Effect of Osteopathic Manipulative Treatment vs Sham Treatment on Activity Limitations in Patients With Nonspecific Subacute and Chronic Low Back Pain: A Randomized Clinical Trial.

Importance: Osteopathic manipulative treatment (OMT) is frequently offered to people with nonspecific low back pain (LBP) but never compared with sham OMT for reducing LBP-specific activity limitations. Objective: To compare the efficacy of standard OMT vs sham OMT for reducing LBP-specific activity limitations at 3 months in persons with nonspecific subacute or chronic LBP. Design, Setting, and Participants: This prospective, parallel-group, single-blind, single-center, sham-controlled randomized clinical trial recruited participants with nonspecific subacute or chronic LBP from a tertiary care center in France starting February 17, 2014, with follow-up completed on October 23, 2017. Participants were randomly allocated to interventions in a 1:1 ratio. Data were analyzed from March 22, 2018, to December 5, 2018. Interventions: Six sessions (1 every 2 weeks) of standard OMT or sham OMT delivered by nonphysician, nonphysiotherapist osteopathic practitioners. Main Outcomes and Measures: The primary end point was mean reduction in LBP-specific activity limitations at 3 months as measured by the self-administered Quebec Back Pain Disability Index (score range, 0-100). Secondary outcomes were mean reduction in LBP-specific activity limitations; mean changes in pain and health-related quality of life; number and duration of sick leaves, as well as number of LBP episodes at 12 months; and consumption of analgesics and nonsteroidal anti-inflammatory drugs at 3 and 12 months. Adverse events were self-reported at 3, 6, and 12 months. Results: Overall, 200 participants were randomly allocated to standard OMT and 200 to sham OMT, with 197 analyzed in each group; the median (range) age at inclusion was 49.8 (40.7-55.8) years, 235 of 394 (59.6%) participants were women, and 359 of 393 (91.3%) were currently working. The mean (SD) duration of the current LBP episode was 7.5 (14.2) months. Overall, 164 (83.2%) patients in the standard OMT group and 159 (80.7%) patients in the sham OMT group had the primary outcome data available at 3 months. The mean (SD) Quebec Back Pain Disability Index scores for the standard OMT group were 31.5 (14.1) at baseline and 25.3 (15.3) at 3 months, and in the sham OMT group were 27.2 (14.8) at baseline and 26.1 (15.1) at 3 months. The mean reduction in LBP-specific activity limitations at 3 months was -4.7 (95% CI, -6.6 to -2.8) and -1.3 (95% CI, -3.3 to 0.6) for the standard OMT and sham OMT groups, respectively (mean difference, -3.4; 95% CI, -6.0 to -0.7; P = .01). At 12 months, the mean difference in mean reduction in LBP-specific activity limitations was -4.3 (95% CI, -7.6 to -1.0; P = .01), and at 3 and 12 months, the mean difference in mean reduction in pain was -1.0 (95% CI, -5.5 to 3.5; P = .66) and -2.0 (95% CI, -7.2 to 3.3; P = .47), respectively. There were no statistically significant differences in other secondary outcomes. Four and 8 serious adverse events were self-reported in the standard OMT and sham OMT groups, respectively, though none was considered related to OMT. Conclusions and Relevance: In this randomized clinical trial of patients with nonspecific subacute or chronic LBP, standard OMT had a small effect on LBP-specific activity limitations vs sham OMT. However, the clinical relevance of this effect is questionable. Trial Registration: ClinicalTrials.gov Identifier: NCT02034864.

Moderate to Substantial Inter-Rater Reliability in the Assessment of Cranial Bone Mobility Restrictions.

Background: The World Health Organization benchmarks for osteopathic training consider cranial osteopathy as an important manual skill. Studies of cranial manual therapy have exhibited poor reliability. The aim of this study was to investigate the inter-rater reliability of the manual mobility tests of the spheno-occipital synchondrosis (SOS), and the temporal, parietal, and frontal bones, as assessed in osteopathic manual therapy. Methods: Twenty-one adults were assessed on a single day by three experienced osteopaths using a standard assessment protocol. Before data collection, the osteopaths participated in a consensus training, which included establishing the criteria for identifying a cranial bone mobility restriction; the application of the seven-step palpation method; a pretesting practice; a fine-tuning palpation training; and a calibration period before the assessment of the subjects. Three subjects were assessed simultaneously with the evaluators rotating to assess each subject. The evaluators were blinded to the subject by a curtain, and each other's assessments. Each bone was rated as restricted or not restricted. The authors applied the Landis and Koch classification to describe the magnitude of inter-rater reliability. Results: Moderate reliability was established for a lateral strain of the SOS (Fleiss' generalized kappa 0.48), substantial reliability was established for the other SOS strain patterns (Fleiss' generalized kappa 0.62-0.75), and almost perfect reliability for temporal, parietal, and frontal bone (Fleiss' generalized kappa 0.81-0.96). Conclusion: The results demonstrate consistency when three experienced osteopaths evaluate cranial bone mobility restrictions. The results highlight the importance of consensus training and rigorous methodology in manual therapy reliability studies.

