Episode #8 - OMT on Chronic Obstructive Pulmonary Disease & Functional Constipation

Hello everyone and welcome to our eighth episode of the OMM Research Podcast! 

Our panelists for this episode are Dr. Stephen Stacey and Dr. Alfred Amendolara.

In this episode, we are an article titled "Effect of selective manual therapy techniques in chronic obstructive pulmonary disease: A randomized control trial" by Mohamed et al. published in the Journal of Taibah University Medical Sciences. The article can be viewed at this link: https://pubmed.ncbi.nlm.nih.gov/39691854/

We are also looking at an article titled "Osteopathic Visceral Manipulation on Functional Constipation in Obese Adults: A Randomized Controlled Clinical Trial" by Zidan et al. published in the Journal of Integrative and Complementary Medicine. The article can be viewed at this link: https://journals.sagepub.com/doi/10.1177/27683605261427696

You can also view this podcast episode on the DO-Touch.NET YouTube Channel and see what is happening in the DO-Touch.NET practice-based research network by visiting our website, which are both linked in this sentence.

Hope you enjoy and feel free to reach out to us at dotouchnet@atsu.edu!

Transcript

SPEAKER_02 0:13

Alright, well, hello to you, our listeners, the manipulated and the manipulators. Uh, welcome to the OMM Research Podcast. The OMM Research Podcast is produced by Deo TouchNet, a practice-based research network that focuses on osteopathic manipulative medicine research. Deo TouchNet is based out of the AT Still Research Institute located at AT Still University in Kirksville, Missouri. Please note that the views and opinions of the panelists in this podcast are personal to each panelist and do not reflect the views or opinions of the AT Still University. My name is Corey Lubring, and I am the practice-based research coordinator of Deo TouchNet and the host of the OMM Research Podcast. Uh, before we get started, we just would like to remind our listeners that this podcast recording has video recorded with it and can be viewed on the Dio Touchnet YouTube channel. As always, we want to start this episode by introducing our panelists, and we'll start with Dr. Amendelara.

SPEAKER_00 1:15

Hi, my name is Al Amendalara. I'm a PGY1 in neurology at St. Luke's in Pennsylvania. And I'm also an adjunct professor of clinical research at Norda College of Osteopathic Medicine.

SPEAKER_02 1:28

And thank you for being with us again this month, Dr. Amendelara. And then we also have Dr. Stacy.

SPEAKER_01 1:34

Hello, my name is Dr. Stephen Kimball Stacey. I am uh Director of Osteopathic Education for the La Crosse Mayo Family Medicine Residency Program and Associate Professor of Family Medicine at Mayo Clinic.

SPEAKER_02 1:48

And thank you also for being with us again this month. We're gonna hop right into the articles uh for this episode. Uh we're gonna be starting with uh the article brought to us by Dr. Stacy, which is a looking at selective manual therapy techniques and chronic chronic obstructive pulmonary disease.

SPEAKER_01 2:07

That's right. The title of this article is Effect of Selective Manual Therapy Techniques in Chronic Obstructive Pulmonary Disease, a randomized control trial. The authors are Mohammed et al. It was published November 19th, 2024 in the Journal of Taibai University Medical Sciences. Apologize to anybody in Cairo who um is listening and listening to me butcher the name. Uh I keep on doing that in this podcast is picking these articles from exotic places and then not saying the names right. So the research question is in patients with mild to moderate COPD, does the addition of manual therapy to physical therapy improve pulmonary outcomes compared to physical therapy alone? And from the abstract, their findings are the combination of manual therapy approaches with conventional physical therapy leads to a clinically significant difference in anterior-posterior chest expansion, FEV, FVC, FEV1, uh, CVA, which is the um which we'll talk about more functional capacity and dyspnea, and a statistically significant difference in kyphosis angle, FEV1 to FEC, and lateral chest expansion compared to using conventional physical therapy alone in patients with COPD.

SPEAKER_02 3:28

Wonderful. So, apart from being something that's recent, what jumped out to you uh related to this article that you wanted to bring into the podcast today?

