A comparison of selected osteopathic treatment and relaxation for tension-type headaches

Clinical Effectiveness of Craniosacral Therapy in Patients with Headache Disorders: A Systematic Review and Meta-analysis

OBJECTIVES

To analyze the effectiveness of craniosacral therapy in improving pain and disability among patients with headache disorders.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Physiotherapy Evidence Database, Scopus, Cochrane Library, Web of Science, and Osteopathic Medicine Digital Library databases were searched in March 2023.

REVIEW METHODS

Two independent reviewers searched the databases and extracted data from randomized controlled trials comparing craniosacral therapy with control or sham interventions. The same reviewers assessed the methodological quality and the risk of bias using the PEDro scale and the Cochrane Collaboration tool, respectively. Grading of recommendations, assessment, development, and evaluations was used to rate the certainty of the evidence. Meta-analyses were conducted using random effects models using RevMan 5.4 software.

RESULTS

The searches retrieved 735 studies, and four studies were finally included. The craniosacral therapy provided statistically significant but clinically unimportant change on pain intensity (Mean difference = -1.10; 95% CI: -1.85, -0.35; I2: 44%), and no change on disability or headache effect (Standardized Mean Difference = -0.34; 95% CI -0.70, 0.01; I2: 26%). The certainty of the evidence was downgraded to very low.

CONCLUSION

Very low certainty of evidence suggests that craniosacral therapy produces clinically unimportant effects on pain intensity, whereas no significant effects were observed in disability or headache effect.

Exploring New Patient Understanding of Osteopathic Manipulative Medicine using a Cross-Sectional Survey and Mixed Methods Approach

INTRODUCTION

Osteopathic manipulative medicine (OMM), a patient-focused approach to medical treatment utilized by doctors of osteopathic medicine (DO), continues to be an under-utilized resource in treating musculoskeletal disorders. Lack of familiarity by both referring physicians and patients of OMM can impact patient-physician communication and impede patient-centered care approaches. This 2020-2021 study was conducted to investigate new patient understanding of OMM within the Michigan State University OMM Clinic.

METHODS

A set of 18 survey questions developed by the authors within their MSU OMM clinic were utilized for the study. The main purpose of the questions was to generally ascertain new patient’s understanding of OMM, its role in patient care, who can place clinic referrals and the services an OMM clinic provides. Respondents were new adult patients at the MSU OMM clinic.

RESULTS

The convenience study sample of 83 respondents was primarily female, 60 (72.3%). Few respondents were familiar with OMM, as only eight (9.64%) reported prior experience with OMM. Of the 83 patients in this study, 69 (80.7%) reported back pain. When examining referral patterns, there were low numbers of referrals from non-PCP providers, especially from advanced practice providers (APP), including physician assistants (n = three, 3.66%) and nurse practitioners (n = eight, 7.96%). Most surveyed patients 61 (73.5%) had been referred by their primary care providers.

CONCLUSIONS

Results indicate that communication directed to non-DO physicians, advanced practice providers and patients about OMM services may be helpful to provide noninvasive symptomatic treatment options for musculoskeletal conditions. Further larger-scale studies examining both non-DO provider and new patient perceptions concerning OMM are clearly warranted.

Effects of Foam Rolling vs. Manual Therapy in Patients with Tension-Type Headache: A Randomized Pilot Study

Background: This study compares the effect of foam rolling (FR) vs. manual therapy (MT) on pain, pressure pain threshold (PPT), headache disability (HDI) and impact of headache (HIT-6) in patients with tension-type headache (TTH). Methods: A total of 38 participants with TTH were randomly assigned to an FR group (FRG, n = 13), an MT group (MTG, n = 13) or a control group (CG, n = 12). FRG received FR treatment; MTG received MT techniques; CG received a placebo treatment. The treatment lasted one month. Outcome measures were assessed at baseline, post-intervention and follow-up. Results: Both FRG and MTG showed significant improvements in all variables after the treatment, but the intervention effect was maintained only for functional disability (p = 0.002 and p = 0.005, respectively), overall disability (p = 0.007; p = 0.030) and HIT-6 (p = 0.002; p = 0.001) at follow-up. After treatment, FRG and MTG presented a significantly higher PPT in right (p = 0.044; p = 0.009) and left suboccipital (p = 0.004; p = 0.021). MTG showed a significantly lower HIT-6 than CG (p = 0.008). No differences between FRG and MTG were found in any variable. Conclusions: Both FR and MT are effective treatments for the improvement of clinical symptoms in TTH. Further studies are needed to confirm our findings in a larger population.

Competitive Anxiety, and Guilt and Shame Proneness From Perspective Type D and Non-type D Football Players

The precompetitive, competitive, and postcompetitive mental states of athletes are currently not sufficiently researched. Long-term exposure to stressors contributes to the formation of mental blocks and leads to various health problems. One of the factors that can explain the variability of athletes' reactions to stress is their personality. This study is the first to examine competitive anxiety, and guilt and shame proneness in the context of the reaction of football players to distress in sports. The study consists of 112 male football players aged 16–24 (21.00 ± 1.90) who were divided into type D and non-type D football players according to scoring on the Denollet Scale (DS14). Football players also filled out the Sport Anxiety Scale (SAS-2) and the Guilt and Shame Proneness Scale (GASP). The taxonomic approach was conducted to test and to examine differences in stressor intensity as a function of type D personality. A correlation, multivariate analysis of variance, and regression analysis were performed in the study. We found that type D football players were more afraid of failures in sports (worry), felt more often autonomous excitement concentrated in the stomach and muscles (somatic anxiety), and showed more frequent concentration disruption than did non-type D football players. We also found that although type D football players were more likely to rate their behavior as negative and inappropriate, they showed a much greater effort to correct it than did non-type D football players. Negative affectivity and social inhibition of type D football players were positively correlated with competitive anxiety. In addition, we noted lower levels of somatic anxiety and lower concentration disruption for football players who used escape strategies to manage stress. The shame proneness subscale monitoring negative self-evaluation was also closely related to the concentration disruption of football players. We found that the examination of athletes by type D personality is necessary due to the fact that negative affectivity and social inhibition are significant predictors of competitive anxiety of football players, which explains their worries at 24.0%, somatic anxiety at 8.2%, and concentration disruption at 10.6%.

