How could it be otherwise, this newsletter is entirely devoted to the coronavirus or COVID-19. Its purpose is to support the osteopathic treatment after an upper respiratory or abdominal infection. In addition, this review is intended to investigate the possibilities of a preventive osteopathic approach. We have made a selection from all relevant studies.
Sander Kales
What is now known about the coronavirus, based on general and scientific sources?
A virus is a protein (RNA) with a protective fat layer, so that it is absorbed into the mucosa of the nose, eyes or lungs. Every virus acts like a parasite, with the aim of multiplying. A virus does this by entering a cell of a host and releasing genetic material into this cell. The virus can then pick up proteins and multiply. Thousands of virus particles can be made in a cell, causing a cell to be so badly damaged that it eventually dies. The more cells are damaged, the sicker someone becomes (Alphens.nl, 2020).
Initially, the current virus was called the corona virus. The WHO has now referred to it as Severe Acute Respiratory Syndrome Corona Virus 2 or SARS-CoV-2. This causes COVID-19 (RIVM, 2020). The virus is a positive sense single strand RNA virus. The virus resembles SARS from 2003, the SARS-CoV-1. The Middle East Respiratory Syndrome (MERS) was caused in 2012 by the MERS-CoV, also a corona virus. Both viruses are zoonotic (jump from animal to human). The SARS-CoV-2 attaches to the ACE2 enzyme receptors. It is now clear that taking Renin-Angiotensin System blockers (RAAS) or ACE inhibitors does not directly lead to an increase in susceptibility (Vaduganathan, 2020). Nitrogen oxide (NO) and Ceramides (fats) promote the uptake of the virus (Donatini, 2020).
The lining in the alveoli thickens, making it more difficult for the lungs to get oxygen through the thin membrane of the vesicles into the bloodstream. The thickening is partly due to the cilia coming to a standstill, even 96 hours after inoculation (Zhu 2020). In addition, the alveoli fill with fluid and pus because the pneumocytes type 2 are virally attacked. The patient becomes short of breath and breathes faster and faster. This is the standard process for all viral pneumonia that gets out of control.
Due to the new corona virus, approximately 80 percent of infected people do not or hardly become ill and recover automatically. The other 20 percent become quite ill. Symptoms include dry cough, breathlessness, sneezing and fever. A large group still recovers after five or seven days, but a fraction suddenly deteriorates for unknown reasons. They then develop a Corona Virus Infected Pneumonia (CVIP) also called SARS-CoV-2 pneumonia (Zhu 2020).
They still have to go to hospital and if they were already there, they end up in intensive care (IC), usually with a “hypoxemic respiratory failure”, with low lymphocytes and platelets levels. One reason for the sudden deterioration could be that the immune response resumes after a few days. The inflammation in the lungs, with edema, would therefore increase, while the virus is no longer detectable. Research shows that the patients who go to the ICU often have underlying conditions, ranging from heart-blood vessel problems, diabetes, intestinal problems or obesity. Another reason may be that the immune system is unable to slow down or get the virus under control in time. It could also be a combination of the above reasons. Finally, complications can also arise. For example, a bacterial lung infection can get over the virus attack.
The immune system starts to fight the virus by flooding the lungs with immune cells, which clean up the damaged cells and repair the lung tissue. If everything is working properly, this inflammatory process is painstaking and limited to the infected tissues. But sometimes the immune response is so great that healthy cells are also destroyed: the so-called cytokine storm. Because of this fierce immune response, one therefore has to deal with more instead of less damage. More waste accumulates in the lungs and the pneumonia gets worse.
In the third phase, the pneumonia worsens even further, which can lead to respiratory failure. Even if the patient does not die as a result, the damage to the lungs can be irreparable. According to the World Health Organization (WHO), SARS led to the formation of holes in the lungs, giving them a “honeycomb-shaped appearance,” and it appears that this pattern can also be seen in patients with the new coronavirus.
The holes are likely caused by immune system hyperresponsiveness, which leads to scar tissue formation and stiffening of the lungs. In that case, the patient usually has to be on a ventilator. Meanwhile, the membranes between the alveoli and the blood vessels become increasingly porous, allowing the vesicles to fill with fluid and no longer supply the bloodstream with oxygen. In very severe cases, the lungs drown and the patient can no longer breathe. This can lead to macrophages destroying blood cells, resulting in Multiple Organ Failure, or heart failure, leading to death.
