Journal of Bodywork & Movement Therapies (2013) 17, 89e94

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A comparative study of cervical hysteresischaracteristics after various osteopathicmanipulative treatment (OMT) modalities

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Precious L. Barnes, DO, MS, MS , Francisco Laboy III, DO , Lauren Noto-Bell,DO , Veronica Ferencz, DO, MBA , Jeffrey Nelson, DO , Michael L. Kuchera,DO, FAAO*

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Human Performance & Biomechanics Laboratory, Department of Osteopathic Manipulative Medicine, Center for ChronicDisorders of Aging, Philadelphia College of Osteopathic Medicine, 4170 City Ave, Philadelphia, PA 19131, USA

Received 9 September 2012; received in revised form 27 September 2012; accepted 1 October 2012

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KEYWORDSBalance ligamentoustension;Counterstrain;Durometer;Fixation;Frequency;High velocity lowamplitude;Hysteresis;Mobility;Motoricity;Muscle energy;Osteopathicmanipulativetreatment;SA201�;Sham;Somatic dysfunction

* Corresponding author. Marian UnivE-mail address: mkuchera@marian

1360-8592/$ - see front matter ª 201http://dx.doi.org/10.1016/j.jbmt.201

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Summary Background: Few objective measures have been used to document change inmyofascial tissues after OMT.Hypothesis: Paraspinal tissues associated with cervical somatic dysfunction (SD) will demon-strate quantifiable change in myofascial hysteresis characteristics after a given OMT techniquebut not after a Sham intervention.Materials & methods: 240 subjects were palpated for cervical articular SD. A randomly selectedintervention (5 OMT techniques or a Sham) was applied to the cervical SD clinically considered tobe most severe. A durometer (SA201�; Sigma Instruments, Cranberry, PA, USA) objectivelymeasured myofascial structures overlying each cervical spinal segment pre- and post- interven-tion. Using a single consistent piezoelectric impulse, this durometer quantified four hysteresis(tissue texture) characteristics e fixation, mobility, frequency, and motoricity.Results: Baseline changes inmedian hysteresis valueswere noted for eachOMT technique but notfor Sham interventions. Notably, segmental counterstrain OMT resulted in significant motoricitychange compared to adjacent segmental myofascial measures (p-value 0.04) along with a sugges-tive trend in the mobility component (p-value 0.12).Conclusion: Whencomparing treated to untreated cervical segments, themost significant changeoccurred post-counterstrain OMT with no overall change following Sham. Overall, quantifiableobjective change occurs in myofascial tissues post-OMT, in addition to the noted clinical palpablechange.ª 2012 Elsevier Ltd. All rights reserved.

ersity College of Osteopathic Medicine, 3200 Cold Spring Rd, Indianapolis, IN 46222, USA..edu (M.L. Kuchera).

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Background

experienced practitioners assess much more than just

Worldwide and independently, healthcare professionalshave identified an entity identified by palpation that isresponsive to a variety of manual therapeutic maneuvers;under various names, they consider this to be a “manipu-lable lesion” (Fryer, 2003). Many groups and indexingprofessionals have adopted the osteopathic glossary term,“somatic dysfunction”, to reference this entity.

The osteopathic profession defines somatic dysfunctionas “impaired or altered function of related components ofthe somatic (body framework) system: skeletal, arthrodial,and myofascial structures, and related vascular, lymphatic,and neural elements. Somatic dysfunction is treatable usingosteopathic manipulative treatment” (Fryer, 2003). Inaddition to the subjective perceptions of their patients,osteopathic practitioners typically assess clinical changes insomatic dysfunction based on the four individual diagnosticelements: Sensitivity (or tenderness), Tissue textureabnormality, Asymmetry, and altered Range of motion(STAR) (Chila, 2010).

