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The Efficacy of Facial Effleurage, a Lymphatic Pump Technique, on Immune Response and Symptoms in Acute Rhinosinusitis: A Randomized, Controlled Study
Weidman, C. [4]
Boyd, M. [1]
Pepper, E. [1]
Hsieh, K. [1]
Kunda, D. T. [1]
Burke, K. S. [2]
Carrasco, M. [1]
Escamilla, O. [1]
Cheng, N. [3]
Bradley, J. H. [4]

Journal: The Journal of the American Osteopathic Association Date: 2020/12, 120(12):Pages: e34-36. doi: Subito , type of study: randomized controlled trial


Keywords:

facial effleurage [4]
immune response [11]
LPT [27]
lymphatic pump technique [43]
randomized controlled trial [889]
rhinosinusitis [10]

Abstract:

Statement of Significance: There are limited data on lymphatic pump techniques in ill people and almost no data on OMT in RS patients in the literature. The application of OMT as a first line of treatment can reduce patients’ symptoms and may reduce antibiotic overprescription. Elucidating the immunological mechanism of action of lymphatic pump techniques in RS patients and quantifying the effect of OMT on symptoms will provide quantitative evidence for more widespread use of lymphatic pump techniques. Research Methods: This was a single-session, randomized, controlled clinical study comparing a standardized lymphatic pump technique protocol, a sham treatment, and standard-of-care antibiotics. The Edward Via College of Osteopathic Medicine Institutional Review Board approved all study protocols. Participants between 18 and 69 years old were recruited from a rural health clinic in Spartanburg, South Carolina. Participants were diagnosed with acute RS (n=78) or as otherwise healthy with no RS symptoms (n=60). Participants were randomized into the following treatment groups: no treatment (healthy participants only), the lymphatic pump protocol, the sham treatment, or antibiotics (RS participants only). The lymphatic pump protocol involved five osteopathic techniques: thoracic inlet release, suboccipital release, Galbreath's maneuver, auricular drainage, and facial effleurage. The sham treatment mimicked the same hand placements and movements as the lymphatic pump techniques, but the provider did not apply any pressure. Participants filled out a validated symptom questionnaire and provided peripheral blood and nasal mucus samples before, 1 hour after, and 7-10 days after treatment was initiated. Nasal swabs were collected before and 7-10 days after treatment. If prescribed, antibiotics were started on the same day as treatment. Physicians at the clinic determined the most appropriate standard-of-care antibiotics for each patient, most commonly amoxicillin±clavulanate. Data Analysis: Symptoms and their severity were tracked using the Sinonasal Outcome Test-20 (SNOT-20), a validated questionnaire ranking 20 symptoms associated with RS from 0 (none) to 5 (worst). Values were summed to generate the total symptom score (TSS) out of a possible 100 points. Nasal bacteria were cultured and identified using biochemical assays and gram staining. Results were used to determine if RS was bacterial. Two blood samples were obtained at each time point: one was centrifuged to isolate the serum, and the other was treated to obtain the white blood cells (WBCs). Serum was analyzed via ELISA to obtain immunoglobulin E (IgE), immunoglobulin G (IgG), immunoglobulin M (IgM), tumor necrosis factor alpha (TNFα), and interleukin 6 (IL-6) concentrations. WBC count was determined using a hemocytometer and WBC populations were quantified via flow cytometry. Concentrations of TNFα and various interleukins in nasal mucus samples were analyzed using a cytometric bead array via flow cytometer. Power analysis showed that this study has 80.0% of power to detect an effect size of 16.38, with an effect size of 28. A two-tailed Fisher's Exact Test was used to compare demographic information between healthy and RS participants. An ANOVA analysis was used to compare the mean TSS of different groups. Student's t tests were used to determine all other significant differences. Significance was determined as a p-value < 0.05. Data analysis and graphing were performed using Prism 8.0.2 (GraphPad). Results: All data are reported as differences between baseline and 1-hour or 7-10 days post-treatment. RS participants reported significantly improved symptoms 1 hour after lymphatic pump protocol compared with RS participants who were prescribed but had not yet started antibiotics (-15.4±8.3 vs -6.0±5.5, p = 0.0001). RS participants who received sham treatment also reported reduced symptoms, but the difference was not significant (-12.3±15.2 vs -6.0±5.5, p = 0.11). RS participants had significantly higher serum IgM levels 1 hour after lymphatic pump treatment compared with healthy controls (32.5±100.7 vs -164.0±390.4 mg/dL, p = 0.04). RS participants who received antibiotics and lymphatic pump treatment had significantly lower serum IL-6 levels 7-10 days after treatment compared with those who just received lymphatic pump treatment (-13.0±18.2 vs 1.6±9.8 pg/mL, p = 0.007). RS participants had significantly elevated serum TNFα levels 1 hour after lymphatic pump treatment compared with those who received sham treatment (52.0±135.5 vs -63.4±132.5 pg/mL, p = 0.01) and those who received (but had not begun) antibiotics (52.0±135.5 vs -36.3±155.5 pg/mL, p = 0.045). Serum TNFα remained significantly elevated 7-10 days after lymphatic pump protocol in RS participants compared with healthy controls (30.8±92.5 vs -56.3±130.1 pg/mL, p = 0.026). Conclusion: Our goal was to capture and objectively measure if lymphatic pump OMT moves lymph and improves RS symptoms, which has been anecdotally shown before. Excitingly, we saw immune changes after OMT but not sham treatment, verifying the presumed mechanism of action. These beneficial effects continued for at least one week after a single OMT treatment. Importantly, participants’ symptoms improve quickly after OMT, but not significantly with sham treatment. Taken together, lymphatic pump OMTs mobilize lymph within an hour, which quickly alleviates RS symptoms after a single treatment. One OMT session can improve patients’ quality of life by reducing RS symptoms almost immediately and promote their healing for at least one week. Using lymphatic pump techniques, such as facial effleurage, as a first line treatment for acute RS will not only help the patient quickly feel better, but it may also reduce the use of unnecessary antibiotics. Limitations include a small sample size per treatment group and limited diversity in participants. Further studies in a larger population and with multiple OMT sessions are needed to determine how lymphatic pump OMT can best benefit RS patients. Acknowledgment/Funding Source: We would like to thank Palmetto Proactive Healthcare for allowing us to recruit patients at their office and have their medical assistants aid in patient sample collection. This research was funded by the American Osteopathic Association (Grant #2031815722). Collection of the pilot data was funded by a research grant through the Edward Via College of Osteopathic Medicine's Research Eureka Accelerator Program (REAP).

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