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Original Contribution  |   April 2010
Effect of Pedal Pump and Thoracic Pump Techniques on Intracranial Pressure in Patients With Traumatic Brain Injuries
Author Notes
  • From the Division of Neurosurgery at Arrowhead Regional Medical Center (ARMC) in Colton, California. 
  • Address correspondence to Dan E. Miulli, DO, FACOS, Graduate Medical Education Office, ARMC, Division of Neurosurgery, 400 N Pepper Ave, Colton, CA 92324-1801. E-mail: miullid@armc.sbcounty.gov 
Article Information
Emergency Medicine / Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment
Original Contribution   |   April 2010
Effect of Pedal Pump and Thoracic Pump Techniques on Intracranial Pressure in Patients With Traumatic Brain Injuries
The Journal of the American Osteopathic Association, April 2010, Vol. 110, 232-238. doi:10.7556/jaoa.2010.110.4.232
The Journal of the American Osteopathic Association, April 2010, Vol. 110, 232-238. doi:10.7556/jaoa.2010.110.4.232
Abstract

Context: Although osteopathic manipulative treatment (OMT) is used to manage myriad conditions, there has been some hesitation regarding the safety of applying OMT to patients with intracranial injuries or elevated intracranial pressure (ICP).

Objective: To assess the safety of two OMT techniques—pedal pump and thoracic pump—on ICP and cerebral perfusion pressure (CPP) in patients with traumatic brain injuries (Glasgow Coma Scale score ≤8).

Methods: We prospectively enrolled consecutive patients admitted to the intensive care unit (ICU) for traumatic brain injury. Patients between the ages of 18 and 75 years and with abnormal CT scans were included in the present study. Patients with baseline ICP values of 20 mm Hg or lower were assigned to group 1, and those with ICP levels greater than 20 mm Hg, group 2. Patients underwent continuous ICP and CPP monitoring, with ICP measured using a ventricular catheter and fiber optic device. Values of ICP and CPP were recorded at baseline, during application of the OMT techniques, and 5 minutes after the two OMT techniques were completed. Patients received up to three treatment cycles. Ventricular drains remained open (stopcock open) during OMT, allowing continued cerebral spinal fluid drainage, except for brief periodic closures (stopcock closed) every minute to register accurate ICP values. Statistical analysis was performed using a dependent t test with repeated measures.

Results: Twenty-four comatose patients, aged 18 to 69 years, received a total of 50 sessions of pedal pump and thoracic pump techniques. In group 1 patients, a slight decrease in ICP values (mean, -0.586 mm Hg) and an increase in CPP values (mean, 1.1613 mm Hg) was noted post-OMT. Patients in group 2 also had decreased mean ICP values (-1.20 mm Hg) and increased mean CPP values (2.2105 mm Hg). Changes were not statistically significant in either group.

Conclusion: According to the present limited study, pedal pump and thoracic pump techniques may be used safely in patients with severe brain injuries.