The reproduction number of an infection is designated R0. R0 applies if someone has not been vaccinated, has had the disease before and if there is no way to limit the infection yet. With an R0 below 1, each infected person will light less than one other. Above 1, each infected will light several people. SARS-CoV-2 has an R0 between 2-4 (measles is 18).
There is an incubation period of 1-14 days in which there are no signs of disease. A cross-section is taken here: 5 days is the average, the RIVM uses 14 days for safety. Many people only recover after a few weeks, a section is also taken here: 2 weeks. In addition, asymptomatic people (people who therefore have no symptoms but are carriers) are also contagious to others. That means there is an infectious period of between 1 and 30 days. During the incubation and illness / symptomatic period, you can transmit the virus to others through the air or feces. Hence the one and a half meter rule.
(Sander Kales)
References: Physiotherapy after COVID-19 (2020)
References elsewhere in this newsletter
Failure of the lymphatic system is implicated in the pathogenesis of various infectious and inflammatory diseases. Thus, interventions that improve lymph circulation, such as osteopathic lymphatic techniques (LPT), should help treat these diseases.
By promoting tissue fluid recirculation, the lymphatic system maintains tissue health, aids in gastrointestinal lipid uptake, and aids immune surveillance. Four studies looked at treatment techniques for lung disease.
The aim of the study by Castillo et al (2018) was to determine whether mobilization during lymphatic pumping techniques (LPT) would alter the function of macrophages in the thoracic lymphatic duct (TDL) in vitro. Lymphatic pump treatment significantly increased TDL flow and protein flow in TDL (P <.001). After culture, macrophage viability was approximately 90%. The redistribution of protective lymph during LPT may provide evidence for the clinical use of LPT to reduce inflammation and treat edema.
The study by Schander et al (2013) measures the effects of repeat LPT on lymph flow, lymph leukocyte counts and inflammatory mediator concentrations in the thoracic lymphatic duct. The LPT was performed twice at 2 hour intervals. From this it was concluded that LPT can be applied at a rate of 1 pump per second for a total of 4 minutes every 2 hours, providing a scientific rationale for using LPT to repeatedly strengthen the lymphatic and immune systems.
Yao et al (2014) investigated effective treatment methods for pneumonia. They specifically looked at techniques aimed at autonomy, lymphatic drainage and mobility of rib cages: 1) Rib expiration, 2) Thoracic pump technique, 3) Doming of the thoracic diaphragm and 4) Muscle Energy Technique (MET) for rib 1.
Rib Raising Technique increases lymphatic flow by improving inspiration and expiration and decreasing the orthosympathetic influence. Excessive autonomic innervation decreases the mobility of the chest wall by generating hypertonicity of the surrounding musculature and increasing intra-abdominal pressure. Since lymphatic flow is dependent on pressure generated by adequate inspiration and expiration, hypertonicity of the surrounding musculature may hinder lymphatic drainage.
The thoracic pump technique increases the flow of lymph and other immune cells by rhythmic, fascial compression of the lymph and regional lymph tissue, especially at the level of the thoracic duct.
The doming technique of the thoracic diaphragm involves manipulation of the thoracic diaphragm, and is involved in respiration, blood circulation and lymph flow. Diaphragm hypertonicity can obstruct the lymphatic flow of the cisternal chili. The doming technique indirectly reduces the hypertonia, and as a result normal lymph flow will return.
A MET technique can help promote lymph flow through better expiration, as mentioned earlier. In addition, myofascial limitations in the clavicular region, such as scalenic hypertrophy or spasm, may impede the drainage of lymph vessels on the way to subclavian vessels. Removing these hypertonicities / spamses can improve lymph flow.
Finally, the study by Noll et al. (2016) analyzed the length of stay in hospital, ventilation dependence, respiratory failure and death rate in the hospital. The OMT included gentle thoracolumbar techniques, rib raising technique, diaphragm doming, soft cervical techniques, suboccipital decompression, thoracic inlet, thoracic lymph pump and pedal pump. Additional osteopathy (OMT) for pneumonia shortened the length of stay in adults 50 to 74 years of age and reduced the death rate in adults 75 years of age and older. Supplemental OMT can also reduce the length of hospital stay and the death rate in older adults with severe pneumonia. This Randomized Control Trial is currently the best available study of techniques for the lymph system. (Nadi Blokhuis)
Castillo R. et al. (2018). Lymphatic Pump Treatment Mobilizes Bioactive Lymph That Suppresses Macrophage Activity In Vitro, J Am Osteopath Assoc. 2018;118(7):455-461.