SPEAKER_01 3:36

They did a lot of things that I like in manual therapy trials that I want to highlight. Let's start with the rationale. They they went into a detailed review on the kinds of findings that have previously been shown in the literature for patients who have COPD with um with regard to how might manual therapy make an improvement. So they talked about things like uh limited diaphragmatic mobility in patients who are kyphotic, why might patients with COPD be more kyphotic? They talked about um limitations in chest range of motion and uh and went into a little bit of detail on the kinds of therapies that they thought might make a difference there and why they wanted to measure the things that they did. They reported on different studies that had looked at things like the FEV1, six-minute walk test, health-related quality of life, really setting up that this is there is background to this, and we really are moving forward, and why this is what moves it forward. So I really like seeing that in manual therapy research. Contrast that with what you see a lot of times, which is um which is sort of just picking something it almost seems like out of thin air. You know what I mean, Al?

SPEAKER_00 4:57

Like Yeah, almost at random, uh to see if there's anything there, sort of uh throwing pasta against the wall to see what sticks. Right.

SPEAKER_01 5:06

So in this case, um it the the research was conducted by physical therapists, not osteopathic physicians, but I think there's a lot we can learn from the manual therapy approaches that they used. The setting was a hospital in Cairo, Egypt, from March 2023 to March 2024. So good on them for getting this into the journal by November. They write faster than I do, I think. So uh they call it a parallel double blind RCT, which was powered to assess pulmonary function, but they didn't really specify the any more about the the power in terms of what size of difference were they looking for. Um they just said that um they would need to recruit at least 52, so 26 in each group. Um so in terms of powering, this I I'm glad to see that they decided beforehand how many people they would need to recruit. The idea of powering, if you're not familiar with it, is to really say, um how can we be sure that we got enough people to show something? So let's say that the study shows no difference whatsoever. Maybe that's because there's not actually a difference, or maybe that's because they just didn't get enough people to show a difference. And so when they're reporting powering, it's nice to say what is the size difference they were expecting to show, so that you can interpret a negative study in that light. Um, but that they they didn't do that here.

SPEAKER_00 6:40

I will say I I think their you know their effect size setting it at 0.5 is is actually a a pretty um ambitious effect size. Uh so I I think they they they ended up finding significant results, so I I suppose that was a reasonable goal, but I would have even accepted it at a slightly smaller effect size.

SPEAKER_01 7:02

Um maybe you noticed this somewhere in the study that I didn't, but they they just said generically pulmonary function, but they had a lot of pulmonary function outcomes like FVC, FEV1, the ratio.

SPEAKER_00 7:13

So I'm not sure what I'm not 100% sure what they were going with either. Um so I appreciate that they did it, but I agree. Yeah.

SPEAKER_01 7:22

Um I'd say that's probably a weakness in reporting more than a weakness in design. But the thing about reporting weaknesses is they could potentially conceal design weaknesses, and you just don't really know. Right. Um so the subjects were they ended up um analyzing 72 adults with COPT based on gold criteria diagnosed by experts in the field. They excluded patients, uh, they reasonably excluded patients with certain major comorbidities like um active cancer, uh with um osteoporosis.

SPEAKER_00 8:00

Like heart failure, yeah. Yeah, exacerbation, recent exacerbations, things like that. Yeah. I do want to make a mention of the uh inclusion. They limit it to patients from 50 to 60 years of age. Um I don't think that's totally unreasonable given the kind of usual age range that we're gonna see COPD in. Uh, but I do think it limits generalizability a little bit.

SPEAKER_01 8:27

Yeah, it could. And and also it makes it harder to recruit. So I don't know why you would limit yourself in that way. But yeah, to just 10 years essentially of um they did end up randomizing 26 to each group, so it seems to me like they probably stopped as soon as they met um their recruitment goal. And uh all the patients received the intended intervention and were also included in the analysis. So, what was the intervention? Uh, group A had physical therapy and they described the techniques as per slit breathing, diaphragmatic breathing, active range of motion of uh both upper extremities. They did that three times a week for eight weeks, so fairly intensive physical therapy, uh, compared with the experimental group that got the same treatment as group one with also manual therapy. And they did a really good job describing the manual therapy techniques that they did. So they described the mobilization techniques, including joint oscillations with mobilization of rib, thoracic facet joints, costovertebral joints. They did this in seated supine prone positions and showed pictures of uh of actual patients in the positions. They also did diaphragmatic myofascial release as well as myofascial release of scaling neck pectoralis muscles, again, with pictures. So uh I really like including enough detail in a manual therapy study that you um have a good chance of actually reproducing the techniques that were performed in the study.

