The Somatic Connection  |   January 2012
The Somatic Connection
Article Information
The Somatic Connection   |   January 2012
The Somatic Connection
The Journal of the American Osteopathic Association, January 2012, Vol. 112, 11-16. doi:10.7556/jaoa.2012.112.1.11
The Journal of the American Osteopathic Association, January 2012, Vol. 112, 11-16. doi:10.7556/jaoa.2012.112.1.11
“As the Twig Is Bent, So Grows the Tree”: Part 2
Lessard S, Gagnon I, Trottier N. Exploring the impact of osteopathic treatment on cranial asymmetries associated with nonsynostotic plagiocephaly in infants. Complement Ther Clin Pract. 2011;17(4):193-198.  
The use of osteopathic manipulative treatment in the care of pediatric patients is 1 of the great contributions of the osteopathic medical profession to health care practice. The somatic dysfunction in patients with developing musculoskeletal structures is likely much more responsive to treatment than that in patients with completed bone growth. This theme was emphasized in the last edition of “The Somatic Connection” (J Am Osteopath Assoc. 2011;111[10]:571-572), which included a review of the effects of osteopathic therapy on postural symmetry in infants. This theme is highlighted again in the present review and in the following review, which looks at the effects of carrying backpacks in children and adolescents. 
Researchers at the McGill University Health Center—Montreal Children's Hospital Trauma Program in Toronto, Canada, studied the impact of osteopathic manipulative therapy (OMTh) on infants with signs of nonsynostotic occipital plagiocephaly (NSOP). As noted by the authors, NSOP may occur in nearly 20% of healthy newborns. The authors provide an excellent review of the morbidity associated with NSOP and report that despite popular belief, the effects of NSOP do not resolve without intervention. Since the American Academy of Pediatrics began efforts to reduce the incidence of sudden infant death syndrome through the “Back to Sleep” campaign, which encouraged parents to place infants in a supine position for sleep, the incidence of NSOP has increased. Conventional interventions for NSOP include counter-positioning, physical therapy, and cranial orthosis (helmet therapy). 
Twelve infants referred to the Children's Hospital Trauma Program were the patients in this pilot study. Inclusion criteria were as follows: “to be younger than 6.5 months at first evaluation, to have a diagnosis or the signs of NSOP, and to have been at term corrected age if born prematurely.” Patients were excluded “if there was a documented craniosynostosis, an ongoing cranial orthosis treatment, and if presenting with any medical condition judged inappropriate by a physician.” 
Each patient received four 60-minute OMTh sessions approximately once every 2 weeks. The OMTh was provided by osteopaths, who followed recommendations from the Collège d'Études Ostéopathiques in Montréal, Canada, that were in regular use by osteopaths in the Children's Hospital Trauma Program. On the basis of references cited and descriptions in the article, it appears that the techniques were the same as the cranial osteopathic manipulative medicine techniques commonly used by osteopathic physicians in the United States to treat pediatric patients. 
The 3 primary outcome measures used in the assessment of NSOP were the differences between the left side and right side measurements of (1) skull base asymmetry (SBA), which uses a line from the tragus of the ear to the subnasal landmark under the nasal septum; (2) cranial vault asymmetry (CVA), which uses the distance between the frontozygomatic suture and eurion, the point most lateral on the head in the parietal region; and (3) transcranial vault asymmetry (TCVA), which uses the diameter of the frontozygomatic suture around the head to the occipital prominence or flatness. These measures are standard anthropometric and plagiocephalometric measurements used in current clinical pediatric practice from a digital spreading caliper. A noninvasive, low-temperature, thermoplastic material was used to obtain cranial circumference molds to document dimensions of oblique diameter differences on the right and left sides of the head. All of these dimensions are illustrated in the article and are well referenced for further study. The primary outcome measures were collected 3 times: before intervention (T1), at the time of the third treatment (T2), and 2 weeks after the fourth treatment (T3). 
Secondary measures included osteopathic assessments of different anatomic structures of the child's body, parental questionnaire collecting information on the child's birth, general health, and perinatal data. 
