Effectiveness of Osteopathic Manipulative Treatment in Treating Symptoms of Irritable Bowel Syndrome: A Literature Review

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder that affects a patient for their entire life. Effective treatments for IBS are scarce, leading to an increased interest in alternative treatments such as osteopathic manipulative treatment (OMT). OMT uses hands-on treatment to reduce pain through various methods. By focusing on visceral techniques, OMT can restore autonomic homeostasis and increase lymphatic flow. This literature review aims to investigate the efficacy of visceral OMT in reducing the severity of IBS symptoms. Five primary research studies were evaluated in this analysis. The concluding results show that visceral OMT effectively reduces the symptoms of IBS and improves patients' quality of life. Therefore, OMT should be considered an alternative therapy for treating IBS.


Introduction And Background
Irritable bowel syndrome (IBS) is a common gastrointestinal (GI) condition that affects approximately 5-20% of the population and has an annual incidence of 196-260 per 100,000 [1]. It is more prevalent in women than in men, and while it may affect all age groups, it often presents in the third or fourth decade of life. Genetics, early life trauma, and chronic stress seem to increase an individual's susceptibility, but the underlying mechanism of IBS remains unclear [1]. Food, bacteria, inflammation, and environmental conditions can have an influence on luminal function. All of these factors should be taken into consideration as it is suspected that IBS is of multifactorial origin. Symptoms can range from tolerable to severe, which may have an extensive impact on an individual's quality of life. These symptoms include continuous or intermittent abdominal pain, bloating, flatulence, and bowel habit changes. Traditional treatment approaches, including lactose reduction, fiber supplementation, bulking agents, laxatives, antispasmodics, antibiotics, and antidepressants, provide minimal therapeutic value [2]. The growing interest in enhancing the management of IBS has led to a focus on alternative treatment options like osteopathic manipulative medicine. IBS can be classified as a "gut-brain axis" disorder because the processing of visceral stimuli is altered and sub-optimal in function, leading to the majority of symptoms patients experience [3]. Therefore, physicians have proposed osteopathic manipulative treatment (OMT) to reduce IBS symptoms by restoring homeostatic balance, normalizing autonomics, and improving lymphatic flow. The addition of visceral techniques to the OMT of IBS has been studied and aims to provide a direct influence on the intestinal flow and function of the colonic tract [4]. This includes the use of treatments such as colonic stimulation and mesenteric release, which directly promote intestinal health and have been considered for patients with constipationpredominant symptoms. utilized in each search engine. Nine primary research studies and one meta-analysis were found using Google Scholar, and three primary research studies were found using the Osteopathic Research Web. These were all reviewed by C.L., J.B., A.J., M.G., E.G., and J.T. The articles most relevant to the research question were determined based on described inclusion and exclusion criteria. Our study included only those research papers that met two criteria: First, they utilized the Rome III Criteria, and second, they had a minimum of five participants. Case studies and articles published in languages other than English were excluded from our study. IBS studies that did not relate to OMT were also excluded from our study. Overall, two primary research studies and one meta-analysis were included from Google Scholar, and one primary research study was included from the Osteopathic Research Web. We came across a fifth study, Hundscheid et al., which was referenced in the research study by Attali et al. Based on the inclusion and exclusion criteria discussed, we included Hundscheid et al. in our analysis. Results were analyzed by comparing the statistical significance of improvement in IBS symptoms following OMT. A flow diagram of included studies is detailed in Figure 1.

FIGURE 1: Meta-analysis methods
This outlines the inclusion and exclusion criteria used in our research.

Results
Four out of the five studies were randomized controlled studies, and the fifth study was an intervention study. Each study used different methods to analyze outcomes. Attali -7). In Steiner's study, the IBS-QOL questionnaire revealed statistical significance with a P value of approximately 0.015, whereas the IBS-SS questionnaire showed a P value of 0.02 for total daily symptom improvement and a P value of 0.015 for individually most severe symptom improvement [3]. When comparing the outcome results, Attali et al. not only showed a decrease in rectal sensitivity but also demonstrated short-term and long-term relief from abdominal distension and pain, lasting up to one year [4]. Steiner demonstrated a decrease in daily IBS-related symptoms [3]. Florance et al. began to show a decrease in IBS symptom severity in the experimental group on day seven after OMT [5]. Hundscheid et al. revealed OMT significantly improved overall IBS symptoms among the osteopathy group with a P value less than 0.006 [6]. Stiedl et al. stated that mean pain levels according to the VAS dropped tremendously in the OMT group (64.5 to 12.9) when compared to the group that received no OMT (63.7 to 49.7) -almost a four times difference in the reduction of pain levels [7]. The study demonstrated that OMT leads to an improvement in constipation intensity among participants [7]. Important characteristics and findings for all included studies are displayed in Table 1.   [4]. Steiner showed that visceral manipulation significantly decreased daily IBS symptoms in patients [3]. Florance et al. concluded that standardized OMT effectively decreased the abdominal pain associated with IBS in the short-term duration [5]. This study also suggested OMT sessions should be conducted at least once a month to maximize the clinical benefit [5]. Hundscheid et al. recognized that OMT patients had a better quality of life with respect to the symptom score [6]. Overall, Stiedl et al. concluded that OMT reduced the symptoms of IBS, including abdominal pain, constipation, diarrhea, and general well-being [7].
There are several theories on how visceral manipulation can improve the symptoms of those with IBS. After somatic manipulation treatment, some physiologic properties improve. These include increased fluid dynamics and nutrition to supply tissue, relaxing smooth muscle in fascia and ligaments, increased blood flow, and improved lymphatic drainage [3]. Additionally, the OMT benefits are amplified if more than one body region (i.e., the abdomen and sacrum) are manipulated. Treating IBS patients with OMT on the abdomen and surrounding viscera helps normalize the blood supply, lymphatic flow, and autonomic balance to restore normal motility. This highlights the osteopathic tenet that the body's structure and function are reciprocally interrelated. Overall, visceral manipulation can help alleviate IBS symptoms due to improving the function of these properties. These research articles validate that OMT is effective in the treatment of IBS symptoms and can be integrated into standardized care.

Conclusions
This review demonstrates a correlation between the benefits of visceral osteopathy and a reduction in the severity of IBS symptoms. The OMT performed did not appear to cause any side effects. Therefore, OMT may be considered a safe alternative or adjunct in the treatment of patients with IBS. However, more research is needed due to a limited number of randomized controlled studies relating to the effectiveness of OMT in alleviating IBS symptoms. Future studies will help demonstrate a stronger causal positive relationship between the benefits of visceral OMT and the reduction of IBS symptoms.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.