SPEAKER_02 10:01

Absolutely.

SPEAKER_00 10:02

I'm always a fan of pictures.

SPEAKER_02 10:03

Always a fan of pictures. So um I'll no I I just want to ask, so you know, so uh not that I want to scare off any of our listeners listeners by talking more about statistics and everything, but um uh what what really kind of jumped out about the you know, the results, the findings with the study, you know, that that make it something that could really be impactful upon uh uh OMM practice.

SPEAKER_01 10:29

Yeah, so it's interesting. Um you know, the way they set things up, uh it's they had a lot of different outcomes and they didn't really differentiate between primary and secondary outcomes. So the the the difference really is the primary outcome is the thing your study is designed to find. So if you look at the power analysis, for example, you can't do a power analysis for 50 different things and then just say um this is well, this is the easiest one to find, so we're gonna do that. That that looks a little bit like um uh cherry picking or yeah, um and you definitely shouldn't do that after the fact, which would be called post hoc data dredging, where you just go and you just sort of sift through things and whatever you can find. So uh you really target the recruitment and everything around finding a single outcome, but they had a variety of outcomes, so they were grouped around things like um anthropometric measurements, so things like chest expansion, craniovertebral angle, uh kyphosis angle. They looked at things like uh pulmonary function, so FEV1, FE, FVC, and then the ratio. And they also did symptomatic measurements like um functional capacity, dyspnea level. And when you have a whole bunch of things like that, the the more you include, the greater is the chance that you're going to end up finding something that would be called statistically significant, even if there is no relationship between the variables, right? So um the the example I use is you know, if you pour 20 MMs on a bag of MMs on the floor of 20 different colors, you're gonna find one is statistically most significant to be closer to the wall, right? Um but that doesn't mean that that you've uncovered something inherent about the universe. So in this case, you want to say that the intervention really did make a difference on the pulmonary function, and they report that it did, right? So they showed that with each of these things, p-values are great, way less than one, like way, way less than one. But then again, you run into this problem of well, how do we know that it didn't just do that randomly or randomly?

SPEAKER_00 12:54

Yeah.

SPEAKER_01 12:55

Uh and that's where you get into um the idea of correcting for multiple hypothesis testing. So they start with an analysis that just looks at all the variables and it says, okay, putting all the variables in one pot and all the other variables in another pot, like, are the two pots different at all, just from the get-go? And so you can do that with a technique called ANOVA or analysis of variance. And uh, in this case, they did a multivariate analysis of variants, and we didn't we don't need to get into the the difference, but that's kind of the gist of it, right? Is saying, like, are the two pots of soup different? And so you come up with the answer, yes, they're different, but it doesn't say necessarily which ingredients are different. And to figure that out, you have to do what would what's called a pairwise comparison. You want to explain that a little bit, Al?

SPEAKER_00 13:46

Sure. So so, like you're saying, when you when you do an ANOVA, uh you put everything into a big pot or two separate pots for your two different groups, um, and you find out that your soup is different to keep that metaphor going. Um, but you don't really know which ingredients are different. So you do pairwise comparisons, usually like a T test or something, um, on each individual uh set of differences to find out which one is significantly uh statistically significant. Now, in their case, they have a bunch of different variables, and I think they rightly do a correction for for multiple comparisons. So, as I you touched on a little bit before, whenever you're running statistical tests over and over again, uh there's going to be a percent chance that you get uh uh incorrectly significant results just due to the fact that we set our uh you know our p-value somewhat arbitrarily at 5%. Um and so we'd always expect when you run enough tests to have a percentage of those tests come back as as false positives. Uh they chose to use something called a Bonferrani correction, uh, which is a fairly conservative test, but reasonable here. Um it's kind of an older, older one.

