. 2021 Sep-Oct;118(5):435–441.
Christena Abraham
1, Shelly NB Sloan
2, Charles Coker
3, Blair Freed
4, Matthew McAuliffe
5, Halden Nielsen
6, Tanner Riscoe
7, Robert Steele
8, Andrew Dettwiler
9, Gia Oberley
10, Kenneth Zaremski
11, Kelley Joy
12, Andi Selby
13, Ree Wells-Lewis
14, Bradley A Creamer
15
PMCID: PMC8504517PMID: 34658436
Abstract
In this pilot study, we examined the efficacy of Osteopathic Manipulative Treatment (OMT) for improving symptoms of stress, anxiety, and depression (SAD) to determine a correlation between overall improvement in health and quality of life for first responders. Participants received weekly OMT or sham OMT targeting autonomic imbalance. Indicators of SAD were examined pre- and post-study. Overall, this pilot study suggests improvement in both the social-psychological (mental) self-assessments, and alterations in SAD-associated biomarkers from OMT.
Introduction
Recent data has shown that at least 30% of first responders in the United States will develop behavioral health conditions such as SAD.1 Traumatic events such as death, serious injury, and violence are at higher prevalence in these fields when compared to other civilian professions and put personnel at an increased risk for experiencing poor physical and mental health. Of the most notable psychological consequences from repeated exposure to traumatic events is the development of serious stress, anxiety, and/or depression that can sometimes lead to Post-traumatic Stress Disorder (PTSD).2 In fact studies have shown law enforcement officers to develop PTSD at rates ranging from 6–32%, EMT/paramedics ranging from 9–22% and firefighters with rates of 17–32%, whereas adults in the United States typically range from 7–12%.3 Such large ranges in rates would suggest other third-variable risk factors are at play such as, within groups — at the individual level and between groups — at the level of occupation type. Regardless of these other variables, first responders should be considered a special population at an increased risk for developing even mild to moderate mental health disorders, including stress and anxiety. In addition to PTSD, first responders are also at greater risk for developing depression, substance abuse, and suicide ideation and attempts.4 A 2017 survey of more than 4,000 first responders found that 6.6% had attempted suicide, which is more than 10 times the rate in the general population.5 Additionally, a 2016 study has shown that amongst 34 first responders who completed biological and psychological evaluations, 18% (n=6) met criteria for anxiety, 47% (n=16) met criteria for depression and 33% (n=12) met criteria for PTSD.6 While there is some success for treatment with efficacious, evidence-based therapies, current treatments are associated with either nonresponse, or high rates of dropout.7–9 As such, there is a tremendous need for the development of comprehensive interventions which aim to relieve the allostatic load in first responders.10
Since mental stress can cause measurable musculoskeletal tension, the concept of using OMT as a therapy to alleviate such symptoms has been examined.11, 12 Osteopathic manipulative treatment is targeted to treat somatic dysfunction—the impaired or altered function of related components of the body framework system: skeletal, arthrodial, and myofascial structures, and their related vascular, lymphatic, and neural elements (Glossary of Osteopathic Terminology). Stress may result in segment facilitation demonstrated as exaggerated muscle tension. The reduction in muscular tension through the use of OMT may reciprocally reduce emotional stress by shifting the balance of sympathetic and parasympathetic systems to a more parasympathetic/relaxed state and could therefore benefit the mental health of those who are dealing with stress, anxiety, and depression resulting from their profession. To date, there have been only a few studies investigating the effectiveness of OMT in patients experiencing stress, anxiety, and/or depression. Nevertheless, it seems logical that OMT could benefit these patients.