Effect of occipitoatlantal decompression on cerebral blood flow dynamics as evaluated by Doppler ultrasonography

Context

Osteopathic manipulative treatment reduces symptoms in patients with headache disorders, but the underlying mechanisms are unclear.

Objective

To evaluate blood flow in the intracranial and extracranial vasculature before and after occipitoatlantal decompression (OAD) using Doppler ultrasonography.

Methods

Healthy, first-year osteopathic medical students from A.T. Still University's Kirksville College of Osteopathic Medicine participated in a randomized, single-blinded, two-period, two-treatment crossover study. The participants were randomly assigned to 1 of 2 treatment interventions: OAD or sham touch. After one week, participants returned to have the other intervention performed. Blood flow parameters-peak systolic velocity (PSV) and end-diastolic velocity (EDV)-in the middle cerebral artery (MCA), internal carotid artery (ICA), and vertebral artery (VA) were evaluated before, immediately after, 5 minutes after, and 10 minutes after treatment. Differences in PSV, EDV, heart rate (HR), and blood pressure (BP) for both interventions were analyzed for the four time points using mixed-effects models.

Results

Thirty healthy medical students (11 men, 19 women; mean age, 24 years) participated in this study. EDV increased after OAD in the MCA, ICA, and VA (all p<0.001); no change occurred after sham touch (all p>0.05). EDV was greater for all post-treatment timepoints after OAD in the MCA, ICA, and VA than after sham touch (all p<0.001). Although baseline PSV in the MCA measured before treatment was different between treatment interventions (p=0.01), no difference was found between interventions at any post-treatment time point (all p>0.59). Changes in PSV in the ICA and VA and for HR and BP did not depend on treatment intervention (p>0.06).

Conclusion

Increases in EDV occurred in major cranial arteries after OAD but not after sham touch, indicating that OAD improves blood flow to the brain. The exact mechanism of this increase is unknown; however, it can be explained by either parasympathetic stimulation through the secretion of vasodilating neurotransmitters or by a decrease in external tissue pressure on ICA and VA, with the resulting flow causing further dilation in the MCA.

Osteopathic Manipulative Treatment in Tension Headaches

Tension-type headaches, associated with young age, poor health, sleep disturbances, anxiety, stress, and poor posture, account for 90% of all headaches diagnosed by healthcare professionals. Diagnosis and treatment of the various headache subtypes are often aimed at determining the underlying cause but commonly involve over-the-counter pain medication. Because recurrence is common in tension-type headaches, with a subsequent refractory response to over-the-counter medications, adjunctive and alternative treatment modalities should be further studied. Here we present a case of tension headache initially non-responsive to pain medication but resolved with osteopathic manipulative treatment and lifestyle modifications. Osteopathic considerations and literature are also reviewed in the broader context of headache management.

Osteopathic Manipulative Treatment Relieves Post-concussion Symptoms in a Case of Polytrauma

Optimal management of post-concussion symptoms (PCS) remains ill-defined but includes multimodal, symptom-guided plans of care. Osteopathic manipulative treatment (OMT) may be used as an adjunct treatment for PCS.

We present a case of a motor vehicle collision victim whose PCS improved directly and progressively after OMT. To our knowledge, this is the first report of OMT utilized for PCS management after polytrauma and as part of an organized trauma system.

Previous studies discuss potential benefits of OMT for patients with PCS after sports-related injuries, and none account for management of multiply injured patients as part of an organized trauma system. Further study of OMT for PCS is warranted and would benefit by recruiting patients from trauma centers in order to observe a range of mechanisms of injury that result in concussion.

Introducing national osteopathy practice-based research networks in Australia and New Zealand: an overview to inform future osteopathic research

Both the Osteopathic Research Innovation Network (ORION) and the Osteopathy Research Connect-New Zealand (ORC-NZ) are practice-based research networks (PBRNs) recently established in Australia and New Zealand. This paper highlights the profile of the osteopaths participating in each PBRN in order to encourage and facilitate further related research in osteopathy. All registered osteopaths in Australia and New Zealand were invited to participate in the ORION and ORC-NZ PBRNs, respectively. This paper presents practice and sociodemographic characteristics of the osteopaths that elected to join the PBRN in their country. A total of 253 registered osteopaths in New Zealand (48.7%) agreed to join ORC-NZ while 992 registered osteopaths in Australia (44.5%) joined ORION. Membership of both PBRNs reflect national geographical spread, and diverse personal and practice characteristics. Combined membership of both PBRNs represents 45.3% of all registered osteopaths in Australasia and 7.7% of the global osteopathic profession. The PBRNs, independently and in combination, hold much potential to advance the evidence-base and capacity of osteopathy research. Both ORION and ORC-NZ PBRNs are powerful, innovative resources available to other interested parties to help conduct further osteopathy research in Australia and New Zealand.

Safety of Osteopathic Cranial Manipulative Medicine as an Adjunct to Conventional Postconcussion Symptom Management: A Pilot Study

Context

Osteopathic cranial manipulative medicine is not a well-established adjunct to conventional treatment for patients with postconcussion symptoms.

