effect of osteopathic medical management on neurologic ... · effect of osteopathic medica l...

Effect of Osteopathic MedicalManagement on NeurologicDevelopment in ChildrenViola M. Frymann, DO, FAAO, Richard E. Carney, PhD, Peter Springall, PhD

For 3 years, children between 18 months and 12 yearsof age with and without recognized neurologic deficitswere studied at the Osteopathic Center for Children.Their response to 6 to 12 Osteopathic manipulative treat-ments directed to all areas of impaired inherent physi-ologic motion was estimated from changes in three sen-sory and three motor areas of performance. Houle'sProfile of Development was used to compare neuro-logic with chronological age and rate of development,

and scores were age-adjusted. Results in children aftertreatment were compared with those following a wait-ing period without treatment.

Neurologic performance significantly improved af-ter treatment in children with diagnosed neurologicproblems and to a lesser degree in children with medi-

cal or structural diagnoses. The advances in neuro-logic development continued over a several months'interval. The results support the use of Osteopathic ma-nipulative treatment as part of pediatric health carebased on Osteopathic medical philosophy and principles.

Osteopathy "is a science that deals with the naturalforces of the body."1 Osteopathic medical philosophyand principles have been used to guide pediatric healthcare at the Osteopathic Center for Children (OCC) of

the College of Osteopathic Medicine of the Pacific(COMP) for more than 10 years. Such care has as-sisted children with a diversity of medical problems,and has enhanced their general well-being. The presentcontrolled research study addresses one aspect of suchcare, the use of Osteopathic manipulative treatment torestore the body's inherent physiologic mobility as ameans of affecting neurologic development.

An increasing number of diagnostic labels are usedto describe a diversity of long-standing problems ofchildren, from attention deficit disorder2 to speech in-adequacies. There are few clear boundaries betweenthem. Any one label may include major and minor com-

ponents of other neurologic disorders; for example, achild with a learning disability may have a behaviorproblem, and disorders of perception may contribute

to the learning difficulty.A variety of etiologic factors may contribute to these

labeled diagnoses; also, a specific etiologic influencemay result in a diversity of clinical dysfunctions. Atraumatic delivery, for example, may lead to mentalretardation, perceptual dysfunction, or neuromotor dis-ability, yet these clinical problems may also be relatedto toxic drug influences during pregnancy, genetic de-fects, or encephalitis in infancy and so on (Figure 1).However, the accessible etiologic component that linksthe etiologic factor to the clinical problem is somaticdysfunction. This is defined as dysfunction of relatedparts of the body's framework. Somatic dysfunction is

the consequence of the delivery experience in most in-stances, or trauma early in life in others. It may befound in the cranial or pelvic mechanism, or at any levelin between; it may also be located in the musculoskel-etal, membranous, and fascial mechanisms.

Observations at the OCC have emphasized the im-portance of the somatic system in the process of growthand development. Somatic dysfunction is found concomi-tantly with delayed neurologic development. Osteopathicmedical principles applied in more than 20 years' prac-tice (V.M.F.) of supplying health care to children haveprovided the basis for relating etiology, dysfunction ordisease, and the need for manipulative treatment.

This study was designed to test the clinical view thatintervention directed toward removing or reducing theinfluence of somatic dysfunction on cerebral dysfunc-tion permits neurologic development and performanceto progress to a child's optimum potential.

MethodsThis research project and method for obtaining the

parent's consent and child's assent were approved by

The AAO Millennium Yearbook 255

DamageNonprogress ivebrain pathology

Biochemicalchanges

Genetic defectBiochemicalinsuf f ic iencyIntrauterinemalnutr i t ionDrug inf luencesRh incompat ibi l i tyKernic terusPrematur i tyFalse laborTraumatic laborCord around neckMeningit isEncephal i t isTraumaDrowning

IHYPOXIA

Mental retardat ionMental def ic iencyBehavior problems

motionaljs turb ance

Aut ismDisorders ofperceptionHearing lossl ,n,. -, >centra lBlindness JLearning disabil ityDyslexiaHyperkinesisSpeech disordersCerebral palsySpastici tyAthetosisH e m i p I e g i aF laccidi tyEpilepsyDown syndrome

Figure 1. Etiologic influences and clinical dysfunctions, in relation to the strain pattern amenable to manipulativetreatment. A distinction should be made between visible organic histopathologic change and the more subtleneurochemical pathophysiologic change.

the COMP Institutional Review Board. All childrenaged 18 months to 12 years brought to the OCC be-tween August 1986 and June 1989 were eligible forinclusion in the research. The children at OCC comefrom a wide geographic area and represent diversepsychosocioeconomic backgrounds.

At the initial visit, the primary care-giver, usuallythe mother, was interviewed alone, told of the researchproject, and asked to study and sign the consent docu-ment. A detailed history, including pregnancy, labor,neonatal state, infancy and childhood growth and de-velopment, traumatic events, illnesses, and nutritionalhabits, and a family history were taken. The child wasweighed, measured, and then evaluated without membersof the family present. A standing study of the anatomiclandmarks was performed if the condition of the childpermitted. Active motion and mobility including crawl-ing, creeping, walking, and skipping were observed.

Examination in the supine position included evalua-tion of leg lengths and range of motion, pelvic align-ment, inherent mobility of the sacrum, vertebral struc-tural and functional symmetry, respiratory excursionof the thoracic cage and its inherent fascial motility,and the structure and inherent motion of the cranialmechanism. Extraocular muscle function and conver-

gence were tested, and any anomalous function wasnoted. Dental occlusion, the form of the oral cavity,and temporomandibular joint function were examined.Special testing, such as tympanometry and audiometry,were included if indicated.

