The Somatic Connection

American Osteopathic Association | Published online: July 1, 2008

Osteopathic Manual Therapy Improves Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common, well-known condition. The efficacy of osteopathic therapy for patients with IBS, on the other hand, is not well documented. Researchers in the Netherlands conducted a randomized controlled trial to evaluate the effects of osteopathic manual therapy in patients with moderate IBS.

Thirty-nine adults (mean age 43.8 y) diagnosed as having IBS were randomly assigned to receive either osteopathic manual therapy (n=20) or standard care (n=19). Standard care consisted of advice and dietary recommendations. Laxatives, loperamide hydrochloride, and mebeverine hydrochloride were prescribed on an as-needed basis for constipation, diarrhea, and cramps, respectively. Separate osteopathic manual therapy sessions were provided five times, 2 to 3 weeks apart, and were individualized for each patient according to the osteopath's findings at each visit. All subjects recorded the severity of IBS, symptoms, quality of life, and adverse effects according to standardized tools (eg, a validated IBS quality of life questionnaire) at baseline and at 1-, 3-, and 6-month follow-up.

Three patients (1 in the osteopathic manual therapy group and 2 receiving standard care) were excluded from data analysis because of protocol violations. Osteopathic manual therapy was superior to standard treatment (P<.006) in overall symptom improvement. In the osteopathic manual therapy group, 13 subjects (68%) reported definite improvement, 5 (27%) had slight improvement, and 1 (5%) reported complete resolution of symptoms. Although subjects receiving osteopathic manual therapy reported a slight transient increase in symptom severity after the first treatment session, no worsening of symptoms was noted in these subjects at 6 months. By comparison, 3 subjects (18%) in the standard care cohort had definite improvement and 10 (59%) reported slight improvement, but 3 (17%) had worsening of symptoms at the 6-month follow-up visit. In addition, the improvement in quality of life was statistically significant (P<.009) in the therapy group, as was the decrease in symptom severity compared with the standard care cohort (P=.02).

Although this study had few subjects, it is a well-designed randomized clinical trial in which the results favored osteopathic manual therapy over standard care. Follow-up studies with a larger patient population, additional osteopaths, or US-trained osteopathic physicians providing osteopathic manipulative treatment are warranted. A sham intervention should be developed and used before definitive conclusions can be drawn. The path is ours to follow. —M.A.S.

Hundscheid HWC et al. J Gastroenterol Hepatol.2007;22:1394-1398.

MDs Advocate Physical Therapy for Cranial Asymmetry

Members of The Cranial Academy and Sutherland Cranial Teaching Foundation, affiliate organizations of the American Academy of Osteopathy, have long advocated osteopathic manipulative treatment for newborns with cranial somatic dysfunction caused by intrauterine position or birth trauma. A recent study conducted by a group of allopathic pediatricians at the University of California in San Diego sought to determine the incidence of torticollis, facial asymmetry, and plagiocephaly among 102 healthy newborns. This prospective, cross-sectional, hospital-based study analyzed neck range of motion, photographic images, and mothers' descriptions of fetal activity and positions.

Most newborns (73%) had one or more types of asymmetry, with plagiocephaly being the most common (61%) followed by facial asymmetry (42%), torticollis (16%), and asymmetry of the mandible (13%). Torticollis was associated with infants being “stuck” in one intrauterine position for more than 6 weeks before delivery; moderate facial asymmetry was associated with a longer second stage of labor, forceps delivery, larger infants, and birth trauma; and moderate cranial and mandibular asymmetries were associated with birth trauma.

Although the authors suggest that minor asymmetries are likely to resolve with adequate “tummy time,” further research is needed to define risk factors for nonresolution of torticollis and deformational posterior plagiocephaly. The authors conclude that standardization of neck range-of-motion assessment and recommendations for initiation of physical therapy would be useful. Even the most controversial of osteopathic concepts is creeping into mainstream medicine. —M.A.S.

Stellwagen L et al. Arch Dis Child. [Published online ahead of print April 1, 2008.]

Spinal Manipulation Study Emphasizes the Need for OMT Guidelines

National clinical guidelines for the management of acute low back pain recommend no more than a couple of days of bed rest before returning to simple everyday activities. Physicians should also reassure patients with favorable prognoses and suggest over-the-counter acetaminophen. The guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs) and spinal manipulation as additional therapeutic options. A double-placebo–controlled randomized clinical trial investigated whether adding these interventions to the standard self-care regimen improves speed of recovery.

Subjects with moderate low back pain and disability for fewer than 6 weeks were recruited from 40 general practitioners in Sydney, Australia. Subjects were excluded if the current episode of pain was not preceded by a pain-free period of at least 1 month, or if there was evidence of serious spinal pathology, nerve root compromise, current NSAID use, or spinal manipulation. Patients (n=240, mean age 41 y) were randomly assigned to one of four groups: spinal manipulation and diclofenac, placebo manipulation and diclofenac, spinal manipulation and placebo drug, or double placebo. Spinal manipulation was provided by one of 15 trained and experienced physiotherapists for up to three sessions per week (maximum of 12 sessions during 4 weeks). Placebo manipulation consisted of detuned pulsed ultrasound for the same frequency and duration. Diclofenac was prescribed at 50 mg twice daily until pain diminished or for a maximum of 4 weeks.