All 12 infants enrolled in the study completed the assessments and interventions. Consistent with data reported in the literature, most of the patients (n=11) presented a right occipital flattening. The average age of the infants at first OMTh session was 4.1 months; 75% were male, 92% had right-sided head flattening (consistent with current prevalence data), and 83% were delivered vaginally. 
All 3 primary outcome measures showed statistically significant reductions in skull asymmetry from T1 to T3 (CVA, F=5.20, P=.02; SBA, F=5.72; P=.01; TCVA, F=7.97; P<.003) during an average period of 8 weeks. Results of the Oblique Diameter Difference Index (ODDI) showed an insignificant effect over the course of the study (F=2.79, P=.08). However, 10 of the 12 participants presented with an ODDI greater than 104%, which is an asymmetry that is considered clinically significant, and 8 of those 10 improved below the 104% threshold after OMTh. 
The secondary outcome measures revealed that the right-sided occipital flattening present in 11 of the participants was associated with a right lateral strain pattern at the sphenobasilar symphysis. Those participants with the right-sided occipital flatness also were initially more restricted in active cervical motion to the left, and the reverse was true for the participant with left occipital flattening. In both cases, improved cervical motion was obtained by the end of treatment. None of the participants manifested balanced tension in the dura mater membranes, presumably because of the cranial bone asymmetry. 
The authors acknowledge that because of the study's small sample size and lack of control group, it cannot absolutely be inferred that OMTh was the cause of improved cranial bone symmetry. The authors go on to point out that the improvement in CVA was 62%; SBA, 48%; and TCVA, 60%. The overall improvement in ODDI was 4%, a very noticeable and palpable finding for an infant's head. It should also be noted that all participants were younger than 6.5 months, a further limitation on the generalizability of the study's data. 
In my 30 years of clinical practice, we obtained similar findings through the application of cranial manipulation in a pediatric population aged up to 7 years. It is now possible to cite some data about alternative interventions when counseling families whose children require helmets.—H.H.K. 
“As the Twig Is Bent, So Grows the Tree”: Part 3
Cheung CH, Shum ST, Tang SF, Yau PC, Chiu TT. The correlation between cranio vertebral angle, backpack weights, and disability due to neck pain in adolescents. J Back Musculoskelet Rehabil. 2010;23(3):129-136.  
In today's schools, it is common for students to carry backpacks to and from school and between classes. To my knowledge, few studies have been conducted on the effects of carrying backpack loads of different weights. Researchers at the Hong Kong Polytechnic University Department of Rehabilitation Sciences studied changes in the craniovertebral angle caused by backpack loads in adolescents aged 13 to 18 years with and without neck pain. 
More than 200 students from randomly selected classes agreed to participate in this study. Inclusion criterion was that the student needed to be using a backpack at the time of the study. For the neck pain group, only those students who had experienced pain in the neck region in the past 3 months were included. Students with a known neurologic disease, spinal pathology (eg, scoliosis), cervical fracture, previous cervical surgical procedure, or inability to stand independently were excluded from the study. Seventy-five students met the criteria for neck pain and 119 met the criteria for no neck pain. Thirty students were randomly selected from both groups for the study. An experienced physical therapist evaluated students in the neck pain group and administered a verbal analog scale for pain. The physical therapist also evaluated all students in the study and screened them for scoliosis. All students filled out the Chinese version of the Northwick Park Neck Pain Questionnaire (NPQ). 
A standard type of backpack, with no internal framing or back support, was used for all subjects. Backpacks had 2 padded adjustable shoulder straps, which were used to center the backpack between T12 and L3. The craniovertebral (CV) angle was measured by a second, blinded, experienced physical therapist. A stopping rule was in place for all participants and consisted of any report of pain during testing. 
The CV angle is formed at the intersection of a horizontal line through the spinous process of the C7 vertebra and a line to the tragus of the ear. This CV angle is a common measurement used to assess forward head posture (FHP) commonly found in individuals who are carrying loads on their backs. The smaller the CV angle, the greater the degree of FHP. Each participant had his or her CV angle measured while wearing a backpack weighted with 5% to 30% of his or her body weight, ranging in loads of 5%, 10%, 15%, 20%, 25%, and 30% of body weight. Each participant experienced a different order of pack weights randomly determined. No students invoked the stopping rule. 
