As her final thesis topic for London College of Osteopathy and Health Sciences (LCO) Diploma in Osteopathic Manual Practice (DOMP) program, Dr. Fadila Naji examines the effects of osteopathy on patients' psychology.

1. ‘Beyond the musculoskeletal system’: Effects of osteopathy on patients’ psychology
Dr. Fadila Naji, MD, DipMedAc, CMTPT
Introduction
OMT is well known for its beneficial effects on the musculoskeletal system; therefore
obviously, one of its main indications is ‘somatic pain’.
Its effects on another aspect of human wellbeing: the patients’ psychological status, is,
however, overlooked.
Pain: a holistic definition
Pain is a complex interdependent psychophysiological phenomenon that cannot be
dissected into individual psychosocial and physical elements. [1, 2]
According to Bendelow, the biomedical approach to pain is reductionist, and commonly
results in both physicians’ and patients’ frustration due to the often-stubborn nature of
pain. [3]
On the other hand, the biopsychosocial model of pain offers a broader view of the
underlying dynamics of chronic pain and provides healthcare providers with additional tools
to address both the biological and the psychosocial aspects of pain.
Osteopathy: a holistic vision
Osteopathy is a patient-centred healthcare practice, whose main tool is manual treatment.
It adopts a holistic approach to patients, based on the principles of interrelation between
the structure and the function of the human body, and the innate body self-healing ability.
The principles of osteopathy are based on a comprehensive clinical and therapeutic
approach considering the patient as a whole entity mechanically, physiologically, and
psychologically.
Osteopathy is mostly popular for musculoskeletal conditions and its positive effects on the
musculoskeletal system are well known. Most studies have focused on the mechanical and
neurophysiologic effects of different osteopathic manipulative approaches [4], whereas its
effects on the patients’ psychological status are less well elucidated, despite the fact that
according to the biopsychosocial model, physical and psychological wellbeing cannot exist
without each other and although the importance of psychological assessment is always
emphasized as part of the clinical assessment of patients suffering from chronic pain.
To that end, several studies have recently looked into the effectiveness of manual treatment
not only on pain, but also on depression and anxiety in chronic pain patients.
The potential impact of OMT on psychological features, such as anxiety, in patients with or
even without musculoskeletal disorders should trigger a more comprehensive outlook on
osteopathy. Obviously, more studies are needed to investigate the non-physical effects of
osteopathic manual practice, especially the potential benefits of OMT for patients with non-
musculoskeletal disorders.

2. According to the scientific literature, does OMT seem to affect patients’ psychological
status?
OMT seems to have an effect, at least on the short term, on anxiety and global body
perception, according to the available scientific literature.
People with musculoskeletal pain may commonly have an underlying, secondary, or
concomitant psychological impairment, and on the other hand, patients with chronic
psychological distress develop increased sympathetic tone and impaired biomechanics in
corresponding areas of the body.[5] The holistic model of osteopathic manipulative
treatment (OMT) seeks to influence mental and emotional status, by targeting these
anatomical locations. Hence, it was proposed that OMT could be used as a treatment
modality for patients with psychological distress and musculoskeletal pain.
A systematic review of the psychological response to spinal manipulation showed
improvement in psychiatric outcomes such as depression and anxiety, suggesting that OMT
may produce a wider scope of benefits to cortical functioning than is commonly believed.
[6,7,]
A trial of patients with neck and back pain in North Wales showed that an osteopathy
primary care clinic improved short-term pain-related outcomes and long-term psychological
outcomes. [8]
CastroSanchez et al. reported that a 20-week massage-myofascial release program
significantly improved anxiety but also quality of sleep and quality of life in patients with
fibromyalgia. The experimental group experienced a significant improvement in anxiety
compared to baseline and to placebo (p< 0.0005). [9]
Findings from the UK Beam trial similarly indicated significant improvement of patients who
received spinal manipulation with respect to pain, back beliefs, and general physical health.
