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The Somatic Connection  |   August 2011
THE SOMATIC CONNECTION
Article Information
The Somatic Connection   |   August 2011
THE SOMATIC CONNECTION
The Journal of the American Osteopathic Association, August 2011, Vol. 111, 465-467. doi:10.7556/jaoa.2011.111.8.465
The Journal of the American Osteopathic Association, August 2011, Vol. 111, 465-467. doi:10.7556/jaoa.2011.111.8.465
Osteopathic Manipulative Therapy Shown to Have Impact on Intima-Media Thickness and Systolic Blood Pressure
Cerritelli F, Carinci F, Pizzolorusso Get al. Osteopathic manipulation as a complementary treatment for the prevention of cardiac complications: 12-months follow-up of intima media and blood pressure on a cohort affected by hypertension. J Bodywork Movement Ther. 2011;15(1): 68-74. 
Italian researchers assigned a consecutive series of hypertensive patients to an osteopathic manipulative therapy group or standard care–only group. All patients were referred by the same cardiologist in Pescara, Italy, and were maintained on conventional antihypertensive treatment throughout the study. Initially, 72 patients entered the study, but 9 were excluded because of multiple risk factors or previous complications that could have impaired safe inclusion in the study. 
Of the 63 patients who completed the study, 31 were nonrandomly assigned to the osteopathic manipulative therapy group, and 32 served as the control group. There were no statistically significant differences between the experimental and control groups on any baseline parameters, which included sex, age, height, weight, antihypertensive medication usage, intima-media thickness (IMT), body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate. 
All participants wore a 24-hour ambulatory electrocardiology monitor to test for hypertension prior to entering the study. Researchers measured patients' resting blood pressure and IMT at the initial visit and again after 12 months. The resting BP was measured with the patient in a supine position for 30 minutes. Examinations also included ultrasonography, which was used to measure IMT for both carotid and femoral bifurcation. Researchers scored IMT findings for each bifurcation of the carotid and femoral arteries according to a scale that corresponded to the World Health Organization's B-ultrasound morphology classification (J Hypertens. 2003;21[11]:1983-1992). Each participant received a single “ultrasound score” based on the sum of these 4 scores. 
Experimental group patients received osteopathic manipulative therapy every 2 weeks for 1 year. Procedures were performed by several different Italian registry osteopaths and did not follow a prescribed protocol. Rather, treatments varied from patient to patient based on the assessment of somatic dysfunction. Because this study is based on a unique combination of osteopathic manipulative therapy procedures designed to best benefit a given patient, the article's outcomes are described as “effectiveness” measures; an efficacy study would employ just 1 procedure on every participant. 
Because of many possible confounding factors (ie, age, BMI, effects of medication), the primary outcomes were analyzed by multivariate linear regression. The result of this analysis showed that improvement in IMT and SBP was associated with osteopathic manipulative therapy; however, DBP was not associated with osteopathic manipulative therapy. Based only on univariate analysis, however, osteopathic manipulative therapy was associated with improvement in IMT, BMI, SBP, DBP, and reduced medication dosage. 
The stronger multivariate analysis that showed benefit in improved IMT characteristics and reduced SBP associated with osteopathic manipulative therapy is an encouraging finding. While preliminary in nature and in need of further study, these results add to the support for the benefit of OMT in the treatment of systemic disorders, especially cardiac and vascular physiologic functioning. 
The authors suggest that osteopathic manipulative therapy may be a useful adjuvant procedure in the management of hypertension. However, the results of the study should be interpreted cautiously because of the study's limitations, including the small number of participants—there was no preliminary study upon which to base a power analysis—and the nonrandom assignment of participants. Nonetheless, findings that identify a way to measure the impact of osteopathic manipulative therapy on cardiac functioning is most encouraging and merits further study. In this regard, it is important to point out that osteopathic manipulative therapy is a noninvasive procedure; it was well tolerated by all patients in the present study, and no adverse events were reported. 
Possible mechanisms of action have been discussed by Meltzer and Standley (J Am Osteopath Assoc. 2007;107[12]:527-536), who suggested that osteopathic manipulative treatment (OMT) reduces the production of inflammatory cytokines, thereby improving the metabolism of the arterial wall. Meltzer and Stanley also suggested that OMT may improve the function of the autonomic nervous system, especially the sympathetic nervous system tone, by modifying the metabolism and hemodynamic factors. These factors in turn affect the metabolism of the arterial wall, especially in circumstances in which the IMT is not too stenotic. 
