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	CV-4's Limited Effects: Responders vs Nonresponders?

Top CV-4's Limited Effects:... Treatment of Myofascial Trigger... Spinal Manipulation in Patients... Trunk Muscle Activity After... Chronic Low Back Pain:... Surgical vs Nonsurgical...

 
There has been minimal research on the physiologic effects of cranial osteopathy. In particular, little is known of compression of the fourth ventricle (CV-4), a technique addressed to the posterior skull that is reported to produce profoundly relaxing effects, diminishing sympathetic nervous system tone and enhancing fluid exchange.

Ten subjects (mean age, 29.8 years), were recruited in Auckland, New Zealand, for a study to compare CV-4 with sham manipulation. Subjects (6 women and 4 men) were healthy nonsmokers who were not taking medication and were not experiencing pain. Intervention was provided by a foreign-trained osteopath with 8 years of experience with CV-4. Treatment was initiated to exaggerate the cranial rhythmic impulse, sustaining it until the still point. Sham intervention consisted of touch with no therapeutic intent. Change was assessed through galvanic skin resistance, body temperature, heart rate variability, and respiratory rate.

There were no differences among subjects for physiologic parameters when baseline measures were compared with both interventions. However, 3 subjects may have had an increase in parasympathetic activity during CV-4. This finding led to the hypothesis that there may be "responders" and "non-responders" to cranial treatment.

Typically, in JAOA, "The Somatic Connection" does not include reports on pilot studies. An exception was made for the Milnes and Moran study because it is one of the first investigations of a characteristically "American" component of manual medicine by a research group outside the United States. In addition, these coinvestigators use outcome measures that may be desirable for future studies that seek to evaluate the efficacy of osteopathy in the cranial field. A study with a larger sample size, more complete comparisons of touch (sham) and CV-4, and the use of a stratified sample of practitioners is recommended.—F.J.R.

Milnes K, Moran RW. Int J Osteopath Med. 2007;10:8 -17.

	Treatment of Myofascial Trigger Point Pain

Top CV-4's Limited Effects:... Treatment of Myofascial Trigger... Spinal Manipulation in Patients... Trunk Muscle Activity After... Chronic Low Back Pain:... Surgical vs Nonsurgical...

 
Musculoskeletal pain is one of the leading reasons patients seek medical care. About one third of these patients have myofascial pain syndrome. The most common sites for trigger points, hyperirritable areas within taut bands of skeletal muscle or fascia, are the muscles involved in maintaining posture. The scarcity of data regarding pathophysiology means that, in the absence of biomarkers and diagnostic imaging criteria, diagnosis of this condition is dependent on palpation skills and patient feedback. In addition, most treatment methods have not been subjected to clinical trials and thus no evidence of efficacy is available to guide physicians as they seek to provide clinical management for myofascial pain syndrome.

Luke D. Rickards, DO (Australia), conducted a systematic review of the literature to assess evidence for the effectiveness of noninvasive interventions in the treatment of patients with myofascial pain syndrome. Twenty-three trials met study inclusion criteria. Five modalities were studied: laser therapy, electrotherapy, ultrasound, magnet therapy, and physical or manual therapies.

The quality of trials assessing laser treatment was high and five of the six trials found a significant difference in favor of treatment over placebo. The five electrotherapy trials included a study on transcutaneous electrical nerve stimulation. This treatment appeared to have an immediate effect on myofascial trigger point pain in the neck and upper back. Ultrasound was no more effective than placebo. For trials examining physical and manual therapies, there was such heterogeneity among the studies that no conclusions could be drawn regarding medium to long-term effectiveness or the effect beyond placebo. None of the trials of manual therapy included osteopathic manipulative treatment.—F.J.R.

Rickards LD. Int J Osteopath Med.2006 ;9:120 -136.

	Spinal Manipulation in Patients with Lumbar Disc Herniation: Uncertainty Persists

Top CV-4's Limited Effects:... Treatment of Myofascial Trigger... Spinal Manipulation in Patients... Trunk Muscle Activity After... Chronic Low Back Pain:... Surgical vs Nonsurgical...

 
Sciatica accompanies about 10% of presentations of low back pain. Nerve root compression by disc herniation is considered the most frequent cause of sciatica. Although some researchers advocate spinal manipulation for the clinical management of disc herniation, others suggest that it is contraindicated.

Nicolas J. Snelling conducted a systematic review of the medical literature as well as the databases of four UK-based insurance companies used by British osteopaths and chiropractors. Four randomized controlled trials relevant to questions of efficacy were located. Three suggested some early benefit of manipulation compared to controls, but none of these investigations suggested that spinal manipulation has long-term benefits. Evidence for harm was based on case reports. Incidence of harm appears to be rare. No data were available from participating insurance companies on evidence of adverse events.

Snelling recommends that manual practitioners establish clinical practice guidelines for the management of disc herniation. He notes that such guidelines are needed for the protection of patients and practitioners alike.—F.J.R.

Snelling NJ. Int J Osteopath Med.2006 ;9:77 -84.

	Trunk Muscle Activity After Spinal Manipulation

Top CV-4's Limited Effects:... Treatment of Myofascial Trigger... Spinal Manipulation in Patients... Trunk Muscle Activity After... Chronic Low Back Pain:... Surgical vs Nonsurgical...

 
Spinal manipulative therapy (SMT) is one of the approaches commonly used in the treatment of low back pain (LBP). Despite positive clinical benefit, the physiologic mechanisms are still unclear. Studies on the role of muscle activation in SMT are inconsistent and contradictory.

