Osteopathic Manipulative Treatment Improves Heart Surgery Outcomes: A Randomized Controlled Trial Annals of Thoracic Surgery
(The Society of Thoracic Surgeons)
January 18, 2017; Vol. 16 [epub]
Vittorio Racca, MD, Bruno Bordoni, MS, Paolo Castiglioni, PhD, Maddalena Modica, MS, Maurizio Ferratini, MD
Cardiology Rehabilitation Center and Biomedical Technology Department, Santa
Maria Nascente Institute-IRCCS, Don C. Gnocchi Foundation, Milan, Italy
The aim of this study was to assess whether osteopathic manipulative treatment
(OMT) contributes to post heart surgical sternal pain relief and “improves
postoperative outcomes.”
Eighty post-sternotomy patients were randomly allocated to receive a standard ,cardiorespiratory rehabilitation program alone (control group) or standard cardiorespiratory rehabilitation with spinal manipulation. Pain intensity and respiratory functional capacity were quantified by the Visual Analogue Scale score and by a standardized breathing test, at the start and end of rehabilitation.
KEY POINTS FROM THIS ARTICLE:
1) “Controlling sternal pain after heart surgery is important to reduce the risk of postoperative complications, but pain is often undertreated because of contraindications and side effects of analgesic drugs.” Postoperative pain
“diminishes patients’ ability to cooperate, delays recovery and may lead to worse outcomes.”
2) “Inadequately controlled postoperative pain negatively affects the immune system, wound healing, and pulmonary function.”
3) Pain can “activate the sympathetic system, increasing demands on cardiac function and favoring cardiac complications such as tachycardia, arrhythmia, or myocardial ischemia.”
4) “Uncontrolled postoperative pain is often responsible for neurologic
complications, episodes of delirium, and other acute confusional states with a multifactorial pathogenesis.”
5) “In addition to discomfort and suffering, pain may cause sleep deprivation, may delay return to normal functioning, and may have nociception-induced adverse effects on cardiovascular functioning and pulmonary morbidity.”
6) Pain intensity was measured using a 10-cm visual analogue scale (VAS)
ranging from “no pain at all” to “unbearable pain.”
7) The improvement in respiratory function was more marked in the
[manipulation] group. “The inspiratory volume was significantly greater in the [manipulation] group.”
8) “Hospitalization was significantly shorter in the [manipulation] group than in the control group (19.1 ± 4.8 versus 21.7 ± 6.3 days).”
9) “Anti-inflammatory drugs may impair renal function, interact with platelet
aggregation, and increase the risk of gastrointestinal damage and bleeding;
analgesic drugs have detrimental neurologic effects and negatively affect visceral motility; and opioids may decrease survival during in-hospital resuscitation and increase duration of hospitalization.”
10) The manipulation in this study began the day after being discharged from the surgery department, and was administered for 5 days.
11) At the end of rehabilitation:
• The manipulation group had a lower Visual Analogue Scale score.
• The manipulation group had higher mean inspiratory volume.
• The manipulation group had shorter stays.
“At the end of the rehabilitation program, the reduction in perceived pain was more marked in the [manipulation] group and the VAS score was significantly lower in [manipulation] patients than in controls.”
13) “The combination of standard care with [manipulation] is effective in
inducing pain relief and functional recovery, and significantly improves the
management of patients after heart surgery with sternotomy.”
14) These authors reference articles that show spinal manipulation does the
following:
• “Intervenes in the process that transforms nociceptive information into the
subjective experience of pain.”
• “Controls pain after abdominal surgery.”
• “Facilitates recovery of functional ability after coronary artery bypass graft
surgery.”
• “Improves cardiac function.”
• “Reduces analgesia that patients with musculoskeletal problems need after
elective knee or hip arthroplasty.”
15) Of the patients who took pain medications, side effects occurred in
22.5%; these side effects included nausea, vomiting, dizziness, difficulty
concentrating, drowsiness, light-headedness, abdominal discomfort, constipation, dry mouth, itching, rash, and blurred vision.
16) Nonsteroidal anti-inflammatory drugs “may increase the risk of thrombotic cardiovascular events, including myocardial infarction, and of gastrointestinal bleeding.”
17) “Overuse of opioid analgesics induces side effects that can delay recovery and worsen the outcome.”
18) “This is the first randomized controlled trial evaluating the effect of OMT on both pain perception and functional outcomes after heart surgery.”
19) “The main results of our study are that OMT treatment decreases dramatically the level of perceived pain, and substantially improves the functional capacity in terms of inspiratory volumes.”
20) “We also observed a reduced hospitalization, on average by more than 2
days, in the OMT-treated group, that could be consequence of the improved
functional capacity.”
21) The gating mechanism of spinal manipulation would have an “analgesic effect, reducing somatic reactivity and muscle spasms.”
22) “The lower pain intensity in the OMT group at discharge suggests that OMT had a direct analgesic effect.” “The shorter duration of hospitalization
in the OMT group might suggest a more rapid functional improvement.”
23) “It can be hypothesized that the pain-relieving action of [manipulation]
enables lower doses of analgesic drugs.” “Our study suggests that [manipulation] may reduce the use of analgesic drugs, lowering the risk of adverse effects during rehabilitation programs.”
24) “The efficacy of [manipulation] on rehabilitation outcomes can therefore be summarized in terms of a more pronounced reduction in pain intensity and a greater improvement in rib cage mobility, both factors that might have played a role in shortening hospitalization.”
25) “Manipulative treatment is safe, free of side effects, and well
accepted by patients. Moreover, it is relatively inexpensive and only moderately time consuming. For these reasons, cardiac rehabilitation programs should include MT.”
26) Manipulation “should begin before the development of the respiratory
sequelae associated with reduced chest and diaphragm mobility.”
27) “We believe that adding [manipulation] to traditional care programs 1 week after surgery is neither too soon nor too late.”
28) These authors suggest that postoperative manipulation “can be expected to improve the quality of patient care and its cost efficiency, by leading to better and more rapid outcomes and by reducing morbidity.”
COMMENTS
This amazing study supports that all post surgical patients should start spinal manipulation within 5 days of surgery, during the rehabilitation process. The benefits include:
• Significantly reduced pain
• Significantly improved function
• Reduced hospital stay and it associated reduced costs
• Avoidance of drugs and all the risks (complications and side effects)
associated with pharmacology