Moreover, interestingly, the study showed improved mental health at three months post
intervention and improved disability at 12 months. [10]
Voigt et al. investigated the effects of OMT on pain and health related quality of life in
patients with migraine and found significant improvements in the intervention group
concerning the number of days lost due to migraine but also in physical functioning, mental
health, vitality and body pain. [11]
The theories behind osteopathic effects on psychology: How can osteopathy influence
psychology?
OMT produces multiple neurophysiological effects.
Studies suggest that OMT increases endocannabinoids in the brain through:
-Stimulation of the periaqueductal grey matter

3. -Stimulation of cannabinoid receptors in the brain by increasing serum levels of anandamide
ANA. [12] Recent research on rats showed that cannabinoid receptor agonism suppresses
anxiety like behavior in rats with essential tremor. [13]
-Down-regulation of the sympathetic system via the Vagus nerve.[14]
OMT can also affect functional connectivity between brain regions involved in pain
modulation.[15] In fact, pain perception seems to be related to distortions of body image in
patients with chronic pain.[16]
Since OMT uses palpation for assessing and treating patients, it is believed that this touch
can create an interaction of sensory inputs such as emotions and physical sensations [17],
which is likely to affect the subject’s emotional status and well-being by influencing body
image and body perception.
Sensory experiences that happen during a body segment movement, are physically and
mentally dependent on the environment as well as on the emotional experiences of the
patient.[18] Similarly, the physician-patient interaction through tactile stimulations may
create physiological changes, increase the patient’s awareness of parts of his body, and thus
possibly increase his compliance with the treatment.
Several studies have reported the effect of touch on anxiety, stress and well-being,[19] and
many have showed significant physiological, biological and psychological changes associated
with it.
Another theory is that OMT improves heart rate variability. [20] In fact, anxiety is associated
with sympathetic system activation, which can be reflected in reduced heart rate variability,
as low variability is associated with a high sympathetic tone. Yergagani et al found low heart
rate variability to be correlated with emotional disorders in children. [21]
Using OMT techniques that can affect heart rate variability is therefore supposed to
decrease anxiety.
Cervical HVLA has been shown to improve heart rate variability in one study of volunteer
patients with neck pain.[22] Osteopathic cranial manipulative medicine has been supposed
to affect heart rate variability through upregulation of the parasympathetic nervous system.
Proximity to this region is likely a factor for the effectiveness of these techniques.
In summary, OMT effects on patients’ psychological status may be related to both the
manipulation of the autonomic nervous system and various effects related to physician
touch.
Study: OMT for stress in osteopathic students
A study was conducted at the Lake Erie College of Osteopathic Medicine-Bradenton in
Florida during the fall 2012 to evaluate the effect of osteopathic manipulative treatment on
self-perceived fatigue, stress, and depression in first-year osteopathic medical students

4. First-year osteopathic medical students voluntarily enrolled in the study and were randomly
assigned to direct OMT, indirect OMT, or control groups. The 2 treatment groups received
treatment by osteopathic physicians weekly for 4 weeks. The control group received no
treatment. All groups completed surveys regarding self-perceived fatigue, stress, and
depression at 0, 2 and 4 weeks of enrolment.
The study concluded that the direct OMT regimen used in the study produced a statistically
significant decrease in self-perceived fatigue in first-year osteopathic medical students, and
that osteopathic manipulative treatment represents a potential modality to reduce self-
perceived distress in medical students. [23]
Suggested manual treatment regimens for anxiety [4,23]
Listed below are possible treatment regime for patients with anxiety. The physician must
use clinical judgment to decide which treatment modality could be best for each individual
patient.
Studies suggest that distress commonly manifests as cervical musculoskeletal dysfunction,
that’s why treatment modalities targeting cervical spine are commonly included in such
treatment protocols.
1. Posterior cervical soft tissue/long axis kneading: performed with the physician at the head
of the table, and his fingertips lateral to the patient’s spinous processes, applying a superior
and lateral pressure on the entire length of the cervical spine.
2. Anterior cervical fascia release: physician applies inferior pressure with his thumb pads in
the patient’s supraclavicular fossa until tension releases, then moves laterally.