Admittedly, beyond the degree of tenderness fewobjective measurements have been made to actuallyquantify the component elements that constitute somaticdysfunction or to assess the degree of change following theapplication of hands-on treatment techniques (Cohenet al., 2005). This is particularly true for assessing myo-fascial tissue texture characteristics associated withsomatic dysfunction before and after OMT. Since the initialphysiological measurements made by Korr and Denslow ofsweat gland activity, red reflex response, EMG activity inrelated paraspinal muscles, and galvanic skin responses(Peterson, 1979); few tissue studies that have beendesigned to measure such objective components of somaticdysfunction before and after OMT. Of these (Cohen et al.,2005, Warner et al., 1997), most have either not beenblinded or were not linked to simultaneous palpatory find-ings, making it difficult to objectively associate the clinicalcomplaints and their relief to either the somatic dysfunc-tion or its treatment.

Clinical words included in the Glossary of OsteopathicTerminology are used to describe tissue texture findingsand denote the “resilient”, “resistant”, “boggy”, “firm”, or“ropy” qualities found in viscoelastic myofascial structures.Many of these words also describe characteristics associ-ated with the phenomenon of “hysteresis”. In a manualmedicine context, hysteresis is the rate at which connec-tive tissue responds to the loading and unloading ofa compressive (deforming) force. More specifically it isdefined as the difference in viscoelastic behavior (energyloss) (Chila, 2010).

Hysteresis has been recognized to account for a signifi-cant part of the nuanced diagnostic interpretation of thetissue texture characteristics considered by Doctors ofOsteopathic Medicine (Warner et al., 1997). The time ittakes for the deformation of targeted tissues to recoil to itsnormal state is specifically influenced by the acute orchronic pathophysiology in the somatic tissues and theirrelated elements. In this fashion, altered hysteresis char-acteristics in tissues that were “boggy” or edematous mightbe recognized by a specific lag time in tissue recoilfollowing diagnostic palpation compared to “normal” or to

“fibrotic” tissues. When referring to tissue response,

range of motion; they interpret motion quality and how thebody reacts to energy transfer via titrated palpation ofa segment or in response to specific manipulations (Warneret al., 1997).

Similar to industrial measures of magnetic materials(Seth, 1994), hysteresis loops may be recorded. Graphi-cally, a hysteresis loop yields visibly useful informationregarding how any structure (including the human body)reacts to energy as it is repetitively applied and withdrawn(Warner et al., 1997). When a force is added to a pliablesystem, over time the system begins to deform and thenrecoils when the force is taken out of that system. Afteraltering particular aspects of a given system (fluid content,muscle tone, etc), repeated hysteresis measurements tothe same force may document that the system recoils moreor less quickly than ideal.

In a human system, hysteresis measures are not dictatedsolely by the physical structure; rather they reflect theindividual’s and the site’s dynamic, functional anatomy asinfluenced by tissue texture characteristics covering thearticular elements. Depending upon how the combinedphysiological and anatomical conditions differ from theoriginal system, there can bemeasurable lag or acceleration(hysteresis) in reforming to its normal state (Ward, 2002).

The SA201� System (Sigma Instruments; Cranberry PA,USA) is an instrument commercially used for spinal analysisand treatment (see Fig. 1a and b). It incorporates tech-nology that reports a unit-less “Durometer” to quantify“hardness”, or in this case, changes in human cervicaltissue occurring in response to a consistent deformingforce. This system can analyze selected regions of the spinefor comparison to adjacent tissues as well as pre and posttreatment changes using computer graphics that measureparticular aspects of tissue texture characteristics inDurometers (Rustler and Tilscher, 2009).

There are four components used to calculate a Durom-eter: motoricity, mobility, frequency, and fixation. Motor-icity (area under the curve) represents overall dysfunction ofa segment.Mobility (time to peak/total time) corresponds tothe range of motion for a segment. Frequency (length of thecurve) is the time it takes to meet either a restrictive orphysiologic barrier. Finally fixation, (peak of the curve)indicates the resistance within the tissues. These fourcharacteristics were analyzed to document the change incervical hysteresis after OMT (see Fig. 2).

Hypothesis

Immediately adjacent paraspinal cervical tissues will showa quantifiable change in fixation, frequency, mobility, andmotoricity after each OMT technique with no objectivechanges following Sham treatment.

Materials & methods

A total of 240 subjects were recruited and consentedaccording to the protocol approved by the InstitutionalReview Board of the Philadelphia College of OsteopathicMedicine. Subjects were treated with a pre-determined

Figure 1 a SA201� machine. b SA201� in use.