The lymphatic system contributes to appropriate fluid balance and sustained immunity. Plasma circulates and filters through the interstitial spaces via blood flow through the capillaries. Much of the interstitial fluid is then reabsorbed by tissue cells or into the vascular compartment. However, if this interstitial fluid is not reabsorbed and the process continues even briefly, the accumulating extravascular fluid can cause edema and tissue destruction. The lymphatic system also contains valuable lymphocytes, which actively protect against opportunistic antigens such as viruses and bacteria that invade the body on a daily basis. When impaired, lymphatic circulation may result in clinically significant complications. 
Osteopathic manipulative treatment (OMT) can help improve lymphatic flow and, subsequently, promote healing. For example, various studies1-3 have demonstrated that OMT techniques may reduce length of hospital stay and prevent infection and hemostasis. However, the safety and efficacy of these techniques have not been established within the extreme conditions of traumatic brain injury (TBI). 
Traumatic Brain Injury
Approximately 1.4 million TBIs occur annually in the United States.4 Brain injuries are defined by both the primary and the secondary insult. Primary injury occurs at the moment of insult and is the direct result of the initial traumatic event. Primary injuries include cortical contusions, lacerations, skull fractures, diffuse axonal injury, and brainstem contusions. 
Secondary injuries develop subsequent to the primary injury. They are a consequence of the physiologic responses to the primary injury. Secondary injuries are responsible for worsened outcomes. For decades, experimental and clinical research has proven that a clinically significant amount of neuronal damage develops and progresses in the hours and days after the initial traumatic event.5-7 Examples of secondary injuries, which are often caused by elevated intracranial pressure (ICP) include intracranial hematomas, edema, hypoxemia, and ischemia. 
Secondary injuries are typically worse in immobilized, comatose, and intubated patients because of their increased risk of infection, sepsis, and violation of the blood-brain barrier. Coagulopathies, variations in blood pressure, systemic vasodilatation, respiratory distress, pulmonary edema, and aspiration result in increased ICP8 and decreased cerebral perfusion pressure (CPP), contributing to additional physical and cognitive deficits. 
Intracranial Pressure
An elevated ICP reflects an increase in cerebral vascular resistance and possible ischemia. The ischemic brain sets into motion a destructive cascade of neurochemical processes.7,9,10 Key features of this cascade are increased anaerobic energy generation, release of excitatory amino acid neurotransmitters and oxygen free radicals, and derangement of ion homeostasis. 
Obtaining ICP readings is invasive and requires technical skill for safe and correct placement. Intracranial pressures are monitored via insertion of a fiber optic wire into either the intracerebral space or catheter placement in the intraventricular space. The fiber optic wire is connected to a transducer, which displays continuous pressure readings. The ICP monitor may be associated with or without ventricular drainage capability via a catheter. If a catheter is used, the pressure line may be open to allow cerebral spinal fluid to drain and therefore decompress the brain and lower ICP. However, to obtain accurate ICP measurements, the line must be closed via a stopcock, much like arterial line tubing. A closed stopcock does not allow for drainage but is needed for a short time to accurately measure ICP. 
Cerebral Perfusion Pressure
The ability of the vascular system to perfuse cerebral tissues is indicated by CPP. A decreased CPP below an individualized threshold results in cerebral ischemia, which can lead to cerebral anoxia, anaerobic metabolism, cellular injury, and death.8 To calculate the CPP, the mean arterial pressure (MAP) is subtracted from the ICP. In adults, adequate CPPs are typically between 60 to 90 mm Hg. If the ICP is high, then the MAP must be increased to compensate and maintain an adequate CPP. For example, a MAP of 93 mm Hg and an ICP of 13 mm Hg would equal a CPP of 80 mm Hg. If the ICP is elevated to 25 mm Hg and the MAP is decreased to 75 mm Hg, then the CPP is only 50 mm Hg. Because an inadequate CPP can adversely affect long-term outcomes, most neurointensivists attempt to maintain a CPP of 70 to 90 mm Hg in most adults with TBI.8-10 
Traumatic Brain Injury Assessment and Management
Glasgow Coma Scale—The Glasgow Coma Scale (GCS) is a noninvasive, objective, and timely method of measurement reflecting current levels of consciousness and physical functioning (Figure 1).9 It is recognized worldwide and thus provides a universal nomenclature in the assessment and management process of all patients with TBI.8-10 The score is based on assessment of the patient's best motor function, best verbal response, and best eye opening. The highest score, 15, represents the best patient functioning, where as the lowest score, 3, represents a patient with no motor function, verbal response, or eye opening. The GCS score of intubated patients will include the letter “T” reflecting the presence of an endotracheal “tube” after the number. A GCS score of 8 or less reflects a comatose state in 90% of patients. Although the present study does not specifically deal with the GCS score, it does use these measurements as part of the inclusion criteria. 
Intracranial and Cerebral Perfusion Pressures—Elevated ICP and decreased CPP are well-known complications associated with severe head injuries and constitute a key concern in the treatment process. There is current and overwhelming evidence supporting the fact that the severely brain-injured patient with an elevated ICP, decreased CPP, and low GCS score are directly associated with a diminished neurologic outcome.8-10 The increased morbidity and mortality rates are a direct result of decreased CPP. Using evidenced-based practices and aggressive management of ICP and CPP, physicians can dramatically improve patient outcomes and positively affect patient quality of life and future functioning. 
Figure 1.
The Glasgow Coma Scale is used in the assessment of patients with traumatic brain injury. Patients are assigned one score from each of the three categories, resulting in a total score of at least 3 but no more than 15.
Figure 1.
The Glasgow Coma Scale is used in the assessment of patients with traumatic brain injury. Patients are assigned one score from each of the three categories, resulting in a total score of at least 3 but no more than 15.
Established therapeutic modalities for decreasing ICP values consist of ventricular drainage, controlled short-period mild hyperventilation, osmotic diuresis, high-dose barbiturates, and craniectomy for elevated and refractory ICP. When ICP levels are at or above 20 to 25 mm Hg, intracranial hypertension is generally considered to be present and requires timely intervention. When the threshold of 20 mm Hg is applied, ICP becomes a reliable predictor of relative risk for the occurrence of neurologic deterioration and eventual worsened outcome.10 