Objective

To determine whether adjunctive osteopathic cranial manipulative medicine is safe for patients with concussion when accompanied by conventional treatments.

Design

Prospective observational pilot study.

Setting

Outpatient concussion clinic.

Participants

Patients who sustained a concussion were prospectively recruited from an outpatient concussion clinic by a neuropsychologist specialized in concussion. All participants were identified to have a cranial dysfunction.

Intervention

Each eligible participant received 1 session of the osteopathic cranial manipulative medicine vault hold technique.

Main Outcome Measures

Self-reported adverse events during or after 1 session of the osteopathic cranial manipulative medicine procedure and improvement in concussion symptoms at return to follow-up.

Results

None of the 9 participants reported adverse events during or immediately after receiving osteopathic cranial manipulative medicine. Five of the 7 participants who returned for follow-up demonstrated improvement in their overall concussion symptoms based on the Post-Concussion Symptom Scale scores.

Conclusions

Osteopathic cranial manipulative medicine was considered a safe adjunctive treatment option to improve concussion-related symptoms and recovery.

Evaluation of New Zealand osteopathy patients experiences of their treatment

OBJECTIVES

To investigate the experiences of patients seeking osteopathy treatment in New Zealand; and to describe their perceptions of osteopathic treatment.

DESIGN

Survey-based research design.

SETTING

Private osteopathy practices.

MAIN OUTCOME MEASURES

Demographic survey and the Patient Perception Measure-Osteopathy (PPM-O).

RESULTS

Twelve osteopaths were recruited as practitioners. Responses from 107 patients were analysed. Approximately 75% of patients reported receiving a 'mostly cranial' treatment approach. The majority of patients (96.2%) indicated that osteopathic treatment helped their condition. The most frequently experienced sensation was 'relaxed'. A positive relationship was observed between the PPM-O and demographic variables.

CONCLUSIONS

This is the first study to report on New Zealand osteopathy patient's experience of their treatment. The sensations and emotions experienced are largely consistent with previous Australian research. Predominantly positive perceptions of osteopathic treatment were reported. The current study provides some evidence of the construct validity of the PPM-O in a New Zealand patient population.

Single Osteopathic Manipulative Therapy Session Dampens Acute Autonomic and Neuroendocrine Responses to Mental Stress in Healthy Male Participants

Context

The efficacy of osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) is supported by observational data and patient feedback, but there is still a need for objective, quantitative biomarkers that allow measurement of the underlying mechanisms. No study exploring the protective potential of OMTh for mental stress has been published, to the authors’ knowledge.

Objectives

To explore the modulating effect of OMTh on autonomic neural regulation of the heart and verifiy its ability to influence the activity of the hypothalmic-pituitary-adrenocortical axis.

Methods

Healthy young adult men who had never received OMTh were exposed to either a brief protocol using craniosacral techniques or sham therapy (control) involving the same anatomical areas. A laboratory stress episode consisting of a 5-minute arithmetic task participants were required to perform in front of a committee preceded the therapy sessions. Continuous electrocardiograph recordings were done before, during, and after the stress episode. Heart rate and frequency-domain parameters of heart rate variability (specifically, high-frequency component power in normalized units and the ratio of low-frequency to high-frequency power) were measured to quantify the activity of the parasympathetic nervous system and the state of sympathovagal balance at the level of the heart, respectively. Saliva samples were also collected at points throughout the study to determine cortisol levels.

Results

Osteopathic manipulative therapy reduced the overall chronotropic effect of the stressor (t=−2.9, P<.05) and counteracted the vagal withdrawal and the shift of autonomic balance toward sympathetic prevalence (t=−2.8, P<.05) that were observed in control participants. Moreover, OMTh participants had a much lower overall cortisol level during the mental stressor compared with control participants (t=−2.3, P<.05). Participants in the OMTh group did not show the statistically significant reduction in the amplitude of the cortisol awakening response observed in their control counterparts after the stress episode (control: t=2.7, P<.05; OMT: P=.83).

Conclusion

The application of a single OMTh session to healthy participants induced a faster recovery of heart rate and sympathovagal balance after an acute mental stressor by substantially dampening parasympathetic withdrawal and sympathetic prevalence. The OMTh session also prevented the typical increase in cortisol levels observed immediately after a brief mental challenge.

Osteopathy for primary headache patients: a systematic review

OBJECTIVE

This systematic review aimed to assess the efficacy, effectiveness, safety, and tolerability of osteopathic manipulative treatment (OMT) in patients with headache.

BACKGROUND

Migraine is one of the most common and disabling medical conditions. It affects more than 15% of the general population, causing high global socioeconomic costs, and the currently available treatment options are inadequate.

METHODS

We systematically reviewed all available studies investigating the use of OMT in patients with migraine and other forms of headache.

RESULTS

The search of literature produced six studies, five of which were eligible for review. The reviewed papers collectively support the notion that patients with migraine can benefit from OMT. OMT could most likely reduce the number of episodes per month as well as drug use. None of the included studies, however, was classified as low risk of bias according to the Cochrane Collaboration's tool for assessing risk of bias.

CONCLUSION

The results from this systematic review show a preliminary low level of evidence that OMT is effective in the management of headache. However, studies with more rigorous designs and methodology are needed to strengthen this evidence. Moreover, this review suggests that new manual interventions for the treatment of acute migraine are available and developing.

