New Online OMM Monthly Journal Club

In an effort to generate some discussion and exchange ideas about OMM between students at different DO schools, I've decided to launch a monthly online OMM journal club. Every month I will post an osteopathically-revelant journal article and include the abstract and links to the PDF file if possible. Alternatively, if you PM with your private email address I will send you a copy.

Participants are encouraged to read the article and post their critiques of the study in typical journal club format. This means that comments should address at least some of the questions listed in the Structure for Journal Club Presentations Link Here. I will moderate the discussion. This should be good practice for medical students as journal club presentations are a usual component of most residency programs.

To begin the series we will begin with this study from our osteopathic (non-physician) colleagues from across the pond...


Link to the PDF


Randomized osteopathic manipulation study (ROMANS): pragmatic trial for spinal pain in primary care.

Williams NH, Wilkinson C, Russell I, Edwards RT, Hibbs R, Linck P, Muntz R.

Department of General Practice, University of Wales College of Medicine, Institute of Medical and Social Care Research, University of Wales-Bangor, Bangor, Wales, UK. [email protected]

BACKGROUND: Spinal pain is common and frequently disabling. Management guidelines have encouraged referral from primary care for spinal manipulation. However, the evidence base for these recommendations is weak. More pragmatic trials and economic evaluations have been recommended. OBJECTIVES: Our aim was to assess the effectiveness and health care costs of a practice-based osteopathy clinic for subacute spinal pain. METHODS: A pragmatic randomized controlled trial was carried out in a primary care osteopathy clinic accepting referrals from 14 neighbouring practices in North West Wales. A total of 201 patients with neck or back pain of 2-12 weeks duration were allocated at random between usual GP care and an additional three sessions of osteopathic spinal manipulation. The primary outcome measure was the Extended Aberdeen Spine Pain Scale (EASPS). Secondary measures included SF-12, EuroQol and Short-form McGill Pain Questionnaire. Health care costs were estimated from the records of referring GPs. RESULTS: Outcomes improved more in the osteopathy group than the usual care group. At 2 months, this improvement was significantly greater in EASPS [95% confidence interval (CI) 0.7-9.8] and SF-12 mental score (95% CI 2.7-10.7). At 6 months, this difference was no longer significant for EASPS (95% CI -1.5 to 10.4), but remained significant for SF-12 mental score (95% CI 1.0-9.9). Mean health care costs attributed to spinal pain were significantly greater by 65 UK pounds in the osteopathy group (95% CI 32-155 UK pounds). Though osteopathy also cost 22 UK pounds more in mean total health care cost, this was not significant (95% CI - 159 to 142 UK pounds). CONCLUSION: A primary care osteopathy clinic improved short-term physical and longer term psychological outcomes, at little extra cost. Rigorous multicentre studies are now needed to assess the generalizability of this approach.

For March I've included a study about a population that is often neglected when it comes to OMM but may in fact benefit tremendously--children. There is a rich tradition of treating children with osteopathic techniques (Galbreath technique for otitis; Viola Frymann's work at Osteopathic Center for Children in San Diego for a variety of disorders, etc) yet the osteopathic profession has been slow to systematically evaluate these modalities and unique approach to patient care. Mills and colleagues are taking a great step in the right direction.

Please feel free to read the following article and accompanying editorial. The same rules and general outline apply as for January. Hopefully, some of you may consider using these articles to form local OMM journal clubs at your COMs...some of your professors may be willing to host Journal Clubs at their houses! You will never know unless you ask!


Link to PDF and full text

The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media.

Mills MV, Henley CE, Barnes LL, Carreiro JE, Degenhardt BF.

Department of Pediatrics, Oklahoma State University Center for Health Sciences, Tulsa 74107, USA. [email protected]

OBJECTIVE: To study effects of osteopathic manipulative treatment as an adjuvant therapy to routine pediatric care in children with recurrent acute otitis media (AOM). STUDY DESIGN: Patients 6 months to 6 years old with 3 episodes of AOM in the previous 6 months, or 4 in the previous year, who were not already surgical candidates were placed randomly into 2 groups: one receiving routine pediatric care, the other receiving routine care plus osteopathic manipulative treatment. Both groups received an equal number of study encounters to monitor behavior and obtain tympanograms. Clinical status was monitored with review of pediatric records. The pediatrician was blinded to patient group and study outcomes, and the osteopathic physician was blinded to patient clinical course. MAIN OUTCOME MEASURES: We monitored frequency of episodes of AOM, antibiotic use, surgical interventions, various behaviors, and tympanometric and audiometric performance. RESULTS: A total of 57 patients, 25 intervention patients and 32 control patients, met criteria and completed the study. Adjusting for the baseline frequency before study entry, intervention patients had fewer episodes of AOM (mean group difference per month, -0.14 [95% confidence interval, -0.27 to 0.00]; P =.04), fewer surgical procedures (intervention patients, 1; control patients, 8; P =.03), and more mean surgery-free months (intervention patients, 6.00; control patients, 5.25; P =.01). Baseline and final tympanograms obtained by the audiologist showed an increased frequency of more normal tympanogram types in the intervention group, with an adjusted mean group difference of 0.55 (95% confidence interval, 0.08 to 1.02; P =.02). No adverse reactions were reported. CONCLUSIONS: The results of this study suggest a potential benefit of osteopathic manipulative treatment as adjuvant therapy in children with recurrent AOM; it may prevent or decrease surgical intervention or antibiotic overuse.


Accompanying Editorial:

Osteopathic Manipulation to Prevent Otitis Media—Does It Work?

Arch Pediatr Adolesc Med. 2003;157:852-853.

ALTERNATIVE AND complimentary therapies for acute otitis media (AOM) are of growing interest to physicians and parents. Osteopathic manipulation treatment (OMT) is a frequently used alternative therapy for AOM among practitioners trained and skilled in the technique. In this issue of ARCHIVES, Mills et al1 introduce the allopathic community to the modalities applied by osteopathic physicians as treatment for AOM and their effect on outcomes. Using a randomized controlled trial design, the investigators looked for differences in frequency of AOM episodes, surgical procedures with tympanostomy tubes, and surgery-free months. Among children prone to having AOM who received OMT vs control subjects across 6 months of intervention, small but statistically significant differences were found favoring OMT. Let's take a look at the methods.

The investigators conducted this study in 4 locations across 2 years and were able to successfully recruit and retain 57 patients. From the denominator of patients with AOM, this total may represent selection bias, and the sample size may be insufficient to convince readers of the validity of the results, given the many vicissitudes of AOM. Regarding biological plausibility, one might question whether an osteopathic physician can cause enough movement between the temporal and sphenoid bones to affect the eustachian tube cartilaginous groove, particularly since OMT was performed in patients as old as 6 years.

The documentation of AOM episodes is a key component to the analysis. This information was extracted from records of the primary care pediatricians who were not active investigators in the trial. The investigators based criteria for qualification of an episode of AOM on guidelines of the Office of Drug Evaluation and Research.2 However, the accuracy of otoscopic diagnosis could be questioned; we recently showed that pediatricians misdiagnose AOM about 50% of the time.3 Nevertheless, any misclassification should have been equally distributed in both treatment groups as a result of the randomization process and would be unlikely to affect the overall results. Future studies should be designed to require more specific signs of AOM as entry criteria, such as ear pain or unaccustomed rubbing or tugging at the ear associated with a distinctly bulging tympanic membrane at otoscopic examination.

In a randomized trial, especially a small one, it is not uncommon to find some imbalance between the intervention and control groups at baseline. This imbalance generates some concern that the results may be influenced by the observed bias. Statistical adjustment may be helpful but is not a complete remedy. From an examination of the tables, it would appear that the groups were unbalanced, with the OMT group being older, having a higher mean number of monthly episodes of AOM, and having a higher mean monthly antibiotic prescription rate. Although both groups showed dramatic improvement from their baseline values during observation, part of the improvement in the OMT group may have been because of regression to the mean.

Eight of 32 patients in the control group dropped out of the analysis because they underwent surgical intervention. This dropout rate is high and contrasts sharply with the dropout rate in the intervention group (1 of 25). Mills et al1 state that dropouts occurred mainly because of loss of continuity of physician care or the inconvenience of a 6-month study. Those reasons should have applied equally to the 2 groups. Instead, one might suspect that the intervention group anticipated benefit from OMT, whereas those randomized to the control group, observing that no intervention was occurring, were more apt to move out of the study and toward other interventions.

Lack of a placebo control will perhaps be considered the greatest weakness of this study. The authors were aware of this at the time of the study design and chose not to attempt a sham treatment because that method is also fraught with pitfalls. If they had not had to obtain informed consent for OMT in all patients before randomization, the control group would not have known what they were missing, as the investigators would have simply followed their clinical course. However, informed consent led to the absolute necessity of informing patients of the experimental OMT procedure. There may have been a way to fake an osteopathic treatment, but this becomes another intervention and we are left with the need to have a separate group without any intervention to compare with the intervention group. The small numbers generated by this study suggest that enrollment in 3 separate groups would have been a monumental challenge.

Whether OMT works because it has a therapeutic effect or simply because it has a psychological benefit that makes parents less prone to complain about the child's ear symptoms and therefore less likely to seek care or antibiotics or pursue surgery was not within the scope of this study. We know that children get better with time. The challenge for the practitioner is what to do during the wait. Too often surgery is suggested to the impatient parent because it is seen as an alternative to just waiting and preferable to prescribing more antibiotics. The fact that the OMT group did not receive as many antibiotics or surgical interventions yet had the same or better hearing than the control group did while exhibiting the same behaviors suggests that OMT served a beneficial purpose. Effective reassurance and close follow-up perhaps could have accomplished the same end.

Michael E. Pichichero, MD
Elmwood Pediatric Group
University of Rochester Medical Center
601 Elmwood Ave, Box 672
Rochester, NY 14642

For April, I thought that we'd look for studies that examine the effectiveness of manipulation in the extremities. This small pilot study looks at the effectiveness of manipulation for lateral epicondylitis. It's a small study, but the results look promising. Also, the link will give you the full text medline article. I would be curious to know if any DO students are actually trying to use these articles in monthly journal clubs, and if so, how's it coming along?




Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study.

Struijs PA, Damen PJ, Bakker EW, Blankevoort L, Assendelft WJ, van Dijk CN.