Statistical analysis revealed no differences between the neck pain group and no neck pain group for age, body weight, height, and body mass index. Results were not statistically significant for the association between the change of CV angle, relative usual backpack weight, verbal analog score, and NPQ score in the neck pain group. There were no statistically significant differences in the unloaded CV angles between the groups, and CV angle changes in different loading between the groups did not show any statistically significant differences at any point of comparisons. 
However, the CV angles for both the neck pain and control groups were statistically significant between baseline and 10% of body weight (P<.05). There was a statistically insignificant but very consistent CV angle difference of 2° to 3° between neck pain and control groups, with the control group having the lower angle measurements showing a greater degree of FHP. The lesser degree of CV angle in the students with neck pain was thought to be due to the pain restriction and flexibility of the cervical spine. 
The authors concluded that their findings suggested it is safest to limit the weight of backpacks for adolescents to no more than 10% of the person's weight. Limitations identified by the authors were that only a static posture was measured and that it is uncertain if such a major change were able to be assessed during locomotion. 
Although these results may seem like common sense to those of us who counsel patients and parents who are concerned about heavy backpack loads, it is good to have empirical evidence to support our recommendations. This study was selected for review because of its relevance to the musculoskeletal system and its evaluation typical in osteopathic medical practice. The device measuring the CV angle may also have use in osteopathic research. From an osteopathic manipulative medicine perspective, the FHP may have somatic dysfunction implications, such as degree of extension (backward bending) in the upper 3 or 4 cervical segments and the degree of flexion (forward bending) in the lower cervical segments. 
As noted in the October installment of “The Somatic Connection” (J Am Osteopath Assoc. 2011[10]:571-572) and the previous review, from my clinical experience, repetitive-use phenomena such as carrying backpacks has been associated with vertebral column somatic dysfunction that has lasting impacts beyond the bone-growth period of childhood and adolescence.—H.H.K. 
Large Clinical Trial Examines 3 Interventions for Chronic Low Back Pain
Bronfort G, Maiers MJ, Evans RL, et al. Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial. Spine J. 2011;11(7):585-598.  
This well-designed and carefully executed clinical trial was carried out by researchers at the Wolfe-Harris Center for Clinical Studies at the Northwestern Health Sciences University in Bloomington, Minnesota. Of the 630 patients with reported chronic low back pain (LBP) who were screened for the study, 301 were enrolled and randomly assigned to 1 of 3 interventions for 12 weeks of treatment. 
Participants were required to be between the ages of 18 and 65 years and to have “a primary complaint of mechanical LBP of at least 6-week duration with or without radiating pain” that could be reproduced by back movements or provocation tests. Exclusion criteria were “previous lumbar spine fusion surgery, progressive neurological deficits, aortic or peripheral vascular disease, pain scores of less than 3 (0-10 scale), pending or current litigation, or ongoing treatment for back pain by other health care providers.” 
One hundred one participants received supervised exercise therapy (SET), which consisted of individualized trunk strengthening exercises delivered during twenty 1-hour sessions, approximately twice per week. Participants in the SET group received one-on-one supervision by an exercise therapist. The program emphasized dynamic trunk strengthening exercises. Participants in this group started at their individually determined level of performance and progressively increased repetitions and loads of exertion. The authors describe the specific exercises and criteria to progress to the next level of performance and considered the SET a “high-dose” treatment regimen. 
One hundred participants received spinal manipulative therapy (SMT), which was delivered by 1 of 9 experienced chiropractors and was individualized according to the assessment of joint motion restriction and pain provocation. These sessions occurred 1 to 2 times per week and were of 15 to 30 minutes duration. At the discretion of the chiropractor, a few minutes of soft-tissue massage, ice, or heat was administered to facilitate the SMT. Some participants were discharged from care if the clinician felt that maximum clinical benefit was obtained. 