Osteopathic manipulative treatment: A systematic review and critical appraisal of comparative effectiveness and health economics research

In recent years, evidence has emerged regarding the effectiveness of osteopathic manipulative treatments (OMT). Despite growing evidence in this field, there is need for appropriate research designs that effectively reflect the person-centred system of care promoted in osteopathy and provide data which can inform policy decisions within the healthcare system. The purpose of this systematic review is to identify, appraise and synthesise the evidence from comparative effectiveness and economic evaluation research involving OMT. A database search was conducted using CINAHL, PubMed, PEDro, AMED, SCOPUS and OSTMED.DR, from their inception to May 2015. Two separate searches were undertaken to identify original research articles encompassing the economic evaluation and comparative effectiveness of OMT. Identified comparative effectives studies were evaluated using the Cochrane risk of bias tool and appraised using the Good Reporting of Comparative Effectiveness (GRACE) principles. Identified economic studies were assessed with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines. Sixteen studies reporting the findings of comparative effectiveness (n = 9) and economic evaluation (n = 7) research were included. The comparative effectiveness studies reported outcomes for varied health conditions and the majority (n = 6) demonstrated a high risk of bias. The economic evaluations included a range of analyses and considerable differences in the quality of reporting were evident. Despite some positive findings, published comparative effectiveness and health economic studies in OMT are of insufficient quality and quantity to inform policy and practice. High quality, well-designed, research that aligns with international best practice is greatly needed to build a pragmatic evidence base for OMT.

Craniosacral Therapy for the Treatment of Chronic Neck Pain: A Randomized Sham-controlled Trial

Objectives:

With growing evidence for the effectiveness of craniosacral therapy (CST) for pain management, the efficacy of CST remains unclear. This study therefore aimed at investigating CST in comparison with sham treatment in chronic nonspecific neck pain patients.

Materials and Methods:

A total of 54 blinded patients were randomized into either 8 weekly units of CST or light-touch sham treatment. Outcomes were assessed before and after treatment (week 8) and again 3 months later (week 20). The primary outcome was the pain intensity on a visual analog scale at week 8; secondary outcomes included pain on movement, pressure pain sensitivity, functional disability, health-related quality of life, well-being, anxiety, depression, stress perception, pain acceptance, body awareness, patients’ global impression of improvement, and safety.

Results:

In comparison with sham, CST patients reported significant and clinically relevant effects on pain intensity at week 8 (−21 mm group difference; 95% confidence interval, −32.6 to −9.4; P=0.001; d=1.02) and at week 20 (−16.8 mm group difference; 95% confidence interval, −27.5 to −6.1; P=0.003; d=0.88). Minimal clinically important differences in pain intensity at week 20 were reported by 78% within the CST group, whereas 48% even had substantial clinical benefit. Significant between-group differences at week 20 were also found for pain on movement, functional disability, physical quality of life, anxiety and patients’ global improvement. Pressure pain sensitivity and body awareness were significantly improved only at week 8. No serious adverse events were reported.

Discussion:

CST was both specifically effective and safe in reducing neck pain intensity and may improve functional disability and the quality of life up to 3 months after intervention.

Osteopathic manipulative treatment in neurological diseases: Systematic review of the literature

OBJECTIVE

The aim of the present systematic review is to critically evaluate the effectiveness of OMT as an adjuvant therapy in the management of patients with neurological diseases.

METHODS

A systematic review was conducted and the findings were reported following the PRISMA statement. Twelve databases were searched for articles reporting the use of osteopathic manipulative treatment in neurological disorders. Each article was assessed using the Cochrane risk of bias tool and the Jadad score.

RESULTS

10 articles were included. OMT was used to test its efficacy and/or effectiveness in treating tension-type headache, migraine, cerebral palsy and gait analysis in patients affected by Parkinson's Disease. The general quality of the included trials ranged from very low, to low and moderate according to Cochrane standards. High heterogeneity between studies was found for the type of intervention, control and outcome measures used.

CONCLUSION

Results showed that studies on the efficacy and/or effectiveness of OMT treatments are scarce, heterogeneous, and of low methodological quality. Further studies should be conducted including a more pragmatic methodology, an exhaustive description of all investigated and concurrent interventions, and a systematic report of adverse events, so as to obtain robust and generalizable results.

Resolution of Concussion Symptoms After Osteopathic Manipulative Treatment: A Case Report

A concussion is the result of a biomechanical force directed toward the head, causing neurologic dysfunction. The inflammatory response and the production of reactive oxygen species are proposed mechanisms for the symptoms and long-term sequelae of concussion. Osteopathic manipulative treatment (OMT) may help reduce inflammation by improving glymphatic flow. The authors describe the effect of OMT on a patient with mild concussion symptoms, including nausea, dizziness, tinnitus, and imbalance. The patient was evaluated with the Sensory Organization Test before and after undergoing a 25-minute session of OMT. After the session, the patient reported resolution of symptoms, and his sensory organization test score improved by 6 points. The role of OMT must be further investigated as an essential and cost-effective tool in the management of concussions.

Effectiveness of Physical Therapy in Patients with Tension-type Headache: Literature Review

BACKGROUND

Tension-type headache (TTH) is a disease with a great incidence on quality of life and with a significant socioeconomic impact.

OBJECTIVES

The aim of this review is to determine the effectiveness of physical therapy by using manual therapy (MT) for the relief of TTH.

DATA SOURCES

A review was done identifying randomized controlled trials through searches in MEDLINE, PEDro, Cochrane and CINAHL (January 2002 - April 2012).

STUDY SELECTION

English-language studies, with adult patients and number of subjects not under 11, diagnosed with episodic tension-type headache (ETTH) and chronic tension-type headache (CTTH) were included.