It is known that emotional and physical stress can induce a physiological response in the human body that allows us to adapt and respond to that stress. Chronic exposure to stress can lead to maladaptive alterations in stress response, hormone levels, and many other physiological processes in response to the increased allostatic load. Recent data suggests that stress, anxiety, and depression can alter the levels of serum inflammatory biomarkers such as interleukins, in addition to a number of hormones.13, 14 In a state of stress, the body shifts to a sympathetic dominant state with relative increased sympathetic activity and decreased parasympathetic activity. When a person experiences chronic stress, there will be elevated levels of catecholamines (epinephrine and norepinephrine) and decreased levels of acetylcholine. A major physiological response to stress is to induce the hypothalamic-pituitary-adrenal (HPA) axis to cause the release of cortisol, a glucocorticoid which triggers gene-expression changes in target tissues.15–19 Proposed mechanisms include altered circulating cortisol levels, dysregulated sensitivity to glucocorticoids, or alterations in feedback mechanisms, all which facilitate an extended or possibly intensified sympathetic nervous system activation.11 This inability to regulate the HPA axis has been reported following chronic or severe stress and can lead to an allostatic load which transitions into an overexposure to stress molecules.20 Increased allostatic load has also been linked to increased vulnerability to many psychiatric and physical disorders.21, 22 One might hypothesize that patients with increased stress are likely to have sympathetic nervous system associated somatic dysfunction. Addressing these dysfunctions with appropriate osteopathic manipulative techniques could aid in as above.23 It is important to note that serious adverse effects of OMT are extremely rare and thus are considered to be a safe method of treatment.24
Examples of stress-related treatments include a specific focus on the suboccipital and thoracic regions which are associated with increased heart rate variability, improved autonomic homeostasis, decreased muscular tension, and reduced perception of stress.20 Rib raising treatment has been shown to reduce sympathetic output which results in parasympathetic predominant state-otherwise understood as a relaxed state.25 Compression of the fourth ventricle (CV4) influences ANS function, and has been shown to alter the physiological parameters of blood flow velocity, heart rate, blood pressure, and cerebral tissue oxygenation.21 In a study done by Cutler et al. in 2005,26 patients who received CV4 when compared to those who received the sham treatment were found to have more rapid sleep onset and decreased muscle sympathetic nerve activity. Other studies determined that CV4 promotes muscle relaxation and a general state of relaxation when measuring alpha band activity (related to relaxation, awake and idle state) on EEG.27 Stimulation of the parasympathetic nervous system is achieved as a result of the effect on the brainstem. Similar to rib raising, CV4 shifts autonomic balance to a parasympathetic predominant state by increasing parasympathetic activity and decreasing sympathetic activity resulting in an overall relaxed state.28 Sacral rocking is an OMT technique that exaggerates sacral movement.29 Sacral rocking can relieve patients of lower back pain and balance autonomic dysfunctions influencing the gastrointestinal and genitourinary systems. Treatment increases parasympathetic outflow from the sacral nerves.30 Inhibitory techniques use mechanical pressure to reduce regional autonomic output (habituation). Suboccipital inhibition (SI) reduces the muscle tension reducing parasympathetic inhibition.31 Tension headaches are often associated with myofascial trigger points or muscle tenderness,32 which can lead to autonomic imbalance and motor disturbances in that region. Treatment using SI led to hypoalgesic effects-decreased sensitivity to painful stimuli and relieving pain.33 Treatment with SI improved the emotional and mental well-being, and better quality of life.32
The benefit of human touch has also been shown to have therapeutic effects, which OMT is expected to provide as well. For example a review of research by Tiffany Field, a leader in the field of touch, found that benefits from touch start at birth, showing newborns that received just three 15-minute sessions of touch therapy each day for 5–10 days gained 47% more weight than premature infants who had received standard medical treatment.34 She also found that massage therapy reduces pain in pregnant women and alleviates prenatal depression in both them and their spouse.35 Another study from UC Berkeley’s School of Public Health found that receiving eye contact and a pat on the back from a doctor may help survival rates for those suffering with complex diseases.22 While OMT is a focused therapy option conducted only by a trained licensed doctor of osteopathy, touch therapy and its benefits were also taken into account for this research by including a sham OMT group. Sham therapy is defined as false treatment. It is typically used as the control group in OMT studies in order to compare the effects of the treatment or therapy in question.36 In a study done by Licciardone et al. 2013, sham OMT involved light touch, active and passive ranges of motion, improper patient positioning, decreased physician force, and purposeful misdirected movements.37
In this pilot study we examined the efficacy of OMT for improving symptoms of SAD and sought to determine a correlation between overall improvement in health and quality of life for first responders who received OMT.
