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Investigation of Suboccipital Release, Muscle Energy, and Combination Therapy, Respectively Evaluating their Effect on Carotid Artery Blood Flow: Preliminary Results
Sabbagh, M. [2]
Moriarty, S. [4]
Perera, I. [2]
Dziepak, S. [1]
Santiago, M. [1]
Peddibhotla, V. [1]
Rubis, C. [1]
Anandakrishnan, R. [7]
Rawlins, F. [4]
Brolinson, P. G. [7]

Journal: Journal of Osteopathic Medicine Date: 2024/12, 124(12):Pages: A69-A71. doi: Subito , type of study: randomized controlled trial

Full text    (https://www.degruyter.com/document/doi/10.1515/jom-2024-2000/html)

Keywords:

blood flow [28]
carotid artery [4]
MET [571]
muscle energy technique [174]
randomized controlled trial [880]
suboccipital release [6]

Abstract:

Context: Head injury, particularly mild Traumatic Brain Injury (mTBI), is common in contact and collision sports, motor vehicle accidents and falls [1]. Research has demonstrated reduced cerebral blood flow (CBF) following mTBI [2-4] and sports related concussions [5]. Importantly, 75% of the CBF is supplied by the carotid arteries or anterior circulation and 25% from the vertebral arteries or the posterior circulation [6]. Our study aimed to investigate the effects of Osteopathic Manipulative Treatment (OMT) on common carotid artery (CCA) blood flow, the dominant source of CBF, with four cohorts of healthy participants: suboccipital release (SR), muscle energy (ME), both SR and ME, and sham. SR was chosen due to effect on suboccipital musculature and occiput, housing the jugular foramen where the vagus and glossopharyngeal nerves travel [7], eliciting effects on the autonomic nervous system, particularly the parasympathetics [8]. Prior research has demonstrated promising results with OccipitoAtlantal decompression treatment on improved cerebral blood flow [9], while others indicate varied outcomes. These variations were demonstrated by researchers observing a transient reduction in CBF immediately following OMT, with CBF later increasing three days post-treatment [10]. Additionally, we chose to evaluate the ME technique directed towards correction of cervical spine somatic dysfunction and its effect on CCA blood flow. To our knowledge, this will be the first study to examine the effects of cervical spine ME on CCA velocities. The literature evaluating the efficacy of OMT in modulating CBF remains sparse and limited. Our study seeks to examine the biological impact of cervical spine OMT on CCA velocity using a robust sample size of healthy participants. By establishing these effects, we lay the groundwork for future research in populations with mTBI, potentially advancing the role of OMT in post-concussive treatment protocols. Objective: To investigate the effects of OMT techniques, specifically ME, SR, combination of SR and ME, and sham, on CCA blood flow. We hypothesize that the combined treatment of ME and SR will yield the greatest increase in CCA blood flow, as measured by Peak Systolic Velocity (PSV) and End Diastolic Velocity (EDV). Methods: Sampling: This study utilizes a randomized controlled trial design. Recruitment consisted of staff and students from the Edward Via College of Osteopathic Medicine, Virginia Campus (VCOM-VA). Preliminary results are based on 47 participants from initial interest and recruitment. Potential participants were notified of the study via email and once prior to the start of a lecture on campus. Inclusion criteria was defined as participants of at least 18 years of age that are staff or students at VCOM-VA. Exclusion criteria included contraindications to the treatments: trauma, bone fractures, joint dislocation, infection, muscle tears, rheumatological conditions affecting the cervical spine, cervical spine instability, internal bleeding, recent myocardial infarction or recent surgery, acute cervical fractures, neurovascular compromise, malignancy, hematoma, aneurysm, open wounds, and focal neurological deficit [11-13]. Study Design: Each participant was assigned an ID number for de-identified data collection. Random assignment to one of four treatment cohorts was achieved using the rand() function in Microsoft Excel. Informed consent was obtained from participants. Participants laid supine for 5 minutes prior to obtaining pre-treatment readings of their PSV and EDV of the right CCA via doppler ultrasound (US). Three initial measurements were taken of the PSV and EDV, recorded in cm/s2. Next, participants had their cervical spine (OA, AA, C2-7) diagnosed and treated according to their assigned cohort. ME involved treatment of all diagnosed cervical dysfunctions. For sham treatment, the patient laid supine with the investigator’s hands placed on the sides of the skull with equal resting pressure. Finally, three more measurements of PSV and EDV were recorded. Statistical Methods: ANOVA and post-hoc comparison was employed to analyze pre- and post-treatment data. Chi-squared tests were used to assess the distribution of possible confounding demographics data amongst our sample. Error Handling: Investigators evaluating and treating with OMT have passed skills checks through their curricula at VCOM-VA and a final check by the study principal investigator. Ultrasonographers have undergone training with an Emergency Medicine physician on the proper technique for measuring CCA velocities. An error study utilizing ANOVA and boxplots was performed to evaluate inter-sonographer reliability. Osteopathic Significance: This study seeks to provide objective evidence on the effects of cervical spine OMT in improving cerebral blood flow. Elucidating the biological impact of cervical spine OMT has the potential to enhance osteopathic practice and deepen current understanding. Results: At a power of 0.8, we calculate the optimal sample size to be 180. With ongoing recruitment, we present preliminary data from 47 participants (n = 47). Data analysis yielded a P-value of 0.195 for PSV and 0.554 for EDV, indicating the observed change was not statistically significant. Initial demographic analysis revealed a predominance of female participants at 73%, with most participants falling between the ages of 21-25 years (56%) and 26-30 years (31%). Approximately 50-60% of participants in each cohort reported medications with the potential to affect the autonomic nervous system. Further analysis employed the Chi-squared test and indicated no significant difference across the treatment cohorts: sex (P = 0.156), age 21 to 25 (P = 0.753), age 26 to 30 (P = 0.672), and medications (P = 0.956). These findings suggest the demographics of our current sample are well-distributed. Conclusion: While our preliminary data failed to demonstrate statistical significance, observations were drawn from current results. Interestingly, in all but one cohort, PSV and EDV decreased after treatment with OMT. The cohort receiving both ME and SR was the exception, showing no decrease in PSV. Looking forward, the project has received approval for recruitment from the general population for a sample size goal of 180. Continuation of our study will aim to further characterize the relationship between cervical spine OMT and CCA blood flow. Conclusions from this study will set the groundwork for future studies examining the role and efficacy of OMT in the mTBI setting, and post-concussive protocols.

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