DATA EXTRACTION

Initial search was undertaken with the words Effectiveness, Tension-type headache, and Manual therapy (39 studies). In addition, a search which included terms related to treatments such as physiotherapy, physical therapy, spinal manipulation was performed (25 studies).

RESULTS

From the two searches 9 studies met the inclusion criteria and were analysed finding statistically significant results: 1) myofascial release, cervical traction, neck muscles trigger points in cervical thoracic muscles and stretching; 2) Superficial heat and massage, connective tissue manipulation and vertebral Cyriax mobilization; 3) cervical or thoracic spinal manipulation and cervical chin-occipital manual traction; 4) massage, progressive relaxation and gentle stretching, program of active exercises of shoulder, neck and pericranial muscles; 5) massage, passive rhythmic mobilization techniques, cervical, thoracic and lumbopelvic postural correction and cranio-cervical exercises; 6) progressive muscular relaxation combined with joint mobilization, functional, muscle energy, and strain/counterstrain techniques, and cranial osteopathic treatment; 7) massage focused on relieving myofascial trigger point activity; 8) pressure release and muscle energy in suboccipital muscles; 9) combination of mobilizations of the cervical and thoracic spine, exercises and postural correction. All studies used a combination of different techniques and none analyzed treatments separately, also all the studies have assessed aspects related to TTH beyond frequency and intensity of pain.

CONCLUSIONS

The findings from these studies showed evidence that physiotherapy with articulatory MT, combined with cervical muscle stretching and massage are effective for this disease in different aspects related with TTH. No evidence was found of the effectiveness of the techniques applied separately.

Multimodal compared to pharmacologic treatments for chronic tension-type headache in adolescents

Chronic tension-type headache (CTTH) in children and adolescents is a serious medical condition, with considerable morbidity and few effective, evidence-based treatments. We performed a chart review of 83 adolescents (age range = 13-18 years; 67 girls and 16 boys) diagnosed with CTTH. Two treatment protocols were compared: multimodal (osteopathic manipulative treatments, mindfulness, and qi gong) and pharmacologic (amitriptyline or gabapentin). Four outcomes (headache frequency, pain intensity, general health, and health interference) were assessed at three time points (baseline, 3 months, and 6 months). A fifth outcome, number of bilateral tender points, was recorded at baseline and 6 months. All five were evaluated statistically with a linear mixed model. Although both multimodal and pharmacologic treatments were effective for CTTH (time effects for all measures were significant at p < .001), results from each analysis favored multimodal treatment (the five group by time interaction effects were significant at or below the p < .001 level). Headache frequency in the pharmacologic group, for example, reduced from a monthly average (95% Confidence Interval shown in parentheses) of 23.9 (21.8, 26.0) to 16.4 (14.3, 18.6) and in the multimodal group from 22.3 (20.1, 24.5) to 4.9 (2.6, 7.2) (a substantial group difference). Pain intensity (worst in the last 24 hours, 0-10 scale) was reduced in the pharmacologic group from 6.2 (5.6, 6.9) to 3.4 (2.7, 4.1) and from 6.1 (5.4, 6.8) to 2.0 (1.2, 2.7) in the multimodal group (a less substantial difference). Across the other three assessments, group differences were larger for general health and number of tender points and less so for pain restriction. Multimodal treatment for adolescent CTTH appears to be effective. Randomized controlled trials are needed to confirm these promising results.

Clinical effectiveness of osteopathic treatment in chronic migraine: 3-Armed randomized controlled trial

OBJECTIVE

To assess the effectiveness of OMT on chronic migraineurs using HIT-6 questionnaire, drug consumption, days of migraine, pain intensity and functional disability.

DESIGN

3-Armed randomized controlled trial setting: all patients admitted in the Department of Neurology of Ancona's United Hospitals, Italy, with a diagnosis of migraine and without chronic illness, were considered eligible for the study.

INTERVENTIONS

Patients were randomly divided into three groups: (1) OMT+medication therapy, (2) sham+medication therapy and (3) medication therapy only. Patients received 8 treatments in a study period of 6 months.

MAIN OUTCOME MEASURES

Changing from baseline HIT-6 score.

RESULTS

105 subjects were included. At the end of the study, ANOVA showed that OMT significantly reduced HIT-6 score (mean change scores OMT-conventional care: -8.74; 95% confidence interval (CI) -12.96 to -4.52; p<0.001 and OMT-sham: -6.62; 95% CI -10.85 to -2.41; p<0.001), drug consumption (OMT-sham: RR=0.22, 95% CI 0.11-0.40; OMT-control: RR=0.20, 95% CI 0.10-0.36), days of migraine (OMT-conventional care: M=-21.06; 95% CI -23.19 to -18.92; p<0.001 and OMT-sham: -17.43; 95% CI -19.57 to -15.29; p<0.001), pain intensity (OMT-sham: RR=0.42, 95% CI 0.24-0.69; OMT-control: RR=0.31, 95% CI 0.19-0.49) and functional disability (p<0.001).

CONCLUSIONS

These findings suggest that OMT may be considered a valid procedure for the management of migraineurs. The present trial was registered on www.ClinicalTrials.gov (identifier: NCT01851148).

Pilot Trial of Osteopathic Manipulative Therapy for Patients With Frequent Episodic Tension-Type Headache

Context: Osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) may be used for managing headache pain and related disability, but there is a need for high-quality randomized controlled trials to assess the effectiveness of this intervention.

Objective: To explore the efficacy of OMTh for pain management in frequent episodic tension-type headache (TTH).

Design: Single-blind randomized placebo-controlled pilot study.

Setting: Patients were recruited from 5 primary care settings.

Patients: Forty-four patients who were affected by frequent episodic TTH and not taking any drugs for prophylactic management of episodic TTH were recruited.

