Fibromyalgia with Gabapentin and Osteopathic Manipulative Medicine: A Pilot Study

Reported biological effects following Osteopathic Manipulative Treatment: A comprehensive mapping review

BACKGROUND AND PURPOSE

Osteopathic Manipulative Treatment (OMT) is a therapeutic whole-body approach mainly focused on correcting somatic dysfunctions. The aim of this scoping review is to systematically map the literature regarding the documented biological effects observed following OMT.

METHODS

The 2020 JBIRM version and the PRISMA-ScR were followed for the conceptualization and reporting of this review. The protocol was registered on the "Open Science Framework Registry" (https://doi.org/10.17605/OSF.IO/MFAUP). We searched for original articles published on Medline, Embase, and Scopus, from inception to the present.

RESULTS

Overall, 10,419 records were identified. After duplicate removal, screening for title and abstract, and specific exclusions with reasons, a total of 146 studies were included. Wide differences were detected among studies in their geographical localization, study design, temporal distribution, participants' condition, OMT protocols, and documented biological effects. Such variety in frequency distribution was properly described through descriptive statistics.

CONCLUSIONS

Biological modifications that appear to be induced by OMT have been detected in several body systems, but mostly in neurophysiological correlates and musculoskeletal changes. Results suggest a growing interest over the years on this topic, especially in the last two decades. More efforts in research are recommended to highlight whether such changes specifically depend on OMT, and to demonstrate its specific contribution to clinical practice.

Does Osteopathic Heart-Focused Palpation Modify Heart Rate Variability in Stressed Participants with Musculoskeletal Pain? A Randomised Controlled Pilot Study

Heart rate variability (HRV) describes fluctuations in time intervals between heartbeats and reflects autonomic activity. HRV is reduced in stressed patients with musculoskeletal pain and improved after osteopathic manipulative treatment and mind-body interventions. Heart-focused palpation (HFP) combines manual and mind-body approaches to facilitate relaxation. This randomised controlled pilot study investigated the feasibility and sample size for a future randomised controlled trial and the effect of a single treatment with HFP or sham HFP (SHAM) on short-term HRV. A total of Thirty-three adults (47.7 ± 13.5 years old) with stress and musculoskeletal pain completed the trial with acceptable rates of recruitment (8.25 subjects per site/month), retention (100%), adherence (100%), and adverse events (0%). HFP (n = 18), but not SHAM (n = 15), significantly increased the root mean square of successive RR interval differences (p = 0.036), standard deviation of the NN intervals (p = 0.009), and ratio of the low-frequency to high-frequency power band (p = 0.026). HFP and SHAM significantly decreased the heart rate (p < 0.001, p = 0.009) but not the stress index and ratio of the Poincaré plot standard deviation along and perpendicular to the line of identity (p > 0.05). A power analysis calculated 72 participants. Taken together, the study was feasible and HFP improved HRV in stressed subjects with musculoskeletal pain, suggesting a parasympathetic effect.

Fast improvements in functional status after osteopathic manipulative treatment based on myofascial release in patients with moderate or severe fibromyalgia: a retrospective study

OBJECTIVES

Fibromyalgia (FM) is a chronic pain syndrome characterized by a large variety of symptoms. Evidence suggests that an alteration of central nervous system processing of pain could be involved. The purpose of this study is to analyze clinical records of patients affected by FM who underwent osteopathic manipulative treatment (OMT), predominantly based on a myofascial release approach (MFR).

METHODS

This retrospective study considered records of 21 FM patients with moderate or severe functional impact, who consented to OMT in addition to their usual care. The assessment considered the following measures: FIQ (functional status), SF36 (quality of life), VAS (pain), TSK (kinesiophobia) and PSQI (quality of sleeping). Patients were preliminarily assessed over a 1 month run-in phase, then after 1, 2 and 4 months; a 1 month follow-up was also considered.