Phys Ther. 2003 Jul;83(7):608-16.

Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, PO Box 22600, 1100 DD Amsterdam, The Netherlands. [email protected]

BACKGROUND AND PURPOSE: Lateral epicondylitis ("tennis elbow") is a common entity. Several nonoperative interventions, with varying success rates, have been described. The aim of this study was to compare the effectiveness of 2 protocols for the management of lateral epicondylitis: (1) manipulation of the wrist and (2) ultrasound, friction massage, and muscle stretching and strengthening exercises. SUBJECTS AND METHODS: Thirty-one subjects with a history and examination results consistent with lateral epicondylitis participated in the study. The subjects were randomly assigned to either a group that received manipulation of the wrist (group 1) or a group that received ultrasound, friction massage, and muscle stretching and strengthening exercises (group 2). Three subjects were lost to follow-up, leaving 28 subjects for analysis. Follow-up was at 3 and 6 weeks. The primary outcome measure was a global measure of improvement, as assessed on a 6-point scale. Analysis was performed using independent t tests, Mann-Whitney U tests, and Fisher exact tests. RESULTS: Differences were found for 2 outcome measures: success rate at 3 weeks and decrease in pain at 6 weeks. Both findings indicated manipulation was more effective than the other protocol. After 3 weeks of intervention, the success rate in group 1 was 62%, as compared with 20% in group 2. After 6 weeks of intervention, improvement in pain as measured on an 11-point numeric scale was 5.2 (SD=2.4) in group 1, as compared with 3.2 (SD=2.1) in group 2. DISCUSSION AND CONCLUSION: Manipulation of the wrist appeared to be more effective than ultrasound, friction massage, and muscle stretching and strengthening exercises for the management of lateral epicondylitis when there was a short-term follow-up. However, replication of our results is needed in a large-scale randomized clinical trial with a control group and a longer-term follow-up.


Full Text

This month I've included two articles that can be considered companion pieces. Often a major stumbling block in OMM-related research is a lack of cumulation of scientific information. It often seems like the same studies keep getting done over and over again with often the same kind of six-of-one-half-a-dozen-of-the-other results that really don't help clinicians decide when manipulation is appropriate and for whom. These studies attempt to answer those questions.

Again, I'd be interested to hear from DO students who have organized OMM journal clubs at their schools how things are going...



Spine J. 2004 May-Jun;4(3):335-56.

Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis.

Bronfort G, Haas M, Evans RL, Bouter LM.

Northwestern Health Sciences University, 2501 W, 84th Street Bloomington, MN 55431, USA.

BACKGROUND CONTEXT: Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain. PURPOSE: To reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB. STUDY DESIGN: RCTs including 10 or more subjects per group receiving SMT or MOB and using patient-oriented primary outcome measures (eg, patient-rated pain, disability, global improvement and recovery time). METHODS: Articles in English, Danish, Swedish, Norwegian and Dutch reporting on randomized trials were identified by a comprehensive search of computerized and bibliographic literature databases up to the end of 2002. Two reviewers independently abstracted data and assessed study quality according to eight explicit criteria. A best evidence synthesis incorporating explicit, detailed information about outcome measures and interventions was used to evaluate treatment efficacy. The strength of evidence was assessed by a classification system that incorporated study validity and statistical significance of study results. Sixty-nine RCTs met the study selection criteria and were reviewed and assigned validity scores varying from 6 to 81 on a scale of 0 to 100. Forty-three RCTs met the admissibility criteria for evidence. RESULTS: Acute LBP: There is moderate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP: There is moderate evidence that SMT has an effect similar to an efficacious prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared to physical therapy. There is limited to moderate evidence that SMT is better than physical therapy and home back exercise in both the short and long term. There is limited evidence that SMT is superior to sham SMT in the short term and superior to chemonucleolysis for disc herniation in the short term. However, there is also limited evidence that MOB is inferior to back exercise after disc herniation surgery. Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain outcomes in the short and long term when compared with placebo and with other treatments, such as McKenzie therapy, medical care, management by physical therapists, soft tissue treatment and back school. Acute NP: There are few studies, and the evidence is currently inconclusive. Chronic NP: There is moderate evidence that SMT/MOB is superior to general practitioner management for short-term pain reduction but that SMT offers at most similar pain relief to high-technology rehabilitative exercise in the short and long term. Mix of acute and chronic NP: The overall evidence is not clear. There is moderate evidence that MOB is superior to physical therapy and family physician care, and similar to SMT in both the short and long term. There is limited evidence that SMT, in both the short and long term, is inferior to physical therapy. CONCLUSIONS: Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.

Phys Ther. 2004 Feb;84(2):173-90.


Factors related to the inability of individuals with low back pain to improve with a spinal manipulation.

Fritz JM, Whitman JM, Flynn TW, Wainner RS, Childs JD.

Department of Physical Therapy, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260, USA. [email protected]

BACKGROUND AND PURPOSE: Although spinal manipulation is one of the few interventions for low back pain supported by evidence, it appears to be underutilized by physical therapists, possibly due to therapists' concerns that a patient may not benefit from the intervention. The purpose of this study was to identify factors that are associated with an inability to benefit from manipulation. SUBJECTS: Seventy-five people with nonradicular low back pain (mean age=37.6 years, SD=10.6, range=19-59; mean duration of symptoms=41.7 days, SD=54.7, range=1-252) participated. METHODS: Subjects underwent a standardized examination that included history-taking; self-reports of pain, disability, and fear-avoidance beliefs; measurement of lumbar and hip range of motion; and use of various tests. All subjects received a spinal manipulation intervention for a maximum of 2 sessions. Subjects who did not show greater than 5 points of improvement on the modified Oswestry Low Back Pain Disability Questionnaire were considered to have shown no improvement with the manipulation. Baseline variables were tested for univariate relationship with the outcome of the manipulation. Variables showing a univariate relationship were entered into a logistic regression equation, and adjusted odds ratios were calculated. RESULTS: Twenty subjects (28%) did not improve with manipulation. Six variables were identified as being related to inability to improve with manipulation: longer symptom duration, having symptoms in the buttock or leg, absence of lumbar hypomobility, less hip rotation range of motion, less discrepancy in left-to-right hip medial rotation range of motion, and a negative Gaenslen sign. The resulting logistic regression model explained 63% of the variance in manipulation outcome. DISCUSSION AND CONCLUSION: The majority of subjects improved with manipulation. Baseline variables could be identified that were predictive of which subjects would not improve.

Sorry it's been so long...


Spine. 2004 Oct 1;29(19):E413-25. Related Articles, Links


Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature.

Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson VM, Murphy LS, Reinsch S.

Department of Osteopathic Manipulative Medicine, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, USA. [email protected]

STUDY DESIGN: A systematic review. OBJECTIVES: To determine the quality of the research and assess the interexaminer and intraexaminer reliability of spinal palpatory diagnostic procedures. SUMMARY OF BACKGROUND DATA: Conflicting data have been reported over the past 35 years regarding the reliability of spinal palpatory tests. METHODS: The authors used 13 electronic databases and manually searched the literature from January 1, 1966 to October 1, 2001. Forty-nine (6%) of 797 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus or a content expert reconciled discrepancies. RESULTS: The quality scores ranged from 25 to 79/100. Subject description, study design, and presentation of results were the weakest areas. The 12 highest quality articles found pain provocation, motion, and landmark location tests to have acceptable reliability (K = 0.40 or greater), but they were not always reproducible by other examiners under similar conditions. In those that used kappa statistics, a higher percentage of the pain provocation studies (64%) demonstrated acceptable reliability, followed by motion studies (58%), landmark (33%), and soft tissue studies (0%). Regional range of motion is more reliable than segmental range of motion, and intraexaminer reliability is better than interexaminer reliability. Overall, examiners' discipline, experience level, consensus on procedure used, training just before the study, or use of symptomatic subjects do not improve reliability. CONCLUSION: The quality of the research on interreliability and intrareliability of spinal palpatory diagnostic procedures needs to be improved. Pain provocation tests are most reliable. Soft tissue paraspinal palpatory diagnostic tests are not reliable.

Spinal Palpation Article Link

This is a very large, prospective randomized controlled trial of manipulation and exercise for back pain. One particular strength of this study is that it was a community based study.



United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care.

[No authors listed]

BMJ. 2004 Nov 19


OBJECTIVE: To estimate the effect of adding exercise classes, spinal manipulation delivered in NHS or private premises, or manipulation followed by exercise to "best care" in general practice for patients consulting with back pain. DESIGN: Pragmatic randomised trial with factorial design. SETTING: 181 general practices in Medical Research Council General Practice Research Framework; 63 community settings around 14 centres across the United Kingdom. PARTICIPANTS: 1334 patients consulting their general practices about low back pain. MAIN OUTCOME MEASURES: Scores on the Roland Morris disability questionnaire at three and 12 months, adjusted for centre and baseline scores. RESULTS: All groups improved over time. Exercise improved mean disability questionnaire scores at three months by 1.4 (95% confidence interval 0.6 to 2.1) more than "best care." For manipulation the additional improvement was 1.6 (0.8 to 2.3) at three months and 1.0 (0.2 to 1.8) at 12 months. For manipulation followed by exercise the additional improvement was 1.9 (1.2 to 2.6) at three months and 1.3 (0.5 to 2.1) at 12 months. No significant differences in outcome occurred between manipulation in NHS premises and in private premises. No serious adverse events occurred. CONCLUSIONS: Relative to "best care" in general practice, manipulation followed by exercise achieved a moderate benefit at three months and a small benefit at 12 months; spinal manipulation achieved a small to moderate benefit at three months and a small benefit at 12 months; and exercise achieved a small benefit at three months but not 12 months.

UK BEAM

Few recent studies have addressed mechanisms of action for OMT. This is a small "proof of concept" paper evaluating the osteopathic "rule of the artery is supreme" concept.


Somatovisceral response following osteopathic HVLAT: a pilot study on the effect of unilateral lumbosacral high-velocity low-amplitude thrust technique on the cutaneous blood flow in the lower limb.

Karason AB, Drysdale IP.

British College of Osteopathic Medicine, London, UK.