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OMT technique to the single cervical segment considered(by palpation) to have the most significant somaticdysfunction.

The four different pre-determined OMT techniqueschosen represented commonly employed clinical manipu-lative techniques; Muscle Energy (ME), Counterstrain (CS),Balanced Ligamentous Tension (BLT), and High-VelocityLow-Amplitude (HVLA). The fifth intervention was a Shamprocedure consisting of touching the mastoid processesbilaterally with two fingers while thinking through twoverses of the “Happy Birthday” song. The palpating osteo-pathic physicians were instructed to pay careful attentionto avoid accidentally engaging the soft tissues or anyinherent body rhythm, which could potentially treat thesubject and impact their Sham status.

The first 200 subjects were randomized prior to palpationinto each of the five intervention groups: 40 HVLA, 40 BLT, 40ME, 40 CS, and 40 Sham OMT groups. Subjects were thenobjectively measured using the SA201� durometer instru-ment before palpatory diagnosis for somatic dysfunction.The last 40 subjects were equally and randomly divided toreceive either HVLA or ME interventions with the principal

Figure 2 Portion of a hysteresis graph used to calculatea Durometer by the SA201� durometer equipment (courtesy ofThomas Rustler, MD; Vienna, Austria). F

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investigator (MLK) wearing pressure sensitive sensors on hisfingers.

In this study, the SA201� was used to analyze portions ofthe cervical hysteresis curves before and after OMT. Areproducibly constant force was induced by the SA201�

sensor head which creates this precise impulse against thetissue after the introduction of 4 lbs (1.82 kg) of compres-sion. This amount of pressure best approximated the fingerforces verified by the principal investigator during pal-patory diagnosis and treatment (Jean et al., 2007). Eachvery rapid gentle mechanical impulse and its subsequenttissue responses were recorded in conjunction with thesame piezoelectric force sensor.

At the onset of the protocol each subject was placed ina standard massage chair in the modified kneeling positionwith their head positioned in a head rest locked roughly ata 60� angle and their arms placed comfortably on the armrests in front of them. The durometer probe was applied atprecise angles to the paraspinal muscles at each cervicallevel obtaining data from the occipitoatlantal region to thelevel of C7 (see Fig. 1b, The SA201� in use).

The study used a single SA201� technician (an osteopathicphysician-in-training who trained in Austria with an experi-enced, published clinical researcher in this field and whopracticed over 300 exams for consistency prior to the study;i.e. being able to produce two similar hysteresis curves usingthe SA201� on each individual in multiple settings).

Each subject blindly chose a number from an envelopewhich correlated with one of the five interventions. Thepalpator (a resident-level osteopathic physician or seniorosteopathic physician, each with additional specialty-levelmanual medicine training) then implemented the chosentechnique after examining the entire cervical spine anddocumenting a specific descriptive diagnosis on the basis ofits STAR characteristics before treatment. After the inter-vention, the same individual reexamined the site and deno-ted if it was “resolved, improved, unchanged, or worse”.

The subject returned in approximately 10 min (afterfilling out a post treatment evaluation form) for reexami-nation with the SA201� by the same technician whoremained blinded to the site treated and the interventionused. Pre- and post- intervention SA201� datawas collected,and hard-copy printouts were also created for each of the240 subjects (for cervical SA201� chart examples see Fig. 3a

Figure 3 a SA201� graphical and objective pretreatment readings. b SA20�1 graphical and objective post treatment readings ofsame subject.

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Figure 4 Change in segmental paraspinal median motoricitymeasure from baseline after each type of OMT technique anda Sham intervention.

Figure 6 Change in segmental paraspinal median frequencymeasure from baseline after each type of OMT technique anda Sham intervention.

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and b). To decrease potential operator error, two pre- andtwo post-measurements were performed consecutively oneach subject. Then both pre-values were averaged togetherto constitute the recorded pre-OMT measurement for eachsubject; this method was also used in recording post-OMTmeasurement values. (Although, scientifically threemeasurements would have been ideally taken and averaged,the SA201� software at this time is preset to obtain only twomeasurements. This is why it was considered particularlyimportant for the SA201� operator to become as proficient aspossible before beginning the study and to demonstrate anexemplary degree of intra-examiner consistency).

