The OMM Research Podcast
A panel of osteopaths review and breakdown current topics in OMM research. This podcast is hosted by DO-Touch.NET, which is based out of the A.T. Still Research Institute at A.T. Still University.
The OMM Research Podcast
Episode #10 - Fascia Manipulation Mechanisms & OMT on Chronic Low Back Pain
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Hello everyone and welcome to our tenth episode of the OMM Research Podcast!
Our panelists for this episode are Dr. Stephen Stacey and Dr. Julien Moreno.
In this episode, we are an article titled "The effects of osteopathic manipulative treatment on pain and disability in patients with chronic low back pain: a single-blinded randomized controlled trial" by Popovich et al. published in the Journal of Osteopathic Medicine. The article can be viewed at this link: https://www.degruyterbrill.com/document/doi/10.1515/jom-2022-0124/html
We are also looking at an article titled "Therapeutic mechanisms of fascia manipulation: A scoping review" by Isaji et al. published in the Journal of Back and Musculoskeletal Rehabilitation. The article can be viewed at this link: https://pubmed.ncbi.nlm.nih.gov/40368128/
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!
Well, hello to you, our listeners, the manipulated and the manipulators. A welcome to the OMM Research Podcast. The OMM Research Podcast is produced by Dio TouchNet, a practice-based research network that focuses on osteopathic manipulative medicine research. Dio 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 AT Still University. My name, as always, is Corey Lubring, and I am the practice-based research coordinator of Deo TouchNet and the host of the OMM Research Podcast. Before we get started, as always, we want to remind you, our listeners, that this podcast recording has video recorded with it and can be viewed on the Dio TouchNet YouTube channel. Starting off, we want to introduce our panelists for this episode, starting with Dr. Stacy.
SPEAKER_02Hi, my name is Stephen Stacy. I'm the director of osteopathic education for the Lacrosse Mayo Family Medicine Residency Program and Associate Professor of Family Medicine at Mayo Clinic and an osteopathic researcher.
SPEAKER_01And thank you again for being with us this month. And we have a new panelist in this episode, and we are happy to introduce Dr. Moreno.
SPEAKER_00Hello, I'm Julian Moreno. I'm a French osteopath, and I'm also teaching in a French school. I'm like an educational coordinator, so I just round the things and make sure that everything is okay in the school.
SPEAKER_01And we are excited to have you with us, Dr. Moreno, this month. Thank you for joining us.
SPEAKER_00Thank you.
SPEAKER_01So we'll be starting off this episode with an article brought to us by Dr. Stephen Stacy, which is looking at therapeutic mechanisms of fashion manipulation.
SPEAKER_02That's right. That's the title Therapeutic Mechanisms of Fascial Manipulation: A Scoping Review by Dr. Zuichi Isaji et al. And we're keeping with the tradition of me butchering author names. These authors are from Japan. The journal is the Journal of Body Work and Movement Therapies. This was published in May 2025. The objective from the abstract was to summarize current evidence on the physiological, structural, and neuromuscular mechanisms underlying fascia manipulation as a therapeutic investigation. And the findings, again from the abstract, fascia manipulation exerts its therapeutic effects through a combination of anti-inflammatory cytokine modulation, mechanoreceptor stimulation, and improvement in fascial gliding and proprioceptive feedback.
SPEAKER_01Sounds interesting. So what about this article? When did you do what made you want to bring it to us for this episode?
SPEAKER_02This is a really cool article looking at the underlying mechanistic rationale of a lot of things that we do. And they even had a pretty good reason for looking at the rationale of the mechanism. So they have seen that studies have shown effectiveness in fascial manipulation, but the underlying mechanisms haven't really been organized really well into a single place. And so the the purpose of this as a scoping review was to provide a focal point for that organization. We've done a few different kinds of systematic reviews in this podcast. We've done um systematic narrative reviews, we've done meta-analyses. I think we've even done an umbrella review, if I remember right. Uh, a scoping review is another kind of systematic review. Its goal is to map themes and concepts, clarify terminology, and identify gaps in the evidence. And those three things, mapping themes and concepts, clarifying terminology, identifying gaps in the evidence, we're going to look at that and see how well this article did as a scoping review and what we can learn from it. Um, keep in mind that a scoping review really isn't structured or designed to prove efficacy or establish causality or quantitatively determine some type of effect size. Um, it's really there to help um help guide future research and and scholarly thought around a topic.