Noll, D. et al. (2016). Multicenter Osteopathic Pneumonia Study in the Elderly: Subgroup Analysis on Hospital Length of Stay, Ventilator-Dependent Respiratory Failure Rate, and In-hospital Mortality Rate, J Am Osteopath Assoc. 2016;116(9):574-587.
Schander, A. et al (2013). Lymphatic pump treatment repeatedly enhances the lymphatic and immune systems. Lymphatic research and biology, 11(4), 219-226.
Yao, S. et al. (2014). Osteopathic Manipulative Treatment as a Useful Adjunctive Tool for Pneumonia, Department of Osteopathic Manipulative Medicine.
Clinical studies show that osteopathic lymphatic pumping techniques (LPT) improves antibody response to bacterial vaccines, shortens the duration of coughing in patients with respiratory disease, and shortens the duration of intravenous antibiotic therapy and hospitalization in patients with pneumonia.
Lymphatic pumping techniques can be applied to the chest (thoracic pump), abdomen (abdominal pump), feet and legs (pedal pump) and the areas of the spleen and liver. Lymphatic pumping techniques (LPT) typically consist of manual compressions of a specific body area at a rate of 20-30 compressions per minute for 2-5 minutes, according to Hodge et al (2011), after studying rats.
Only recently have experiments shown that these LPT procedures increase lymph flow in rats and dogs. In addition, animal studies show that LPT also increases the concentration of leukocytes in the lymph. LPT stimulates the mobilization of Gut-associated lymphoid tissue (GALT) derived leukocytes into the lymphatic circulation and the release of leukocytes from mesenteric lymph nodes. These experimental observations support findings that LPT is a valuable adjunctive therapy for infectious diseases, including influenza and pneumonia.
The purpose of the study by Creasy et al (2013) was to determine whether the thoracic pump technique or abdominal pump technique would reduce Streptococcus pneumonia colony-forming units in the lungs of rats with acute pneumonia. In this study, both chest and abdomen LPT were found to significantly reduce S. pneumoniae bacteria in the lungs. Although they did not identify the mechanism responsible for this protection in the study by Creasy et al. (2013), previous studies showed that LPT promotes the uptake of interstitial antigens, improves lymph flow of the thoracic ducts, improves leukocyte in the thoracic and mesenteric lymph increases and improves the flux of inflammatory mediators in the lymph. By enhancing lymphatic drainage from pathogens or antigens, LPT can facilitate activation of specific lymphocytes in secondary lymphoid tissues. In addition, by increasing leukocytes and inflammatory mediators in the lymphatic circulation, LPT can facilitate the association of leukocytes with pathogens and enhance immunity. Both mechanisms can potentially enhance immunity to infectious diseases.
In addition, LPT can also support lung function. It may aid in clearing the tracheobronchial tissues, increase sputum production and shorten cough duration in patients with lower respiratory tract disease. The data suggests that LPT may protect against pneumonia by inhibiting bacterial growth in the lung. However, several questions remain unanswered:
– Does LPT improve lung immunity by redistributing lymph cells and inflammatory mediators to the lungs?
– Does LPT improve the delivery of pharmaceuticals from the lymph or blood to the lungs?
– Or does LPT improve lung function?
Once these mechanisms are understood, LPT can be optimally applied to patients with pneumonia, which can significantly reduce morbidity, mortality and hospitalization.
(Nadi Blokhuis)
Hodge L.M., Downey H.F. (2011). Lymphatic pump treatment enhances the lymphatic and immune systems, Experimental Biology and Medicine.
Creasy C. et al. (2013). Thoracic and Abdominal Lymphatic Pump Techniques Inhibit the Growth of S. pneumoniae Bacteria in the Lungs of Rats, Lymphatic research and biology.
In his article Hruby describes the treatment options for the osteopath in the context of the avian flu virus. COVID-19 makes this article very relevant again. In the article he makes a comparison with the Spanish flu of 1918-1919, when almost 40 million people died.