An exit conference with both parents, if possible, andwithout the child allowed them to receive a diagnosticimpression as well as an introduction to the osteopathicmedical concept in general and its specific indicationsfor the child. Any additional diagnostic studies indi-cated were requested at this time. Instructions concern-ing the testing schedule and treatment program weregiven but the actual appointment schedule was arrangedby the appointment secretary.

Children were assigned to one of two diagnosticgroups: medical or neurologic. The medical groupincluded children with medical or structural problemsbut no recognized neurologic deficits. The neurologicgroup included children with previously diagnosedneurologic inadequacies in such areas as academic per-formance, behavior, neuromotor function, developmen-tal delay, and/or learning.

Osteopathic manipulative treatments were scheduledby the appointment secretary to begin soon after theinitial interview for the start-first group or after 8 to 12

256 The AAO Millennium Yearbook

Table 1Profile of Development: Sensory Input *

Scale/age range

• Excellent: 36 months• Average: 72 months

Satisfactory: 96months

* Excellent: 22 months• Average: 48 months


• Excellent: 13 months• Average: 24 months• Satisfactory: 45

months

Excellent 8 months• Average: 12 months• Satisfactory: 26

months



• Excellent: 1 month• Average: 2. 5 months

Satisfactory: 4.5months

Birth

Visual

Able to read first-gradematerial; evidences laterality

Able to identify visual symbolswithin experience

Able to discriminate dissimilarand similar pictures

Able to converge eyes; hassimple depth perception

Tracks vertically, perceivesdetail

Tracks horizontally, perceivesoutlines

Pupils~respond to light

Auditory

Further understands languageand abstract concepts;evidences laterality

Begins to understand languageand abstract concepts

Understands 25 words

Consistently able to understand2 words

Aware of meaningful change intonality

Consistently able to react tothreatening sounds

Reflexly responds to suddenloud noise

Tactile

Tactiley identifies heads andtails of coins; evidences

laterality

Tactiley differentiates miniatureobjects

Tactiley differentiates medium-size objects

Able to tactiley discriminate thethird dimension

Perceives and responds tognostic sensation

Reacts normally to painfulstimulus

Exhibits Babinski reflex

* Adapted from "Profile of Development." American Academy for Human Development, Piqua, Ohio, 1989.

weeks' delay for the waiting-list group. This assign-ment to start-first or waiting-list group was based onthe physician's (V.M.F.) appointment schedule. Osteo-pathic palpatory examination and treatment data ob-tained at research treatment visits were coded and en-tered into the computer data base.

Assessments of neurologic development were madeby a co-researcher (P.S.) before the series of osteopathicmanipulative treatments, once for the start-first group andtwice for the waiting-list group. These data were en-tered into the computer data base, but data and analysiswere not available to the physician administering ma-nipulative treatment (V.M.F.) until the child had com-pleted the treatment schedule.

Estimation of neurologic developmentHoule's3 Profile of Development (POD), based on ear-

lier studies by LeWinn,4 was used to estimate the neuro-logic developmental status of the children. The profileincludes three measures of sensory performance (visual,auditory, and tactile competence) (Table 1) and three ofmotor performance (manual competence, mobility, and

spoken language) (Table 2).The POD measures (Tables 1 and 2) identify slow,

average, and exceptional rate of development withineach sensory and motor performance level. The per-formance levels predict development rate and allowself-comparison of a child's development duringgrowth. The age for each highest sensory and motorperformance is averaged to obtain an estimate of neu-rologic developmental age.

We divided the child's averaged neurologic devel-opmental age by the chronological age at the time oftesting. This ratio minimizes the influence of aging onchanges occurring in a series of POD assessments. Theratio would have been artificially reduced when a child'stest data occurred after age 6 years. In the few cases inwhich this occurred, the POD normative score and theratios were adjusted by adding months to the POD agerange (Tables 1 and 2) corresponding to the differencebetween 72 months and the actual chronological age.

An age-adjusted score of 1 represents an average neu-rologic development score for a child of that age. Age-adjusted scores above 1 represent above-average neu-


Table 2Profile of Development: Motor Input*

Scale/age range

Excellent: 36 months• Average: 72 months






Excellent: 8 months• Average: 12 months


• Excellent: 4 months• Average: 8 months• Satisfactory: 13

months

• Excellent: 1 month• Average: 2. 5 months

Satisfactory: 4.5months

Birth

Mobility

Able to do skilled activities;evidences laterality

Walks and runs in nonaberratedcross pattern

Walks with arms held belowwaist

Walks unassisted withoutpattern for 10 steps; arms

elevated

Creeps in nonaberrated crosspattern

Crawls in nonaberrated crosspattern

Randomly moves arms and legs

Language

Uses first-grade vocabularywith good sentence structure

Speaks 5- to 8-word sentenceswith good articulation

Speaks 25 words and usesseveral 2-word couplets

Spontaneously uses 2 words

Makes meaningful, and goal-directed sounds with good

tonality

Consistently has vital cry inresponse to threatening sounds

or events

Birth cry present

Manual

Writes on first-grade level

Performs bimanual tasksefficiently

Capable of cortical oppositionbilaterally and simultaneously

Capable of cortical opposition,either hand

Has volitional prehensile grasp

Able to release object grasped

Reflexly able to grasp object

'Adapted from "Profile of Development" American Academy for Human Development, Piqua, Ohio, 1989.

rologic development, and age-adjusted scores below1, a below-average score.