3. Suboccipital/Occipito-atlantal decompression: patient lies supine while physician places
index and middle fingers in the suboccipital musculature at the insertion of the extensor
cervical muscles at the occiput and applies anterior and lateral pressure for a period of 2
minutes until relaxation is felt. Effect is probably due to the proximity of the Vagus nerve.
4. Sternocleidomastoid inhibition: physician applies pressure with thumb at the insertion
point of SCM on the mastoid process until a soft tissue release is felt, then grasps the belly
of SCM between his thumbs and fingers, applying inhibitory pressure until relaxation occurs.
Process repeated down the SCM until the insertion point near the jugular notch, where the
physician also applies pressure with his thumb.
5. Levator scapulae inhibition: physician places his thumbs on the participant’s upper medial
border of both scapulae at the levator scapulae insertion points. Inhibitory pressure is
applied until soft tissue tension releases. Pressure is repeated along the scapula and up to
the mid–cervical spine muscle attachment.
6. Compression of the Fourth Ventricle – technique that addresses the periaqueductal grey
area around the fourth ventricle. The physician sits at the head of the supine patient.
Physician’s hands are placed palmar side up and medial to the occipito-mastoid suture.

5. Using thenar eminences on the occiput the physician encourages cranial extension while
limiting cranial flexion until a still point is achieved.
7. Cervical High Velocity/Low Amplitude (cervical HVLA): thought to improve heart rate
variability. Somatic dysfunction barrier is engaged in the cervical spine and short quick
thrust applied to localized segments.
8. Doming of the respiratory diaphragm: Patient is in the supine position, physician inserts
thumbs under the costal margin lateral to the xyphoid process and has the patient breath in
and out while applying a superior and little bit medial pressure.
9. Rib raising, with physician’s finger pads at the rib angles
10. Sacral decompression: Due to the proximity of the parasympathetic nervous system to
the sacral region, a simple side lying sacral decompression may be helpful to decreasing the
level of a patients’ perceived anxiety.
Indirect OMT Protocols have also been used in studies to control for the bias related to the
benefits of experiencing physical contact by a physician in direct OMT therapies.
11. Facilitated positional release of the lower extremities:
Physician grasps patient’s foot with thumb on the dorsum and fingers on the plantar
surface, and externally rotate and abduct the hip while bringing the knee into 90° flexion.
The knee is then allowed to drop laterally, and the foot inverted and internally rotated.
Physician then draws foot inferiorly to straighten and place tension on the knee.
Position held until a release is felt. In the same position, physician grasps calcaneus and
forefoot, flexing and adducting the hip and bending the knee to 90°. The foot is then
externally rotated and drawn inferiorly, straightening, and placing tension on the knee.
12. Unwinding of the lower extremities: physician grasps patients’ ankles, applying
combinations of distraction, traction, compression, twisting, and bending to provide release
of the lower extremities
13. Facilitated positional release of the upper extremities: patient supine while physician
grasps the olecranon with thumb and index finger, with the patient’s elbow bent to 90°.
Using his other hand, the physician grasps the dorsum of the wrist and then rotates the
forearm into pronation, compresses it, and then extends it. This position is held until the
elbow is fully extended and release is felt
14. Unwinding of the upper extremities: physician grasps the participant’s wrists.
Combinations of distraction, traction, compression, twisting, and bending is applied to
provide release of the upper extremity
15. Integrated neuromusculoskeletal release of the pelvis: physician cups the proximal and
distal anterior superior iliac spine with palms, compressing medially and rotating anteriorly
and posteriorly. When resistance is met, position is held until release occurs. Physician then

6. places his caudad hand behind the sacrum, covering the sacroiliac joint with his index and
ring fingers. Then places his cephalad hand on the distal anterior superior iliac spine, with
his forearm on the proximal anterior superior iliac spine. Physician engages barriers using
distraction, compression, and twisting until release is noted.
(Note: the above described manoeuvres were taken from references 4 and 23 with minimal
paraphrasing)
These manoeuvres may represent one part of the treatment protocol that can be used for
psychological distress.
Additionally, patient active contribution in his treatment protocol is always expected to
bring about a better response to treatment and better compliance.
