Abdominal Lymphatic Pump Treatment Increases Leukocyte Count and Flux in Thoracic Duct Lymph

Augmentation of immune response to vaccinations through osteopathic manipulative treatment: a study of procedure

CONTEXT

Anecdotal evidence suggested that osteopathic manipulative treatment (OMT) may have imparted survivability to patients in osteopathic hospitals during the 1918 influenza pandemic. In addition, previous OMT research publications throughout the past century have shown evidence of increased lymphatic movement, resulting in improved immunologic function qualitatively and quantitatively.

OBJECTIVES

The following is a description of a proposed protocol to evaluate OMT effects on antibody generation in the peripheral circulation in response to a vaccine and its possible use in the augmentation of various vaccines. This protocol will serve as a template for OMT vaccination studies, and by adhering to the gold standard of randomized controlled trials (RCTs), future studies utilizing this outline may contribute to the much-needed advancement of the scientific literature in this field.

METHODS

This manuscript intends to describe a protocol that will demonstrate increased antibody titers to a vaccine through OMT utilized in previous historical studies. Confirmation data will follow this manuscript validating the protocol. Study participants will be divided into groups with and without OMT with lymphatic pumps. Each group will receive the corresponding vaccine and have antibody titers measured against the specific vaccine pathogen drawn at determined intervals.

RESULTS

These results will be statistically evaluated. Our demonstration of a rational scientific OMT vaccine antibody augmentation will serve as the standard for such investigation that will be reported in the future. These vaccines could include COVID-19 mRNA, influenza, shingles, rabies, and various others. The antibody response to vaccines is the resulting conclusion of its administration. Osteopathic manipulative medicine (OMM) lymphatic pumps have, in the past through anecdotal reports and smaller pilot studies, shown effectiveness on peripheral immune augmentation to vaccines.

CONCLUSIONS

This described protocol will be the template for more extensive scientific studies supporting osteopathic medicine's benefit on vaccine response. The initial vaccine studies will include the COVID-19 mRNA, influenza, shingles, and rabies vaccines.

Effects of manual lymphatic drainage on total knee replacement: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Total knee joint replacement (TKR) is an effective method for the treatment of severe knee osteoarthritis. With an increasing number of surgeries, complications such as lower limb edema, pain, and limited mobility have caused a heavy burden. Manual lymphatic drainage (MLD) may be a solution to solve the problem. The study aims to evaluate the efficacy of MLD in reducing knee edema, pain, and improving range of motion (ROM) in patients after TKR.

METHODS

A search was conducted in PubMed, Embase, Cochrane Library, Web of Science, CNKI, VIPs, WanFang database, and Google Scholar from inception to June 2023. Only randomized controlled trials (RCTs) that compared the effects of MLD and non-MLD (or another physiotherapy) on improving knee edema, pain, and ROM after TKR were included. Stata 16.0 was used for meta-analysis. GRADE was used to assess the quality of evidence.

RESULTS

In total, 7 RCTs with 285 patients were identified. There were no significant differences found in the ROM of knee flexion (standardized mean difference (SMD) = 0.03, 95% confidence interval (CI): -0.22, 0.28, P = 0.812) and the ROM of knee extension (SMD= -0.30, 95%CI: -0.64, 0.04, P = 0.084). No differences were observed in the lower extremity circumference after TKR (SMD= -0.09, 95%CI: -0.27, 0.09, P = 0.324). For postoperative pain, there was no significant advantage between the MLD and non-MLD groups (SMD= -0.33, 95%CI: -0.71, 0.04, P = 0.083).

CONCLUSIONS

Based on the current evidence from RCTs, manual lymphatic drainage is not recommended for the rehabilitation of patients following total knee replacement.

Does the osteopathic pedal pump reduce lower limb volume in healthy subjects?

CONTEXT

Lymphatic treatments are gentle and passive techniques believed to enhance movement of lymph back into the central circulatory system. Animal studies provide supportive evidence, yet there are few studies in humans.

OBJECTIVES

The aim of this study is to investigate whether the osteopathic pedal pump protocol reduces volume in the lower limbs of healthy subjects.

METHODS

A total of 30 first- and second-year medical students were recruited. Subjects were excluded from participating if they had acute asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure, active infections, fractures of the lower extremities, or metastatic cancer. A within-subjects study design with pre- and posttreatment measurement of lower limb volume was utilized. Pretreatment lower limb volume measurements were obtained utilizing a volumetric water gauge prior to myofascial thoracic inlet release and a 5 min pedal lymphatic pump protocol treatment. Posttreatment lower limb measurements were taken immediately following the protocol treatment. A telephone interview was conducted 2-3 days after the treatment to assess the participants' experience of the treatment and whether the treatment elicited a subjective change from baseline. A paired t test was utilized to determine the statistical significance of volume displacement posttreatment.

RESULTS

The mean change of pretreatment to posttreatment lower limb volume was -45.63 mL with a standard deviation of 37.65 mL. The change between the pretreatment and posttreatment volume measurements was statistically significant (p<0.001). The minimum displacement was +19 mL, and the maximum displacement was -167 mL. The majority of participants perceived the treatment as effective and enjoyable, were likely to recommend it to others, and were willing to have it performed on them at routine office visits if there was a need.

CONCLUSIONS

The osteopathic pedal pump technique, when utilized on those without leg lymphedema, reduces lower limb volume as measured by the volumetric water gauge. Further studies are warranted, especially in persons with excess lower-extremity edema, lymphedema or venous stasis.

