The Somatic Connection  |   July 2013
Osteopathic Manipulative Therapy Affects the Position of Internal Organs in Humans
Author Affiliations
  • Hollis H. King, DO, PhD
    University of Wisconsin School of Medicine and Public Health, Madison
Article Information
The Somatic Connection   |   July 2013
Osteopathic Manipulative Therapy Affects the Position of Internal Organs in Humans
The Journal of the American Osteopathic Association, July 2013, Vol. 113, 577-579. doi:
The Journal of the American Osteopathic Association, July 2013, Vol. 113, 577-579. doi:
Tozzi P, Bongiorno D, Vitturini C. Low back pain and kidney mobility: local osteopathic fascial manipulation decreases pain perception and improves renal mobility. J Bodyw Mov Ther. 2012;16(3):381-391.  
Low back pain (LBP) is of interest globally because of its association with disability and its effect on health care costs.1 The osteopathic medical profession has been intrigued by associations between the fascia and nonspecialized connective tissues of the back and the pathophysiologic profile of LBP,2,3 as well as by fascial connections between the kidneys and the dorso-lumbo-pelvic structures. Building on their earlier research, which I reviewed in the October 2012 installment of “The Somatic Connection,”4 clinical researchers in Italy assessed the impact of osteopathic fascial manipulation (OFM) on right kidney mobility through the use of Dynamic Ultrasound Topographic Anatomy Evaluation and measurements of perceived LBP. 
The investigators recruited 101 asymptomatic individuals (30 women; 71 men; mean [standard deviation (SD)] age, 38.9 [8] years) who met the following inclusion criteria: no history of LBP, absence of other chronic pain that limited activities of daily living or work, and a current pain index that was less than 1 on a 10-point visual analog scale. They also recruited 140 individuals with LBP (66 women, 74 men; mean [SD] age, 39.3 [8] years) who met the following inclusion criteria: age 18 to 60 years, complaint of nonspecific pain in the lumbar area lasting at least 3 weeks and not more than 3 months, and magnetic resonance imaging or ultrasonography findings confirming the absence of inherited or acquired pathologic conditions of the spine or kidneys. Individuals in the group with nonspecific LBP were then randomly assigned to an experimental group (n=109) or a control group (n=31). 
Exclusion criteria, which were the same for asymptomatic individuals and individuals with LBP, included previous severe injury to, operation performed on, or pathologic findings for the back, kidneys, or lower extremity; major structural derangement, such as scoliosis, kyphosis, or stenosis; ankylosing spondylitis or rheumatoid arthritis; spinal fracture, tumor, or infection; bleeding; neurologic or major psychiatric disorder; pregnancy; kidney ptosis; acute systemic infection; receipt of concomitant physical or manual therapy; use of an analgesic or anti-inflammatory medication (or both) in the previous 72 hours; and litigation for LBP. 
Perceived pain in individuals with LBP was assessed using the Short-Form McGill Pain Assessment Questionnaire. The total pain score (scale, 0-45), which was the outcome of this study, was determined by adding affective pain and sensory rating scores. 
An experienced osteopath performed both the osteopathic assessment and the OFM. The osteopathic assessment involved identifying somatic dysfunction through “fascial listening posts,” as described by DiGiovanna et al,5 and induction of motion to assess restricted planes of motion, as performed by Greenman.6 Deep tissue palpation of the abdomen was not performed. 
The duration of OFM was 3.5 minutes and comprised 2 minutes of Still technique7 and 1.5 minutes of fascial unwinding.8 The illustrations in this study provide good representations of these osteopathic techniques, which seem to have been performed in a manner typical of US-trained osteopathic physicians and foreign-trained osteopaths. For the control group, the authors used a novel sham treatment in which an untrained layperson simply rested his hands on the lumbar region of the patient for the same length of time and in the same positions used during application of OFM in the experimental group. 
The outcome measure, the kidney mobility score (KMS) (ie, the difference in kidney height on maximal inspiration and maximal expiration), was assessed in a standard manner with the participant supine. The mean (SD) KMS for the asymptomatic group was 1.92 (1.14) mm, whereas that for the group with nonspecific LBP was 1.52 (0.79) mm, which was statistically significant (P<.05). Comparison of the pre- and posttreatment KMS showed a statistically significant increase in kidney motion in the experimental group compared with that in the control group (P<.001). A statistically significant decrease in pain, as measured by the Short-Form McGill Pain Assessment Questionnaire, was also noted for the experimental group compared with that in the control group (P<.001). 
The authors note several possible limitations of their study. For example, abdominal breathers have been shown to have greater kidney displacement, whereas thoracic breathers have displacement that is below average.9 This varied displacement was not controlled for in the present study. Only the right kidney motion was assessed, apparently because of time constraints and the perceived ease of measuring movement of the right kidney compared with that of the left kidney. Displacement will need to be controlled for in any future research on this topic. 
This study demonstrates the effects of common manual techniques on the viscera. In my opinion, manual therapy does more than just affect kidney position. Osteopathic interventions aid the self-regulatory and self-healing capacity of the body, thereby exemplifying a main tenet of osteopathic medicine, and they also support the structure-function relationship. Additional research regarding the structure-function relationship is necessary; however, on the basis of the presumption that improved kidney mobility is a good thing, this study shows how osteopathic interventions could benefit kidney function. 
   Editor's Note: The article by Tozzi et al was also reviewed in the January 2013 installment of “The Somatic Connection” (2013;113[1]:102). The section editors believed there were more insightful points to be made about the article, however, so an additional review from Dr King's perspective is offered here. Readers are encouraged to comment on this and other articles reviewed in “The Somatic Connection” in letters to the editor.
Williams DA, Feuerstein M, Durbin Det al. Health care and indemnity costs across the natural history of disability in occupational low back pain. Spine (Phila Pa 1976). 1998;23(21):2329-2336. [CrossRef] [PubMed]
Corey SM, Vizzard MA, Badger GJ, Langevin HM. Sensory innervation of the nonspecialized connective tissues in the low back of the rat. Cells Tissues Organs. 2011;194(6):521-530. [CrossRef] [PubMed]
Langevin HM, Sherman KJ. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Med Hypotheses. 2007;68(1):74-80. [CrossRef] [PubMed]
King HH. Empirical measurement of the effects of myofascial release in cervical and lumbar regions [abstract of Tozzi P, Bongiorno D, Vitturini C. Fascial release effects on patients with non-specific cervical or lumbar pain. J Bodyw Mov Ther. 2011;15(4):405-416]. J Am Osteopath Assoc. 2012;112(10):655-656.
DiGiovanna EL, Schiowitz S, Dowling DJ. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
Greenman PE. Principles of Manual Medicine. 2nd ed. Baltimore, MD: Williams and Wilkins; 1989.
Van Buskirk RL. The Still Technique Manual. 2nd ed. Indianapolis, IN: American Academy of Osteopathy; 2006.
Ward RC. Integrated neuromusculoskeletal release and myofascial release. In: Ward RC, executive ed. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2003:931-968.
Davies SC, Hill AL, Holmes RB, Halliwell M, Jackson PC. Ultrasound quantitation of respiratory organ motion in the upper abdomen. Br J Radiol. 1994;67(803):1096-1102. [CrossRef] [PubMed]