Osteopathic manipulative treatment in gynecology and obstetrics, a systematic review

Methods

• Articoles analyzed: 24
• Stringa di ricerca: a combination of the following terms, free and as MeSH: dysmenorr*, female infertility, menopaus*, menstr*, childbirth, pelvic pain, pelvic floor, pregnan*, maternal-fetal, gravid*, labor, birth, stillbirth, climacteric, fertility, #menopaus*, #sterility*, #fert*, child-birth, cranial sacral treat*, craniosacral, osteopath*, man* medic*, spinal manipul*, osteopath* manipul*, osteopath* treat*, gynecol*, obstet*.
• Criteria of inclusion:
  • studies on women after menarche in any gynaecological or obstetric conditions, including pregnancy, delivery, infertility, dysmenorrhea, pelvic pain and menopause; randomized controlled trials (RCT), multicentric RCT, quasi-RCT, controlled before-after, with interrupted time series, control cases, case reports, case series and observational studies; unpublished studies;
  • studies that have evaluated OMT, regardless of its application and combination with other treatments; any type of control, including sham treatment, performed manually or by means of particular tools, other treatments, none; any language.
• Criteria of exclusion: reviews; personal contributions; studies evaluating manual therapy different from OMT.

Characteristics of the studies

• RCT, retrospective, controlled before-after, case reports, case-control, case series and mixed methods studies (both quantitative and qualitative research), of which 14 published in peer-reviewed journals and 10 as thesis of specialization
• 8 studies on pregnancy
• 4 studies on childbirth
• 4 studies on infertility
• 4 studies on menopause
• 3 studies on dysmenorrhoea
• 1 study on pelvic pain
• 12 studies with control group and 12 without
• The studies ranged from low to high risk of bias (according to the Cochrane risk of bias – RoB – evaluation and the GRADE system)
• High heterogeneity (for this reason the systematic review became a narrative review)

Participants

• Studies: on pregnancy: 914 women
• Studies on childbirth: 579 women
• Studies on infertility: 48 women
• Studies on menopause: 69 women
• Studies on dysmenorrhoea: 80 women
• Study on pelvic pain: 86 women
• Number in the smallest study (excluding the description of individual cases): 6 women
• Number in the biggest study: 511 women
• Total: 1840 women
• Average age: from 18 to 60 years

Interventions and evaluations

In the OMT groups:

• Use of direct and indirect techniques as: high-velocity low-amplitude, visceral, soft tissues, fascial, ligamentous tensions balancing, craniosacral, muscular, structural energy, myofascial, joint release, fluid and lymphatic drainage, emotional, global pelvic manipulation
• 20 to 90 minutes sessions
• 7 studies with a precise OMT protocol
• 9 studies with OMT based on patient’s needs
• 2 studies with a half-way approach in relation to the 2 previous ones

In the control group:

• Sham treatment; placebo as a drug or as manual therapy; standard of care; no treatment; ultrasounds
  20 to 45 minutes sessions
• OMT practiced by experienced osteopaths (with more than 10 years of experience), students in osteopathy supervised by tutors, students in osteopathy unsupervised, husbands (in this case the techniques were simple)
• Control interventions carried out by osteopaths, physiotherapists or hospital staff

Results

• Primary outcomes:
  • Pregnancy: OMT reported some improvement in disability, pain and functioning, as well as showing a reduction in the risk of amniotic fluid stained by the meconium of the newborn, in the risk of preterm births and of the use of forceps
  • Childbirth: OMT has favored a reduction in pain and the use of analgesics during childbirth, a lower rate of cesarean sections, perineal lacerations and episiotomy
  • Infertility: it appears that OMT increased the likelihood of conception in women diagnosed with secondary or idiopathic infertility (60% of women treated with OMT became pregnant, but no information on the pregnancies was reported)
  • Menopause: OMT seems to have decreased the frequency and intensity of hot flashes, improved mood and reduced urological problems related to menopause
  • Dysmenorrhoea: OMT favored a reduction of pain, with a potential decrease in the use of analgesics and in serotonin concentration (able to promote inflammation)
  • Pelvic pain: two OMT treatments improved pain, measured by VAS.
• Secondary outcomes:
  • Many studies have reported neither the number nor the description of adverse effects. The studies evaluating this outcome showed that OMT is generally well tolerated and safe.

Discussion

OMT seems able to improve the patients’ clinical status and also the outcomes related to childbirth and, therefore, potentially to the newborns’ health (for example, the reduction of preterm deliveries, namely the risk of prematurity, means healthier newborns, less at risk of complications and of neurodevelopmental problems).
Unfortunately, the high heterogeneity of the studies and the small sample size in most studies prevents strong conclusions from being drawn, with the exception of pregnancy-related low back pain, on which OMT shows important positive results.

In particular, the heterogeneity of study designs (including the use of different outcomes), the lack of data on adverse effects, the lack of cost-benefit analyses, the lack of studies on relevant gynecological and obstetric conditions (eg, endometriosis, polycystic ovary syndrome) make it difficult to understand the actual role of OMT in this field.
As a result, rigorous new studies are needed as soon as possible.