The American Osteopathic Association retrospectively collected data after the influenza pandemic and suggested that osteopathic physicians (DO), using their specific osteopathic manipulative treatment (OMT), saw significantly lower morbidity and mortality among their patients, compared to standard allopathic medical treatments. doctors (MD) at the time. It is therefore obvious that OMT could be part of the treatment of post-COVID patients. Incidentally, a small side note: osteopaths saw less mortality in their practice, but there was also less mortality in their region anyway.
The article describes the evidence base for the inclusion of OMT as part of influenza treatment, and describes a number of specific OMT treatment techniques for influenza patients. The evidence supports the use of OMT techniques that were also used in 1918 during the Spanish flu. The research base describes OMT procedures that have a positive effect on the immune system and the arterial, venous and lymphatic circulation. Especially liver, spleen and lymphatic pumping techniques showed a positive effect. Other techniques used were Chapman’s lung reflex points, which have previously proven useful in patients with pneumonia.
Hruby also recommends taking the following precautions when treating patients with post-COVID-19:
* Be familiar with the clinical characteristics of COVID-19;
* Have an action plan for the treatment of post-COVID-19 patients;
* Perform those OMT procedures that may have a positive effect on post-COVID-19 patients.
(Joppe ten Brink)
Hruby, R.J., and Hoffman, K.H., Avian influenza: an osteopathic component to treatment. Osteopathic Medicine and Primary Care (2007) 1:10.
The 2007 study by Hruby and Hoffman provided the impetus for further research. What are the possibilities of osteopathy in infectious diseases of the respiratory tract? Is there already a scientific basis that we can build on?
The arrival of the SARS-CoV-2 virus is giving osteopaths worldwide an instigation for research. What are our options and what scientific basis is already there? Sanderlin et al (2007) have been one of many who analyzed Hruby and Hoffman’s article on osteopathy in the 1918-1919 pandemic flu (see article above). They ask three questions. First, what is the reliability of the evidence that osteopathic intervention resulted in fewer deaths in the 1918-1919 pandemic compared to conventional medicine. They cannot find the validity of the causal relationship of the number of deaths, due to the fact that it is unclear whether the patient groups were comparable. Secondly, when a pandemic develops, there is always a lack of knowledge about the virus in question, its infectivity and virulence, due to possible mutations. Third, they find too little evidence for the use of osteopathy in respiratory infections. Sanderlin et al. Believe that more scientific research is needed and that proper planning and organization of health care is necessary in order to propose large-scale osteopathic treatments during a pandemic flu wave.
Noll et al. (2010) accordingly conducted a double-blind randomized controlled trial (RTC) and investigated the effect of osteopathy as an adjunctive treatment in 406 hospitalized patients with pneumonia. They divided their study population into three conditions: conventional therapy alone, a sham group with additional light-touch therapy and a third study group with additional osteopathy for 15 minutes twice a day. The osteopathic treatment consisted of: thoracolumbar soft tissue techniques, rib raising, diaphragm doming with myofascial release, soft tissue techniques cervical, suboccipital decompression, thoracic inlet treatment with myofascial release and lymphatic pumping techniques. The length of hospitalization was significantly shorter, the duration of antibiotic use decreased and the incidence of respiratory failure and mortality decreased significantly. This was also observed in the sham group with light touch, but antibiotic use remained higher than in the group treated with osteopathy. The researchers indicate that further research is necessary to determine which techniques and touch (light-touch) have the most effect on patients with pneumonia and what the specific effect is of the mechanism behind these research results.
Zanotti et al. (2012) conducted a pilot study to map the effects of pulmonary rehabilitation in combination with osteopathy in stage III COPD. In addition, they treated 20 COPD patients 5 times a week for four weeks, half of them with OMT. The osteopathic intervention was done once a week for 45 minutes, and consisted of treatment of mainly C0-C2, C3-C4, Th2-Th9, Th12-L1, costae, sternum, craniosacral and all diaphragms. The researchers observed a significant improvement in the study group that received OMT, due to a significant increase in the number of meters in the 6-minute walk test. Residual Volume also decreased by 11% and FEV1 improved by 14%. The researchers indicate that further research is necessary because the research group is too small and also to determine which mechanism is responsible for this improvement.
(Liesbeth van den Berg)
Sanderlin B.W., Licciardone J.C. (2007). Osteopathic manipulative treatment for pandemic influenza: many questions, few answers. Osteopathic Medicine and Primary Care, 10.1186/1750-4732-1-12.