Lipedema: Insights into Morphology, Pathophysiology, and Challenges

Lipedema is an adipofascial disorder that almost exclusively affects women. Lipedema leads to chronic pain, swelling, and other discomforts due to the bilateral and asymmetrical expansion of subcutaneous adipose tissue. Although various distinctive morphological characteristics, such as the hyperproliferation of fat cells, fibrosis, and inflammation, have been characterized in the progression of lipedema, the mechanisms underlying these changes have not yet been fully investigated. In addition, it is challenging to reduce the excessive fat in lipedema patients using conventional weight-loss techniques, such as lifestyle (diet and exercise) changes, bariatric surgery, and pharmacological interventions. Therefore, lipedema patients also go through additional psychosocial distress in the absence of permanent treatment. Research to understand the pathology of lipedema is still in its infancy, but promising markers derived from exosome, cytokine, lipidomic, and metabolomic profiling studies suggest a condition distinct from obesity and lymphedema. Although genetics seems to be a substantial cause of lipedema, due to the small number of patients involved in such studies, the extrapolation of data at a broader scale is challenging. With the current lack of etiology-guided treatments for lipedema, the discovery of new promising biomarkers could provide potential solutions to combat this complex disease. This review aims to address the morphological phenotype of lipedema fat, as well as its unclear pathophysiology, with a primary emphasis on excessive interstitial fluid, extracellular matrix remodeling, and lymphatic and vasculature dysfunction. The potential mechanisms, genetic implications, and proposed biomarkers for lipedema are further discussed in detail. Finally, we mention the challenges related to lipedema and emphasize the prospects of technological interventions to benefit the lipedema community in the future.

Adjunctive osteopathic therapy for hospitalized COVID-19 patients: A feasibility-oriented chart review study with matched controls

Background

Osteopathic manipulative treatment (OMT) may improve outcomes during COVID-related respiratory distress - the most common cause of death from novel coronavirus (SARS-CoV-2). Outcomes from OMT treatments of respiratory distress during the COVID-19 pandemic have not been reported.

Objective

Assess adjunctive OMT in hospitalized patients with SARS-CoV-2 and respiratory distress.

Design

Feasibility oriented retrospective observational cohort study.

Setting

COVID-19 (non-ICU) ward in a tertiary academic medical center.

Methods

Inpatients received daily OMT treatments of rib raising, abdominal diaphragm doming, thoracic pump and pedal pump. Primary outcomes were procedural acceptance, satisfaction, side effects, and adverse events. Secondary outcomes were patient-reported clinical change after therapy; number of hospital days; need during hospitalization for high-flow oxygen, C-PAP/BiPAP or intensive care; need for supplementary oxygen at discharge; and discharge disposition.

Participants

Hospitalized adults with SARS-CoV-2 infection and respiratory distress.

Results

OMT (n = 27) and Control (n = 152) groups were similar in demographics and most laboratory studies. 90% of patients accepted OMT and reported high satisfaction (4.26/±0.71 (maximum 5)), few negative effects, no adverse events, and positive clinical change (5.07 ± 0.96 (maximum 7)). Although no significant differences were found in secondary outcomes, OMT patients trended towards fewer hospital days than Controls (p = 0.053; Cohen's d = 0.22), a relationship that trended towards correlation with number of co-morbidities (p = 0.068).

Conclusion

Hospitalized patients with respiratory distress and COVID-19 reported acceptance, satisfaction, and greater ease of breathing after a four-part OMT protocol, and appear to have a shorter length of hospitalization. Randomized controlled trials are needed to confirm these results.

The Lymphatic System: An Osteopathic Review

Osteopathic principles and philosophy suggest the use of osteopathic manipulative treatment (OMT) to restore, augment, or facilitate lymphatic fluid flow to maintain body fluid balance, and/or to stimulate immune system responses to aid in the recovery from illness and maintain normal body defense mechanisms. This review provides an osteopathic view of the role of the lymphatic system in health and disease, with an emphasis on the use of OMT to alleviate somatic dysfunctions (SD) that inhibit the optimum function of the lymphatic system. The current evidence base is reviewed for the use of OMT to assist in restoring or augmenting lymphatic system function to help patients recover from illness and maintain health and wellness. An overview is provided on how osteopathic principles and philosophy relative to the immune system are applied in practice. A literature search was conducted using databases such as Medline, PubMed, Ostmed-DR, and Scopus, focusing on osteopathic approaches to the lymphatic system. Keywords used included osteopathic manipulative medicine, OMT, and lymphatic manual treatment or therapy. Current osteopathic textbook information was also surveyed. There is support for the application of osteopathic principles and OMT for certain conditions that involve the lymphatic system. More prospective research is needed.

The rationale for including osteopathic manipulative treatment in the management of infections: a hermeneutic review

INTRODUCTION

As the prevalence of drug-resistant infections continues to outpace the development of new antibiotics, we must explore all reasonable options for enhancing the effectiveness of existing anti-infectives. The emergence of novel pathogens without initial drug treatments or vaccines, typified by the severe acute respiratory syndrome coronavirus-2 pandemic, further underscores the need for non-pharmacologic adjunctive measures for infection management. Osteopathic manipulative treatment (OMT) may represent such an adjunct.

AREAS COVERED

PubMed, CINAHL, Google Scholar, Cochrane databases and relevant chapters of major osteopathic texts were searched for animal experiments, case reports, observational studies, non-randomized, and randomized trials pertaining to infection, OMT, and the complications or safety of OMT. OMT was associated with one or more of the following: decreased bacterial colony counts in lung tissue; changes in immunologic profiles manifested by significant differences dendritic cells and levels of IL-8, MCP-1, MIP-1a, and G-CSF; shorter durations of IV antibiotics; decreased length of hospitalization; decreased rates of respiratory failure and death; decreased post-surgical lengths of stay; and enhanced patient satisfaction.

EXPERT OPINION

Preliminary, lower-grade evidence suggests that OMT can improve some infection-related outcomes, and is safe. The role of OMT in infection management should undergo further controlled trials without delay.

Standard of care for lipedema in the United States

Background

Lipedema is a loose connective tissue disease predominantly in women identified by increased nodular and fibrotic adipose tissue on the buttocks, hips and limbs that develops at times of hormone, weight and shape change including puberty, pregnancy, and menopause. Lipedema tissue may be very painful and can severely impair mobility. Non-lipedema obesity, lymphedema, venous disease, and hypermobile joints are comorbidities. Lipedema tissue is difficult to reduce by diet, exercise, or bariatric surgery.