SPEAKER_01Interesting.
SPEAKER_00Fascia is like a big trend. I I don't know here in the in the US, but I I know that in Europe, it's like uh the big thing right now. Uh everybody's talking about fascia and how it might work, it might not work. So that could be really interesting to see what's in that scoping review. I I didn't really know yet, so I I'm excited.
SPEAKER_02Yeah, and I I've seen fascia really, it's having a moment recently, isn't it?
SPEAKER_00Yeah.
SPEAKER_02It's uh especially in the manual therapy world, a lot of the research coming out is showing the mechanistic rationale and the effectiveness of fascial manipulation. Um, and so in this article, what they were looking for in their review was studies that um had human or animal subjects who received fascial manipulation, and that the the paper focused on the underlying mechanisms of that manipulation. So maybe they did pre-post biopsies or some type of imaging, really whatever tried to help organize or helped uh helped establish what is the underlying mechanism. They looked at all the usual databases, including gray literature and unpublished studies. Um they uh had initial extraction via chat GPT, and then the investigator reviewed all the extracted information to ensure accuracy, which was an interesting design choice. It's not wrong per se, uh, but they didn't really give a lot of information on what was investigator driven versus AI-driven in terms of some of the outputs. Uh, and you know, AI-driven outputs aren't wrong any more than human-driven outputs are right, but I would have appreciated a little bit more clarity and just understanding which is which, which they didn't really report on much.
SPEAKER_01Yeah, that's I yeah, I was gonna say, like, that's the thing that I've even experienced uh in some of my coursework, you know, going into my doctorate and everything is the use of AI and research and everything, and at what level, especially with the how new AI is, do we need to report exactly like what's what's the input exactly, what's the output, um, just to make sure that we are completely transparent with the use of AI being involved in studies. Didn't mean to open, but it's uh you know something that I have experience with.
SPEAKER_02That's absolutely right, is um you know it it isn't really standard or established how much detail is the right amount. Uh all I can say here is it seems like the amount of detail they gave was not quite enough. And so you could go clear on the other side and give way too much detail, and then it's just kind of boring and irrelevant, but you know, somewhere in the middle.
SPEAKER_00Yeah, but that's always a problem when you write a paper because you you you don't have so much space and what what do you want to report, what do we don't want to report, what do you put in supplementary materials and and everything, and especially with AI and with AI, sorry, it's uh it's it's like uh a subject because you you you don't really know there's like a gray gray area in in that AI thing. So there's not like standardized uh I would say protocol, but it's sometimes it's you you don't know, as you said, what's the human part, what's the AI part. So sometimes you don't know.
SPEAKER_02Yeah, and and honestly, it's it can be so back and forth that drawing a line clearly between one and the other might be irrelevant.
SPEAKER_01Um what findings did they did they uh come out of the scoping review?
