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The Somatic Connection  |   December 2009
The Somatic Connection
Article Information
The Somatic Connection   |   December 2009
The Somatic Connection
The Journal of the American Osteopathic Association, December 2009, Vol. 109, 624-627. doi:
The Journal of the American Osteopathic Association, December 2009, Vol. 109, 624-627. doi:
Positive Effects of Cervicothoracic Manipulation on Perceived Levels of Neck Pain
Foreign-trained osteopaths and physical therapy researchers in Spain, three of whom are faculty members at the Escuela de Osteopatía de Madrid, examined the effect of manipulation at the cervicothoracic junction on changes in the pressure pain threshold (PPT). I selected this particular research article for review because it pertains to current concerns about cervical spine manipulation efficacy and safety—a topic on which the AOA has called for additional research and which has been at the forefront of previous installments of “The Somatic Connection” (J Am Osteopath Assoc. 2009;109:214-215, 474-476). 
The authors' stated rationale for the study was to assess the efficacy of manipulation at the cervicothoracic junction for changes at higher cervical levels. They were concerned about possible adverse effects of upper cervical manipulation. 
Exclusion criteria were previous whiplash injury, receiving spinal manipulation to the cervical or thoracic spine within the previous 12 months, regular use of analgesic or anti-inflammatory drugs, and exhibiting a positive extension-rotation test. During this test, the patient is asked to actively bend their head backward and then, in extension, to rotate the head right and then left. If there is any vertebral artery compromise, the patient may exhibit dizziness or nystagmus. (Faculties at US osteopathic medical schools instruct students to conduct and document the results of this test as part of the routine musculoskeletal examination. Negative tests provide protection to practitioners in the event that adverse effects occur after cervical manipulation [Principles of Manual Medicine. 3rd ed. 2003:196-197].) 
Subjects were 30 asymptomatic, right-hand dominant volunteers (13 men and 17 women, aged 19-35 y). Preintervention PPT measurements were obtained for all subjects before they were randomly assigned to receive right side (ie, dominant), left side (ie, nondominant), or placebo intervention. The same therapist delivered all interventions and was blinded to the initial and follow-up PPT assessment. 
The primary outcome measure was PPT, which was defined as “the minimal amount of pressure that results in the sense of pressure changing to pain” and was measured using a pressure algometer. During manipulation, subjects pushed a button to stop the pressure once the pain threshold was reached. An assessor blinded to the subject's treatment condition assessed PPT over the C5-C6 zygapophyseal joint. For analysis, the researchers used the mean of 3 assessments. 
Manipulation was applied at the C7-T1 junction on either the left or right side with high-velocity, low-amplitude (HVLA) thrust applied in a lateral direction. If a “pop” or cavitation was not produced, the patient was repositioned and a second thrust was applied. Two attempts at cavitation were attempted for each subject. In the placebo intervention group, the therapist set up to do the HVLA but did not take up tissue tension, or, in osteopathic terms, “reach the barrier,” and this position was held for 15 seconds. 
There were no statistically significant differences among initial PPT assessments for subjects in each of the three groups. The post-intervention PPT assessment showed that the subjects who received the HVLA had notably less pain. That is, it took more pressure (PPT) for subjects in the intervention group to elicit the pain report than subjects in the placebo group. 
Subjects who received manipulation on the right (dominant) side had greater improvements in the PPT level than subjects manipulated on their left (nondominant) side. However, experimental groups had substantially improved PPT assessments compared to the placebo manipulation group. Men reported more pain reduction than women in the HVLA intervention, but there was no difference between men and women in the placebo intervention group. The authors reported that the effects size was sufficiently large in the manipulation group to suggest a strong clinical benefit. 
The authors observed that modern day computer-driven lifestyles contribute to C7-T1 joint restriction and may explain such a significant effects size. The authors also acknowledged certain limitations to this study. For example, only immediate effects of manipulation were studied; long-term effects need examination as well. It is unknown if these effects would be obtained in symptomatic subjects as the subjects in the present study were asymptomatic. An interesting limitation, termed “cavitation bias,” implies a psychological effect caused by the “pop” heard by manipulation subjects but not placebo subjects. Also, caution is advised in the use of algometer assessment based on individual responses to perceived pain. That is, some people may be more stoic in reporting pain than others. 
Despite these limitations, the study was well designed and serves as a basis for future studies using this technology on a broader range of vertebral levels and subject populations. For those researchers concerned about adverse effects of cervical manipulation, this article adds to a growing body of literature suggestive of cervical spine manipulation safety and efficacy. —H.H.K. 
Fernández-de-las-Peñas C et al. J Manipulative Physiol Ther. 2008;31:332-337.  
