Intestinal complaints are in the top 5 list of reasons why people visit an osteopath, according to the Osteosurvey 2014. Every reason to devote a newsletter to that theme. Donatini (2018) already stated that intestinal complaints for an osteopath is still an almost unexplored area. We will have to combine our techniques from the mechanical, respiratory-circulatory, metabolic, neurological and biopsychosocial explanatory model. This newsletter helps to support an evidence informed practice.
Table of contents:
Hopeful future for Irritable Bowel Syndrome
Worldwide, almost 20% of the population suffers from symptoms of Irritable Bowel Syndrome (IBS). If a medical examination does not reveal an allergy, these symptoms are often not taken seriously.
In a food allergy, the body gives off a general immune response. In the case of a food intolerance, there is only a local immune reaction in the intestinal wall. In osteopathic practice we mainly see people with intolerances, especially for gluten and lactose. What biological mechanisms underlie this?
Researchers at the Catholic University of Leuven discovered that the mast cells that release histamine after contact with certain foods cause the abdominal pain. In addition, they saw in mouse research that an intolerance could start with a general intestinal infection. This hypothesis, in which the presence of a certain food during such a general intestinal infection may develop into a food intolerance, could be a step forward in research into the development of IBS.
Scientists in Great Britain examined data from gut organoids in great detail. They examined genes that are important master regulators in the gut and that are associated with symptoms of IBS. In doing so, they saw that Paneth cells release the antimicrobial peptides to protect the gut against pathogens. The goblet cells release mucus to create a protective barrier. Organoids can also be adapted to study the relative importance of different cell types within the system and to investigate interactions between different genes in healthy or diseased cells. By examining organoids generated by patients with IBS, the effects of drugs or probiotics on these cell types can be analyzed.
More research in mice and subsequently also in humans is needed in order to be able to develop a targeted therapy in the future. (LvdB)
Title: Local immune response to food antigens drives meal-induced abdominal pain.
Authors: J. Aguilera-Lizarraga et. already.
Published in: Nature 590, 2021; 151–156. doi.org/10.1038/s41586-020-03118-2
Title: Regulatory network analysis of Paneth cell and globet cell enriched gut organoids using transcriptomics approaches.
Authors: A. Treveil et. already.
Published in: Molecular Omics, 2020 Feb 17; 16(1):39-58. doi: 10.1039/c9mo00130a
There are adhesions in your abdomen and we can treat them?
What exactly are adhesions in the abdomen, how do they arise? And which abdominal complaints can we treat well as an osteopath? Research has been done on irritable bowel syndrome (IBS), constipation and infantile colic. With varying results.
As an osteopath we are always looking for restrictions or ‘adhesions’. But what exactly is such an adhesion and how does it arise in our abdomen?
It was already suspected that special immune cells called macrophages play a decisive role in the development of adhesions. Macrophages are found in what is called peritoneal fluid, a lubricant between the peritoneum, and a similar lining around the organs in the abdominal cavity. Macrophages swim passively in this fluid, just like plankton in the sea. Their tasks include eliminating pathogens, as well as closing injuries in the abdominal cavity as quickly as possible. When injured in the abdominal cavity, the macrophages spring into action within minutes to form clot-like structures. This will heal the injury.
This works fine for minor injuries, but something else happens with major injuries. The macrophages lose control, the clots do not stop growing and form long strands. Researchers at the University of Bern were able to show that these strands are the cause of the adhesions.
But what is the effect of osteopathy on abdominal complaints such as IBS, constipation and infantile colic? The effects of abdominal massage on changes in intestinal motility, visceral hypersensitivity and its possible mechanism were investigated by Li et al. It emerged that continuous abdominal massage can improve intestinal transit and visceral hypersensitivity of IBS and increase the number of mast cells or mastocytes (specialized cells that located in tissues in contact with the outside world), which can alleviate the severity of symptoms. These results suggest that continuous abdominal massage is the appropriate adjunctive therapy for the treatment of IBS.
Erdrich et al analyzed multiple studies on the effectiveness of manual therapy for the treatment of constipation. This shows that manual therapy can have an effect on the symptoms of constipation, but the evidence for this is very limited.
In addition to the disorders that often occur in adults, abdominal complaints in babies have also been examined. Infant colic is a condition that affects up to 25% of infants and is characterized by excessive crying. Two studies have looked at what we can achieve with manual actions. However, both studies showed no significant difference in symptom reduction or crying, since crying decreased in both groups. (NB)
Titel: Does a manual therapy approach improve the symptoms of functional constipation? A systematic review of the literature.
Auteur: Erdrich, L. M., Reid, D., & Mason, J.
Verschenen in: International Journal of Osteopathic Medicine (2020).
Titel: Identifying potential treatment effect modifiers of the effectiveness of chiropractic care to infants with colic through prespecified secondary analyses of a randomised controlled trial.
Auteur: Vilstrup Holm L. et al.
Verschenen in: Chiropractic & Manual Therapies volume 29, Article number: 16 (2021)
Titel: The effect of chiropractic care on infantile colic: results from a single-blind randomised controlled trial.
Auteur: Vilstrup Holm L. et al.
