Effectiveness of Osteopathic Manipulative Treatment (OMT) and Vestibular Rehabilitation Therapy (VRT) alone or in combination on Balance and ...

Effectiveness of Osteopathic Manipulative
      Treatment (OMT) and Vestibular
  Rehabilitation Therapy (VRT) alone or in
combination on Balance and Visual Function
  in Individuals with Vertigo and Somatic
                Dysfunction

            Marcel Fraix, DO, FAAPMR
                Assistant Professor
        Departments of PM&R and NMM
   Western University of Health Sciences / COMP
                    Pomona, CA

Overview
• Background
  o Vertigo
  o Use of OMT in Patients with Vertigo
  o Research pre-dating current study
• Clinical Study
  o Objectives
  o Methods
     • Design
     • Interventions
     • Measurement
  o Data and Preliminary Results
  o Obstacles

Thank you

Vertigo
• Dizziness
   o Frequently encountered
     clinical complaint
       • Geriatric population
   o Types
       • Pre-syncope
       • Psychophysiological
          dizziness
       • Disequilibrium without
          vertigo
       • Vertigo
             o Central
             o Peripheral

Vertigo
• Balance
  o Semicircular Canals and CN VIII
  o CN II
  o PNS and Proprioception

• Cervical Spine
  o Joint Capsule
      • Mechanoreceptors
        transmit information to
        vestibular system
  o Suboccipital and Paraspinal
    Muscles
      • Muscle spindles connect
        with spinovestibular tract

Manual Medicine and Vertigo
• OMT                                   • Chiropractic
  o Fraix M, Gordon A, Graham V,          o Hawk C, Khorsan R, Lisi A, et al.
    et al. Use of the SMART Balance         Chiropractic care for
    Master to quantify the effects
                                            nonmusculoskeletal conditions:
    of osteopathic manipulative
    treatment in patients with              a systematic review with
    dizziness. J Am Osteopath               implications for whole systems
    Assoc. 2013 May;113(5):394-             research. J Altern Complement
    403.                                    Med. 2007;13(5):491-512.
  o Lopez D, King H, Knebl J. Effects     o Heikkila H, Johansson M,
    of comprehensive osteopathic            Wenngren B. Effects of
    manipulative treatment on               acupuncture, cervical
    balance in elderly patients: a          manipulation and NSAID
    pilot study. J Am Osteopath
                                            therapy on dizziness and
    Assoc. 2011;111(6):382-388.
                                            impaired head repositioning of
  o Fraix M. Osteopathic
                                            suspected cervical origin.
    manipulative treatment and
    vertigo: a pilot study. PM R.           Man Ther. 2000;5(3):151-157.
    2010;2(7):612-618.

Manual Medicine and Vertigo
• Primary Outcome
  Measures
  o Dizziness Handicap Inventory
    (DHI)
      • Subjective
  o Computerized Dynamic
    Posturography (CDP)
      • Objective
      • Composite Score (CS)

Manual Medicine and Vertigo

   Fraix M, Gordon A, Graham V, et al. Use of the     Fraix M. Osteopathic manipulative treatment and
  SMART Balance Master to quantify the effects of     vertigo: a pilot study. PM R. 2010;2(7):612-618.
osteopathic manipulative treatment in patients with
        dizziness. J Am Osteopath Assoc. 2013
                   May;113(5):394-403

Effectiveness of Osteopathic Manipulative
      Treatment (OMT) and Vestibular
  Rehabilitation Therapy (VRT) alone or in
combination on Balance and Visual Function
  in Individuals with Vertigo and Somatic
                Dysfunction
                Clinical Study

Objectives
•   To measure the response to OMT and/or vestibular rehabilitation
    therapy (VRT) by using the Dizziness Handicap Inventory (DHI) and
    Computerized Dynamic Posturography (CDP) in participants
    experiencing vertigo.
•   To determine if the degree of somatic dysfunction correlates with
    the degree of imbalance in participants with a diagnosis of
    vertigo.
•   To compare the effectiveness of OMT to VRT, head to head and
    synergistically, and to no treatment, in participants with a
    diagnosis of vertigo.
•   To assess the effect of OMT and/or VRT aimed at improving visual
    function disorders related to a diagnosis of vertigo.

Design

OMT    OMT / VRT   VRT

        Control

Design
Week 1          Week 2          Week 3          Week 16
Evaluation      Evaluation      Evaluation      Evaluation
• DHI           • Somatic       • DHI           • DHI
• CDP             Dysfunction   • CDP           • CDP
• Somatic       Treatment       • Somatic       • Somatic
  Dysfunction   • OMT             Dysfunction     Dysfunction
Treatment       • OMT / VRT     Treatment
• OMT           • VRT           • OMT
• OMT / VRT                     • OMT / VRT
• VRT                           • VRT

Interventions
• OMT                              • VRT
  o OMT                              o Peripheral Vestibular
     • Indirect Techniques             Hypofunction
          o Counterstrain               • Balance Exercises
          o Myofascial Release               o Gaze Stabilization
          o Balanced Ligamentous             o Kinesthetic and
            Release                            Proprioceptive
          o Soft Tissue                        Training
     • Direct Techniques             o Peripheral Motion
                                       Hypersensitivity
          o HVLA
                                        • Habituation Exercises
          o Articulatory

Measurement
• Dizziness Handicap
  Inventory (DHI)
  o Total Score
      • 0 – 100
  o Subscales
      • Physical
      • Emotional
      • Functional
  o Severity
      • Mild
           o 0 – 30
      • Moderate
           o 31 – 60
      • Severe
           o 61 – 100

Measurement
• Computerized Dynamic
  Posturography (CDP)
  o Evaluates sensory and motor
    components of postural control
  o Provides graphic and quantitative
    analyses of sway through responses
    to sensory organization tests (SOT)
      • Composite Score (%)
          o Mean for all trials across all
             SOTs
          o Global marker of balance
             and postural control
          o 100% = no motion or sway
          o 0% = fall

Measurement
• Somatic Dysfunction
  o Outpatient Osteopathic SOAP
    Note
     • TART
         o Cervical
         o Thoracic
         o Costal
         o Lumbar
         o Sacral /Pelvic
         o Extremities
     • Cranial Osteopathy
         o SBS Compression
         o Torsion
         o Side bending Rotation
         o Lateral and Vertical
            Strains

Measurement
• Blinding
   o Osteopathic Physicians
      • One DO assessing somatic
         dysfunction
           o Blinded to patient group
      • One DO providing OMT
           o Blinded to whether or not
              participant receiving VRT
   o Doctors of Physical Therapy
      • One DPT performing CDP
           o Blinded to patient group
      • One DPT providing VRT
           o Blinded to whether or not
              participant receiving OMT

Data and Preliminary
       Results

Data and Preliminary
       Results

Data and Preliminary
       Results

Obstacles
• Recruitment
  o Physicians
     • ENT
     • Primary Care
  o Advertisement
     • Email
     • Newspaper
  o Organizations
     • National
           o VEDA
     • Local
           o Senior Living Centers
           o YMCA