Interventions: Patients were randomly allocated to an experimental or control group. The experimental group received corrective OMTh techniques, tailored for each patient; the control group received assessment of the cranial rhythmic impulse (sham therapy). The study included a 1-month baseline period, a 1-month treatment period, and a 3-month follow-up period.

Main Outcome Measures: The primary outcome was the change in patient-reported headache frequency, and secondary outcomes included changes in headache pain intensity (discrete score, 1 [lowest perceived pain] to 5 [worst perceived pain]), over-the-counter medication use, and Headache Disability Inventory score.

Results: Forty patients completed the study (OMTh, n=21; control, n=19). The OMTh group had a significant reduction in headache frequency over time that persisted 1 month (approximate reduction, 40%; P<.001) and 3 months (approximate reduction, 50%; P<.001) after the end of treatment. Moreover, there was an absolute difference between the 2 treatment groups at the end of the study, with a 33% lower frequency of headache in the OMTh group (P<.001).

Conclusion: This feasibility study demonstrated the efficacy of OMTh in the management of frequent episodic TTH, compared with sham therapy in a control group. Osteopathic manipulative therapy may be preferred over other treatment modalities and may benefit patients who have adverse effects to medications or who have difficulty complying with pharmacologic regimens. This protocol may serve as a model for future studies.

The Positive Impact of Integrative Medicine in the Treatment of Recalcitrant Chronic daily Headache: A Series of Case Reports

People who suffer from recalcitrant chronic daily headache (CDH)-a primary, episodic headache occurring at least 15 days per month, and lasting four or more hours per day for at least three consecutive months(1)-have generally tried many pain relief medications with few positive results. These patients often continue to add more and more medications and travel from clinician to clinician seeking help, without relief. Patients with recalcitrant CDH are often caught in a vicious cycle of increasing pain which results in a substantial impact from their disease on productivity and quality of life. Studies in the United States and Europe indicate that four to five percent of the general population has recalcitrant CDH,(2) which encompasses transformed migraine and chronic tension-type headache.(3) The disability associated with recalcitrant CDH is substantial, as patients have a significantly diminished quality of life and mental health, as well as impaired physical, social, and occupational functioning.(4,5) Research shows that CDH may not be treated effectively with conventional medicine (CM). Integrative medicine (IM) offers a complex, personalized intervention necessary to treat CDH. Many integrative therapies have shown benefit, effectiveness, cost effectiveness and low side effect profile in patients with both chronic headache and chronic pain.(6-17) Yet even within the IM community, clinicians often struggle with the balance between providing evidence-based therapy and patient-centered, complex, personalized integrative approaches, which may use popular but unproven therapies. In this article, we present a series of cases comprising patients with CDH who had previously been recalcitrant to CM approaches. In each case, employing a five-pronged treatment algorithm resulted in the successful IM treatment of CDH. By using this five-pronged approach, clinicians can offer the standardized protocols and scientific rationale they are accustomed to when employing CM options while additionally offering the benefit of IM possibilities.

Efficacy of manual therapy in the treatment of tension-type headache. A systematic review from 2000-2013

OBJECTIVES

To study the efficacy of manual therapy in the treatment of tension-type headache (TTH) by assessing the quality of randomized control trials (RCTs) published from the year 2000 to April 2013.

METHODS

A search was performed in the following databases: MEDLINE, EBSCO, CINAHL, SCOPUS, PEDRO and OVID. An analysis was made of RCT including patients with TTH receiving any manual therapy, and assessing outcome measures including the intensity, and frequency or duration of the headache. Two independent referees reviewed the methodological quality of RCTs using the Jadad scale. Data from the studies were extracted by two different reviewers.

RESULTS

A total of fourteen RCTs were selected. Twelve studies showed acceptable quality (Jadad scale ≥3), and the remaining 2 had low quality (Jadad=2). The studies showed positive results, including reduction in headache intensity and/or frequency, reduction of medication consumption, and improvement in quality of life.

CONCLUSIONS

The effectiveness of manual therapy for TTH cannot be completely assessed due to the heterogeneity in study design, outcome measures, and different treatments. Nevertheless, the results suggest patients with TTH receiving manual therapies showed better progress than those receiving conventional treatment or placebo. Further studies of high quality using manual therapy protocols, and also including standardized outcome measures, are now needed to clarify the efficacy of manual therapy in the management of TTH.

Efficacy of manual and manipulative therapy in the perception of pain and cervical motion in patients with tension-type headache: a randomized, controlled clinical trial

OBJECTIVE

The purpose of this study was to evaluate the efficacy of manipulative and manual therapy treatments with regard to pain perception and neck mobility in patients with tension-type headache.

METHODS

A randomized clinical trial was conducted on 84 adults diagnosed with tension-type headache. Eighty-four subjects were enrolled in this study: 68 women and 16 men. Mean age was 39.76 years, ranging from 18 to 65 years. A total of 57.1% were diagnosed with chronic tension-type headache and 42.9% with tension-type headache. Participants were divided into 3 treatment groups (manual therapy, manipulative therapy, a combination of manual and manipulative therapy) and a control group. Four treatment sessions were administered during 4 weeks, with posttreatment assessment and follow-up at 1 month. Cervical ranges of motion pain perception, and frequency and intensity of headaches were assessed.

RESULTS

All 3 treatment groups showed significant improvements in the different dimensions of pain perception. Manual therapy and manipulative treatment improved some cervical ranges of motion. Headache frequency was reduced with manipulative treatment (P < .008). Combined treatment reported improvement after the treatment (P < .000) and at follow-up (P < .002). Pain intensity improved after the treatment and at follow-up with manipulative therapy (P < .01) and combined treatment (P < .01).