Verschenen in: Chiropractic & Manual Therapies volume 29, Article number: 15 (2021)
Titel: Abdominal Massage Reduces Visceral Hypersensitivity via Regulating GDNF and PI3K/AKT Signal Pathway in a Rat Model of Irritable Bowel Syndrome.
Auteur: Li, B. et al.
Verschenen in: Evidence-Based Complementary and Alternative Medicine, vol. 2020, Article ID 3912931, 10 pages, 2020.
Titel: Controlling adhesions in the abdomen.
Auteur: University of Bern.
Verschenen in: ScienceDaily, 5 March 2021.
Atlanto-occipital decompression has an effect
Activation of the cholinergic anti-inflammatory system by osteopathic manipulative treatment (OMT) or by direct vagus stimulation may require lower doses of anti-inflammatory drugs.
This would reduce healthcare costs and prevent possible side effects of such medications. The inflammatory reflex is an endogenous mechanism that responds to acute and chronic pro-inflammatory stimuli such as local tissue injury, pathogenic factors, and rheumatoid or autoimmune diseases. This reflex is activated by local inflammatory mediators. Think of cytokines or pathogenic products. These are detected by afferent vagal nerve fibers and project onto the central nervous system. They activate the efferent reflex arc which uses efferent vagal nerve fibers to inhibit cytokine production.
The researchers randomized healthy adult subjects into three groups: atlanto-occipital decompression (AOD), auricular vagal electrostimulation (VNS), and no intervention. Saliva was collected before and after the interventions to determine the concentrations of cytokines. Arterial blood pressure and electrocardiogram were measured before, during and after the intervention to record heart rate and blood pressure variability (indices of vagal and sympathetic function). Both OAD and VNS showed an anti-inflammatory effect, which was associated with an increase in heart rate variability. These findings suggest that OAD and VNS stimulate the parasympathetic anti-inflammatory reflex. (JtB)
Original title: Activation of the cholinergic anti-inflammatory reflex by occipitoatlantal decompression and transcutaneous auricular vagus nerve stimulation.
Authors: Kania, A.M., Weiler, K.N., Kurian, A.P., Opena, M.L., Orellana, J.N., Stauss, H.M.
Published in: Journal of Osteopathic Medicine 2021; 121(4): 401–415
Respiratory Circulatory Model
Abdominal breathing, an extra dose of oxygen through our intestines?
Tabeke states that mammals can absorb oxygen-rich gas and liquid through the gastrointestinal tract. Is gas exchange an important factor in intestinal problems?
A number of marine organisms have evolved unique intestinal respiratory mechanisms that allow them to survive in conditions of low oxygen levels. So they do not use their lungs or gills, but the gastrointestinal system. Takebe’s research shows that there are also intestinal respiratory mechanisms in rats, mice and pigs.
In case of respiratory problems, the animals appeared to benefit from the supply of oxygen-rich fluids via the rectum. After administration, the animals had longer endurance during physical activity and higher oxygen levels in their hearts. Oxygen also enters the circulation via the gastrointestinal fluids and symptoms of respiratory insufficiency decrease. In the recent SARS-COV-2 pandemic, this may provide an additional opportunity to support patients with respiratory insufficiency.
The above research points to clinical situations in which the oxygen content is so low that the organism seizes the extra opportunity to absorb oxygen via the intestines. The question is under what conditions are mammals, including humans, claiming this additional way of oxygen uptake in our gastrointestinal tract.
In embryological development we see that the airways arise from the primitive gut. After birth, a transition must take place from absorption of oxygen via the blood from the umbilical cord to gas in the lungs. Bloating in babies may therefore also be related to the gas absorption function of the gastrointestinal tract. The colon must develop to absorb gas. It could be that, for example, patients with irritable bowel syndrome do not process these gases properly and that this creates tension in the abdomen. (ML)
Title: Mammalian enteral ventilation ameliorates respiratory failure.
Authors: Ryo Okabe, Toyofumi F. Chen-Yoshikawa, Yosuke Yoneyama, Yuhei Yokoyama, Satona Tanaka, Akihiko Yoshizawa, Wendy L. Thompson, Gokul Kannan, Eiji Kobayashi, Hiroshi Date, Takanori Takebe.
Published in: Med, 2021; DOI: 10.116/j.medj.2021.04.004
It's just a belly
Every belly is different. I keep running into this in practice. What am I really feeling under my fingers in that belly? How can I be sure that what I feel is really what I think I feel? Or is my observation based on assumptions?
I also found my experience in the scientific literature on anatomical studies of the abdomen. For example, Zytowski et al describes in his article ‘Anatomical normality and variability: Historical perspective and methodological considerations’ that an organism is never the same. Over the years, anatomical knowledge has become almost standardized. This gives textbooks an ideal image of beauty and perfect internal harmony. But this doesn’t do justice to reality.
Setting a standard is helpful. As a result, we learn to recognize what is abnormal or pathological. However, not every change turns out to be anomalous and/or pathological, sometimes they just belong to the normal variations known in reality.