Methods
Research Study Design
We designed a single blind study to investigate OMT as a therapy for reducing stress, anxiety, and depression in the first responder population of a rural area in Joplin, Missouri. Approval was obtained from the Missouri Southern State University Institutional Review Board (IRB# 1512565-1). Participants were assigned randomly to either: 1) an OMT group, or 2) a sham OMT group. Names and any identifying information were not used, and all participants were assigned a random identifier on all documents throughout the study. Each participant signed a consent form authorizing participation in the pilot study. The duration of the pilot study was six weeks. Intravenous blood samples and surveys were collected on week one and week six. OMT was performed week one through week five, for a total of five treatments (Figure 1).
Baseline Demographics
Socio-demographic data were collected for each first responder: age, gender, marital status, racial/ethnic identity, highest education, and household income at the initial timepoint (Table 1).
Table 1.
Participant socio-demographic profile variables.
Total Participants | N=9 |
---|---|
Gender | |
Male | 9 (100%) |
Age (years/mean) | |
40 (range: 34–47 years old) | |
Education | |
Some college/Associate’s | 5 (55%) |
Bachelor’s | 3 (33%) |
Professional Degree | 1 (11%) |
Race/Ethnicity | |
White | 8 (89%) |
Hispanic | 1 (11%) |
Household Income | |
<$49,000 | 2 (22%) |
$50,000–$99,999 | 5 (53%) |
>$100,000 | 2 (22%) |
Marital Status | |
Never Married | 1 (11%) |
Married | 7 (78%) |
Separated/divorced | 1 (11%) |
Osteopathic Manipulative Therapy Protocol
The OMT protocol for this study was developed by Andi Selby, DO, and Kelley Joy, DO, consisting of four standard OMT methods: Rib Raising, Sacral Rock, Suboccipital Inhibition, and CV4 treatments (Table 2). Participants were instructed by the operator when to inhale and exhale as to receive better extension and flexion of the treated area and ultimately the desired outcome of treatment.
Table 2.
OMT study protocol procedures, key steps, and desired outcomes
OMT Technique | Key Steps in Treatment | Desired Outcome |
---|---|---|
Rib raising | 4 second cycles of rhythmic pressure on rib angle | Reduced sympathetic output |
Sacral Rock | Augmentation of sacral flexion and extension | Increased parasympathetic output |
Suboccipital Inhibition | Continuous unaltered pressure | Increased parasympathetic output |
CV4 (stillpoint induction) | Progressive encouragement of occipital extension until a still point is reached | Global shift towards parasympathetic balance |
Open in a new tab
Sham Protocol
The sham protocol, also created by Dr. Selby, was adapted from the OMT protocol described above. Sham OMT was performed by individuals who received sham training but had no additional experience in performing OMT prior to this study. Participants were not instructed when to inhale or exhale and any touch used did not consist of extension or flexion, but rather only enough pressure to make the participants were aware they were being touched.
Scales
Various assessments of stress and anxiety were collected at week one and at week six. The Perceived Stress Scale was completed by participants to self-report their perception of stress.38 For first responders’ self-reported measurement of anxiety, we used the State Trait Anxiety Inventory.39 We incorporated three scales previously used in trauma studies,40 including a seven-point Likert scale (strongly agree to strongly disagree) that measured indicators of Satisfaction with Work and a Vicarious Trauma Scale with measures of distress from exposure to work experiences, such as interactions with traumatized or distressed people and difficult situations, as well as feelings of helplessness, and being overwhelmed by their workloads. Finally, a Coping Mechanisms Scale with nearly a dozen possible items (including both positivity and negatively perceived coping mechanisms) was administered.
Vital Signs Collection
Participant vital signs, including height, weight, pulse oximetry, blood pressure, pulse, and respiration rate were recorded prior to each OMT or sham session.
Biomarker Sample Collection
The amount of 5mL of whole blood was collected via venipuncture from each participant using sterile techniques at week one and week six timepoints. Samples were stored and processed according to ELISA manufacturer directions.