Craniosacral Therapy for Lower Urinary Tract Symptoms in Multiple Sclerosis Patients
In a novel and unprecedented study, a group of Israeli researchers studied the effect of craniosacral therapy (CST) on lower urinary tract symptoms (LUTS) and quality of life (QOL) in patients with multiple sclerosis (MS). Subjects were recruited from the Multiple Sclerosis Center at the Sheba Medical Center affiliated with the Sackler School of Medicine in Tel Aviv, Israel. 
Among the inclusion criteria were diagnosis of definitive MS, LUTS (at least 3 months duration), unsuccessful treatment of LUTS using antimuscarinic agents, and evidence of overactive bladder. Exclusion criteria included antimuscarinic medication within the previous 3 months, indwelling or intermittent urinary catheter, post voiding residual volume (PVR) greater than 200 cc, and upper urinary tract decompensation (hydronephrosis). Out of 100 potential participants, 28 (4 men and 24 women) met the study criteria, with ages ranging from 23 to 75 years. Researchers confirmed bladder hyper-reflexia in all 28 subjects using urodynamic evaluation. Detrusor sphincter dyssinergia was noted in 16 subjects. 
All subjects underwent a neurologic examination using the Expanded Disability Status Scale, a MS-specific tool used to quantify neurologic disability. Ultrasonography was used to detect hydronephrosis and assess PVR. Urinary frequency and urgency and QOL were assessed using subjective numeric scales. 
A staff physical therapist administered CST to all 28 subjects. Therapy sessions lasted 50 minutes and occurred once a week for 4 weeks. The physical therapist used the CST 10-step protocol, which includes an array of cranial manipulation maneuvers adopted from osteopathic training and would be readily recognized by osteopathic practitioners. In addition to cranial and sacral bone alignment and correction maneuvers, an important element of this protocol includes attention to respiratory and pelvic diaphragm areas to achieve a “release”—or reduction of tension in the myofascial structures in close proximity to the urinary tract. 
Mean (SD) PVR decreased from 150.9 mL (125.7 mL) before CST to 66.1 mL (89.5 mL) after CST (P<.001, paired t test). There were also reductions in episodes of urinary frequency (mean [SD], 5.1 [.09] pre-CST; 3.1 [1.0] post-CST) and urinary urgency (mean [SD], 5.4 [1.1] pre-CST; 3.4 [1.4] post-CST) (P<.001, paired t test). Twenty-two subjects (79%) reported improved QOL, while 6 subjects (21%) reported no change. The increase in mean (SD) QOL score was statistically significant (P<.001, paired t test). All subjects complied with intervention and no side effects of CST were reported. 
The authors discussed the pathophysiology of the demyelinating process of MS and its effect on the urinary tract. They reported that standard treatment using antimuscarinic agents had potential adverse effects that reduce patient compliance and, thus, that the search for nonpharmacologic treatment modalities is a high priority in the management of MS. The authors speculated about the effects of CST—including its possible mechanism of action that increases cerebrospinal fluid flow—which, in turn, may have an effect on neurologic structures undergoing a destructive process. However, they concluded that no definitive evidence exists for the salutary effect of CST and that only in this particular study was there empirical evidence of change on PVR levels and QOL ratings. 
While this study has limitations, including a small number of subjects, lack of a control group, and just one treatment provider, the authors concluded that the effects of the study were sufficient to warrant further investigation because the pre- to posttreatment PVR change was dramatic and demonstrably improved subjects' QOL. 
As the author of the chapter on osteopathy in the cranial field for the third edition of Foundations for Osteopathic Medicine, I welcome this study as an addition to the evidence base for cranial manipulation. Another study that supports osteopathy in the cranial field is reviewed on page 627. While some may question the cranial manipulation studies by clinicians other than osteopathic physicians or international osteopathy practitioners, this particular study was well designed, carried out in a well-known medical facility, and used techniques familiar to osteopathic physicians and practitioners. This study is worthy of replication, and I hope that this review will advance that possibility. —H.H.K. 
Raviv G et al. Complement Ther Clin Pract. 2009;15:72-75.  
Manual Therapy for Patients With Temporomandibular Disorders
As of November 2009, JAOA—The Journal of the American Osteopathic Association has published 21 review articles, case reports, and other contributions related to temporomandibular disorder (TMD), according to a search on the JAOA`s Web site. However, none of these articles were original research studies on the treatment of patients with TMD. A group of researchers in Spain and the United States sought to fill this void in TMD research and reported reduced pain among patients with TMD who received manipulation of the cervical spine. 
Study subjects were recruited consecutively from four dental clinics and had a primary diagnosis of myofascial pain, bilateral pain involving the masseter and temporal regions, pain symptoms for at least 3 months prior to the study, and reported pain of 30 mm or higher on a 100 mm visual analog scale (VAS). Exclusion criteria included signs of disc displacement, arthrosis, arthritis of the temporomandibular joint, history of traumatic injuries, fibromyalgia, systemic disease, neurologic disorders, concomitant diagnosis of any primary headache, and any form of treatment in the 3 months prior to the study. 
