Combined Myofascial Technique for a Second Posterior Sacral Segment Dysfunction

The OSTEOPATHIC Trial demonstrated substantial improvement in pain intensity, decreased need for rescue medication for pain, and greater likelihood of recovery in patients with chronic low back pain who received 6 osteopathic manipulative treatment (OMT) sessions over 3 months. To assess osteopathic medical care and the effectiveness of OMT for chronic low back pain in a real-world setting without the constraints of a rigid research protocol. An observational study of 445 adults with chronic low back pain who had an established osteopathic physician (ie, DO) or allopathic physician (ie, MD) was conducted within the PRECISION Pain Research Registry from April 2016 through February 2019. Primary outcome measures included a numerical rating scale for low back pain intensity, the Roland-Morris Disability Questionnaire for back-related functioning, and use of nonsteroidal anti-inflammatory drugs or opioids for low back pain. A total of 79, 48, and 318 patients, respectively, were treated by DOs who used OMT, DOs who did not use OMT, or MDs. Patients treated by DOs who used OMT reported significantly lesser low back pain intensity (mean numerical rating score, 5.6; 95% CI, 5.1-6.1 vs 6.1; 95% CI, 5.9-6.3; P=.04) and back-related disability (mean Roland-Morris Disability score, 12.4; 95% CI, 11.1-13.8 vs 14.4; 95% CI, 13.7-15.0; P=.009) than patients treated by MDs. Patients treated by DOs who used OMT also reported less frequent use of nonsteroidal anti-inflammatory drugs (multivariate odds ratio, 0.41; 95% CI, 0.24-0.70; P=.001) or opioids (multivariate odds ratio, 0.52; 95% CI, 0.28-0.98; P=.04). There were no significant differences in primary outcomes between DOs who did not use OMT and MDs. This study of community-based patients in a pain research registry supports the effectiveness of OMT as an integral component of osteopathic medical care for chronic low back pain. Patients treated by DOs who did not use OMT did not experience better results than patients treated by MDs in any primary outcome measure. Further research is needed to more specifically compare the effects of OMT with other treatment effects that may be attributed to patient-DO interactions during medical encounters.

Osteopathic manipulative treatment (OMT) is a hands-on therapy approach used by osteopathic physicians that aims to alleviate viscero-somatic changes by considering the interconnectedness of the body, mind, and spirit. One of the most common uses for OMT is the treatment of musculoskeletal (MSK) complaints, which are a significant cause of pain and disability across various populations, including the US Military, where personnel often face unique and physically demanding working conditions. In 2019, MSK injuries alone accounted for nearly half of the limited duty days in the US Army, with low back pain being the leading cause of medical encounters over the past 10 years among active-duty personnel. Previous studies have shown that OMT can improve functional status, reduce pain, and have minimal adverse effects when treating low back pain. It has also been found to be twice as effective as placebo treatments and comparable to nonsteroidal anti-inflammatory drugs in terms of pain relief. Given the high incidence rates of MSK issues during active duty in the military, OMT may be a viable treatment or adjunctive therapy option for this population. The purpose of this scoping review is to evaluate the current research on OMT among US military members and veterans, determining any potential positive or negative effects that may be attributed to this therapy. A comprehensive search was conducted across six databases from inception to November 2023, yielding 497 articles, which were screened according to inclusion and exclusion criteria. Nine studies were ultimately included and evaluated based on the target treatment area. The most commonly employed forms of OMT included myofascial release, soft tissue manipulation, and counterstrain techniques. The primary outcomes after OMT were reduced pain and improved range of motion or functionality. Other positive findings included a decrease in opioid usage, reduced nausea, lower healthcare costs, and lower incidence of alcohol and substance use disorders within the military populations studied. This is the first review of its kind to evaluate OMT within military populations, demonstrating its effectiveness in reducing pain, increasing functionality, and lowering complications associated with military duties. Further research into the utilization of OMT within the military should be pursued, considering itas a potential first-line or adjunctive therapy for service members and veterans across various settings and dysfunctions to continue evaluating its long-term effectiveness.