SPEAKER_01 15:04

And so the issue with the Bonferrani correction really is going to be that you are more likely to have a false negative, which which we we put up with that because in research we've just decided we would rather have false negatives than false positives, and so a lot of things are geared towards that outcome, frankly, being more likely. But in this case, they found that the outcomes were positive anyway, so it's hard to really criticize their use of a much more conservative correction.

SPEAKER_02 15:36

Sure. So so to kind of wrap up conversation on this article, what what would be the message you would want our listeners to take home related to you know this study, or where would you take this for like a next step?

SPEAKER_01 15:51

Yeah, good question. So the what they found is that all of these things improved, but remember the intervention was several times per week for several weeks, which is more often than we typically have the availability to do in osteopathic medicine. It was also protocol driven, which um has its pluses and minuses. If we were to continue to evaluate this, I think looking at other types of manual therapy routines would be really important. Do you really need that intensive of a treatment to see the benefit that they showed? Uh, could you do physician-directed manual therapy as opposed to protocol-directed manual therapy? And would the outcomes be the same? And so I think they did a good job answering this question. I don't know that this necessarily needs to be repeated as it is.

SPEAKER_00 16:44

I think well, I I will say I think their follow-up time, given how intensive this was and given the chronic nature of COPD, I'd be interested to know how people fare further out. Whether this is something to people do we need to be doing continuous OMT for you know years, essentially, as a as a chronic therapy, or does a one-off intensive treatment really make a difference that's since sustained over a period of time? I think those are the type of questions that this doesn't answer, along with you know, variations in treatment protocol, whether physician-directed therapy makes a difference, or practitioner-directed kind of uh treatment therapy makes a difference to this.

SPEAKER_01 17:26

You make a really good point that I would love to see a follow-on report of what happened after eight weeks, what happened at you know, you know, six months or a year, yeah.

unknown 17:36

Yeah.

SPEAKER_02 17:37

Awesome. Well, thanks for bringing that article to us this month. Uh, we just want to remind our listeners before we go into the next uh article that this episode can be viewed on the Dio Touchnet YouTube channel. Uh that's do-to-c-h dot n e t. Um, and you can also check us out on the website if you want to see what's happening within the network. All right, so we're gonna be jumping into our second article brought here by Dr. Mendelara, which is looking at visceral manipulation on constipation in obese adults.

SPEAKER_00 18:12

Yeah, so this article is titled Osteopathic Visceral Manipulation on Functional Constipation in Obese Adults, a randomized controlled trial. It was published in the Journal of Integrative and Complementary Medicine. Um in, I believe it was 2025. Um by 2026. 2026, sorry. Yeah, by Zidden. Yeah, fairly, fairly recently. Uh by Zidane et al. I'm sure I'm butchering their name as we'll keep this theme going of mispronouncing everyone's names. Um mispronouncing, I believe.

SPEAKER_02 18:49

Mispronunciing, I like that.

SPEAKER_00 18:52

So, you know, what they were looking at here essentially is whether or not visceral manipulation um is effective at reducing the the various symptoms of functional constipation, specifically in in obese adults uh who had a BMI of over 30. Um, they based this on, they based the diagnosis of functional constipation on the Rome 4 criteria, which is a fairly common diagnostic set uh for this uh uh ailment. Uh and they went and they did a visceral manipulation um over four weeks. They again they had a pretty intensive treatment routine, and then they compared it to a sort of a standard of care, uh, dietary recommendations and some uh exercise and physical therapy recommendations. Um, and then they took a look and they actually used a lot of the same approaches as uh our prior paper. They used a Menova, which is that multivariate analysis of variants. They did a Bonfrani correction for the pairwise analysis of very similar statistical um tests here, and they found that um their visceral manipulation group showed improvements in stool consistency, defecation, frequency, reduced pain, and uh lower uh laxative intake over their study period. And uh they conclude that uh this visceral manipulation that they used was an effective uh uh therapy in addition to the standard of care for this functional constipation in obese adults.

SPEAKER_02 20:31

So, apart from being hot off the presses, what is the hot take that you're wanting to share with us uh bringing this article to us this month?

