Brain connectivity changes after osteopathy

Summary

Use of fMRI to reveal neurophysiological effects following Osteopathic Manual Treatment (OMT) showed significant changes compared to placebo treatment. OMT influences connectivity in cen- tres involved in emotion, behaviour, sensorimotor integration and motor control.

Keywords

Osteopathic Manual Treatment; Neurophysiological effects; Functional brain connectivity; fMRI; Treatment Effects; Manual therapy;

Whilst the effectiveness of osteopathic treatment may not be questionable, the exact mechanisms of its effect have long been under debate. Models have frequently included neurophysiological mechanisms but this recent paper is one of the first to provide a direct investigation of brain mechanisms following OMT.

Neural functional connectivity refers to how brain areas become active and communicate with each other, and can be calculated using functional MRI (fMRI) scans. Such patterns of communi- cation are important to dynamically drive behaviour and cognition: the brain organising as a whole, rather than viewing specific areas of function in isolation.

This randomised manual placebo-controlled trial of 30 healthy, pain-free, osteopathy-naive sub- jects involved two groups: Osteopathic Manual Treatment and Placebo Group. fMRI scans were taken before, immediately after, and three days after a 45-minute treatment. All subjects were ex- amined osteopathically before treatment. The osteopathic group received a treatment based on examination findings and included variably: visceral techniques; myofascial release; cranial treat- ment; indirect techniques; manipulations. Subjects in the placebo group were also examined but received a set procedure of “passive touch” to different body areas without mobilisation.

Results showed an increase in activity and connectiveness in areas related to motor control im- mediately after OMT treatment yet activity decreased in the same area following placebo treat- ment. 3 days later, activity decreased significantly in the caudate area (an area involved in control of movements and muscle tone but also activated during stress) for the OMT group yet increased in the placebo group. There was also a change in activity and connections in the amygdala both immediately (decreased) and 3-days (increased) after OMT but again, the opposite was found in the placebo group. The amygdala integrates multiple emotional, behavioural and motivational in- puts, and helps activate appropriate behaviour after processing fear or threat stimuli. Similar changes were found in the other sensorimotor areas including the cerebellar vermis III (posture, locomotion). There was no significant change between scans taken before treatment and 3-days later implying a reversible treatment effect.

The changes in neural connectivity after OMT, with the opposite effects in the placebo group, was striking. This type of study could well be an emerging area of osteopathic research: use of the rapidly developing neurophysiological investigative field to highlight some of the mechanisms of Osteopathy. It is in line with other studies demonstrating functional brain connectivity changes following chiropractic, therapeutic touch, spinal manipulation. It should be noted, however, the broad variety of osteopathic techniques utilised makes it difficult to interpret which, and what as- pect of the osteopathic encounter, had what effect. Overall, it is encouraging to see a study using fMRI that specifically looks at osteopathy.

Reference: Tramontano M, Cerritelli F, Piras F, Spanò B, Tamburella F, Piras F, Caltagirone C, Gili T. Brain Connectivity Changes after Osteopathic Manipulative Treatment: A Randomized Manual Placebo-Controlled Trial. Brain Sciences. 2020; 10(12):969. https://doi.org/10.3390/brain- sci10120969

Manual Therapy and cervical artery dysfunction

Brief summary: Cervical artery dysfunction (CeAD) may mimic many musculoskeletal presentations. This paper provides a comprehensive review of the best available evidence for risk assessment prior to manipulation of the cervical and upper thoracic spine. Consider CeAD with the following presentation: An uncharacteristic headache, and a neck trauma in the past month.

Key words: Cervical Artery Dysfunction (CeAD), High Velocity Thrust Techniques (HVT), Mobilisation, Dissection, Vertebral Artery, Internal carotid artery, Osteopathic Medicine.

This is an extensive review of the current literature and provides an excellent summary of key fndings and recommendations, for an important aspect of osteopathic practice. This is a good example of a literature review research method to help guide best practice.

