Vertigo and Balance Disorders - The Role of Osteopathic Manipulative Treatment: A Systematic Review

An overview of systematic reviews on the efficacy and safety of osteopathic techniques

OBJECTIVE

To investigate the efficacy and safety of manipulative osteopathic techniques in persons of all ages with various medical indications.

DESIGN

Overview of systematic reviews and meta-analyses.

METHOD

We conducted a systematic literature search for systematic reviews of randomized controlled trials in English or German that compared osteopathic interventions to no treatment, sham treatment or any other non-osteopathic treatment, in bibliographic databases and other sources.

RESULTS

We included 27 systematic reviews covering nine therapeutic indications. Based on moderate quality of evidence, osteopathic treatment was an effective means of reducing pain and partially improving physical function in adults with acute neck pain, chronic non-specific low back pain, low back pain in pregnancy, and chronic non-oncologic pain. It can also shorten the length of hospital stays in premature infants. Furthermore, osteopathic treatment may relieve symptoms in adults with chronic neck pain, postpartum low back pain, migraine, and irritable bowel syndrome, and it may help children with otitis media. It did not appear to provide relief to adults with acute non-specific low back pain, fibromyalgia, headaches of various causes, women with lower urinary tract symptoms, and children with cerebral palsy. Evidence for other indications like vertigo, chronic obstructive pulmonary disease, hypertension, gynecological or birth-related complaints, and a number of pediatric indications was insufficient to draw firm conclusions.

CONCLUSION

Manipulative osteopathic techniques appears to be particularly effective in musculoskeletal conditions. Overall, the evidence base for the outcomes of manual osteopathic treatment has improved, despite heterogeneous studies that are partly of poor methodological quality.

Patient-Practitioner-Environment Synchronization: Four-Step Process for Integrating Interprofessional and Distinctive Competencies in Osteopathic Practice-A Scoping Review with Integrative Hypothesis

BACKGROUND

A major goal for a significant portion of the osteopathic community is to update osteopathic principles, satisfying three needs: sourcing from the origin, proposing original and unique practical approaches, and describing the entire process in a scientifically updated way. On this line, several interprofessional proposals for healthcare providers have already been made by implementing patient-centered care and touch-based strategies informed by the enactive model. Enactivism principles can provide a foundation for rethinking osteopathic care by integrating environmental, psychological, social, and existential factors to facilitate the patient's biobehavioral synchronization with the environment and social context, address health needs, and enhance the quality of multiprofessional healthcare services. However, there is a need to develop a conceptual model that offers a framework for organizing and interpreting disciplinary knowledge, guiding clinical observation and practical strategies, and defining both interprofessional collaboration and the unique focus of the profession. This scoping review and integrative hypothesis aim to fulfill the need for a more detailed and comprehensive understanding of the distinctive osteopathic care to biobehavioral synchrony, emphasizing both interprofessional collaboration and the profession's unique competencies.

METHODS

The present article was developed in accordance with established guidelines for writing biomedical scoping reviews.

RESULTS

A total of 36 papers were considered for thematic and qualitative analyses, which supported the integrative hypothesis. Considering the current tenets for osteopathic rational practice, we propose an integrative hypothesis to focus on a practical framework for osteopathic patient biobehavioral synchronization. Patient-practitioner-environment synchronization could be promoted through a four-step process: (1) a narrative-based sense-making and decision-making process; (2) a touch-based shared sense-making and decision-making process; (3) hands-on, mindfulness-based osteopathic manipulative treatment; (4) patient active participatory osteopathic approaches to enhance person-centered care and rational practice.

CONCLUSIONS AND FUTURE DIRECTIONS

The proposed model fosters patient-practitioner synchronization by integrating updated traditional osteopathic narratives and body representations into practice, offering a culturally sensitive approach to promoting health, addressing contemporary health needs, and improving inclusive health services. Future studies are required to assess the transferability and applicability of this framework in modern settings worldwide.