SPEAKER_02Yeah, it led to a really good mapping of themes and concepts. And table two is especially interesting. It shows the research findings from the different articles and uh and summarizes them. Uh, I won't read the whole thing, but just highlight some main findings. Uh they found, for example, that uh fascial manipulation reduced fascial densification, which seemed to be related to decreased unbound glycoseminoglycan water. So if you look at what's going on molecularly with the fascia, you have these long-chain glycoseminoglycans that are supposed to slide past one another, and they do that better when they are bound to water. And when the water leaves that binding, then the tissue adheres, the tissue becomes more dense, and they found that fascial manipulation seems to reverse that. Um sort of unrelated to that, they found that it didn't activate coagulation pathways or increase thrombosis risk, which is a um which is uh a contraindication or a caution you'll see sometimes. And they looked at a lot of different molecular pathways, uh, like anti-inflammatory effects through cytokine modulation, analgesic effects through adenosine receptors, um, and and seeing opioid-independent analgesic pathways in mice, for example, um, they showed that it seemed to have a transient inflammatory response. And this was an interesting thing that they highlighted there, which um, you know, reading between the lines, they didn't really emphasize this a lot, but they seem to be drawing a distinction between acute inflammation versus chronic inflammation. So in chronic inflammation, it's more persistent, it's more fibrotic, uh, it's macrophage and lymphocyte predominant, and it's associated with ongoing cytokine signaling, extracellular matrix remodeling, fibrosis. Uh, and that can be a part of the problem in a lot of chronic pain patients, versus it seemed that fascial manipulation probably induced some amount of acute inflammation, which they saw through increased temperature, uh different molecular pathways. And the thought there is that acute inflammation may lead to a short-lived, regulated, neutrophil-dominant, pro-resolution inflammatory response that is associated more with tissue repair and remodeling, and less with the the extracellular matrix densification. So I thought that was pretty cool.
SPEAKER_00Yeah, it's a little bit same thing happen when you do like HVLA or things like that. We know that there's like a little bit of inflammation after, but that's that's part of the process. So it's I would say it's a good thing if there's a little bit of inflammation after. It does not mean that there will be a lot of pain, a lot more pain, but it's it's something that something's going on there. And so the what what we what we did on with the patient is that there's we changed something in in body spatiation. So that that's that's always something really interesting to see. And and you could uh oh go ahead. Yeah, do you know if they talk about what kind of facial manipulation or facial technique or whatever, or is that really like general? Did do they define the facial thing?
SPEAKER_02That wasn't really the main purpose of the study, and they didn't really report on the specific fascial techniques used. They did exclude other soft tissue techniques that weren't reported as primarily fascia-based. So things like um uh like massage, for example, would be excluded if they didn't target fascia, especially. Um they they grouped all of these different pathways, and this is really what I think is helpful for a scoping review, is to give a way of thinking about the problem. And so they grouped it into mechanical pathways, neurophysiological pathways, and biochemical pathways that led to improvement. So for mechanical, uh, they said physical disruption of fascial adhesions or densifications restore tissue gliding and reduce mechanical irritation of nosusceptive fibers. For a neuropsychological, they said stimulation of mechanoreceptors such as Rafini endings and Pisidian corpuscles can modulate central pain processing and enhance proprioceptive feedback. For the biochemical mechanisms, they said modulation of inflammatory cytokines and receptors can lead to enhanced tissue regeneration by stimulating fibroblast activity and extracellular matrix remodeling. And so these are some really cool um some really cool ways of organizing it. Where so so that's in in the plus. Any any other comments on the plus side before I go to what what I might have liked to see in this study?
SPEAKER_00Well, that that's really interesting because there's like a lot of how to say that uh imaginary thing around fascia. It's like a lot of people think about it like it's it's it's a magic technique or something. So I think that's good just to have some insight on what's going on when we we do facial technique and what could be the the mechanism, especially just to have something plausible, because uh not everything is like a mechanical thing we do. There's there's like a lot of as you said, neurophysiological thing going on, and especially if we talk about a little bit about pain, it's it's also a lot about that. It's it's a really complex thing, and even though we we study some technique, it's it's it's just part of the everything we're doing in the clinic. So what what are your takeaway on that?
