by Mirjam Bonanno, MSc, and Rocco Salvatore Calabrò, MD, PhD
Ms. Bonanno and Dr. Calabrò are with Neurorehabilitation Unit, IRCCS Neurolesi Center “Bonino-Pulejo” in Messina, Italy.

Funding: No funding was provided for this article.

Disclosures: The authors have no conflcits of interest relevant to the content of this article.

Innov Clin Neurosci. 2023;20(7–9):8–10.

Abstract

Osteopathic manipulative treatment (OMT) is a hands-on therapy that aims to promote homeostasis by individuating and treating somatic dysfunctions (SDs), including alterations in muscular tissue. Presently, patients affected by neurological disorders (e.g., Parkinson’s disease [PD], multiple sclerosis [MS], and mild traumatic brain injury) often present to the osteopaths for treatment of motor symptoms, fatigue, stiffness, and chronic pain. OMT could be a safe adjunct treatment to promote physical wellness in such patients. However, there are many unanswered questions about its efficacy, especially regarding patients with neurological diseases. In this commentary, the authors encourage and promote the implementation of OMT as a complementary therapy in the neurorehabilitation field.

Keywords: Osteopathic manipulative treatment, complementary treatment, neurological disorders, neurorehabilitation

Osteopathic manipulative treatment (OMT) is a hands-on therapy that aims to promote homeostasis by individuating and treating somatic dysfunctions (SDs; e.g., body asymmetry, tissue modifications, and restriction of motion) to improve neurological, circulatory, and metabolic functioning.1 It is not uncommon for patients affected by neurological disorders, including Parkinson’s disease (PD), multiple sclerosis (MS), and brain injury, to visit private osteopathic clinics for the treatment of motor symptoms, fatigue, stiffness, and chronic pain.2 OMT is mostly focused on the fluidity of muscular tissues associated with patient health status and involves a wide range of manual techniques (e.g., soft tissue stretching, visceral technique, resisted isometric muscle energy stretches, spinal manipulation, and cranialsacral therapy).3,4 In particular, osteopathic treatment is characterized by its holistic approach, and manual therapy can be applied to many body regions and tissues, including those distant from the symptomatic area. It is noteworthy that OMT is based on postural and palpatory evaluation of the patient, which is key in guiding the manual treatment.5

Sometimes, the use of innovative neurorehabilitation tools, including robotic devices and virtual reality, makes us forget the importance of human touch and a more person-centered care model6 based on clinical assessment, including palpatory findings.7 In the last 20 years, neurorehabilitation has undergone technological improvments, developing new generation systems6 and neglecting the “old” use of hands-on techniques. The osteopathic approach involves listening to both the patient and their body by using the three crucial dimensions of touch: analgesic, somatic perceptual, and affective.8

The osteopathic community is facing a growing debate about the validity and efficacy of OMT and manual therapy, especially in patients with neurological diseases.3,5 What we do know is that osteopathic medicine is primarily founded on four principles: 1) The body is a unit, which also includes mind and spirit; 2) The body is able to self-regulate, self-heal, and maintain health status; 3) Structures are linked with functions, and vice versa; and 4) Rational treatment is based on the understanding and application of principles 1 to 3.9

According to the latest evidence,3,4,10 OMT is safe and could improve patient quality of life through the variety of manipulation techniques targeting the body homeostasis as a functioning unit. In addition, OMT is more affordable and less invasive than other medical treatments, and it is adjusted based on patient condition, age, weight, and other clinical features.4 However, there is still a wide gap between rigorous scientific approach and osteopathic clinical intuition and perception, which could negatively influence any conclusive indication about its implementation in the public healthcare systems. To overcome this concern, a better understanding of how to translate osteopathic principles and practice into evidence-based medicine is imperative.

From our point of view, complementary and alternative approaches, such as OMT, might provide additional benefits in the treatment of chronic neurological conditions (e.g., PD, MS, and mild traumatic brain injury)2 with concurrent neurorehabilitation, both standard (e.g., Bobath and Kabat methods) and/or advanced (e.g., robotics, virtual reality, and neuromodulation). Indeed, neurological disorders, such as PD, determine balance and gait alterations, stiffness, and bradykinesia,11 while MS presents more often with with spasticity, fatigue, and ataxia, among other symptoms.2 It seems that OMT in patients with PD could act on muscle tension, reducing muscle, fascial, and tendon shortening that are involved in decreased joint range of motion (ROM) and postural instability.12 Additionally, the individuation and treatment of hip and knee ROM restrictions might help to improve joint kinematics during gait and decrease fall risk.13 In the same way, OMT could be a safe alternative treatment in patients with a brain injury, especially in the management of posttraumatic headaches and dizziness, through the palpitation of the occipito-atlantal joint and treatment of cranial dysfunctions.14 Otherwise, OMT in patients with MS should be focused on fatigue-related symptoms that are currently resistant to pharmacologic treatment, thus helping clinicians to better manage these disabling symptoms.15 The neurorehabilitation team should consider OMT as an adjunct treatment to promote physical wellness and reduce chronic pain with its noninvasive direct and indirect techniques.4 Notably, indirect techniques, including fascial manipulation, are characterized by a gentle and soft touch,16 which could be adaptable in those patients with neurological disorders at high risk of bone fracture due to osteoporosis.

How can OMT contribute to the physical wellbeing of patients through touch? Therapeutic touch (TT) during a massage induces a form of relaxation associated with a decrease of stress makers, including cortisol and heart rate regulation.8 Notably, TT allows for physical relief by reducing the activation of the dorsal anterior cingulate cortex (ACC) and anterior insular cortex (AIC), both brain regions involved in pain perception.17 In addition, the insular cortex plays a role in the regulation of immune and neuroendocrine systems, guaranteeing homeostatic balance through allostasis.16 The AIC is also crucial in the central modulation of oxytocin, which is released with the use of TT during hands-on techniques, such as OMT. Oxytocin together with endogenous peptides can help with analgesia due to its link with reduced activity in the AIC in response to noxious stimuli, regulation of noxious threats, and increased activity in the prefrontal lobe.18 Therefore, it is plausible that pain and pain-related symptoms in patients with neurological disorders might improve after OMT.

Moreover, it is important to understand if and to what extent OMT could boost brain plasticity, which is fundamental to allow functional recovery in patients with neurological disorders. Ponzo et al19 showed that OMT could modulate motor cortical excitability in subjects with SD, which is associated with altered afferent input to the central nervous system (CNS), causing plastic neural changes. According to a systematic review,20 spinal manipulation, a technique often used by osteopaths, can play a key role in brain activity, but long-term clinical and beneficial effects on patients remain unknown. Furthermore, in neurorehabilitation, we have to deal with brain changes and progressive neural alteration, especially in patients with neurodegenerative disorders, including PD11 and MS. Hence, it becomes useful to understand whether OMT can contribute more, not only in improving motor symptoms, but also in ensuring long-term plastic neural processes, limiting the progression of the neurological disease.

For all these reasons, OMT could be considered an innovative approach in the management of neurological patients, even if it exploits the “old” method of using hands and palpatory skills. Researchers in the neurorehabilitation field should consider the use of OMT in patients with neurological disorders since it offers a different and complementary tool in the evaluation and treatment, and it could be decisive for achieving better long-term outcomes.

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