Methods

This paper is a consensus guideline on lipedema written by a US committee following the Delphi Method. Consensus statements are rated for strength using the GRADE system.

Results

Eighty-five consensus statements outline lipedema pathophysiology, and medical, surgical, vascular, and other therapeutic recommendations. Future research topics are suggested.

Conclusion

These guidelines improve the understanding of the loose connective tissue disease, lipedema, to advance our understanding towards early diagnosis, treatments, and ultimately a cure for affected individuals.

Evidence-based assessment of potential therapeutic effects of adjunct osteopathic medicine for multidisciplinary care of acute and convalescent COVID-19 patients

Although the COVID-19 pandemic affects predominantly the respiratory function, epidemiological studies show that multiple systems can be affected. The severe complications of SARS-CoV-2 infection seem to be induced by an inflammatory dysregulation (“cytokine storm”), which can also induce an immunodepression. Several studies highlight beneficial effects of osteopathic medicine on inflammation and immune regulation. A careful review of evidence-based literature brings to the fore significant improvements of osteopathic manipulative treatment (OMT) in adjunction to conventional care. OMT can improve the condition of infected patients by decreasing symptoms and boosting the efficiency of conventional care. OMT might also benefit surviving patients by reducing the long-lasting consequences of the infection as well as improving their quality of life during convalescence. This review should constitute an argument in favor of multidisciplinary care, although further biological and clinical research is essential to better assess the potential beneficial contributions of adjunct osteopathic medicine to conventional care in the fight against pandemics such as COVID-19.

Lymphatic Pump Treatment Mobilizes Bioactive Lymph That Suppresses Macrophage Activity In Vitro

Context

By promoting the recirculation of tissue fluid, the lymphatic system preserves tissue health, aids in the absorption of gastrointestinal lipids, and supports immune surveillance. Failure of the lymphatic system has been implicated in the pathogenesis of several infectious and inflammatory diseases. Thus, interventions that enhance lymphatic circulation, such as osteopathic lymphatic pump treatment (LPT), should aid in the management of these diseases.

Objective

To determine whether thoracic duct lymph (TDL) mobilized during LPT would alter the function of macrophages in vitro.

Methods

The thoracic ducts of 6 mongrel dogs were cannulated, and TDL samples were collected before (baseline), during, and 10 minutes after LPT. Thoracic duct lymph flow was measured, and TDL samples were analyzed for protein concentration. To measure the effect of TDL on macrophage activity, RAW 264.7 macrophages were cultured for 1 hour to acclimate. After 1 hour, cell-free TDL collected at baseline, during LPT, and after TDL was added at 5% total volume per well and co-cultured with or without 500 ng per well of lipopolysaccharide (LPS) for 24 hours. As a control for the addition of 5% TDL, macrophages were cultured with phosphate-buffered saline (PBS) at 5% total volume per well and co-cultured with or without 500 ng per well of LPS for 24 hours. After culture, cell-free supernatants were assayed for nitrite (NO2-), tumor necrosis factor α (TNF-α) and interleukin 10 (IL-10). Macrophage viability was measured using flow cytometry.

Results

Lymphatic pump treatment significantly increased TDL flow and the flux of protein in TDL (P<.001). After culture, macrophage viability was approximately 90%. During activation with LPS, baseline TDL, TDL during LPT, and TDL after LPT significantly decreased the production of NO2-, TNF-α, and IL-10 by macrophages (P<.05). However, no significant differences were found in viability or the production of NO2-, TNF-α, or IL-10 between macrophages cultured with LPS plus TDL taken before, during, and after LPT (P>.05).

Conclusion

The redistribution of protective lymph during LPT may provide scientific rationale for the clinical use of LPT to reduce inflammation and manage edema.

Adjuvant Lymphatic Osteopathic Manipulative Treatment in Patients With Lower-Extremity Ulcers: Effects on Wound Healing and Edema

Context

In 2012, the US wound registry estimated that the cost of managing chronic wounds in the United States exceeded $50 billion. A large percentage of these wounds are venous stasis ulcers of the lower extremity. Evidence suggests that adjuvant osteopathic manipulative treatment (OMT) may provide a benefit by reducing edema and subsequent healing times in venous stasis ulcers of the lower extremity.

Objective

To determine whether a lymphatic OMT protocol improves wound healing rates among patients with lower-extremity edema.

Methods

This pilot study was a nonrandomized before-after community trial of lymphatic OMT in patients with lower-extremity wounds and edema. Wound surface area measurements for the preliminary phase were obtained retrospectively. During the intervention period, patients received 10 minutes of OMT twice per week. The OMT protocol, which aimed to improve lymphatic flow, included myofascial thoracic outlet release, doming of the diaphragm, pelvic diaphragm release, popliteal release, and pedal pump (2-3 minutes of continuous pump) performed in sequence. Rates of wound healing were compared between the preliminary (standard therapy), intervention (standard therapy plus OMT), and follow-up (standard therapy) phases. Rates of change in edema (measured using leg volume) were evaluated during the intervention phase. A custom-designed questionnaire was used to assess patients’ satisfaction with their treatment and confidence that its effects on their health were good.

Results

Eight patients were included in the study. The wound surface area increased during the preliminary phase by a mean of 10 cm2/wk and decreased during the intervention phase by a mean of 4.9 cm2/wk. Patients’ mean leg volume decreased during the intervention phase. Six patients were “very satisfied” with their treatment.

Conclusion

The adjunctive OMT protocol may have reduced edema and reversed the trend of wound growth in patients with venous stasis ulcers. Edema reduction is a mainstay of current wound therapy, and any modality that decreases edema may subsequently decrease healing times.

