Startseite Effect of manual manipulation on mechanical gait parameters
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Effect of manual manipulation on mechanical gait parameters

  • Solomon B. Yanuck EMAIL logo , Sarah K. Fox , Bethany R. Harting und Thomas M. Motyka
Veröffentlicht/Copyright: 30. Mai 2024
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Journal of Osteopathic Medicine
Aus der Zeitschrift Journal of Osteopathic Medicine Band 124 Heft 10

Abstract

Context

A variety of manual manipulation techniques are utilized in clinical practice to alleviate pain and improve musculoskeletal function. Many manual practitioners analyze gait patterns and asymmetries in their assessment of the patient, and an increasing number of gait motion capture studies are taking place with recent improvements in motion capture technology. This study is the first systematic review of whether these manual modalities have been shown to produce an objectively measurable change in gait mechanics.

Objectives

This study was designed to perform a systematic review of the literature to assess the impact of manual medicine modalities on biomechanical parameters of gait.

Methods

A master search term composed of keywords and Medical Subject Headings (MeSH) search terms from an initial scan of relevant articles was utilized to search six databases. We screened the titles and abstracts of the resulting papers for relevance and then assessed their quality with the Cochrane Risk of Bias Tool. Clinical trials that featured both a manual manipulation intervention and multiple mechanical gait parameters were included. Case reports and other studies that only measured gait speed or other subjective measures of mobility were excluded.

Results

We included 20 studies in our final analysis. They utilize manipulation techniques primarily from osteopathic, chiropractic, massage, and physiotherapy backgrounds. The conditions studied primarily included problems with the back, knee, and ankle, as well as healthy patients and Parkinson’s patients. Control groups were highly variable, if not absent. Most studies measured their gait parameters utilizing either multicamera motion capture systems or force platforms.

Conclusions

Twelve of 20 papers included in the final analysis demonstrated a significant effect of manipulation on gait variables, many of which included either step length, walking speed, or sagittal range of motion (ROM) in joints of the lower extremity. However, the results and study design are too heterogeneous to draw robust conclusions from these studies as a whole. While there are initial indications that certain modalities may yield a change in certain gait parameters, the quality of evidence is low and there is insufficient evidence to conclude that manual therapies induce changes in biomechanical gait parameters. Studies are heterogeneous with respect to the populations studied and the interventions performed. Comparators were variable or absent across the studies, as were the outcome variables measured. More could be learned in the future with consistent methodology around blinding and sham treatment, and if the gait parameters measured were standardized and of a more robust clinical significance.

Keywords: chiropractic; gait; manual therapy; massage; motion-capture; osteopathic

Manual manipulation is an adjunctive therapy utilized by many practitioners to help relieve pain, improve physical function, and decrease disease burden for patients with a variety of musculoskeletal and systemic conditions. Manual manipulation has been shown to be cost-effective and efficacious for musculoskeletal conditions when compared with general practitioner care [1]. Prominent schools of manual manipulation include osteopathic manipulative treatment (OMT), chiropractic manipulation, massage, and physiotherapy joint mobilization, all of which have been shown to have efficacy for a variety of conditions. OMT has been shown to provide clinical benefit for patients with chronic low back pain (n=433) [2], neck pain (n=90) [3], and patellofemoral pain syndrome (n=82) [4]. Systematic reviews have shown the clinical benefits of chiropractic manipulation for patients with low back pain [5] and neck pain [6]. Massage is efficacious for patients with knee osteoarthritis (OA) (n=175) [7, 8] and has been shown to reduce delayed-onset muscle soreness after exercise (n=78) [9]. Finally, systematic reviews have demonstrated clinical benefits of joint mobilization therapy in patients with frozen shoulder [10], lateral ankle sprain [11], and knee OA [12].

Gait, or the steady state of walking, requires the integration of multiple types of sensory information from somatosensory, vestibular, and visual systems in addition to the active engagement of cortical integration of sensory input with motor output, central pattern generators, reflex systems, and complex executive functions [13]. Manual therapy can improve overall posture including head position, thoracic kyphosis, and pelvic position [14]. It has also been demonstrated to improve postural stability, balance, strength, and range of motion (ROM) [15], [16], [17], [18]. These improvements may be mediated through changes that manipulation can affect in motor unit behavior, cortical drive, cortical processing, sensorimotor integration, motor control, joint position sense, and central integration [19], [20], [21], [22], [23], [24], [25], [26]. Manipulative treatment may also improve pain conditions, such as knee OA, that may alter gait [27]. It is therefore reasonable to expect that manual therapy intervention could influence gait by means of changing any or all of these factors.

