The Somatic Connection  |   April 2009
The Somatic Connection
Article Information
The Somatic Connection   |   April 2009
The Somatic Connection
The Journal of the American Osteopathic Association, April 2009, Vol. 109, 214-215. doi:
The Journal of the American Osteopathic Association, April 2009, Vol. 109, 214-215. doi:
Supplementing Manual Therapy for Lymphedema
Manual therapy is the standard of care throughout the world for the 54% of women who develop lymphedema after breast cancer treatment. Silke Jahr, PhD, and colleagues conducted a study in Berlin, Germany, focusing on the phenomenon of breast lymphedema by supplementing manual lymphatic drainage with Deep Oscillation, an adjuvant treatment in which an intermittent electrostatic field of low intensity (U=100-400 V, I=150 μA) and low frequency (30-200 Hz, rectangular, biphase) is applied to the affected area. 
Twenty-one patients were randomly assigned to two groups. The control group (n=10) continued standard manual lymphatic drainage alone (one or two 30-45 min sessions per week); the treatment group (n=11) underwent 12 sessions of manual lymphatic drainage supplemented by Deep Oscillation, an hour-long procedure administered after manual treatment. The authors evaluated patients' subjective assessment of pain and swelling, and conducted range-of-motion testing for the shoulder and cervical spine, as well as objective breast volume measures. 
In initial physical examination, all patients had high pain and swelling scores and impaired shoulder mobility, with poorer range of motion on the affected side. Restriction of cervical spine mobility was common at baseline and declined further in the control group posttreatment. Deep Oscillation resulted in significant pain reduction in the treatment group. Using three-dimensional measurement, the subjective reported reduction of swelling in both groups was objectively confirmed in the treatment group. Between the two groups, the difference in forward flexion of the cervical spine posttreatment was statistically significant (P<.05), with poorer mobility in the control group and slight improvement in the treatment group. 
An obvious critique, not uncommon in pilot “effectiveness” studies, is that the benefits of Deep Oscillation may simply be a result of additional time required to administer the procedure. Unfortunately, there was no sham oscillation treatment for the control group. 
Nevertheless, those who apply manual lymphatic drainage techniques will find these results of interest. The Deep Oscillation apparatus was connected to the therapist and the patient. According to the authors, during treatment, “the impulse of the voltage induces an electrostatic force of attraction on the patient's tissue and leads to a higher force of friction while massaging the [edema].” The “force of friction” explanation for the electronic device sounds very similar to osteopathic manipulative treatment techniques—specifically soft tissue and myofascial release, in which continuous palpatory feedback guides treatment—and may resemble percussion hammer oscillation. 
Because osteopathic medical research has used thoracic lymphatic pump techniques in animal (J Am Osteopath Assoc. 2005; 105:447-456) and human (J Am Osteopath Assoc. 2000;100:776-782) studies with demonstrated benefit for immune system function, other applications of this treatment modality in relation to the lymphatic system may be beneficial. —HHK 
Jahr S et al. J Rehab Med.. (2008). ;40:645-650.  
Musculoskeletal Findings in Women With Chronic Pelvic Pain
This blinded, controlled pilot study by Frank F. Tu, MD, MPH, and coauthors examines musculoskeletal findings in women with chronic pelvic pain (CPP). Researchers recruited 19 women aged 18 to 55 years with CPP and 20 healthy age-matched female control subjects. Musculoskeletal diagnostic tests were performed and included several of those used in osteopathic structural diagnosis: iliac crest height, pubic symphysis symmetry, and leg length discrepancy. The two examiners were physical therapists. 
The authors found a higher occurrence of musculoskeletal abnormalities among women with CPP than those in the control group, including iliac crest height asymmetry (11 of 18 [61%] vs 5 of 20 [25%]), pubic symphysis height asymmetry (9 of 18 [50%] vs 2 of 20 [10%]), and positive posterior pelvic provocation (7 of 18 [37%] vs 1 of 20 [5%]). All of these results were statistically significant (P<.05). Structural assessment findings that were more frequent in the CPP group but were not statistically significant included the active straight leg raise test, hamstring tightness, and the Thomas test for iliopsoas tightness. 
Interestingly, this type of study had only been done before on men. Findings from previous studies show that men with CPP also have a higher frequency of musculoskeletal abnormalities compared with healthy control participants (J Urol. 2003;170:828-831). 