The Potential of Osteopathic Manipulative Treatment in Antimicrobial Stewardship: A Narrative Review

The contemporary management of infectious diseases is built around antimicrobial therapy. However, the development of antimicrobial resistance threatens to create a post-antibiotic era. Antimicrobial stewardship attempts to reduce the development of antimicrobial resistance by improving their appropriate use. Osteopathic manipulative treatment as an adjunctive treatment has the potential for enhancing antimicrobial stewardship by enhancing the human immune system, shortening the duration of antimicrobial therapy, reducing complications, and improving treatment outcomes. The present article reviews the evidence published in the literature since this unique treatment approach was first developed more than 100 years ago. The evidence suggests that adjunctive osteopathic manipulative treatment has great potential for enhancing antimicrobial stewardship and should be further investigated.

Lymphatic Pump Treatment as an Adjunct to Antibiotics for Pneumonia in a Rat Model

Background: Lymphatic pump treatment (LPT) is a technique used by osteopathic physicians as an adjunct to antibiotics for patients with respiratory tract infections, and previous studies have demonstrated that LPT reduces bacterial load in the lungs of rats with pneumonia. Currently, it is unknown whether LPT affects drug effcacy.

Objective: To determine whether the combination of antibiotics and LPT would reduce bacterial load in the lungs of rats with acute pneumonia.

Methods: Rats were infected intranasally with 5×107 colony-forming units (CFU) of Streptococcus pneumoniae. At 24, 48, and 72 hours after infection, the rats received no therapy (control), 4 minutes of sham therapy, or 4 minutes of LPT, followed by subcutaneous injection of 40 mg/kg of levofoxacin or sterile phosphate-buffered saline. At 48, 72, and 96 hours after infection, the spleens and lungs were collected, and S pneumoniae CFU were enumerated. Blood was analyzed for a complete blood cell count and leukocyte differential count.

Results: At 48 and 72 hours after infection, no statistically significant differences in pulmonary CFU were found between control, sham therapy, or LPT when phosphate-buffered saline was administered; however, the reduction in CFU was statistically significant in all rats given levofoxacin. The combination of sham therapy and levofoxacin decreased bacterial load at 72 and 96 hours after infection, and LPT and levofoxacin significantly reduced CFU compared with sham therapy and levofoxacin at both time points (P<.05). Colony-forming units were not detected in the spleens at any time. No statistically significant differences in hematologic findings between any treatment groups were found at any time point measured.

Conclusion: The results suggest that 3 applications of LPT induces an additional protective mechanism when combined with levofoxacin and support its use as an adjunctive therapy for the management of pneumonia; however, the mechanism responsible for this protection is unclear.

Lymphatic pump treatment repeatedly enhances the lymphatic and immune systems

BACKGROUND

Osteopathic practitioners utilize manual therapies called lymphatic pump techniques (LPT) to treat edema and infectious diseases. While previous studies examined the effect of a single LPT treatment on the lymphatic system, the effect of repeated applications of LPT on lymphatic output and immunity has not been investigated. Therefore, the purpose of this study was to measure the effects of repeated LPT on lymphatic flow, lymph leukocyte numbers, and inflammatory mediator concentrations in thoracic duct lymph (TDL).

METHODS AND RESULTS

The thoracic ducts of five mongrel dogs were cannulated, and lymph samples were collected during pre-LPT, 4 min of LPT, and 2 hours post-LPT. A second LPT (LPT-2) was applied after a 2 hour rest period. TDL flow was measured, and TDL were analyzed for the concentration of leukocytes and inflammatory mediators. Both LPT treatments significantly increased TDL flow, leukocyte count, total leukocyte flux, and the flux of interleukin-8 (IL-8), keratinocyte-derived chemoattractant (KC), nitrite (NO2(-)), and superoxide dismutase (SOD). The concentration of IL-6 increased in lymph over time in all experimental groups; therefore, it was not LPT dependent.

CONCLUSION

Clinically, it can be inferred that LPT at a rate of 1 pump per sec for a total of 4 min can be applied every 2 h, thus providing scientific rationale for the use of LPT to repeatedly enhance the lymphatic and immune system.

Osteopathic manipulative treatment as a useful adjunctive tool for pneumonia

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 2007 (1) and resulted in the hospitalization of 1.1 million patients (2). With an average length of in-patient hospital stay of five days (2), pneumonia and influenza comprise significant financial burden costing the United States $40.2 billion in 2005 (3). Under the current Infectious Disease Society of America/American Thoracic Society guidelines, standard-of-care recommendations include the rapid administration of an appropriate antibiotic regiment, fluid replacement, and ventilation (if necessary). Non-standard therapies include the use of corticosteroids and statins; however, these therapies lack conclusive supporting evidence (4). (Figure 1) Osteopathic Manipulative Treatment (OMT) is a cost-effective adjunctive treatment of pneumonia that has been shown to reduce patients' length of hospital stay, duration of intravenous antibiotics, and incidence of respiratory failure or death when compared to subjects who received conventional care alone (5). The use of manual manipulation techniques for pneumonia was first recorded as early as the Spanish influenza pandemic of 1918, when patients treated with standard medical care had an estimated mortality rate of 33%, compared to a 10% mortality rate in patients treated by osteopathic physicians (6). When applied to the management of pneumonia, manual manipulation techniques bolster lymphatic flow, respiratory function, and immunological defense by targeting anatomical structures involved in the these systems(7,8, 9, 10). The objective of this review video-article is three-fold: a) summarize the findings of randomized controlled studies on the efficacy of OMT in adult patients with diagnosed pneumonia, b) demonstrate established protocols utilized by osteopathic physicians treating pneumonia, c) elucidate the physiological mechanisms behind manual manipulation of the respiratory and lymphatic systems. Specifically, we will discuss and demonstrate four routine techniques that address autonomics, lymph drainage, and rib cage mobility: (1) Rib Raising, (2) Thoracic Pump, (3) Doming of the Thoracic Diaphragm, and (4) Muscle Energy for Rib 1.

The short-term effect of a lymphatic pump protocol on blood cell counts in nursing home residents with limited mobility: a pilot study

CONTEXT

Lymphatic pump techniques have the potential to alter blood cell counts and thus enhance immune function in elderly adults with diminished mobility.

OBJECTIVE

To test whether an osteopathic manipulative treatment (OMT) protocol designed to enhance immune function will have an effect on lymphocyte and lymphocyte subset counts compared with a sham control group.

