The effectiveness of an Osteopathic Treatment Protocol on Multiple

Sclerosis Symptoms: a case study

Casimiro E.1, Finet G.2, Fontes A.P.3, Lombardozzi M.4, Mingelli B.5,
Williame C.6,
1 School of health Jean Piaget / Algarve - Piaget Institute – Portugal 2 – 6 Polytechnic Faculty of Mons –
Belgium 3 Private Hospital of Algarve - Gambelas Unit – Portugal
4 University of Cuiabá – UNIC - Sinop Unit – Brazil 5 School of health Jean Piaget / Algarve - Piaget Institute ;
Research in Education and Community Intervention (RECI) – Portugal

INTRODUCTION:

Multiple sclerosis (MS) is a chronic, demyelinating, autoimmune,

exclusive and progressive inflammatory disease of the central
nervous system with multi factorial etiology not fully clarified yet.
Among the various causes that may favor the development of its
symptoms, a recent theory attributes the manifestation of MS, to a
reduction of the cranial venous outflow (CVO), associated to a
chronical cerebrospinal venous insufficiency (CCSVI), a congenital
malformation of the cerebrospinal veins, that leads to a decrease of
neuronal cell perfusion and to an iron brain-accumulation [1]. The
vascular theory of MS development has been criticized, as there are
no evidence that an iron brain accumulation, due to an induced
CCSVI in rats, is able to develop MS. However, the same studies
showed that an iron brain accumulation really occurs in CCSVI
induced rats, underestimating the fact that MS is basically a genetic
disease, which requires a predisposition to be developed [2]. Some
studies also attribute the failure of vascular theory to the fact that
the surgical cerebrospinal veins dilatation angioplasty, does not give
long-term results in improving MS symptoms. However, It is known
that CVO can be reduced due to postural tensions (PT), which cause
an increase in central venous pressure (CVP) [3]. It is also known
that the blood flow depends on intra-abdominal pressure (IAP) [4],
whose increase is associated to various morbid conditions, including
joint dysfunctions, and that it is possible to reverse this increase, by
a manual technique of pelvic compression [5]. Based on this
evidence we suppose that by normalizing the chronic PT with a
series of manual techniques it would be possible to control the CVP
and improve the blood CVO, improving the symptoms of MS. Thus
the aim of this study, is to evaluate the efficacy of the application of
an Osteopathic Treatment Protocol (OTP), in a patient with MS, in
the relapse-remitting form, at regular intervals, during a period of
six months, measuring the evolution of symptoms through a series
of specific tests.

METHODS:

A quasi-experimental and longitudinal case study was developed.

The sample was a female patient with MS, 28 years old, diagnosed
since she was 18, who had a total of 40 crises since she was
diagnosed, at average intervals of one every 3-4 months. The
patient was being treated with natalizumab administered by
intravenous infusion every 28 days. No changes, in pharmacological
therapy, were introduced during the study. The measuring
instruments used were: a sociodemographic scale, the Mini Mental
State Examination (MMSE), Numerical Rating Scale for pain
assessment (NRS), Berg Balance Scale (BBS), Functional
Independence Measure (MIF), Expanded Disability Status Scale
(EDSS), Modified Fatigue Impact Scale (MFIS), Scale of Functional
Determination of Quality of Life (DEFU) and Functional Testing for
Muscle Strength Assessment. Superficial, deep and combined
sensitivity were also assessed. The Evaluations Tests were applied
at the beginning and after the intervention period. For the data
analysis, descriptive statistics were used, using central tendency and
dispersion measures, in order to compare the values obtained
before and after the intervention period. The intervention was
represented by the application of a Treatment Protocol based on 28
Osteopathic Techniques (TAB I), aimed to reduce the postural
tension (PT), normalize the IAP and the CVO, that was applied
during a period of 6 months and divided in 12 fortnightly sessions.
The OTP has been developed by M. Lombardozzi in collaboration
with G. Finet and C. Williame, according to the theory about the
Visceral Pressure Columns, as fully described in their recent “Traité
d’Osteopathie” (Finet e Williame 2016). Executing modality and
duration of each technique were strictly controlled (Table I presents
the techniques applied in their order, name, executing time,
application side of the body, classification and desired physiological
effects).