Osteopathic palpatory diagnosis andmanipulative treatment

The osteopathic palpatory diagnosis and manipula-tive treatments were provided by a single physician(V.M.F.). The objective of the treatment program was

the restoration of unrestricted, symmetric, physiologicinherent mobility in all parts of the body. Manifestclinical change in symptoms was of secondary consid-eration. The individual treatment was tailored to theneeds of the particular child and might be administeredto any part of the body from the head to the feet. Eachtreatment was a completed experience whereby changesoccurring in one area would be compatible with re-sponses elsewhere, and bilateral symmetry of functionwould be established in the area of treatment. The feelof the tissues is the ultimate guide to the procedure per-formed and the point of conclusion.

Techniques used included measures to influencebone and articulations, membranes and fascia, muscleactivity, lymphatic drainage and cerebrospinal fluid

motility, arterial and venous circulation, and visceralfunction, all of which serve to enhance the body's owninherent therapeutic potency. (Detailed records of eachtreatment are on file.)

Six to 12 treatments were usually given at 1-weekintervals. The child was taught to lie on the table with-out restraints unless there were uncontrollable invol-untary motions for which protection was needed lest

the child roll on to the floor. Interesting toys held at-tention, and live classical piano music accompanied alltreatments.

Research designTable 3 shows the research design and number of

participants at each POD testing. All children who hadan initial diagnostic examination and were tested withthe POD at least once are included in this Table. Theinitial testing of the waiting-list group is called the base-line and the second test the pretest because it was fol-lowed by treatment. The start-first group began treat-ment soon after the initial examination, so their firsttesting was called a pretest. Tests immediately follow-ing completion of treatments were called post-tests, and


Table 3Research Design and Number of Participants in Each Testing*

Groups

Research Groups• Waiting-list

BoysGirls

Total

Start-firstTBoysGirls

Total

Comparison groups5

• IncompleteBoysGirls

Total

• Drop-outBoysGirls

Total

Neurologic problems

Baseline

1210

22

126

18

1711

28

Pretest

119

20

2311

34

Post-test

88

16

2111

31-32*

Follow-up

57

12

83

11

Medical problems

Baseline

34

7

1413

27

96

15

Pretest

33

6

1520

35

Post-test

21

3

1418

32

Follow-up

10

~T

613

19

Grand total (first test) 1 86

*Data are for all participants who took the tests.TThe first test for the start-first group was the pretest; for the waiting-list group, the first test was the baseline test.*One child had incomplete data on some subscales.sThe incomplete and dropout comparison groups were not part of the original research design. They consist of children who took only onetest. They either then had treatment and left the program without a second test (incomplete group) or left the program withoutparticipating in treatment (dropout group).

tests made weeks after treatment, follow-up tests.The numbers of participants changed so much from

one testing to another (Table 3) that statistical com-parisons were based on different samples as the studyproceeded. As a partial control for bias, those childrenwho did not complete a second testing on the POD wereplaced in comparison groups as noted in Table 3. Chil-dren in the comparison groups are not classified by theirpotential research group assignment (waiting-list, start-first) since these assignments were not made until afterthe second testing. Control for bias due to failure tocomplete testings after the second test was partiallyaccomplished by using a repeated measures design inwhich participants served as their own controls. Noattempt was made to compare for possible differentialdropping out after the second testing in terms of abso-lute levels of performance, but this possibility can beinferred from the tables.

The initial design did not contemplate classifyingthe children according to diagnostic categories of medi-

cal and neurologic problems. This classification, how-ever, is shown in Table 3, because it later proved to beimportant.

The POD scores for individuals were not availableto the treating physician (V. M. F.) before the initialevaluation and assignment to treatment schedules.Changes in these scores were not known by the physi-cian until after all treatments were completed.

The assignments of participants to the waiting-listand start-first groups and types of presenting problemswere not available to the co-investigator for researchdesign data analysis (R.E.C.) until after treatments werecompleted and the POD data had been entered into thedata base. The co-investigator for POD testing andscoring (P.S.) was also blind to the group and type-of-problem assignments until all testing was completed.Both co-investigators were blind to demographic back-ground and medical history of participants until comple-tion of treatments.

All data entered into the data base were analyzed by


Table 4Age-Adjusted Total Profile of Development (POD) Scores and those for Mobility and Manual Dexterity from

Initial Testing, by Group, Type of Problem, and Sex

Group and scale*

Waiting list(baseline)

MobilityManualTotal

Start-first(pretest)

MobilityManualTotal

Dropout(baseline)

MobilityManualTotal

Incomplete(baseline)

MobilityManualTotal

Neurologic problems

Boys

Mean

0.6730.7350.809

(n =

0.5010.7280.717

(n = .

0.4140.5230.622

(n =

0.5250.6190.633

(n =

SD

0.1780.1720.092

12)

0.3400.2820.308

22t)

0.3680.2970.251

13)

0.3360.2920.312

10)

Girls

Mean

0.7700.7450.808

(n =

0.4880.5350.614

(n =

0.5120.7020.635

(n =

0.6320.6920.771

(n =

SD

0.3510.2720.289

10)

0.2960.2420.213

11)

0.2300.3270.207

8)

0.4950.5000.471

6)

Medical problems

Boys

Mean

0.7380.7140.842

(n =

1.0450.9801.061

(n =

1.0071.2721.216

(n =

0.7880.9440.955

(n =

SD

0.0070.2970.197

3)

0.6460.3780.445

15)

0.5240.3770.371

9)

0.3790.2400.287

13)

Girls

Mean

1.1260.9370.969

(n =

0.8791.0021.071

(n =

0.7100.9270.873

(n

0.9941.0691.048

(n =

SD

0.8380.9910.543

= 3')

0.3650.3090.258

= 20)

0.1930.1260.111

= 3)

0.4800.4720.276

= 11)

Total Group

Mean

0.7630.7580.826

(n =

0.7300.8330.881

(n =

0.6260.8070.810

(n =

0.7560.8590.875

(n =

SD

0.3530.3460.241

= 28)