From the osteopathic perspective, these musculoskeletal abnormalities would be considered “somatic dysfunction,” and as Melicien A. Tettambel, DO, suggested, could be beneficially addressed by osteopathic manipulative treatment (J Am Osteopath Assoc. 2007;107[suppl 6]:ES17-ES20). Many osteopathic physicians work in clinic settings where they can conduct valuable research on CPP diagnosis and treatment. 
I encourage osteopathic medical researchers interested in this topic to explore research funding opportunities under the “Research and Grants” tab on DO-Online ( The Louisa Burns Osteopathic Research Committee of the American Academy of Osteopathy ( is also a good resource for researchers. —HHK 
Tu F et al. Am J Obstet Gynecol.. (2008). ;198:272.e1-272.e7.  
Symptom Reduction for Patients With Chronic Neck Pain
Chronic neck pain is commonly treated with manual therapy. While there have been many systematic reviews on this topic, there has been little focus on randomized control trials (RCTs) that obtained change scores from outcome measures (eg, visual analog scale [VAS]) after a single session of treatment. 
Howard Vernon, DC, PhD, and Barry Kim Humphreys, DC, PhD, in Toronto, Ontario, Canada, conducted a systematic analysis of studies that reported group change scores for adults with chronic neck pain. Subjects' neck pain was not caused by whiplash and was not accompanied by headache or arm pain. All were treated in single sessions using manual techniques. Of the 9 RCTs that met the inclusion and exclusion criteria, 6 used spinal manipulation; 4, spinal mobilization; and 1, ischemic compression (manual trigger therapy). Two studies used more than one intervention. No trials reported using massage therapy or manual traction. 
The common outcome variable allowing comparison among all 9 studies was the use of a 100-mm VAS to quantify neck pain. Where possible, the authors analyzed change scores for absolute change, percentage change, and effect size. The 4 manipulation RCTs reported mean (SD) immediate changes (–18.94 [9.28] mm; effect size, 0.33-2.3). Two mobilization RCTs reported immediate VAS changes (–11.5 mm, effect size 0.36; –4 mm, effect size 0.22, respectively). Ischemic compression showed statistically significant immediate decreases in pain measure (–14.6 mm, P<.05). The authors concluded that patients who receive a single session of spinal manipulation demonstrate “immediate clinically important improvements.” However, less substantial evidence existed for mobilization, and the evidence for ischemic compression was insufficient to draw conclusions. 
In addition to providing evidence that one treatment of manual therapy can reduce neck pain, this study highlights two points relevant to osteopathic research. The first is nomenclature. The osteopathic medical profession uses the definitions determined by the Educational Council on Osteopathic Principles, which subsumes all manual techniques under the category of “manipulation.” For example, in the Council's glossary, included in Foundations for Osteopathic Medicine edited by Robert C. Ward, DO, soft tissue and myofascial techniques are considered manipulation. In chiropractic, physical therapy, and massage therapy terminology, “manipulation” means high-velocity low amplitude thrust technique. Everything else is “mobilization” with four categories on the continuum from “vigorous,” such as muscle energy, to “very light,” such as soft tissue and cranial techniques. Despite these nomenclature differences, there are well-designed manual medicine research publications that do not use osteopathic terminology and yet are valuable for osteopathic research and, in some cases, for education in osteopathic principles and practice course work. 
Second, as previously mentioned, no neck pain trials used in this systematic review reported the use of massage therapy, manual traction, or—it must be added—osteopathic manipulative treatment (OMT). Research on OMT for neck pain is necessary to generate data on the efficacy and safety of cervical spine manipulation. An American Osteopathic Association position paper on cervical manipulation ( calls for research on OMT for neck pain, specifically to distinguish the risk of vertebrobasilar accident associated with manipulation done by provider type and the relationship of vertebrobasilar accident with different types of manipulative treatment. As of April 2009, no research grant applications have been funded by the American Osteopathic Association. Such research would go a long way toward enhancing the use of OMT and increasing the likelihood of vastly improved reimbursement for osteopathic physicians. —HHK 
Vernon H, Humphreys BK. J Manual Manipulative Ther.. (2008). ;16(2):E42-52.  
 “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 (, or Editorial Board Member Hollis H. King, DO, PhD (
 Editor's Note: “The Somatic Connection” will also appear in the May 2009 issue of the JAOAJournal of the American Osteopathic Association.