INTRODUCTION: Spinal manipulative treatment is widely used among manual therapists, although knowledge regarding the absolute physiological effects has not been clearly established. In this study, 20 healthy male subjects underwent a unilateral high-velocity low-amplitude thrust (HVLAT) to the lumbosacral junction, while the cutaneous blood flow in the corresponding dermatome of the lower limb was monitored. METHODS: Subjects underwent a sham manipulation before the actual manipulation and acted as their own control. Laser Doppler flowmetry was used to measure relative changes in the cutaneous blood flow over the L5 dermatome for 5 minutes before the sham manipulation, for 5 minutes between the sham and the actual manipulation, and for 5 minutes after the spinal adjustment. Analysis of variance (ANOVA) and Tukey post hoc analysis was used in the interpretation of the data. RESULTS: Twelve nonsmoking subjects, who received a successful HVLAT manipulation, showed a significant increase (P <.001) in blood perfusion, both ipsilaterally and contralaterally. Six smokers responded with a significant decrease in blood flow ipsilaterally (P <.01) and contralaterally (P <.001) after HVLAT manipulation. CONCLUSION: The results from this study support previous published hypotheses that spinal adjustments outside the region of the sympathetic outflow result in an increase in cutaneous blood flow. Further studies will be needed to confirm the outcome of this study, and more knowledge is needed regarding the specific neurophysiological effects of spinal manipulation.

Link to Full Text Access

February's articles address the issue of inter-examiner reliability in detecting craniosacral motion. Studies of examiner agreement of physical examination findings (ranging from heart murmurs to skin rashes) has generally showed poor inter-examiner reliability. Agreement and reliability for musculoskeletal findings are poorer yet, though certain kinds of training paradigms and have been shown to improve detection and agreement.



Intraexaminer and interexaminer reliability for palpation of the cranial rhythmic impulse at the head and sacrum.

J Manipulative Physiol Ther. 2001 Mar-Apr;24(3):183-90.

Moran RW, Gibbons P.

School of Health Sciences, Victoria University, Melbourne, Australia.

BACKGROUND: A range of health care practitioners use cranial techniques. Palpation of a cranial rhythmic impulse (CRI) is a fundamental clinical skill used in diagnosis and treatment with these techniques. There has been little research establishing the reliability of CRI rate palpation. OBJECTIVE: This study aimed to establish the intraexaminer and interexaminer reliability of CRI rate palpation and to investigate the "core-link" hypothesis of craniosacral interaction that is used to explain simultaneous motion at the cranium and sacrum. DESIGN: Within-subjects, repeated-measures design. SUBJECTS: Two registered osteopaths, both with postgraduate training in diagnosis and treatment, using cranial techniques, palpated 11 normal healthy subjects. METHODS: Examiners simultaneously palpated for the CRI at the head and the sacrum of each subject. Examiners indicated the "full flexion" phase of the CRI by activating silent foot switches that were interfaced with a computer. Subject arousal was monitored using heart rate. Examiners were blind to each other's results and could not communicate during data collection. RESULTS: Reliability was estimated from calculation of intraclass correlation coefficients (2,1). Intrarater reliability for examiners at either the head or the sacrum was fair to good, significant intraclass correlation coefficients ranging from +0.52 to +0.73. Interexaminer reliability for simultaneous palpation at the head and the sacrum was poor to nonexistent, ICCs ranging from -0.09 to +0.31. There were significant differences between rates of CRI palpated simultaneously at the head and the sacrum. CONCLUSIONS: The results fail to support the construct validity of the "core-link" hypothesis as it is traditionally held by proponents of craniosacral therapy and osteopathy in the cranial field.


Simultaneous palpation of the craniosacral rate at the head and feet: intrarater and interrater reliability and rate comparisons.

Phys Ther. 1998 Nov;78(11):1175-85.

Rogers JS, Witt PL, Gross MT, Hacke JD, Genova PA.

US Air Force Academy Cadet Physical Therapy Clinic, US Air Force Academy, CO 80840, USA. [email protected]

BACKGROUND AND PURPOSE: The main purpose of this study was to determine the interrater and intrarater reliability of measurements obtained during palpation of the craniosacral rate at the head and feet. Palpated craniosacral rates of head and feet measured simultaneously were also compared. Subjects. Twenty-eight adult subjects and 2 craniosacral examiners participated in the study. METHODS: A within-subjects repeated-measures design was used. A standard cubicle privacy curtain, hung over the subject's waist, was used to prevent the examiners from seeing each other. RESULTS: Interrater intraclass correlation coefficients (ICCs) were .08 at the head and .19 at the feet. Intrarater ICCs ranged from .18 to .30. Craniosacral rates simultaneously palpated at the head and feet were different. CONCLUSION AND DISCUSSION: The results did not support the theories that underlie craniosacral therapy or claims that craniosacral motion can be palpated reliably.


Craniosacral rhythm: reliability and relationships with cardiac and respiratory rates.

J Orthop Sports Phys Ther. 1998 Mar;27(3):213-8.


Hanten WP, Dawson DD, Iwata M, Seiden M, Whitten FG, Zink T.

Texas Woman's University, Houston 77030, USA.

Craniosacral rhythm (CSR) has long been the subject of debate, both over its existence and its use as a therapeutic tool in evaluation and treatment. Origins of this rhythm are unknown, and palpatory findings lack scientific support. The purpose of this study was to determine the intra- and inter-examiner reliabilities of the palpation of the rate of the CSR and the relationship between the rate of the CSR and the heart or respiratory rates of subjects and examiners. The rates of the CSR of 40 healthy adults were palpated twice by each of two examiners. The heart and respiratory rates of the examiners and the subjects were recorded while the rates of the subjects' CSR were palpated by the examiners. Intraclass correlation coefficients were calculated to determine the intra- and inter-examiner reliabilities of the palpation. Two multiple regression analyses, one for each examiner, were conducted to analyze the relationships between the rate of the CSR and the heart and respiratory rates of the subjects and the examiners. The intraexaminer reliability coefficients were 0.78 for examiner A and 0.83 for examiner B, and the interexaminer reliability coefficient was 0.22. The result of the multiple regression analysis for examiner A was R = 0.46 and adjusted R2 = 0.12 (p = 0.078) and for examiner B was R = 0.63 and adjusted R2 = 0.32 (p = 0.001). The highest bivariate correlation was found between the CSR and the subject's heart rate (r = 0.30) for examiner A and between the CSR and the examiner's heart rate (r = 0.42) for examiner B. The results indicated that a single examiner may be able to palpate the rate of the CSR consistently, if that is what we truly measured. It is possible that the perception of CSR is illusory. The rate of the CSR palpated by two examiners is not consistent. The results of the regression analysis of one examiner offered no validation to those of the other. It appears that a subject's CSR is not related to the heart or respiratory rates of the subject or the examiner.

March brings us more mechanistically oriented articles examining how spinal manipulation may effect physiologic changes in an organism. These studies should provide a road map to more comprehensive basic science/ bench investigations of spinal manipulation which logically ought to be a part of all osteopathic medical school's research programs.


Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous theories.

J Manipulative Physiol Ther. 2002 May;25(4):251-62.

Evans DW.

British School of Osteopathy, London, United Kingdom.

OBJECTIVES: When the clinical efficacy of spinal manipulative treatment for spinal pain has been assessed, high-velocity low-amplitude thrust (HVLAT) manipulation and mobilization have been regarded as clinical interventions giving identical and equivalent biologic effects. The objective of this review is to critically discuss previous theories and research of spinal HVLAT manipulation, highlighting reported neurophysiologic effects that seem to be uniquely associated with cavitation of synovial fluid. DATA SOURCE: The biomedical literature was searched for research and reviews on spinal manipulation. MEDLINE and EMBASE databases were used to help find relevant articles. STUDY SELECTION: All articles relevant to the objectives were selected. DATA EXTRACTION: All available data were used. DATA SYNTHESIS: The main hypotheses for lesions that respond to HVLAT manipulation were critically discussed: (1) release of entrapped synovial folds or plica, (2) relaxation of hypertonic muscle by sudden stretching, (3) disruption of articular or periarticular adhesions, and (4) unbuckling of motion segments that have undergone disproportionate displacements. RESULTS: There appear to be 2 separate modes of action from zygapophyseal HVLAT manipulation. Intra-articular "mechanical" effects of zygapophyseal HVLAT manipulation seem to be absolutely separate from and irrelevant to the occurrence of reported "neurophysiologic" effects. Cavitation should not be an absolute requirement for the mechanical effects to occur but may be a reliable indicator for successful joint gapping. CONCLUSIONS: It is hoped that identification of these unique neurophysiologic effects will provide enough theoretical reason for HVLAT manipulation and mobilization to be assessed independently as individual clinical interventions.

Link


The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain.

Arch Phys Med Rehabil. 2003 Jul;84(7):1057-60.

Flynn TW, Fritz JM, Wainner RS, Whitman JM.

US Army-Baylor University Graduate Program in Physical Therapy, San Houston, Texas, 78234-6138, USA. [email protected]

OBJECTIVE: To determine the relationship between an audible pop and symptomatic improvement with spinal manipulation in patients with low back pain (LBP). DESIGN: A prospective cohort study. SETTING: Two outpatient physical therapy clinics located in military medical centers. PARTICIPANTS: A cohort of 71 patients with nonradicular LBP referred to physical therapy. INTERVENTIONS: Participants underwent a standardized examination and standardized spinal manipulation treatment program. All patients were treated with a sacroiliac (SI) region manipulative technique and the presence or absence of an audible pop was noted.Main Outcome Measures: Subjects were reassessed 48 hours after the manipulation for changes in range of motion (ROM), numeric pain rating scale (PRS) scores, and modified Oswestry Disability Questionnaire (ODQ) scores. RESULTS: An audible pop occurred in 50 of the 71 subjects during the manipulative procedure. Both groups-those who had an audible pop and those who did not-improved over time in flexion ROM, PRS scores, and modified ODQ scores; however, there were no differences between groups (P>.05). Nineteen of the 71 (27%) patients improved dramatically (mean drop in modified ODQ, 67.6%). In 14 of the 19 dramatic responders, an audible pop occurred. However, the odds ratio (1.2; 95% confidence interval, 0.38-4.04) suggested that the occurrence of a manipulative pop would not improve the odds of achieving a dramatic reduction in symptoms after the manipulation. CONCLUSION: There is no relationship between an audible pop during SI region manipulation and improvement in ROM, pain, or disability in individuals with nonradicular LBP. Additionally, the occurrence of a pop did not improve the odds of a dramatic improvement with manipulation treatment.