RESULTS

After one month, 71% of patients reported a decrease in functional impact and scores remained stable until follow-up (from 69.8 to 52.37, p≤0.001). Overall, after four months, patients improved their quality of life, with a score ranging from 33.47 to 42.6 (p≤0.05). We also observed a reduction of pain (p≤0.05).

CONCLUSIONS

A series of OMT sessions based on MFR could play a therapeutic role in improving functional status, pain and quality of life over a period of 4 months.

Defining the landscape of patient harm after osteopathic manipulative treatment: synthesis of an adverse event model

BACKGROUND

In the United States, osteopathic manipulative treatment (OMT), is a popular complementary physical health approach for the treatment of neuromusculoskeletal disorders. However, post-OMT adverse events (AEs) are poorly defined in terms of frequency, severity, and temporal evolution. To date, no benchmark for patient safety exists. To improve understanding in this field, we set out to model the landscape of patient harm after OMT.

METHODS

We conducted a comprehensive search of all available primary clinical research studies reporting on the occurrence of post-OMT AEs in nonpregnant, adult outpatients treated by an osteopathic physician in the United States. The methodology of eligible studies was then reviewed to select those containing the minimum required dataset to model the post-OMT AEs. The minimum required dataset consisted of four model parameters: 'post-OMT interval', 'OMT encounters with post-OMT interval assessment', 'AEs preceded by an OMT encounter', and 'AE severity.' We used the dataset extracted from selected studies to calculate a patient safety benchmark defined as the incidence rate of AEs per 100 post-OMT interval-days.

RESULTS

From 212 manuscripts that we identified, 118 primary clinical research studies were assessed for eligibility. A total of 23 studies met inclusion criteria for methodological review, of which 13 studies passed and were selected for modeling. Mild AEs were the most frequent, accounting for n = 161/165 (98%) of total AEs observed in the literature. The cumulative incidence of mild AEs was also significantly greater (P = 0.01) than both moderate and severe grades. The benchmark incidence rate was 1.0 AEs per 100 post-OMT interval-days.

CONCLUSIONS

The majority of post-OMT AEs observed in the primary clinical literature were of mild severity. Modeling of the combined dataset on post-OMT AEs allowed for the derivation of a patient safety benchmark that, to date, has not been established in the field of osteopathic manipulative medicine. Additional research is needed to improve model resolution during the post-OMT period. This work conceptualized a model for identifying and grading post-OMT AEs, which should facilitate future comparisons between institutions in order to continually improve patient safety standards in the field of osteopathic manipulative medicine.

Effectiveness of spinal manipulation in addition to pharmacological treatment in fibromyalgia: A blinded randomized trial

BACKGROUND

It has been suggested that spinal manipulation may alter sensorimotor integration in the central nervous system and therefore may be used to treat central sensitization syndromes.

OBJECTIVE

To investigate the effectiveness of spinal manipulation in addition to pharmacological treatment in patients with fibromyalgia.

DESIGN

A single-center, randomized, and placebo-controlled trial with three parallel arms SETTING: Outpatient clinics at a tertiary health care facility.

PARTICIPANTS

Female patients aged 18-55 years receiving pharmacological treatment.

INTERVENTIONS

Spinal manipulation, sham manipulation, and control groups. Patients in the spinal manipulation group received high-velocity low-amplitude manipulation treatment twice a week for 3 weeks. Patients in the sham group received an application that was very similar to the active treatment but was not expected to have any real therapeutic effect. Patients in the control group continued to receive pharmacological therapy.

MAIN OUTCOME MEASURES

The primary outcome, pain score (visual analog scale), and secondary outcomes, pressure pain threshold (PPT), Revised Fibromyalgia Impact Questionnaire (FIQR), Widespread Pain Index (WPI), and Fibromyalgia Severity Score (FSS) were measured before, 1 month, and 3 months after randomization.