This study was selected for review because it was carried out by a strong and well-established Italian osteopathic research center: the European Institute for Evidence Based Osteopathic Medicine in Pescara, Italy. Research from this group merits serious consideration by everyone in the manual medicine and manual therapy professions. This study also supports the long-held osteopathic clinical opinion that OMT does have benefit in the treatment of systemic disorders. The data presented in this study also comprise the basis for determination of a power analysis for future study. —H.H.K. 
Health Outcomes in Older Adults Improved by Massage
Munk N, Zanjani F. Relationship between massage therapy usage and health outcomes in older adults. J Bodywork Movement Ther. 2011;15: 177-185. 
Researchers at the University of Kentucky conducted a survey that analyzed self-reported health outcomes of individuals aged 60 years or older who either had or had not received massage therapy in the past year. Survey respondents were randomly recruited from voter registration lists and from massage therapy offices in Lexington, Kentucky. The study included 81 individuals who had not received massage therapy in the last year and 64 who had received therapy. One massage was enough for inclusion in the “received massage therapy” group. 
All respondents filled out a form that asked about demographics, health, ethnicity, education, and income. Respondents also completed the RAND 36-Item Health Survey 1.0, which measures quality of life in 9 different categories comprising physical, social, emotional, and health. Respondents who had received massage therapy in the last year had higher mean scores in all 9 RAND 36 categories than those who did not receive a massage. However, statistical significance between the groups was reached only for the “limits due to emotional issues” category (P<.05). This finding implied that those who received massage therapy had fewer limitations in life due to emotional issues. 
Multiple linear regression analysis was applied to the data to control for the variations between groups due to potential confounding variables. The multiple linear regression analysis, which controlled for massage therapy, age, and cumulative health morbidities, showed that respondents who had received massage therapy reported fewer problems in life due to “physical limitations” and “emotional limitations.” In addition, they reported overall better “emotional health.” 
One shortcoming of the study discussed by the authors is the cross-sectional design, which, like a correlation study, limits the ability to claim causation. In studies with this design, findings can only be asserted, not confirmed. Aside from this statistical design observation, the study had a large sample size to give the results gravitas sufficient for consideration and review in”The Somatic Connection.” 
The authors go on to speculate that the benefits of massage therapy may be related to increased serotonin levels found after massage therapy, which has been suggested in previous research. This theory may also be related to the benefits found in the use of serotonin-reuptake inhibitors frequently used for depression in elderly patients. 
From the perspective of osteopathic research, these results support Noll et al's findings showing benefit of osteopathic manipulative treatment (OMT) in older adults with pneumonia (Osteopath Med Prim Care. 2010;4:2) and Lopez et al's study on the benefit of OMT for balance in older adults (J Am Osteopath Assoc. 2011;111[6]:382-388). 
I suggest that research on the benefits of OMT in older adults is a fertile ground for study. Research suggestive of immune system benefit from lymphatic pump procedures (Lymphat Res Biol. 2007;5[2]:127-132; Lymphat Res Biol. 2010;8[2]:103-110), which were also used in the Noll et al 2010 pneumonia study, hold promise of impacting the standard of care for pneumonia in older adults if additional research supports these studies' findings. Likewise, if OMT can be shown to improve balance in the elderly, the morbidity and expense of falls resulting in hip fractures could be substantially reduced—an obvious benefit to society. 
As suggested by Munk and Zanjani, the expense of manual therapy is a fraction of the cost compared with the expense of treating older adults for morbidities such as depression and propensity to falls associated with age-related diminished balance and equilibrium. Further research and cost-benefit analyses are needed, but this study has cleared the path for clinical and basic science researchers to initiate additional projects on this topic. Findings from this study that support an emotional benefit of massage therapy in older adults relate to the first tenet of osteopathic medicine, which states that the person is a product of a dynamic interaction between mind, body, and spirit (J Am Osteopath Assoc. 2002;102[2]:63-65). There has been a lack of focus in the osteopathic medical profession with regard to the spiritual benefits of OMT, both in the areas of research and philosophy. Perhaps the massage therapy researchers have shown us a path for productive osteopathic research as well.—H.H.K. 
Use of Manual Therapy Improves Recovery Time for Long-Standing Groin Pain
Weir A, Jansen J, van de Port I, Van de Sande H, Tol JL, Backx FJ. Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial. Man Ther. 2011;16(2): 148-154. 
