JAOA • Vol 108 • No 4 • April 2008 • 194-195
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Improved Infantile Postural Asymmetry After Osteopathic Manipulative Therapy
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More than 40 years ago, Frymann reported an 88% incidence of asymmetric
somatic findings and cranial somatic dysfunction among 1250 newborns—58%
of whom were symptomatic and 30% were asymptomatic (J Am Osteopath
Assoc. 1966;65:1059). A 2006 single-blind, randomized clinical trial by
Philippi and colleagues—including two foreign-trained
osteopaths—investigated the effectiveness of osteopathic manipulative
therapy to improve structural asymmetry in infants.
Infants with a gestational age of at least 36 weeks, post-term aged 6 to 12
weeks, with a diagnosis of postural asymmetry and no significant underlying
disease, no predominant oblique body position masking the trunk curvature, and
not undergoing any other treatment for postural asymmetry, were recruited in
Mainz, Germany. To establish the degree of asymmetry using a standardized
scale (4 points, no symmetry; 24, maximal asymmetry), 61 referred infants
underwent neurologic and physical examinations. Of these infants, 32 (18 male,
14 female) met the inclusion criterion of a score greater than 12.
Subjects were randomized to receive osteopathic manipulative therapy or
sham therapy (touch only; 16 infants per group). Subjects received a weekly
45- to 60-minute intervention administered by an osteopath for 4 weeks.
Asymmetry was measured using video-based scoring before the first treatment
and 1 week after the final treatment by three independent, blinded, trained
observers who demonstrated high interrater reliability. Five infants in the
sham therapy group improved, 8 infants were unchanged, and 3 infants
"deteriorated"; the mean (SD) improvement was 1.2 (3.5) points. In
the osteopathic manipulative therapy group, 13 infants improved and 3 remained
unchanged, for a mean improvement of 5.9 (3.8) points. The difference between
groups was statistically significant (P=.001).
The authors concluded that osteopathic manipulative therapy in the first
months of life improves the degree of asymmetry in infants with postural
asymmetry. They were unable to find predictive outcome measures in those
infants that improved naturally (with sham therapy) or were nonresponders to
osteopathic intervention. No complications or adverse events were reported,
though some vegetative symptoms (eg, sleeping, crying) were transiently
aggravated in some patients in both groups. Long-term follow-up to determine
stability of improvement is warranted.—M.A.S.
Philippi H et al. Dev Med Child
Neurol. 2006;48:5
-9[Medline]
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Manipulation and Exercise: Best Noninvasive Treatments for Neck Pain
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The Bone and Joint Decade 2000-2010 Neck Pain Task Force recently published
results from its "best-evidence synthesis" on the use,
effectiveness, and safety of noninvasive therapeutic treatments for patients
with musculoskeletal neck pain and its associated disorders. The
recommendations of the study were directed toward reducing the medical,
social, and economic consequences of this common affliction.
The task force systematically searched and appraised relevant articles
published in scientific peer-reviewed journals between 1980 and 2006. Articles
that evaluated various aspects of neck pain management (eg, risk factors,
prevention, prognosis, rehabilitation) or that measured economic costs,
health-care use, or safety were included. Studies on at least 20 subjects with
neck pain or at risk for neck pain; whiplash-associated disorders (WADs);
work-related injuries and strains; or neck pain of unknown etiology were also
included, as were case series if judged to have special relevance to the Neck
Pain Task Force report. Studies of patients with serious local pathologic
conditions or systemic diseases were excluded. Of 31,878 citations screened,
the task force analyzed 139 scientifically admissible articles on noninvasive
interventions. Within this group of articles, there were 25 systematic reviews
and one systematic review of systematic reviews. Seventeen studies (reported
in 27 articles) focused on manual therapies for "nonspecific" neck
pain or associated disorders—including one randomized clinical trial on
osteopathic manipulative treatment (J Am Osteopath Assoc.
2005;105:57-68).
In summary, the authors recommended the following:
- For WADs, combine educational videos, mobilization, and exercises
- For other neck pain, use manual therapy and supervised exercise
interventions, low-level laser therapy, or acupuncture
- No particular course of care (long vs short, early vs late) with any
intervention improves the prognosis for whiplash or other neck disorders, but
high rates of healthcare use can slow recovery from whiplash
- Episodes of care should not last longer than 6 to 8 weeks with any one or
combination of noninvasive interventions
The study also recommended that future research efforts focus on the design
and evaluation of neck-pain prevention strategies in the community and
workplace. The study of noninvasive interventions for patients with acute
non-traumatic neck disorders, disorders with radicular symptoms, and
cervicogenic headache were also suggested.—M.A.S.
Hurwitz EL et al. Spine.2008
;33(suppl 4):S123
-S152[Medline]
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Further Insight Into Viscerosomatic Reflexes
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In 1953, Louisa Burns, DO, reported on the etiologic factors of heart
disease and provided clinical data from around the United States documenting
its association with somatic dysfunction in the upper cervical spine (J Am
Osteopath Assoc. 1953;52:369-372). Recent research indicates that not
only do cardiopulmonary afferents affect spinal cord activity at the C1 and C2
spinal segments, but they also affect neural transmission of sensory
information from distal spinal cord segments (ie, the lumbar spine).
Zhang, Chandler, and Foreman at the University of Oklahoma Health Sciences
Center in Oklahoma City performed experiments on 33 anesthetized male
Sprague-Dawley rats. The researchers stimulated cardiopulmonary sympathetic
afferents (CPSA) and vagal afferents and observed the extracellular effects on
C1-C2 descending propriospinal neurons to lumbar spinal segments.
Extracellular action potentials were recorded from C1-C2 neurons whose axons
were antidromically activated from T12-L2 spinal segments. Using noxious
(pinch) and innocuous (brush and tap) mechanical stimuli from the head, neck,
abdomen, back, or limb regions, the researchers mapped the somatic receptive
fields in the C1 and C2 spinal segments. Carbon-filament glass microelectrodes
were used to record extracellular potentials of single propriospinal neurons
in the C1-C2 spinal gray matter.
More CPSA than vagal afferents excited or inhibited some, but not all, of
these neurons. Also, CPSA stimulation excited more neurons with excitatory
somatic fields than did the vagal stimulation. Although neurons in lamina V of
the spinal cord responded to both CPSA and vagal stimulation, most neurons in
lamina X responded only to CPSA stimulation. The researchers concluded that
CPSA and vagal afferent activation from the heart or lungs modulates C1-C2
spinal cord propriospinal neurons that in turn moderate somatosensory
information from distant spinal segments. Based on the latency of C1-C2 spinal
segments' response to stimulation, the researchers postulated that the
autonomic afferents relay their information to C1 and C2 spinal segments
before stimulating the brain. Although this article is 5 years old and uses a
rat laboratory model, it provides insight into the complexity of spinal
reflexes and contributes to the osteopathically oriented and clinically
relevant knowledge in this field.—M.A.S.
Zhang J et al. Brain Res.2003
;969:53
-58.[Medline]
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Footnotes
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"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)
Editor's Note: Robert D. Foreman, PhD, a coauthor of the referenced
article, has been studying spinal cord reflexes for the past 25 years. Dr
Foreman and other internationally renowned scientists and clinicians shared
their research and proposed future research inquiries in this field of study
at the International Research Symposium on Somato-Visceral Interactions and
Autonomic Mechanisms of Manual Therapy. The conference was held at the
Osteopathic Research Center in Fort Worth, Tex, from March 31, 2008, to April
1, 2008.
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