Subjects receiving diclofenac, spinal manipulation, or both recovered at rates similar to the double-placebo group. The authors concluded that to save patients money and avoid potential adverse effects, spinal manipulation and diclofenac (and other NSAIDs) should no longer be recommended as additional standard care options for low back pain.

Although this study was carefully planned and executed, the authors' broad recommendation has many problems, including: (1) the researchers did not allow the use of muscle energy, which is commonly used by osteopathic physicians and physical therapists; (2) no palpatory reassessment of findings occurred after the manipulative intervention to determine if the intention of the treatment was indeed accomplished; and (3) no osteopathic physicians were involved in the diagnosis, treatment, or evaluation of the palpatory findings or manipulative procedures. The physiotherapists who provided the manual treatments merely used “low-velocity mobilization,” which consists primarily of pressing repetitively posterior to anterior on the lumbar vertebra of the prone subjects. Only 5% of the patients received high-velocity thrust manipulation. In addition, physiotherapists used patient “resting symptoms” to determine manipulation force, duration, and dosage.

It is important for the osteopathic medical profession to provide osteopathic manipulative treatment guidelines for the care of patients with low back pain based on our own clinical trials rather than on physical therapy trials such as this one. Appropriately, the Clinical Guideline Subcommittee on Low Back Pain, commissioned by the American Osteopathic Association, is developing such guidelines. —M.A.S.

Hancock MJ et al. Lancet. 2007;370:1638-1643.

Hancock MJ et al. BMC Musculoskelet Disord. 2005;6:57 .

Anatomic Variability in Lumbo-Pelvic Landmarks

Although physicians and other clinicians often use bony landmarks to identify spinal vertebral levels, few clinical studies have tested the accuracy of such tools. Researchers at the Kirksville (Mo) College of Osteopathic Medicine-A.T. Still University tested the anatomic relationship between the level of the iliac crests and its intersection between the fourth and fifth lumbar vertebrae (L4 and L5), known as Tuffier's line. First, a retrospective analysis of 200 on-file anteroposterior standing radiographs of the lumbar spine of osteopathic medical students (100 men, 100 women) was used to determine Tuffier's line in standing subjects. Second, a prospective study examined 60 posteroanterior lumbar radiographs of subjects (27 [45%] men; 33 [55%] women; age range 20-60 y) in a supine position. Sex, height, weight, and body mass index were correlated with the radiographic findings.

Although Tuffier's line varied in both sexes, statistically significant differences (P<.0001 standing; P<.0004 prone) between genders were evident regarding where Tuffier's line most often intersected the lumbar spine. In men, this anatomic marker appeared at the L4 body or inferior endplate; in women, the L5 body or superior endplate. Differences between standing and prone findings were not significant. Although weight and body mass index had no correlation, Tuffier's line intersected L4 more commonly in taller subjects.

The authors recommend that because anatomic variations exist related to sex and height, objective evaluations (eg, fluoroscopy, computed tomography, ultrasound) should be used to improve accuracy in identifying lumbar vertebrae for invasive procedures, particularly in obese patients whose palpatory landmarks may be obscured. They also suggest that anatomic differences in subjects be considered in interexaminer reliability studies of palpatory assessment of anatomic landmark location and symmetry. —M.A.S.

Snider KT et al. Spine. 2008;33:E161-E165.

Sacral Palpatory Findings Unreliable Down Under

Developing reliable methods of diagnosing pelvic somatic dysfunction in patients with or without low back pain has been a challenge for all practitioners who use manipulative therapies, particularly those in osteopathic medicine or osteopathy. Investigators at the School of Biomedical and Health Sciences at the University of Western Sydney in Australia assessed the intra- and interexaminer reliability of two experienced osteopaths and two senior osteopathy students to identify asymmetry of selected anatomic landmarks indicative of pelvic somatic dysfunction in subjects with and without low back pain.

The four examiners assessed 9 subjects (5 symptomatic, 4 asymptomatic) for symmetry of the posterior superior iliac spine, sacral sulcus, sacral inferior lateral angle, anterior superior iliac spine, and medial malleoli. Intra- and interexaminer reliability were analyzed using the κ (kappa) statistic and were reported in conjunction with observed agreement.

Intraexaminer reliability was better than interexaminer reliability, and the assessment of anterior superior iliac spine and medial malleoli symmetry had greater κ values than other landmarks. However, κ values for all markers were still less than 0.6, which many researchers and clinicians consider the minimum acceptable value for the reliability of a diagnostic test. Also, though osteopathic clinicians had a higher reliability rating on sacral inferior lateral angle measures and students rated better on measures of the sacral sulcus, both groups of examiners were unable to demonstrate acceptable reproducibility or agreement of their findings.

Although this study had very few subjects, its sound methodology allows for replication with a larger study population. Indeed, this study highlights the requisite need to find reliable and accurate palpatory tests for somatic dysfunction. If palpatory assessments used to diagnose and treat somatic dysfunction with osteopathic manipulative treatment are unreliable, they may also be invalid. —M.A.S.

Kmita A et al. Internat J Osteopath Med.2008;11:16-25.

    “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 Editoral Advisory Board member Michael A. Seffinger, DO (), or Editioral Board member Hollis H. King, DO, PhD ().

Published Online: 2008-07-01
Published in Print: 2008-07-01

The American Osteopathic Association