In a single-blind, randomized controlled clinical trial, Dutch researchers compared an exercise therapy (ET)–only protocol to a multi-modal treatment program (MMT) that included heat, manual therapy, and stretching. Participants were athletes referred for sports medicine care who had been experiencing groin pain for at least 2 months. All participants were examined by the same blinded physician at baseline and at 6 weeks and 16 weeks after the start of treatment. If needed, participants were also examined at 24 weeks to determine the outcome of the ET and MMT programs. 
Fifty-four athletes met the study's inclusion criteria. Twenty-five participants were randomly assigned to the ET group and 29 were randomly assigned to the MMT group, with 22 and 26 completing the study, respectively. Prior research had determined that 21 participants in each group constituted sufficient power for meaningful statistical analysis. 
Participants in the ET group were seen by sports physical therapists and instructed to perform an extensive exercise regimen 3 times per week at home. The ET regimen emphasized stretching and strengthening exercises for abdominal muscles and leg adductor and abductor muscles. The MMT included heat, manual therapy, and stretching. One of 3 sports medicine physicians administered the manual therapy. The article depicts the manual therapy routine as an articulatory procedure in which the physician assessed the participant's adductor muscle tension with the participant's hip and knee flexed. When a palpated decrease in muscle tension was detected, the participant's knee was extended and the adductor muscle was stretched as the leg was moved in a circular hip range of motion. For each manual therapy session, this procedure was repeated 3 times. After the manual therapy, the participant performed adductor stretches and then laid in a warm bath for 10 minutes. 
The results showed that the mean (SD) time before returning to sports was 12 (6) weeks for participants who received the MMT regimen and 17.3 (4.4) weeks for participants in the ET group, with a statistically significant difference between groups (P=.043). However, only 50% of participants in the MMT group and 55% of participants in the ET group returned to full sports participation, with no statistically significant difference between groups. Results of a visual analogue scale on groin pain at weeks 0 and 16 showed statistically significant improvement in both ET and MMT groups, with no differences found between the groups. 
The authors expressed surprise that the results were not more dramatic for the MMT group because a prior retrospective study (Scan J Med Sci Sports. 2009;19[5]:616-620) had shown a much higher return to full sports participation than the present study. The differences in the 2 studies' findings could be attributed to the present study's prospective study design, which was more rigorous than the previous study's retrospective design. In addition, the present study's inclusion criteria of “at least two months of adductor-related groin pain” could have resulted in a more injured study population than in the retrospective study, which did not have this criterion. Because of the differences in the degree of injury, participants in the present study may have had injuries that were more resistant to treatment than those in the retrospective study. The authors also point out that, without a control group, they were unable to evaluate which part of the MMT regimen helped the most or not at all. The authors did conclude that the MMT regimen is safe and resulted in a statistically significant quicker return to full sports participation. 
Even with these limitations, this article is an example of what can be done with an OMT study on similar or identical sports injury conditions. The single-blind aspect has been seen as a limitation to OMT research designs, but I suggest that this is really not an impediment at all, as illustrated by the fact that the research design for the present study passed a rigorous peer-review process. Of course, an OMT study patterned after the present study would need to include a third control group to facilitate analysis of any OMT effects. 
Also of interest is the set of specific manual maneuvers used in this way for treatment of adductor muscle pain. This procedure was reported to have worked well in a previous retrospective study (Scan J Med Sci Sports. 2009;19[5]:616-620) and may well have been the “active ingredient” in producing the benefits reported in this study (though, as previously mentioned, this cannot be asserted as true without a control group). 
From an osteopathic sports medicine perspective, a strain-counterstrain procedure to the adductor muscles may have produced better results; the application of the physician's finger on the pubic symphysis for strain-counterstrain “tender points” would appear to be a more complete treatment than the one illustrated and described in the present article. In addition, the authors of the present study state that they do not know the mechanism of action for the procedure used in the study. Conversely, osteopathic strain-counterstrain procedures have a presumed mechanism of action that could give greater understanding to any results of a similar study that used strain-counterstrain in its treatment protocol. 
Osteopathic researchers can learn from this study and apply its design to future research projects. The association of manual therapy with shorter recovery time for patients with sports injury adds to the evidence base for all manual medicine–based procedures, including OMT. —H.H.K. 
   “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).