Historically, decreased gait speed has been identified as a useful clinical indicator of poor long-term health outcomes in elderly patients [28, 29]. Slower gait speed has also been associated with impaired activities of daily living and is an important predictor of health-related quality of life [30, 31]. Poor mobility, with gait speed as the most commonly reported mobility measure, has been associated with depressive symptoms [32]. In addition, there is significant evidence to support that variability in gait is associated and may be predictive of future fall risk, especially in elderly patients [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42]. The impacts of falls in this population include high morbidity and mortality as well as poor overall health, stress, depression, and loss of independence [43], [44], [45]. Gait also plays a role in injury progression in the lower extremity, hips, and back, all of which are affected by symmetry and magnitude of forces that impact the body during each step [46], [47], [48]. Finally, gait disturbance due to concussion has been demonstrated, and although we identified no trials studying the effect of manipulation on gait in concussion patients, this represents an emerging field of study [49].

With the improvement in motion capture camera technology, gait analysis has become a popular area of study for medical researchers in a variety of fields. Many manual medicine practitioners have identified objective gait analysis systems as a tool that could provide additional evidence basis for the efficacy, and potentially an underlying mechanism of action, of their treatments. In theory, identifying gait parameters that reliably predict clinical health outcomes in a certain population and then demonstrate an ability to consistently improve that parameter with manipulation could provide robust evidence of the efficacy of the treatment.

In this study, we assess all available research investigating the impact of a manual manipulation intervention on a patient’s gait utilizing mechanical gait analysis variables as their primary outcome measure.

Methods

An initial search was performed in PubMed with the following terms along with “gait”: osteopathic, chiropractic, manual medicine, manipulative medicine, manual therapy, massage, and manual-therapy physical therapy (PT). Relevant papers were reviewed for Medical Subject Headings (MESH) search terms and keywords, and after compiling an initial list, the research team (SY, SF, BH, TM, AF) agreed on a final list of search terms to be utilized in each database search (Figure 1). The following databases were searched on June 21, 2022 utilizing our keywords: CINAHL (Cumulative Index to Nursing and Allied Health Literature), PubMed, Scopus, SPORTDiscus, Trip Database Pro, Embase (Excerpta Medica dataBASE).

Figure 1: The master search terms.
Figure 1:

The master search terms.

Search results yielded 5,532 total results that were aggregated in Rayyan. The software automatically removed 220 duplicates and flagged an additional 570 papers as potential duplicates. The research team scanned the titles and abstracts for relevance, excluding case reports and any study that did not include both a manual therapy intervention and a stated outcome measure involving gait. Review papers were excluded, but their references were scanned for relevant studies. This narrowed the initial search results down to 115 papers for consideration. Of that group, 27 were selected for further analysis as they demonstrated both a manual manipulation intervention and a mechanical measurement of gait parameters in their outcome data. Of note, functional assessments of gait such as the Western Ontario and McMaster Universities Arthritis (WOMAC) Index, which is a 24-point questionnaire utilized to assess pain, stiffness, and function in knee and hip OA, were insufficient for inclusion. Papers utilizing gait speed as their only gait parameter were also excluded. Within the final inclusion group, three papers were excluded because they were not available in English, and four were excluded due to insufficient description of their methods, bringing the final count of papers for analysis to 20 (Figure 2). Included papers were assessed for risk of bias utilizing the Cochrane Risk of Bias Tool for Randomized Trials. Disagreements among the research team were addressed through whole-group discussion until a consensus was reached.

Figure 2: The study flow throughout the review of search results.
Figure 2:

The study flow throughout the review of search results.

Results

Full PICO (P – Patient, problem, or population; I – Intervention; C – Comparison, control or comparator; O – Outcome[s]) breakdown of the included studies can be seen in Table 1. The 20 studies ranged in size from 9 to 100 subjects, with two studying women only, one men only, and 17 all sexes. The studies involved 787 subjects in total, 419 men and 331 women, and 37 sex not specified. Ages studied ranged from 15 to 70. The conditions studied included healthy subjects, knee OA, Parkinson’s disease, low back pain, chronic sacroiliac (SI) joint problems, acute-inversion ankle sprain, restriction in knee extension after ACL surgery, and abnormal gait after stroke.