SPEAKER_02You know, from the perspective of listing out some of the evidence, I thought they did really pretty well. Um you could have seen maybe a little bit more synthesis. So for for the evidence review part of it, I'll give maybe an A minus. So still a pretty high grade. As a scoping review, I have to give this article more of like a B or a B minus, because they don't really help with some of the other aspects of a scoping review, like clarifying terminology in the field. And the biggest ball they dropped, I think, was identifying gaps in the evidence. To me, that would have been the really, really helpful thing that this piece needs. You know, if they'd call themselves a systematic narrative review, I could have lived with that, but they called it a scoping review. And for me, that that involves a little bit more flexibility in what you report and also really needing to identify like what is next for research. And you can't end with just a bland like more research and bigger studies are needed, which is kind of what they said, and you know, and you can say that about any topic in the world. But if they had gone the extra mile and said specifically, you know, here's what's going to be cutting edge fascial research for people who are focused on the mechanical properties. Here would be cutting edge fascia research for people focused on the neuropsychological properties, here would be cutting edge research for people focused on biochemical properties, they could have taken that um framework that they used and really helped drive it towards moving the field as a whole forward. And um, I was really disappointed to not see more effort put into that aspect.
SPEAKER_01So, what would be the key message you would like our listeners to take away uh related to this article, Dr. Stacy?
SPEAKER_02Uh, if you're doing fascial manipulation or research in fascial manipulation, there's a lot of bench research that has been done on your behalf, get to know it and design further research with that in mind.
SPEAKER_01And Dr. Moreno, if you had all of the funding that you needed and all the uh facilities needed to do whatever research you know you wanted, what would you see as next steps for something related to this study? You know, what where would you take this information to to uh the next steps?
SPEAKER_00Well, um I think the first step would be something around what what's happening directly on the chemistry thing in the tissue, what's what's going on uh on the fibroblast, on all all those chemicals inside the fascia, just to to know exactly how and when it changes, and then just uh link it to the clinical aspect. So if we have a patient with such symptoms, how uh does uh the manipulation actually affect those symptoms? Is that a real effect? Is that a it's so it's so hard just to isolate the a specific effect, especially on manipulative therapy, osteopathic manipulative therapy, but manual therapy in general. So I would go this way first.
SPEAKER_01Awesome. Well, thank you very much for such an awesome article this month, Dr. Stacy. Before we move on to our next article, we do want to just remind our listeners that if you want to see our beautifully bearded faces, you can hop over to the Dio TouchNet YouTube channel and uh watch the video that is associated with this podcast. If you want to check out stuff that's happening within the research network, you can go to our website, which is do-touch.net. That's do-to-c-h dot n-e-t, to check out stuff that's happening within the network there. Uh, so our next article is brought to us by Dr. Moreno, uh, and it is looking at the treatment of uh or the use of OMT on the treatment of pain and disability and chronic low back pain.
SPEAKER_00Yeah, so the the title article is The Effect of Osteopathic Manipulative Treatment on Pain and Disability in Patient with Chronic Low Back Pain, a single blinded randomized controlled trial by Popovich and all. It's from the Journal of Osteopathic Medicine, and it's uh a 2024 article. So I I really like outcomes article, and this one has just uh like a twist inside, and that's why I choose this one. It it's an interesting article on yeah, how they how they manage the the data management and where they're from because there's like uh an origin story on where they're from in this in this study. So they they try to compare immediate to MT within three or four sessions over four, six weeks, and they use like mandatory mandatory HVLA plus optional MET, soft tissue, my facial, and articulatory technique, and they compared it to uh waiting period control, so it's a crossover, and I think that that's a really interesting one, especially because the data are like a bioproduct of another study, because that's that wasn't the the main goal of the study. So the uh it's a really interesting thing. So if we go to the the objective, so the objective of this study was to evaluate the efficacy of an OMT intervention for reducing pain and disability in patients with chronic low back pain. And the conclusion of the study is that OMT intervention is safe and effective in reducing pain along with improving sleep and anxiety profiles in patients with chronic LBP. So I think that's something really interesting because uh one of the main criteria was pain, but uh the interesting thing is with this study is that the main improvement is on pain and anxiety, and there's like a lot of good things inside, especially in in the methodology. And the only thing I I have is that the uh the data are uh as I said a byproduct of another study because the the the initial study was to validate uh uh a new seated balance test to quantify postural control, and they just took the the data they took from this study to to just write the article. So that's that's interesting, but the thing is that from a like methodological point of view, there's um I would say some little tweaks inside that I just want to point out. Just for example, the the crossover design was interesting for the the seated balance test because it was designed for this test, but it was really not designed for the clinical inference on on the I would say the data and all the the outcomes.