DESIGN

The study design was a single-session, randomized, controlled clinical trial comparing a standardized lymphatic pump protocol with a light-touch protocol. Participants were assigned to 1 of 2 groups by using a 1:1 allocation ratio.

SETTING

The study was conducted in 2 rural long-term care facilities in Missouri.

PARTICIPANTS

Residents in the long-term care facilities who were aged 60 years or older and who were confined to a bed or wheelchair for most of their waking hours. Twenty residents were recruited to participate in the study, and 10 were randomly assigned to each group.

INTERVENTIONS

Baseline blood samples were obtained. Then each patient received a 6-minute study protocol treatment. Thirty minutes after completion, posttreatment blood samples were obtained. The OMT protocol consisted of 3 osteopathic techniques: myofascial release to the thoracic inlet, the splenic pump, and the pedal lymphatic pump. The light touch protocol was applied to the same body areas as the OMT protocol for 6 minutes.

OUTCOME MEASURES

A pretreatment and posttreatment lymphocyte subset panel, complete blood cell count, and automated white blood cell count differential was obtained from each participant.

RESULTS

There was a statistically significant between-group difference in mean change for platelet counts: counts in the OMT group decreased by a mean (standard deviation) of 15,400 (7947) platelets per microliter and the light touch group increased by 4,700 (17,857) platelets per microliter (P=.004). The between-group differences for the mean (standard deviation) absolute lymphocyte cell count, red blood cell count, hemoglobin level, and hematocrit measures all decreased, but the changes were not statistically significant relative to the control group.

CONCLUSION

The OMT protocol used in this pilot study modestly reduced platelet counts in nursing home residents with limited mobility.

Osteopathic manipulative therapy induces early plasma cytokine release and mobilization of a population of blood dendritic cells

It has been claimed that osteopathic manipulative treatment (OMT) is able to enhance the immune response of individuals. In particular, it has been reported that OMT has the capability to increase antibody titers, enhance the efficacy of vaccination, and upregulate the numbers of circulating leukocytes. Recently, it has been shown in human patients suffering chronic low back pain, that OMT is able to modify the levels of cytokines such as IL-6 and TNF-α in blood upon repeated treatment. Further, experimental animal models show that lymphatic pump techniques can induce a transient increase of cytokines in the lymphatic circulation. Taking into account all these data, we decided to investigate in healthy individuals the capacity of OMT to induce a rapid modification of the levels of cytokines and leukocytes in circulation. Human volunteers were subjected to a mixture of lymphatic and thoracic OMT, and shortly after the levels of several cytokines were evaluated by protein array technology and ELISA multiplex analysis, while the profile and activation status of circulating leukocytes was extensively evaluated by multicolor flow cytometry. In addition, the levels of nitric oxide and C-reactive protein (CRP) in plasma were determined. In this study, our results show that OMT was not able to induce a rapid modification in the levels of plasma nitrites or CRP or in the proportion or activation status of central memory, effector memory or naïve CD4 and CD8 T cells. A significant decrease in the proportion of a subpopulation of blood dendritic cells was detected in OMT patients. Significant differences were also detected in the levels of immune molecules such as IL-8, MCP-1, MIP-1α and most notably, G-CSF. Thus, OMT is able to induce a rapid change in the immunological profile of particular circulating cytokines and leukocytes.

Thoracic and abdominal lymphatic pump techniques inhibit the growth of S. pneumoniae bacteria in the lungs of rats

BACKGROUND

Osteopathic physicians utilize manual medicine techniques called lymphatic pump techniques (LPT) to improve lymphatic flow and enhance immunity. Clinical studies report that LPT enhances antibody responses to bacterial vaccines, shortens duration of cough in patients with respiratory disease, and shortens the duration of intravenous antibiotic therapy and hospital stay in patients with pneumonia. The purpose of this study was to identify if thoracic LPT (Th-LPT) or abdominal LPT (Ab-LPT) would reduce Streptococcus pneumoniae colony-forming units (CFU) in the lungs of rats with acute pneumonia.

METHODS AND RESULTS

Rats were nasally infected with S. pneumoniae and received either control, sham, Ab-LPT, or Th-LPT once daily for 3 consecutive days. On day 4 post-infection, lungs were removed and bacteria were enumerated. Three daily applications of either Ab-LPT or Th-LPT were able to significantly (p<0.05) reduce the numbers of pulmonary bacteria compared to control and sham. There were no significant differences in the percentage or concentration of leukocytes in blood between groups, suggesting neither Ab-LPT nor Th-LPT release leukocytes into blood circulation.

CONCLUSIONS

Our data demonstrate that LPT may protect against pneumonia by inhibiting bacterial growth in the lung; however, the mechanism of protection is unclear. Once these mechanisms are understood, LPT can be optimally applied to patients with pneumonia, which may substantially reduce morbidity, mortality, and frequency of hospitalization.

Osteopathic lymphatic pump techniques to enhance immunity and treat pneumonia

Pneumonia is a common cause of morbidity and mortality worldwide. While antibiotics are generally effective for the treatment of infection, the emergence of resistant strains of bacteria threatens their success. The osteopathic medical profession has designed a set of manipulative techniques called lymphatic pump techniques (LPT), to enhance the flow of lymph through the lymphatic system. Clinically, LPT is used to treat infection and oedemaand might be an effective adjuvant therapy in patients with pneumonia.The immune system uses the lymphatic and blood systems to survey to rid the body of pathogens; however, only recently have the effects of LPT on the lymphatic and immune systems been investigated. This short review highlightsclinical and basic science research studies that support the use of LPT to enhance the lymphatic and immune systems and treat pneumonia, and discusses the potential mechanisms by which LPT benefits patients with pneumonia.