Cardiac coherence training for example can be helpful as an adjunctive or take-home
exercise. Handheld biofeedback tools also can help patients with improving heart rate
variability. Focused mindful breathing can be very helpful as well in decreasing anxiety levels
and can be used in any setting.
Conclusion
Osteopathic manipulative treatment represents an unexplored method to reduce symptoms
of psychological distress. This review suggests that OMT can be used as a treatment
modality to reduce psychological distress. Patients undergoing mental health care may find
benefit of OMT as an adjunct treatment.
In the future, osteopaths might benefit from a better awareness of the way in which their
intervention influences patients' psychosocial outcomes.
Different aspects of care such as the rapport with the patient, good patient education,
patient empowerment and empathy may all contribute to improved patient outcomes.
Osteopaths are ideally positioned to educate patients regarding how certain factors like
psychological distress can contribute to the onset and maintenance of pain.
Being aware of psychosocial factors will also lead to a better understanding of the whole
pain experience and the context in which chronic pain occurs. This should always be an
essential aspect of osteopathic teachings, as osteopathic medicine is holistic medicine.
References
1. Saracutu M, Rance J, Davies H, Edwards DJ. The effects of osteopathic treatment on
psychosocial factors in people with persistent pain: A systematic review. International
Journal of Osteopathic Medicine. 2018;27:23-33. doi:10.1016/j.ijosm.2017.10.005.
2. Turk DC, Monarch ES. Biopsychosocial perspective on chronic pain. In: Turk DC,
Gatchel RJ, editors. Psychological approaches to pain management: a practitioner's
handbook. second ed. New York: Guilford Press; 2002. p. 3 e30

7. 3. Bendelow G. Chronic Pain Patients and the Biomedical Model of Pain. Journal of Ethics
|American Medical Association. https://journalofethics.ama-assn.org/article/chronic-
pain-patients-and-biomedical-model-pain/2013-05. Published May 1, 2013. Accessed
November 21, 2020.
4. Blumer T et al. Osteopathic Approach to Anxiety. Osteopathic Family Physician (2017)
26 – 34. https://ofpjournal.com/index.php/ofp/article/download/512/431/. Accessed
November 21, 2020.
5. Darren J Edwards CT. An evaluation of osteopathic treatment on psychological
outcomes with patients suffering from chronic pain: A prospective observational
cohort study collected through a health and well-being academy - Darren J Edwards,
CraigToutt,2018.SAGEJournals.
https://journals.sagepub.com/doi/full/10.1177/2055102918774684.
6. Rizkalla M et al,J Am Osteopath Assoc. 2018;118(9):617-622
doi:10.7556/jaoa.2018.136. Does Osteopathic Manipulative Treatment Make a
Neuropsychological Difference in Adults with Pain? A Rationale for a New Approach
7. Williams NH, Hendry M, Lewis R, Russell I, Westmoreland A, Wilkinson C. Psychological
response in spinal manipulation (PRISM): A systematic review of psychological
outcomes in randomised controlled trials. Complementary Therapies in Medicine.
https://www.sciencedirect.com/science/article/abs/pii/S096522990700009X.
Published March 8, 2007. Accessed November 21, 2020.
8. Williams NH, Wilkinson C, Russell I, Edwards RT, Hibbs R, Linck P, Muntz R. Randomized
osteopathic manipulation study (ROMANS): pragmatic trial for spinal pain in primary
care. Fam Pract. 2003 Dec;20(6):662-9. doi: 10.1093/fampra/cmg607. PMID:
14701889.
9. Castro-Sánchez AM, Matarán-Peñarrocha GA, Granero-Molina J, Aguilera-Manrique
G, Quesada-Rubio JM, Moreno-Lorenzo C. Benefits of massage-myofascial release
therapy on pain, anxiety, quality of sleep, depression, and quality of life in patients
with fibromyalgia. Evid Based Complement Alternat Med. 2011;2011:561753.
doi:10.1155/2011/561753
10. Brealey S, Burton K, Coulton S, et al. UK Back pain Exercise and Manipulation (UK
BEAM) trial--national randomised trial of physical treatments for back pain in primary
care: objectives, design and interventions [ISRCTN32683578]. BMC Health Serv Res.