Valid and Invalid Indications for Osteopathic Interventions: A Systematic Review of Evidence-Based Practices and French Healthcare Society Recommendations

The main aim of this study was to determine the level of evidence in the literature for the main indications of osteopathy as recommended by the French osteopathy societies. This systematic review followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and evaluated articles published between January 2012 and January 2022 with one modification: when level one evidence studies were available, level two to five studies were excluded. Sources included PubMed, the Cochrane library, the French National Health Authority (HAS) and its affiliates. Inclusion criteria were level one published studies on the indications for osteopathic treatment in French and English, and level two to three studies when no level one studies were available. The level of evidence assessment was based on the Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence classification. The primary outcome was the level of evidence in the literature supporting osteopathic practices. The secondary outcome was to assess French professional osteopathy recommendations and French HAS guidelines in relation to the scientific literature. A total of 51 articles and nine recommendations from the HAS and its affiliates met the inclusion criteria for the systematic review. Analysis of the studies revealed 41 osteopathic indications from French osteopathy societies for musculoskeletal, neurosensory, psychological, pediatric, gynecological, digestive, and pulmonary disorders. High-level scientific evidence supported the use of osteopathy for low back pain, sciatica, cervical radiculopathy, and ankle sprain. There was moderate evidence for tension headache, temporomandibular joint disorder, endometriosis, and low back and pelvic pain in pregnant women. HAS recommended five indications, while nine indications were supported in the scientific literature. Osteopathy has been shown to have evidence-based benefits for a range of conditions, in particular for musculoskeletal and neurosensory disorders.

Impact of osteopathic manipulative techniques on the management of dizziness caused by neuro-otologic disorders: systematic review and meta-analysis

CONTEXT

Osteopathic manipulative treatment (OMT) has been utilized by osteopathic clinicians as primary or adjunctive management for dizziness caused by neuro-otologic disorders. To our knowledge, no current systematic reviews provide pooled estimates that evaluate the impact of OMT on dizziness.

OBJECTIVES

We aimed to systematically evaluate the effectiveness and safety of OMT and analogous techniques in the treatment of dizziness.

METHODS

We performed a literature search in CINAHL, Embase, MEDLINE, Allied and Complementary Medicine Database (AMED), EMCare, Physiotherapy Evidence Database (PEDro), PubMed, PsycINFO, Osteopathic Medicine Digital Library (OSTMED.DR), and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to March 2021 for randomized controlled trials (RCTs) and prospective or retrospective observational studies of adult patients experiencing dizziness from neuro-otological disorders. Eligible studies compared the effectiveness of OMT or OMT analogous techniques with a comparator intervention, such as a sham manipulation, a different manual technique, standard of care, or a nonpharmacological intervention like exercise or behavioral therapy. Assessed outcomes included disability associated with dizziness, dizziness severity, dizziness frequency, risk of fall, improvement in quality of life (QOL), and return to work (RTW). Assessed harm outcomes included all-cause dropout (ACD) rates, dropouts due to inefficacy, and adverse events. The meta-analysis was based on the similarities between the OMT or OMT analogous technique and the comparator interventions. The risk of bias (ROB) was assessed utilizing a modified version of the Cochrane Risk of Bias Tool for RCTs and the Cochrane Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) for observational studies. The quality of evidence was determined utilizing the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

RESULTS

There were 3,375 studies identified and screened, and the full text of 47 of them were reviewed. Among those, 12 (11 RCTs, 1 observational study, n=367 participants) met the inclusion criteria for data extraction. Moderate-quality evidence showed that articular OMT techniques were associated with decreases (all p<0.01) in disability associated with dizziness (n=141, mean difference [MD]=-11, 95% confidence interval [CI]=-16.2 to -5.9), dizziness severity (n=158, MD=-1.6, 95% CI=-2.4 to -0.7), and dizziness frequency (n=136, MD=-0.6, 95% CI=-1.1 to -0.2). Low-quality evidence showed that articular OMT was not associated with ACD rates (odds ratio [OR]=2.2, 95% CI=0.5 to 10.2, p=0.31). When data were pooled for any type of OMT technique, findings were similar; however, disability associated with dizziness and ACD rates had high heterogeneity (I²=59 and 46%). No studies met all of the criteria for ROB.