Manuela L. Ferreira, MSc, and colleagues designed a study to determine whether postural activity of the trunk muscles could be modified by SMT and whether these effects differed among people with and without LBP. Electromyography recordings were made with fine-wire electrodes inserted into the transversus, obliquus internus, and externus abdominus. Subjects (N=20, 10 with LBP and 10 healthy controls) were asked to flex an arm rapidly in response to a visual cue before and after a small amplitude rotational mobilization at L4 and L5.

In subjects with LBP, there was an increase in the postural response of the obliquus internus and an overall increase in the externus abdominus. No change was noted in the transversus or rectus abdominus for these patients. No changes occurred in control subjects. The authors conclude that SMT increases activity of the oblique abdominal muscles but met with no change in the deep trunk muscle, the transversus abdominus, which is often the target of exercise-based interventions.—F.J.R.

Ferreira RA et al. Manual Ther.2007 ;12:240 -248.

	Chronic Low Back Pain: General Exercise vs Motor Control Exercise vs Spinal Manipulation

Top CV-4's Limited Effects:... Treatment of Myofascial Trigger... Spinal Manipulation in Patients... Trunk Muscle Activity After... Chronic Low Back Pain:... Surgical vs Nonsurgical...

 
Low back pain (LBP) is the primary cause of work absenteeism and disability in industrialized nations. Clinical practice guidelines provide recommendations on the management of chronic (>3 months) LBP. These recommendations often include home exercise and spinal manipulation. However, such interventions have not been the subject of many head-to-head comparisons.

Manuela L. Ferreira, MSc, and coworkers recruited patients with chronic nonspecific LBP (N=240).

Patients were randomized to one of three study groups: general exercise (group 1), motor control exercise (group 2), or spinal manipulative therapy (SMT, group 3). Patients attended up to 12 treatment sessions during an 8-week period.

Subjects in group 1 were asked to complete strengthening and stretching exercises for main muscle groups and to exercise for cardiovascular fitness. Group 2 subjects were prescribed exercises designed to improve the function of the trunk muscles (ie, transversus abdominus, multifidus, diaphragm, and pelvic floor muscles). Participants allocated to group 3 were treated with direct mobilization or manipulation applied to the spine or pelvis.

Subjects assigned to the motor control exercise or SMT group (groups 2 and 3) improved more than those allocated to the general exercise group (group 1). There were no differences among the three study groups at 6- or 12-month follow-up. No adverse events were reported.—F.J.R.

Ferreira ML et al. Pain.2007 ;131:31 -37.[Medline]

	Surgical vs Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis

Top CV-4's Limited Effects:... Treatment of Myofascial Trigger... Spinal Manipulation in Patients... Trunk Muscle Activity After... Chronic Low Back Pain:... Surgical vs Nonsurgical...

 
Degenerative spondylolisthesis, though generally asymptomatic, can be associated with spinal stenosis. Symptomatic spinal stenosis is the most common reason adults older than 65 years undergo lumbar surgery. Patients typically present with neurogenic claudication—pain in the buttocks or legs with walking or standing. This pain is often resolved with sitting or lumbar flexion.

The Spine Patient Outcomes Research Trial was designed to compare the effectiveness of surgical and nonsurgical treatment among participants with confirmed diagnoses of intervertebral disc herniation, spinal stenosis, and degenerative spondylolisthesis. The 5-year multisite trial was conducted at 13 medical centers in seven states.

All patients had neurogenic claudication or radicular leg pain with associated neurologic signs, spinal stenosis shown on cross-sectional imaging, and degenerative spondylolisthesis shown on lateral radiographs obtained with the patient in a standing position. The patients had persistent (12 weeks) symptoms and had been confirmed as surgical candidates by their physicians. The nature of nonsurgical care before enrollment was not prespecified, but 68% had received physical therapy; 63%, anti-inflammatory agents; 55%, epidural injections; 30%, opioid analgesic agents; and 25%, chiropractic treatment.

James N. Weinstein, DO, and colleagues enrolled 607 participants: 304 were in the randomized cohort and 303 in the observational cohort. In the randomized cohort, 159 patients were assigned to surgery; of those, 57% underwent surgery by 1 year and 64% by 2 years. In the group assigned to nonsurgical care, 44% underwent surgery by 1 year and 49% by 2 years. In the observational cohort, 173 patients initially chose surgery. Of those, 97% underwent surgery by 1 year. Although 130 subjects initially chose nonsurgical care, 17% of these underwent surgery by 1 year and 25% by 2 years. When both cohorts are combined, 372 patients underwent surgery in the first 2 years and 235 received only nonsurgical treatment.

In this study, intention-to-treat analysis found no significant advantage for surgery over nonsurgical care, but this analysis was severely limited by extensive treatment crossover. As-treated analyses showed that surgery was superior to nonsurgical treatment in relieving symptoms and improving function. This treatment effect could be seen at the 6-week follow-up visit and persisted for more than 2 years. There was little evidence of harm from either treatment. No patients undergoing surgical or nonsurgical treatment had cauda equina syndrome; 89% of surgical patients had no operative complications.—F.J.R.

Weinstein JN et al. N Engl J Med.2007 ;356:2257 -2270.[Abstract/Free Full Text]

	Footnotes

 
"The Somatic Connection" highlights and summarizes important contributions to the growing body of literature on the musculoskeletal system's role in health and disease. This section of JAOA—The Journal of the American Osteopathic Association strives to chronicle the significant increase in published research on manipulative methods and treatments in the United States and the renewed interest in manual medicine internationally, especially in Europe.

To submit scientific reports for possible inclusion in "The Somatic Connection," readers are encouraged to contact JAOA Associate Editor Felix J. Rogers, DO (fjrogers{at}aol.com), or Michael A. Seffinger, DO (mseffinger{at}westernu.edu).

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