The authors describe cervical artery dysfunction (CeAD) to include range of disorders. The link between cervical spine (CSp), high velocity thrust techniques (HVT) and CeAD, is an association, not a clear causal relationship.

CSp movement not just HVT are important factors and an increased length of the styloid process may be a risk factor to CeAD, together with trauma to the CSp.

The peak incidence of CeAD is between 34-54 years of age, and 61% of cases are spontaneous.

There is a risk of misdiagnosis with lack of clinical reasoning being a main factor, with reported adverse efects from manual therapy.

CeAD may mimic musculoskeletal complaints for example acute onset CSp pain.

Headaches associated with CeAD are typically unilateral, frontal-temporal and often with occipital pain. They tend to be throbbing and sharp, but most importantly, unlike anything experienced by the patient before.

The pain is often less than a week in onset, and if associated with ptosis, facial numbness and unsteadiness then immediate referral to the medical services is recommended.

Around 12-34% of cases are the result of trivial trauma e.g. sneezing or sport related injury. The authors strongly recommend considering CeAD for all trauma to the neck in the frst month, and check for the above signs and symptoms.

This article contains much useful information, but much is summarised in clear tables e.g., table 3 potential signs and symptoms of CeAD, table 4 Red Flags, and table 5 Clinical tests.

In summary, if patients complain of an uncharacteristic headache, and have had a neck trauma in the past month, consider the possibility of CeAD.

References

Vaughan, B, Moran, R, Tehan, P, Fryer, G, Holmes, M, Vogel, S & Taylor, A (2016) Manual Therapy and cervical artery dysfunction: Identifcation of potential risk factors in clinical encounters, International Journal of Osteopathic Medicine, vol 21: 40-50

Osteopathy and Tension-type Headaches

Summary

Osteopathy, specifically manual joint mobilisation, may have a positive effect on quality of life and headache frequency for adults with tension-type headaches.

Keywords

Tension-type Headache (TTH), Osteopathy, Manual Joint mobilisation techniques, Headache frequency, Quality of life, systematic review, meta analysis.

Overview

Tension type Headache (TTH) is ranked as the second most prevalent health condition worldwide. There has been a lack of evidence for the effectiveness of manual therapy for TTH but this latest review suggests that Manual Joint mobilisation techniques may decrease frequency of headache occurance and improve quality of life.

A systematic literature review was conducted in february 2020 based on the PICO framework (Population, Intervention, Comparison and Outcome) and adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Methodology followed the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. Six relevant Randomised Controlled Trials (RCT) were found after a searching databases EMBASE, PsycINFO, MEDLINE, CINAHL and PEDRO.

Only RCTs of sufficient quality were included in the review. Patients,18 years or older, diagnosed with TTH according to the International Classification of Headache disorder were included. Manual joint mobilisation techniques were compared to no mobilisation technique, other treatment, treatment as usual, placebo or sham intervention. Headache Frequency was measured in days per month of headache. Both Quality of Life and Headache frequency were assessed at the end of treatment.

Manual joint mobilisation techniques were defined as any manual technique, mobilisation or manipulation within normal range of motion of the joint, aimed at affecting the joints, muscles and connective tissues of the neck, chest and lower back.

Results found that manual joint mobilisation had a positive effect on both headache frequency and quality of life. However, the certainty of evidence was very low due to risk of bias, inconsistency and imprecision. A weak recommendation is therefore made by the review for manual joint mobilisation techniques as a supplement to medical treatment for adult patients with
TTH.

The review also assessed the effectivness of supervised physical activity, psychological treatment, acupuncture and patient education on TTH.Patient education was defined as information about the TTH, treatment, medication over use, self care, lifestyle, physical activity, regular diet and sleep. The review found that no RCTs had been conducted for Patient education but that clinical experience suggests that patient education may have a positive effect on the patients ability to manage their disease. Supervised physical activity was defined as planned, repeated and structured physical activity. Two RCTs were found and results showed potential effect of reducing headache intensity. However, the risk of bias and imprecision was high so the certainty of evidence is very low.