Manipulation techniques for infant torticollis. / Manipulasjonsteknikker ved nakkeasymmetri hos spedbarn.

BACKGROUND: Professionals in fields including chiropractic, physiotherapy, manual therapy and osteopathy recommend manipulation techniques for the treatment of infant torticollis. This article summarises the research evaluating such treatment. MATERIAL AND METHOD: The article is based on a search in MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, AMED, PEDro, and the Index to Chiropractic Literature in August 2017. Controlled studies were included to assess efficacy, and observational studies to reveal the risk of harm. RESULTS: We reviewed 3 418 unique hits from the literature search. We included three randomised controlled studies on the efficacy of manual therapy or osteopathy and three observational studies on possible adverse effects. Two studies on manual therapy suggested that manipulation techniques do not have any greater effect on symmetry and motor outcomes than parental guidance, physiotherapy and home exercises. One study suggested that osteopathy may contribute to increased symmetry compared to placebo, but the clinical significance of this change is uncertain. Neither the three randomised studies nor a large patient series involving 695 infants found manipulation techniques to be associated with a risk of serious adverse events, but three patient histories demonstrated that manipulation techniques may cause harm if the observed asymmetry has serious underlying causes. INTERPRETATION: Manipulation techniques have not been shown to be efficacious in the treatment of infant torticollis, but the available evidence must be considered uncertain.

Addressing the ongoing friction between anecdotal and evidence-based teachings in osteopathic education in Europe.

Despite a growing interest in research and the implementation of standards for osteopathic education and practice in Europe, the inter-professional dialogue remains insubstantial. This article calls attention to the continuous challenges of reconciling anecdotal and evidence-based perspectives and offers suggestions on how to address these areas further.

American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain.

BACKGROUND: Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement conventional management of musculoskeletal disorders, including those that cause low back pain (LBP). Osteopathic manipulative treatment is defined in the Glossary of Osteopathic Terminology as "The therapeutic application of manually guided forces by an osteopathic physician (U.S. Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction. OMT employs a variety of techniques" (eAppendix). Somatic dysfunction is defined as "Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment." These guidelines update the AOA guidelines for osteopathic physicians to utilize OMT for patients with nonspecific acute or chronic LBP published in 2010 on the National Guideline Clearinghouse.1 METHODS: This update process commenced with literature searches that included electronic databases, personal contact with key researchers of OMT and low back pain, and Internet search engines. Early in the process, the Task Force on the Low Back Pain Clinical Practice Guidelines discovered the 2014 systematic literature review conducted by Franke et al2; this study serves as the basis for this updated guideline and further builds upon the literature used to support the previous guidelines. Findings from other eligible studies published after the search parameters of the Franke et al systematic review were also incorporated. RESULTS: The authors of the systematic review identified 307 studies. Thirty-one were evaluated and 16 were excluded. Of the 15 studies included in the review, 6 were retrieved from Germany, 5 from the United States, 2 from the United Kingdom, and 2 from Italy. Two additional studies published after the Franke et al review were also included. Osteopathic manipulative treatment significantly reduces pain and improves functional status in patients, including pregnant and postpartum women, with nonspecific acute and chronic LBP. Franke et al found that in acute and chronic nonspecific LBP, moderate-quality evidence suggested that OMT had a significant effect on pain relief (mean difference [MD], -12.91; 95% CI, -20.00 to -5.82) and functional status (standard mean difference [SMD], -0.36; 95% CI, -0.58 to -0.14). More specifically, in chronic nonspecific LBP, the evidence suggested a significant difference in favor of OMT regarding pain (MD, -14.93; 95% CI, -25.18 to -4.68) and functional status (SMD, -0.32; 95% CI, -0.58 to -0.07). When examining nonspecific LBP in pregnancy, low-quality evidence suggested a significant difference in favor of OMT for pain (MD, -23.01; 95% CI, -44.13 to -1.88) and functional status (SMD, -0.80; 95% CI, -1.36 to -0.23). Conversely for nonspecific LBP postpartum, Franke et al found that moderate-quality evidence suggested a significant difference in favor of OMT for pain (MD, -41.85; 95% CI, -49.43 to -34.27) and functional status (SMD, -1.78; 95% CI, -2.21 to -1.35).2 CONCLUSION: The conclusions of Franke et al further strengthen the findings that OMT reduces LBP. In a 2005 systematic review conducted by Licciardone et al3 and the basis of the LBP guidelines published in 2010, it was determined that OMT reduces pain more than expected from placebo effects alone, and these results had the potential to last beyond the first year of treatment. Franke et al specifically stated that clinically relevant effects of OMT were found for reducing pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women 3 months after treatment. Larger randomized controlled trials with robust comparison groups are needed to further validate the effects of OMT on LBP. In addition, more research is needed to understand the mechanics of OMT and its short- and long-term effects, as well as the cost-effectiveness of such treatment.