Patients with low back pain (LBP) may receive osteopathic manipulative treatment (OMT) to resolve or manage their pain. The indication for OMT for patients with LBP is the presence of somatic dysfunction, diagnosed using palpatory examination. Because palpatory findings commonly have poor interexaminer reliability, the current study used ultrasonography (US) to establish pre-OMT and post-OMT musculoskeletal measurements of relative asymmetry between pelvic and sacral bony landmarks. To document objective musculoskeletal changes that occur in response to OMT using US and to compare palpatory assessment of landmark asymmetry with US assessment. Sixty men and women aged 20 to 55 years with at least 1 episode of LBP in the past 2 weeks were assigned to a seated control, walking control, or OMT group (20 participants per group). Participants received an initial, bilateral US measurement of the skin to posterior superior iliac spine (SPSIS), skin to sacral base position (SBP), and sacral sulcus depth (SSD). Participants in seated control and OMT groups received a palpatory assessment of SBP and SSD prior to initial US assessment. After assessment, the seated control group sat in a waiting room for 30 minutes, the walking control group walked for 5 minutes, and the OMT group received OMT to address sacral base asymmetry using predominantly direct techniques for a maximum of 20 minutes. Participants then received a second US assessment of the same structures. Body mass index (BMI) was correlated with SPSIS (r=0.5, P=.001) and SBP (r=0.6, P<.001). More participants in seated control (75%) and OMT (65%) groups had an increase in asymmetry from first to second US assessment for SPSIS compared with participants in the walking control group (35%, P=.05). No significant differences were found between groups for absolute asymmetry or total change in asymmetry (all P>.10). The κ was -0.1 (95% CI, -0.2 to 0.03) for SBP and -0.01 (95% CI, -0.1 to 0.1) for SSD. Musculoskeletal changes in SPSIS and SBP measurements related to OMT could not be readily identified using US. The SPSIS and SBP measurements were dependent on BMI, which may have affected the accuracy of US to detect small changes in asymmetry. Qualitative palpatory assessments did not correlate with US measurements. Further study is needed to identify US measurements that demonstrate change with OMT. (ClinicalTrials.gov number NCT02820701).

PurposeTo assess response to osteopathic manual treatment (OMT) according to baseline severity of chronic low back pain (LBP). MethodsThe OSTEOPATHIC Trial used a randomized, double-blind, sham-controlled, 2×2 factorial design to study OMT for chronic LBP. A total of 269 (59%) patients reported low baseline pain severity (LBPS) (<50mm/100mm), whereas 186 (41%) patients reported high baseline pain severity (HBPS) (≥50mm/100mm). Six OMT sessions were provided over eight weeks and outcomes were assessed at week 12. The primary outcome was substantial LBP improvement (≥50% pain reduction). The Roland–Morris Disability Questionnaire (RMDQ) and eight other secondary outcomes were also studied. Response ratios (RRs) and 95% confidence intervals (CIs) were used in conjunction with Cochrane Back Review Group criteria to determine OMT effects. ResultsThere was a large effect size for OMT in providing substantial LBP improvement in patients with HBPS (RR, 2.04; 95% CI, 1.36–3.05; P<0.001). This was accompanied by clinically important improvement in back-specific functioning on the RMDQ (RR, 1.80; 95% CI, 1.08–3.01; P=0.02). Both RRs were significantly greater than those observed in patients with LBPS. Osteopathic manual treatment was consistently associated with benefits in all other secondary outcomes in patients with HBPS, although the statistical significance and clinical relevance of results varied. ConclusionsThe large effect size for OMT in providing substantial pain reduction in patients with chronic LBP of high severity was associated with clinically important improvement in back-specific functioning. Thus, OMT may be an attractive option in such patients before proceeding to more invasive and costly treatments.