One hundred participants received home exercise and advice (HEA), a service administered by 11 different chiropractors and exercise therapists during two 1-hour appointments. An individualized program was developed and consisted of advice and instructions on self-care activities such as simple stretching and strengthening exercises, which included lumbar extension, bridging, and abdominal crunches. Self-care measures such as ice and heat and ergonomic recommendations for home and work were provided. In addition, participants “received a book and laminated cards describing the exercises” and were encouraged to practice those exercises daily. About 1 to 2 weeks after the initial session, participants in the HEA group were seen again and instructed to continue with the exercises on their own for the duration of the intervention phase. This intervention was considered a “low-dose” regimen because of the low number of provider visits and simplicity of the exercises. 
Outcome measures were collected at baseline and at 4, 12, 26, and 52 weeks after randomization. Self-reported pain measured on an ordinal 11-box scale, the Modified Roland-Morris Disability Questionnaire, and the 36-Item Short Form Health Survey were completed by the participants at each of the 5 data collection points. Also, blinded evaluators assessed trunk performance measures such as range of motion, strength, and endurance at baseline and at week 12. At week 12, all participants took part in an individual interview to report their satisfaction and perception of global improvement. 
At baseline, the SET group reported that their LBP awakened them at night less frequently than the other 2 groups (P<.05). Results showed that adherence to study interventions were high (86%-96% completion rates). At week 12, all 3 groups demonstrated improved outcomes, and there were no statistically significant differences between groups except for the satisfaction variable—the SET group was most satisfied and the HEA least satisfied (P<.01 at 12 weeks and P<.0001 at 52 weeks)—using univariate analysis of covariance. There were no differences between groups for pain scores, Roland-Morris disability scores, or reports of global improvement. Participants in the SET group also had statistically significant greater gains in trunk strength and endurance at week 12. 
That there were no statistically significant differences between the groups with regard to functional ability or perceived pain, yet improvements in these dimensions were found, led the authors to suggest that all 3 types of interventions were useful in the treatment of patients with chronic LBP. The data on the cost-benefit ratios for the 3 interventions are planned for a subsequent publication, yet the authors note that the satisfaction and functional improvement found in the SET group will need to be carefully compared in cost to the improvements in the less costly interventions of SMT and HEA. 
To my knowledge, there has been no comparable study that used osteopathic manipulative treatment (OMT) as 1 of the interventions, and it is my opinion that the nature of OMT may have a qualitatively different effect when compared with an intensive program such as the SET or the HEA conditions used in this study. It is worth consideration by osteopathic researchers to replicate this study using OMT. 
The authors describe a potential limitation of the study in that it was not set up to differentiate between the specific effects of treatment and the contextual effects, especially regarding patient-provider interactions and the greater amount of patient-provider time spent in the intervention in the SET group. It is also my opinion that the nature of an OMT intervention, which takes 30 minutes or more, would compare very favorably with either the SET or HEA conditions in this particular study.—H.H.K. 
Decreased Ankle Dorsiflexion Increases Risk for Patellar Tendinopathy
Backman LJ, Danielson P. Low range of ankle dorsiflexion predisposes for patellar tendinopathy in junior elite basketball players [published online ahead of print September 14, 2011]. Am J Sports Med. 2011;39(12):2626-2633.  
Two of the key tenets of osteopathic medicine are (1) the body is a unit; the person is a unit of body, mind, and spirit and (2) structure and function are reciprocally interrelated. The first of these principles is often stated as “dysfunction in 1 part of the body affects function in other parts.” Indeed, the capabilities and health of athletes rely on the harmonious balance of various anatomic structures working in concert to generate peak performance. When structure begins to deviate from the necessary balance, performance dissipates, and the health and biopsychosocial well-being of the athlete is affected. In 1980, Blood described the osteopathic approach to treating patients with sprained ankles (J Am Osteopath Assoc. 1980;79[11]:680-692). In 2003, Eisenhart et al (J Am Osteopath Assoc. 2003;103[9]:417-421) described the ability of this approach to improve range of motion, including ankle dorsiflexion, in acute ankle sprains in the emergency room. It has long been conjectured that if the ankle does not regain its motion after an acute sprain, then further musculoskeletal problems will ensue. 