SPEAKER_00 20:40

Well, constipation is a very, very common issue that we deal with, and uh functional constipation can be difficult uh to treat and to manage. Uh, it's common in obese adults, uh, but in general, it's a very common issue. And it's generally defined as a constipation uh that doesn't have any sort of um at least identifiable physiologic reason. So those reasons being medication use, like opioids can cause constipation, um transit issues, uh meaning gut dysmotility or things of that nature, abdominal surgeries, um, any sort of I think one thing I'd contrast between this indication and the last one we talked about is we have in general a lot more options to treat constipation than we do to treat COPD.

SPEAKER_01 21:34

And the constipation treatments work typically really pretty well. If you're gonna compare that with other types of things where you know their procedure was 20 sessions over four weeks, that's pretty intensive to treat constipation when we have probably a lot more patient centered options out there.

SPEAKER_00 21:55

I will I I agree with that, but I I think that um I at least in my Personal experience, I know that dealing sometimes with these sort of chronic functional constipation patients, um, a a low-risk alternative option for treatments is is nice to have. Uh sometimes people really just struggle with this for their entire lives, and we we have things that work, you know, laxatives work and things like that. But um I think it's nice to have an extra tool set, especially one or a tool in the the tool set, especially one that that is uh effective and doesn't have a lot of side effects or doesn't have a lot of other issues. I do agree, and and I actually I think I think there's an issue, there's the the same kind of questions that this paper raises that yours did, which is this is a really intensive treatment, their follow-up is rather short, and this is a chronic long-term condition. So is this something that they would require long-term continuous treatment for? Or does this fairly intensive shorter duration make a difference in six months or a year and make a kind of a sustains?

SPEAKER_01 23:08

Correct me if I'm wrong. Um, you read this in more detail than I did, but I didn't see anything that commented that actually the most severe patients were the ones selected for this study, or people that had failed more conservative measures.

SPEAKER_00 23:21

No. No, I I didn't get any indication that this was anything, that their their inclusion criteria was anything other than um patients who were diagnosed with functional constipation based on the Rome 4 criteria.

SPEAKER_01 23:38

And so as as people are interpreting this and trying to think about how I would use this in my own practice, I would just caution against saying I can do a single treatment, you know, a visceral manipulation, and that's going to help with this com constipation based off of the results of this study, because that's not what this study shows.

SPEAKER_02 23:57

But this could be like an additive, something if someone was in being seen for something else and they had, you know, a secondary complaint of constipation, you know, if if this shows efficacy, you could provide visceral treatment to to treat it.

SPEAKER_01 24:11

Yeah, potentially.

SPEAKER_00 24:12

Yeah, I think so. I I think the main strength of this is that it it shows that there's something that could potentially work here. Um now they do have a fairly narrow age range. These were young participants, 18 to 25, um, who were B uh obese based on BMI. So we have a fairly narrow study population. We have a short follow-up, and again, we don't have a great sense of whether or not these these participants had failed other treatments or had some anything else going on.

SPEAKER_01 24:45

Um let's be clear, that's not a failure of the study.

SPEAKER_00 24:49

No, it's totally it's just a consideration when we interpret these results. Absolutely. And I think you know, when we when we get into the statistical analysis and what they actually show, I think they generally did a good job. Um, they also do a power analysis, their randomization seems reasonable. I think their outcomes are reasonable. I do think there's a question of how they divided their outcomes. Uh, one specific difference, I think, between our two papers is, and you can correct me if I'm wrong, but I believe they did essentially a single large MANOVA test in your paper. In this case, they split it between their primary and secondary outcomes, which in my opinion are somewhat arbitrarily chosen. Um, they looked at stool consistency and pain for their primary outcomes, and then their secondary outcomes was defecation frequency and uh oral laxative use, which to me, I don't know why those were chosen as primary versus secondary outcomes. In my mind, constipation, especially functional constipation. The main thing I'm asking is how often are people going to the bathroom essentially having bowel movements in addition to the to the pain or stool consistency. Um so I wonder if running multiple manovas here with so few variables uh I I don't know if that was the ideal way to do this. I don't think it's wrong, um, but I think it's a a discussion on the statistical decisions here.