CONCLUSIONS

Both treatments, administered both separately and combined together, showed efficacy for patients with tension-type headache with regard to pain perception. As for cervical ranges of motion, treatments produced greater effect when separately administered.

Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report

BACKGROUND

This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report.

METHODS

A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added.

RESULTS

25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive.

CONCLUSIONS

Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted.

Italian guidelines for primary headaches: 2012 revised version

The first edition of the Italian diagnostic and therapeutic guidelines for primary headaches in adults was published in J Headache Pain 2(Suppl. 1):105–190 (2001). Ten years later, the guideline committee of the Italian Society for the Study of Headaches (SISC) decided it was time to update therapeutic guidelines. A literature search was carried out on Medline database, and all articles on primary headache treatments in English, German, French and Italian published from February 2001 to December 2011 were taken into account. Only randomized controlled trials (RCT) and meta-analyses were analysed for each drug. If RCT were lacking, open studies and case series were also examined. According to the previous edition, four levels of recommendation were defined on the basis of levels of evidence, scientific strength of evidence and clinical effectiveness. Recommendations for symptomatic and prophylactic treatment of migraine and cluster headache were therefore revised with respect to previous 2001 guidelines and a section was dedicated to non-pharmacological treatment. This article reports a summary of the revised version published in extenso in an Italian version.

[Dento-facial orthopedics and osteopathy]

Osteopathy has grown rapidly. Given their common action on children and adolescents, the collaboration between dentofacial orthopedics and osteopathy is increasingly common. It therefore becomes necessary and urgent to investigate whether, based on data acquired from science, there is evidence of possible interrelations between the two disciplines. After reviewing the literature, very few scientific publications demonstrate the utility of osteopathy and its relationships with other disciplines. However, the relationship between occlusion and posture seem relatively proven, especially in the sagittal direction. On the other hand, although the mobility of the cranial bones is established, the primary respiratory motion is still subject to controversy, even among osteopaths. This, even as orthodontics has long been accused of countering the primary respiratory motion of cranial bones (PRM). Today osteopaths do not reject orthodontics anymore, because the return to a physiological bite situation is considered beneficial. According to expert opinion (without proof, however), some orthodontic devices (like headgears) which block the sutures are still to be avoided and require appropriate monitoring osteopathy. The controversy over the adverse effects of orthodontic treatment is becoming more nuanced by osteopaths, and modern orthodontics claiming a «global» approach of patient, collaboration may be possible in future year.

Evidence-based guidelines for the chiropractic treatment of adults with headache

OBJECTIVE

The purpose of this manuscript is to provide evidence-informed practice recommendations for the chiropractic treatment of headache in adults.

METHODS

Systematic literature searches of controlled clinical trials published through August 2009 relevant to chiropractic practice were conducted using the databases MEDLINE; EMBASE; Allied and Complementary Medicine; the Cumulative Index to Nursing and Allied Health Literature; Manual, Alternative, and Natural Therapy Index System; Alt HealthWatch; Index to Chiropractic Literature; and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an overall strength of evidence (strong, moderate, limited, or conflicting) and to formulate practice recommendations.

RESULTS

Twenty-one articles met inclusion criteria and were used to develop recommendations. Evidence did not exceed a moderate level. For migraine, spinal manipulation and multimodal multidisciplinary interventions including massage are recommended for management of patients with episodic or chronic migraine. For tension-type headache, spinal manipulation cannot be recommended for the management of episodic tension-type headache. A recommendation cannot be made for or against the use of spinal manipulation for patients with chronic tension-type headache. Low-load craniocervical mobilization may be beneficial for longer term management of patients with episodic or chronic tension-type headaches. For cervicogenic headache, spinal manipulation is recommended. Joint mobilization or deep neck flexor exercises may improve symptoms. There is no consistently additive benefit of combining joint mobilization and deep neck flexor exercises for patients with cervicogenic headache. Adverse events were not addressed in most clinical trials; and if they were, there were none or they were minor.

CONCLUSIONS

Evidence suggests that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches. The type, frequency, dosage, and duration of treatment(s) should be based on guideline recommendations, clinical experience, and findings. Evidence for the use of spinal manipulation as an isolated intervention for patients with tension-type headache remains equivocal.

Efficacy of osteopathic manipulative treatment of female patients with migraine: results of a randomized controlled trial

OBJECTIVES

Migraine is one of the most prevalent neurological disorders in Europe, severely affecting ability to work and quality of life. Medical therapies are considered to be the "gold standard" of treatment. This study addresses osteopathic treatment for acute therapy or prophylactic therapy as an alternative to traditional therapies.

DESIGN

Forty-two (42) female patients with migraine were randomized into an intervention group (n = 21) and a control group (n = 21). Outcomes were evaluated with three questionnaires before the treatment (t1) and 6 months later (t2).

INTERVENTIONS

The intervention group received five 50-minute osteopathic manipulative treatments (OMT) over a 10-week period. The control group did not receive OMT, sham treatment, or physical therapy. Patients of this group only filled the questionnaires. Both groups continued with previously prescribed medication.

METHODS

The Migraine Disability Assessment (MIDAS) and Short Form-36 (SF-36) questionnaires as well as a German "pain questionnaire" were used to assess pain intensity, the impact of migraine on daily life and health-related quality of life (HRQoL), and the number of days subjects suffered from migraine.

RESULTS

Three (3) of the eight HRQoL domains of the SF-36 form in the intervention group showed significant improvement (from t1 to t2), with a general betterment exhibited in the other domains. The total MIDAS score, pain intensity, and disturbance in occupation due to migraine as well as number of days of disablements were also significantly reduced. The control group showed insignificant differences in these areas.