SPEAKER_02So yeah, I agree. I was looking at that thinking it was a it was a bit of an interesting um design choice. And and we covered this a little bit on on last month's version that was uh another article by the same group, but more on neck pain than low back pain. Um you know, one thing that I think about as we're looking in these studies is what is the underlying question that they're trying to answer? Because a really, really interesting question is going to have relevance, whatever answer you get, whether it's a positive study or a negative study. study. What do you what would you say is the underlying fundamental question, like the unknown that they're trying to uncover with this study?
SPEAKER_00Well with this with this study there's like um the the unknown question is that is that is OMM helps with improving patients pain with chronic low back pain in patient with chronic low back pain. But is is that an unknown though? Like I feel like that study's been done a lot. We kind of know but you know yeah I know the well if if I go for the unknown that's that's hard to say with this one because the first the data come from another study for the seated balance test. So I guess that once they were designing the first study the question was around this seated balance test just to help to assess and maybe guide the the treatment with with these tests. But for for this one I think it's more around the other outcomes the secondary outcomes so that that's why I think they conclude that the the sleep and um the anxiety was improving after this treatment.
SPEAKER_02So the and I think this maybe makes sense as exploratory research from that regard is to say let's look a little bit deeper into this. You know if I think about how a lot of OMM research is performed it's it's physician directed very symptom focused which isn't bad. It's just looking at things at a different level and we've really looked at things on that level long enough it it's sort of like if you were doing treatment for depression and saying people who see psychologists for their depression do better than people who just sit in a room and talk with an untrained professional for an hour. And that's kind of what I feel like we're missing in this study is that that next level of like what do we really learn about OMM from this study?
SPEAKER_00Yeah I at the end I was like okay anxiety sleep were improved but I was like on my end and I I wanted just a little bit more and especially on the study where the secondary outcomes are like I would say I would say positive but it's they're improving the secondary outcomes and not the the first one sometimes it gives you a very good insight of what's going on because maybe the secondary outcomes are the things that are important for the patient just as an inform from a pure clinical point of view. If um I'm in the clinic I see patients and a lot of patients come primarily for pain but pain sometimes is not the first thing they want to treat it's it's like the the consequence and sometimes it's just that of course they have anxiety they have a lot of stress maybe sleep disturbance and everything and maybe just improving those aspects maybe won't improve the pain aspect but they will manage it pretty well and that that that's what it is interesting with this study because we pay sometimes a lot of attention to to pain and pain is just sometimes a consequence and it's like when you pay attention to something that's really important for you or for the patient sometimes you lose the other things and yeah and that's what interesting study.
SPEAKER_02The opposite could be true too where you're saying that these other factors are contributing to the pain but then the pain can also contribute to the other factors. Sure which it really gets back to the osteopathic philosophy philosophy that form follows function and the other way around right so form and function are reciprocally interrelated they affect one another and the the manipulation that we do is designed to help help with the function with the somatic dysfunction but we can't really discount the the therapeutic alliance that's formed purely through the act of treatment and if that is found to be the underlying mechanism behind some of the treatment that we do we can continue to hold on to that with our treatments as we continue to also look for is there some treatment that we could perform that has more biologic effect than another one. And so one thing that this adds somewhat interestingly is forcing HVLA into it. It doesn't go quite as far as isolating the effect of HVLA but it is a it is a bit of a unique design choice.
SPEAKER_00Yeah it gives a really great insight on how how from a pragmatic way when you're using HVLA how it can help the patient and how it can improve things in the clinic and what you you were saying is is interesting because in the discussion there's like um narrative opportunism at some point when sometimes when they say pain improve it's it's it's like OMT but when there's not improvement it's like the dose response or every anything those so there's like a different levels of I would say explanation in the discussion so it's it's really interesting to see that there's some effect but we can see that it's really hard to say to quantify this effect and especially with the waiting list design because it's just a waiting list so it's not a sham it's not so I I would love to see some sort of study with Almada design and with a sham just to to see if there's any difference there.