0.4800.3490.368

= 68)

0.4430.4370.379

= 33)

0.4400.4010.354

= 40)

*Mobility: section of POD score measuring only mobility, Manual: section of POD score measuring only manual dexterity, Total:POD score including mobility, manual dexterity, speech, visual ability, auditory competence, and perceptive tactility.'Small discrepancies between n value here and in Table 3 were produced because some children were not measurable on mobilityand manual scales and only complete data for these scales were analyzed.

using SPSS PC-Plus programs.5 A multivariate analy-sis of variance (MANOVA) was carried out to deter-mine the contributions of different variables and theircombinations (interactions) to the variance and the sta-tistical significance of the contributions. Significancelevels of .06 to .10 were considered worthy of furtherinvestigation, whereas levels of .05 or less were judgedto be fully acceptable evidence for the research hypoth-esis being tested (for rejecting a null hypothesis of nosignificant outcome).

ResultsOnly the most essential results are presented here.

The basic data and complete analysis may be obtainedby writing the senior author (V.M.F.).

The total number of children of appropriate ages andwith medical, structural, or neurologic problems whopresented themselves to OCC between August 1986 andJune 1989 was 209. For a variety of reasons 23 of thesechildren did not return for the initial testing with thePOD. Of the 186 remaining children (105 boys and 81


Mean age-adjustedProfile of Development Score

1.1-

1.0-

0.9-

0.8-

0.7-

0.6- •

Test 1

o Waiting-ljst group/neurologic problems

O Waiting list/medical problems

Time of testingTest 2

Start-first group/neurologic problemsStart-first group/medical problems

Figure 2. Comparison of changes in average total Profile of Develop-ment scores between firstand second testings for children classified by research group, waiting-list (wait) or start-first(start), and by type of problem, neurologic (neuro) or medical (med). Test 1 for the wait subgroupsis baseline and test 2 is pretest with no treatment between testings. Test 1 for the start subgroups ispretest, and test 2, post-test with treatment between the two testings.Reprinted with permission from JAOA 92(6): 729-744, Jun 1992

girls), all met the criterion for entering the study bycompleting at least one POD testing. As can be seen inTable 3, 43 children failed to complete the treatmentschedule (dropout group) and 45 failed to take a post-test after completing treatments (incomplete group). Afollow-up test was completed by only 43 of the origi-nal 186. In the waiting-list group only 13 completedthe follow-up testing.

Analysis of health and background variablesWhen levels of initial POD test scores were analyzed

by MANOVA using health status and background (suchas age, birth weight, duration of breast feeding, devel-opmental milestones, and family history) as dependentvariables and research versus comparison groups, typesof problem (neurologic, medical) and sex as indepen-dent variables, no significant differences were foundfor either the separate independent variables or theirinteractions. The research groups were in fact wellmatched with the comparison groups in terms of healthand background variables.

Initial Profile of Development ScoresTable 4 presents the mean POD scores for mobility

and manual dexterity and total sensory and motor de-velopment from initial testing when the full researchdesign including comparison groups (incomplete anddropout) (Table 3) is used. MANOVA showed no sig-nificant differences for group or sex variables or anyinteraction between variables. Only the effect for typeof problem was significant (typically at the .001 levelon the POD total scale and most subscales). The medi-cal category had consistently higher POD means thanthe neurologic category. The initial average POD totalscore for those classified as having medical problemswas equal to that expected for the normative sample(1.0), whereas the average for those in the neurologiccategory was sharply lower (.60).

The research groups were comparable to compari-son groups at the first testing on POD scales, as theywere on background variables. Profile of Developmentsubscales testing for motor functioning were selectedbecause this was initially assumed to be the area onwhich osteopathic treatment would have the greatesteffect.


TablesMean Profile of Development (POD) Scores from Tests 1 and 2,

by Group, Type of Problem, Scale, and Time of Testing

Test andscale*

Waiting-list group

Neurologic problems

Mean SD

Medical problems

Mean SD

Test 1 Baseline

MobilityManualTotal

Test 2

MobilityManualTotal

0.7240.7370.815

0.2800.2280.197

0.7050.5780.777

0.1560.3030.212

Pretest

0.8010.8260.872

(n =

0.3410.2050.202

20)

0.7160.7880.943

(n =

0.1640.2640.160

:6)

Start-first group

Neurologic problems

Mean SD

Medical problems

Mean SD

Pretest

0.4890.6650.678

0.3290.2900.289

0.9730.9861.071

0.5140.3410.360

Post-test

0.6930.8770.872

(n=31

0.3950.4240.379

-32T)

1.1151.0871.151

(n =

0.5230.3750.356

32)

Total sample

Mean

0.7330.7930.858

0.8720.9370.977

(n =

SD

0.4370.3300.338

0.4640.3710.350

88)

* Mobility, section of POD score measuring only mobility; Manual, section of POD score measuring only manual dexterity; Total. PODscore including mobility, manual dexterity, speech, visual ability, auditory competence, and perceptive tactility.T0ne child had incomplete data on some scales.

Table 6F-Ratios (MANOVA) for Profile of Development (POD) Scores: Test 1 Versus Test 2

Comparison

Group (G)Type of problem (7P)G*7P1Test (T) (1,2)GxTTPxTGxTPxT

Total*

n

1.154.333.55

29.610.300.005.97

*Total: POD score including mobilitysection of POD score measuring onlyt F ratio compares mean differences t<^Probability of the mean difference re<'The number of degrees of freedom, btheFratio.'Two or more symbols with a times si

/t

.29

.04

.06

.00

.59

.96

.02

df§

1/84

Mobility

F

0.543.285.20

12.914.271.150.00

P

.47

.07

.03,00.04.31.97

df

1/85

Manual

F

2.240.964.54

18.860.010.012.74

P

.14

.33

.04

.00

.92

.94

.10

df

1/84

, manual dexterity, speech, visual ability, auditory competence, and perceptive tactility. Mobility.mobility. Manual: section of POD score measuring only manual dexterity.> error;urring by chance only. P z .05 is considered significant; P«.00 means a P value < .005.ased on the number of mean differences (numerator) and scores in the error term (denominator) of

pi between them represent the joint effect of two or more variables (an interaction).