Tratamientos del dolor en la litiasis renal / No disponible

Las patologías más frecuentes en las consultas urológicas, con una repercusión socioeconómica a nivel mundial muy alta. El cólico nefrítico (CN) es la presentación clínica más frecuente de la litiasis renal y una de las principales urgencias urológicas. El tratamiento farmacológico más utilizado para el control del dolor son los AINEs, seguidos de una amplia gama de fármacos como los opiáceos, anticolinérgicos, analgésicos, etc. Las manipulaciones vertebrales también tienen un efecto analgésico, aunque es necesario estudios que proporcionen una mayor evidencia científica. Objetivos: En esta revisión se pretende analizar las diferentes estrategias terapéuticas sobre el dolor en la LR y valorar la efectividad de los distintos tratamientos. Material y Métodos: Se realizó una revisión sistemática con una muestra de análisis bibliográfico integrado por 25 artículos (n=25) que cumplieron los criterios de selección en dos fases de análisis, lo que supone un 13.02% del total de los artículos encontrados (n=192) y el 43,85% de los artículos que cumplieron los criterios de selección de inclusión y exclusión (n=57). Se usaron las bases de datos Embase.com, Science Direct y PEDro. Como palabras clave principales se usaron «nephrolithiasis», «osteopathic medicine» y «spinal manipulation». Posteriormente se usaron otros términos como «complementary medicine», «chiropractic» y «pharmacology». Resultados: Se analizaron 8 estudios en los que se utilizaron distintas técnicas para el tratamiento del dolor en la LR: AINEs, opiáceos, ansiolíticos, anticolinérgicos, analgésicos, calor, estimulación nerviosa transcutánea (TENS) y manipulaciones vertebrales. Conclusiones: El uso de los AINEs, tanto de manera aislada como en combinación con otros fármacos parece ser el tratamiento farmacológico más eficaz para paliar el dolor. Los opiáceos, tienen como contrapartida efectos adversos no deseados. En cuanto a las terapias físicas el uso del calor local y el TENS son capaces de disminuir el dolor. Las manipulaciones vertebrales son capaces de reducir el dolor a corto plazo, sin los efectos adversos de los fármacos, aunque son necesarios más estudios que demuestren la evidencia (AU)

No disponible

Tratamiento osteopático en adultos con proyección anterior de cabeza y cervicalgia mecánica crónica / No disponible

Introducción: La Cervicalgia Mecánica Crónica (CMC) tiene alta prevalencia en la población adulta, y se acompaña con frecuencia de Proyección Anterior de la Cabeza (PAC). Objetivos: Mostrar la eficacia de un protocolo de tratamiento osteopático durante 4 semanas con 5 evaluaciones y describir la evolución clínica en una Serie de Casos de 7 pacientes adultos con PAC y CMC. Material y Métodos: Se incluyeron 7 pacientes (edad media; 30±6 años) que presentaron PAC y CMC recibieron tratamiento osteopático, con 4 sesiones de intervención y una última sesión exclusivamente evaluativa. En cada sesión se les realizó una evaluación pre y post intervención donde se valoró y estudió la PAC, el Rango de Movilidad Cervical (RMC), el Umbral del Dolor a la Presión (UDP) en los Puntos Gatillo Miofasciales (PGM) mediante algometría y la Percepción al Dolor mediante Escala Visual Analógica (EVA) sobre los PGM así como durante la Movilidad Cervical. Resultados: Nuestro estudio encontró diferencias significativas (p<0,05) en todas las evaluaciones algométricas en los PGM, con alta significación (p<0,001) en el PGM de suboccipitales derechos y Esternocleidomastoideo (ECM) izquierdo. También encontramos mejoría significativa en la Percepción Dolorosa de los PGM, salvo para el Trapecio derecho e izquierdo (mejoría no significativa). En el RMC observamos eficacia significativa para todos los movimientos cervicales excepto las lateroflexiones. No encontramos resultados significativos para el Ángulo Cráneo-Cervical (ACC) en sedestación y en bipedestación. Conclusiones: El tratamiento osteopático aplicado en sujetos con PAC y CMC produce un aumento significativo (p<0,05) en todos los UDP y en el RMC salvo en flexión y en la Percepción al Dolor mediante EVA en Trapecio izquierdo y durante los movimientos de Flexión y las rotaciones. No hay mejoría (p>0,05) para la PAC (AU)