All non-pharmacological interventions were found to be safe. The certainty of evidence was found to be low or very low due to risk of bias and imprecision.

From an osteopathic perspective it is interesting that patient education, supervised physical activity and manual jount mobilisation, as well as being safe for patients, may positivly affect frequency of tension type headaches as well as improve quality of life.

Reference:

Krøll, L.S., Callesen, H.E., Carlsen, L.N. et al. Manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education for patients with tension-type headache. A systematic review and meta- analysis. J Headache Pain 22, 96 (2021). https://doi.org/10.1186/ s10194-021-01298-4

Caroline Frost September 2021

Vi måste prata ryggsmärta!

Idag är det World spine day. Svenska Osteopatförbundet tar därför tillfället i akt att belysa den påverkan ländryggssmärta idag har i samhället och världen. Det gör vi med stöd av den vetenskap som presenteras i The Lancet i en tre delars serie om ryggsmärta och som utöver att identifiera problemet också presenterar en möjlig väg framåt.

 

Vi behöver fortsätta att prata om ländryggssmärta! Ländryggssmärta drabbar med få undantag alla någon gång under livet. För de stora flertalet av individer blir det en kortvarig episod av värk i ryggen som inte behöver leda till återkommande besvär. Det är dock vanligt med ytterliggare episoder av smärta för många och för ett fåtal slutar det aldrig att göra ont. På sikt leder detta till både ökad sjukfrånvaro och minskad livskvalitet.

 

Faktum är att problemet är så stort att ländryggssmärta idag är den främsta anledningen till sjukskrivning och förtidspensionering. Och trots teknologiska framsteg både vad gäller magnetkameraundersökning och operationstekniker ökar problemet lavinartat.

 

Ett globalt och växande problem

Ländryggssmärta ökade globalt med 54% mellan 1990 och 2015, delvis på grund av en ökad population och livslängd. Ländryggssmärta är den främsta orsaken till funktionsnedsättning sett till hela världen. Av dessa har en mycket liten andel en medicinsk diagnos gällande sjukdom i ryggen tex kotfraktur, cancer eller infektion. Det stora flertalet av de som drabbas av långvarig ländryggssmärta kan inte få en klar diagnos trots kontakt med sjukvård och tillgång till röntgenutrustning.

 

Däremot finns det samband mellan hårt fysiskt arbete, mentala och fysiska komorbiditeter samt rökning och fetma. Depression och ryggsmärta har visat sig ha samband. Ländryggssmärta är överrepresenterat hos de socioekonomiskt låg status.

 

Vi i Svenska Ostopatförbundet vill under denna dagen uppmärksamma det stora problem som ryggsmärta innebär för samhället både i mänskligt lidande och i faktiska kostnader. Studier visar att det stora flertalet av dem som drabbas av ryggsmärta saknar en sjukdomsorsak eller strukturell skada och vi behöver därför tänka om vad gäller hanteringen av de personer som drabbas av detta.

 

Förändra sättet vi hanterar ländryggssmärta på

Det saknas idag en klar plan för att hantera problemet. Detta trots att enorma resurser läggs på operationer, sjukskrivningar och mediciner. De förslag som The Lancet tagit fram betonar vikten av ett evidensbaserat förhållningssätt med flera viktiga insatser såsom:

 

Ett personcentrerat och individuellt omhändertagande

Att hjälpa individer att återgå till arbete och sammanhang

Skapa goda vanor med motion och rörelse som en daglig aktivitet

Att få hjälp på att minska dåliga vanor såsom rökning och alkohol och att minska på farlig övervikt

Att manuell terapi kan implementeras som en effektiv insats för de som lider av långvarig ryggsmärta

Kirurgiska interventioner har i regel en dålig effekt på ospecifik ländryggssmärta men är förenat med stora risker

Medicinering med framförallt opioider har trots mycket dålig effekt ökat stort i västvärlden och kan leda till missbruk och död på grund av överdosering

Att identifiera och stötta de som har dåligt socialt skyddsnät eller socioekonomiskt utsatt situation