Treatment of Refractory IBS with Visceral Osteopathy. Attali, Thu-Van. J of Digestive Diseases 14; 654-661 (2013).

Pelvic PT Distance Journal Club September 7, 2016
Jane Franczak

Purpose

To investigate the effectiveness of Visceral Osteopathy for IBS

Definitions

IBS: Association between abdominal pain and or abdominal distention and bowel dysfunction for recurrent periods. Rome III criterion recurrent abdominal pain or distention lasting at least 3 days/month over 3 months with 2 or more of these:
1.       Improves with defecation
2.       Onset assoc. with change in stool frequency
3.       Onset assoc with change in form of stool

32 Consecutive refractory IBS patients study: failed to improve after variety of drug therapies or high health care usage despite aggressive treatment and unhappy about care.

Osteopathy: manual treatment that relies on various mobilization procedures aimed at relieving patient’s pain. Visceral mobilization was provided by an osteopath.

Design

Single center randomized
Gr A: phase I, 1st 3 session are placebo manipulations, Phase II next 3 are osteopathic manips
GrB: phase I 1st 3 sessions are Osteopathic manips , Phase II placebo manips
Ev1= Evaluation at inclusion
 EV2 and EV3 = Evaluation after each phase of Rx, EVf = 1 year post treatment
Each treatment 45 min, administered by Senior osteopath, 6 sessions over 2 months at 2 week intervals.

Techniques:

a. Global visceral technique to abdomen( gentle vibration to abdomen) then Local vibration via fingers around sensitive area
b. Sacral technique gentle manip of sacrum to stimulation. Pelvic splanchnic nerves of parasympathetic nature. Arise from S2, S3, S4 through sacral foramina.
Placebo hands applied at same points of abdomen. Placebo manip= superficial abdominal Massage, NO organs manips.
Ph I and II immediately consecutive to minimize risk of differentiation btw. the 2 phases.

Symptoms: Pts filled out questionnaire on functional GI disorders as defined by Rome 3 criteria B4 study.

During 12 weeks, daily diary using VAS, constipation, Diarrhea, abdominal Distention, and abdominal Pain
At end, tests for rectal sensitivity, colonic transit time and pain quantification.
IBSs phenotype for trial based on dominant sx. of constipation, diarrhea, Alternating or unspecificied. Also, presence of depression.
Patients were asked to eval Sx at start and 1 year after study. 

Rectal sensitivity

5 cm latex Balloon – max volume 420 Ml
Inflated with Air, injected via syringe 30-120 sec to distending volume then deflated.
3 volumes (threshold sensation volume, Constant sensation vol. and Max tol. Vol) recorded. Its hadn’t had previous rectal sensory testing B4 inclusion.

Total  and segmental colonic transit time

12 radiopaque markers in a Gelatin capsules were swallowed 9am for 6 days and filmed on 7^th day at 9am. Markers were localized and counted in different segments of colorectal acc to Bony landmarks
3 Zones of interest were defined for measurement of transit time: R colon, L colon, recto sigmoid area.
Segmental and total colorectal transit time were calculated acc to the distribution of markers in different segments of bowel over the days by an equation ( see article). Total time was sum of 3 segmental times.
Nl colorectal transit were regarded as btw 24-65 hours.

Results
Total of 31 patients, 8 men, 23 women, BMI 25.1. age 50+/- 2,

Eval’d for depression, 4 sx of constipation, diarrhea, abdominal Discomfort and abdominal Pain. B4 and after each phase via VAS, rectal sensitivity and colonic transit time. f/u in  year.

Outcome Group A Placebo 1^st                                                                                      

Decreased abd. Distention and abd. Pain as compared at start EV1 vs EV2, then osteopathy. Decreased diarrhea, distention and pain

Group B all 4 sx of constip, diarrhea, distention and pain decreased. Then placebo, no signif additional changes.

At EV2. No change btw A and B

Abd. Pain decreased in 7 of 9 segments.

Analysis of osteopathy: Signif decrease of diarh, abd dist and abd pain at 1 year.

Rectal sensitivity (RS), (threshold sensation volume, constant sensation vol and max tol volume)

Osteopathy Improved RS vs. Placebo No change

No change in colonic transit time.

IBS phenotypes changed during study, at end and at 1 year, but not significantly.

Discussion

Objective changes rectal sensitivity and transit time. Only limited changes of IBS sx after 1 year

Study limitations

Crossover study

Small sample size

Study shows effectiveness of VO on bloating and pain in IBS.

Questions:

Is anyone using VM with patients and with what results?

Despite study weakness, would you consider using VM given that it is accepted as a treatment by SoWH?

Input on positive outcomes from VM welcomed.