Effects of treatment and motivationTable 5 shows the POD means for the research

sample that completed two POD testings. The sampleon the second testing was reduced slightly in size (Table3). The variables of group, type of problems, and typeof test were compared to study the relative effect ofosteopathic manipulative treatment on neurologic de-velopment versus the combined motivational effects ofbeing examined, interviewed, tested with the POD, and

accepted into the treatment program. Figure 2 showschanges in average total POD scores between the base-line test and pretest (without treatment) for the wait-ing-list group, and between the pretest and post-test(after completion of treatment) for the start-first group.These changes are shown separately for the neurologicand medical categories. Table 5 shows the values onwhich Figure 2 is based.

Table 6 shows the results from a MANOVA for in-


Table?Mean Age-Adjusted Profile of Development (POD) Scores

by Group and Type of Problem for Children Who Completed Tests 1, 2, and 3

Test andscale*

Waking-list group

Neurologic problems

Mean SD

Medical problems

Mean SD

Test 1 Baseline

MobilityManualTotal

0.7120.7390,807

0.3060.2370.215

0.6730.6570.783

0.1870.3930.276

Test 2 Pretest

MobilityManualTotal

0.7940.8250.865

0.3790.1830.281

0.6500.7130.870

0.1760.2390.160

Test 3 Post-testMobilityManualTotal

0.9290.8840.969

(n =

0.3500.1580.236

16)

0.7550.9701.020

(n =

0.1240.2890.223

= 3)

Start-first group

Neurologic problems

Mean SD

Medical problems

Mean SD

Pretest

0.4560.7350.729

0.2260.2260.113

0.8680.9701.001

0.3890.3010.275

Post-test

0.7060.9940.931

0.2720.3750.241

1.0311.0341.086

0.4520.3480.300

Follow-up

0.9461.0211.036

(n =

0.5350.2910.304

11)

1.1431.0831.159

(n =

0.4330.2610.286

19)

Total Group

Mean

0.7140.8230.863

0.8570.9370.966

1.0050.9971.061

(n =

SD

0.3480.2880.250

0.3990.3150.268

0.4280.2490.276

49)

* Mobility: section of POD score measuring only mobility; Manual, section of POD score measuring only manual dexterity; Total. PODscore including mobility, manual dexterity, speech, visual ability, auditory competence, and perceptive tactility.

TablesF-Ratios (MANOVA) for Profile of Development (POD) Scores: Tests 1, 2, and 3

Comparison

Group (G)Type of problem (TP)GxTPlTest (T) (1,2)G*TTPxTGxTPxTTest 1 & 2 only for

medical & neurologiccategories separatelyfor GxT effect

NeurologicMedical

Total*

Ft

1.461.260.99

27.060.740.391.87

3.540.00

n.23.27.33.00.48.73.16

.07

.98

df§

1/45

2/90

1/251/20

Mobility

F

0.740.582.93

12.002.441.240.11

P

.39

.45

.09

.00

.09

.29

.90

df

1/45

2/90

Manual

F

3.810.180.68

15.011.271.362.38

P

.06

.67

.41

.00

.29

.26

.10

df

1/45

2/90

*7bto/: POD score including mobility, manual dexterity, speech, visual ability, auditory competence, and perceptive tactility. Mobility.section of POD score measuring only mobility. Manual: section of POD score measuring only manual dexterity.T F ratio compares mean differences to error.^Probability of the mean difference recurring by chance only. P z .05 is considered significant; P«.00 means a P value < .005.§The number of degrees of freedom, based on the number of mean differences (numerator) and scores in the error term (denominator) ofthe F ratio.'Two or more symbols with a times sign between them represent the joint effect of two or more variables (an interaction).


dependent groups and repeated measures for both thetotal POD score and for the mobility and manual dex-terity subscales. With all children combined into onetotal sample, the change in POD scores on the threescales between the first and second testing (the test ef-fect) was highly significant (P<.001). When the scoresfor both testings are combined for the waiting-list andstart-first groups and averaged, no significant differ-ences are found: The groups are equivalent when allother variables are combined. Some smaller and lessconsistently significant effects were found on sensory

POD scales, but the results are not presented here.However, the mean scores of the type-of-problem

categories (neurologic, medical) within groups differalmost significantly on all three POD scales when scoresfor tests 1 and 2 are combined (the groups x type-of-problem interaction). This was not true on the scoresfrom the initial testing alone. Changes for the waitinglist group took place in the absence of treatments,whereas those for the start-first group are seen shortlyafter completion of treatment. The waiting-list neuro-logic group averages dropped slightly between thebase-line and pretest whereas averages of the start-first neurologic group rose sharply between tests (aseparate analysis of change for this category aloneshowed significant increase in average score betweentests, P<.01). In contrast, the increases between testsin the waiting-list medical group and start-first medi-cal group averages were nearly the same and wereequally significant (P<.01 in both cases).

Table 7 gives the mean POD scores for the groups ofchildren who completed the first three POD testings. Thenumber of children who completed three tests, 49, was amarked reduction from the 88 who completed two tests(see Table 5).