Background and Purpose Fibromyalgia is characterized by idiopathic long-lasting pain that negatively impacts patients’ quality of life. Although many therapeutic interventions are available; treatment is still challenging due to the condition’s complexity. Therefore, comparative researches are required to decide which treatment is better to produce the best clinical decision for fibromyalgia. The purpose of this study was to compare the effect of ‘muscle energy technique and myofascial release’ on fibromyalgia patients. Materials and Methods In this randomized controlled trial, seventy-four women aged 30 to 45, with a body mass index ranging from 25 - 34.9 kg/m², were participated. They were assigned to either the ‘muscle energy technique or myofascial release’ group. Each treatment was conducted over four weeks, with three weekly sessions lasting 25 minutes each. Meanwhile, the ‘myofascial release’ group received treatment for 20 minutes, three times per week for the same duration. Outcome measures included ‘pain levels assessed via a visual analog scale, range of motion evaluated with a universal goniometer, and quality of life determined through the fibromyalgia impact questionnaire’. Results ‘Muscle energy technique and myofascial release’ showed a significant decrease (p&lt;0.001) in cervical pain, low back pain, and fibromyalgia impact questionnaire score, and a significant increase (p&lt;0.001) in cervical and trunk range of motion after treatment. The myofascial release group showed more significant decrease in cervical pain (p=0.002), low back pain (p=0.003), fibromyalgia impact questionnaire score (p=0.001), cervical left bending (p=0.007), and trunk extension (p=0.003), right bending (p=0.014), left bending (p=0.007), right rotation (p=0.009), and left rotation (p=0.007) than muscle energy technique group. Conclusion ‘Muscle energy technique and myofascial release’ is beneficial methods for fibromyalgia patients. However, myofascial release was more effective than muscle energy technique in improving pain, quality of life, and trunk range of motion.

Osteopathic physicians are trained to treat patients with musculoskeletal symptoms, to treat somatic dysfunction with osteopathic manipulative treatment (OMT), and to avoid unnecessarily prescribing drugs such as opioids. It is also generally believed that osteopathic physicians provide a unique patient-centered approach to medical care that involves effective communication and empathy. Such training and characteristics of osteopathic medical care (OMC) may enhance clinical outcomes among patients with chronic pain. The objectives of this study were to measure and compare the process and longitudinal outcomes of chronic low back pain (CLBP) treatment provided by osteopathic and allopathic physicians and to identify mediators of the treatment effects of OMC. This retrospective cohort study was conducted utilizing adult participants with CLBP within the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION) from April 2016 through December 2022. Participants having an osteopathic or allopathic physician for at least 1month prior to registry enrollment were included and followed at quarterly intervals for up to 12months. Physician communication and physician empathy were measured at registry enrollment. Opioid prescribing and effectiveness and safety outcomes were measured at registry enrollment and for up to 12months and were analyzed with generalized estimating equations to compare participants treated by osteopathic vs. allopathic physicians. Multiple mediator models, including physician communication, physician empathy, opioid prescribing, and OMT, with covariate adjustments, were utilized to identify mediators of OMC treatment effects. A total of 1,079 participants and 4,779 registry encounters were studied. The mean (SD) age of participants at enrollment was 52.9 (13.2) years, 796 (73.8 %) were female, and 167 (15.5 %) reported having an osteopathic physician. The mean physician communication score for osteopathic physicians was 71.2 (95 % CI, 67.6-74.7) vs. 66.2 (95 % CI, 64.8-67.7) for allopathic physicians (p=0.01). The respective mean scores for physician empathy were 41.6 (95 % CI, 39.9-43.2) vs. 38.3 (95 % CI, 37.6-39.1) (p<0.001). There was no significant difference in opioid prescribing for low back pain between osteopathic and allopathic physicians. Although participants treated by osteopathic physicians reported less severe nausea and vomiting as adverse events potentially attributable to opioids in a multivariable model, neither result was clinically relevant. OMC was associated with statistically significant and clinically relevant outcomes pertaining to low back pain intensity, physical function, and health-related quality of life (HRQOL) over 12months. Physician empathy was a significant mediator of OMC treatment effects in each of the three outcome domains; however, physician communication, opioid prescribing, and OMT were not mediators. The study findings indicate that osteopathic physicians provide a patient-centered approach to CLBP treatment, particularly involving empathy, that yields significant and clinically relevant outcomes pertaining to low back pain intensity, physical function, and HRQOL over 12months of follow-up.