ELISA
Biological indicators of stress and anxiety were assessed using enzyme-linked immunosorbent assays. Measures of human IL-6 (KHC0061), IL-1beta (BMS224-2), TNF-alpha (BMS223HS), cortisol (EIAHCOR), IL-2 (EH2IL2), C reactive protein (KHA0031), and IL-17alpha (BMS2017) were purchased from Thermo Fisher Scientific (http://www.thermofisher.com). Human BDNF (ab99978) was purchased from Abcam (http://www.abcam.com). Manufacturer protocols were followed, and assays were carried out using Synergy HTX Multimode Reader, software Gen5 3.05.
Statistics
All statistical analysis was carried out using GraphPad Prism version 8.2.1 for Windows, GraphPad Software, San Diego, California USA. All statistical significance was measured at p=.05.
Results
A total of nine participants were recruited into the pilot study (six OMT and three sham OMT). Six total participants completed the study (three OMT and three sham OMT). Socio-demographic data for the nine total participants are presented in Table 1.
When evaluating the social-psychological (mental) survey data, we observed that the average work satisfaction (Figure 2A) for both groups was on the higher side (5.2 – 5.8 out of 7), with the OMT (experimental) group reporting a slight increase in job satisfaction from week one to week six, and the sham OMT (control) group reporting a slight decrease in their job satisfaction. These data also indicate that the sham OMT group experienced a slight decrease in vicarious trauma indicators (Figure 2B) across the course of the study, while the OMT group’s indicators of vicarious trauma increased slightly over the six-week period. Both the sham OMT group and the OMT group increased their positive coping mechanisms (Figure 2C) over the study, and both groups also reported a decrease in negative coping strategies (Figure 2D). Finally, both the sham OMT and OMT groups reported increases in their perceived stress scores at the end of the six-week study (Figure 2E).
Analysis of serum biomarkers for stress, anxiety and depression were carried out via ELISA assay on week one and week six of the study. No statistically significant change in biomarker levels were observed, however, there were trends that indicate a slight decrease (Figure 3). Levels of IL-6, BDNF, IL-2, IL-17α, and cortisol trended lower at week six than week 1 in the OMT group. In addition, IL-17α levels were also decreased in the sham OMT group at week six when compared to week one. Only levels of human C reactive protein trended higher at week six in the OMT group (Figure 3D). In the sham OMT group, IL-6, IL-2, hCRP, and cortisol all trended higher, but did not reach statistical significance. It is important to note that there was a high degree of variance across each group, and due to the relatively small number of participants, this likely is associated with a lack of statistical significance over time.
Discussion
In this pilot study we were able to identify numerical increases in positive coping mechanisms and decreases in negative coping mechanisms for all participants over the course of the study. The pre- to post-study increases in satisfaction with work satisfaction for the OMT treatment group was in the expected direction. On the other hand, data on first responders’ impressions of vicarious trauma associated with work were not expected: control group members felt less and treatment group members felt more vicarious trauma by the end of the study.
Further, perceived stressors increased for both groups. These findings could be influenced by variations in individuals’ exposure to stressful or anxious situations, such as differing responsibilities held across work positions, having different shifts or working in different stations that influence the calls to which each first responder was dispatched. However, a larger social factor may have been the emergence of the Covid-19 pandemic, increasing national, state and community-level fears and requiring the quick implementation of social distancing protocols. Somewhat contradictory, both groups also reported increased calmness, security, and feelings of ease and relaxation by the end of the study. The extra attention, human touch, and social interactions experienced by our participants were likely felt by those who received both authentic or sham OMT.
The authors note a likely confounding effect of having both prescription and non-prescription drugs labeled as a “negative” coping strategy to work-related stressors. Future studies may deconstruct this item, since compliance with physician’s orders to take prescription medication may be perceived as a “positive.”
This pilot study detected trends toward a decrease in serum biomarkers associated with stress, anxiety, and depression. Inflammatory cytokines are currently being further investigated as primary biomarkers for a number of neurological conditions, including anxiety and major depressive disorder. Our data indicate that several of the interleukins and other hormones potentially associated with these conditions were influenced by this protocol. Increasing the frequency of treatment and/or the duration of the study may show a continuation of this trend to statistical significance. In addition, the addition of educational materials designed for the reduction of stress, anxiety and feelings of depression may work in conjunction with OMT to improve these conditions in first responders.