Table 8 shows the results of MANOVA on the total,mobility, and manual dexterity POD scales (see Table7). Only the time of testing (T) showed significant in-creases (all three scales P<.0001).

The pattern of change in average POD performancefor tests 1, 2, and between 2 and 3 is similar to thatshown for the larger sample for tests 1 and 2. The medi-cal problem groups show significant and comparableimprovement regardless of what happens to them (wait-ing, treatment, follow-up). The neurologic groups showgreater improvement after treatment (pretest to post-test) than between the base-line and pretest (waiting-list group) or post-test and follow-up (start-first group)when no treatment is given. This difference, however,shows only marginal significance on the mobility scaleonly (P=.07). The medical group showed virtually no

changes on test scores attributable to their being in thewaiting-list or start-first groups.3

Separate analyses (MANOVA) were done for thechanges between POD tests 1 and 2 for those childrenwho completed test 3. The results were closely compa-rable to those shown in Tables 5 and 6. Whatever thereasons for not continuing on in the research, they hadlittle effect on the pattern of findings shown between tests1 and 2 for the children who continued on to test 3.

Persistence of effects after treatmentTable 9 shows the mean POD scores for the 13 chil-

dren in the waiting-list group who completed all fourpossible testings. Scores for the total group steadilyincreased from the first to third test. This trend washighly significant (P<.001). The sample was too smallto test between patterns for the type-of-problem cat-egories. The performance scale increases for thissample during the follow-up period, as was found forthe start-first group between their post-test and follow-up testings (Table 7). Because the pattern between tests1 and 3 for the waiting-list group was similar whetheror not the group continued to test 4, the final outcomewas unlikely to be due to reduced sample size.

Review of literatureVariations in neurologic performance have been re-

lated to neurophysiologic measures of central nervoussystem functions. Pinkerton and associates6 compared18 "good readers" with 14 "poor readers" in an ordi-nary classroom of 8- and 9-year-old children. Brain-stem auditory evoked potentials in the right ear weresignificantly different from those in the left in the goodreaders, but such asymmetry was not found in childrenwith learning difficulty. Small and coworkers7 demon-strated similar electroen-cephalographic findings inchildren with attention deficit. Beckett,8 Sklar9

Satterfield,10 Murdoch,11 Van Mechelse,12 Rebert,13 andGasser14 and their respective coauthors have identifiedincreased low-frequency electroencephalographicpower in children with various learning problems.

These reports reflect an interaction between someaspect of behavior and the presence of asymmetric oraltered nervous system conduction or transmission ofafferent nerve impulses (or both). To what extent thosedifferences in central nervous system measurementswould be present in asymmetry of somatic function, ordysfunction, and to what extent they might be improvedby osteopathic manipulative treatment that changes theneurologic developmental profile remains to be deter-mined.


Table 9Mean Age-Adjusted Profile of Development (POD) Scores for Tests 1 through 4

for Waiting-List Group

Test and scale*

Test 1 (baseline)MobilityManualTotal

Test 2 (pretest)MobilityManualTotal

Test 3 (post-test)MobilityManualTotal

Test 4 (follow-up)MobilityManualTotal

Neurologic problems

Mean

0.7350.7360.812

0.8130.8350.880

0.9370.9010.980

1.0860.9511.042

(n =

SD

0.3480.2460.244

0.4350.1920.246

0.4020.1660.263

0.5250.2170.291

12)

Medical problems

Mean

0.7650.9611.005

0.7290.916L041

0.8851.1261.247

0.8591.3271.420

(n =

SD

0.0000.0000.000

0.0000.0000.000

0.0000.0000.000

0,0000.0000.000

1)

Total Group

Mean

0.7380.7530.826

0.8070.8420.892

0.9330.9191.000

1.0680.9831.072

(n =

SD

0.3340.2440.240

0.4170.1850.240

0.3850.1700.262

0.5070.2320.297

13)

*Mobility: section of POD score measuring only mobility; Manual: section of POD score measuring only manual dexterity; Total: PODscore including mobility, manual dexterity, speech, visual ability, auditory competence, and perceptive tactility.

The osteopathic medical approach to health and dis-ease is founded on the concept that structure and func-tion are interdependent. The important concept statedby Korr,15 that the musculoskeletal system is "the pri-mary machinery of life," is implicit in this approach.The autonomic nervous system fine tunes this support-

ive apparatus of the body to meet the ever-changingdemands of that primary machinery. The parasympa-thetic division protects the internal environment, that

is, it is trophotropic because of its nutritional function.The sympathetic division, by contrast, is ergotropic,influencing the performance of the whole body in re-sponse to the environment.

The studies on microcirculation of nerves bySjostrand and coworkers16 demonstrate that slighttrauma, that is, moderate nerve compression, mightinduce microvascular injury limited to the superficialnerve layers as indicated by microbleedings and edemaformation in the epineurium. This is a reversible situ-ation if the duration of compression is limited. We be-lieve that impairment of physiologic inherent motilityof any part of the musculoskeletal system will adverselyaffect nerve pathways passing through the region. Thisadverse effect in turn will induce capillary congestion

in the immediate area and in viscera at the nerve's end-ing and reduce venous and lymphatic drainage. Fur-thermore, as Hix17 indicates, the transport of an axo-plasm along an axon to a terminal end organ is essen-tial for complete growth and the maintenance of nor-mal function. He concludes: "The inability of a vis-ceral nerve to exert its early trophic influence on theorgan it innervates may have meaningful consequenceson the ability of the denied organ to metamorphose to

its full anatomic and physiologic maturity." This state-ment of Hix suggests the importance of treating themusculoskeletal problems of children.