The criteria used in the decision process for ICP monitoring has evolved during the past decade. In 2000, the Brain Trauma Foundation, in association with the American Association of Neurological Surgeons, published guidelines and indications for ICP monitoring.8 Both organizations agree that ICP monitoring is recommended for TBI patients with a GCS score of 8 or lower, in conjunction with abnormal head computed tomography (CT) scan findings such as tight basilar cisterns, mass effect, significant brain edema, or contusions. Studies have demonstrated that approximately 50% of patients with intracranial mass lesions and 33% of those with diffuse cerebral injuries have persistently elevated ICPs. Sustained ICP elevation is frequently associated with a poorer prognosis and outcome. Studies11,12 have confirmed that in patients with severe head injuries, poorer prognoses and outcomes, including mortality, directly correlate with the level of ICP elevation. Therefore, detecting, monitoring, and managing an elevated ICP is extremely important in providing an optimal environment for neurologic recovery. 
Complications of Traumatic Brain Injury—Many—if not all—patients with severe head injury are at risk for a secondary injury, which worsens morbidity and mortality associated with TBI. Many patients with TBI develop respiratory difficulties ranging from atelectesis, pneumonia, or adult respiratory distress syndrome.6-8 These common problems can be difficult to manage in conjunction with elevated ICPs and decreased CPPs. Patients with such secondary injuries are likely to benefit from pedal pump and thoracic pump techniques,1-3 but there has been some hesitation regarding the safety of applying these OMT techniques to patients with intracranial injuries or elevated ICPs. 
Osteopathic medicine has a history of incorporating adjunct and holistic treatment modalities in patient management. Although adjunct therapies may sometimes appear at odds with some established medical modalities, research supports the use of pedal pump and thoracic pump techniques1-3 as well as other interventions that have a proven basis in physiology.5-7 For this reason, we sought to evaluate the safety of incorporating pedal pump and thoracic pump into the treatment of patients with TBI. 
Although TBI primarily affects the brain, it has ominous consequences for other body systems as well. Therefore, the effect of these two OMT techniques on ICP is extremely relevant to this patient population because of the potential benefits the techniques might have for other vital organs and affected physiologic systems. 
The incidence and severity of adverse effects of exercise on intracranial hypertension is generally unknown; however, in a 1997 prospective study, Brimioulle et al13 performed passive range-of-motion exercises with comatose patients. The study failed to identify any adverse effects or associated increases in ICP values.13 Studies that specifically examine the safety of pedal pump and thoracic pump in patients with TBI and measure intracranial pressure monitoring are nonexistent. Moreover, it remains unknown if any one procedure has a greater risk of deleterious consequences in the presence of severe brain injury (GCS score of 3 to 8; ICP >20 mm Hg). 
We attempt to establish whether two OMT techniques, specifically the pedal pump and thoracic pump techniques used in the treatment of thoracic disease, alter ICP and CPP values and whether these techniques are safe in this patient population. Of the two OMT techniques examined in the present study, we believe thoracic pump would theoretically cause an increase in the ICP because of changes to central venous blood return, increased intra-thoracic pressures, and subsequently increased ICPs. 
Methods
The Arrowhead Regional Medical Center Internal Review Board (IRB) approved the study. Because OMT is a widely practiced and accepted treatment modality, its application is approved through hospital consent for treatment, and additional written consent was not required as approved by the IRB committee. 
We prospectively enrolled consecutive patients with severe closed-head injuries consistent with a GCS score of 8 or lower. All patients were in the intensive care unit at Arrowhead Regional Medical Center in Colton, California, between December 2006 and May 2007. Patients were required to be between the ages of 18 and 75 years and to have abnormal results from head CT scans—consistent with the ICP monitoring recommendations previously described.8 Patients were excluded from the present study if they had multiple rib fractures or chest tubes, lower extremity fractures, or unstable spine fractures. 
Patients were categorized into one of two groups according to their ICP status at baseline. Patients with ICP measurements of 20 mm Hg or lower were placed in group 1, and those with an ICP of more than 20 mm Hg (ie, threshold for ICP being a reliable predictor of relative risk for neurologic deterioration) were placed in group 2. 
Two OMT techniques—pedal pump and thoracic pump—were provided to all patients as follows: 
  • Pedal Pump—The patient is placed in the supine position with the physician standing at the patient's feet. The physician then gently grasps the patient's feet and applies dorsiflexion. The force caused by the hyperdorsiflexion of the feet continues in a cephalad movement, which is followed by a rebound wave moving caudally. As the rebound wave returns to the feet, the physician reapplies the dorsiflexion force, thereby creating an oscillatory pump.
  • Thoracic Pump—Using the thoracic pump technique, the patient is placed in the supine position (at 30 degrees) with the physician at the head of the bed with his or her hands placed on the patient's thoracic wall over the pectoralis muscles. A rhythmic pumping action is introduced by alternating pressure and release through the physician's hands at a rate of 110 to 120 times per minute. Care was taken to avoid intracranial monitors, drains, central intravenous catheters, or endotracheal tubing.
Each session of pedal pump and thoracic pump techniques lasted approximately 5 minutes total. Treatment was provided by one of 10 osteopathic neurosurgical residents or osteopathic medical students who were trained in the two OMT techniques as part of their osteopathic medical education. Each patient was eligible to receive the OMT technique protocol a maximum of three times for purposes of the study. If patients remained stable and continued to have a GCS score of ≤8, up to three treatments were allowed. However, no more than three treatments were allowed because we wanted to have multiple patients to demonstrate a range of conditions. For patients who received more than one OMT session, a minimum of 24 hours passed between OMT applications. Because ICP varies, some patients could be included in both groups according to their ICP readings at the time before the two OMT techniques were applied. 
Patients' ICP and CPP levels were recorded before, during, and 5 minutes after the OMT techniques were applied. Intracranial pressure was measured using a ventricular catheter and fiber optic device as previously described. With each session, baseline ICP and CPP measurements were compared with posttreatment ICP and CPP values. All patients continued to receive standard acute management (eg, intubation, ventilator settings, medication) as prescribed by the physician. 
The present study did not follow patients for long-term outcomes. A repeated measures t test was used to interpret the statistical significance of the collected data measurements. Alpha was set at .05. 
Results
A total of 24 patients (15 men, 9 women) participated, with 50 treatments administered in total. All patients were comatose. Ages ranged from 18 to 69 years, with a mean age of 41 years. Five patients received one regimen of pedal pump and thoracic pump techniques, 12 patients received two regimens, and 7 patients received three regimens (Table). Three patients were included in both groups. There were no adverse incidents. 
Effects of Two OMT Techniques in Patients With Traumatic Brain Injuries: Intracranial Pressure and Cerebral Perfusion Pressure, mm Hg (N=24) *