The English word for intestines, abdomen, comes from the Latin word abdere or ‘to hide’. According to regular care, many organs cannot be palpated. They are literally hidden, unless something is wrong with them. Meanwhile osteopathy claims to be able to palpate every organ. I have been told for years that you learn to feel the organs with a lot of palpating. During my studies I learned dozens of palpation techniques. But do I really feel them or have I taught my brain to feel them?
In short, I’ll never know for sure that I’m feeling what I think I feel or might even “secretly” want to feel. How can I trust that these techniques are always effective, if they are based on a standard body; of normality, regularity and perfection?
What do you mean, brush your bowels?
Research shows that our mouth and gut influence each other. This creates new possibilities for the diagnosis, research and treatment of patients with inflammatory bowel disease (IDD).
It is becoming increasingly clear that the oral microbiome plays an important role in the regulation of our health and that it could possibly be used as a mechanism for the diagnosis and/or prognosis of inflammatory bowel disease (IDD). There is also written about an ‘oral-gut axis’ and even a ‘gum-gut axis’ (Byrd & Gulati, 2021). More than 50 systemic disorders have now been linked to gingivitis, periodontitis and IDZ and there is talk of a bi-directional relationship between the mouth and intestines. However, the underlying mechanisms are not yet clear.
Byrd and Gulati suspected that there is positive feedback between the mouth and the gut. Prolonged disruption of the oral immune system leads to the development of a gum-gut axis, resulting in dysbiosis of the gum microbiome.
Kitamoto et al discovered that IBS involved an overgrowth of bacteria in the gut normally found in the mouth. What is happening? If there is an imbalance of the oral microbiome, more pathobionts are formed in the mouth. These can enter the intestines directly through the saliva and thus influence the immune system of the intestine. In addition, the immune system will produce more T cells in the mouth and these can end up in the intestines via the lymphatic system. A healthy intestinal system can withstand this well. In IBS, however, this leads to exacerbation of the inflammatory responses.
In short, good oral health, hygiene and microbiome is extremely important. To reduce positive feedback, treatment should actually focus on restoring the oral and intestinal system. So know that if you take good care of your gums and teeth, you also help your gut.
According to Bonaz et al, a low vagal tone is frequent in IBS. They describe that the vagus nerve may have a cholinergic anti-inflammatory role. Improving vagal tone could lead to reduced intestinal permeability and inhibition of peripheral inflammation. Stress often plays a major role in the development and persistence of low vagal tone. Restoring the autonomous balance therefore has the highest priority.
Arienti et al reports that the CV4 technique and rib-raising lead to a more parasympathetic state. Although this is a small research group, these results are promising for osteopathy. Cerritelli et al describe a similar ‘hyperparasympathetic effect’. The autonomic nervous system, central autonomic network and our interoception mediate these processes.
Incidentally, the osteopathic local treatment of affected tissues of our general digestive system could lead to changes in cytokine levels and lead to less pain. Reducing the pro-inflammatory state of the tissue could lead to reduced neurogenic neuroinflammation and thus help break the cycle of positive feedback. (JV)
Título original: Variations of HRV and skin conductance reveal the influence of CV4 and Rib Raising techniques on autonomic balance: A randomized controlled clinical trial.
Authors: Arienti, C., Farinola, F., Ratti, S., Daccò, S., & Fasulo, L.
Appeared in: Journal of Bodywork and Movement Therapies (2020), 24(4), 395–401.
Título original: The Vagus Nerve at the Interface of the Microbiota-Gut-Brain Axis.
Authors: Bonaz, B., Bazin, T., & Pellissier, S.
Appeared in: Frontiers in Neuroscience (2018), 12.49.
Título original: The Intermucosal Connection between the mouth and gut in commensal. pathobiont-driven colitis.
Authors: Kitamoto, S., Nagao-Kitamoto, H., Jiao, Y., Gillilland, MG, Hayashi, A., Imai, J., Sugihara, K., Miyoshi, M., Brazil, JC, Kuffa, P ., Hill, BD, Rizvi, SM, Wen, F., Bishu, S., Inohara, N., Eaton, KA, Nusrat, A., Lei, YL, Giannobile, WV, & Kamada, N.
Appeared in: Cell (2020), 182(2), 447–462.e14
Título original: The “Gum-Gut” Axis in Inflammatory Bowel Disease: A Hypothesis-Driven. Review of Associations and Advances.
Authors: Byrd, K. M., & Gulati, A. S.
Appeared in: Frontiers in Immunology (2021), 12:620124
Título original: Osteopathy modulates brain–heart interaction in chronic pain patients: an ASL study.
Authors: Cerritelli, F., Chiacchiaretta, P., Gambi, F., Saggini, R., Perrucci, M. G., & Ferretti, A.
Appeared in: Scientific Reports (2021), 11(1).
Título original: Dysbiosis of Salivary Microbiota in Inflammatory Bowel Disease and Its Association With Oral Immunological Biomarkers.
Authors: Said, HS, Suda, W., Nakagome, S., Chinen, H., Oshima, K., Kim, S., Kimura, R., Iraha, A., Ishida, H., Fujita, J. , Mano, S., Morita, H., Dohi, T., Oota, H., & Hattori, M.
Appeared in: DNA Research (2013), 21(1), 15–25