Conclusion
First responders are commonly exposed to traumatizing incidents or disasters in the course of their duties. Police, firefighters, EMTs, and paramedics who respond to these emergencies and tragedies are likely to experience psychological and physical stress, and this constitutes a great risk for their physical and behavioral health. This pilot study highlights the therapeutic potential of OMT for SAD reduction in this population. Further research is needed on this topic, expanding the sample size and modifying the methods based on the findings of this study to develop more evidence-based conclusions.
Footnotes
Christena Abraham, BS, Charles Coker, BS, Blair Freed, BS, Matthew McAuliffe, BS, Halden Nielsen, BA, Tanner Riscoe, BS, Robert Steele, MS, and Andrew Dettwiler, BS, are medical students at Kansas City University College of Osteopathic Medicine (KCU-COM). Shelly N.B. Sloan, MS, is a Research Associate at KCU-COM. Gia Oberley, BS, is an undergraduate student at Missouri Southern State University in Joplin. Kenneth Zaremski, DO, is an Assistant Professor in the Department of Osteopathic Manipulative Medicine, Kansas City Campus of KCU-COM. Kelley Joy, DO, is Vice Chair of Osteopathic Manipulative Medicine, Joplin Campus of KCU-COM. Andi Selby, DO, is an Assistant Professor in the Department of Osteopathic Manipulative Medicine, Joplin Campus of KCU-COM. Ree Wells-Lewis, PhD, is a Professor in the Department of Social Sciences, Missouri Southern State University in Joplin. Bradley Creamer, PhD, (above), is an Associate Professor in the Department of Basic Sciences, Joplin Campus of KCU-COM.
Disclosure
None reported.
References
- 1.Abbot C, Barber E, Burke B, et al. What’s killing our medics? http://www.revivingresponders.com/originalpaper.
- 2.McKeon G, Steel Z, Wells R, et al. Mental health informed physical activity for first responders and their support partner: a protocol for a stepped-wedge evaluation of an online, codesigned intervention. BMJ Open. 2019 Sep 11;9(9):e030668. doi: 10.1136/bmjopen-2019-030668. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Lewis-Schroeder NF, Kieran K, Murphy BL, Wolff JD, Robinson MA, Kaufman ML. Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues. Harv Rev Psychiatry. 2018 Jul-Aug;26(4):216–227. doi: 10.1097/hrp.0000000000000176. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Administration SAaMHS. First Responders: Behavioral Health Concerns, Emergecy Response, and Trauma. 2018 [Google Scholar]
- 5.Venteicher W. Increasing suicide rates among first responders spark concern, in The Pittsburgh Tirbune-Review. Philadelpha. 2017 [Google Scholar]
- 6.Bergen-Cico D, Lane S, Thompson M, et al. The impact of post-traumatic stress on first responders: analysis of cortisol, anxiety, depression, sleep impairment and pain. International Paramedic Practice. 2015;5(3):78–87. [Google Scholar]
- 7.Hembree EA, Foa EB, Dorfan NM, Street GP, Kowalski J, Tu X. Do patients drop out prematurely from exposure therapy for PTSD? J Trauma Stress. 2003 Dec;16(6):555–62. doi: 10.1023/B:JOTS.0000004078.930127d. [DOI] [PubMed] [Google Scholar]
- 8.Libby DJ, Pilver CE, Desai R. Complementary and alternative medicine use among individuals with posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy. 2013;5(3):277–285. doi: https://psycnet.apa.org/doi/10.1037/a0027082. [Google Scholar]
- 9.Schottenbauer MA, Glass CR, Arnkoff DB, Tendick V, Gray SH. Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry Summer. 2008;71(2):134–68. doi: 10.1521/psyc.2008.71.2.134. [DOI] [PubMed] [Google Scholar]
