored textbook, Foundations for Osteopathic Medicine (Ward RC, ed. 2003). 
Previous guidelines defined a specific timeframe within which musculoskeletal pain should be managed, including recommendations for limited (eg, 1 month) manual therapy. Therefore, even though OMT is not specifically mentioned in this set of guidelines, the management approach is generally supportive of the osteopathic approach to treating the patient—individualized care, reassessment at each visit, customized yet flexible treatment plan based on patient history and ongoing physical findings, and no predetermined course of treatment. 
Another interesting aspect of this document is its five-point recommendation for the management of chronic musculoskeletal pain conditions, as follows: 
  1. Develop a management plan with the patient.
  2. Tailor the plan to meet the patient's needs.
  3. Create a “backup plan” (ie, actions to take if pain recurs, is exacerbated, or is slow to resolve).
  4. Make sure the plan is clear to the patient and requires review at follow-up visits.
  5. Ensure that the plan enables the patient to take responsibility for care.
These points resonate with the proposed set of tenets of osteopathic medicine and principles for patient care (J Am Osteopath Assoc. 2002;102:63-65). 
The task force of the international Bone and Joint Decade 2000-2010 recommends adopting the management style that uses a collaborative physician-patient treatment plan and places the burden of responsibility on the patient for his or her own healthcare. It will be interesting to see how two future AOA publications—the third edition of the Foundations textbook and the forthcoming OMT guidelines for patients with low back pain—will compare with these recommendations. —MAS 
Walsh NE et al. Arch Phys Med Rehabil. 2008;89:1830-1845.  
OMT Improves Postoperative Ileus
At some point in nearly every osteopathic principles and practice curriculum, an osteopathic manipulative medicine (OMM) faculty member will comment that OMT reduces postoperative ileus. Until recently, support for such comments had been limited to studies published in the Academy of Applied Osteopathy yearbooks by Tilley et al (1959:9-19) and Young (1970:77-82). Studies published in Osteopathic Profession by Tomajan (1935;2[9]:14-17,58) and Siehl (1946;14[3]:20-23,44,46,48) were not as well known. 
However, one study was conducted in a central Florida hospital between 2003 and 2006 to evaluate OMT's effect on postoperative ileus. Of the 331 patients who met inclusion criteria for this retrospective chart review of patients with postoperative ileus who had undergone abdominal surgery, 172 received OMT and 139 did not. Data analysis revealed that OMT patients had significantly shorter hospital stays (11.8 vs. 14.6 days; P=5.029). 
For me, one of the most impressive aspects of this study is the simple fact that a hospital exists in which OMT is provided to inpatients in sufficient numbers to produce this type of retrospective study. As described, OMT was based on the osteopathic diagnosis of somatic dysfunction found, which was addressed by OMT applied to the body regions involved. The variety of OMT providers—from trainees to staff physicians—is a strength of this study, suggesting that the favorable outcomes did not depend on the unique skill of highly experienced OMT specialists. 
Although this study was not designed to examine viscerosomatic interactions, it is a prime example of the potential impact of OMT on physiologic processes and systemic disorders. The authors discuss the concept of facilitated segments and autonomic nervous system interactions, which is highly correlated with the body areas commonly treated in these patients and likely plays a substantial role in ileus in general. 
The results reported in this research study constitute a contribution to the evidence base for OMM in general and the application of OMM in the care of systemic—rather than musculoskeletal—disorders. —HHK 
Crow WT et al [published online ahead of print March 12 , 2008]. Intern J Osteopath Med..  
Risk Factors for Low Back Pain Hospitalization
Compared with 30 years ago, hospitalization for low back pain (LBP) has become less common while the epidemiologic understanding of this condition has improved. For example, it is now known that LBP is an episodic condition, that nearly one-fifth of adolescents have recurrent severe LBP, and that the strongest predictor of a future back pain episode is a history of LBP. 
A prospective longitudinal study assessed the predictive validity of various factors—from health behaviors to school success—on future hospitalization for LBP in a cohort of 72,378 adolescents (aged 14 to 18 years) who were solicited to participate in a national biennial survey in Finland between 1979 and 1997. Follow-up lasted an average of 11.1 years (range, 0 to 23 years). The endpoints were the date of the first LBP hospitalization, the date of death, or the end of the study on December 31, 2001. 
Only 810 (1.1%) participants—620 males, 190 females—were hospitalized for LBP. In multivariate Cox analysis, the strongest risk factors for LBP hospitalization for all participants were weekly health complaints, daily smoking, and poor school success. Alcohol abuse increased and late puberty decreased the risk in young men. Among young women, non-nuclear family and participation in “sports clubs” were associated with an increased risk for LBP hospitalization. These associations persisted into adulthood. 
