The role of osteopathic manipulative treatment for dystonia: a literature review

Dystonia, a neurological movement disorder, proves to be a significant challenge for patients and physicians alike. Dystonia is the third most common movement disorder in the United States, with as many as 250,000 people affected [1]. This condition can be defined as sustained muscle contractions, typically causing twisting movements and abnormal postures [2]. Dystonia can affect any patient population, with no predilection to patients of a particular age or ethnicity. Dystonia results from abnormal functioning of the basal ganglia leading to twisting, repetitive movements often accompanied by abnormal and potentially pain-inducing postures. Various parts of the body can be affected, including the extremities, cervical region, or even the vocal cords.

Dystonia can present with posturing and abnormal movements, where muscle hypertonicity and somatic dysfunctions (SDs) often result. A principle of osteopathic manipulative treatment (OMT) is that structure and function are interrelated. An abnormality in the structure of a body part can lead to abnormal and suboptimal function [3]. This is evident by SDs resulting from muscle contracture and hypertonicity in patients with dystonia. Pain is also a common complication of dystonia. Uncontrolled muscle movements can put stress on joints, potentially leading to the onset of osteoarthritis [1].

From the physician’s perspective, the management of dystonia proves to be challenging due to its complex nature and variability in progression. With the goal of optimal movement and physical functioning in mind, nonpharmacological treatment modalities, such as OMT, are a possible option to consider. OMT has been shown to improve biomechanical functioning among patients with a movement disorder such as Parkinson’s disease, and in patients with inherited spasmodic torticollis [2]. One component of dystonia that OMT can potentially target is SDs that may occur with muscle hypertonicity. With an overarching goal of achieving and maintaining homeostasis of the body, OMT treatments such as cranial and oculocephalogyric muscle energy techniques, balanced ligamentous tension/articular ligamentous strain (BLT/ALS), muscle energy (ME), thoracic high-velocity low-amplitude (HVLA), myofascial release (MFR), and reciprocal inhibition can be effective [4].

Our goals for this review are to provide a background of dystonia and OMT with current treatment modalities, to define OMT and elucidate the potential benefit of OMT in the treatment of various forms of dystonia, to discuss the proposed mechanisms regarding the underlying effects of OMT on dystonia, and to discuss challenges and opportunities for future research and clinical applications of dystonia.

Methods

Two databases, PubMed and Google Scholar, were searched, yielding a total of 715 records – 2 records from PubMed and 713 records from Google Scholar. A total of 640 records were marked as ineligible by automation tools; we considered research from 2004 to 2024, leaving 75 records for screening. During the screening phase, titles and abstracts were reviewed, and 67 records were excluded because they did not meet the inclusion criteria. The remaining eight records were sought for full-text retrieval, and all eight were successfully retrieved and assessed for eligibility. Upon detailed examination of the full texts, four reports were excluded because they did not meet the inclusion criteria, which focused on the specified search terms. The exclusion criteria eliminated any studies that did not focus on “osteopathic manipulative treatment,” “osteopathic manual treatment,” “osteopathic manipulative medicine,” and “dystonia.” Ultimately, four studies were included in the review. These studies were selected based on their relevance to the inclusion criteria and contributed to understanding the role of OMT in managing dystonia. This selection process was completed by the authors and concluded that the review includes only these pertinent studies, providing a focused analysis of the topic as shown in Figure 1 and Table 1.

Figure 1:

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram.

Results

Discussion

The aim of OMT in cases of dystonia is to support the physiological condition of structures like muscle tone and connective tissue, which may be compromised by dystonia, thereby potentially restoring function and balance in the body [21]. Although some studies report minimal symptom improvement with OMT, others suggest that it may contribute to enhanced pain management and contractility in patients with different forms of dystonia, which could lead to increased mobility and improved quality of life. The proposed mechanism by which OMT may produce relief of pain and increased mobility involves addressing muscle hypertonicity, a characteristic feature of dystonia. Muscle contraction due to the overactivation of specific muscle groups in dystonia may present a suitable target for OMT. According to the biochemical model of osteopathic medicine, the dysregulation of movement control can impact the musculoskeletal system and connective tissues, potentially contributing to certain forms of dystonia. OMT aims to restore normal muscle tone, joint mobility, and the body’s natural alignment while alleviating pain associated with synovial joint distortion [22]. Thus, the goal of OMT is to improve structures that may be contributing to dysfunction and decreased homeostasis in the body. Although OMT does not directly target neurological centers like the basal ganglia, it may help mitigate environmental factors, such as repetitive activity and trauma, that can exacerbate dystonia [21].