One of the physical examination findings found in athletes with ankle injuries is a decrease in ankle dorsiflexion. Researchers in Sweden recently conducted a prospective, 1-year study to assess whether decreased ankle dorsiflexion increases the risk for developing patellar tendinopathy (PT) in teenaged basketball players. According to research cited by the authors, PT is not as common in teenagers (7% prevalence) as it is in athletes between the ages of 19 and 29 years (32% prevalence), but more than half of athletes with PT retire from athletics because of the condition. 
Ninety Swedish junior elite basketball players (aged 14-20 years) attending an annual training camp were recruited for the study. Fifteen met exclusion criteria (eg, anatomic or functional abnormalities) and were thus excluded from the study. The remaining 75 athletes (38 males, 37 females) met inclusion criteria and completed the study. 
At the beginning of the camp, each player completed a short questionnaire during a standardized interview regarding weekly sport-specific and non–sport-specific exercise, history of ankle sprain, dominant leg, and history of knee injuries and treatment. Mean ankle dorsiflexion was measured in the dominant and nondominant legs using a weight-bearing lunge test. To address limb-specific risk factors (range of ankle joint dorsiflexion and number of ankle sprains), and because the difference in mean ankle dorsiflexion between dominant and nondominant legs was statistically significant (mean difference, 1.3°; 95% confidence interval [CI], 0.3-2.3; P=.015), each leg was analyzed separately. After 1 year of play, a short interview and a clinical examination were used to assess the participants for development of PT. Diagnostic criteria for PT included history of activity-related anterior knee pain and reduced function of the knee, distinct palpation tenderness at the site of pain (patellar tendon), and knee pain provoked by a single-legged decline squat test. All measurements were taken by the same physiotherapist. 
At 1-year follow-up, 12 players (8 males, 4 females) had evidence of unilateral PT (there were no cases of bilateral PT). This finding suggests a 1-year incidence of 16.0%. Players who developed PT had reduced mean ankle dorsiflexion range at baseline compared with baseline dorsiflexion seen in healthy players. Dominant leg and nondominant leg mean ankle dorsiflexion in athletes with PT was 4.7° (P=.038) and 5.1° (P=.024) less, respectively, compared with that of healthy players. No statistically significant differences were discovered between groups regarding the incidence of PT in dominant vs nondominant legs, age, sex, weight, height, body mass index, or exercise-training hours. It was also found that 2 or more ankle sprains resulted in decreased ankle dorsiflexion compared with that of healthy players (mean difference, 1.5°-2.5° depending on the leg); this finding was statistically significant for the nondominant leg (P=.048) but not for the dominant leg (P=.233). 
The authors used these data to generate a receiver operating characteristic (ROC) curve to determine if there was a clinically significant cut-off point for ankle dorsiflexion range that can be used to identify individuals at high risk for developing PT. The area under the ROC curve was 0.78 (P=.024) for the dominant leg and 0.81 (P=.013) for the nondominant leg. Applying the curves, less than 36.5° of ankle dorsiflexion was discovered to be a cut-off point for assigning individuals to a high-risk category for development of PT (both dominant and nondominant legs). Individuals in this high-risk category had a posttest probability of 18.5% in the dominant leg and 29.4% in the nondominant leg of developing PT within 1 year. Individuals in the low-risk group had a posttest probability of 2.1% (dominant leg) and 1.8% (nondominant leg). The statistical significance of the curves for both the dominant and the nondominant legs of the high-risk group indicated that a cut-off point of 36.5° can be used clinically as a screening tool for future PT development. The sensitivity of this cut-off point is 83.3% (dominant and nondominant legs) and the specificity is 68.1% in the dominant leg and 82.1% in the nondominant leg. 
This study demonstrates that low-range ankle dorsiflexion in young basketball athletes is a risk factor for developing PT within 1 year of play. However, the age of the athletes in this study narrows the application of these findings. Also, it is unclear whether ankle dorsiflexion restrictions in older professional athletes, as well as common recreational athletes, will correlate with possible development of PT. Additional studies are needed to explore these conclusions. Regardless, the use of osteopathic manipulative medicine in these junior elite athletes appears to be a perfect fit for possible prophylactic interventions for PT. This study paves the way for future research regarding prophylactic osteopathic manipulative treatments in this athletic population to decrease the incidence of PT.—B.S.R.* and M.A.S. 