As described by the authors, education, reduction of adolescent smoking, and better preventive care during organized sports may decrease LBP hospitalizations. In the context of osteopathic medicine, a study on somatic dysfunction in adolescence as a risk for adult LBP hospitalization as well as osteopathic manipulative treatment's ability to decrease that risk would be interesting. I hope this question will be answered through the osteopathic registry research project, which is scheduled to begin in January 2009. —MAS 
Mattila VM et al. Pain. 2008;139:209-217.  
Risk Factors for Lumbar Discectomy
Lumbar discectomy for herniated nucleus pulposus causing radiculopathy is a relatively common orthopedic surgical procedure in adults. Researchers used Finland's national biennial Adolescent Health and Lifestyle Survey as baseline data to conduct a large prospective longitudinal study of risk factors for lumbar discectomy in adolescents. All individuals have equal access to healthcare in Finland and, likewise, the same likelihood of obtaining the monitored condition (ie, lumbar discectomy). 
Survey respondents totaled 57,408 (ages 14-18) over an average of an 11-year span (follow-up, range 5 to 23 years). Study endpoints were lumbar discectomy, death, or end of study on December 31, 2001. 
Of the 57,382 respondents who met study criteria, 251 (0.4%)—166 males, 85 females–underwent lumbar discectomy during follow-up, resulting in a person-based incidence of 40.8 per 100,000 person-years. The median age at the onset of lumbar discectomy was 27 years (range 15 to 41 years). Ten patients (4%) were younger than 18 at the time of surgery, 166 (66%) were aged between 18 and 29 years, and 75 (30%) were older than 30 years. 
In multivariate Cox regression analysis, the significant risk factor for lumbar discectomy among male respondents was daily smoking. In females, the associated risks were frequent participation in “sports clubs” and being overweight. To avoid one case of lumbar discectomy, 3050 men would have to restrain from daily smoking (95% CI, 2510-3830); 4420 women would have to lose weight (95% CI, 3170-6940); or 5240 women would have to restrain from frequent participation in organized sports (95% CI, 3390-11,800). 
The authors conclude that further study may improve physicians' understanding of the causes of lumbar disc herniation and subsequently reduce the need for lumbar discectomy. I hope future research also investigates the role of somatic dysfunction in lumbar discectomy and osteopathic manipulative treatment in decreasing that risk. —MAS 
Mattila VM et al. Eur Spine J. 2008;17:1317-1323.  
Bone Setting Relieves Chronic Neck Pain
Before he founded osteopathic medicine, Andrew Taylor Still, MD, DO, called himself a “lightning bone setter.” Therefore, it is not surprising that many osteopathic manual techniques evolved from those traditionally used in bone setting. 
Bone setting is still a recognized profession in Finland, where a randomized clinical trial compared the effectiveness of bone setting with physiotherapy and massage therapy in treating adults with chronic neck pain. 
In this study, traditional bone-setting treatment consisted of painless, gentle soft tissue and joint mobilization from toe to head for 90 minutes to relax tense muscles, improve joint motion, and correct body asymmetries. Physiotherapy consisted of 45 minutes of massage, therapeutic stretching, and exercise therapy as determined by the therapist, as well as an at-home stretching program. Massage therapy comprised a 1 hour session of upper body massage by a registered massage therapist. All subjects received five treatment sessions with their respective therapist every 1 to 2 weeks. 
Follow-up occurred at 1, 6, and 12 months posttreatment. Outcome measures were a visual analog pain scale, self-perceived disability, global assessment, sick days, neck mobility, medication use, depression, therapist's communication, and interaction experience. Other measures included machine-measured cervical spine mobility amplitudes in horizontal, frontal, and sagittal planes as well as visual spinal flexion range in the seated position. 
Researchers recruited 105 working adults (37 men, 68 women; mean age, 41.5 years) with chronic (average 11 years) neck pain. Almost all subjects (102 [97%]) completed the treatments, and 91% returned the surveys at 6-month and 1-year follow-up. 
Although all three forms of treatment reduced neck pain and self-perceived disability at 1 month, subjects who received bone setting had improved global self-assessment at 1-month and 1-year follow-up. In addition, two-thirds of subjects in the bone-setting group, compared with fewer than half in each of the other groups, stated they had less disability and were satisfied with therapist communication and interaction. Subjects in the bone setting group had greater cervical and total spine range of motion and slightly fewer sick days and less medication use. Therefore, bone-setting manual therapy was considered effective and safe for patients with chronic neck pain. —MAS 
Zaproudina N et al. J Manipulative Physiol Ther. 2007;30:432-437.  
 “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 and treatments in the United States and the renewed interest in manual medicine internationally, especially in Europe.
 
 To submit scientific reports for possible inclusion in “The Somatic Connection,” readers are encouraged to contact JAOA Editoral Advisory Board member Michael A. Seffinger, DO (mseffinger@westernu.edu), or Editioral Board member Hollis H. King, DO, PhD (hhkingdo@hotmail.com).