Lymphatic pump manipulation mobilizes inflammatory mediators into lymphatic circulation

Lymph stasis can result in edema and the accumulation of particulate matter, exudates, toxins and bacteria in tissue interstitial fluid, leading to inflammation, impaired immune cell trafficking, tissue hypoxia, tissue fibrosis and a variety of diseases. Previously, we demonstrated that osteopathic lymphatic pump techniques (LPTs) significantly increased thoracic and intestinal duct lymph flow. The purpose of this study was to determine if LPT would mobilize inflammatory mediators into the lymphatic circulation. Under anesthesia, thoracic or intestinal lymph of dogs was collected at resting (pre-LPT), during four minutes of LPT, and for 10 min following LPT (post-LPT), and the lymphatic concentrations of interleukin-2 (IL-2), IL-4, IL-6, IL-10, interferon- γ, tissue necrosis factor α,  monocyte chemotactic protein-1 (MCP-1), keratinocyte chemoattractant, superoxide dismutase (SOD) and nitrotyrosine (NT) were measured. LPT significantly increased MCP-1 concentrations in thoracic duct lymph. Further, LPT increased both thoracic and intestinal duct lymph flux of cytokines and chemokines as compared with their respective pre-LPT flux. In addition, LPT increased lymphatic flux of SOD and NT. Ten minutes following cessation of LPT, thoracic and intestinal lymph flux of cytokines, chemokines, NT and SOD were similar to pre-LPT, demonstrating that their flux was transient and a response to LPT. This re-distribution of inflammatory mediators during LPT may provide scientific rationale for the clinical use of LPT to enhance immunity and treat infection.

Lymphatic pump treatment augments lymphatic flux of lymphocytes in rats

BACKGROUND

Lymphatic pump techniques (LPT) are used by osteopathic practitioners for the treatment of edema and infection; however, the mechanisms by which LPT enhances the lymphatic and immune systems are poorly understood.

METHODS AND RESULTS

To measure the effect of LPT on the rat, the cisterna chyli (CC) of 10 rats were cannulated and lymph was collected during 4 min of 1) pre-LPT baseline, 2) 4 min LPT, and 3) 10 min post-LPT recovery. LPT increased significantly (p < 0.05) lymph flow from a baseline of 24 ± 5 μl/min to 89 ± 30 μl/min. The baseline CC lymphocyte flux was 0.65 ± 0.21 × 10⁶ lymphocytes/min, and LPT increased CC lymphocyte flux to 6.10 ± 0.99 × 10⁶ lymphocytes/min (p < 0.01). LPT had no preferential effect on any lymphocyte population, since total lymphocytes, CD4+ T cells, CD8+ T cells, and B cell numbers were similarly increased. To determine if LPT mobilized gut-associated lymphocytes into the CC lymph, gut-associated lymphocytes in the CC lymph were identified by staining CC lymphocytes for the gut homing receptor integrin α4β7. LPT significantly increased (p < 0.01) the flux of α4β7 positive CC lymphocytes from a baseline of 0.70 ± 0.03 × 10⁵ lymphocytes/min to 6.50 ± 0.10 × 10⁵ lymphocytes/min during LPT. Finally, lymphocyte flux during recovery was similar to baseline, indicating the effects of LPT are transient.

CONCLUSIONS

Collectively, these results suggest that LPT may enhance immune surveillance by increasing the numbers of lymphocytes released in to lymphatic circulation, especially from the gut associated lymphoid tissue. The rat provides a useful model to further investigate the effect of LPT on the lymphatic and immune systems.

Lymphatic pump treatment enhances the lymphatic and immune systems

The osteopathic medical profession has long advocated the use of osteopathic lymphatic pump treatments (LPT) to improve lymphatic circulation, reduce edema and combat infectious disease. However, until recently, there was no scientific evidence that LPT enhances function of the lymphatic and immune systems. This review discusses the physiological functions of the lymphatic system, the ability of LPT to increase lymph flow under normal and experimental conditions, the clinical benefits of LPT, current research models for the study of LPT and the potential mechanisms by which LPT enhances lymphatic and immune function.

Lymph flow in instrumented dogs varies with exercise intensity

BACKGROUND

Although it is generally accepted that exercise accelerates lymph flow, no study has directly measured lymph flow as a function of exercise intensity. In this study, we have measured flow in the thoracic lymph duct of five instrumented dogs while they ran on a treadmill.

METHODS AND RESULTS

Dogs were surgically instrumented with an ultrasonic flow transducer on the thoracic lymph duct and a catheter in the descending thoracic aorta. After recovery from surgery, the dogs ran on a treadmill at speeds which varied stepwise from 0 to 10 mph and from 10 to 0 mph. Dogs ran for 1 min at each speed with 15 min rest between each exercise. Heart rate increased significantly during exercise, whereas mean aortic pressure did not change. Resting lymph flow was 1.7+/-0.2 ml/min. Exercise at 1.5 mph significantly increased lymph flow to 3.9 +/- 0.6 ml/min (P < 0.01), 121% higher than resting flow. Lymph flow was further elevated at higher treadmill speeds, reaching 9.0 +/-1.6 ml/min (P < 0.01) at 10 mph, 419% higher than resting flow. Regression analysis demonstrated a linear relationship between treadmill speed and the percent increase in lymph flow. Lymph flow returned to the resting rate 1-2 min post-exercise.

CONCLUSION

Lymph flow in the thoracic duct is positively correlated with exercise intensity.

Lymphatic pump treatment increases thoracic duct lymph flow in conscious dogs with edema due to constriction of the inferior vena cava

BACKGROUND

Osteopathic lymphatic pump treatments (LPT) are used to treat edema, but their direct effects on lymph flow have not been studied. In the current study, we examined the effects of LPT on lymph flow in the thoracic duct of instrumented conscious dogs in the presence of edema produced by constriction of the inferior vena cava (IVC).

