The Somatic Connection  |   July 2007
The Somatic Connection
Article Information
The Somatic Connection   |   July 2007
The Somatic Connection
The Journal of the American Osteopathic Association, July 2007, Vol. 107, 248-250. doi:
The Journal of the American Osteopathic Association, July 2007, Vol. 107, 248-250. doi:
Missing Link: Meta-analysis Leads the Way to Physician Reimbursement
Although there have been numerous systematic reviews of clinical trials on spinal manipulation for patients with low back pain (LBP), few have specifically addressed trials of osteopathic manual techniques. 
Using the results of six clinical trials that met study inclusion criteria, John C. Licciardone, DO, MBA, and others at the Osteopathic Research Center in Fort Worth, Tex (, performed the first systematic review of published data on osteopathic manipulative treatment (OMT) and meta-analysis of randomized controlled trials for patients with LBP. 
The authors found that osteopathic manipulation reduced symptoms of LBP in patients regardless of practitioner type and trial location (ie, United States vs United Kingdom). According to analyses using effect sizes, when compared to active standard treatment, placebo, or no treatment controls, spinal manipulation using osteopathic techniques significantly reduced patients' LBP. The duration of treatment effects extended through short, intermediate, and long-term follow-up visits—at least 3 months. 
The results presented in this article will likely be used in the future to develop evidence-based practice recommendations and guidelines for the use and reimbursement of OMT for osteopathic physicians and other practitioners who provide spinal manipulation to alleviate patients' LBP. —M.A.S. 
Licciardone JC et al. BMC Musculoskelet Disord. 2005;6:43 .  
Key Osteopathic Indicators in Patients With Type 2 Diabetes Mellitus
Osteopathic physicians diagnose somatic dysfunction based on visual and palpatory assessments of structural asymmetry, restriction in range of motion, and tissue texture abnormalities. Systemic dysfunction is commonly related to somatic dysfunction in pathophysiology, but osteopathic physicians must distinguish between physical findings that are somatic in origin (ie, amenable to osteopathic manipulative treatment [OMT]), and those that arise from pathologic processes. Visceral, or systemic, disease requires more extensive evaluations and treatments, and OMT often plays an adjunctive, supportive, or palliative role in patient care. 
To determine whether there are distinct palpable paraspinal soft-tissue abnormalities related to type 2 diabetes mellitus, John C. Licciardone, DO, MBA, and others at the Osteopathic Research Center in Fort Worth, Tex (, conducted physical examinations for 60 patients with type 2 diabetes mellitus and 32 normal control subjects (N=92). Investigators analyzed 30 distinct osteopathic palpatory findings at various segmental levels, including skin, trophic, and tissue changes, as well as tenderness and spinal mobility. Logistic regression models that adjusted for age, sex, and comorbidity were used to compute odds ratios and 95% confidence intervals for the associations between type 2 diabetes mellitus and each of the observed variables. Paired predoctoral osteopathic manipulative medicine fellows evaluated subjects independently. 
The palpatory finding with the highest interexaminer reliability was tissue change. Other palpatory tests were of fair to poor reliability. The only consistent finding after adjusting for demographic variables and comorbidities was an association between type 2 diabetes mellitus and tissue changes at T11 through L2 on the right side. Subgroup analyses of subjects with type 2 diabetes mellitus and hypertension demonstrated significant associations with tissue changes at T11 through L2 bilaterally. End organ involvement was not assessed, nor were patients observed for disease progression. 
As is typical with most research studies, more questions were generated than answered. Palpable paraspinal tissue abnormalities at T11 through T12 are often associated with renal disease. Several questions arise: 
  • Is it possible that these palpable findings represent somatic dysfunction that was present prior to the onset of type 2 diabetes mellitus, hypertension, or end-organ renal disease, creating a somatovisceral reflex?
  • Are these findings only secondary to pathologic processes— and are they instead viscerosomatic in origin?
Larger prospective studies are warranted to clarify and validate researchers' observations. Basic science investigations into the mechanisms underlying palpable findings are also indicated. —M.A.S. 
Licciardone JC et al. Osteopath Med Prim Care. 2007;1:6 .  
Control Procedures in OMT Clinical Trials
Researchers have found it extremely challenging to develop appropriate placebo treatments for use in clinical trials of manual therapies. The osteopathic medical research community has long debated the necessity—and, indeed, the feasibility—of administering an appropriate placebo for osteopathic manipulative treatment (OMT). Osteopathic medical researchers must also carefully address other treatment-specific methodologic challenges, including subject-blinding protocols and reproducibility, as treatment methods can vary widely among practitioners (J Am Osteopath Assoc. 2006;106: 457-463). 
Kimberly G. Fulda, MPH, and others at the Osteopathic Research Center in Fort Worth, Tex (, used a randomized crossover trial to determine which of two potential control procedures was most credible to subjects (N=30) when compared with the osteopathic high velocity/low amplitude (HVLA) technique. Subjects watched a video with a 2-minute demonstration of all three procedures presented in a random sequence: HVLA and the two potential control procedures, sham manipulative treatment (“placebo light touch”) and subtherapeutic ultrasound. Subjects then completed a survey designed to assess their expectations of benefit from each treatment method. Repeated measures analysis of variance, a partial η2, and effect sizes (Cohen's d) were calculated where appropriate. 