CONCLUSIONS

The current review found moderate-quality evidence that treatment with articular OMT techniques was significantly associated with decreased disability associated with dizziness, dizziness severity, and dizziness frequency. However, our findings should be interpreted cautiously because of the high ROB and small sample sizes in the eligible studies.

Evidence (-based medicine) in manual medicine/manual therapy—a summary review

Objective

The aim of this summary review is to analyse the current state of evidence in manual medicine or manual therapy.

Methods

The literature search focussed on systematic reviews listed in PubMed referring to manual medicine treatment until the beginning of 2022, limited to publications in English or German. The search concentrates on (1) manipulation, (2) mobilization, (3) functional/musculoskeletal and (4) fascia. The CASP Checklist for Systematic Reviews was used to present the included reviews in a clear way.

Results

A total of 67 publications were included and herewith five categories: low back pain, neck pain, extremities, temporomandibular disorders and additional effects. The results were grouped in accordance with study questions.

Conclusion

Based on the current systematic reviews, a general evidence-based medicine level III is available, with individual studies reaching level II or Ib. This allows manual medicine treatment or manual therapy to be used in a valid manner.

The Role of Osteopathic Care in Gynaecology and Obstetrics: An Updated Systematic Review

Background: Many efforts are made to find safer and more feasible therapeutic strategies to improve gynaecological care. Non-pharmacological treatments, such as osteopathic interventions, could be used as complementary strategies to better manage different gynaecological conditions. This review aims to report the effectiveness of osteopathic treatment in the gynaecology and obstetrics field, updating the previous review published in 2016. The secondary aim was to elucidate the role of somatic dysfunction (SD) in osteopathic assessment and treatment procedures, as well as their health and economic implications. Methods: An electronic search was conducted in the following databases: Embase, MEDLINE (PubMed), and Science direct. All types of clinical studies published between May 2014 and December 2021 have been included: randomised controlled trial (RCT), controlled before/after, interrupted time series quasi RCT, case controls, case reports, case series, observational, clinical studies involving any type of osteopathic treatment, (standardised, semi-standardised or patients’ need-based treatment) performed alone or in combination with other treatments, were included). Results: A total of 76,750 were identified through database searching and other sources. After the removal of duplicates, 47,655 papers were screened based on title and abstract. A total of 131 full-text articles were consequently assessed for eligibility. Twenty-one new articles were included in the synthesis. A total of 2632 participants with a mean age of 28.9 ± 10.5 years were included in the review. Conclusions: Results showed an effectiveness of osteopathic care in gynaecology and obstetrics, but the studies were too heterogeneous to perform quantitative analysis and make clinical recommendations. Nevertheless, osteopathic care could be considered a safe complementary approach to traditional gynaecological care.

The Clinical Use of the Suppression Head Impulse Paradigm in Patients with Vestibulopathy: A Systematic Review

Background: This review aims to explore the potential clinical application of the suppression head impulse paradigm (SHIMP) in patients with unilateral and bilateral vestibulopathy. Methods: An electronic search was conducted by two independent reviewers in the following databases: Embase, MEDLINE (PubMed), and Scopus. The screening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers. The included studies were quality appraised using a modified version of the Newcastle–Ottawa Scale. Results: The results were reported following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Our search yielded 935 unique records, of which 16 remained after screening titles and abstracts. A total of 11 studies were included, covering a total of 418 participants (230 patients and 188 healthy participants). Conclusion: SHIMP could be a useful tool to diagnose a VOR alteration in patients with vestibulopathy in both the acute and chronic phases of vestibulopathy.