Research on the effects of osteopathic manipulative treatment (OMT) on visual functions and conditions is very limited. This study continues the exploration on the application of OMT with the intent of lowering intraocular pressure (IOP). A pilot randomized clinical trial was conducted to assess the impact of one OMT session on patients diagnosed with suspected ocular hypertension (OHT) or glaucoma. Patients meeting the inclusion and exclusion criteria were randomized to OMT treatment or no-treatment control groups. Total n=16: treatment=9, control=7. The OMT included osteopathic cranial manipulative medicine (OCMM) along with myofascial release (MFR) and soft-tissue procedures. There were no adverse events reported in either cohort. Each patient was seen in AM and PM sessions for 5days; the first 2days established eligibility to be randomized to treatment or control cohorts after the Day 3 AM IOP assessment. Subjects in the control group laid on the treatment table with no OMT performed. Immediately after the intervention, the patient had a second Day 3 IOP assessment, then a PM IOP assessment. On Day 4, the patient received an AM and PM IOP assessment, and on Day 5, at the 1-week follow-up time period the patients again received AM and PM IOP assessments. In the OMT treatment group, significant IOP reductions were detected posttreatment with differences between the Day 3 initial AM pre-randomization IOP level and the immediate postintervention IOP (p=0.027;-1.361 mmHg), the Day 4 PM (p=0.016;-1.556 mmHg), and the Day 5 PM (p=0.014; 1.382 mmHg). The application of OMT shows potential benefit in the reduction of IOP in patients with suspected OHT and patients with suspected glaucoma.

The evidence gap in low back pain management strategies – Authors' reply

Permanent paraparesis and cauda equina syndrome after epidural blood patch for postdural puncture headache.

Previous studies showed improved dynamic-balance (DB) performance after core-stability (CS) exercises in populations with chronic low back pain. Although clinical massage plus exercise is likely to better enhance analgesia than exercise alone, its efficacy on balance remains unclear. To evaluate the immediate effects of CS exercises plus myofascial trigger-point (MTrP) therapy in comparison with CS exercises alone on DB performance, pressure-pain threshold (PPT), and cross-sectional area of active MTrPs in patients with clinical instability of the lumbar spine and chronic myofascial pain syndrome. Randomized, assessor-blind, test-retest. University research laboratory. 10 physically active adults (5 men, 5 women). Single-leg DB performance and side-to-side ratios in 2 planes of motion (frontal, sagittal), as well as PPT and cross-sectional area of active MTrPs, were measured using stabilometry, pressure algometry, and real-time ultrasound scanning, respectively. The 1st group performed CS exercises alone, whereas the same exercise program was applied in the 2nd group plus cross-fiber friction on active MTrPs (3.5 min/MTrP). Within-group statistically and clinically significant differences were observed only for group II in PPT. However, group I also exhibited a large effect size with clinically significant changes from baseline on this outcome. Furthermore, patients in group II clinically improved their balance ratios and differed from group I at posttest in sagittal-plane DB performance of the painful side. CS exercises immediately increase the PPT of active MTrPs in physically active adults with clinical instability of the lumbar spine and chronic myofascial pain syndrome. When MTrP therapy is added, side-to-side asymmetries in DB are minimized.

Psoas syndrome is an easily missed diagnosis. However, it is important to consider this condition as part of the differential diagnosis for patients presenting with low back pain--particularly for osteopathic physicians, because patients may view these practitioners as experts in musculoskeletal conditions. The authors describe the case of a 48-year-old man with a 6-month history of low back pain that had been attributed to "weak core muscles." The diagnosis of psoas syndrome was initially overlooked in this patient. After the correct diagnosis was made, he was treated by an osteopathic physician using osteopathic manipulative treatment, in conjunction with at-home stretches between office treatments. At his 1-month follow-up appointment, he demonstrated continued improvement of symptoms and a desire for further osteopathic manipulative treatment.

One of the most common complaints during pregnancy is lower back pain. Women believe that this will disappear after they give birth, however, there are a significant number of women who suffer from persistent, unresolving pain that affects their daily lives. Very often, women will wrongfully blame the epidural anesthesia as the cause, however, there are physiologic and anatomic changes that occur. Patients often experience persistent pain when there is an absence of proper postpartum management. The lack of proper management can lead to unresolved pelvic rotation and dislocation, resulting in short leg syndrome. The common treatment for postpartum lower back pain includes various analgesics, physical therapy, and steroid injections. However, with a proper pelvic assessment, treatment with osteopathic manipulation alone, or reinforced with anesthesia, can be successful. Here, we present a case in which a patient presented with persistent lower back two years postpartum. She had been treated with common modalities prior to coming to our clinic and was subsequently found to have a short leg. We discuss the importance of a proper pelvic and leg length assessment in women who present with postpartum lower back pain, as well as how to both prevent and treat short leg syndrome in postpartum patients.