Plagiocephaly is a term used here to describemembranous articular strains that distort the cranialmechanism and impair symmetric inherent physi-ologic motility. In a study of 1250 newborn babies,18

such strains were found in nearly 90% of neonates.Children with learning problems exhibit a wide rangeof somatic strain patterns related to trauma.19 Newtechnology, such as computed tomography of thebrain and magnetic resonance imaging, provides ad-ditional evidence of brain injury.

Somatic dysfunction is not confined to the cranialmechanism. It may be found throughout the musculosk-


eletal, membranous, and fascial systems, in the coordina-tion of diaphragmatic function, and in scars. The criticalfinding is impairment, distortion, or obstruction of theinherent motility. Such dysfunction is accessible to ma-nipulative treatment, which will modify the dysfunctionand restore the motility. Osteopathic physicians usingosteopathic palpatory diagnosis and manipulative treat-ment have demonstrated beneficial effects in children with

a wide diversity of academic, behavioral, developmental,neuromuscular, and perceptual problems.

No specific area of somatic dysfunction is presumedto be related to a particular clinical manifestation. Nei-ther does treatment of one specific anatomic region re-solve a child's problem. Treatment must address allareas of impaired inherent physiologic motion with theobjective of restoring free and symmetric inherentmotility.

DiscussionA number of factors influence results in research

studies. We had to consider the possible influences oflearning to take the tests and environmental factors atOCC or at home. The interest and expectations of theresearchers, staff, and parents may create a favorableeffect on a child. The changes in POD scores between

the first and second tests in the waiting-list groups pro-vide an estimate of such influences. We assume thatbecause these are greatest at the beginning of our re-search study, their impact is much less after the child'ssecond test.

Other controls for bias were used here. These in-cluded adjusting the original POD scores for age to re-move possible changes in scoring that were due tomaturation, comparing POD scoring in the various in-dependent variable categories to equate for possiblesampling bias resulting from children leaving the pro-gram initially and during the course resulting from chil-dren leaving the program initially and during the courseof the research, and examining the relationships be-tween medical history, background variables, and PODscoring. The fact that the average initial POD scoreswithin the research groups (waiting-list and start-first)and within the comparison groups (incomplete anddropout) were not significantly different indicates thatthe makeup of the research groups was matched; also,that those who failed to take more than one POD test

did not significantly bias the POD status of the remain-ing sample that continued on to take two or more PODtests. In short, differences between the first and latertest scores were not biased significantly by selectiveelimination of children from the original sample due to

different initial POD scores.A significant change in the medical problem group's

performance as estimated by the POD was observedboth before treatment was initiated and after the periodof osteopathic manipulative treatment. It is our obser-vation that there are many children who perform atgrade level, conduct themselves in an acceptable fash-ion, and, therefore, do not attract attention to minordeficiencies in neurologic development. Once inher-ent physiologic motion is restored by manipulative treat-ment, these children have improved capability toachieve a higher level of performance. Are these theunderachievers of society?

These children provide an interesting comparisonwith children with manifest neurologic inadequacies.Children with diagnosed neurologic problems showedno significant response to the general motivational as-pects of the program. Instead, their performance on

the POD improved specifically in response to the os-teopathic treatment (Tables 6 and 8). It appears thatthe rate of neurologic development in children withmedical problems increases with or without treatmentbut that children with neurologic problems need spe-cific intervention to improve their rate of neurologicdevelopment.

Our research provides an answer to one question fre-quently asked of osteopathic physicians, "How long doesthe effect of manipulative treatment last?" Although only

a few parents were sufficiently enthusiastic about re-search to bring their children back for a follow-up PODassessment, Table 9 records significant (P<.001, totalsample), continuing, positive changes several monthsafter treatment was concluded. Because osteopathicmanipulative treatment liberates and stimulates the in-herent therapeutic potency in the patient, such continu-ing progress after treatment is to be expected.

Osteopathic medical managementKorr20 emphasizes that osteopathic health care should

be evaluated as customarily presented. The health careprocedures usually used at OCC in providing children'shealth care were modified only to the extent necessaryfor conducting research. It is possible that non-treatmentaspects of health care based on osteopathic medical phi-losophy and principles may have affected our results.Such non-treatment aspects are described to help thereader to estimate their impact. The focus on osteopathicmanipulative treatment and neurologic developmentalmeasurement, in our opinion, provides a reasonable ba-sis for attributing the observed changes in performanceto osteopathic manipulative treatment.


Osteopathic medical philosophy emphasizes care forthe whole individual. This care includes attention tothe somatic components of illness, interaction of bodysystems to illness and interventions, and interaction ofthe individual with the psychosocial environment.Music therapy, that is, live classical piano music se-lected to match the state of the child, and homeopathicmedical treatment that stimulates the body's inherentdefense are individualized for each child's health caremanagement at OCC. Homeopathic medications arereserved for patients in whom response to osteopathicmanipulative treatment has reached a plateau. Coop-eration of young children is gained by guided play withpurposeful toys. These interventions are changed dur-ing the course of care.

The plan at OCC to manage the challenging prob-lems in childhood development is based on the follow-ing osteopathic medical principles:

• There is an interrelationship between structureand function. Structural integrity permitting freedomof inherent physiologic motion is the optimum condi-tion in the musculoskeletal system that allows efficientfunction of all other body systems affected bysomatovisceral and viscerosomatic reflexes.21

• There is a dynamic unity of the body. The fas-cia, one contributing influence on body unity, providescontinuity of structure from the soles of the feet to thetop of the head. Every musculoskeletal change resultsin widespread adjustments mediated throughout thefascial system.

• It is the body's inherent therapeutic capacitythat heals a laceration, unites a fracture, overcomesacute infection, or stimulates neurologic development,integration, and function. This capacity is enhancedfollowing osteopathic manipulative treatment.