The patient read and signed an informed consent term.

The study was approved by the Bio Ethics Committee of the

“Instituto Superior de Saúde Jean Piaget” of Faro (Portugal).

RESULTS:

After six months, no differences were found in the MMSE,

compared to the initial assessment, which corresponded to the
maximum score obtainable. The initial NRS assessment for pain,
showed a joint pain level 2, worsening when resting in bed. A
"vascular type" pain was present in the lower limbs, improving at
rest. In the state of crisis, the pain increased up to grade 6.

At the date of the final evaluation, the basic level of pains remained
the same as the initial, however, the patient reported that those
occurred less frequently. The patient also reported that she didn’t
suffer any disease crisis during the six months and the pains
remained at the basic level the whole time. The BBS improved from
44 to 55 points in the final assessment, compared to the initial one.
An improvement from 111 to 120 points was measured in the MIF,
of which the most important, was the bowel sphincters control, that
improved from 2 to 7, comparing the initial to the final assessment.
The EDSS at the date of the initial evaluation showed a ranking of
6.5 points (bilateral assistance - equivalents are more than 2 FS
degrees 3+) and at the date of the final evaluation, the patient
presented a classification of 4.0 points (full ambulation, up to 500m
without help or rest - 1 FS grade 4, others 0 or 1). There are also to
be remarked the evolutions in the pyramidal functions in 1 point,
bladder functions in 1 point and intestinal functions in 3 points. The
application of the MFIS recorded an initial classification of 58 points
and a final one of 40 points. This classification is indicative of the
decrease in the patient fatigue indexes that in the final evaluation
are close to the limit value (38) which refers to the absence of
fatigue, recording an evolution of 18 points with respect to the
initial evaluation.

The analysis of the sub-scales shows that is the physical domain, the
one in which the greatest reduction of indexes occurred (11 points),
followed by the cognitive sub-scale, in which there was an
improvement of 7 points.

In the psychosocial sub-scale there were no alterations, having

shown, both in the initial and in the final assessment, a classification
of 3 points, indicative of a low level of fatigue. The DEFU score was
79 in the initial assessment and 94 in the final evaluation.

All the sub-scales recorded higher final values, in comparison with

the initial assessment, with the exception of the emotional state
sub-scale.

The sub-scale that recorded the highest increase in quality of life,

registered with the DEFU, was that of Thinking and Fatigue, with a
score of 9 points in the initial evaluation and 15 points in the final
one. There were no differences in the final evaluation of surface,
deep and combined sensitivity, compared to the initial one, since no
dysfunction was found, in these skills, at the beginning.

In the initial assessment of muscle strength, some alterations were

found in various muscle groups of the left half-body.

Only the results referring to the altered muscle groups are reported.

The initial classification obtained was 3 for the flexors and the
extensors of the wrist, flexors and extensors of the hand, flexors and
extensors of the elbow, hip flexors and knee flexors.

The score for the knee extensors was 3+.

The classification obtained for the hip extensors, torsion-tarsal

flexors and toes flexors was grade 2.

All the other muscle groups presented the maximum functional

degree both in the right and the left half-body.

In the final evaluation there were no changes in the muscle groups

that obtained the highest degree in the initial evaluation, remaining
at the same level. Therefore these results were not reported in
Table II.

An increase in strength levels was measured in all the muscle groups

of the left half-body, which had shown alterations in the initial
assessment, having some groups reached the maximum level in the
final evaluation.

Thus, the flexors and extensors of the wrist, the flexors and
extensors of the fingers, the flexors and extensors of the elbow and
the hip flexors, reached the grade 5 of strength, after six months.
The hip extensors were classified with grade 3+, knee-length
extensors with grade 4-, the knee flexors, ankle dorsal flexors, and
toes flexors, with grade 4.

It is also remarkable that the patient, before the study had a

frequency of crises of one every 3-4 months. However, since the
beginning of the study, completely stopped having crises. She is at
her 4th year crises free.

Table II summarizes the results of the scales and tests applied to the
patient in the initial and final evaluation. With regards to the
Functional Testing for Muscle Strength Assessment, only the results
of the muscle groups that presented changes, after the six months
treatment period, are reported in Table II .