Link


Spinal reflex attenuation associated with spinal manipulation.

Spine. 2000 Oct 1;25(19):2519-24

Dishman JD, Bulbulian R.

Department of Anatomy, New York Chiropractic College, Seneca Falls, New York 13148, USA. [email protected].

STUDY DESIGN: This study evaluated the effect of lumbosacral spinal manipulation with thrust and spinal mobilization without thrust on the excitability of the alpha motoneuronal pool in human subjects without low back pain. OBJECTIVES: To investigate the effect of high velocity, low amplitude thrust, or mobilization without thrust on the excitability of the alpha motoneuron pool, and to elucidate potential mechanisms in which manual procedures may affect back muscle activity. SUMMARY OF BACKGROUND DATA: The physiologic mechanisms of spinal manipulation are largely unknown. It has been proposed that spinal manipulation may reduce back muscle electromyographic activity in patients with low back pain. Although positive outcomes of spinal manipulation intervention for low back pain have been reported in clinical trials, the mechanisms involved in the amelioration of symptoms are unknown. METHODS: In this study, 17 nonpatient human subjects were used to investigate the effect of spinal manipulation and mobilization on the amplitude of the tibial nerve Hoffmann reflex recorded from the gastrocnemius muscle. Reflexes were recorded before and after manual spinal procedures. RESULTS: Both spinal manipulation with thrust and mobilization without thrust significantly attenuated alpha motoneuronal activity, as measured by the amplitude of the gastrocnemius Hoffmann reflex. This suppression of motoneuronal activity was significant (P < 0.05) but transient, with a return to baseline values exhibited 30 seconds after intervention. CONCLUSIONS: Both spinal manipulation with thrust and mobilization without thrust procedures produce a profound but transient attenuation of alpha motoneuronal excitability. These findings substantiate the theory that manual spinal therapy procedures may lead to short-term inhibitory effects on the human motor system.

Link

Int J Mol Med. 2004 Sep;14(3):443-9.


Nitric oxide as a possible mechanism for understanding the therapeutic effects of osteopathic manipulative medicine (Review).

Salamon E, Zhu W, Stefano GB.

Neuroscience Research Institute, State University of New York, College at Old Westbury, Old Westbury, NY 11568, USA.

Throughout the history of medicine we have seen the progression of medical therapies from the empirical to the counter-intuitive, with much pressure being placed upon the scientific community to distinguish the two. This exercise has proven the effectiveness of numerous modern therapeutic techniques that have been adapted into modern medicine with remarkable success. While it is certain that many of these techniques yield beneficial results, the mechanisms by which these results are achieved have not been fully realized. In the present report, we consider the case of osteopathic manipulative medicine (OMM), which represents a therapeutic technique developed over a century ago as a means of non-invasive treatment for numerous ailments. Our intention is to use current findings from our laboratory, as well as those of our colleagues in the area of nitric oxide (NO) research to explain the mechanism through which osteopathic manipulations aid the patient. These reports demonstrate that fluidic motions applied to vascular and nerve tissue in a manner comparable to manipulations can cause a remarkable increase in NO concentration within the blood and vasculature. These findings combined with the overwhelming amount of research into the beneficial effects of constitutive NO provide a dynamic theoretical framework to explain the therapeutic effects of OMM.



PMID: 15289898 [PubMed - indexed for MEDLINE]

J Am Osteopath Assoc. 2003 Sep;103(9):417-21.

Link to full text

Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries.

Eisenhart AW, Gaeta TJ, Yens DP.

Department of Emergency Medicine, St Barnabas Hospital, Bronx, NY, USA.

STUDY OBJECTIVE: The purpose of this study was to evaluate the efficacy of osteopathic manipulative treatment (OMT) as administered in the emergency department (ED) for the treatment of patients with acute ankle injuries. METHODS: Patients aged 18 years and older with unilateral ankle sprains were randomly assigned either to an OMT study group or a control group. Independent outcome variables included edema, range of motion (ROM), and pain. Both groups received the current standard of care for ankle sprains and were instructed to return for a follow-up examination. Patients in the OMT study group also received one session of OMT from an osteopathic physician. RESULTS: Patients in the OMT study group had a statistically significant (F = 5.92, P = .02) improvement in edema and pain and a trend toward increased ROM immediately following intervention with OMT. Although at follow-up both study groups demonstrated significant improvement, patients in the OMT study group had a statistically significant improvement in ROM when compared with patients in the control group. CONCLUSIONS: Data clearly demonstrate that a single session of OMT in the ED can have a significant effect in the management of acute ankle injuries.



PMID: 14527076 [PubMed - indexed for MEDLINE]

Rigorous evidence-based OMT research will only be achieved when clear physiologic parameters can be linked to objective clinical outcomes. Finding reliable physiologic paramenters has been difficult. The first study summarizes some promising work on the physiologic markers that may be linked to the phenomenon of cranial "primary respiration." The second study is a good quality randomized clinical trial (a pragmatic trial) that reflects how osteopathic physicians incorporate manipulation into "usual care." The editorial exchange that follows is also instructive.


Altern Ther Health Med. 2002 Nov-Dec;8(6):74-6.


The effect of cranial manipulation on the Traube-Hering-Mayer oscillation as measured by laser-Doppler flowmetry.

Sergueef N, Nelson KE, Glonek T.

Department of Osteopathic Manipulative Medicine, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Ill, USA.

CONTEXT: A correlation has been established between the Traube-Hering-Mayer oscillation in blood-flow velocity, measured by laser-Doppler flowmetry, and the cranial rhythmic impulse. OBJECTIVE: To determine the effect of cranial manipulation on the Traube-Hering-Mayer oscillation. DESIGN: Of 23 participants, 13 received a sham treatment and 10 received cranial manipulation. SETTING: Osteopathic Manipulative Medicine Department, Midwestern University, Downers Grove, Ill. PARTICIPANTS: Healthy adult subjects of both sexes participated (N = 23). INTERVENTION: A laser-Dopper flowmetry probe was placed on the left earlobe of each subject to obtain a 5-min baseline blood-flow velocity record. Cranial manipulation, consisting of equilibration of the global cranial motion pattern and the craniocervical junction, was then applied for 10 to 20 min; the sham treatment was palpation only. MAIN OUTCOME MEASURE: Immediately following the procedures, a 5-min posttreatment laser-Doppler recording was acquired. For each cranial treatment subject, the 4 major components of the blood-flow velocity record, the thermal (Mayer) signal, the baro (Traube-Hering) signal, the respiratory signal, and the cardiac signal, were analyzed, and the pretreatment and posttreatment data were compared. RESULTS: The 10 participants who received cranial treatment showed a thermal signal power decrease from 47.79 dB to 38.49 dB (P < .001) and the baro signal increased from 47.40dB to 51.30 dB (P < .021), while the respiratory and cardiac signals did not change significantly (P > .05 for both). CONCLUSION: Cranial manipulation affects the blood-flow velocity oscillation in its low-frequency Traube-Hering-Mayer components. Because these low-frequency oscillations are mediated through parasympathetic and sympathetic activity, it is concluded that cranial manipulation affects the autonomic nervous system.

Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial.

Ann Intern Med. 2004 Sep 21;141(6):432-9.

Bergman GJ, Winters JC, Groenier KH, Pool JJ, Meyboom-de Jong B, Postema K, van der Heijden GJ.

University of Groningen and University Hospital of Groningen, Groningen, The Netherlands. [email protected]

BACKGROUND: Dysfunction of the cervicothoracic spine and the adjacent ribs (also called the shoulder girdle) is considered to predict occurrence and poor outcome of shoulder symptoms. It can be treated with manipulative therapy, but scientific evidence for the effectiveness of such therapy is lacking. OBJECTIVE: To study the effectiveness of manipulative therapy for the shoulder girdle in addition to usual medical care for relief of shoulder pain and dysfunction. DESIGN: Randomized, controlled trial. SETTING: General practices in Groningen, the Netherlands. PATIENTS: 150 patients with shoulder symptoms and dysfunction of the shoulder girdle. INTERVENTIONS: All patients received usual medical care from their general practitioners. Only the intervention group received additional manipulative therapy, up to 6 treatment sessions in a 12-week period. MEASUREMENTS: Patient-perceived recovery, severity of the main complaint, shoulder pain, shoulder disability, and general health. Data were collected during and at the end of the treatment period (at 6 and 12 weeks) and during the follow-up period (at 26 and 52 weeks). RESULTS: During treatment (6 weeks), no significant differences were found between study groups. After completion of treatment (12 weeks), 43% of the intervention group and 21% of the control group reported full recovery. After 52 weeks, approximately the same difference in recovery rate (17 percentage points) was seen between groups. During the intervention and follow-up periods, a consistent between-group difference in severity of the main complaint, shoulder pain and disability, and general health favored additional manipulative therapy. LIMITATIONS: The sample size was small, and assessment of end points was subjective. CONCLUSION: Manipulative therapy for the shoulder girdle in addition to usual medical care accelerates recovery of shoulder symptoms.



1 February 2005 | Volume 142 Issue 3 | Page 226

---------------------------------------
TO THE EDITOR:
The use of manipulative therapy in shoulder dysfunction is analogous to using "medicine" to treat chest pain. Both the nature of condition and the specific treatment need to be identified. In their article on manipulative therapy for shoulder symptoms (1), Bergman and colleagues described the type of treatments used but did not classify the nature of the underlying cause of the symptoms. For example, shoulder dysfunction can be caused by dysfunction of the spine, ribs, and shoulder articulations. Have the authors performed an analysis of the efficacy of treatment with regard to specific conditions? If yes, what are the results of the subset analysis?


Richard C. Galgano, DO
Harvard Vanguard Medical Associates, Watertown, MA 02472.