Results

When comparing the median values of each Durometercomponent, a change from baseline regardless of

Figure 5 Change in segmental paraspinal median fixationmeasure from baseline after each type of OMT technique anda Sham intervention.

treatment was displayed in motoricity, fixation, andfrequency. This was true except for the Sham interventionwhich showed no change from baseline (see Figs. 4e7)Mobility also showed a change from baseline post OMTwith ME, CS, and BLT interventions; however, there wasa slight change in the Sham cohort and no Mobility changein HVLA (see Fig. 7).

The Analysis of Variance test (ANOVA) was used tonotate the difference between the means of two or more ofthe treatment groups simultaneously. When using theANOVA test to analyze the four Durometer componentseach one had statistically significant and suggestivevalues at various levels. However, the Motoricity compo-nent displayed the most individual levels of statisticalsignificance followed by frequency, fixation, and thenmobility. Evaluating each treatment group, it seemed thatCS appeared to display the most significant changes postOMT with a p-value of 0.04 in motoricity and a suggestivetrend for CS in mobility with a p-value of 0.12.

Figure 7 Change in segmental median mobility measurefrom baseline after each type of OMT technique and a Shamintervention. F

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Conclusion

This study confirmed that using a durometer (in this case,the SA201�) to objectively measure tissue textureresponses to mechanical deformation provides objectivedata capable of denoting change to manual treatment. Thetreatment modality that yielded the most segmental tissueresponse in this nonhomogeneous and largely asymptomaticpopulation was counterstrain. When comparing treated tountreated cervical somatic dysfunction, an appreciableobjective change is noted in some aspect of each of thefour SA201� Durometer components post OMT. There are nooverwhelming changes in such findings associated withSham, and only slight changes in mobility. Overall, it isevident that not only does a subjective change in themyofascial structures occur post-OMT, but a quantifiableobjective change transpires as well.

Discussion

Each of the four components of the Durometer measures itsown unique characteristic of hysteresis. Numerous sugges-tive trends were appreciated and could best be furtherinvestigated by increasing the number of subjects in eachtreatment group or perhaps by selecting amore homogenouspopulation (possibly with a given symptomatic complaint orspecific type/location of somatic dysfunction). It is apparentthat treating one segment can produce a change; however,the study design did not fully test the manner in which OMTtechniques are typically used in constructing a cohesive,integratedOMM treatment in a clinical situation. It could alsobe argued that the randomization of technique type mightlead to use of an activating force less suited to makinga change than one chosen for the type or site of thedysfunction. Furthermore, in this study design, it becameapparent that in many instances, treating a single identifiedkey dysfunction sometimes modified other underlying oradjacent somatic dysfunctions.

We will be exploring further the effects that eachtreatment technique has on each cervical segmental levelas the data seemed to suggest that different cervical levelsresponded better to specific treatments. Classification ofthe dysfunctions as “acute” (ostensibly containing morefluid in the tissues) or “chronic” (ostensibly stiffer tissues)

might also lead to sub analysis and better interpretation ofthe direction of the measured Durometer changes.

Acknowledgments

The researchers wish to thank John Crunick and SigmaInstruments for thedonationof theSA201�equipmentneededfor objectively documenting change in tissue response, BruceStouch, PhD for his statistical analysis with the data, and toThomas Rustler, MD (Vienna) for patience, guidance andtraining that resulted in those skills with the equipmentneeded for consistent application and measurement (Rustlerand Tilscher, 2009).

References

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Fryer, G., 2003. Intervertebral dysfunction: a discussion ofmanipulable spinal lesion. Journal of Osteopathic Medicine 6(2), 64e73.

Jean, N.T., Kuchera, M.L., Williams, L., Schoenfeldt, B., Vardy, T.,Dombroski, R.T., 2007. Measuring pressures used by physiciansand students for cervical diagnosis of segmental somaticdysfunction using the Iso-TOUCH� Palpation Monitor System(abstract). The Journal of the American Osteopathic Association107 (8), 327e328.

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