Effectiveness of visceral fascial therapy targeting visceral dysfunctions outcome: systematic review of randomized controlled trials

Methods

• Articles analyzed: 11
• Search string: “osteopathic manipulation” OR “osteopathic manipulative treatment” OR “osteopathic manipulative treatments” OR “visceral manipulation” OR “visceral manual therapy” OR “visceral osteopathy” OR “osteopathic visceral manipulation AND “randomized clinical trials” OR “RCT”
• Criteria of inclusion: age > 16 years, any pathology or condition related to the visceral system, any duration, any outcome related to the visceral system with description of functional measures, texts or rating scales; randomized controlled trials; each technique included in Fascial Therapy directed to the viscera

• Criteria of exclusion: non-randomized clinical trial, pilot studies, cross-sectional studies, case series, case reports, animal studies, technical notes, feasibility, tolerance or safety studies, studies with no new scientific data, systematic reviews, uncontrolled studies

Characteristics of the studies

• 10 RCT
• 1 RCT with cross-over design
• evaluation of the quality of the studies through RoB  (risk of bias in randomized trials)
  • most of the studies were considered to be at a high risk of bias

Participants

• Number in the smallest study: 22 people
• Number in the biggest study:  94 people
• Total: 490 people, 261 in the Fascial Therapy Group and 229 in the Control Group (age: 18 to 80)

Interventions and evaluations

• Evaluation of each outcome related to the visceral system
• Fascial therapy directed to the viscera: variable according to the study

Results

• Primary outcomes:
  • Gastrointestinal dysfunctions: Fascial Therapy has significantly reduced problems such as diarrhea, abdominal distension, abdominal pain in irritable bowel syndrome (but without showing changes in the assessment of constipation by Visual Analog Scale, VAS). As for gastroesophageal reflux, Fascial Therapy has produced a reduction in symptoms and pain and improved cervical mobility already a week after the treatment.

However, in other studies, involving patients with irritable bowel syndrome and Crohn’s disease, or women with breast surgery and stroke survivors, fascial therapy did not appear to have produced any changes in the control of bowel symptoms and their severity, in the sense of fatigue, depression or anxiety, or other outcomes (although the severity of bowel and fatigue symptoms improved as well as quality of life and gait in stroke survivors)

• • Cardiorespiratory dysfunctions: two studies (one on healthy people and one on patients with heart failure) found no changes in spirometric or Doppler parameters
  • Musculoskeletal dysfunctions: while one study in low back pain showed a reduction in pain compared to the placebo group, another study showed no difference in the perception of pain, quality of life, and function
  • Urogenital dysfunctions: while one study showed that fascial therapy, in combination with a low-calorie diet, induced statistically significant improvements in the severity of menstrual problems in women with polycystic ovary syndrome, another study found no difference in symptoms in women with urinary incontinence
• Adverse effects: Fascial Therapy was well tolerated. Only one study reported slight feelings of fatigue after the treatment.

Discussion

Only 3 out of the 11 studies analyzed showed a low risk of bias and, among these, only 2 showed positive results in favor of Fascial Therapy. Specifically, long-term reduction of pain in people with low back pain and short-term improvement of gastroesophageal reflux symptoms.

Most of the studies had a low sample size (number of people recruited) and therefore were “unable” to find therapeutic effects, thus creating false negatives (ie, a study does not show any effect when such effect actually occurs).

The techniques used, the control groups, the population included, the number of therapy sessions, follow-up and many other parameters are extremely heterogeneous, which prevents the realization of a meta-analysis.

More standardized studies are therefore needed – with special regard to the timing of the treatment sessions – in order to obtain more adequate and reliable results in the short, medium and long term.

This knowledge would primarily serve the therapists themselves, who will be able to inform their patients properly about the duration of the therapy. Furthermore, this would help to better understand whether Fascial Therapy directed at the viscera is a useful long-term therapy.

This systematic review also shows the need to better define how to implement a good and standardized protocol for sham treatments used as control for manual interventions. Whereas each study actually followed its own guidelines, with the risk of defining as sham a number of treatments that cannot actually be defined as such. In turn, this can negatively affect the subject recruited for the study. In fact, it is necessary to focus on various aspects such as: type of touch, pressure, movement, patient position, contact area, contact time and characteristics of the therapist.

In view of the fact that the 2 studies with the most positive effects followed a localized approach, that is directed to the problem, further studies should also understand whether a specific localized approach to the pathological condition or a global approach to the whole person would be more effective.

Finally, it is important to remind researchers that it is essential to describe every aspect of the study protocol used in the best possible way for the study to be replicable and easily understandable.
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