2003;3(1):16. Published 2003 Aug 1. doi:10.1186/1472-6963-3-16
11. Efficacy of Osteopathic Manipulative Treatment of Female Patients with Migraine:
Results of a Randomized Controlled Trial. Journal of alternative and complementary
medicine (New York, N.Y.) 17(3):225-30.DOI: 10.1089/acm.2009.0673
12. Solinas M, Goldberg SR, Piomelli D. The endocannabinoid system in brain reward
processes. Br J Pharmacol. 2008;154(2):369-383. doi:10.1038/bjp.2008.130
13. Abbassian H, Esmaeili P, Tahamtan M, Aghaei I, Vaziri Z, Sheibani V, Whalley BJ,
Shabani M. Cannabinoid receptor agonism suppresses tremor, cognition disturbances
and anxiety-like behaviors in a rat model of essential tremor. Physiol Behav. 2016 Oct
1;164(Pt A):314-20. doi: 10.1016/j.physbeh.2016.06.013. Epub 2016 Jun 15. PMID:
27317835.

8. 14. Henley CE, Ivins D, Mills M, Wen FK, Benjamin BA. Osteopathic manipulative
treatment and its relationship to autonomic nervous system activity as demonstrated
by heart rate variability: a repeated measures study. Osteopath Med Prim Care.
2008;2:7. Published 2008 Jun 5. doi:10.1186/1750-4732-2-7
15. Necka EA, Lee IS, Kucyi A, Cheng JC, Yu Q, Atlas LY. Applications of dynamic functional
connectivity to pain and its modulation. Pain Rep. 2019;4(4):e752. Published 2019 Aug
7. doi:10.1097/PR9.0000000000000752
16. Trojan J, Diers M, Valenzuela-Moguillansky C, Torta DM. Body, space, and pain. Front
Hum Neurosci. 2014;8:369. Published 2014 May 28. doi:10.3389/fnhum.2014.00369
17. Elkiss ML, Jerome JA. Touch-More Than a Basic Science. The Journal of the American
Osteopathic Association. https://jaoa.org/article.aspx?articleid=2094445. Published
August 1, 2012. Accessed November 21, 2020.
18. Oosterwijk S, Lindquist KA, Anderson E, Dautoff R, Moriguchi Y, Barrett LF. States of
mind: emotions, body feelings, and thoughts share distributed neural
networks. Neuroimage.2012;62(3):2110-2128.
doi:10.1016/j.neuroimage.2012.05.079
19. Murphy MLM, Janicki-Deverts D, Cohen S. Receiving a hug is associated with the
attenuation of negative mood that occurs on days with interpersonal conflict. PLoS
One.2018;13(10):e0203522.Published 2018 Oct 3. doi:10.1371/journal.pone.0203522
20. Carnevali L, Lombardi L, Fornari M, Sgoifo A. Exploring the Effects of Osteopathic
Manipulative Treatment on Autonomic Function Through the Lens of Heart Rate
Variability. Front Neurosci. 2020;14:579365. Published 2020 Oct 7.
doi:10.3389/fnins.2020.579365
21. Ask TF, Ranjitkar S, Ulak M, et al. The Association Between Heart Rate Variability and
Neurocognitive and Socio-Emotional Development in Nepalese Infants. Front
Neurosci. 2019;13:411. Published 2019 Apr 26. doi:10.3389/fnins.2019.00411
22. Win NN, Jorgensen AM, Chen YS, Haneline MT. Effects of Upper and Lower Cervical
Spinal Manipulative Therapy on Blood Pressure and Heart Rate Variability in
Volunteers and Patients With Neck Pain: A Randomized Controlled, Cross-Over,
Preliminary Study. J Chiropr Med. 2015;14(1):1-9. doi:10.1016/j.jcm.2014.12.005
23. Wiegand S, Bianchi W, Quinn TA, Best M, Fotopoulos T. Osteopathic manipulative
treatment for self-reported fatigue, stress, and depression in first-year osteopathic
medical students. J Am Osteopath Assoc. 2015 Feb;115(2):84-93. doi:
10.7556/jaoa.2015.019. PMID: 25637614.