No disponible

Influencia postural de la técnica en rotación del atlas en pacientes con cervicalgia mecánica crónica / No disponible

Introducción: La cervicalgia mecánica crónica (CMC) es una patología común en la sociedad actual. Se define como dolor con una duración de al menos 3 meses desde el inicio de los síntomas, altera las funciones sensoriomotoras, y por tanto, la capacidad de mantener una postura correcta, incluyendo una reducción del rango de movimiento. Objetivos: Valorar el efecto de la manipulación en rotación del atlas (MRA) sobre la estabilometría en pacientes que padezcan: (i) dolor cervical de más de 3 meses de evolución y (ii) presenten un test de flexión-rotación cervical (TFRC) positivo. Material y Métodos: Estudio experimental, controlado, aleatorizado, doble ciego. Han participado 24 pacientes con CMC, 12 formaron parte del Grupo Experimental (GE) y 12 del Grupo Control (GC). Se midió la estabilometría con una plataforma de presiones, y el TFRC, estas mediciones se repitieron post-intervención inmediata, tras 7 y 15 días. Resultados: Encontramos que el gasto energético del paciente, para mantener la postura (L/S) mejora al final del estudio y se observa una mejora significativa (-79.20±5.45;p<0.001) a los 15 días, período en el que su organismo podría haberse adaptado a la nueva situación. Hay un claro aumento de los grados de rotación inmediatamente después de la manipulación (8.33±0.95;p<0.001). Conclusiones: La manipulación en rotación del atlas mejora la movilidad en rotación de la cabeza, y con el paso de los días hay una disminución en el esfuerzo para mantener la postura bípeda, con lo que mejora el gasto energético postural de los pacientes (AU)

No disponible

Técnica neuromuscular en el músculo temporal / No disponible

Introducción: Las técnicas neuromusculares (TNM) son un grupo de técnicas especializadas en el tratamiento del tejido muscular y conjuntivo, que permiten simultanear a la vez la exploración diagnóstica y el tratamiento. Las alteraciones de las estructuras musculares están ligadas a las disfunciones temporomandibulares. Objetivos: Realizar un análisis bibliográfico con el objetivo de conocer la funcionalidad y aplicación terapéutica así como de los cambios fisiológicos que producen las TNM. Material y Métodos: Analizamos la información bibliográfica contenida en artículos relacionados con las TNM, terapias manuales, disfunción temporomandibular (DTM) y puntos gatillos (PGs). Resultados: Se encontró un total de 52 artículos con información referente a los diferentes temas de búsqueda. Realizamos una descripción técnica de sus recomendaciones aplicadas a la clínica diaria. Conclusiones: Las TNM están especialmente indicadas en el tratamiento de los puntos gatillos miofasciales produciendo una disminución de la tensión local y alivio de los síntomas relacionados como con el dolor (AU)

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Técnica de thrust C3 en cervicalgias: modificaciones del umbral del dolor a la presión / Thrust technique C3 in neck pain: modifications of the pressure pain threshold