Physiologic Response After “Pop” Sound During HVLA Technique
Clark BC, Goss DA Jr, Walkowski S, Hoffman RL, Ross A, Thomas JS. Neurophysiologic effects of spinal manipulation in patients with chronic low back pain. BMC Musculoskelet Disord. 2011;12:170.  
High-velocity, low-amplitude (HVLA), or thrust, technique is a form of osteopathic manipulative treatment (OMT) that osteopathic physicians use to treat somatic dysfunction. This technique involves moving the restricted joint through its restrictive barrier within its physiologic range of motion. Often, a “pop” sound is elicited when the physician administers the technique. Osteopathic physicians are taught in medical school that the pop sound is not required to improve motion of the joint. However, researchers at the Ohio University Heritage College of Osteopathic Medicine found an association between the pop sound and the physiologic response in study participants who received HVLA technique. 
Inclusion criteria for the LBP group were previous medical care, chiropractic care, or physical therapy for LBP. Exclusion criteria comprised history of spinal surgical procedure, orthopedic or neurologic impairment other than LBP, fracture of the spine, tumor, arthroplasty, osteoporosis, cardiopulmonary disorder, and severe osteoarthritis. Patients who had been using narcotics or muscle relaxants for pain, who were pregnant, or who exhibited frank neurologic signs were also excluded from the study. Additional factors that excluded patients from participating were a body mass index greater than 32, history of clinical depression, unexplained weight loss, an elevated temperature, manual therapy intervention in the past month, pending litigation related to an episode of LBP, disability payments, medication known to influence trans cranial magnetic stimulation parameters, or any condition that is contraindicated for exposure to a magnetic field. Inclusion criteria for the control group consisted of no history of LBP and a current LBP rating of 0 on a 10-point visual analog scale. The asymptomatic control patients were matched to the LBP patients for age, sex, and body mass index. 
The researchers measured the motor evoked potentials (MEPs) and the short-latency stretch reflexes of participants' erector spinae muscles before and after administration of a single HVLA thrust. Transcranial magnetic stimulation elicited MEPs (an index of corticospinal excitability) and electromechanical tapping elicited short-latency stretch reflexes (an index of Ia afferent reflex pathway excitability) in 5 men and 5 women with chronic low back pain (LBP; defined as symptoms lasting >12 weeks) and 10 asymptomatic control patients. Mean (standard deviation [SD]) characteristics of the participants with LBP included usual LBP, 4.0 (1.2); current LBP, 2.6 (1.6); and lifestyle change imposed from the LBP, 3.9 (3.1), all rated using a 10-point visual analog scale. Mean (SD) duration of LBP was 3.2 (3.1) years. Mean (SD) scores on the Roland Morris Disability Questionnaire and the Tampa Scale for Kinesiophobia were 5.9 (4.3) and 33.5 (6.5), respectively. 
On the day of testing, all patients received a standard osteopathic structural examination, which entailed visual and palpatory assessment for evidence of somatic dysfunction in the thoracic, lumbar, sacral, and pelvic regions. Palpatory evidence for somatic dysfunction diagnosis included asymmetry of anatomic landmarks, restriction of joint motion, soft-tissue hypertonicity, or tenderness. Participants were placed in the lateral recumbent position and a rotary thrust was applied to the spinal segment with somatic dysfunction. 
Researchers found that spinal manipulation did not alter the erector spinae MEP amplitude in patients with LBP or in asymptomatic control patients up to 10 minutes after intervention. However, participants in whom an audible response (ie, pop sound) occurred during HVLA technique exhibited a 20% decrease in the stretch reflex (P<.05). The researchers interpreted their findings as follows:

The short-latency stretch reflex occurs in response to a muscle being rapidly stretched, which excites the Ia afferent fibers within the muscle spindles. This observation suggests that when [spinal manipulation] results in an audible response it mechanistically acts by down-regulating the sensitivity of the muscle spindles and/or the various other segmental sites of the Ia stretch reflex pathway. … Spinal manipulation that results in an audible response may conceivably function to restore greater motion to a vertebral segment (as opposed to spinal manipulation that does not result in an audible response), and this biomechanical effect could result in subsequent changes in reflex activity as we observed.