RESULTS

Sixty patients with a mean age of 41.7 years (SD = 8.0) were enrolled in the study. A mixed-design repeated analysis of covariance was used to test the data. At 1 month after randomization, pain scores did not differ between groups. At 3 months after randomization, the spinal manipulation group had a significantly lower pain score (adjusted mean = 4.3 cm, SE: 0.4) than the control group (adjusted mean = 6.8 cm, SE: 0.4) and the sham manipulation group (adjusted mean = 5.7 cm, SE: 0.4). PPT did not differ between groups at any time point. FIQR, WPI, and FSS showed some improvement 1 or 3 months after randomization in favor of the spinal manipulation group.

CONCLUSIONS

Spinal manipulation used in addition to pharmacological treatment in young/middle-aged female patients with fibromyalgia could be an effective treatment for pain, disease severity, and functionality.

ROLE OF MANUAL THERAPY AND MASSAGE IN THE TREATMENT OF FIBROMYALGIA: TESTING THE HYPOTHESIS

Fibromyalgia syndrome (FMS) is a chronic rheumatic disease in which pain is predominant and accompanied by fatigue, anxiety, depression, sleep disturbance and cognitive dysfunction. Although there are numerous pharmacological and non-pharmacological therapeutic alternatives, symptom control is frequently problematic. Manual therapy covers manipulating soft tissue and various joints using the hands. It is organized by mapping of soft tissue structures with rhythmically applied pressure to improve physical function, facilitate daily activities, promote rehabilitation procedures and decrease pain.  Massage is generally accepted as an essential component of manual therapy. Stretching and mobilizations are also part of manual therapy. Although numerous beneficial effects of manual therapy and massage on the musculoskeletal system and pain have been proven, the data in FMS patients studies are inconclusive. We hypothesize that manual therapy and massage are beneficial therapeutic options for the control of symptoms of FMS patients. Furthermore, these strategies can be employed in conjunction with well-established and high-evidence therapeutic procedures. Future research should focus on establishing standardized protocols for manual therapy and massage, which is one of the major limitations. To ensure a high level of evidence, research studies with large sample sizes, long follow-up periods and methodologically complete are needed.

Dropout associated with osteopathic manual treatment for chronic noncancerous pain in randomized controlled trials

CONTEXT

Reviews exploring harm outcomes such as adverse effects (AE), all cause dropouts (ACD), dropouts due to inefficacy, and dropouts due to AE associated with osteopathic manipulative treatment (OMT) or osteopathic manual therapy (OMTh) are scant.

OBJECTIVES

To explore the overall AE, ACD, dropouts due to inefficacy, and AE in chronic noncancerous pain (CNCP) patients receiving OMTh through a systematic review of previous literature.

METHODS

For this systematic review and meta-analysis, the authors searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Physiotherapy Evidence Database (PEDro), EMCare, and Allied and Complementary Medicine Database (AMED), and Ostmed.Dr, as well as the bibliographical references of previous systematic reviews evaluating OMTh for pain severity, disability, quality of life, and return to work outcomes. Randomized controlled trials with CNCP patients 18 years or older with OMTh as an active or combination intervention and the presence of a control or combination group were eligible for inclusion. In this sub-study of a previous, larger systematic review, 11 studies (n=1,015) reported data that allowed the authors to perform meta-analyses on ACD and dropouts due to AE. The risk of bias (ROB) was assessed with the Cochrane ROB tool and the quality of evidence was determined with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

The pooled analysis showed that ACD was not significantly different for visceral OMTh (vOMTh) vs. OMTh control (odds ratio [OR]=2.66 [95% confidence interval [[CI]], 0.28, 24.93]) or for OMTh vs. standard care (OR=1.26 [95% CI, 0.84, 1.89]; I²=0%). Single study analysis showed that OMTh results were nonsignificant in comparison with chemonucleolysis, gabapentin, and exercise. OMTh in combination with gabapentin (vs. gabapentin alone) and OMTh in combination with exercise (vs. exercise alone) showed nonsignificant ACD. Dropouts due to AE were not significantly different, but the results could not be pooled due to an insufficient number of studies.