SPEAKER_01 26:23

Yeah, and some there's also something yeah, just in terms of you know selecting primary versus secondary outcomes, they do have some that that are definitely patient-oriented outcomes, like education pain for sure. Yeah, some other ones I may look at as more of a um disease-oriented outcome, you know, so like stool consistency, it's important to know about um constipation, but you know, if you ask people what's important about their constipation, they don't point to the Bristol chart and they're like, it looks like this and not like that. So that's more of a disease-oriented outcome, or or it's something that has definitely good correlation with patient-oriented outcomes, so it's a good surrogate marker with with evidence behind it. Um, but I I tend I like to elevate the more patient-oriented outcomes to as the primary outcome, and I really try to design studies where there's just one primaryist outcome.

SPEAKER_00 27:22

I agree. I agree. I think they they sort of split the difference a little bit too much here. They should have had either a single primary outcome, or frankly, these could all be reasonably their sort of primary outcomes. I don't think they needed to make uh a real uh differentiation between them. In my opinion, I like the combination of of more disease-oriented and patient-oriented outcomes. I think disease-oriented outcomes often give us more objective measures that sometimes uh get lost with when we only focus on on patient-oriented outcomes. So I don't think that they they necessarily mischose their their outcomes here, but I I agree that I would have um thought about it a little differently.

SPEAKER_01 28:08

Yeah, I mean I probably would have picked different ones, but I I don't I don't I wouldn't say that that's the same as they made a mistake.

SPEAKER_00 28:15

Right, exactly. And so to be honest, I think. We are getting close to end of time.

SPEAKER_02 28:19

I do apologize. I just wanted to uh so to kind of conclude the same way with the other one, what what's the take-home message you want you want our listeners that have for this, or where would you take the study for next steps?

SPEAKER_00 28:30

Yeah, so I I actually I think this was a well-done study that shows a significant effect in their population. And I think it does a good job answering their question. In terms of how you would actually apply this, uh, it's difficult for all the reasons that we we sort of talked about. It's a limited patient population, it's a fairly intensive treatment, and we only look at limited follow-up. So the recommendation from this would not necessarily be to run out and do an intensive four-week um osteopathic treatment on all your patients who come in with constipation. But I do think this gives us a reasonable basis to say that this works. It's a possible option for therapy if you're in the appropriate setting for it. And I also think that this gives us a good foundation to do further research, maybe broadening some of these things, maybe broadening our inclusion criteria, maybe looking at again further out uh uh follow-up, maybe less intensive routines, things like that, so so that we can put this into a more practical, practical format that someone kind of boots on the ground could go ahead and and implement into their their day-to-day work. Sure.

SPEAKER_02 29:47

Well, thank you both for uh joining us this month and for these awesome articles. Dr. Stacy, Dr. Mandelara, what uh extend my gratitude to both of you for being here again. Uh to our listeners.

SPEAKER_01 29:58

Uh I was just gonna say, can we put in a plug for the uh for the upcoming conference? Oh yeah, no, absolutely. Plug away. Well, we've got the uh the Dio TouchNet annual conference coming up.

SPEAKER_02 30:10

Yeah, so we have the Dio TouchNet uh annual meeting coming up. That is gonna be on June 13th. Uh, and it's gonna be all virtual. It's at n starts at noon US Central time. Uh, if you would like to join us at that event, you can always register uh from our website, um, which is douchnet. Uh that's do-to-u-c-h dot n-et-t. And you can also find out more what's happening uh uh within the network from the website then. And then I believe, Dr. Stacy, you also have a uh conference coming up up at the Mayo Clinic soon.

SPEAKER_01 30:45

Yes, we have the Mayo Osteopathic Research and Education Conference on September 18th and 19th, 2026 in Rochester, uh, Minnesota. It focuses on the practice, the research, and the education of osteopathic manipulation. If you want to come have a really high-yield, fast-paced, hands-on conference, it's a great place to come. If you want to come uh discuss research like we're doing here or present some research of your own, also great place to come.

SPEAKER_02 31:16

And if you want to get in contact about any comments or if you have any questions about that, you can always reach out to me or us at douchnet at atsu.edu. Or you can leave a comment on YouTube or your podcast platform of choice. And make sure you're also smashing that subscribe and follow button to continue to follow along with us. Uh, thank you both again for being with us this month. That's gonna conclude our episode. Thanks.

SPEAKER_00 31:42

Awesome, thank you.