----------------------------------------

IN RESPONSE:
The question regarding subgroup analysis is logical, considering the positive message of our study. Our study was designed to examine the efficacy of additional manipulative treatment for shoulder complaints. At baseline, all of the included patients experienced manifest pain in or dysfunction of the shoulder. At the same time, the physical examination also demonstrated a concomitant dysfunction of the cervicothoracic spine and the adjacent ribs (shoulder girdle dysfunction). We did not perform subgroup analyses on the efficacy of manipulative treatment with regard to specific conditions for several reasons. Subgroup analysis should be based on theoretical considerations. We do not expect large differential effects of manipulative techniques in treatment of shoulder dysfunction due to various postulated specific dysfunctions of the shoulder girdle. A firm theory regarding subgroup effects according to specific shoulder girdle dysfunction is lacking. Moreover, in our opinion, there are more similarities than differences among available manipulative techniques for specific conditions of the cervicothoracic spine and adjacent ribs. In addition, physical examination has not been shown to contribute to the accurate location of such specific conditions or differentiation among them (1). A recent study demonstrated that clinicians cannot accurately distinguish between neck and shoulder problems on physical examination (2). Finally, with our sample size of 150 patients, we were able to demonstrate significant results in our main analysis. Any subgroup analysis would require a larger sample size; the statistical power of such additional analyses in our sample is likely to be insufficient (3).


Gert J.D. Bergman, MSc;
Jan C. Winters, MD, PhD;
Geert J.M.G. van der Heijden, PT, PhD

From University of Groningen, 9700 AD Groningen, and University Medical Center Utrecht, 3508 GA Utrecht, the Netherlands.



1. Pool JJ, Hoving JL, de Vet HC, van Mameren H, Bouter LM. The interexaminer reproducibility of physical examination of the cervical spine. J Manipulative Physiol Ther. 2004;27:84-90. [PMID: 14970808].[Medline]

2. Groenier KH, Winters JC, de Jong BM. Classification of shoulder complaints in general practice by means of nonmetric multidimensional scaling. Arch Phys Med Rehabil. 2003;84:812-7. [PMID: 12808531].[Medline]

3. Brookes ST, Whitely E, Egger M, Smith GD, Mulheran PA, Peters TJ. Subgroup analyses in randomized trials: risks of subgroup-specific analyses; power and sample size for the interaction test. J Clin Epidemiol. 2004;57:229-36. [PMID: 15066682].[Medline]

If you are using the Online Monthly OMM Journal Club at your COM please let me know. I'd like feedback about how this is working.



Continuing the theme of more mechanistically-oriented studies of spinal manipulation, these investigators evaluated and documented intra-capsular pressures generated in cadavers during simulated HVLA-type manuevers.


Spine J. 2005 May-Jun;5(3):277-90.


Comparison of human lumbar facet joint capsule strains during simulated high-velocity, low-amplitude spinal manipulation versus physiological motions.

Link to PDF

Ianuzzi A, Khalsa PS.

Department of Biomedical Engineering, Stony Brook University, Health Sciences Center, T18-030, Stony Brook, NY 11794, USA.

BACKGROUND CONTEXT: Spinal manipulation (SM) is an effective treatment for low back pain (LBP), and it has been theorized that SM induces a beneficial neurophysiological effect by stimulating mechanically sensitive neurons in the lumbar facet joint capsule (FJC). PURPOSE: The purpose of this study was to determine whether human lumbar FJC strains during simulated SM were different from those that occur during physiological motions. STUDY DESIGN/SETTING: Lumbar FJC strains were measured in human cadaveric spine specimens during physiological motions and simulated SM in a laboratory setting. METHODS: Specimens were tested during displacement-controlled physiological motions of flexion, extension, lateral bending, and axial rotations. SM was simulated using combinations of manipulation site (L(3), L(4), and L(5)), impulse speed (5, 20, and 50 mm/s), and pre-torque magnitude (applied at T(12) to simulate patient position; 0, 5, 10 Nm). FJC strains and vertebral motions (using six degrees of freedom) were measured during both loading protocols. RESULTS: During SM, the applied loads were within the range measured during SM in vivo. Vertebral translations occurred primarily in the direction of the applied load, and were similar in magnitude regardless of manipulation site. Vertebral rotations and FJC strain magnitudes during SM were within the range that occurred during physiological motions. At a given FJC, manipulations delivered distally induced capsule strains similar in magnitude to those that occurred when the manipulation was applied proximally. CONCLUSIONS: FJC strain magnitudes during SM were within the physiological range, suggesting that SM is biomechanically safe. Successful treatment of patients with LBP using SM may not require precise segmental specificity, because the strain magnitudes at a given FJC during SM do not depend upon manipulation site.

More mechanistically oriented manual medicine research...

Am J Phys Med Rehabil. 2005 Apr;84(4):251-7.


Manual treatment effects to the upper cervical apophysial joints before, during, and after endotracheal anesthesia: a placebo-controlled comparison.

Buchmann J, Wende K, Kundt G, Haessler F.

Department of Child and Adolescent Neuropsychiatry, University of Rostock, Rostock, Germany.

OBJECTIVES: In this preliminary, placebo-controlled clinical trial, two different manual treatments were compared, spinal manipulation and postisometric relaxation, for dysfunctional motion segments of the upper cervical spinal column. The influence of the muscular portion on the joint-play restriction of a motion segment can be ignored in anesthesia, and the manual evaluation of this joint-play restriction must be focused on nonmuscular structures. By retesting in anesthesia, it is possible to examine whether mobilization and manipulation affect exclusively the muscular structures or also affect the other parts of the motion segment. Conclusions can be drawn about the superiority of one or both treatments and about the structural basis of the restricted joint play and its palpation. DESIGN: A total of 26 inpatients at the surgical or orthopedic department of the University of Rostock were examined manually at four testing times: before and after manual treatment, in anesthesia, and within 24 hrs of completing anesthesia. They were randomized into three groups: postisometric relaxation (mobilization), spinal manipulation (thrust technique), and placebo. RESULTS: A highly significant effect for both treatments was found posttherapeutically (P < 0.01) but not for placebo. In anesthesia, the treatment effect of spinal manipulation was further significant (P < 0.01) when compared with placebo. For postisometric relaxation, however, it was not (P = 0.160). A significant difference between spinal manipulation and postisometric relaxation was not found in anesthesia (P = 0.137). The treatment effect postnarcotically was further significant when compared with placebo only for spinal manipulation (P = 0.011). CONCLUSIONS: Both treatments are superior to placebo. Postisometric relaxation seems to affect mainly the muscular parts of the treated segments and less so the other parts, such as the joint capsule or the segmental affiliated ligaments and fascia. Spinal manipulation seems to influence all other segmental parts more effectively, and the treatment effect persists longer. A joint-play restriction cannot be an exclusively muscular tension phenomenon. Segmental motion dysfunctions show a high variability in their spontaneous course.


Link to full text

BMC Musculoskelet Disord. 2005 Aug 4;6(1):43


Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials.

Licciardone JC, Brimhall AK, King LN.

BACKGROUND: Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement their conventional treatment of musculoskeletal disorders. Previous reviews and meta-analyses of spinal manipulation for low back pain have not specifically addressed OMT and generally have focused on spinal manipulation as an alternative to conventional treatment. The purpose of this study was to assess the efficacy of OMT as a complementary treatment for low back pain. METHODS: Computerized bibliographic searches of MEDLINE, EMBASE, MANTIS, OSTMED, and the Cochrane Central Register of Controlled Trials were supplemented with additional database and manual searches of the literature. Six trials, involving eight OMT vs control treatment comparisons, were included because they were randomized controlled trials of OMT that involved blinded assessment of low back pain in ambulatory settings. Data on trial methodology, OMT and control treatments, and low back pain outcomes were abstracted by two independent reviewers. Effect sizes were computed using Cohen's d statistic and meta-analysis results were weighted by the inverse variance of individual comparisons. In addition to the overall meta-analysis, stratified meta-analyses were performed according to control treatment, country where the trial was conducted, and duration of follow-up. Sensitivity analyses were performed for both the overall and stratified meta-analyses. RESULTS: Overall, OMT significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 - -0.13; P = .001). Stratified analyses demonstrated significant pain reductions in trials of OMT vs active treatment or placebo control and OMT vs no treatment control. There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States. Significant pain reductions were also observed during short-, intermediate-, and long-term follow-up. CONCLUSIONS: OMT significantly reduces low back pain. The level of pain reduction is greater than expected from placebo effects alone and persists for at least three months. Additional research is warranted to elucidate mechanistically how OMT exerts its effects, to determine if OMT benefits are long lasting, and to assess the cost-effectiveness of OMT as a complementary treatment for low back pain.

PMID: 16080794

Patients with headaches commonly seek treatment from manual medicine practitioners. Anecdotal evidence supports the use of various physical modalities, including cervical spine manipulation, for treating headache symptoms but data from rigorously designed clinical trials is lacking. Meta-analysis of outcomes from smaller studies has been hampered by poor methodology, unstandardized outcomes, and small sample sizes. This area of research should be of high priority for manual medicine researchers.

------------------------------------------------------------

Spinal manipulative therapy in the management of cervicogenic headache.

Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado ML, Pareja JA.

Patients suffering from cervicogenic headache (CeH) are commonly treated with spinal manipulative therapy. We have analyzed the quality and the outcomes of published, randomized, controlled trials assessing the effectiveness of spinal manipulation in CeH. Among 121 relevant articles, only two met all the inclusion criteria. Methodological quality scores were 8/10 and 7/10 points. Only one of the trials made use of a headache diary. Both the trials reported positive (+) results on headache intensity, headache duration, and medication intake, so that spinal manipulative therapy obtained strong evidence of effectiveness (level 1) with regard to these outcomes. Conversely, spinal manipulation obtained no more than limited evidence (level 3) in reducing headache frequency, as it was analyzed only in one study with positive (+) results. A greater number of well-designed, randomized, controlled trials are required to confirm or refute the effectiveness of spinal manipulation in the management of CeH. (Headache 2005;45:1260-1270).

Link to abstract and full text


Non-invasive physical treatments for chronic/recurrent headache.

Bronfort G, Nilsson N, Haas M, Evans R, Goldsmith CH, Assendelft WJ, Bouter LM.

Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, 2501 W 84th St, Bloomington, MN 55431, USA. [email protected]

BACKGROUND: Non-invasive physical treatments are often used to treat common types of chronic/recurrent headache. OBJECTIVES: To quantify and compare the magnitude of short- and long-term effects of non-invasive physical treatments for chronic/recurrent headaches. SEARCH STRATEGY: We searched the following databases from their inception to November 2002: MEDLINE, EMBASE, BIOSIS, CINAHL, Science Citation Index, Dissertation Abstracts, CENTRAL, and the Specialised Register of the Cochrane Pain, Palliative Care and Supportive Care review group. Selected complementary medicine reference systems were searched as well. We also performed citation tracking and hand searching of potentially relevant journals. SELECTION CRITERIA: We included randomized and quasi-randomized controlled trials comparing non-invasive physical treatments for chronic/recurrent headaches to any type of control. DATA COLLECTION AND ANALYSIS: Two independent reviewers abstracted trial information and scored trials for methodological quality. Outcomes data were standardized into percentage point and effect size scores wherever possible. The strength of the evidence of effectiveness was assessed using pre-specified rules. MAIN RESULTS: Twenty-two studies with a total of 2628 patients (age 12 to 78 years) met the inclusion criteria. Five types of headache were studied: migraine, tension-type, cervicogenic, a mix of migraine and tension-type, and post-traumatic headache. Ten studies had methodological quality scores of 50 or more (out of a possible 100 points), but many limitations were identified. We were unable to pool data because of study heterogeneity.For the prophylactic treatment of migraine headache, there is evidence that spinal manipulation may be an effective treatment option with a short-term effect similar to that of a commonly used, effective drug (amitriptyline). Other possible treatment options with weaker evidence of effectiveness are pulsating electromagnetic fields and a combination of transcutaneous electrical nerve stimulation [TENS] and electrical neurotransmitter modulation. For the prophylactic treatment of chronic tension-type headache, amitriptyline is more effective than spinal manipulation during treatment. However, spinal manipulation is superior in the short term after cessation of both treatments. Other possible treatment options with weaker evidence of effectiveness are therapeutic touch; cranial electrotherapy; a combination of TENS and electrical neurotransmitter modulation; and a regimen of auto-massage, TENS, and stretching. For episodic tension-type headache, there is evidence that adding spinal manipulation to massage is not effective. For the prophylactic treatment of cervicogenic headache, there is evidence that both neck exercise (low-intensity endurance training) and spinal manipulation are effective in the short and long term when compared to no treatment. There is also evidence that spinal manipulation is effective in the short term when compared to massage or placebo spinal manipulation, and weaker evidence when compared to spinal mobilization.There is weaker evidence that spinal mobilization is more effective in the short term than cold packs in the treatment of post-traumatic headache. REVIEWERS' CONCLUSIONS: A few non-invasive physical treatments may be effective as prophylactic treatments for chronic/recurrent headaches. Based on trial results, these treatments appear to be associated with little risk of serious adverse effects. The clinical effectiveness and cost-effectiveness of non-invasive physical treatments require further research using scientifically rigorous methods. The heterogeneity of the studies included in this review means that the results of a few additional high-quality trials in the future could easily change the conclusions of our review.

Abstract and Link to full article

A systematic review of craniosacral therapy: biological plausibility, assessment reliability and clinical effectiveness.

Green C, Martin CW, Bassett K, Kazanjian A.

BC Office of Health Technology Assessment, University of British Columbia, Vancouver, Canada.

OBJECTIVES: The objective of this research was to review critically the scientific basis of craniosacral therapy as a therapeutic intervention. DESIGN: A systematic search for and critical appraisal of research on craniosacral therapy was conducted. Medline, Embase, Healthstar, Mantis, Allied and Alternative Medicine, Scisearch and Biosis were searched from their start date to February 1999. MAIN OUTCOME MEASURES: A three-dimensional evaluative framework with related appraisal criteria: (A) craniosacral interventions and health outcomes; (B) validity of craniosacral assessment; and (C) pathophysiology of the craniosacral system. RESULTS: The available research on craniosacral treatment effectiveness constitutes low-grade evidence conducted using inadequate research protocols. One study reported negative side effects in outpatients with traumatic brain injury. Low inter-rater reliability ratings were found. CONCLUSIONS: This systematic review and critical appraisal found insufficient evidence to support craniosacral therapy. Research methods that could conclusively evaluate effectiveness have not been applied to date.

The use of OMT for the treatment of systemic disease is a controversial application of manual medicine. Yet, prior to the development of effective pharmaceutical interventions for many serious diseases, osteopathic physicians commonly used OMT either as an adjunctive modality or in combination with other treatments including surgery. Recent investigations about OMT for systemic disease and peri-operative medicine are lacking. Here are a couple review articles.

Heart Dis. 2003 Jul-Aug;5(4):272-8.


Osteopathic manipulative medicine in the treatment of hypertension: an alternative, conventional approach.

Spiegel AJ, Capobianco JD, Kruger A, Spinner WD.

Department of Osteopathic Medicine, New York College of Osteopathic Medicine, Old Westbury, NY 11568, USA.

The branch of medicine known as osteopathy was founded by Andrew Taylor Still in the mid to late 19th century. Osteopathy is a philosophy of medicine. Osteopathic physicians use techniques collectively referred to as osteopathic manipulative medicine (OMM). One of the most common diseases suffered by those residing in westernized nations is hypertension. Although osteopathic physicians are taught to incorporate OMM into the management of medical disorders, the usefulness of OMM in treating hypertension is less clear. This review reflects on the past 90 years of biomedical literature and attempts to address the utility of OMM used alone, or in combination with other treatments including antihypertensive medication, for the effective management of hypertension. Preliminary evidence may suggest a role for OMM in treating hypertension within the context of a multifaceted and long-lasting treatment regimen that may include traditional pharmacotherapeutics. To have universal acceptance, controlled and blinded outcome studies are needed to determine the effectiveness of OMM for the routine treatment of hypertension.

J Am Osteopath Assoc. 2001 Oct;101(10):576-83.


The muscle hypothesis: a model of chronic heart failure appropriate for osteopathic medicine.

Link to article

Rogers FJ.

Michigan State University College of Osteopathic Medicine, East Lansing, MI 48824-1316, USA. [email protected]

Chronic heart failure is one of the most serious medical problems in the United States, affecting some 4 million persons. In spite of its common occurrence, and comprehensive literature regarding this condition, no unifying hypothesis has been accepted to explain the signs and symptoms of chronic heart failure. The cardiocirculatory and neurohormonal models place an emphasis on left ventricular ejection fraction and cardiac output and do not provide appropriate explanations for the symptoms of breathlessness and fatigue. The muscle hypothesis supplements these conventional models. It proposes that abnormal skeletal muscle in heart failure results in activation of muscle ergoreceptors, leading to an increase in ventilation and sensation of breathlessness, the perception of fatigue, and sympathetic activation. At least one fourth of patients with chronic heart failure are limited by skeletal muscle abnormalities rather than cardiac output. Cardiac rehabilitation exercise can lead to an increase in exercise capacity that is superior to that gained from digitalis or angiotensin-converting enzyme inhibitors. Exercise tends to reverse the skeletal muscle myopathy of chronic heart failure and reduces the abnormal ergoreflex. Other interventions that have been shown to have a favorable outcome include localized muscle group training, respiratory muscle training, and dietary approaches. The possibility that osteopathic manipulative treatment might be of benefit is an attractive, but untested, possibility.

J Am Osteopath Assoc. 1996 Feb;96(2):97-100.


Update on osteopathic medical concepts and the lymphatic system.

Degenhardt BF, Kuchera ML.

Department of Osteopathic Manipulative Medicine, Kirksville College of Osteopathic Medicine, Mo 63501, USA.

The osteopathic medical profession has long recognized the importance of the lymphatic system in maintaining health. A review of scientific studies shows much information on the mechanisms and importance of lymph circulation. Many osteopathic manipulative techniques designed to treat patients with tissue congestion are based on early research recognizing that lymph flow is influenced by myofascial compression. Osteopathic manipulative treatment of the diaphragm was substantiated when pressure differentials created by the thoracic diaphragm were shown to influence lymph flow. Current research demonstrates that autonomically mediated, intrinsic lymphatic contractility plays a significant role in lymph propulsion, supporting the use of osteopathic manipulative techniques directed at influencing the autonomic nervous system to improve lymphatic circulation. Although research provides an explanation of how osteopathic manipulative techniques influence the lymphatic system, experimentation to test the direct influence of manipulation on lymph circulation is needed. Clinical outcomes studies are also necessary to substantiate the clinical efficacy of osteopathic manipulative techniques.


J Am Osteopath Assoc. 1989 Oct;89(10):1309-14, 1319-22.

Postoperative osteopathic manipulative management of median sternotomy patients.

Dickey JL.

More than 250,000 patients yearly undergo coronary bypass graft surgery accomplished via the median sternotomy incision, an approach that has been gaining widespread acceptance. This surgical approach has been associated with a growing number of patients with structural complaints. This article describes a postoperative treatment protocol for improving healing and reducing musculoskeletal disability associated with such cardiac procedures and presents a logical sequence of treatment graded to the patient's changing condition and stage of healing. The author challenges the osteopathic medical profession to meet the opportunity that exists to educate patients and physicians about the benefits of osteopathic healthcare.


Altern Ther Health Med. 2000 Sep;6(5):77-81.


The effectiveness of osteopathic manipulative treatment as complementary therapy following surgery: a prospective, match-controlled outcome study.

Jarski RW, Loniewski EG, Williams J, Bahu A, Shafinia S, Gibbs K, Muller M.

Complementary Medicine and Wellness Program, Oakland University, Rochester, Mich., USA. [email protected]

CONTEXT: Osteopathic manipulative treatment has been reported to relieve a variety of conditions, but no studies have examined the outcome effects of osteopathic manipulative treatment as a complementary modality for treating musculoskeletal problems during postoperative recovery. OBJECTIVE: To assess osteopathic manipulative treatment as a complementary therapy for patients undergoing elective knee or hip arthroplasty. DESIGN: Prospective, single-blinded, 2-group, match-controlled outcome study. SETTING: Osteopathic teaching hospital. PATIENTS: Of 166 eligible patients, 38 were assigned to a treatment group and matched with 38 control subjects. INTERVENTION: The treatment group received osteopathic manipulative treatment on postoperative days 2 through 5. MAIN OUTCOME MEASURES: Days to independent negotiation of stairs, distance ambulated, supplemental intramuscular analgesic use, length of hospital stay, and patients' perceptions of treatment. RESULTS: Compared to control subjects, the intervention group negotiated stairs 20% earlier (mean = 4.3 postoperative days, SD = 1.2; control subjects 5.4, SD = 1.6, P = .006) and ambulated 43% farther on the third postoperative day (mean = 24.3 m, SD = 18.3; controls = 13.9, SD = 14.4, P = .008). The intervention group also required less analgesia, had shorter hospital stays, and ambulated farther on postoperative days 1, 2, and 4. CONCLUSIONS: Patients receiving osteopathic manipulative treatment in the early postoperative period negotiated stairs earlier and ambulated greater distances than did control group patients.