Outcome measures were the VAS, pressure pain threshold (PPT), and active pain-free mouth opening. All measures were obtained at baseline, 48 hours after the last treatment, and at 12-week follow-up. 
The authors defined PPT as “the amount of pressure where the sense of pressure first changes to pain.” This outcome measure was assessed using a mechanical device consisting of a round rubber disc (1 cm2) attached to a pressure gauge that displayed values in kilograms. The PPT assessments were made over a masseter point, located 1 cm superior to 2 cm anterior from the angle of the mandible, and the temporal point, 2 cm above the zygomatic arch. The mean of three readings was reported. Intraexaminer reliability was very high—on a scale of 0 to 1, intraclass correlation coefficients (ICC) were 0.91. 
For active pain-free mouth opening assessment, subjects were supine and asked to “open [their] mouth[s] as wide as possible without causing pain.” At the end position, the distance between the subject's upper and lower incisors was measured. Like the PPT measure, the mean of three measurements was used for analysis. This outcome measure also had high intraexaminer reliability (ICC=0.9-0.98). 
Subjects underwent intervention 10 times (twice a week for 5 weeks). The treatment protocol, provided by an experienced physical therapist, was to the cervical spine. The first maneuver was upper cervical mobilization with one of the operator's hands on the occipital bone and the other on the frontal bone. The mobilizing force was delivered by flexing the upper cervical region using a combination of cephalic traction with the occipital hand and caudal pressure with the frontal hand. Oscillation was done every 2 seconds for 10 minutes. 
In the second treatment maneuver, the subject was prone and the cervical spine was in a neutral position. The tips of the operator's thumbs were placed on the C5 spinous process, with his fingers resting around the subject's neck. A posterior-anterior technique was applied centrally to the C5 spinous process in an oscillatory manner every 2 seconds for 9 minutes. 
The third treatment maneuver was a craniocervical flexor stabilization exercise performed with the subject supine. This exercise involved flexion of the head on the cervical spine while the back of the head remained in contact with the table. Subjects' motion was monitored by a pressure feedback device attached to the sternocleidomastoid and scalene muscles. Baseline measures were taken and subjects were instructed to contract the flexor muscles in such a way the pressure was increased without increased pain. 
All 19 study subjects (5 men and 14 women, aged 19-57 y) were right-hand dominant and had TMD symptoms for an average of 9.2 months. For the PPT outcome measure, changes over the masseter muscle and temporalis muscle were statistically significant from baseline to posttreatment and from baseline to follow-up (P<.001), but not from posttreatment to follow-up. There was no difference between the right or left sides for either masseter or temporalis muscle PPT. Results were similar for the VAS and active pain-free mouth opening with regard to differences from baseline to posttreatment (P<.001), with no statistically significant differences between the posttreatment and follow-up periods. The treatment effects were large given the small sample size. 
The authors concluded that there may be benefit in the management of TMD with manual therapy because of the large effects' statistical significance, but they were cautious given the small sample size. They speculated about the mechanism of action being a general—rather than specific—effect of muscle tension in the cervical spine for the muscles that connect to head and mandibular structures. This speculation is consistent with osteopathic formulations presented in some of the articles published in the JAOA that manipulation of the omohyoid and digastric muscles (Royder. JAOA. 1981;80:460-467) and the long muscles of the neck (eg, sternoleidomastoid) (Hruby. JAOA. 1985;85:502-510) affected temporomandibular joint function. 
This study did not have a control group, so no direct cause and effect relationship can be asserted. However, this study is notable because it reports evidence of possible safe and efficacious cervical manipulation. Also, many osteopathic physicians treat patients with TMD, and this preliminary report of manipulation benefit may encourage the use of osteopathic manipulative treatment in such cases. This study also presents a research paradigm and outcome measures that could easily be used in osteopathic research. Why reinvent the wheel? —H.H.K. 
La Touche R et al. J Oral Rehab. 2009;36:644-652.  
OMT Relieves Low Back Pain During Pregnancy
As early as 1911, osteopathic physicians have reported benefits of osteopathic manipulative treatment (OMT) in improving outcomes when used during pregnancy (J Am Osteopath Assoc. 2003;103:577-582). Nearly a century later, researchers at The Osteopathic Research Center, which resides at University of North Texas Health Science Center—Texas College of Osteopathic Medicine in Fort Worth, reported the results of the first randomized, placebo-controlled clinical trial of OMT for low back pain during uncomplicated pregnancy. 