Despite conflicting evidence, chest physiotherapy has been widely used as an adjunctive treatment for adults with pneumonia. To assess the effectiveness and safety of chest physiotherapy for pneumonia in adults. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 3); MEDLINE (1966 to August 2009); EMBASE (1974 to August 2009); CBM (1978 to August 2009); the National Research Register (August 2009) and Physiotherapy Evidence Database (PEDro) (1929 to August 2009). Randomised controlled trials (RCTs) assessing the efficacy of chest physiotherapy for treating pneumonia in adults. Two authors independently assessed trial eligibility, extracted data and appraised trial quality. Primary outcomes were mortality and cure rate. We used risk ratios (RR) and mean difference (MD) for individual trial results in the data analysis. We performed meta-analysis and measured all outcomes with 95% confidence intervals (CI). Six RCTs (434 participants) appraised four types of chest physiotherapy (conventional chest physiotherapy; osteopathic manipulative treatment (which includes paraspinal inhibition, rib raising and myofascial release); active cycle of breathing techniques (which include active breathing control, thoracic expansion exercises and forced expiration techniques); and positive expiratory pressure).None of the physiotherapies (versus no physiotherapy or placebo) improved mortality rates of adults with pneumonia.Conventional chest physiotherapy (versus no physiotherapy), active cycle of breathing techniques (versus no physiotherapy) and osteopathic manipulative treatment (versus placebo) did not increase the cure rate or chest X-ray improvement rate.Osteopathic manipulative treatment (versus placebo) and positive expiratory pressure (versus no physiotherapy) reduced mean duration of hospital stay by 2.0 days (mean difference (MD) -2.0 days, 95% CI -3.5 to -0.6) and 1.4 days (MD -1.4 days, 95% CI -2.8 to -0.0), respectively. Conventional chest physiotherapy and active cycle of breathing techniques did not.Positive expiratory pressure (versus no physiotherapy) reduced fever duration (MD -0.7 day, 95% CI -1.4 to -0.0). Osteopathic manipulative treatment did not.Osteopathic manipulative treatment (versus placebo) reduced duration of intravenous (MD -2.1 days, 95% CI -3.4 to -0.9) and total antibiotic treatment (MD -1.9 days, 95% CI -3.1 to -0.7).Limitations of this review are that the studies addressing osteopathic manipulative treatment were small, and that the six published studies which appear to meet the inclusion criteria are awaiting classification. Based on current limited evidence, chest physiotherapy might not be recommended as routine adjunctive treatment for pneumonia in adults.

Osteopathic manipulative medicine (OMM) is a unique skill set consisting of physical manipulations that treatthe neuromusculoskeletal system. Although OMM can improve patient outcomes such as functionality and pain, as well as increase physician reimbursement, its use is declining. Barriers to its use include a lack of proficiency, support, reimbursement, and time. Knowledge gaps remain as to how OMM training during graduate medical education (GME) affects OMM use. This study describes relationships between OMM exposure during GME and the use of OMM in practice. An online survey of physicians in a variety of medical fields during late 2022 assessed the impact of OMM education during postgraduate training on its use in clinical practice. Survey data were analyzed to compare training characteristics and OMM use via chi-square tests and binary logistic regression. A total of 299 surveys were completed. Respondents who received formal OMM education during residency were more likely (59.8 %) to utilize OMM in medical practice than those who practiced OMM informally (37.8 %, p<0.001) and those who had no OMM exposure during residency (10.3 %, p<0.001). Respondents who trained with more osteopathic attendings (p<0.001) and co-residents (p=0.012) were also more likely to utilize OMM. Those who completed residencies that were accredited by the Accreditation Council for Graduate Medical Education (ACGME) with an Osteopathic recognition track, by the American Osteopathic Association (AOA), and were dually-accredited (ACGME/AOA), were all more likely to utilize OMM (60 %, 56 %, and 53 %, respectively) than those who completed residencies with ACGME accreditation alone (22 %, p<0.01). Although OMM can improve patient outcomes, it is underutilized by Doctors of Osteopathic Medicine (DOs) in practice. Lack of training after medical school has been identified as a contributing factor to its disuse. The results of our study illustrate that there is a positive association between OMM education during postgraduate training and OMM use in clinical practice.

Back and neck pain and poor sleep quality in adolescents are associated even after controlling for confounding factors: An epidemiological study.