OMT


Baseline
Pedal Pump
Thoracic Pump
Post-OMT
Patient
Age, y
Sex
ICP
CPP
ICP
CPP
ICP
CPP
ICP
CPP
▪ Group 1*
□ 1 41 M 20 77 18 73 19 73 17 72
□ 255W1997199721902290
1969208920882385
□ 4 22 M 11 78 10 84 10 91 10 97
13 86 11 84 13 92 11 96
12 80 10 79 9 80 15 81
□ 536M1091119512971497
15100129511911390
10100139411991192
□ 6 18 W 3 88 3 90 4 89 3 89
3 88 4 89 4 89 3 88
7 85 3 90 0 90 0 90
□ 757W585689783783
9778741079969
1270107812801074
□ 8 42 M 9 74 10 74 8 72 7 71
10 74 10 70 8 66 8 73
□ 944M460568568668
869869870871
□ 10 31 W 15 59 15 71 14 72 13 77
18 84 22 88 18 80 16 79
□ 1148M969870970970
1475157716741375
□ 12 67 M 6 69 5 72 10 67 8 69
13 62 11 66 14 63 12 65
□ 1327M1080107811771177
□ 15 51 W 9 72 6 71 10 80 7 83
17 74 13 94 22 68 15 75
16 96 14 96 1 89 7 84
□ 1744M1768226217601761
1770205917671771
▪ Group 2*
□ 141M2570197420691967
□ 2 55 W 22 71 20 88 24 67 20 72
□ 327W3074328437633662
4165287743654364
4361436040644065
□ 13 27 M 26 64 22 66 28 60 25 63
□ 1460M2560266827602761
2159226126622365
□ 16 20 W 36 55 34 60 33 61 38 64
□ 1829W2566267025712272
2263206622682464
□ 19 61 M 36 60 36 59 34 65 32 66
27 71 28 75 26 72 22 65
□ 2018M2764287526722869
□ 21 69 M 31 61 32 63 24 69 25 70
28 66 27 65 30 66 25 64
□ 2232M2866287023742880
□ 23 45 W 21 75 22 89 25 81 20 82
□ 2433M4060415839624158
 Abbreviations: CPP, cerebral perfusion pressure; M, man; W, woman.
 *A total of 24 patients received 50 sessions of osteopathic manipulative treatment (OMT). Patients in group 1 had a baseline intracranial pressure (ICP) ≤20 mm Hg. Patients in group 2 had a baseline ICP >20 mm Hg.
 Patient was in group 1 for the first trial and group 2 for the second trial.
 Patient was in group 1 for the first and second trials and group 2 for the third trial.
Effects of Two OMT Techniques in Patients With Traumatic Brain Injuries: Intracranial Pressure and Cerebral Perfusion Pressure, mm Hg (N=24) *