METHODS AND RESULTS

Six dogs were surgically instrumented with an ultrasonic flow transducer on the thoracic lymph duct and catheters in the descending thoracic aorta and in IVC. After postoperative recovery, lymph flow and hemodynamic variables were measured 1) pre-LPT, 2) during 4 min LPT, 3) post-LPT, in the absence and presence of edema produced by IVC constriction. This constriction increased abdominal girth from 60 +/-2.6 to 75 +/- 2.9 cm. Before IVC constriction, LPT increased lymph flow (P < 0.05) from 1.9 +/- 0.2 ml/min to a maximum of 4.7 +/-1.2 ml/min, whereas after IVC constriction, LPT increased lymph flow (P < 0.05) from 7.9 +/-2.2 to a maximum of 11.7 +/-2.2 ml/min. The incremental lymph flow mobilized by 4 min of LPT (ie, the flow that exceeded 4 min of baseline flow), was 10.6 ml after IVC constriction. This incremental flow was not significantly greater than that measured before IVC constriction.

CONCLUSIONS

Edema caused by IVC constriction markedly increased lymph flow in the thoracic duct. LPT increased thoracic duct lymph flow before and after IVC constriction. The lymph flow mobilized by 4 min of LPT in presence of edema was not significantly greater than that mobilized prior to edema.

Lymphatic pump treatment mobilizes leukocytes from the gut associated lymphoid tissue into lymph

BACKGROUND

Lymphatic pump techniques (LPT) are used clinically by osteopathic practitioners for the treatment of edema and infection; however, the mechanisms by which LPT enhances lymphatic circulation and provides protection during infection are not understood. Rhythmic compressions on the abdomen during LPT compress the abdominal area, including the gut-associated lymphoid tissues (GALT), which may facilitate the release of leukocytes from these tissues into the lymphatic circulation. This study is the first to document LPT-induced mobilization of leukocytes from the GALT into the lymphatic circulation.

METHODS AND RESULTS

Catheters were inserted into either the thoracic or mesenteric lymph ducts of dogs. To determine if LPT enhanced the release of leukocytes from the mesenteric lymph nodes (MLN) into lymph, the MLN were fluorescently labeled in situ. Lymph was collected during 4 min pre-LPT, 4 min LPT, and 10 min following cessation of LPT. LPT significantly increased lymph flow and leukocytes in both mesenteric and thoracic duct lymph. LPT had no preferential effect on any specific leukocyte population, since neutrophil, monocyte, CD4+ T cell, CD8+ T cell, IgG+B cell, and IgA+B cell numbers were similarly increased. In addition, LPT significantly increased the mobilization of leukocytes from the MLN into lymph. Lymph flow and leukocyte counts fell following LPT treatment, indicating that the effects of LPT are transient.

CONCLUSIONS

LPT mobilizes leukocytes from GALT, and these leukocytes are transported by the lymphatic circulation. This enhanced release of leukocytes from GALT may provide scientific rationale for the clinical use of LPT to improve immune function.

Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial

Background

The Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) is a registered, double-blinded, randomized, controlled trial designed to assess the efficacy of osteopathic manipulative treatment (OMT) as an adjunctive treatment in elderly patients with pneumonia.

Methods

406 subjects aged ≥ 50 years hospitalized with pneumonia at 7 community hospitals were randomized using concealed allocation to conventional care only (CCO), light-touch treatment (LT), or OMT groups. All subjects received conventional treatment for pneumonia. OMT and LT groups received group-specific protocols for 15 minutes, twice daily until discharge, cessation of antibiotics, respiratory failure, death, or withdrawal from the study. The primary outcomes were hospital length of stay (LOS), time to clinical stability, and a symptomatic and functional recovery score.

Results

Intention-to-treat (ITT) analysis (n = 387) found no significant differences between groups. Per-protocol (PP) analysis (n = 318) found a significant difference between groups (P = 0.01) in LOS. Multiple comparisons indicated a reduction in median LOS (95% confidence interval) for the OMT group (3.5 [3.2-4.0] days) versus the CCO group (4.5 [3.9-4.9] days), but not versus the LT group (3.9 [3.5-4.8] days). Secondary outcomes of duration of intravenous antibiotics and treatment endpoint were also significantly different between groups (P = 0.05 and 0.006, respectively). Duration of intravenous antibiotics and death or respiratory failure were lower for the OMT group versus the CCO group, but not versus the LT group.

Conclusions

ITT analysis found no differences between groups. PP analysis found significant reductions in LOS, duration of intravenous antibiotics, and respiratory failure or death when OMT was compared to CCO. Given the prevalence of pneumonia, adjunctive OMT merits further study.

The immediate effect of individual manipulation techniques on pulmonary function measures in persons with chronic obstructive pulmonary disease

BACKGROUND

The use of manipulation has long been advocated in the treatment of chronic obstructive pulmonary disease (COPD), but few randomized controlled clinical trials have measured the effect of manipulation on pulmonary function. In addition, the effects of individual manipulative techniques on the pulmonary system are poorly understood. Therefore, the purpose of this study was to determine the immediate effects of four osteopathic techniques on pulmonary function measures in persons with COPD relative to a minimal-touch control protocol.

METHODS

Persons with COPD aged 50 and over were recruited for the study. Subjects received five, single-technique treatment sessions: minimal-touch control, thoracic lymphatic pump (TLP) with activation, TLP without activation, rib raising, and myofascial release. There was a 4-week washout period between sessions. Protocols were given in random order until all five techniques had been administered. Pulmonary function measures were obtained at baseline and 30-minutes posttreatment. For the actual pulmonary function measures and percent predicted values, Wilcoxon signed rank tests were used to test within-technique changes from baseline. For the percent change from baseline, Friedman tests were used to test for between-technique differences.

RESULTS

Twenty-five subjects were enrolled in the study. All four tested osteopathic techniques were associated with adverse posttreatment changes in pulmonary function measures; however, different techniques changed different measures. TLP with activation increased posttreatment residual volume compared to baseline, while TLP without activation did not. Side effects were mild, mostly posttreatment chest wall soreness. Surprisingly, the majority of subjects believed they could breathe better after receiving osteopathic manipulation.

CONCLUSION

In persons with COPD, TLP with activation, TLP without activation, rib raising, and myofascial release mildly worsened pulmonary function measures immediately posttreatment relative to baseline measurements. The activation component of the TLP technique appears to increase posttreatment residual volume. Despite adverse changes in pulmonary function measures, persons with COPD subjectively reported they benefited from osteopathic manipulation.