Table 1:

PICO+ results from 20 analyzed studies.

Author Year n= Power analysis Population/condition Intervention Frequency Comparison Measure Outcome variables Risk of bias Result
Green et al. 2001 41 No Acute ankle sprain Joint mobilization+RICE 7 sessions in 2 weeks or until discharge Taping+RICE Single video camera GS, SL, SST, GSym High Pos
Herzog et al. 1991 37 No Chronic SI joint dysfunction Chiropractic spinal manipulation 10 sessions in 4 weeks Back school Force platform/treadmill VGRF, APGRF, MLGRF High Pos
Wojtowicz et al. 2017 57 No Healthy adults Chiropractic SI joint manipulation Single session Waiting period Force platform/treadmill AFF, AFB, FR, SL, StrL, DSP%, ST, StrT, Cad, MPF, MPM, MPH High Pos
Ward et al. 2013 12 No Healthy adults Chiropractic SI joint manipulation Not reported No manipulation MoCap SHA, SKA, SAA, DST, StaT, SL, StrL Low Neg
Ward et al. 2014 21 No Healthy adults Chiropractic drop table SI joint manipulation Not reported No manipulation MoCap SHA, SKA, SAA, DST, StaT, SL, StrL Moderate Neg
Ditcharles et al. 2017 22 No Healthy adults T9 HVLA Single session Sham treatment Force platform/treadmill APCOGAcc, COGV, COGD, FC, TO, APAs Moderate Pos
Hill et al. 2021 42 Yes Healthy adults Whole body OMT Single session No control MoCap SL, StrL, StaT, VGRF, VGRFI, PKFA High Neg
Gopalswami et al. 2021 100 Yes Knee DJD Joint mobilization, MET, interferential therapy, exercise, education 6 sessions in 2 weeks Interferential therapy, exercises, education Footprint method StrL, SL, Cad High Neg
Robinson et al. 1987 9 No Low back pain Chiropractic SI joint manipulation Single session No control Force platform/treadmill Described 46 gait variables High Neg
Herzog et al. 1988 11 No Low back pain Chiropractic SI joint manipulation 7 sessions in 2 weeks No control Force platform/treadmill MLGRF, VGRF, APGRF High Pos
Krekoukias et al. 2021 75 Yes Low back pain Manual therapy 5 sessions in 5 weeks 1. Stretching, TENS unit, massage. 2. Sham treatment MoCap GRF, trunk and pelvis symmetry Moderate Pos
Kang et al. 2015 24 Yes Men with <10 degrees of DF ROM of the ankle in knee extension Joint mobilization+stretching Single session Stretching MoCap THO, ADFHO Low Pos
Wells et al. 1999 28 No Parkinson’s disease Standardized whole body OMT protocol Single session Sham treatment MoCap StrL, Cad, SV, AV, WV, HV, KV, AnV Moderate Pos
Terrell et al. 2022 84 Yes Parkinson’s disease Whole body OMT Single session 1. Neck down OMT 2. Sham treatment 18 camera motion capture system with dual belt treadmill SHA, SKA, SAA Low Neg
Hunt et al. 2010 12 No Limited knee ext post ACL surgery Anterio tibiofemoral glides Single session No control MoCap SL, StrL, GS, SKA High Pos
Vismara et al. 2016 45 No Prader Willi syndrome Whole body OMT Single session No manipulation MoCap GS, Cad, stance%, SL, SHA, SKA, SAA, ICAK, MinKFMS, MaxKFS, PADSt, MinAAS, PADSw, MaxAPFTS, MaxAPTS, MVF High Pos
Albin et al. 2019 72 Yes Open reduction internal fixation of ankle fracture Joint mobilization 3 sessions in 10 days Sham treatment Force platform/treadmill GS, StaT, stance% Low Neg
Cho et al. 2020 45 Yes Stroke Joint mobilization+stretching Single session 1. Joint mobilization 2. Stretching G Walk gait sensor Cad, StrL, GS Low Neg
Zhu et al. 2015 20 No Women with knee OA Chinese massage 6 sessions in 2 weeks No control MoCap GS, SL, SW, TST, IDST, SST, ICAA, ICAK, ICAH High Pos
Sabet et al. 2021 30 Yes Women with knee OA Swedish massage 12 sessions in 4 weeks No manipulation MoCap GS, StrL, SW, TST, IDST, SST Moderate Pos