- 10.Reynolds CW, Wagner SL. Stress and First Responders: The need for a Multidimensional Approcah to Stress Management. Int J Disability Management. 2012;2(2):27–36. doi: 10.1375/jdmr.2.2.27. [DOI] [Google Scholar]
- 11.Fornari M, Carnevali L, Sgoifo A. Single Osteopathic Manipulative Therapy Session Dampens Acute Autonomic and Neuroendocrine Responses to Mental Stress in Healthy Male Participants. J Am Osteopath Assoc. 2017 Sep 1;117(9):559–567. doi: 10.7556/jaoa.2017.110. [DOI] [PubMed] [Google Scholar]
- 12.Plotkin BJ, Rodos JJ, Kappler R, et al. Adjunctive osteopathic manipulative treatment in women with depression: a pilot study. J Am Osteopath Assoc. 2001 Sep;101(9):517–23. [PubMed] [Google Scholar]
- 13.Kopschina Feltes P, Doorduin J, Klein HC, et al. Anti-inflammatory treatment for major depressive disorder: implications for patients with an elevated immune profile and non-responders to standard antidepressant therapy. J Psychopharmacol. 2017 Sep;31(9):1149–1165. doi: 10.1177/0269881117711708. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Bandelow B, Baldwin D, Abelli M, et al. Biological markers for anxiety disorders, OCD and PTSD: A consensus statement. Part II: Neurochemistry, neurophysiology and neurocognition. World J Biol Psychiatry. 2017 Apr;18(3):162–214. doi: 10.1080/15622975.2016.1190867. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Antonijevic I. HPA axis and sleep: identifying subtypes of major depression. Stress. 2008 Jan;11(1):15–27. doi: 10.1080/10253890701378967. [DOI] [PubMed] [Google Scholar]
- 16.Tsigos C, Kyrou I, Kassi E, Chrousos GP. Stress: Endocrine Physiology and Pathophysiology. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext. MDText.com, Inc; 2000. Copyright © 2000–2021. MDText.com, Inc. [PubMed] [Google Scholar]
- 17.Turner AI, Smyth N, Hall SJ, et al. Psychological stress reactivity and future health and disease outcomes: A systematic review of prospective evidence. Psychoneuroendocrinology. 2020 Apr;114:104599. doi: 10.1016/j.psyneuen.2020.104599. [DOI] [PubMed] [Google Scholar]
- 18.Turner-Cobb JM. Psychological and stress hormone correlates in early life: a key to HPA-axis dysregulation and normalisation. Stress. 2005 Mar;8(1):47–57. doi: 10.1080/10253890500095200. [DOI] [PubMed] [Google Scholar]
- 19.Zänkert S, Bellingrath S, Wüst S, Kudielka BM. HPA axis responses to psychological challenge linking stress and disease: What do we know on sources of intra- and interindividual variability? Psychoneuroendocrinology. 2019 Jul;105:86–97. doi: 10.1016/j.psyneuen.2018.10.027. [DOI] [PubMed] [Google Scholar]
- 20.Emmet D, Nuño V, Pierce-Talsma S. OMT to Address the Physiologic Effects of Stress. J Am Osteopath Assoc. 2018 Feb 1;118(2):e11. doi: 10.7556/jaoa.2018.028. [DOI] [PubMed] [Google Scholar]
- 21.Żurowska A, Malak R, Kołcz-Trzęsicka A, Samborski W, Paprocka-Borowicz M. Compression of the Fourth Ventricle Using a Craniosacral Osteopathic Technique: A Systematic Review of the Clinical Evidence. Evid Based Complement Alternat Med. 2017;2017:2974962. doi: 10.1155/2017/2974962. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Field T. Massage therapy research review. Complement Ther Clin Pract. 2014 Nov;20(4):224–9. doi: 10.1016/j.ctcp.2014.07.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Reeves RR. Diagnosis and management of posttraumatic stress disorder in returning veterans. J Am Osteopath Assoc. 2007 May;107(5):181–9. [PubMed] [Google Scholar]
- 24.Seffinger MA. The Safety of Osteopathic Manipulative Treatment (OMT) J Am Osteopath Assoc. 2018 Mar 1;118(3):137–138. doi: 10.7556/jaoa.2018.031. [DOI] [PubMed] [Google Scholar]