Introducción: El dolor cervical crónico se localiza a nivel posterior del cuello (desde la nuca hasta la zona interescapular) durante más de 12 semanas, teniendo mayor incidencia en el sexo femenino. Este dolor crónico puede asociarse a periodos de reagudización invalidante, que pueden ocurrir con frecuencia y duración variables. Existe una amplia variedad de tratamientos aplicables en pacientes con cervicalgia crónica, aunque existe escasa evidencia sobre la eficacia de los mismos. Objetivos: Determinar el efecto de la manipulación de C3 sobre el umbral de Dolor a la Presión (UDP) en los puntos gatillos (PG) de los músculos esternocleidomastoideos (ECOM) y en la apófisis espinosa de C3 en pacientes con cervicalgia mecánica crónica. Material y métodos: Se realizó un ensayo clínico aleatorizado, doble ciego con mediciones pre y post intervención en el grupo control y experimental. El tamaño muestral analizado fue de sesenta pacientes (n=60). Se utilizó un dinamómeto digital para medir el umbral de dolor a la presión (UDP) del PG1 de los músculos ECOM y en la apófisis espinosa de C3. Resultados: No se encontraron cambios significativos entre los grupos control y experimental en relación al umbral del dolor a la presión en los PG de los músculos ECOM (p=0,769 ECOM derecho; p=0,082 ECOM izquierdo). Tampoco hubo diferencias estadísticamente significativas en el UDP en la apófisis espinosa de C3 (p=0,777). Conclusiones: La manipulación de C3 no provoca cambios estadísticamente significativos en el UDP en los músculos ECOM ni en la apófisis espinosa de C3. En ambos grupos se aprecia un incremento del umbral de dolor en la medición posterior a la intervención, que es mayor en el grupo experimental en el punto gatillo del músculo ECOM izquierdo y en la apófisis espinosa de C3 (AU)

Introduction: Chronic cervical pain is located posterior to the neck (from the neck to the interscapular zone) for more than 12 weeks, with a higher incidence in the female sex. This chronic pain can be associated with periods of invalidating exacerbation, which can occur with variable frequency and duration. There is a wide variety of treatments applicable in patients with chronic cervicalgia, although there is little evidence regarding their efficacy. Objective: To determine the effect of manipulation of C3 on the Pressure Pain Threshold (PPT) in the trigger points (TP) of the sternocleidomastoid muscles (SCM) and in the spinous process of C3 in patients with chronic mechanical cervicalgia. Material and methods: We performed a randomized, double-blind clinical trial with pre and post intervention measurements in the control and experimental groups. The analyzed sample size was 60 patients (n=60). A digital dynamometer was used to measure the pressure pain threshold (PPT) of PG1 of the SCM muscles and in the spinous process of C3. Results: No significant changes were found between the control and experimental groups in relation to the pressure pain threshold in the PG of the SCM muscles (p=0.769 right SCM; p=0.082 left SCM). There were also no statistically significant differences in UDP in the spinous process of C3 (p=0.777). Conclusions: The manipulation of C3 does not cause statistically significant changes in the PPT in the SCM muscles or in the spinous process of C3. In both groups, there is an increase in the pain threshold in the post-intervention measurement, which is greater in the experimental group at the trigger point of the left SCM muscle and in the spinous process of C3 (AU)

Técnica de Thrust para la disfunción posterior de la cabeza del radio / Thrust technique for posterior disfunction of the radial head

Las disfunciones osteopáticas en el codo pueden causar absentismo laboral, con el gasto económico que ello conlleva para la sociedad, debido a la alta incidencia con la que estas disfunciones se presentan. Una de las lesiones osteopáticas que se pueden dar en el codo, es la disfunción de cabeza de radio posterior, que provoca un aumento del tono del músculo supinador corto, que a su vez puede referir dolor en la región externa del brazo y antebrazo. El objetivo de la técnica de thrust para la cabeza de radio posterior con contacto indexial, será anteriorizar la cabeza del radio, para así poder recuperar la funcionalidad en la articulación del codo. Para realizar correctamente la técnica, previamente habrá que llegar a un diagnóstico adecuado basado en la inspección, palpación, pruebas de movilidad, pruebas musculares, pruebas ortopédicas y radiología (AU)

Osteopathic dysfunctions in the elbow can cause work absenteeism, and the economic expense that this entails for society, due to the high incidence with which these dysfunctions occur. One of the osteopathic injuries that can occur in the elbow is posterior radial head dysfunction, which causes an increase in tone of the short supinator muscle, which in turn may refer pain in the external region of the arm and forearm. The objective of the thrust technique for the posterior radial head with indexial contact will be to forward the radial head in order to recover the functionality at the elbow joint. In order to correctly perform the technique, a proper diagnosis based on inspection, palpation, mobility tests, muscle tests, orthopedic tests and radiology must be previously arrived at (AU)

Clinical decision-making and therapeutic approaches in osteopathy - a qualitative grounded theory study.