OMT


Baseline
Pedal Pump
Thoracic Pump
Post-OMT
Patient
Age, y
Sex
ICP
CPP
ICP
CPP
ICP
CPP
ICP
CPP
▪ Group 1*
□ 1 41 M 20 77 18 73 19 73 17 72
□ 255W1997199721902290
1969208920882385
□ 4 22 M 11 78 10 84 10 91 10 97
13 86 11 84 13 92 11 96
12 80 10 79 9 80 15 81
□ 536M1091119512971497
15100129511911390
10100139411991192
□ 6 18 W 3 88 3 90 4 89 3 89
3 88 4 89 4 89 3 88
7 85 3 90 0 90 0 90
□ 757W585689783783
9778741079969
1270107812801074
□ 8 42 M 9 74 10 74 8 72 7 71
10 74 10 70 8 66 8 73
□ 944M460568568668
869869870871
□ 10 31 W 15 59 15 71 14 72 13 77
18 84 22 88 18 80 16 79
□ 1148M969870970970
1475157716741375
□ 12 67 M 6 69 5 72 10 67 8 69
13 62 11 66 14 63 12 65
□ 1327M1080107811771177
□ 15 51 W 9 72 6 71 10 80 7 83
17 74 13 94 22 68 15 75
16 96 14 96 1 89 7 84
□ 1744M1768226217601761
1770205917671771
▪ Group 2*
□ 141M2570197420691967
□ 2 55 W 22 71 20 88 24 67 20 72
□ 327W3074328437633662
4165287743654364
4361436040644065
□ 13 27 M 26 64 22 66 28 60 25 63
□ 1460M2560266827602761
2159226126622365
□ 16 20 W 36 55 34 60 33 61 38 64
□ 1829W2566267025712272
2263206622682464
□ 19 61 M 36 60 36 59 34 65 32 66
27 71 28 75 26 72 22 65
□ 2018M2764287526722869
□ 21 69 M 31 61 32 63 24 69 25 70
28 66 27 65 30 66 25 64
□ 2232M2866287023742880
□ 23 45 W 21 75 22 89 25 81 20 82
□ 2433M4060415839624158
 Abbreviations: CPP, cerebral perfusion pressure; M, man; W, woman.
 *A total of 24 patients received 50 sessions of osteopathic manipulative treatment (OMT). Patients in group 1 had a baseline intracranial pressure (ICP) ≤20 mm Hg. Patients in group 2 had a baseline ICP >20 mm Hg.
 Patient was in group 1 for the first trial and group 2 for the second trial.
 Patient was in group 1 for the first and second trials and group 2 for the third trial.
×
Overall, no statistically significant differences in ICP or CPP were found, though improvement in mean values was demonstrated. In the prospectively planned subgroup analysis, 19 treatments were administered in group 1 patients, and 31 treatments were administered in group 2 patients. In group 1 patients (ie, baseline ICP ≤20 mm Hg), the pedal and thoracic pump techniques decreased mean ICP values by 0.58 mm Hg (P=.254) (Figure 2). In the same group of patients, CPP increased by a mean value of 1.16 mm Hg (P=.413) (Figure 3). In group 2 patients (ie, baseline ICP >20 mm Hg), the pedal and thoracic pump techniques decreased mean ICP values by 0.89 mm Hg (P=.245) (Figure 2) and increased CPP by a mean value of 2.21 mm Hg (P=.130) (Figure 3). The pedal pump technique did not significantly affect ICP or CPP more or less than the thoracic pump technique. 
In our cohort, the age, gender, and number of the two OMT technique procedures received per patient do not statistically correlate with changes of ICP or CPP after OMT by dependent t test analysis. All patients were monitored for complications during and after each trial of the two OMT techniques. No complications were detected during the 5-minute trials or in the 5 minutes immediately after application of the two OMT techniques. 
Discussion
Despite the clinically proven benefits of pedal pump and thoracic pump in acutely ill patients,1-3 there is a concern that these techniques may be contraindicated in patients with head injuries because of the concern that they may adversely affect ICP or CPP. The effect of these two techniques on ICP and CPP had yet to be fully investigated until this present study, though other studies14-16 have investigated various other conditions, which may affect ICP and CPP. 
It is often assumed that coughing can produce increases in ICP because of the resulting increases in intrathoracic and central venous pressure, thus increasing cerebral venous pressure and cerebral blood volume. A case report by Matta et al3 described the effects of several sustained Valsalva maneuvers on ICP and CPP given to a head-injured patient in an effort to prevent atelectasis and hypoxemia while intubated.14 No increase in ICP was observed. Although small increases in intrathoracic and central venous pressure such as those induced by positive end-expiratory pressure do not usually result in any significant increases in ICP, severe obstruction of venous drainage from the brain will contribute to increases in ICP.15,16 These studies15,16 suggest that ICP is resistant to the changes in intrathoracic pressure that may take place during the application of the two OMT techniques applied in the present study. 