  1. PICO, P – Patient, problem, or population; I – Intervention; C – Comparison, control or comparator; O – Outcome[s]; DGD, degenerative joint disease; MoCap, multicamera motion capture system with reflective markers; GS, gait speed; SL, step length; SST, single support time; GSym, gait symmetry; VGRF, vertical ground reaction force; VGRFI, vertical ground reaction force impulse; APGRF, anteroposterior ground reaction force; MLGRF, mediolateral ground reaction force; AFF, average force forefoot; AFB, average force backfoot; FR, foot rotation; StrL, stride length; DSP%, double stance phase%; ST, step time; StrT, stride time; Cad, cadence; MPF, max pressure forefoot; MPM, max pressure mid foot; MPH, max pressure heel; SHA, sagittal hip angle; SKA, sagittal knee angle; SAA, sagittal ankle angle; DST, double support time; StaT, stance time; APCOGAcc, anteroposterior center of gravity acceleration; COGV, center of gravity velocity; COGD, center of gravity displacement; FC, foot contact; TO, toe off; APAs, anticipatory postural adjustments; PKFA, peak knee flexion angle; THO, time to heel off; ADFHO, ankle dorsiflexion before heel off; SV, shoulder velocity; AV, arm velocity; WV, wrist velocity; HV, hip velocity; KV, knee velocity; AnV, ankle velocity; TST, total support time; IDST, initial double support time; ICAK, initial contact angle of knee; ICAH, initial contact angle of hip; ICAA, initial contact angle of ankle; SW, step width; MinKFMS, minimum knee flexion in mid stance; MaxKFS, maximum knee flexion in swing; PADSt, peak ankle dorsiflexion during stance; MinAAS, minimum ankle angle in stance; PADSw, peak ankle dorsiflexion in swing; MaxAPFTS, maximum ankle plantar flexion in terminal stance; MaxAPTS, maximum ankle power in terminal stance; MVF, maximum vertical force; MET, muscle energy technique; RICE, rest, ice, compression, and elevation; SI, sacroiliac; HVLA, high-velocity, low-amplitude; GRF, ground reaction force; DFROM, dorsiflexion range of motion; TENS, transcutaneous electrical nerve stimulation.

The interventions studied were PT, osteopathic, chiropractic, and massage. The interventions varied in number and length of treatment sessions, and in treatment of specific body part vs. whole-body treatment. The most commonly utilized interventions included whole-body OMT, ankle joint mobilization, and chiropractic manipulation to the SI joint.

Interventions were assessed against many different types of control conditions. Although some studies utilized sham manual treatment, stretching, or other well-established conservative treatments, many studies compared their manipulation group to a “no manipulation” control, whereas others did not include a control group at all.

Mechanical gait parameters were primarily measured utilizing either a multicamera motion capture system utilizing reflective markers placed on standardized body locations, or some variation of a force platform walkway or treadmill that measured forces transmitted from the subject into the floor during the gait cycle. Some studies utilized both technologies simultaneously. The most commonly assessed gait variables included stride length, step length, step width, walking speed (m/s), walking cadence (steps/minute), stance time, stance percentage, double support time, single support time, vertical ground reaction force (VGRF), and the sagittal angle of the ankle, knee, and hip throughout gait. Significant changes in mechanical gait parameters were reported in 12 out of the 20 included studies.

Risk of bias analysis yielded 10 papers with a high risk of bias, five with a moderate risk of bias, and five with a low risk of bias. Eight studies performed power analysis, whereas 12 did not describe power analysis methodology [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69]. Six studies were identified that were considered to have a low or moderate risk of bias and that also conducted a power analysis. Among those studies were four manual physiotherapy studies, one massage study on knee OA, and one whole-body OMT study in Parkinson’s patients.

Discussion

Overall, 12 of the 20 studies found a significant effect of manipulation on their gait parameters. However, a high risk of bias, a small sample, and the presence of significant heterogeneity of design between studies makes it irresponsible to draw any robust conclusions from this group of studies as a whole or to perform a meta-analysis. Although some subgroups of studies do have notable overlap in the style of intervention, gait analysis methodology, and gait variables measured, significant variability still exists in terms of disease state of the population of interest, specifics of the intervention implemented, extent and nature of comparison groups, and outcome measures deemed to be most pertinent by the research groups. This prevailing heterogeneity would undermine the validity of any conclusions drawn from an analysis of any cluster of these studies.

