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Constipation in Parkinson’s Disease Improved by an Osteopathic Manipulative Medicine Sequence in a Repeated Measures Study
Valasareddi, S. [1]
Mathai, M. [1]
Li, T. S. [10]
Yao, S. C. [54]
Mancini, J. [25]

Journal: Journal of Osteopathic Medicine Date: 2019/12, 119(12):Pages: e129-e131. doi: Subito , type of study: pretest posttest design

Full text    (https://www.degruyter.com/document/doi/10.7556/jaoa.2019.128/html)

Keywords:

constipation [34]
OMT [2951]
osteopathic manipulative treatment [2973]
pretest posttest design [108]

Abstract:

Statement of Significance: The impact of this study is that it is assessing the effect of OMM in PD in which constipation symptoms often impair quality of life as much as motor symptoms and may become severe enough to require hospitalization. Methods: The pathophysiological factors contributing to constipation and gastrointestinal dysmotility in PD were determined from literature review and clinical expertise with applying the 5 osteopathic treatment models. This treatment sequence combined techniques to specifically address PD-related factors. The goals of the techniques were normalization of the ANS dysregulation, balance tone of the pelvic floor muscles that may be dystonic, improve gastrointestinal inertia to reduce the bradykinesia effects on the gastrointestinal system, and release myofascial restrictions to allow for better thoracic excursion and diaphragm motion to enhance their pumping mechanics. An NYIT-IRB-approved (BHS1065), Clinicaltrials.gov# NCT02344485 repeated measures study on men and women over 40 years old with constipation and PD was conducted. Exclusion criteria included no PD, no constipation, other neurodegenerative disease, acute illness, and relative and absolute contraindications to OMM. PD severity was quantified by a standardized, validated assessment. Constipation severity, symptoms, and quality of life were measured by validated questionnaires for 4 weeks of no-intervention, 4 weekly OMM-sequence treatments, and 2 weeks of no-intervention. Gastrointestinal motility was measured using the Bristol 7-type stool scale by participants and participant-obtained stool photos by investigators. The participants’ past and weekly medical history, including medications, exercise, and nutrition were documented. Data Analysis: A previously calculated mean score improvement with pharmaceutical management of constipation on PAC QOL of 11pts and overall effect size of 1.77 was used to determine sample size. The initial measures of UPDRS, age, years of PD, years of constipation, weight, and sex were compared with the initial constipation measures. The repeated outcome measures Wexner Cleveland Clinic Constipation Severity scoring system, PAC-SYM, and PAC-QOL of mean pre-OMM were compared with postOMM using repeated measures ANOVA with P<.05 considered significant. The inter-rater reliability between weekly participant and investigator Bristol stool scale ratings was calculated with participant and investigator ratings within 20% of each other being considered agreement. Variables from the weekly medical and health history were quantified and evaluated for variability and effect on repeated measures. Results: The OMM-sequence addressed ANS dysfunction, enteric nervous system (ENS) dysfunction, puborectalis muscle dystonia, bradykinesia, and restricted respiratory syndrome that contribute to constipation in PD. Age, MDS-UPDRS total score, and H&Y (n=7) did not significantly correlate with constipation severity, symptoms, or quality of life. Treatment was well tolerated and participants easily monitored their constipation by using the Bristol stool scale. There were significant improvements in the Wexner Cleveland constipation severity 4.2 pts (P<.001) and PAC-QOL 10.6 pts (P=.002). The mean Bristol stool 7-type Scale rating improved from type-2 to type-3. The goal of type 3 or 4 on the Bristol Stool scale was reached by 5 (71%) participants with no significant change in pharmaceutical or behavioral management. Participants had a 7% improvement in quality of life receiving this OMM-sequence in adjunct to their existing management. Conclusion: This OMM-sequence for constipation in PD significantly improved severity and quality of life when applied once weekly. There was good inter-rater reliability of the participants upon teaching them how to use the Bristol stool scale for self-monitoring. By addressing the features of ANS and ENS dysregulation, pelvic floor muscle dystonia, bradykinesia, and restricted respiratory syndrome contributing to constipation in PD, this OMM-sequence procedure significantly improved constipation severity scores and participant assessment of constipation quality of life scores. Limitations of this study include inability to isolate the effects of participant medications on the gastrointestinal tract, lack of an independent control group, and relying on participant tracking of diet, fluid intake, and physical activity. The Rome criteria was designed for functional constipation in the absence of secondary factors, such as medications and systemic illness, and thus its applicability in the PD population is not clear. Application of the Rome criteria also requires that participants be asked about their bowel habits when not taking medications for constipation. This approach was not applied in this study because the common use of medications among our participants to address their constipation would have made it impractical for finding eligible participants. Future research can try to capture more detailed information on factors such as food intake, hydration, and activity to better assess influences on constipation.

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