Manipulative techniques are difficult to perform systematically in a scientific study because subjective minor differences in technique may occur between healthcare providers. These differences are inherently present in the current study because 10 different healthcare providers with varying levels of OMT experience administered the pedal and thoracic pump techniques. Although identical application of the two OMT techniques was not possible, such differences may in fact strengthen the findings of the present study because they represent the real differences in technique among osteopathic physicians and medical students. 
Figure 2.
Direct effect of osteopathic manipulative treatment (OMT) on intracranial pressure (ICP) and indirect effect on cerebral perfusion pressure (CPP). Overall, OMT reduced ICP, but this finding was not statistically significant.
Figure 2.
Direct effect of osteopathic manipulative treatment (OMT) on intracranial pressure (ICP) and indirect effect on cerebral perfusion pressure (CPP). Overall, OMT reduced ICP, but this finding was not statistically significant.
Figure 3.
Direct effect of osteopathic manipulative treatment (OMT) on cerebral perfusion pressure (CPP) and indirect effect on intracranial pressure (ICP). Overall, OMT reduced ICP, but this finding was not statistically significant.
Figure 3.
Direct effect of osteopathic manipulative treatment (OMT) on cerebral perfusion pressure (CPP) and indirect effect on intracranial pressure (ICP). Overall, OMT reduced ICP, but this finding was not statistically significant.
Comatose patients may be able to perceive more sensation than previously thought. Family members of comatose patients often describe reactions of patients to external stimuli such as voices or human touch. Although the benefit of human touch in critically ill patients is unclear at this time, pedal pump and thoracic pump techniques may provide an added benefit of human contact, which may help patients in ways that are very difficult to study scientifically. Families may also benefit from the perception of care and concern when therapeutic touch is directed toward their family members. 
In the future, research studies may investigate the influence of other OMT techniques on lowering ICP in the refractory patient. The importance of ICP in TBI was previously described. Treatment options to lower ICP, such as ventricular drainage, controlled hyperventilation, osmotic diuresis, high-dose barbiturates, and craniectomy are limited and not without consequences. Inhibitory pressure techniques, which may affect the autonomic nervous system and ICP and CPP levels, ought to be evaluated more extensively in the future. 
Conclusion
The purpose of OMT is to promote well-balanced and optimal function of the lymphatic system in the presence of a disruption. Without an effective lymphatic system, patients are prone to edema, infection, inflammation, or third spacing. Because the lymphatic system is a passive drainage system and dependant on motion for function, OMT has long provided an additional measure of physiologic movement to facilitate an effective fluid dynamic. Osteopathic manipulative treatment is associated with increased thoracic duct flow, absorption of fluids, increased circulation and respiration, decreased extravasation of proteins into the interstitium, and a normal pH balance.17,18 
Because many of the disabilities from head injuries evolve from predictable types of secondary injuries, the use of pedal pump and thoracic pump techniques in the presence of closed head injuries was examined. Although not definitive, the techniques were determined to be safe in patients with severe brain injuries with regard to ICP and CPP. The results of the present small study provide an initial step forward in the exploration of the use of these two OMT techniques in patients with TBIs. Thus far, not only do these techniques improve lymphatic drainage and contribute to recovery, they do not significantly impair ICP or CPP. On the contrary, our study demonstrated no detrimental effect of ICP and CPP with pedal pump and thoracic pump techniques. Future studies are needed to investigate the benefit of other OMT techniques on ICP and the efficacy of the pedal and thoracic pump techniques in preventing infection and improving overall outcomes in patients with TBI. 
 Financial Disclosures: None reported.
 