There is limited understanding of how osteopaths make decisions in relation to clinical practice. The aim of this research was to construct an explanatory theory of the clinical decision-making and therapeutic approaches of experienced osteopaths in the UK. Twelve UK registered osteopaths participated in this constructivist grounded theory qualitative study. Purposive and theoretical sampling was used to select participants. Data was collected using semi-structured interviews which were audio-recorded and transcribed. As the study approached theoretical sufficiency, participants were observed and video-recorded during a patient appointment, which was followed by a video-prompted interview. Constant comparative analysis was used to analyse and code data. Data analysis resulted in the construction of three qualitatively different therapeutic approaches which characterised participants and their clinical practice, termed; Treater, Communicator and Educator. Participants' therapeutic approach influenced their approach to clinical decision-making, the level of patient involvement, their interaction with patients, and therapeutic goals. Participants' overall conception of practice lay on a continuum ranging from technical rationality to professional artistry, and contributed to their therapeutic approach. A range of factors were identified which influenced participants' conception of practice. The findings indicate that there is variation in osteopaths' therapeutic approaches to practice and clinical decision-making, which are influenced by their overall conception of practice. This study provides the first explanatory theory of the clinical decision-making and therapeutic approaches of osteopaths.

A qualitative grounded theory study of the conceptions of clinical practice in osteopathy - a continuum from technical rationality to professional artistry.

How practitioners conceive clinical practice influences many aspects of their clinical work including how they view knowledge, clinical decision-making, and their actions. Osteopaths have relied upon the philosophical and theoretical foundations upon which the profession was built to guide clinical practice. However, it is currently unknown how osteopaths conceive clinical practice, and how these conceptions develop and influence their clinical work. This paper reports the conceptions of practice of experienced osteopaths in the UK. A constructivist grounded theory approach was taken in this study. The constant comparative method of analysis was used to code and analyse data. Purposive sampling was employed to initially select participants. Subsequent theoretical sampling, informed by data analysis, allowed specific participants to be sampled. Data collection methods involved semi-structured interviews and non-participant observation of practitioners during a patient appointment, which was video-recorded and followed by a video-prompted reflective interview. Participants' conception of practice lay on a continuum, from technical rationality to professional artistry and the development of which was influenced by their educational experience, view of health and disease, epistemology of practice knowledge, theory-practice relationship and their perceived therapeutic role. The findings from this study provide the first theoretical insight of osteopaths' conceptions of clinical practice and the factors which influence such conceptions.

Técnica con arcos botantes para la abertura de la sutura occipitomastoidea / Using the structural buttresses of the skull to open the occipitomastoid suture

El agujero rasgado posterior es una zona clave en el tratamiento craneal osteopático, pues nos permite actuar sobre el importante paquete vasculonervioso que lo atraviesa. Las técnicas estructurales de articulación se utilizan para liberar las suturas y devolver la movilidad a las fibras óseas e intersuturales en disfunción. El objetivo de la Técnica con arcos botantes para la sutura occipitomastoidea es mejorar la elasticidad ósea para desimbricar la sutura descomprimiéndola, y liberar el agujero rasgado posterior y su contenido. Son indispensables una buena evaluación diagnóstica, el conocimiento de los beneficios y riesgos, y una correcta ejecución, para recuperar la movilidad del la sutura y los huesos occipital y temporal, consiguiendo de este modo, mejorar la sintomatología (AU)

The jugular foramen is key to atypical cranial osteopathy treatment as it allows us to act on the vasculonervous bundle that passes through it. Structural articulatory techniques were used to open the sutures and restore mobility to the dysfunctioning intersutural and bone fibers. The objective of using the structural buttresses technique to open the occipitomastoid suture is to improve bone elasticity to open the decompresed suture and to release the jugular foramen and the elements its contains. A good diagnostic assessment, awareness of the benefits and risks and correct employment of the technique are essential to restore mobility to the suture and the occipital and temporal bones, thereby improving the symtomatology (AU)

Abordaje de la lumbalgia crónica a través del tratamiento del diafragma: a propósito de un caso / Treating the diaphragm as a complementary approach to treating chronic low back pain: a case study