The landmark study compared three treatment options: (1) “usual obstetric care and OMT” (OMT group); (2) “usual obstetric care and sham ultrasound treatment” (sham treatment group); and (3) “usual obstetric care only” (usual care only). Outcomes included average pain levels as reported by subjects on an 11-point subjective pain scale and the Roland-Morris Disability Questionnaire to assess back-specific functioning. Intention-to-treat analyses included 144 subjects. Subjects in the OMT and sham treatment groups received seven 30-minute treatment sessions (bi-weekly for weeks 30 through 35 and then weekly after the 36th week until delivery). In the OMT group, myofascial release, muscle energy, soft tissue, and articulatory techniques were used to treat somatic dysfunction as indicated by osteopathic structural examination findings. High-velocity, low-amplitude and compression of the fourth ventricle were not used. Treatment was applied by osteopathic physician faculty specializing in neuromusculoskeletal medicine and osteopathic manipulative medicine at the university. 
The Roland-Morris Disability Questionnaire scores increased (indicating greater level of disability) for all groups during pregnancy. However, the decreased deterioration of back-specific function in the OMT group was statistically significant compared to the usual care only group (effect size, 0.72; 95% confidence interval, 0.31-1.14; P=.001). Differences between the OMT group and the sham treatment group did not achieve statistical significance (effect size, 0.35; 95% confidence interval, -0.06 to 0.76; P=.09). Using the previously mentioned subjective pain scale, subjects in the OMT group reported a decrease in back pain during pregnancy, subjects in the sham treatment group reported no change in pain, and the usual care only group reported an increase in pain (though no between-group difference achieved statistical significance). No adverse events or injuries from OMT were reported by patients who received OMT. 
Researchers concluded that OMT slows or halts the deterioration of back-specific functioning during the third trimester of pregnancy. This trial adds to the evidence-based literature on the safety and efficacy of OMT for low back pain. —M.A.S. 
Licciardone JC et al. Am J Obstet Gynecol. [Published online ahead of print Sept19 , 2009].  
Cranial Bone Motion Demonstrated by MRI
More than 70 years ago, William Garner Sutherland, DO, a student of Andrew Taylor Still, MD, DO, discovered that cranial bone motion was important in health and disease in adults (The Osteopathic Physician. February 1979:13-19). However, many osteopathic physicians did not believe cranial motion was possible after growth and development until 1971, when JAOA—The Journal of the American Osteopathic Association published a landmark study by Viola M. Frymann, DO, in which electrophysiology was used to demonstrate that, indeed, the skull has inherent motion even in adults (1971;70:1-18). Readers of the JAOA were also the first to read about electrophysiology studies demonstrating cranial motion in monkeys (1975;74:866-869) and in cats (1992;92:599-622). 
Nearly 40 years after Frymann's study, clinician researchers from four American osteopathic institutions collaborated to investigate whether serial magnetic resonance imagery (MRI) technology would demonstrate calvarium motion in humans. 
The researchers, including “The Somatic Connection” contributor Hollis H. King, PhD, DO, recruited 20 healthy subjects (13 men and 7 women, aged 24-52 y). Subjects were volunteer healthcare professionals and were excluded from the study if they were pregnant, had previous surgery of the cranium or face, or had metal implants. 
During intervention, subjects were asked to lie as still as possible in a closed MRI system (GE Medical Systems 1.5 Tesla Signa EXCITE HD) with the head stabilized in a rubber head mount (GE Medical Systems 1.5 Split Head Coil). Each subject had 8 serial T-1 weighted MRI scans (mid-cranial diameter, parietal bone level) every 45 seconds at 450 milliseconds per slice. Width, height, major axis, and feret (longest distance between any two points along the boundary) changed substantially during the 6-minute period, but findings were not statistically significant. Difference values for area (mean, 122 m2) were statistically significant (P<.003) and exceeded the resolution threshold (0.898 mm/pixel). The authors could not determine the mechanism of action or source of motion. However, the total intracranial area appeared to expand and recede, probably as a result of intracranial fluid pressure and volume fluctuations. 
While the effect of cranial motion on health and disease could not be ascertained by this study, it adds to the growing evidence demonstrating inherent cranial bone motion. —M.A.S. 
Crow WT et al. Osteopath Med Prim Care. 2009;3:8 .  
 “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 Editorial Advisory Board member Michael A. Seffinger, DO (mseffinger@westernu.edu), or Editorial Board member Hollis H. King, DO, PhD (hking@atsu.edu).
 
 Editor's Note: In 2006 and 2007, Dr King participated in two focused research forums at The Osteopathic Research Center in Fort Worth, Texas, on the topic of “Cervical Spine Manipulation: Safety and Efficacy.” Reports on the research forums were presented to the AOA Council on Scientific Affairs in 2006 and the AOA Bureau of Scientific Affairs in 2007. In 2009, the AOA House of Delegates reaffirmed Resolution H-257 (A/2004—Osteopathic Manipulative Treatment of the Cervical Spine), which asserted the need for research on the safety and efficacy of cervical spine manipulation (http://www.do-online.org/pdf/cal_hod09res257.pdf).