CommentA number of factors affected the outcome of this re-

search. At the time of the initial visit to the Center,factors in the history, the course of the disability, thedysfunction, or the disease, and memories of previousexperiences in diagnosis or treatment contribute to a child'spotential for initial participation in the program. Gainingthe cooperation and confidence of a child and inspiringthat child to participate in treatment have a major impacton the outcome of care. Delay in initiation of osteopathicmanipulative treatment may have contributed negativelyto this outcome or to failure to complete a treatment pro-gram or to return for the final assessment. Because manypatients come from distant parts, these geographic fac-tors often contributed to dropping out.

Credibility of the research will be affected by thelack of a paradigm accepted by osteopathic clinical re-searchers for designing descriptive research studies.Our study has provided methods that reduce thephysician's, evaluator's, and analyst's bias. Treatmentof all subjects was based on a stated set of criteria forresearch and health care decisions. A quantitative mea-sure was used for assessing sensory and motor perfor-mance. Data were collected, coded, and archived forfuture review. These procedures are steps toward es-tablishing the acceptance of a paradigm and increasingthe credibility of similar research.

Within the limitations posed by these considerations,the improvement in sensory and, to a greater extent,motor performance, assessed by a standard establishedto evaluate neurologic development, supports our as-sumption that the change in neurologic development isassociated with somatic changes that accompany os-teopathic manipulative treatment.

ConclusionThis controlled study provides quantitative descrip-

tive data to support the use of osteopathic manipula-tive treatment as part of pediatric health care based onosteopathic philosophy and principles. The manage-ment used for children in this research study providessignificantly improved sensory and motor performancein children with neurologic problems.

References1. Sutherland, WG. Final lecture. Seminar in Cranial Osteopa-

thy. Des Moines. April 25, 1948. Contributions of Thought.1967. p 147.

2. Agresti, LM. Attention deficit disorder. The hyperactive child.Osteopath Ann. 1989. 14:6-16

3. Houle, N. Profile of Development, ed 2. Piqua, Ohio. Ameri-can Academy for Human Development. 1980. Appendix 1.

4. LeWinn, EB. Human Neurological Organization. Spring-field, IL. Charles C Thomas Publisher. 1977. pp 72-154.

5. Norusis, MJ. SPSS/PC+, chap 7-11, 13. Advanced StatisticsSPSS/PC+, chap 4, 5. Chicago, IL. SPSS, Inc. 1986.

6. Pinkerton F, Watson DR, McClelland RJ. A neurophysiologi-cal study of children with reading, writing and spelling diffi-culties. Dev Child Neurol 1989. 31:569-581.

7. Small JG, Milstein V, Jay S. Clinical EEG studies of shortand long term stimulant drug therapy of hyperkinetic children.Clin Encephalogr. 1978.9:186-194.

8. Beckett, PGS, Bickford, RG, Keith, HM. The electroencepha-logram and various aspects of mental deficiency. / DisabilChildhood. 1956. 92:374-381.

9. Sklar B, Hanley J, Simmons WW. An EEG experiment aimedtoward identifying dyslexic children. Nature. 1972.240:414-416.


10. Satterfield JH, Lesser LI, Cantwell DP. EEG aspects in thediagnosis and treatment of minimal brain dysfunction. AnnNYAcadSci. 1973.205:274-282.

11. Murdoch, BD. Changes in the electroencephalogram in mini-mal cerebral dysfunction: A controlled study of over 8 months.South AfrMedJ. 1974.23:606-610.

12. Van Mechelse K, Gemunde JJ, Nije JD, et al. Visual and quan-titative analysis of EEGs of normal schoolchildren with spe-cific reading disability. Electroencephalogr Clin Neurophysiol.1975.39:106-107.

13. Rebert CS, Wexler BN, Sproul A. EEG asymmetry in educa-tionally handicapped children. Electroencephalogr ClinNeurophysiol. 1978. 45:436-442.

14. Gasser T, Mocko J, Lenard HG, et al. The EEG of mildlyretarded children: developmental classificatory and topo-graphic aspects. Electroencephalogr Clin Neurophysiol. 1983.55:131-144.

15. Korr, IM. The sympathetic nervous system as mediator be-tween the somatic and suportive processes. In Kugelmass IN(ed): The Physiologic Basis of Osteopathic Medicine. NewYork, Postgraduate Institute of Osteopathic Medicine and Sur-gery. 1970. pp 21-37.

16. Sjostrand J, Rydevik B, Lundborg G, et al. Impairment ofintraneural microcirculation, blood-nerve barrier and axonaltransport in experimental nerve ischemia and compression, inKorr, IM (ed). The Neurobiological Mechanisms in Manipu-lative Therapy. New York. Plenum Publishing Co. 1978. pp337-355.

17. Hix, EL. The trophic function of visceral nerves. In The Physi-ologic Basis of Osteopathic Medicine. New York, NY. Post-graduate Institute of Osteopathic Medicine and Surgery. 1970.pp 101-113.

18. Frymann, VM. Relation of disturbances of craniosacral mecha-nisms to symptomatology of the newborn: Study of 1,250infants. JAOA. 1966. 65:1059-1075.

19. Frymann, VM. Learning difficulties of children viewed inlight of the osteopathic concept. JAOA. 1976. 76:46-61.

20. Korr, IM. Osteopathic research: The needed paradigm shift.JAOA. 1991.91:156-171.

21. Burns, L, Chandler, LC, Rice, RW (eds). Pathogenesis of Vis-ceral Disease Following Vertebral Lesions. Chicago, AOA.1948. pp 56-57.

[Reprinted from the Journal of the American OsteopathicAssociation. June 1992. 92:6:729-744]


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