Additionally, many of the studies included were either at high risk of bias, or failed to perform a power analysis, creating further barriers to drawing firm conclusions from their findings, whether positive or negative.

We identified six studies considered low or moderate risk of bias that also conducted a power analysis, including four manual physiotherapy studies, one massage study on knee OA, and one whole-body OMT study in Parkinson’s patients.

Krekoukias et al. [60] demonstrated a positive clinical effect of five sessions of manual therapy in patients with low back pain, along with a weak trend toward symmetrical gait. Albin et al. [66] found no significant changes in gait after three sessions of manual therapy to the ankles of patients postsurgical fixation of ankle or midfoot fracture. Cho and Park [67] demonstrated increases in cadence, stride length, and speed among stroke patients receiving a single session of joint mobilization and stretching, or just stretching, to the ankle joint. However, these treatment groups outperformed the group undergoing joint mobilization alone, pointing to stretching as the primary mediator of their findings [67]. Among healthy patients with limited ankle dorsiflexion range of motion (DF ROM), Kang et al. [61] demonstrated increased time to heel off and DF ROM before heel off after a single session of joint mobilization and stretching. In contrast to the stroke study by Cho and Park [67], Kang et al. [61] found that this treatment outperformed the stretching alone group, pointing to joint mobilization as the mediator of their observed effect.

Terrell et al. [63] compared the effect of one session of whole-body OMT, neck-down OMT, and sham treatment on gait in a population of Parkinson’s patients. Although they reported improved hip ROM in the whole-body OMT group, they found no significant difference in their gait parameters, including the sagittal angle of the hip, knee, and ankle throughout the gait cycle [63].

Finally, Sabet et al. [68] demonstrated significant changes in clinical measures and gait parameters in women with knee OA after 12 sessions of Swedish massage. They reported increases in speed, total support time, and single support time, along with decreases in step width and initial double support time [68]. This study was considered to have a moderate risk of bias, and utilized a “usual treatment” group as their control group, leaving open the possibility that a similar level of significance could have been found with a light touch or sham massage control group. Of note, Qingguang et al. [69] investigated the effect of six sessions of Chinese massage on women with knee OA. While they also reported significant increases in gait speed and total support time, they reported increases in step width [69], which contrasts with the findings of Sabet et al [68]. While interpretation of these studies taken together should be guarded because they include a study at high risk of bias, they may serve as an example for future gait and manipulation studies, because they utilized similar overall study design and gait analysis methodology. With a reduced risk of bias and increased sample size, studies like these could be analyzed together to make a stronger overall conclusion regarding the effect of massage on gait in women with knee OA.

Limitations

Of note, we only analyzed studies utilizing mechanical gait measurement systems, and we excluded many manipulation studies that utilized subjective, clinically oriented mobility indices like the timed up and go (TUG) test and the WOMAC Index. Although these indices may lack the precision of computer-generated data, they have a significant head start in terms of their established significance in the clinical setting [70]. By excluding these studies, we were left with a group of studies looking at a conglomeration of gait variables, very few of which were grounded with a clear description of clinical significance.

While certain gait variables have been shown to have a consistent clinical significance, the majority of common variables for analysis have poor or mixed results in the currently available literature. Gait changes associated with increased risk of falls in the elderly include increased double support time variability, double support time, and step length variability, and decreased stride length and gait speed, although these last two associations have been challenged by some authors [71], [72], [73], [74], [75], [76]. Knee OA has been associated with reduced gait speed and increased stride time variability, but these studies were not designed to establish directional causality [31]. In recreational runners, increased prospective injury risk was associated with increased stride length and flight time, and decreased contact time and ratio of contact time:stride time. VGRFs are commonly thought to mediate running-related injury. While two studies found a greater VGRF loading rate in runners with stress fracture and plantar fasciitis, the majority of the available evidence found no association between VGRFs and the risk for running-related injury [77], [78], [79].

Conclusions

While the literature demonstrates specific populations where gait analysis can provide reliable clinical utility, the majority of studies looking to establish clinical significance have yielded mixed or negative results. Additionally, very few of these studies have established directional causality, which weakens our ability to make claims about the benefits of a potential change in gait due to manipulation. Nevertheless, objective measurement of mechanical gait parameters represents an intriguing method for investigating the effect of manual manipulation on gait and the role of gait in overall health.