CONCLUSIONS

This study affirms the effects of OMT on migraine headache in regard to decreased pain intensity and the reduction of number of days with migraine as well as working disability, and partly on improvement of HRQoL. Future studies with a larger sample size should reproduce the results with a control group receiving placebo treatment in a long-term follow-up.

An introduction to clinical research in osteopathic medicine

Osteopathic medicine is a profession that has existed for more than 130 years. However, the profession is poorly understood by many health care professionals. This article introduces osteopathic medicine, including similarities and differences between osteopathic physicians (DOs) and allopathic physicians (MDs). It describes osteopathic manipulative treatment (OMT), including the risks and many of the challenges faced while doing clinical research on OMT. Finally, the article reviews the research that has evaluated the effect of OMT on various medical conditions, including musculoskeletal, neurologic, respiratory, obstetric, gynecologic, and pediatric conditions.

Effectiveness of manual therapies: the UK evidence report

BACKGROUND

The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions.

METHODS

The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs.

RESULTS

By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments.

CONCLUSIONS

Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.

A randomized, placebo-controlled clinical trial of chiropractic and medical prophylactic treatment of adults with tension-type headache: results from a stopped trial

OBJECTIVES

Tension-type headache (TTH) is the most common headache experienced by adults in Western society. Only 2 clinical trials of spinal manipulation for adult tension-type headache have been reported, neither of which was fully controlled. In 1 trial, spinal manipulation was compared to amitriptyline. There is an urgent need for well-controlled studies of chiropractic spinal manipulation for TTH. This trial was stopped prematurely due to poor recruitment. The purposes of this report are (1) to describe the trial protocol, as it contained several novel features, (2) to report the limited data set obtained from our sample of completed subjects, and (3) to discuss the problems that were encountered in conducting this study.

METHODS

A randomized clinical trial was conducted with a factorial design in which adult TTH sufferers with more than 10 headaches per month were randomly assigned to four groups: real cervical manipulation + real amitriptyline, real cervical manipulation + placebo amitriptyline, sham cervical manipulation + real amitriptyline, and sham cervical manipulation + placebo amitriptyline. A baseline period of four weeks was followed by a treatment period of 14 weeks. The primary outcome was headache frequency obtained from a headache diary in the last 28 days of the treatment period.

RESULTS

Nineteen subjects completed the trial. In the unadjusted analysis, a statistically significant main effect of chiropractic treatment was obtained (-2.2 [-10.2 to 5.8], P = .03) which was just below the 3-day reduction set for clinical importance. As well, a clinically important [corrected] effect of the combined therapies was obtained (-9 [-20.8 [corrected] to 2.9], P = .13), but this did not achieve statistical significance. In the adjusted analysis, neither the main effects of chiropractic nor amitriptyline were statistically significant or clinically important; however, the effect of the combined treatments was -8.4 (-15.8 to -1.1) which was statistically significant (P = .03) and reached our criterion for clinical importance.

CONCLUSION

Although the sample size was smaller than initially required, a statistically significant and clinically important effect was obtained for the combined treatment group. There are considerable difficulties with recruitment of subjects in such a trial. This trial should be replicated with a larger sample.

Osteopathic manipulative treatment and its relationship to autonomic nervous system activity as demonstrated by heart rate variability: a repeated measures study

Background

The relationship between osteopathic manipulative treatment (OMT) and the autonomic nervous system has long been acknowledged, but is poorly understood. In an effort to define this relationship, cervical myofascial release was used as the OMT technique with heart rate variability (HRV) as a surrogate for autonomic activity. This study quantifies that relationship and demonstrates a cause and effect.

Methods

Seventeen healthy subjects, nine males and eight females aged 19–50 years from the faculty, staff, and students at Oklahoma State University Center for Health Sciences College of Osteopathic Medicine, acted as their own controls and received interventions, administered in separate sessions at least 24 hours apart, of cervical myofascial OMT, touch-only sham OMT, and no-touch control while at a 50-degree head-up tilt. Each group was dichotomized into extremes of autonomic activity using a tilt table. Comparisons were made between measurements taken at tilt and those taken at pre- and post-intervention in the horizontal.

The variance of the spectral components of HRV, expressed as frequencies, measured the response to change in position of the subjects. Normalized low frequency (LF) and high frequency (HF) values, including LF/HF ratio, were calculated and used to determine the effect of position change on HRV.

Results

Predominantly parasympathetic responses were observed with subjects in the horizontal position, while a 50-degree tilt provided a significantly different measure of maximum sympathetic tone (p < 0.001). Heart rate changed in all subjects with change in position; respirations remained constant. When OMT was performed in a sympathetic environment (tilt), a vagal response was produced that was strong enough to overcome the sympathetic tone. There was no HRV difference between sham and control in either the horizontal or tilt positions.

Conclusion

The vagal response produced by the myofascial release procedure in the maximally stimulated sympathetic environment could only have come from the application of the OMT. This demonstrates the association between OMT and the autonomic nervous system. The lack of significance between control and sham in all positions indicates that HRV may be a useful method of developing sham controls in future studies of OMT.

Trial registration

clinicaltrials.gov NCT00516984.

Future therapeutic perspectives for tension-type headache

The therapy for tension-type headache remains insufficient, and recent advances have been scarce. Although tricyclic antidepressants are at the forefront of treatment advances, upcoming agents tentatively modifying central sensitization are promising. Botulinum toxin failed to meet expectations. This article reviews current treatments, emphasizing newer approaches. Much remains to be achieved.