The National Osteopathic Research Center at the University of North Texas Health Science Center: inception, growth, and future

The osteopathic profession has long recognized the need to carry out research in order to improve clinical care. Osteopathic physicians have a particular obligation to carry out research in areas, such as osteopathic manipulative medicine (OMM), that are unique to osteopathic medicine. OMM is similar to manual therapy that is performed by other types of practitioners, but it has some distinctive characteristics. Osteopathic doctors also use OMM to treat infectious disease-not just musculoskeletal disorders.In 2001, several osteopathic professional organizations agreed to jointly fund a national osteopathic research center at one of the osteopathic medical colleges. Five osteopathic colleges submitted research proposals in response to a request for applications. The University of North Texas Health Science Center (UNTHSC) was chosen to be the site for the Osteopathic Research Center (ORC) and was funded for four years with $1.1M. Between 2002 and 2007, the ORC received an additional $11M in research support from multiple sources including federal funds. With this support, it has made substantive contributions to science. These include oversight of the recently completed four-year, $1.5M multicenter study on the efficacy of OMM as a treatment for pneumonia in the elderly and a three-year, $1.9M National Institutes of Health-funded developmental research center to perform mechanistic studies of some OMM actions.The authors discuss the long-term costs, benefits, and sustainability of the national ORC at UNTHSC in the contexts of research accomplished, the training of new medical osteopathic researchers, and an effort to develop other successful regional osteopathic research centers.

Systematic review of efficacy for manual lymphatic drainage techniques in sports medicine and rehabilitation: an evidence-based practice approach

Manual therapists question integrating manual lymphatic drainage techniques (MLDTs) into conventional treatments for athletic injuries due to the scarcity of literature concerning musculoskeletal applications and established orthopaedic clinical practice guidelines. The purpose of this systematic review is to provide manual therapy clinicians with pertinent information regarding progression of MLDTs as well as to critique the evidence for efficacy of this method in sports medicine. We surveyed English-language publications from 1998 to 2008 by searching PubMed, PEDro, CINAHL, the Cochrane Library, and SPORTDiscus databases using the terms lymphatic system, lymph drainage, lymphatic therapy, manual lymph drainage, and lymphatic pump techniques. We selected articles investigating the effects of MLDTs on orthopaedic and athletic injury outcomes. Nine articles met inclusion criteria, of which 3 were randomized controlled trials (RCTs). We evaluated the 3 RCTs using a validity score (PEDro scale). Due to differences in experimental design, data could not be collapsed for meta-analysis. Animal model experiments reinforce theoretical principles for application of MLDTs. When combined with concomitant musculoskeletal therapy, pilot and case studies demonstrate MLDT effectiveness. The best evidence suggests that efficacy of MLDT in sports medicine and rehabilitation is specific to resolution of enzyme serum levels associated with acute skeletal muscle cell damage as well as reduction of edema following acute ankle joint sprain and radial wrist fracture. Currently, there is limited high-ranking evidence available. Well-designed RCTs assessing outcome variables following implementation of MLDTs in treating athletic injuries may provide conclusive evidence for establishing applicable clinical practice guidelines in sports medicine and rehabilitation.

Rediscovering the classic osteopathic literature to advance contemporary patient-oriented research: A new look at diabetes mellitus

Patient care experiences represent opportunities for establishing theories, testable hypotheses, and data to assess the potential use of osteopathic manipulative treatment in various disease conditions. The re-analysis of Bandeen's 1949 raw data described herein summarizes the effects of osteopathic manipulative treatment involving pancreatic stimulatory and inhibitory techniques in diabetic and non-diabetic patients seen over a 25-year period of clinical practice. Bandeen's data demonstrate a reduction in blood glucose levels at 30 and 60 minutes following pancreatic stimulation in 150 diabetic patients, and an elevation in blood glucose levels at 30 and 60 minutes following pancreatic inhibition in 40 non-diabetic patients. Such patient-oriented research conducted during the classic era of osteopathy in the United States provides a foundation and data for generating hypotheses about the potential mechanisms of action of osteopathic manipulative treatment. Osteopathic investigators would be well-served to rediscover the classic osteopathic literature to help advance contemporary evidence-based medicine.

Lymph flow in the thoracic duct of conscious dogs during lymphatic pump treatment, exercise, and expansion of extracellular fluid volume

BACKGROUND

This investigation examined interactions between expansion of the extracellular fluid volume (ECE), osteopathic lymphatic pump treatment (LPT), and exercise on lymph flow in the thoracic duct of eight instrumented, conscious dogs.

METHODS AND RESULTS

After recovery from surgery, LPT was performed for 8 min before and after ECE with normal saline, i.v., 4.4+/-0.3% of body weight. Baseline lymph flow was 1.7+/-0.5 mL/min. LPT rapidly increased lymph flow to 5.0+/-1.1 mL/min at 1 min, and lymph flow remained above baseline for 4 min (p<0.05). LPT produced a net increase in lymph flow of 15.4+/-1.1 mL. Following ECE, baseline lymph flow was 4.8+/-0.6 mL/min (p<0.05). LPT increased lymph flow to 9.9+/-1.1 mL/min at 1 min (p<0.05), and lymph flow remained above baseline for 4 min (p<0.05); all flow values after ECE were greater than corresponding values before ECE. However, the net increase in lymph flow produced by 8 min of LPT (18.3+/-3.8 mL) was not significantly greater than that observed before ECE. Moderate treadmill exercise increased lymph flow for 4 min before ECE and for 6 min after ECE. All lymph flows during exercise were greater after ECE than before ECE. The net increase in lymph flow produced by 8 min of exercise was 24.9+/-5.5 mL before ECE and 39.6+/-5.1 mL after ECE (p<0.05).

CONCLUSIONS

Expansion of the extracellular fluid volume produced large increases in thoracic duct lymph flow, that were further augmented by lymphatic pump treatment and by moderate treadmill exercise.