Further research and standardization of the measurement of motion capture collected gait variables seen across the studies in this review is needed in order to evaluate significance and assess clinical relevance and predictive values. Lack of concordance between clinical data like symptom and functionality questionnaires and the gait metrics that were reported in many of these studies further underlines the need for future studies in which gait variables can demonstrate a reliable association with improved clinical outcomes. The premise that a faster or more symmetric gait is associated with improved clinical outcomes was a working assumption for many of the authors reviewed in this study, but those premises need more investigation before being broadly accepted in larger populations of interest.

Lastly, creating a methodological consensus around blinding, sham treatment, and measurement of relevant gait variables will be crucial to create the conditions for higher-quality manipulation and gait studies. Future research will benefit from this standardization, because it will allow for larger-scale aggregation of data for high-powered meta-analysis, yielding more robust conclusions about the impact of manipulation on gait.

Corresponding author: Solomon B. Yanuck, BA, Leon Levine Hall of Medical Sciences, Campbell University Jerry M. Wallace School of Osteopathic Medicine, 4350 US Hwy 421 S, Lillington, NC 27546, USA, E-mail:

Acknowledgments

The authors would like to thank Adam Foster, PhD (Associate Professor of Anatomy, CUSOM) for assisting with the initial literature search and large-scale article review process; and Sarah Wade, MLS, AHIP (CUSOM Medical Librarian) for assisting with the literature search, organization of our sources, acquiring full text copies of studies, and ensuring adequacy of the paper’s citations.

  1. Research ethics: Not applicable.

  2. Informed consent: Not applicable.

  3. Author contributions: The authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  4. Competing interests: None declared.

  5. Research funding: None declared.

  6. Data availability: Not applicable.

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Received: 2023-08-31
Accepted: 2024-04-09
Published Online: 2024-05-30

© 2024 the author(s), published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.

Artikel in diesem Heft

  1. Frontmatter
  2. Medical Education
  3. Original Article
  4. Assessing nutrition literacy and nutrition counseling proficiency following an interdisciplinary culinary medicine elective
  5. Neuromusculoskeletal Medicine (OMT)
  6. Original Article
  7. Investigating Fryette’s mechanics in computed tomography scans: an analysis of vertebrae spinal physiology using open-sourced datasets and three-dimensional vertebral orientation
  8. Review Article
  9. Effect of manual manipulation on mechanical gait parameters
  10. Obstetrics and Gynecology
  11. Original Article
  12. The impact of prepregnancy body mass index on pregnancy and neonatal outcomes
  13. Public Health and Primary Care
  14. Original Article
  15. Associations of clinical personnel characteristics and telemedicine practices
  16. Clinical Image
  17. Davener’s dermatosis: a unique presentation of frictional hypermelanosis
  18. Letters to the Editor
  19. Fostering a research culture in osteopathic medical education
  20. Response to “Fostering a research culture in osteopathic medical education”
  21. Corrigendum
  22. Corrigendum to: A superficial dissection approach to the sphenopalatine (pterygopalatine) ganglion to emphasize osteopathic clinical relevance
https://doi.org/10.1515/jom-2023-0203
Schlagwörter für diesen Artikel
chiropractic; gait; manual therapy; massage; motion-capture; osteopathic
Creative Commons
BY 4.0

Artikel in diesem Heft

  1. Frontmatter
  2. Medical Education
  3. Original Article
  4. Assessing nutrition literacy and nutrition counseling proficiency following an interdisciplinary culinary medicine elective
  5. Neuromusculoskeletal Medicine (OMT)
  6. Original Article
  7. Investigating Fryette’s mechanics in computed tomography scans: an analysis of vertebrae spinal physiology using open-sourced datasets and three-dimensional vertebral orientation
  8. Review Article
  9. Effect of manual manipulation on mechanical gait parameters
  10. Obstetrics and Gynecology
  11. Original Article
  12. The impact of prepregnancy body mass index on pregnancy and neonatal outcomes
  13. Public Health and Primary Care
  14. Original Article
  15. Associations of clinical personnel characteristics and telemedicine practices
  16. Clinical Image
  17. Davener’s dermatosis: a unique presentation of frictional hypermelanosis
  18. Letters to the Editor
  19. Fostering a research culture in osteopathic medical education
  20. Response to “Fostering a research culture in osteopathic medical education”
  21. Corrigendum
  22. Corrigendum to: A superficial dissection approach to the sphenopalatine (pterygopalatine) ganglion to emphasize osteopathic clinical relevance
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