SPEAKER_02Yeah I think that more research that we do on the kinds of controls that we use whether weight list controls, sham control, different kind of sham is a real um opportunity for future OMM research is to say what is the effect of our sham treatments and uh and what do we learn about the treatment experience based off of those effects because different kinds of shams are going to emphasize different different aspects of it.
SPEAKER_00Yeah and with those kinds of study when I when I see sleep in anxiety improvement what what I what I like to see is like a nice qualitative research just to get the patient's experience just to have like a a a deeper point of view not only statistical that statistical data are really interesting but sometimes when you get to like human being and everything just getting nice qualitative study helps you just to transfer things in the clinic maybe sometimes more uh I second that entirely I think there's too much of a of a view out there that qualitative research isn't real science but it is it's oh it is and you learn so much from it and through that qualitative research you figure out what is the right thing to pay attention to with your quantitative research um that you know research needs all of it and I think giving more priority to the qualitative research is really important. Yeah and that that that's why this study is really really interesting because it it gives a lot of insight on what could be really interesting to focus on on next study especially uh I I would say general psychosocial factors and I would love to see a really nice and big qualitative study just to see okay so if there's improvement on those factors so what's the patient experience what why I just I just want to understand what's happening there.
SPEAKER_02So anybody who wants to get that qualitative study started sounds like they need to reach out to you.
SPEAKER_00Oh yeah I really love qualitative study I I I discovered it when I I did my master's degree and I just fell into it and it's like it's like doing uh the clinic you know you you're you have like your interview framework and you you just try to to to chat with people and getting some some data and after that you analyze that with your team and it's you discover a lot of amazing things and you you you connect the dot and it's like a map you know a new new map that you you can see and I I love that especially maybe we should combining yeah let's have a qualitative study on our next podcast yeah oh yes sure I remember I I I went to first time in Kirksville it was three three years ago and I was with Corey also I remember I don't know it wasn't Corey but I recorded uh it was not like a podcast because it was like a small presentation and I I presented uh qualitative research of on mental imagery in osteopathy how osteopaths uses mental imagery with their palpation skills and just to to represent them what they are palpating and it was a really interesting one not not a really I would say good one from a methodological point of view but just the topic was interesting from an osteopathic point of view.
SPEAKER_01So Dr. Moreno what's the key message you want our our listeners to take home about this article?
SPEAKER_00Well I think for the practitioners is just paying attention to other factors within the clinic not only pain not only function but how the patient is experiencing his pain also that's I think that's one of the the key points of this study is just pointing that okay there's pain but there's something else that is also really interesting and that that's why we we're doing in the clinic so that that gives a lot of strength to what we're doing in the clinic and we're not just only working on the patient's body there's like body mind and spirit so it it gives the strength to what we're doing in in our osteopathic practice and no matter where you are in the US in Europe in Japan or whatever it's the same thing everywhere so we're just we just need to focus more on those factors just to try to help people to get better.
SPEAKER_01Well said well thank you both uh thank you for bringing that article to us this month and thank you both for being on this episode of the OMM Research Podcast again if you all want to find out more than what's happening at DOTnet you can always follow us on social media or go to our website that's do-touch.net to find out things that are happening within the network um and I still want to give time um for Dr. Stacy to talk about the upcoming conference that's happening at the Mayo Clinic.
SPEAKER_02That's right anybody who wants to come join with the osteopathic manipulation presentations and explore some new research directions come to the Mayo Osteopathic research and education conference on September 18th and 19th in Rochester Minnesota.
SPEAKER_01All right and Dr. Moreno thank you very much for joining us on this episode Dr. Stacy good to see you again yeah and uh we will uh see you all next time