Twenty-two (73%) participants were women, 16 (53%) were white, and 11 (37%) had a college education. The mean (SD) age of subjects was 43 (15) years. Researchers found that the osteopathic HVLA technique was perceived by study participants as being more appropriate and effective than sham manipulative treatment. Because subject expectations for the effectiveness of subtherapeutic ultrasound were similar to those of HVLA technique, however, researchers determined that it would be the better control procedure for comparison with HVLA. 
Contrary to popular belief, the authors point out that it is not necessary to use a hands-on control treatment for OMT in clinical trials. An intervention that appears to the subject as equally effective and beneficial as OMT will suffice—as long as it has no physiologic effect. —M.A.S. 
Fulda KG et al. Osteopath Med Prim Care. 2007;1:3 .  
Mechanisms of Action in HVLA for Foreign Osteopaths
The effectiveness of spinal manipulation in relieving low back pain or neck pain and in improving or restoring functional mobility has been established by clinical trials, outcome studies, and expert panels. However, the mechanisms underlying this effect are not well understood. Certainly, neurophysiologists have been able to demonstrate that spinal manipulation alters spinal reflex activity, central and peripheral nervous system sensory-information processing, and muscle excitability. However, the precise location of the primary effect of this therapeutic intervention has yet to be determined. 
Heidi Haavik-Taylor, BSc, and Bernadette Murphy, DC, PhD, conducted a study at the Human Neurophysiology and Rehabilitation Laboratory in the Department of Sport and Exercise Science at the University of Auckland in New Zealand ( to use somatosensoryevoked potentials (SEPs) to pinpoint the location along the somatosensory pathway where the high velocity/low amplitude (HVLA) technique, when applied to the cervical spine, has immediate sensorimotor neurophysiologic effect. Asymptomatic subjects with a history of recurring neck stiffness or pain (n=12) received a single session of cervical spine HVLA manipulation while another group of age-matched asymptomatic subjects (n=12) participated in a passive–head-movement control experiment. Spinal (N11, N13), brainstem (P14), and cortical (N20, N30) SEPs to median nerve stimulation were recorded preintervention and for 30 minutes postintervention. 
Compared to pretreatment values, there was a significant decrease in the amplitude of parietal N20 and frontal N30 SEP components after HVLA therapy. These changes lasted an average of 20 minutes postintervention. No changes were observed in the control group. 
The authors concluded that not only does cervical spinal manipulation lead to transient cortical plastic changes, but that muscle Ia afferents are the most likely mediators of this central nervous system effect, supporting the work of previous researchers (Spine. 1993;18:1096-1102). —M.A.S. 
Haavik-Taylor H et al. Clin Neurophysiol. 2007;118:391-402 . 
Osteopathy for Patients With Tension-Type Headaches
Increasingly, foreign-trained osteopaths are engaging in clinical investigations on the effectiveness of osteopathic manipulation for the clinical management of a variety of clinical conditions. In their randomized clinical study of patients with tension-type headaches (TTH), Rosemary E. Anderson, BScPT, DOMP, and Caryn Seniscal, RMT, DOMP, compare the effects of progressive muscular relaxation (PMR) alone and in combination with selected osteopathic manual techniques. A common condition, TTH is found in one-third to three-fourths of the population. 
Using the International Headache Classification Sub-committee criteria for TTH (Cephalalgia. 2004;24:14-21), 26 patients aged 17 years and older with TTH were recruited and randomly assigned to the PMR only (n=12) or the PMR plus osteopathic manipulation (n=14) group. Subjects in both groups completed the study, practicing PMR exercises at home unassisted while the experimental group also received three sessions of osteopathic manipulative therapy, once weekly for 3 weeks, as provided by one of the two Canadian osteopaths who conducted this investigation. 
Exclusion criteria for medical comorbidities denied study entry to patients who had traumatically induced headaches, cluster or migraine headaches, temporomandibular joint disorder, severe depression or anxiety, seizures, uncontrolled diabetes or hypertension, or severe sinus conditions. In addition, patients who were taking antidepressants were also excluded from this investigation. Use of analgesic medication was not restricted for study subjects; all but 1 subject took these medications on an as-needed basis. All participants recorded headache frequency and intensity in a headache diary for 2 weeks pretreatment, and continued recording medication use during the treatment period (ie, until reassessment) for a total of 6 to 7 weeks. All subjects were reassessed within 2 weeks posttreatment by another researcher who was blinded to group assignment. 
Researchers assessed subjects for physiologic motion restriction in several regions of the body. Manual therapy combined aspects of many well-known osteopathic techniques, including: articulatory treatment system, the functional method, muscle energy, Osteopathy in the Cranial Field, and Strain/Counterstrain. 
The two groups were comparable in demographic variables, symptom history, and compliance with prescribed at-home PMR exercises. Statistical analysis using t test and analysis of variance revealed significant improvement among subjects in the experimental group with regard to the number headache-free days per week recorded. 
Although this study's sample size is small, investigators' results demonstrated the effectiveness of osteopathic manipulation as an adjuvant to PMR home exercises and analgesic medication in patients with TTH. Larger studies are warranted to further elucidate the role of osteopathic techniques in this patient population. —M.A.S. 
Anderson RE et al. Headache. 2006;46:1273-1280.  
 “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 Felix J. Rogers, DO (, or Michael A. Seffinger, DO (