In summary, the pop heard with the HVLA OMT technique signifies a distinct, measurable physiologic effect that is different than the effect of a silent HVLA maneuver. Whether this finding makes a difference in terms of somatic findings on structural examination, as is typically performed as a reassessment after the procedure, or if it affects the patient's health, motion, or pain was not assessed with this research design. Nevertheless, this study, performed by researchers employing a novel method of assessment at a US osteopathic medical college, provides new information about the physiologic effects of a single lumbar spine HVLA OMT procedure.—M.A.S. 
Efficacy Unproven for Vertebroplasty vs Placebo
Staples MP, Kallmes DF, Comstock BA, et al. Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: meta-analysis. BMJ. 2011;343:d3952. doi: 10.1136/bmj.d3952.  
For obvious reasons, high-velocity, low-amplitude (HVLA) osteopathic manipulative treatment is contraindicated at the site of acute vertebral compression fractures. Although surgical intervention has been proposed as a viable option for pain relief and functional restoration for patients with spinal fractures, it is rare to find randomized placebo-controlled clinical trials testing this therapy. In 2009, the New England Journal of Medicine published not only 1 but 2 studies on vertebroplasty with similar research designs.1,2 These studies were unable to demonstrate efficacy of vertebroplasty compared with placebo, but many researchers speculated that subgroup analysis may show benefit. In 2011, researchers in Australia and the United States collaborated to perform a meta-analysis of these 2 rare studies using subgroup analysis, which was published in BMJ. 
The researchers sought to determine whether vertebroplasty was more effective than placebo for vertebral compression fracture in 2 subgroups of patients: those with recent pain (<6 weeks) and those with severe pain (⩾8 on a 10-point scale). They combined the results of the multicentered randomized controlled trials, which were based in Australia (n=78)1 and in the United States (n=131).2 
Between the 2 studies, 57 participants had a recent onset of pain, of whom 25 received percutaneous vertebroplasty and 32 received a placebo procedure. Ninety-nine participants had severe pain at baseline, of whom 50 received vertebroplasty and 49 received placebo. The main outcome measures were pain scale scores and function at 1 month, as determined by the modified, 23-item Roland-Morris disability questionnaire. 
No statistically significant differences in mean change scores were found for either subgroup. Interestingly, participants in the vertebroplasty group were 25% more likely than those in the placebo group to be using opioid analgesic medication after 1 month (relative risk, 1.25; 95% confidence interval, 1.14 to 1.36; P<.001). Although 68% of participants in each group were using opioids for pain at baseline, 64% of the vertebroplasty group compared with 46% of the placebo group were using opioids after 1 month (P=.018). 
The placebo used in both trials included infiltrated local anesthetic under the skin, subcutaneous tissues, and periosteum, which some have argued may be an active control. The authors refuted this notion by citing results of a recent open cohort study3 that used an identical local anesthesia regimen and failed to show any benefit. 
The authors concluded that there was no advantage of vertebroplasty over placebo for participants with recent onset vertebral compression fracture or severe pain. In addition, their analysis showed that patients who receive vertebroplasty are more likely to use opioid medication at 1 month after operation.—M.A.S. 
   “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 Associate Editor Michael A. Seffinger, DO (, or Editorial Board Member Hollis H. King, DO, PhD (
  *  Submitted by Brendon S. Ross, OMS III, Western University College of Osteopathic Medicine of the Pacific, Pomona, California; edited by Michael A. Seffinger, DO.
Buchbinder R, Osborne RH, Ebeling PRet al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009;361(6):557-568. [CrossRef] [PubMed]
Kallmes DF, Comstock BA, Heagerty PJet al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med. 2009;361(6):569-579. [CrossRef] [PubMed]
Brinjikji W, Comstock B, Gray L, Kallmes D. Local Anesthesia with Bupivacaine and Lidocaine for vertebral fracture trial (LABEL): a report of outcomes and comparison with the Investigational Vertebroplasty Efficacy and Safety Trial (INVEST). AJNR Am J Neuroradiol. 2010:31(9):1631-1634. [CrossRef] [PubMed]