Noll DR, Shores JH, Gamber RG, Herron KM, Swift J Jr. Benefits of osteopathic manipulative treatment for hospitalized elderly patients with pneumonia. J Am Osteopath Assoc. 2000:100(12):776-782. http://www.jaoa.org/cgi/reprint/100/12/776. Accessed April 8, 2010.
Carr RR, Nahata MC. Complementary and alternative medicine for upper-respiratory-tract infection in children. Am J Health Syst Pharm. 2006 :63(1):33-39.
Cantieri MS. Inpatient osteopathic manipulative treatment; impact on length of stay. Am Acad Osteopath J. 1997;7(4):25-29.
Brain injury statistics. Brain & Spinal Cord Web site. http://www.brainand-spinalcord.org/brain-injury/statistics.html. Accessed April 12, 2010.
Jenkins LW, Moszynski K, Lyeth BG, Lewelt W, DeWitt DS, Allen A, et al. Increased vulnerability of the mildly traumatized rat brain to cerebral ischemia: the use of controlled secondary ischemia as a research tool to identify common of different mechanisms contributing to the mechanical and ischemic brain injury. Brain Res. 1989;477(1-2):211-224.
Hovda DA, Becker DP, Katayama Y. Secondary injury and acidosis. J Neurotrauma. 1992;9(Suppl 1):S47-S60.
Jones PA, Andrews PJ, Midgley S, Anderson SI, Piper IR, Tocher JL, et al. Measuring the burden of secondary insults in head-injured patients during intensive care. J Neurosurg Anesthesiol. 1994;6:4-14.
The Brain Trauma Foundation; The American Association of Neurological Surgeons; The Joint Section on Neurotrauma and Critical Care. Indications for intracranial pressure monitoring. J Neurotrauma. 2000;17(6-7):479-491.
Teasdale G, Jennet B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-84.
Becker DP, Miller JD, Ward JD, Greenberg RP, Young HF, Sakalas R. The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg. 1977;47(4):491-502.
Marshall LF, Smith RW, Shapiro HM. The outcome with aggressive treatment in severe head injuries. Part II: acute and chronic barbiturate administration in the management of head injury. J Neurosurg. 1979;50(1):26-30.
Miller JD. Physiology of trauma. Clin Neurosurg. 1982;29:103-130.
Brimioulle S, Moraine JJ, Norrenberg D, Kahn RJ. Effects of positioning and exercise on intracranial pressure in a neurosurgical intensive care unit. Phys Ther. 1997;77(12):1682-1689. http://ptjournal.apta.org/cgi/reprint/77/12/1682. Accessed April 8, 2010.
Matta B, Strebel S, Lam A. Effect of the Valsalva maneuver on intracranial hypertension [case report]. J Neurosurg Anesthesiol. 1994;6(4):280-283.
Shapiro HM, Marshall LF. Intracranial pressure responses to PEEP in head-injured patients. J Trauma. 1978 :18(4):254-256.
Toung T, Ngeow YK, Long DL, Rogers MC, Traystman RJ. Comparison of the effects of positive end-expiratory pressure and jugular venous compression on canine cerebral venous pressure. Anesthesiology. 1984;61(2):169-172.
Knott EM, Tune JD, Stoll ST, Downey HF. Increased Lymphatic Flow in the Thoracic Duct During Manipulative Intervention. J Am Osteopath Assoc. 2005:105(10):447-456. http://www.jaoa.org/cgi/content/full/105/10/447. Accessed April 8, 2010.
Ward RC, ed. Foundations for Osteopathic Medicine. Philadelphia, PA: Lippincott Williams & Wilkins;2003 .
Figure 1.
The Glasgow Coma Scale is used in the assessment of patients with traumatic brain injury. Patients are assigned one score from each of the three categories, resulting in a total score of at least 3 but no more than 15.
Figure 1.
The Glasgow Coma Scale is used in the assessment of patients with traumatic brain injury. Patients are assigned one score from each of the three categories, resulting in a total score of at least 3 but no more than 15.
Figure 2.
Direct effect of osteopathic manipulative treatment (OMT) on intracranial pressure (ICP) and indirect effect on cerebral perfusion pressure (CPP). Overall, OMT reduced ICP, but this finding was not statistically significant.
Figure 2.
Direct effect of osteopathic manipulative treatment (OMT) on intracranial pressure (ICP) and indirect effect on cerebral perfusion pressure (CPP). Overall, OMT reduced ICP, but this finding was not statistically significant.
Figure 3.
Direct effect of osteopathic manipulative treatment (OMT) on cerebral perfusion pressure (CPP) and indirect effect on intracranial pressure (ICP). Overall, OMT reduced ICP, but this finding was not statistically significant.
Figure 3.
Direct effect of osteopathic manipulative treatment (OMT) on cerebral perfusion pressure (CPP) and indirect effect on intracranial pressure (ICP). Overall, OMT reduced ICP, but this finding was not statistically significant.
Effects of Two OMT Techniques in Patients With Traumatic Brain Injuries: Intracranial Pressure and Cerebral Perfusion Pressure, mm Hg (N=24) *