CONCLUSIONS

Most articles did not explicitly report AEs, ACD rates, or dropouts due to AEs and inefficacy. The limited data available on dropouts showed that OMTh was well tolerated compared with control interventions, and that the ACD and dropouts due to AEs were not significantly different than comparators. Future trials should focus on explicit reporting of dropouts along with beneficial outcomes to provide a better understanding of OMTh efficacy.

Osteopathic Manual Treatment for Pain Severity, Functional Improvement, and Return to Work in Patients With Chronic Pain

Context

Chronic non-cancer pain (CNCP) is associated with disability, poor quality of life (QOL), and failure to return to work (RTW). Osteopathic manipulative treatment (OMT) or osteopathic manual therapy (OMTh) are increasingly offered to patients with CNCP; however, the existing systematic reviews and meta-analyses in the literature that explore the effectiveness of OMTh have major limitations.

Objective

To systematically evaluate the quality of evidence documenting the effectiveness of OMTh for patients with CNCP using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and to evaluate the efficacy of OMTh in patients with CNCP through a meta-analysis of pooled data from previous studies.

Methods

We searched online the databases Ovid, MEDLINE, Embase, OSTMED.DR, EMCare, Allied and Complementary Medicine Database (AMED), Physiotherapy Evidence Database (PEDro), and Cochrane Central Register of Controlled Trials (CENTRAL), as well as the bibliographic references of previous systematic review articles evaluating OMTh for pain severity, disability, QOL, or RTW outcomes. Eligibility included randomized controlled trials methodology, CNCP patients 18 years or older, use of previously validated assessment tools, use of OMTh as an active or combination intervention, and presence of a control or comparison group. We pooled studies based on the homogeneity between OMT comparator treatment and outcomes. Risk of bias was assessed with the Cochrane risk of bias tool and the quality of evidence was determined with GRADE.

Results

Sixteen randomized controlled trials (n=1158 patients) were eligible for data extraction. Moderate quality evidence showed that OMTh vs. standard care was significantly associated with a reduction in pain [standardized mean difference (95% CI)=[-.37 (-.58, -.17)] and disability [-.28 (-.46, -.10)], as well as improved QOL [.67 (.29, 1.05)]. Moderate quality evidence showed that OMTh plus exercise vs. exercise only was significantly associated with reduction in pain severity [-1.25 (-1.67, -.83)] and disability [-1.15 (-1.57, -.74)]. Moderate quality evidence showed that using visceral OMTh vs. general OMTh was significantly associated with reduction in pain severity [-.74 (-1.09, -.39)] and disability [-.52 (-.91, -.13)]. In comparison to physiotherapy, gabapentin, and OMTh plus gabapentin, OMTh did not show any significant effect for any of the outcomes. OMTh vs. standard care did not show significant improvement in RTW at 12 weeks, although the effect was significant at 8 weeks after OMTh.

Conclusion

Moderate quality evidence suggests that OMTh is effective for CNCP patients. There was a significant association between visceral OMTh and reduced pain severity and disability. More robust, high-quality randomized controlled trials with larger sample sizes are required to further explore the effectiveness of the OMTh in the management of CNCP.

Effectiveness of osteopathic interventions in chronic non-specific low back pain: A systematic review and meta-analysis

BACKGROUND

Chronic low back pain (CLBP) is a frequent cause of disability and it represents a medical, social and economic burden globally. Therefore, we assessed effectiveness of osteopathic interventions in the management of NS-CLBP for pain and functional status.

METHODS

A systematic review and meta-analysis were conducted. Findings were reported following the PRISMA statement. Six databases were searched for RCTs. Studies were independently assessed using a standardized form. Each article was assessed using the Cochrane risk of bias (RoB) tool. Effect size (ES) were calculated at post-treatment and at 12 weeks' follow up. We used GRADE to assess quality of evidence.