Neurogenic Bowel Dysfunction Changes after Osteopathic Care in Individuals with Spinal Cord Injuries: A Preliminary Randomized Controlled Trial

Background: Neurogenic bowel dysfunction (NBD) indicates bowel dysfunction due to a lack of nervous control after a central nervous system lesion. Bowel symptoms, such as difficulties with evacuation, constipation, abdominal pain and swelling, are experienced commonly among individuals with spinal cord injury (SCI). Consequentially, individuals with SCI experience a general dissatisfaction with the lower perceived quality of life (QoL). Several studies have demonstrated the positive effects of manual therapies on NBD, including Osteopathic Manipulative Treatment (OMT). This study aimed to explore OMT effects on NBD in individuals with SCI compared with Manual Placebo Treatment (MPT). Methods: The study was a double-blind randomized controlled trial composed of three phases, each one lasting 30 days (i: NBD/drugs monitoring; ii: four OMT/MPT sessions; iii: NBD/drug monitoring and follow-up evaluation). Results: the NBD scale, the QoL on worries and concerns sub-questionnaire, and the perception of abdominal swelling and constipation significantly improved after treatments compared to baseline only for individuals who underwent OMT. Conclusion: These preliminary results showed positive effects of OMT on bowel function and QoL in individuals with SCI, but further studies are needed to confirm our results.

International Overview of Somatic Dysfunction Assessment and Treatment in Osteopathic Research: A Scoping Review

BACKGROUND

Osteopathic manipulative treatment (OMT) is a patient-centred, whole-body intervention aimed at enhance the person's self-regulation. OMT interventions are focused on somatic dysfunctions (SD) that can be defined as an altered regulative function associated with inflammatory signs palpable in the body framework in different body regions. The conceptual model that sustains SD, as well as its usefulness for the osteopathic profession, is still being discussed by the osteopathic community. Understanding the role and the application of SD is the aim of this scoping review.

METHODS

A literature search was carried out through the main biomedical databases: Pubmed (Medline), Cochrane, Central (Cochrane), Embase, PEDro and Scopus. Grey literature was considered via Google Scholar and the Osteopathic Research Web. The review was prepared by referring to the "Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews" (PRISMA-ScR).

RESULTS

A total of 37,279 records were identified through database searching and other sources. After the duplicates were removed, 27,023 titles and abstracts were screened. A total of 1495 full-text articles were assessed for eligibility. The qualitative synthesis included 280 studies.

CONCLUSIONS

Treating SD is an important part of osteopathic practice that varies from country to country. SD should be considered as a clinical value that assists in the clinical assessment and guides the decision-making process of osteopathic practitioners. Further studies should be designed to better understand why and how to choose the different assessment and intervention modalities to approach SD and to evaluate new osteopathic models.

Osteopathic Models Integration Radar Plot: A Proposed Framework for Osteopathic Diagnostic Clinical Reasoning

OBJECTIVE

The purpose of this article is to propose a tool to assist with clinical reasoning to select and integrate different osteopathic models and evidence-based actions into clinical practice.

DISCUSSION

The authors adopted the guidelines for writing a commentary as a reporting framework for the present article. The proposed Osteopathic Models Integration Radar Plot has potential for integration into clinical practice and the educational environment. This framework may enable clinicians to manage complex clinical phenomena, such as musculoskeletal disorders related to allostatic load.

CONCLUSION

This proposed framework may be helpful to communicate the outcome of osteopathic evaluations to other healthcare professionals. This proposed model will need to be tested to determine feasibility.

Osteopathic structure/function models renovation for a person-centered approach: a narrative review and integrative hypothesis

OBJECTIVES

The construct of the osteopathic structure-function models is reported as a cornerstone of clinical reasoning and treatment processes. Nevertheless, there are no shared procedures described for their use in clinical practice. The present narrative review aims to analyze a more comprehensive perspective on the phenomenon.

METHODS

A structured narrative review was conducted. A database search was conducted using Pubmed, ScienceDirect, and Google Scholar. Peer-reviewed papers without specifying limits on dates and design were included.