OMT


Baseline
Pedal Pump
Thoracic Pump
Post-OMT
Patient
Age, y
Sex
ICP
CPP
ICP
CPP
ICP
CPP
ICP
CPP
▪ Group 1*
□ 1 41 M 20 77 18 73 19 73 17 72
□ 255W1997199721902290
1969208920882385
□ 4 22 M 11 78 10 84 10 91 10 97
13 86 11 84 13 92 11 96
12 80 10 79 9 80 15 81
□ 536M1091119512971497
15100129511911390
10100139411991192
□ 6 18 W 3 88 3 90 4 89 3 89
3 88 4 89 4 89 3 88
7 85 3 90 0 90 0 90
□ 757W585689783783
9778741079969
1270107812801074
□ 8 42 M 9 74 10 74 8 72 7 71
10 74 10 70 8 66 8 73
□ 944M460568568668
869869870871
□ 10 31 W 15 59 15 71 14 72 13 77
18 84 22 88 18 80 16 79
□ 1148M969870970970
1475157716741375
□ 12 67 M 6 69 5 72 10 67 8 69
13 62 11 66 14 63 12 65
□ 1327M1080107811771177
□ 15 51 W 9 72 6 71 10 80 7 83
17 74 13 94 22 68 15 75
16 96 14 96 1 89 7 84
□ 1744M1768226217601761
1770205917671771
▪ Group 2*
□ 141M2570197420691967
□ 2 55 W 22 71 20 88 24 67 20 72
□ 327W3074328437633662
4165287743654364
4361436040644065
□ 13 27 M 26 64 22 66 28 60 25 63
□ 1460M2560266827602761
2159226126622365
□ 16 20 W 36 55 34 60 33 61 38 64
□ 1829W2566267025712272
2263206622682464
□ 19 61 M 36 60 36 59 34 65 32 66
27 71 28 75 26 72 22 65
□ 2018M2764287526722869
□ 21 69 M 31 61 32 63 24 69 25 70
28 66 27 65 30 66 25 64
□ 2232M2866287023742880
□ 23 45 W 21 75 22 89 25 81 20 82
□ 2433M4060415839624158
 Abbreviations: CPP, cerebral perfusion pressure; M, man; W, woman.
 *A total of 24 patients received 50 sessions of osteopathic manipulative treatment (OMT). Patients in group 1 had a baseline intracranial pressure (ICP) ≤20 mm Hg. Patients in group 2 had a baseline ICP >20 mm Hg.
 Patient was in group 1 for the first trial and group 2 for the second trial.
 Patient was in group 1 for the first and second trials and group 2 for the third trial.
Effects of Two OMT Techniques in Patients With Traumatic Brain Injuries: Intracranial Pressure and Cerebral Perfusion Pressure, mm Hg (N=24) *






OMT


Baseline
Pedal Pump
Thoracic Pump
Post-OMT
Patient
Age, y
Sex
ICP
CPP
ICP
CPP
ICP
CPP
ICP
CPP
▪ Group 1*
□ 1 41 M 20 77 18 73 19 73 17 72
□ 255W1997199721902290
1969208920882385
□ 4 22 M 11 78 10 84 10 91 10 97
13 86 11 84 13 92 11 96
12 80 10 79 9 80 15 81
□ 536M1091119512971497
15100129511911390
10100139411991192
□ 6 18 W 3 88 3 90 4 89 3 89
3 88 4 89 4 89 3 88
7 85 3 90 0 90 0 90
□ 757W585689783783
9778741079969
1270107812801074
□ 8 42 M 9 74 10 74 8 72 7 71
10 74 10 70 8 66 8 73
□ 944M460568568668
869869870871
□ 10 31 W 15 59 15 71 14 72 13 77
18 84 22 88 18 80 16 79
□ 1148M969870970970
1475157716741375
□ 12 67 M 6 69 5 72 10 67 8 69
13 62 11 66 14 63 12 65
□ 1327M1080107811771177
□ 15 51 W 9 72 6 71 10 80 7 83
17 74 13 94 22 68 15 75
16 96 14 96 1 89 7 84
□ 1744M1768226217601761
1770205917671771
▪ Group 2*
□ 141M2570197420691967
□ 2 55 W 22 71 20 88 24 67 20 72
□ 327W3074328437633662
4165287743654364
4361436040644065
□ 13 27 M 26 64 22 66 28 60 25 63
□ 1460M2560266827602761
2159226126622365
□ 16 20 W 36 55 34 60 33 61 38 64
□ 1829W2566267025712272
2263206622682464
□ 19 61 M 36 60 36 59 34 65 32 66
27 71 28 75 26 72 22 65
□ 2018M2764287526722869
□ 21 69 M 31 61 32 63 24 69 25 70
28 66 27 65 30 66 25 64
□ 2232M2866287023742880
□ 23 45 W 21 75 22 89 25 81 20 82
□ 2433M4060415839624158
 Abbreviations: CPP, cerebral perfusion pressure; M, man; W, woman.
 *A total of 24 patients received 50 sessions of osteopathic manipulative treatment (OMT). Patients in group 1 had a baseline intracranial pressure (ICP) ≤20 mm Hg. Patients in group 2 had a baseline ICP >20 mm Hg.
 Patient was in group 1 for the first trial and group 2 for the second trial.
 Patient was in group 1 for the first and second trials and group 2 for the third trial.
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