Interest and demand among some MD's for education in OMT and manual medicine is not new. Several osteopathic groups sponsor continuing medical education programs in osteopathic manipulation for interested MD's. Recently, a serious lack of knowledge and skills among primary care physicians in diagnosing and treating musculoskeletal conditions has been identified. One proposed solution to this problems has been incorporating features of osteopathic medical education into allopathic training programs. Articles this month review this topic. Improving musculoskeletal education and treatment may be a tangible way for the osteopathic profession to impact the US health care system.

Comments welcome.
-----------------------------------------------------------------

Fam Med. 2005 Nov;37(10):693-5.

Link to PDF

Allopathic Family Medicine Residents Can Learn Osteopathic Manipulation Techniques in a 1-month Elective.

Leiber JD.

Malcolm Grow Medical Center Family Medicine Residency, Andrews Air Force Base, Md.

BACKGROUND: Graduating family medicine residents report a relative lack of confidence in managing musculoskeletal problems, and many primary care physicians desire more instruction in manual medicine. METHODS: We conducted a 1-month osteopathic manipulative treatment elective with five allopathic family medicine residents, utilizing multiple teaching and assessment strategies. RESULTS: Residents averaged 30 patient encounters each. Faculty graded their attainment of the knowledge and skills objectives at 3.9 and 3.8 on a 5-point scale, respectively. Residents reported unanimously that the course had reasonable expectations and fostered independent decision making and that they achieved the educational goals. CONCLUSIONS: After a 1-month elective, allopathic residents demonstrated competency in a defined set of osteopathic principles and skills.


Training in back care to improve outcome and patient satisfaction. Teaching old docs new tricks.

Link to PDF

Curtis P, Carey TS, Evans P, Rowane MP, Jackman A, Garrett J.

Department of Family Medicine, University of North Carolina at Chapel Hill, 27599, USA. [email protected]

BACKGROUND: We examined clinical outcomes and patient perceptions of back care given by physicians before and after an intensive course of training in back care and limited manual therapy techniques. METHODS: From a prospective observational cohort study of low back pain involving 208 physicians (115 primary care) and their patients and a subsequent clinical trial of treatment of low back pain given by 31 physicians specially trained in manual therapy and enhanced back care, outcome data from the patients of 13 physicians participating in both studies were compared. In the observational study, the 13 physicians cared for 120 patients. In the manual therapy trial (191 patients) a control group of 94 patients received enhanced back care and an intervention group of 97 patients received enhanced back care plus manual therapy. Pearson's chi-square comparisons and linear and Cox proportional hazard modeling were used to examine effects of variables and recovery time. RESULTS: Characteristics of the 13 physicians' patients in the cohort group and the manual therapy trial showed some differences in income, workers' compensation, previous employment, and baseline dysfunction. Both control and intervention patients in the manual therapy trial showed more rapid improvement in functional status over time and greater satisfaction with their care than those in the previous cohort study. However, there was no difference between the studies in patient-reported time to return to performing usual daily activities. CONCLUSIONS: A structured clinical approach to low back care may bring modestly improved clinical outcomes and patient satisfaction.

J Am Osteopath Assoc. 2004 Apr;104(4):149-55.

Link to PDF

Musculoskeletal disorders: does the osteopathic medical profession demonstrate its unique and distinctive characteristics?

Sun C, Desai GJ, Pucci DS, Jew S.

Department of Family Medicine/Medical Affairs, University of Health Sciences College of Osteopathic Medicine, Kansas City, MO 64106-1453, USA. [email protected]

The authors used the National Ambulatory Medical Care Survey: 1999 Summary to compare the practice patterns of osteopathic and allopathic physicians in the management of musculoskeletal disorders in family practice settings. Patient and physician characteristics, diagnostic test ordering patterns, treatments, and amount of time spent with patients during visits were compared. Patients who visited osteopathic physicians were more likely to be middle-aged and referred, with injury-related visits that were self-paid. Osteopathic physicians spent more time with patients, ordered a greater number of nontraditional diagnostic tests, and provided more manual and complementary modes of therapy. In contrast, although most of the patients seen by both osteopathic and allopathic physicians were white, allopathic physicians had a greater percentage of patients who were of an ethnic minority or under Medicaid or Medicare. Allopathic physicians ordered a greater number of traditional diagnostic tests and prescribed more medications. Based on the nationally representative data, osteopathic physicians used physiotherapy (including osteopathic manipulative treatment and physical modes of therapy) and complementary treatments to a greater degree in their physician-patient contacts. In contrast, allopathic physicians spent more resources on diagnosis versus treatment (eg, physiotherapy) and seemed to focus on the search for a nonstructural medical cause.


Am J Phys Med Rehabil. 1995 Nov-Dec;74(6):439-43.

Interest in manual medicine among residents in physical medicine and rehabilitation. The need for increased instruction.

Atchison JW, Newman RL, Klim GV.

Department of Physical Medicine and Rehabilitation University of Kentucky College of Medicine, Lexington 40536-0284, USA.

Manual medicine is an important part of the practice of physical medicine and rehabilitation (PM&R). Using a two-part questionnaire, we surveyed PM&R residents to determine their level of interest in manual medicine, their attitudes about this type of treatment, and the amount of formal training in manual medicine offered in PM&R residencies. Questionnaires were sent to all 75 PM&R residency training programs. Responses were received from 470 residents (41.6%) of 1126 potential respondents; this represented 55 (73%) of the programs surveyed. Of the 470 respondents, 363 (77.2%) believed that manual medicine should be a part of PM&R, 386 (82.1%) wanted more training in manual medicine, 389 (82.8%) believed that manual medicine is useful in the treatment of back/neck pain, and 392 (83.4%) would refer patients for manual medicine treatment. However, only 124 (27.3%) were receiving formal instruction in manual medicine during their PM&R residency training. Most of the 305 respondents who had received some exposure to manual medicine had done so through conferences (88.7%) and independent reading (66.9%). The results of this survey of PM&R residents demonstrate both a widespread interest in the use of manual medicine and an unmet desire for more instruction. Educational experiences in manual medicine should be provided so that, as residents become practicing physiatrists, they can either utilize this form of treatment or appropriately refer patients to other practitioners.

Other Links:

Harvard OMT Continuing Medical Education Series (MD's and DO's)

Academy of Osteopathy Continuing Medical Education Series (DO's only).

Michigan State University Manual Medicine Continuing Medical Education Series (MD's and DO's)

The analgesic and psychotropic effects of physical modalities such as OMT may be grounded in the modulation of the body's various stress hormones. Recent developments in this area of research include identifying and measuring various biomarkers such as inflammatory markers, nitric oxide, endorphins, and perhaps even more promising, various endocannabinoids before and after the application of physical treatments such as OMT. This month's series of articles will overview the pharmacology of the endocannabinoids and their potential impact on future OMT research.



J Pharmacol Exp Ther. 2001 Jul;298(1):7-14.

Mechanisms of endocannabinoid inactivation: biochemistry and pharmacology.

Link to full article

Giuffrida A, Beltramo M, Piomelli D.

Department of Pharmacology, University of California, Irvine, California 92697-4625, USA. [email protected]

The endocannabinoids, a family of endogenous lipids that activate cannabinoid receptors, are released from cells in a stimulus-dependent manner by cleavage of membrane lipid precursors. After release, the endocannabinoids are rapidly deactivated by uptake into cells and enzymatic hydrolysis. Endocannabinoid reuptake occurs via a carrier-mediated mechanism, which has not yet been molecularly characterized. Endocannabinoid reuptake has been demonstrated in discrete brain regions and in various tissues and cells throughout the body. Inhibitors of endocannabinoid reuptake include N-(4-hydroxyphenyl)-arachidonylamide (AM404), which blocks transport with IC50 (concentration necessary to produce half-maximal inhibition) values in the low micromolar range. AM404 does not directly activate cannabinoid receptors or display cannabimimetic activity in vivo. Nevertheless, AM404 increases circulating anandamide levels and inhibits motor activity, an effect that is prevented by the CB1 cannabinoid antagonist N-(piperidin-1-yl)-5-(4-chlorophenyl)-1-(2,4-dichlorophenyl)-4-methyl-1H-pyrazole-3-carboxamide hydrochloride (SR141716A). AM404 also reduces behavioral responses to dopamine agonists and normalizes motor activity in a rat model of attention deficit hyperactivity disorder. The endocannabinoids are hydrolyzed by an intracellular membrane-bound enzyme, termed anandamide amidohydrolase (AAH), which has been molecularly cloned. Several fatty acid sulfonyl fluorides inhibit AAH activity irreversibly with IC50 values in the low nanomolar range and protect anandamide from deactivation in vivo. alpha-Keto-oxazolopyridines inhibit AAH activity with high potency (IC50 values in the low picomolar range). A more thorough characterization of the roles of endocannabinoids in health and disease will be necessary to define the significance of endocannabinoid inactivation mechanisms as targets for therapeutic drugs.



Proc Natl Acad Sci U S A. 2005 Dec 13

Antidepressant-like activity and modulation of brain monoaminergic transmission by blockade of anandamide hydrolysis.

Link to full text


Gobbi G, Bambico FR, Mangieri R, Bortolato M, Campolongo P, Solinas M, Cassano T, Morgese MG, Debonnel G, Duranti A, Tontini A, Tarzia G, Mor M, Trezza V, Goldberg SR, Cuomo V, Piomelli D.

Department of Psychiatry, McGill University, Montreal, QC, Canada H1N 3V2.