Objetivos: El objetivo de este estudio es valorar la eficacia del tratamiento de diafragma en el marco de la lumbalgia crónica a propósito de un caso. Para ello se valorará la evolución en parámetros de flujo espiratorio (peak flow), movilidad lumbar (test de Schober modificado), elasticidad de la cadena posterior (DDS) y dolor a la movilidad lumbar (EVA). Material y método: Se realizó el seguimiento de un paciente con lumbalgia crónica durante un mes, que siguió un protocolo de tratamiento de diafragma durante 4 sesiones repartidas con una periodicidad semanal. Se utilizó la siguiente hipótesis: El tratamiento del diafragma puede mejorar ciertos parámetros (peak flow, test de Schober modificado, DDS y EVA) en los pacientes con lumbalgia crónica. El protocolo de tratamiento consistió en la técnica de Sutherland para el agujero rasgado posterior (tratamiento X par craneal), manipulación vertebral de C3-C4 mediante la técnica de Ashmore (relación con nervio frénico), manipulación vertebral D12-L1 con dog technique (relación con pilares del diafragma) y estiramiento de la parte anterior del diafragma. Como métodos diagnósticos se utilizaron un medidor «Pocket peak spire tm» para la medición del peak flow, una cinta métrica para las mediciones del test de Schober modificado y la distancia dedos-suelo (DDS), y una escala analógica visual (EVA) para la valoración subjetiva del dolor a los movimientos de flexión, extensión, lateroflexión y rotación del tronco. Resultados: Dentro de cada sesión se tomaron mediciones antes y después del tratamiento, observándose mejoría en la mayoría de los parámetros de forma inmediata. Entre cada sesión, mejoraron progresivamente los parámetros de peak-flow y test de Schober modificado. El dolor a los movimientos del tronco y la DDS mejoraron globalmente al final de las cuatro sesiones, aunque en la segunda sesión se produjo una regresión respecto a la sesión precedente. Conclusiones: El tratamiento del diafragma puede ser una herramienta útil en los pacientes que padecen lumbalgia crónica, y sería recomendable su utilización de forma complementaria al tratamiento osteopático de esta patología. Invitamos a seguir investigando en esta línea para conseguir mayor información sobre este tema (AU)

Objectives: The objective of this study is to determine the effectiveness of treating the diaphragm within the framework of chronic low back pain, using a case study. The parameters of analysis will be peak flow, lumbar mobility (modified Schober test), posterior chain flexibility (FTF) and pain perceived with lumbar mobility (VAS). Materials and Method: We monitored a patient with chronic low back pain for a month, following a treatment protocol for the diaphragm over 4 weekly sessions. We used the following hypothesis: treating the diaphragm can improve certain parameters (peak flow, modified Schober test, FTF and VAS in patients with chronic low back pain). Treatment protocol: Sutherland's technique for the jugular foramen (treating the cranial pair X), vertebral manipulation of C3-C4 using the Ashmore Manipulation Technique (relations with the phrenic nerve), vertebral manipulation of T12-L1 using the «Dog» Technique (relations with the crura of the diaphragm) and stretching of the anterior part of the diaphragm. Diagnostic methods: a «Pocket Peak Spire tm» was used to measure peak flow, a metric tape measure was used for the modified Schober test and the Fingertips-to-Floor (FTF) test and a Visual Analogue Scale (VAS) was used to objectively assess pain perception on flexion, extension, side bending and rotation of the trunk. Results: Measurements were taken before and after treatment in each session, with immediate improvements observed in most parameters. The peak-flow and modified Schober test parameters also improved progressively between the sessions. There was an overall improvement in pain on movements of the trunk and FTF at the end of the four sessions, despite a regression in the second session. Conclusions: Treating the diaphragm can be a useful tool for treating patients with chronic low back pain and is recommended as a complementary therapy to osteopathic manipulative treatment. We propose that further research be conducted in order to gain more information (AU)

Efectos de las técnicas manipulativas de tratamiento comúnmente utilizadas en osteopatía para la cervicalgia / Effects of the manipulative treatment techniques commonly used in osteopathy for cervicalgias

Introducción: Diversas técnicas se han estudiado a lo largo de la historia para proponer tratamientos que optimicen la regeneración del tejido, la resolución de dolor o la limitación, en varias estructuras que podrían ser responsables de la cervicalgia mecánica, considerada de etiología idiopática. Dirigido a las articulaciones inter-apofisarias, con sus efectos neurofisiológicos asociados, encontramos técnicas de manipulación de alta velocidad y corta amplitud (HVLA) y técnicas de movilización descritas por quiroprácticos, osteópatas y terapeutas manuales, con la intención de generar un efecto general en todos los tejidos a través del sistema vascular y del sistema nervioso. En la bibliografía tienen respaldo científico sus efectos tanto en la recuperación de la movilidad, como en la disminución del dolor y la discapacidad. Objetivos: En este estudio la intención será comparar los distintos abordajes manipulativos para determinar cual podría ser más conveniente en el tratamiento de la cervicalgia mecánica. Material y Métodos: Se realizado un comentario crítico tras la revisión bibliográfica de estudios aleatorizados y controlados, analizando los posibles riesgos y beneficios asociados a la manipulación y la movilización en la zona cervical y dorsal. Resultados: Las técnicas de alta velocidad cuentan con mas evidencia científica que apoya su efectividad, tanto aplicadas a la región dorsal como a la cervical, aunque se asocian con riesgos neurovasculares poco frecuentes. Las movilizaciones también resultan efectivas para ese fin. Conclusiones: Tanto las manipulaciones (cervicales y dorsales) como las movilizaciones consiguen analgesia, y mejoran la movilidad de la columna cervical y la satisfacción del paciente, así como su discapacidad a corto, medio y largo plazo, comparado con el uso de medicamentos. Tiene un efecto mayor la manipulación, al menos a corto plazo, en la cervicalgia (AU)