- 25.Arienti C, Farinola F, Ratti S, Daccò S, Fasulo L. Variations of HRV and skin conductance reveal the influence of CV4 and Rib Raising techniques on autonomic balance: A randomized controlled clinical trial. J Bodyw Mov Ther. 2020 Oct;24(4):395–401. doi: 10.1016/j.jbmt.2020.07.002. [DOI] [PubMed] [Google Scholar]
- 26.Cutler MJ, Holland BS, Stupski BA, Gamber RG, Smith ML. Cranial manipulation can alter sleep latency and sympathetic nerve activity in humans: a pilot study. J Altern Complement Med. 2005 Feb;11(1):103–8. doi: 10.1089/acm.2005.11.103. [DOI] [PubMed] [Google Scholar]
- 27.Miana L, Bastos VH, Machado S, et al. Changes in alpha band activity associated with application of the compression of fourth ventricular (CV-4) osteopathic procedure: a qEEG pilot study. J Bodyw Mov Ther. 2013 Jul;17(3):291–6. doi: 10.1016/j.jbmt.2012.10.002. [DOI] [PubMed] [Google Scholar]
- 28.Curi ACC, Maior Alves AS, Silva JG. Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression in systemic hypertensive subjects. J Bodyw Mov Ther. 2018 Jul;22(3):666–672. doi: 10.1016/j.jbmt.2017.11.013. [DOI] [PubMed] [Google Scholar]
- 29.Yu K, Pfotenhauer K, Pierce-Talsma S. OMT for Patients With Sacral Somatic Dysfunction. J Am Osteopath Assoc. 2018 Mar 1;118(3):e15. doi: 10.7556/jaoa.2018.041. [DOI] [PubMed] [Google Scholar]
- 30.Gerhartz B, Bordoni B. StatPearls. StatPearls Publishing; 2021. Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions. [PubMed] [Google Scholar]
- 31.Espi-Lopez GV, Olivia-Pascual-Vaca A. Atlanto-Occipital Joint Manipulation and Suboccipital Inhibition Technique in the Osteopathic Treatment of Patients with Tension-Type Headache. Eur J Ost Clin Rel Res. 2012;7(1):10–21. [Google Scholar]
- 32.Jiang W, Li Z, Wei N, Chang W, Chen W, Sui HJ. Effectiveness of physical therapy on the suboccipital area of patients with tension-type headache: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2019 May;98(19):e15487. doi: 10.1097/md.0000000000015487. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Oliveira-Campelo NM, Rubens-Rebelatto J, Martí NVFJ, Alburquerque-Sendí NF, Fernández-de-Las-Peñas C. The immediate effects of atlanto-occipital joint manipulation and suboccipital muscle inhibition technique on active mouth opening and pressure pain sensitivity over latent myofascial trigger points in the masticatory muscles. J Orthop Sports Phys Ther. 2010 May;40(5):310–7. doi: 10.2519/jospt.2010.3257. [DOI] [PubMed] [Google Scholar]
- 34.Field T. Touch for socioemotional and physical well-being: A review. Dev Review. 2010;30(4) doi: 10.1016/j.dr.2011.01.001. [DOI] [Google Scholar]
- 35.Field T. Massage therapy research review. Complement Ther Clin Pract. 2016 Aug;24:19–31. doi: 10.1016/j.ctcp.2016.04.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Cerritelli F, Verzella M, Cicchitti L, D’Alessandro G, Vanacore N. The paradox of sham therapy and placebo effect in osteopathy: A systematic review. Medicine (Baltimore) 2016 Aug;95(35):e4728. doi: 10.1097/md.0000000000004728. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Licciardone JC, Minotti DE, Gatchel RJ, Kearns CM, Singh KP. Osteopathic manual treatment and ultrasound therapy for chronic low back pain: a randomized controlled trial. Ann Fam Med. 2013 Mar-Apr;11(2):122–9. doi: 10.1370/afm.1468. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983 Dec;24(4):385–96. [PubMed] [Google Scholar]
- 39.Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press; 1983. [Google Scholar]
- 40.Vrklevski LP, Franklin J. Vicarious trauma: The impact on solicitors of exposure to traumatic material. Traumatology. 2008;14(1):106–118. doi: https://doi.apa.org/doi/10.1177/1534765607309961. [Google Scholar]