DISCUSSION:

The results obtained in this study showed improvements in

strength, balance, fatigue and quality of life after application of the
treatment sessions. Although not so evident, there have been
improvements in pain. The data obtained in this study were
evaluated with different scales, which, to a certain extent, are
correlated. Of all the results obtained, the most evident were the
improvements in muscle strength, fatigue reduction and sphincter
control, since they seem to be the ones that contribute most to
improving the patient's quality of life.

As far as the balance is concerned, improvements have been

observed, in particular at the level of the most dynamic activities in
the bipedal support evaluated through the BBS. The evaluation of
this component is extremely important when it comes to
rehabilitation in MS, because its loss, in many cases, is one of the
first symptoms to appear when the disease is installed.
The most significant improvement occurred in the reduction of
disease crises, taking into account that during the six months of OTP
application, the patient did not suffer any crisis, considering that the
previous year had recorded a series of five crises. The patient has
been accompanied by a longitudinal study, about the evolution of
the disease crises, in which showed a total interruption of episodes,
having reached, so far, a period of four years and five months
without any crisis.

According to the results obtained in this study, the development of

a standardized protocol based on manual techniques seems to be a
valid alternative to endovascular surgery to improve the symptoms
associated with MS. However, there is still a need for further
investigation in this area, as one of the limitations of the present
study is the fact that it is a case study, being presently unable to
obtain similar results when applied to a group of people with MS.
However, this study allows us to establish a starting point for
research in this area.

Future investigations become necessary, with the inclusion of a

greater number of patients that allow identifying and understanding
if the results can be effective in all the variants of MS and if they can
be maintained over time. A possible diminution of self-esteem and
motivation for the fight against the natural course of the disease
and its symptoms, caused by the progression of disability, can be a
determining and limiting factor in the search for a better quality of
life. Not having been evaluated these factors could be a source of
further investigation in future research related to this matter.
REFERENCES:

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sclerosis. Singh av1, Zamboni p.; J Cereb Blood Flow Metab. 2009
dec;29(12):1867-78. doi: 10.1038/jcbfm.2009.180. epub 2009 sep 2.

[2] Failure of The vascular hypothesis of Multiple Sclerosis in a rat

model of Chronic Cerebrospinal Venous Insufficiency. Zakaria Mma,
Mikhael Sy, Hussein Aka, El-Din Ras, El-Malak Hwa, Hewedi Ih,
Nadim Hs.; Folia Neuropathol. 2017;55(1):49-59. Doi:
10.5114/Fn.2017.66713.

[3] Quantifying The Effect of Posture on Intracranial Physiology In

Humans By Mri Flow Studies. Alperin N, Lee Sh, Sivaramakrishnan A,
Hushek Sg.; J Magn Reson Imaging. 2005 Nov;22(5):591-6. Links

[4] Effects of Abdominal Pressure on Venous Return: Abdominal

Vascular Zone Conditions. Takata M, Wise Ra, Robotham Jl.; J Appl
Physiol. 1990 Dec;69(6):1961-72.

