Effectiveness of Osteopathic Manipulative Treatment (OMT) and Vestibular Rehabilitation Therapy (VRT) alone or in combination on Balance and Visual Function in Individuals with Vertigo and Somatic Dysfunction Marcel Fraix, DO, FAAPMR Assistant Professor Departments of PM&R and NMM Western University of Health Sciences / COMP Pomona, CA Overview • Background o Vertigo o Use of OMT in Patients with Vertigo o Research pre-dating current study • Clinical Study o Objectives o Methods • Design • Interventions • Measurement o Data and Preliminary Results o Obstacles Thank you Vertigo • Dizziness o Frequently encountered clinical complaint • Geriatric population o Types • Pre-syncope • Psychophysiological dizziness • Disequilibrium without vertigo • Vertigo o Central o Peripheral Vertigo • Balance o Semicircular Canals and CN VIII o CN II o PNS and Proprioception • Cervical Spine o Joint Capsule • Mechanoreceptors transmit information to vestibular system o Suboccipital and Paraspinal Muscles • Muscle spindles connect with spinovestibular tract Manual Medicine and Vertigo • OMT o Fraix M, Gordon A, Graham V, et al. Use of the SMART Balance Master to quantify the effects of osteopathic manipulative treatment in patients with dizziness. J Am Osteopath Assoc. 2013 May;113(5):394403. o Lopez D, King H, Knebl J. Effects of comprehensive osteopathic manipulative treatment on balance in elderly patients: a pilot study. J Am Osteopath Assoc. 2011;111(6):382-388. o Fraix M. Osteopathic manipulative treatment and vertigo: a pilot study. PM R. 2010;2(7):612-618. • Chiropractic o Hawk C, Khorsan R, Lisi A, et al. Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research. J Altern Complement Med. 2007;13(5):491-512. o Heikkila H, Johansson M, Wenngren B. Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin. Man Ther. 2000;5(3):151-157. Manual Medicine and Vertigo • Primary Outcome Measures o Dizziness Handicap Inventory (DHI) • Subjective o Computerized Dynamic Posturography (CDP) • Objective • Composite Score (CS) Manual Medicine and Vertigo Fraix M, Gordon A, Graham V, et al. Use of the SMART Balance Master to quantify the effects of osteopathic manipulative treatment in patients with dizziness. J Am Osteopath Assoc. 2013 May;113(5):394-403 Fraix M. Osteopathic manipulative treatment and vertigo: a pilot study. PM R. 2010;2(7):612-618. Effectiveness of Osteopathic Manipulative Treatment (OMT) and Vestibular Rehabilitation Therapy (VRT) alone or in combination on Balance and Visual Function in Individuals with Vertigo and Somatic Dysfunction Clinical Study Objectives • • • • To measure the response to OMT and/or vestibular rehabilitation therapy (VRT) by using the Dizziness Handicap Inventory (DHI) and Computerized Dynamic Posturography (CDP) in participants experiencing vertigo. To determine if the degree of somatic dysfunction correlates with the degree of imbalance in participants with a diagnosis of vertigo. To compare the effectiveness of OMT to VRT, head to head and synergistically, and to no treatment, in participants with a diagnosis of vertigo. To assess the effect of OMT and/or VRT aimed at improving visual function disorders related to a diagnosis of vertigo. Design OMT OMT / VRT Control VRT Design Week 1 Week 2 Week 3 Week 16 Evaluation Evaluation Evaluation Evaluation • DHI • CDP • Somatic Dysfunction • Somatic Dysfunction • DHI • CDP • Somatic Dysfunction • DHI • CDP • Somatic Dysfunction Treatment • OMT • OMT / VRT • VRT Treatment • OMT • OMT / VRT • VRT Treatment • OMT • OMT / VRT • VRT Interventions • OMT o OMT • Indirect Techniques o Counterstrain o Myofascial Release o Balanced Ligamentous Release o Soft Tissue • Direct Techniques o HVLA o Articulatory • VRT o Peripheral Vestibular Hypofunction • Balance Exercises o Gaze Stabilization o Kinesthetic and Proprioceptive Training o Peripheral Motion Hypersensitivity • Habituation Exercises Measurement • Dizziness Handicap Inventory (DHI) o Total Score • 0 – 100 o Subscales • Physical • Emotional • Functional o Severity • Mild o 0 – 30 • Moderate o 31 – 60 • Severe o 61 – 100 Measurement • Computerized Dynamic Posturography (CDP) o Evaluates sensory and motor components of postural control o Provides graphic and quantitative analyses of sway through responses to sensory organization tests (SOT) • Composite Score (%) o Mean for all trials across all SOTs o Global marker of balance and postural control o 100% = no motion or sway o 0% = fall Measurement • Somatic Dysfunction o Outpatient Osteopathic SOAP Note • TART o Cervical o Thoracic o Costal o Lumbar o Sacral /Pelvic o Extremities • Cranial Osteopathy o SBS Compression o Torsion o Side bending Rotation o Lateral and Vertical Strains Measurement • Blinding o Osteopathic Physicians • One DO assessing somatic dysfunction o Blinded to patient group • One DO providing OMT o Blinded to whether or not participant receiving VRT o Doctors of Physical Therapy • One DPT performing CDP o Blinded to patient group • One DPT providing VRT o Blinded to whether or not participant receiving OMT Data and Preliminary Results Data and Preliminary Results Data and Preliminary Results Obstacles • Recruitment o Physicians • ENT • Primary Care o Advertisement • Email • Newspaper o Organizations • National o VEDA • Local o Senior Living Centers o YMCA