Introduction: Different techniques were studied throughout the history, in order to propose treatments for optimizing tissue regeneration, pain resolution or limitation, in several structures that could responsible for mechanical cervicalgia, which has an idiopathic etiology. Aimed for the interapophyseal joints, with their corresponding neurophysiologic effects, we found high-velocity low-amplitude manipulation techniques (HVLA) and mobilisation techniques described by chiropractors, osteopaths and manual therapists, with the purpose of producing a general effect in all the tissues, through the vascular and nervous system. References reveal the scientific support of their effects for both recovering mobility and decreasing pain and disability. Objectives: In this study, the objective is to compare different manipulative approaches, to be able to choose the most convenient one for treating mechanical cervicalgia. Material and methods: A critical commentary was performed after the bibliographic review of the randomized and controlled trials, analysing the possible risks and benefits associated to manipulation and mobilisation in the cervical and thoracic area. Results: High-velocity techniques have more scientific evidences that support their effectiveness, no matter if they are applied in the cervical or thoracic area, although they are associated with rare neurovascular risks. Mobilisations are also effective for this purpose. Conclusions: Both manipulations (cervical and thoracic) obtain analgesia, like mobilisations, and improve cervical spinal ́s mobility and patient's satisfaction, as well as his/her disability in short, medial and long-term, compared to the use of drugs. Manipulation has a greater effect, at least in short-term, for cervicalgia (AU)

Can laypersons be trained to effectively deliver osteopathic manual therapy to patients with HIV?: a pilot study.

CONTEXT: Osteopathic manipulative treatment (OMT) may provide added benefits to standard human immunodeficiency virus (HIV) and AIDS treatments. However, lack of access to trained OMT providers is a potential barrier to the widespread use of OMT in the management of HIV and AIDS. OBJECTIVES: To determine the best time to measure the short-term impact of a brief OMT protocol on white blood cell counts in individuals with HIV and AIDS. Also, to explore recruiting and training laypersons to administer select osteopathic manual techniques. METHODS: Participants were HIV-positive men aged between 18 and 65 years who had not undergone antiretroviral therapy in the past 12 months, had CD4(+) lymphocyte counts of 200 to 700 cells/mm(3), and had viral load levels of less than 100,000 copies/mL. Participants were randomly assigned to an OMT group or a control group; those in the OMT group recruited a layperson for training in osteopathic manual therapy. Participants in the OMT group received a 15-minute OMT protocol consisting of myofascial release of the thoracic inlet, pectoral traction, rib raising, thoracic pump, and abdominal pump. Participants in the control group engaged in conversation with the researcher for 15 minutes. Between-group differences for each white blood cell type were examined at varying time intervals after the protocols. Laypersons were trained to administer thoracic and abdominal pump techniques. They were tested by multiple choice examinations and by an independent rater for fidelity of administration. RESULTS: Twenty-one participants met the eligibility criteria. Of those, 18 returned for their study visit (OMT group, n=9; control group, n=9). An optimal time interval for measurement of white blood cell changes across the 5 cell types was not determined. However, P values for the 30-minute interval were consistently below 0.18 for neutrophils, eosinophils, and monocytes. Nine laypersons were trained in osteopathic manual therapy, 5 of whom scored 100% on initial completion of the multiple-choice examination; the remaining 4 laypersons scored 80% on the first try and 100% on the second try. All laypersons appropriately administered the manual therapy protocol. CONCLUSION: It is feasible to recruit and train laypersons to administer selected osteopathic manual therapy techniques with fidelity. Longitudinal studies on this concept are needed to examine patient outcomes and to evaluate the retention and fidelity of laypersons over time.