Noll D.R., Degenhardt B.F., Morley T.F., Blais F.X., Hortos K.A., Hensel K., Johnson J.C., Pasta D.J., Stoll S.T. (2010). Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial. Osteopathic Medicine and Primary Care 2010, 4:2.
Zanotti E., Berardinelli P., Bizarri C., Civardi A., Manstretta A., Rossetti S., Fracchia C. (2012). Osteopathic manipulative treatment effectiveness in severe chronic obstructive pulmonary disease: A pilot study. Complementary Therapies in Medicine 2012: 20, 16-22.
There are currently no effect studies available on optimal rehabilitation or aftercare for patients with COVID-19 and their loved ones, reports the website medicalspecialist.nl.
Osteopathic lung fascia treatment is important after respiratory infections. However, information about how osteopathy works as a prevention for immunological or respiratory conditions is not yet known. Pulmonary physiotherapists recommend performing clinimetry (measuring clinical signs) after patients are discharged from intensive care.
In the context of the Coronavirus (COVID-19) outbreak, the REACH (Rehabilitation after Critical Illness and Hospital discharge) network has (accelerated) their ‘Post intensive care Toolkit’ available, which can support physiotherapists and other paramedics in the treatment of patients after discharge from the hospital.
In the rehabilitation phase, osteopathy can play a role in the mobility of the thorax and the mobility of the neck organs (see other articles in this newsletter).
The REACH Toolkit does not originally contain any information about the treatment of patients with pulmonary problems. It is expected that patients recovering from the COVID-19 virus will experience more pulmonary complaints than other IC patients. The REACH Toolkit is a dynamic database and will be updated regularly when new material is released. It is recommended to work closely with lung physiotherapists. They recommend rehabilitation 2-5 times a week.
Osteopathy may play a role in the increase in the mobility of the thorax and intra-thoracic fascia. Mobilizing the fascia will have to be done together with the rehabilitation process of the lung physiotherapist. Preventive, osteopathy can play a role in keeping the fascia of the neck and thorax mobile. In addition, it has been shown by Meltzer and Standley (2007) that fascial techniques influence the reduction of the cytokines.
Since patients with secondary morbidity and low-threshold inflammation are prone to developing symptoms, it is advisable to ensure optimal mobility of the fascia preventively. In addition, giving lifestyle advice (sleep, nutrition, relaxation, breathing) is recommended to influence the immunological parameters.
(Sander Kales)
Alphens.nl, (2020) https://w.alphens.nl/nieuws/coronavirus-wat-is-het.html. Geraadpleegd op 4 april 2020
Borsboom, D. geraadpleegd 16 april 2020, https://strategiesversuscorona.com/en/resources/
Donatini, B. (2020). Covid-19 and osteopathy
Fysiotherapie in de eerstelijn na COVID-19, F&W Expert Opinion (2020). 4: Mw. L.C. Holzapfel MSc, Mw. drs. M. Lammers, Mw. drs. S. Werner, Drs. D.M. Keesenberg
Medischspecialist.nl https://www.demedischspecialist.nl/sites/default/files/Standpunt%20Nazorg%20COVID19.pdf
Revalidatie project REACH, https://revalidatiegeneeskunde.nl/sites/default/files/attachments/Beleid/COVID-19/behandelprogramma_covid-19_post-ic_versie_1.0_de_hoogstraat_30_maart_2020.pdf
Reach toolkit, https://www.npi.nl/pdf/reachREACH_FT_behandeling_verantwoording.pdf
RIVM.nl, geraadpleegd 16 april 2020, https://www.rivm.nl/en/novel-coronavirus-covid-19/novel-coronavirus-covid-19/questions-and-answers#informationvirus
Meltzer K.R., Standley P.R. (2007). “Modeled Repetitive Motion Strain and Indirect Osteopathic Manipulative Techniques in Regulation of Human Fibroblast Proliferation and Interleukin Secretion.” JAOA.
Vaduganathan, M., Vardeny, O., Michel, T., McMurray, J. J., Pfeffer, M. A., & Solomon, S. D. (2020). Renin–angiotensin–aldosterone system inhibitors in patients with Covid-19. New England Journal of Medicine.
Zhu, N., Zhang, D., Wang, W., Li, X., Yang, B., Song, J. & Niu, P. (2020). A novel coronavirus from patients with pneumonia in China, 2019. New England Journal of Medicine.