RESULTS

Twenty-five findings were reported and grouped into two main themes: 1) Debate on models and theoretical frameworks for osteopathic care; 2) Clinical reasoning and decision-making process in the osteopathic field.

CONCLUSIONS

An integrated osteopathic care approach based on the structure/function models represents a starting point to establish a shared osteopathic diagnostic and clinical reasoning and an evidence-informed practice promoting health in an interdisciplinary person-centered care process. The present review highlights the limited amount of literature on using osteopathic conceptual models in decision-making and treatment strategies. A research plan is required to develop a common framework for an evidence-based osteopathic practice that promotes well-being in an interdisciplinary person-centered care process.

The Challenges and Perspectives of the Integration Between Virtual and Augmented Reality and Manual Therapies

Virtual reality (VR) and augmented reality (AR) have been combined with physical rehabilitation and psychological treatments to improve patients' emotional reactions, body image, and physical function. Nonetheless, no detailed investigation assessed the relationship between VR or AR manual therapies (MTs), which are touch-based approaches that involve the manipulation of tissues for relieving pain and improving balance, postural stability and well-being in several pathological conditions. The present review attempts to explore whether and how VR and AR might be integrated with MTs to improve patient care, with particular attention to balance and to fields like chronic pain that need an approach that engages both mind and body. MTs rely essentially on touch to induce tactile, proprioceptive, and interoceptive stimulations, whereas VR and AR rely mainly on visual, auditory, and proprioceptive stimulations. MTs might increase patients' overall immersion in the virtual experience by inducing parasympathetic tone and relaxing the mind, thus enhancing VR and AR effects. VR and AR could help manual therapists overcome patients' negative beliefs about pain, address pain-related emotional issues, and educate them about functional posture and movements. VR and AR could also engage and change the sensorimotor neural maps that the brain uses to cope with environmental stressors. Hence, combining MTs with VR and AR could define a whole mind-body intervention that uses psychological, interoceptive, and exteroceptive stimulations for rebalancing sensorimotor integration, distorted perceptions, including visual, and body images. Regarding the technology needed to integrate VR and AR with MTs, head-mounted displays could be the most suitable devices due to being low-cost, also allowing patients to follow VR therapy at home. There is enough evidence to argue that integrating MTs with VR and AR could help manual therapists offer patients better and comprehensive treatments. However, therapists need valid tools to identify which patients would benefit from VR and AR to avoid potential adverse effects, and both therapists and patients have to be involved in the development of VR and AR applications to define truly patient-centered therapies. Furthermore, future studies should assess whether the integration between MTs and VR or AR is practically feasible, safe, and clinically useful.

Vibrotactile-Based Rehabilitation on Balance and Gait in Patients with Neurological Diseases: A Systematic Review and Metanalysis

Postural instability and fear of falling represent two major causes of decreased mobility and quality of life in cerebrovascular and neurologic diseases. In recent years, rehabilitation strategies were carried out considering a combined sensorimotor intervention and an active involvement of the patients during the rehabilitation sessions. Accordingly, new technological devices and paradigms have been developed to increase the effectiveness of rehabilitation by integrating multisensory information and augmented feedback promoting the involvement of the cognitive paradigm in neurorehabilitation. In this context, the vibrotactile feedback (VF) could represent a peripheral therapeutic input, in order to provide spatial proprioceptive information to guide the patient during task-oriented exercises. The present systematic review and metanalysis aimed to explore the effectiveness of the VF on balance and gait rehabilitation in patients with neurological and cerebrovascular diseases. A total of 18 studies met the inclusion criteria and were included. Due to the lack of high-quality studies and heterogeneity of treatments protocols, clinical practice recommendations on the efficacy of VF cannot be made. Results show that VF-based intervention could be a safe complementary sensory-motor approach for balance and gait rehabilitation in patients with neurological and cerebrovascular diseases. More high-quality randomized controlled trials are needed.