The case reports and case studies under review looked at methods such as BLT, ME, and MFR that have been shown to result in improvement in pain, range of motion, and increased homeostasis throughout the body [19]. These improvements, reported in some studies, may be attributed to the relief of muscle spasm and tonicity, potentially leading to increased range of motion and pain reduction. Regarding gait disruption that some patients may experience with dystonia, the cases we shared from the literature have reported OMT as a possible treatment option for several somatic dysfunctions leading to the gait disturbance such as dysfunction in the cranial sutures, pelvis, upper and lower extremity, and hypertonicity of the abdominal wall, allowing for stability and alleviation of symptoms [18]. When applied to various dysregulated areas due to dystonia, OMT may support the body’s return to a state of homeostasis, aiding in the regulation of muscle tonicity.

Several different manipulative techniques were utilized and analyzed in these studies, most notably BLT, MFR, and ME. BLT is a technique that operates on the principle that ligaments offer proprioceptive feedback when tension is evenly distributed across the ligaments within a joint [23]. In dystonia, there may be an imbalance of this feedback mechanism that causes dysfunction and contraction. Therefore, utilizing BLT in areas of dystonia and dysfunction can rebalance the proprioception of the ligaments and joints that can allow for muscle relaxation and pain relief. MFR is another manipulative technique utilized to relax and soften tissues, allowing for increased range of motion and decreased pain. This technique engages the restrictive barrier of the facial tissues with constant force until relaxation and release occur [24]. These case reports and case studies have suggested OMT’s possible utility in patients with dystonia by its ability to relax and release tissues, allowing for more increased range of motion of the muscles involved. Moreover, ME is a third technique that can aid in pain relief and muscle relaxation. This technique involves the patient contracting the muscle against the physician’s counterforce for a duration of time, allowing for a process called reciprocal inhibition. With reciprocal inhibition, hypertonicity of the agonist muscle causes reflexive relaxation of the antagonist muscle, thus leading to pain relief and decreased contractility of the dystonic muscle [25]. The aim of utilizing these techniques and OMT is to reduce muscle tone and contractility, which both contribute to the painful muscle spasms experienced by patients with dystonia. Simultaneously, OMT can allow the body to enter a state of short-term neuromuscular homeostasis, possibly assisting in the regulation of proprioception and muscle reflexes.

Dystonia is often refractory and often leads to additional musculoskeletal problems, such as abnormal posture or joint issues, which can further complicate the patient’s condition. Current treatments, like botulinum toxin injections and antispasmodics, can be extremely useful when treating dystonia but also have undesirable side effects when utilized chronically such as muscle weakness, confusion, paralysis, and difficulty swallowing [5], similarly to the mechanism of botulinum toxin working at the neuromuscular junction and at the level of the muscle itself. OMT, like botulinum toxin, works at the neuromuscular level but without the associated medication side effects. Introducing a manual nonpharmacological treatment method such as OMT could provide significant benefits and improve patient care by offering relief without the adverse effects associated with long-term medication use. Therefore, OMT may serve as an adjunctive treatment, providing relief and pain control for patients with dystonia.

It is important to note that the studies described in this paper are case reports and small case series, which lack statistical power to provide definitive conclusions. There are no randomized controlled trials, making it difficult to generalize findings and create a gold standard for OMT with dystonia. Currently, there is a lack of statistical data that supports OMT’s role in dystonia; however, most studies highlighted in the paper show subjective applications in its use to manage pain, improve range of motion, and benefit patient’s functionality. Some of the studies relied on subjective measures such as pain relief and patient satisfaction, whereas one study utilized scores including mean Toronto Western Spasmodic Torticollis (TWSTRS) and Cervical Dystonia Impact Profile (CDIP). Patient-reported outcomes in these studies varied widely because the techniques utilized were variable, which complicates the standardization of OMT protocols. Dystonia encompasses a wide range of conditions that can vary in severity, underlying causes, and affected body parts, making it a challenge to compare results and create a one-size-fits-all treatment approach. Acknowledging these limitations, we urge further research to determine the efficacy of OMT in dystonia management.

Conclusions

Currently, botulinum toxin, oral medications, physical therapy, and rehabilitation have been the mainstay of dystonia management. The studies selected in this paper show possible improvements in pain and muscle hypertonicity, in patients with dystonia. It should be determined if variables such as the type of dystonia (focal vs. segmental), and the underlying cause of the dystonia (idiopathic or secondary to trauma, infection, autoimmune, medication side effects, etc.) affect the treatment outcomes. We encourage additional research to be completed regarding OMT’s role in dystonia management.