[5] Altered Motor Control Strategies In Subjects With Sacroiliac

Joint Pain During The Active Straight-Leg-Raise Test. O'sullivan Pb,
Beales Dj, Beetham Ja, Cripps J, Graf F, Lin Ib, Tucker B, Avery A.;
Spine. 2002 Jan 1;27(1):E1-8.
 Table I : Resume of the 28 OTP techniques
Order Name of the technique Time Application Classification Physiological effect
1 Pelvis Lift 1x each breathing (3x) Bilateral Muscular hinibition IAP normalization
Direct joint
2 Sacroiliac joint counter shear in VD 15” Bilateral IAP normalization
manipulation
Diaphragm
3 Thorax compression in VD 1 Minute Bilateral IAP normalization
normalization
Sacroiliac joint counter shear in Dorsal Direct Joint
4 15” Bilateral IAP normalization
decubitus manipulation
4 Positions (3x each position – 5’’ pelvic Reduction of the visceral-parietal tension of
5 Obturator foramen techniques Bilateral Visceral
contraction) the small pelvis
Diaphragm
6 Thorax compression in Dorsal decubitus 1 Minute Bilateral IAP normalization
normalization
7 MET for iliac rotation 3xtechniques of 5” Bilateral MET IAP normalization
8 MET for lumbar spine rotation 3 techniques of 5” Bilateral MET IAP normalization
9 Opening the acromioclavicular joint ------------------------------- Bilateral HVLA IAP normalization
10 MET for clavicle rotation 3 techniques of 5” for each side Bilateral MET IAP normalization
MET for the 1st rib in exhalation
11 1x each breathing (x3) Bilateral MET IAP normalization
dysfunction
12 General mobilization of the thoracic spine ------------------------------- Bilateral MET IAP normalization
13 Dog T9 ------------------------------- Medial HVLA Reflex technique for the adrenal glands
Modulation of the parasympathetic nervous
14 Dog T4 ------------------------------- Medial HVLA
system and cardiorespiratory system
Thorax compression in Dorsal decubitus Diaphragm
15 1 Minute Bilateral IAP normalization
(2nd) normalization
Normalization of the pressure relationship
Visceral normalization according to the Direct visceral area
16 30’’ Each technique (5 techniques) Unilateral between the diaphragmatic hemi-domes
pressure columns model manipulation
and the ipsilateral viscera
Relaxation of the suprahyoid muscles and
During the exhalation breathing phase (3
17 Inhibition of digastric muscle Medial inhibition muscles in connection with the thoracic
cycles)
outlet
 Relaxation of the suprahyoid muscles and
18 Hyoid bone mobilization 1 minute Bilateral Facial release muscles in connection with the thoracic
outlet
Relaxation of the suprahyoid muscles and
19 Neck fascial mobilization 15 Movements Bilateral Fascial release muscles in connection with the thoracic
outlet
Muscle Energy technique for the neck Neck muscles release, and normalization
20 3 repeats for each side Bilateral Muscle Energy
spine rotation of the neck spine mobility

21 Cranial base release 1 Minute Direct Cranial technique ICP normalization

22 Opening of the occipital condyles 1 Minute Bilateral Cranial technique ICP normalization
Opening the joints of the petrous portion
23 1 Minute (15’’ for each position) Bilateral Craniale technique ICP normalization
and scale of the temporal bone
24 Pompage of the TMJ 15 movements Bilateral Cranial technique ICP normalization
25 Cranial venous sinus dreinage 1 Minute for each position Bilateral Cranial technique ICP normalization
26 Longitudinal cranial compression 30” each side Bilateral Cranial technique ICP normalization
27 Liver dreiange 3x Unilateral Visceral Portal venous flux normalization

28 Sacroiliac joint counter shear in D/D 15” Bilateral Direct Joint IAP normalization
manipulation

D/D: Dorsal decubitus; HVLA: High Velocity Low Amplitude; IAP: Intra Abdominal Pressure; ICP: Intra Cranial Pressure; MET Muscle Energy
Technique; TMJ: Temporomandibular Joint; V/D: Ventral Decubitus.
Table II – Results of scales and tests applied to the patient

Test Entry score Final score

Mini Mental State Examination 30 30
Numerical Rating Scale for Pain
2 2
Assessment
Berg Balance Scale 44 55
Functional Independence Measure 111 120
Expanded Disability Status Scale 6,5 4
Modified Fatigue Impact Scale Total 58 40
Physical 26 15
Cognitive 29 22
Psychosocial 3 3
Total 79 94
Mobility 9 11
Symptoms 14 16
Scale of Functional Determination of Emotional State 18 16
Quality of Life in MS Personal Satisfaction 18 22
Thinking and fatigue 9 15
Social and family
11 14
status
Superficial, deep and combined sensitivity Normal Normal
Left Hemibody
Muscle groups Entry Final
Wrist Flexors 3 5
Wrist Extensors 3 5
Finger flexors 3 5
Finger extensors 3 5
Functional Testing for Muscle Strength Elbow flexors 3 5
Assessment Elbow extensors 3 5
Hip Flexors 3 5
Hip Extensors 2 3+
Knee Flexors 3 4
Knee Extensors 3+ 4-
Ankle flexors 2 4
Toe flexors 2 4