Francesca Galiano
20/09/2022 - Last update 28/12/2022

Francesca Baroni, Damiana Mancini, Silvia Chiara Tuscano, Simone Scarlata, Christian Lunghi, Francesco Cerritelli, Jason Haxton | Year 2021

Osteopathic manipulative treatment and the Spanish flu, a historical literature review


Influenza (Flu)

Type of study:

Historical literature review

Date of publication of the study’:



Purpose of the study

  • Objective: to analyze OMT techniques used to manage Spanish flu on the basis of: principles and procedures followed, frequency and duration of treatment, adverse effects and advice given to patients
  • Measured outcomes:
    • Primary: evidence linked to principles and procedures followed, frequency and duration of OMT, adverse effects and advice given to patients


  • Articles analyzed: 16
  • Search string:
    • use of the following terms MeSH: manipulation, osteopathic; influenza pandemic, 1918-1919; epidemics
    • use of the following terms free: Spanish influenza, flu, epidemic, grippe, pneumonia, or osteopathic management/treatment
  • Criteria of inclusion: studies with description of the OMT intervention and of the advice given to patients; studies published between 1900 and 1940; beside the classic scientific database, the research was carried out at the Museum of Osteopathic Medicine International Center for Osteopathic History of Kirksville, Missouri.
  • Criteria of exclusion: missing description of the manipulative treatment.

Characteristics of the studies

16 articles found in books, magazines and other sources collected from the Museum of Osteopathic Medicine International Center for Osteopathic History

Interventions and evaluations

  • OMT:
    • Techniques focusing on musculoskeletal regions, from the cranium to the spine and down to lower extremities: articulatory, soft tissues, relaxation and deep inhibition techniques
    • Techniques focusing on the organic function, in particular on the cardiovascular, respiratory, neurologic, intestinal and immune systems immunitario


Primary outcomes:

  • Principles and procedures of the OMT: treating the patients and not the disease, in order to maximize health potential, trying in this way to prevent the spread of the infection. OMT was used to release muscle blocks, repair bone lesions, support the respiratory system and promote blood and lymphatic circulation, as well as help autonomic nervous system, endocrine production and metabolism, on the basis of the evaluation of the dysfunctions and of the clinical reasoning on their supposed causes (rather than symptoms). Particular attention was invested in treating pregnant women, newborns and children. Different sources have reported a very low mortality rate (eg, 0.25%), lower than the average of those who received OMT.
  • Frequency and duration of OMT: personalized on the basis of the severity of the patient’s condition and of their response to the treatment. The sessions ranged from daily to up to 4 a day in the most severe cases. Moreover, they were mainly quite short (15 minutes maximum) as it looked like, in this way, the OMT was more tolerable and could be applied more often.
  • Adverse effects: 3 articles reported an increase in fever after OMT and a possible exacerbation of the symptoms, followed by the indication to wait at least 24-48 hours before applying a new treatment. It was hypothesized that the increase in fever was due to the stimulation of the lymphatic circulation and therefore of the immune activity.
  • Advice given to patients: during the period of fever, most of the advice concerns a liquid diet, hot drinks, frequent hydration (eg, 1 glass of water every hour) and vegetable or meat broth. Once the fever had resolved, the consumption of more substantial foods was advised, both vegetable and meat-based, in order to sustain the body with proteins and carbohydrates. As for the environment, patients were advised to stay in a warm but ventilated room, possibly using different types of essential oils. In addition, it was recommended to rest on one side as lying on the back would favor the worsening of the respiratory function and the aggravation of pneumonia.


Analysis of the literature related to the use of OMT during Spanish influenza showed that OMT was used to support the overall health of patients, in combination with advice that could, in turn, avoid tiring patients and support their bodies.
Although the reports of the time are weak from the point of view of modern scientific methodology, they fully show the clinical reasoning that osteopaths applied in an emergency situation, thus helping contemporary osteopaths in their daily practice.

The data concerning the lower mortality induced by OMT, unfortunately, was not obtained through strict standards and, therefore, may have been influenced by different methods of evaluating and reporting morbidity and mortality. Moreover, precisely because of the non-rigorous methodology, it is really difficult to establish a causal link between the use of OMT and mortality. For this reason, the collected data must be used primarily to stimulate the clinical reasoning and induce the production of new clinical research on the subject, instead of “validating a priori” the usefulness of OMT in a situation of pandemic. The same can be said in relation to the hypothesis that certain techniques, like lymphatic pump techniques, could have stimulated the immune activity directly: the data available are few, and they are more often coming from laboratory studies or studies on animal models than from studies conducted on human beings.

With regard to the dietary and environmental advice given to the patients, the modern research tends to confirm their utility, as during a strong immune response a good protein support is necessary, as well as several studies show the antiviral and antimicrobial properties of different essential oils.

The review of Osteopedia

By Marco Chiera

Strengths: inclusion in the research of paper studies besides the classic digital database; evaluation of the osteopathic intervention in its various aspects (techniques, frequency, etc.) and under consideration of the lifestyle; interesting description of specific techniques given by the osteopaths.

Limits: possibly, it would have been interesting to give more examples of the clinical reasoning that the osteopaths followed during the Spanish flu pandemic.

Are you an osteopath?

Register and enjoy the membership benefits. Create your public profile and publish your studies. It's free!

Register now

School or training institution?

Register and enjoy the membership benefits. Create your public profile and publish your studies. It's free!

Register now

Do you want to become an osteopath? Are you a student?

Register and enjoy the membership benefits. Create your public profile and publish your studies. It's free!

Register now