RESULTS

10 articles were included. Studies investigated osteopathic manipulative treatment (OMT, n = 6), myofascial release (MFR, n = 2), craniosacral treatment (CST, n = 1) and osteopathic visceral manipulation (OVM, n = 1). None of the study was completely judged at low RoB. Osteopathy revealed to be more effective than control interventions in pain reduction (ES: -0.59; 95% CI: -0.81, -0.36; P < 0.00,001) and in improving functional status (ES: -0.42; 95% 95% CI: -0.68, -0.15; P = 0.002). Moderate-quality evidence suggested that MFR is more effective than control treatments in pain reduction (ES: -0.69; 95% CI: -1.05, -0.33; P = 0.0002), even at follow-up (ES: -0.73; 95% CI: -1.09, -0.37; P < 0.0001). Low-quality evidence suggested superiority of OMT in pain reduction (ES: -0.57; 95% CI: -0.90, -0.25; P = 0.001) and in changing functional status (ES: -0.34; 95% CI: -0.65, -0.03; P = 0.001). Very low-quality evidence suggested that MFR is more effective than control interventions in functional improvements (ES: -0.73; 95% CI: -1.25, -0.21; P = 0.006).

CONCLUSION

Results strengthen evidence that osteopathy is effective in pain levels and functional status improvements in NS-CLBP patients. MFR reported better level of evidence for pain reduction if compared to other interventions. Further high-quality RCTs, comparing different osteopathic modalities, are recommended to produce better-quality evidence.

Fibromyalgia: Recent Advances in Diagnosis, Classification, Pharmacotherapy and Alternative Remedies

Fibromyalgia (FM) is a syndrome that does not present a well-defined underlying organic disease. FM is a condition which has been associated with diseases such as infections, diabetes, psychiatric or neurological disorders, rheumatic pathologies, and is a disorder that rather than diagnosis of exclusion requires positive diagnosis. A multidimensional approach is required for the management of FM, including pain management, pharmacological therapies, behavioral therapy, patient education, and exercise. The purpose of this review is to summarize the recent advances in classification criteria and diagnostic criteria for FM as well as to explore pharmacotherapy and the use of alternative therapies including the use of plant bioactive molecules.

Optimised transcranial direct current stimulation (tDCS) for fibromyalgia-targeting the endogenous pain control system: a randomised, double-blind, factorial clinical trial protocol

INTRODUCTION

Fibromyalgia (FM) is a common debilitating condition with limited therapeutic options. Medications have low efficacy and are often associated with adverse effects. Given that FM is associated with a defective endogenous pain control system and central sensitisation, combining interventions such as transcranial direct current stimulation (tDCS) and aerobic exercise (AE) to modulate pain-processing circuits may enhance pain control.

METHODS AND ANALYSIS

A prospective, randomised (1:1:1:1), placebo-controlled, double-blind, factorial clinical trial will test the hypothesis that optimised tDCS (16 anodal tDCS sessions combined with AE) can restore of the pain endogenous control system. Participants with FM (n=148) will undergo a conditioning exercise period and be randomly allocated to one of four groups: (1) active tDCS and AE, (2) sham tDCS and AE, (3) active tDCS and non-aerobic exercise (nAE) or (4) sham tDCS and nAE. Pain inhibitory activity will be assessed using conditioned pain modulation (CPM) and temporal slow pain summation (TSPS)-primary outcomes. Secondary outcomes will include the following assessments: Transcranial magnetic stimulation and electroencephalography as cortical markers of pain inhibitory control and thalamocortical circuits; secondary clinical outcomes on pain, FM, quality of life, sleep and depression. Finally, the relationship between the two main mechanistic targets in this study-CPM and TSPS-and changes in secondary clinical outcomes will be tested. The change in the primary efficacy endpoint, CPM and TSPS, from baseline to week 4 of stimulation will be tested with a mixed linear model and adjusted for important demographic variables.

ETHICS AND DISSEMINATION

This study obeys the Declaration of Helsinki and was approved by the Institutional Review Board (IRB) of Partners Healthcare under the protocol number 2017P002524. Informed consent will be obtained from participants. Study findings will be reported in conferences and peer-reviewed journal publications.

TRIAL REGISTRATION NUMBER

NCT03371225.