Although anecdotal reports suggest that cannabis may be used to alleviate symptoms of depression, the psychotropic effects and abuse liability of this drug prevent its therapeutic application. The active constituent of cannabis, Delta(9)-tetrahydrocannabinol, acts by binding to brain CB1 cannabinoid receptors, but an alternative approach might be to develop agents that amplify the actions of endogenous cannabinoids by blocking their deactivation. Here, we show that URB597, a selective inhibitor of the enzyme fatty-acid amide hydrolase, which catalyzes the intracellular hydrolysis of the endocannabinoid anandamide, exerts potent antidepressant-like effects in the mouse tail-suspension test and the rat forced-swim test. Moreover, URB597 increases firing activity of serotonergic neurons in the dorsal raphe nucleus and noradrenergic neurons in the nucleus locus ceruleus. These actions are prevented by the CB1 antagonist rimonabant, are accompanied by increased brain anandamide levels, and are maintained upon repeated URB597 administration. Unlike direct CB1 agonists, URB597 does not exert rewarding effects in the conditioned place preference test or produce generalization to the discriminative effects of Delta(9)-tetrahydrocannabinol in rats. The findings support a role for anandamide in mood regulation and point to fatty-acid amide hydrolase as a previously uncharacterized target for antidepressant drugs.


J Pharmacol Exp Ther. 2002 Jan;300(1):34-42.

The potent emetogenic effects of the endocannabinoid, 2-AG (2-arachidonoylglycerol) are blocked by delta(9)-tetrahydrocannabinol and other cannnabinoids.

Link to full article

Darmani NA.

Department of Pharmacology, Kirksville College of Osteopathic Medicine, Kirksville, Missouri 63501, USA. [email protected]

Cannabinoids, including the endogenous cannabinoid or endocannabinoid, anandamide, modulate several gastrointestinal functions. To date, the gastrointestinal effects of the second putative endocannabinoid 2-arachidonoylglycerol (2-AG) have not been studied. In the present study using a shrew (Cryptotis parva) emetic model, 2-AG (0.25-10 mg/kg, i.p.) potently and dose-dependently increased vomiting frequency (ED(50) = 1.13 mg/kg) and the number of animals vomiting (ED(50) = 0.48 mg/kg). In contrast, neither anandamide (2.5-20 mg/kg) nor methanandamide (5-10 mg/kg) induced a dose-dependent emetogenic response, but both could partially block the induced emetic effects. Delta(9)-Tetrahydrocannabinol and its synthetic analogs reduced 2-AG-induced vomiting with the rank order potency: CP 55,940 > WIN 55,212-2 > Delta(9)-tetrahydrocannabinol. The nonpsychoactive cannabinoid, cannabidiol, was inactive. Nonemetic doses of SR 141716A (1-5 mg/kg) also blocked 2-AG-induced vomiting. The 2-AG metabolite arachidonic acid also caused vomiting. Indomethacin, a cyclooxygenase inhibitor, blocked the emetogenic effects of both arachidonic acid and 2-AG. CP 55,940 also blocked the emetic effects of arachidonic acid. 2-AG (0.25-10 mg/kg) reduced spontaneous locomotor activity (ED(50) = 11 mg/kg) and rearing frequency (ED(50) = 4.3 mg/kg) in the shrew, whereas such doses of both anandamide and methanandamide had no effect on locomotor parameters. The present study indicates that: 1) 2-AG is an efficacious endogenous emetogenic cannabinoid involved in vomiting circuits, 2) the emetic action of 2-AG and the antiemetic effects of tested cannabinoids are mediated via CB(1) receptors, and 3) the emetic effects of 2-AG occur in lower doses relative to its locomotor suppressant actions.


J Am Osteopath Assoc. 2005 Jun;105(6):283-91.


Cannabimimetic effects of osteopathic manipulative treatment.

Link to full text


McPartland JM, Giuffrida A, King J, Skinner E, Scotter J, Musty RE.

Unitec Institute of Technology, Auckland, New Zealand. [email protected]

Endogenous cannabinoids activate cannabinoid receptors in the brain and elicit mood-altering effects. Parallel effects (eg, anxiolysis, analgesia, sedation) may be elicited by osteopathic manipulative treatment (OMT), and previous research has shown that the endorphin system is not responsible for OMT's mood-altering effects. The authors investigate whether OMT generated cannabimimetic effects for 31 healthy subjects in a dual-blind, randomized controlled trial that measured changes in subjects' scores on the 67-item Drug Reaction Scale (DRS). Chemical ionization gas chromatography and mass spectrometry were also used to determine changes in serum levels of anandamide (AEA), 2-arachidonoylglycerol (2-AG), and oleylethanolamide (OEA). In subjects receiving OMT, posttreatment DRS scores increased significantly for the cannabimimetic descriptors good, high, hungry, light-headed, and stoned, with significant score decreases for the descriptors inhibited, sober, and uncomfortable. Mean posttreatment AEA levels (8.01 pmol/mL) increased 168% over pretreatment levels (2.99 pmol/mL), mean OEA levels decreased 27%, and no changes occurred in 2-AG levels in the group receiving OMT. Subjects in the sham manipulative treatment group recorded mixed DRS responses, with both increases and decreases in scores for cannabimimetic and noncannabimimetic descriptors and no changes in sera levels. When changes in serum AEA were correlated with changes in subjects' DRS scores, increased AEA correlated best with an increase for the descriptors cold and rational, and decreased sensations for the descriptors bad, paranoid, and warm. The authors propose that healing modalities popularly associated with changes in the endorphin system, such as OMT, may actually be mediated by the endocannabinoid system.

Well,

After a hiatus of only 1.5 years, I thought it might be time to bring back the Online OMM Journal Club. To get back in the swing of things, here are the results of an elegant experiment by Gwirtz et al examining palpatory findings associated with viscerosomatic in a canine model. Licciardone et al also look at possible viscerosomatic palpatory findings in humans with type II diabetes using a case-control study. Enjoy.

J Appl Physiol. 2007 May 3

VISCERO-SOMATIC INTERACTION INDUCED BY MYOCARDIAL ISCHEMIA IN CONSCIOUS DOGS.

Gwirtz PA, Dickey J, Vick D, Williams MA, Foresman B.
Integrative Physiology, University of North Texas Health Science Center, Fort Worth, Texas, United States.

Studies tested the hypothesis that myocardial ischemia induces increased paraspinal muscular tone localized to the T2-T5 region which can be detected by palpatory means. This is consistent with theories of manual medicine suggesting that disturbances in visceral organ physiology can cause increases in skeletal muscle tone in specific muscle groups. Clinical studies in manual and traditional medicine suggest this phenomenon occurs during episodes of myocardial ischemia and may have diagnostic potential. However, there is little direct evidence of a cardiac-somatic mechanism to explain these findings. Chronically instrumented dogs (12 neurally-intact and 3 following selective left ventricular [LV] sympathectomy) were examined before, during and after myocardial ischemia. Circumflex blood flow (CBF), left ventricular contractile function, electromyographic (EMG) analysis, and blinded manual palpatory assessments (MPA) of tissue over the transverse spinal processes at segments T2-T5 and T11-T12 (control) were performed. Myocardial ischemia was associated with a decrease in myocardial contractile function and an increase in heart rate. MPA revealed increases in muscle tension and texture/firmness during ischemia in the T2-T5 segments on the left, but not on the right or in control segments. EMG demonstrated increased amplitude for the T4-T5 segments. After LV sympathectomy, MPA and EMG evidence of increased muscle tone were absent. In conclusion, myocardial ischemia is associated with significant increased paraspinal muscle tone localized to the left side T4-T5 myotomes in neurally intact dogs. LV sympathectomy eliminates the somatic response, suggesting that sympathetic neural traffic between the heart and somatic musculature may function as the mechanism for the interaction.

Key words: Cardiac, Coronary, Osteopathic, Somatic dysfunction, Sympathetic.

Osteopath Med Prim Care. 2007 Feb 8;1:6.

A case-control study of osteopathic palpatory findings in type 2 diabetes mellitus.

Licciardone JC, Fulda KG, Stoll ST, Gamber RG, Cage AC.
Osteopathic Research Center, University of North Texas Health Science Center-Texas College of Osteopathic Medicine, Fort Worth, TX 76107, USA. [email protected].

ABSTRACT: BACKGROUND: Although type 2 diabetes mellitus is often managed by osteopathic physicians, osteopathic palpatory findings in this disease have not been adequately studied. METHODS: A case-control study was used to measure the association between type 2 diabetes mellitus and a series of 30 osteopathic palpatory findings. The latter included skin changes, trophic changes, tissue changes, tenderness, and immobility at spinal segmental levels T5-T7, T8-T10, and T11-L2 bilaterally. Logistic regression models that adjusted for age, sex, and comorbid conditions were used to compute odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between type 2 diabetes mellitus and each of these findings. RESULTS AND DISCUSSION: A total of 92 subjects were included in the study. After controlling for age, sex, hypertension, and clinical depression, the only significant finding was an association between type 2 diabetes mellitus and tissue changes at T11-L2 on the right side (OR, 5.54; 95% CI, 1.76-17.47; P = .003). Subgroup analyses of subjects with type 2 diabetes mellitus and hypertension demonstrated significant associations with tissue changes at T11-L2 bilaterally (OR, 27.38; 95% CI, 1.75-428; P = .02 for the left side and OR, 24.00; 95% CI, 1.51-382; P = .02 for the right side). Among subjects with type 2 diabetes mellitus and hypertension, there was also a strong diabetes mellitus duration effect for tissue changes at T11-L2 bilaterally (OR, 12.00; 95% CI, 1.02-141; P = .05 for short duration vs. OR, 32.00; 95% CI, 2.29-448; P = .01 for long duration on the left side; and OR, 17.33; 95% CI, 1.39-217; P = .03 for short duration vs. OR, 32.00; 95% CI, 2.29-448; P = .01 for long duration on the right side). CONCLUSION: The only consistent finding in this study was an association between type 2 diabetes mellitus and tissue changes at T11-L2 on the right side. Potential explanations for this finding include reflex viscerosomatic changes directly related to the progression of type 2 diabetes mellitus, a spurious association attributable to confounding visceral diseases, or a chance observation unrelated to type 2 diabetes mellitus. Larger prospective studies are needed to better study osteopathic palpatory findings in type 2 diabetes mellitus.

PMID: 17371582 [PubMed - in process]

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17371582