Treatment of refractory irritable bowel syndrome with visceral osteopathy, short-term and long-term results of a randomized trial

Participants

• Number: 31 people (23 female and 8 male, mean age 50 years).
• Criteria of inclusion: voluntary participation of specialist centers’ patients, diagnosed with IBS (according to Rome III criteria) and considered refractory, that is, who had not shown any improvement despite the use of many therapies, or who were particularly dissatisfied with their current situation; exclusion of organic diseases.
• Groups of study: two groups obtained by randomization
  • Group 1: sham treatment followed by visceral OMT, 16 people
  • Group 2: visceral OMT followed by sham treatment, 15 people
  • All of them had had symptoms that lasted for more than 3 months per year for at least 2 years
  • Only one person had previously received an osteopathic treatment

Interventions and evaluations

• Symptoms assessment at the beginning of the study using a questionnaire on functional gastrointestinal disorders as defined by the Rome III criteria
• People were examined at the beginning of the study, after the first 3 sessions and at the end of the study to assess the total or segmental colonic transit time, rectal sensitivity (anorectal manometry) and pain intensity according to the VAS scale in 9 abdominal segments
• During the 12 weeks of the study and for 1 year after the last session, people had to keep a daily diary where to note, according to a VAS scale of 10cm, the intensity or severity of constipation, diarrhea, abdominal distension and abdominal pain visceral OMT sessions and 3 sham treatment sessions, all 45 minutes long and 2 weeks apart
  • Group 1 received first the 3 sham treatment sessions and at a later time the 3 visceral OMT sessions
  • Group 2 received first the 3 visceral OMT sessions and at a later time the 3 sham treatment sessions
• Visceral OMT: initial global techniques on the abdomen, local techniques based on the people sensitivity to pain, sacral techniques
• Sham: techniques with movements similar to visceral OMT, but without mobilization of internal organs (in practice, a superficial massage)
• All treatments have been performed by only one expert osteopath

Results

Primary outcomes: while group 1 showed statistically significant improvements in abdominal distension and pain with sham treatment, and in abdominal distension, abdominal pain and diarrhea after visceral OMT, group 2 showed statistically significant improvements in constipation, diarrhea, abdominal distension and abdominal pain only after visceral OMT (in practice, sham treatment following OMT did not lead to further improvement).

After the last session, the symptoms of constipation, diarrhea, distension, and abdominal pain decreased in a statistically significant manner, with a decrease in pain in 7 out of 9 abdominal segments.
After 1 year from the last session, the symptoms of diarrhea, distension and abdominal pain were still significantly lower than at the beginning of the study, while the symptoms of constipation, although also lower than at the beginning, have not reached statistical significance.

No differences were highlighted in depressive symptoms before and after the study.
Visceral OMT reduced rectal sensitivity in a statistically significant manner, unlike sham treatment, while none of the treatments significantly reduced colonic transit time.
Non sono stati riportati effetti avversi dovuti ai trattamenti.

Discussion

Compared to sham treatment, visceral OMT proved to reduce symptoms connected to diarrhea, abdominal distension and abdominal pain, although it did not have the same impact on depressive symptoms that often characterize IBS sufferers.
After 1 year from the last session, only the abdominal pain remained at the same level reached after the end of treatments: the symptoms of abdominal distension, diarrhea and especially constipation showed a tendency to increase, although they remained lesser than before the treatments.

Of particular importance is the reduction of rectal sensitivity thanks to OMT as IBS seems to be characterized by a high visceral hypersensitivity, so much so that rectal sensitivity is considered a means of discriminating between IBS and other gastrointestinal diseases. OMT could act on rectal sensitivity thanks to the direct stimulation of the afferent and autonomic nerve fibers, although the matter requires more in-depth studies.

On the other hand, it seems that colonic transit time is not a useful parameter to assess the severity of IBS, nor does it seem to differ from normality, except in particularly severe cases.

From a brief analysis, it looks like patients could not discriminate between OMT and sham treatment, although some patients noticed some differences: indeed, some patients reported preferring sham as less painful than OMT.