Osteopathic Manipulative Treatment During Post-operative Recovery: A Scoping Review

Surgery is a common and often necessary treatment option for a wide range of medical conditions, with an estimated 40 to 50 million surgeries performed in the US alone each year. While the various types of surgeries performed may be effective in treating or managing different conditions, the post-operative period can be challenging for patients. Osteopathic manipulative treatment (OMT) is a hands-on approach to medical care that seeks to restore balance and harmony to the body from the lens of an interconnected mind, body, and spirit. Given the potential for adverse events in patients following surgical treatments, OMT may be a viable adjunct post-operatively to enhance patient care and recovery. The purpose of this scoping review is to evaluate the state of current research examining the effectiveness of OMT in improving outcomes in post-operative patients. Three hundred articles were collected; 53 duplicates were removed. Eleven independent reviewers evaluated all 247 articles. Thirty articles were identified, including nine in general surgery, six in cardiothoracic surgery, five in orthopedic surgery, four in spinal surgery, three in neurosurgery, and three others (otolaryngology, oral/maxillofacial, and gynecologic surgery). Post-operative patients were treated with various OMT techniques with myofascial release and muscle energy being some of the most common treatments utilized in all surgical fields. Many studies demonstrated the benefits of OMT usage including significant pain relief, improved and earlier bowel function, and decreased lengths of hospital stay. This study demonstrates how OMT can be effective in reducing post-operative pain, reducing the incidence of post-operative ileus, and shortening the length of stay. Further research into the utilization of OMT in post-operative patients should be considered a potential adjunct to surgical intervention, especially in vulnerable patient populations.


Introduction And Background
Osteopathic manipulative medicine (OMM) involves a subset of medicine that aims to correct somatic dysfunctions from the focus of an interconnected body, mind, and spirit [1,2].Somatic dysfunction refers to impaired or altered function in the body's framework and is associated with TART changes: Tissue texture change, Asymmetry, Range of motion decrease, and Tenderness [3,4].Often, patients present with overlapping somatic dysfunctions, leading to pain and symptoms in more than one part of the body [1][2][3].Somatic dysfunctions can arise during the post-operative period due to the surgical manipulation of tissues [5].Surgical procedures can also cause physiologic derangements and anatomic or postural changes as compensatory mechanisms to address the new state the body is in [5].Some of the causes of post-operative pain include a variety of factors: incisional pain, nerve injury or entrapment, pneumoperitoneum, intraoperative positioning, tissue manipulation, and metabolic changes, among others [6].
It is estimated that approximately 312 million surgical operations are performed worldwide each year [7].With regards to post-operative recovery, osteopathic manipulative therapy (OMT) is the therapy utilized to address found somatic dysfunctions [6].It may be utilized to help promote the self-healing of a patient to reduce pain, minimize the usage of analgesics, increase limited range of motion, increase blood flow and lymphatic circulation, and overall return the patient to homeostasis [1][2][3]8].Overall, OMT can potentially be utilized to allow patients greater ability to complete activities of daily living (ADLs) [5].
Osteopathic physicians evaluate and treat a variety of different body systems with OMT corresponding to various viscerosomatic reflexes that may be compromised during these surgical procedures [9].Treatment of these specific viscerosomatic points in the post-operative period can be performed either as a solo technique or a combination of techniques that include high-velocity low amplitude (HVLA), facilitated positional release (FPR), muscle energy (ME), and myofascial release (MFR) techniques [3].
Many studies focus on the use of OMT in reference to pain relief, but only a few focus on the use of OMT in aiding surgical patient recovery [8,40].Studies have demonstrated that although OMT is beneficial in improving musculoskeletal pain symptoms, the frequency of OMT use is low, which may suggest many physicians are unaware or uninformed of the potential benefits [41].In addition, a study utilizing patient surveys revealed an overwhelming majority of patients felt that OMT was helpful for their own recovery and would recommend OMT as part of other patients' recovery and treatment plans during hospitalizations [28].
This review aims to explore the current literature on the usage and results of OMT in all post-operative patient management, as well as identify how the use of OMT could be implemented into a more standard practice of post-operative care.

Identifying the Research Question
The research question was based on the Population, Concept, and Context (PCC) strategy: population included patients of any age, concept included post-operative patients in the setting of a hospital, clinic, or rehabilitation facility, and context included the usage of OMT in post-operative patients.Through this strategy, the review question was "What are the benefits of OMT in post-operative patients?"Our inclusion criteria included articles that were peer-reviewed, written, and published in English, and included the usage of osteopathic manipulative treatment (OMT) techniques in post-operative patients.
Research studies from any time period were included in this review.Articles were excluded if the techniques involved in patient treatment were acupuncture, physical therapy, chiropractic, other non-specified osteopathic manipulation techniques, or not performed by an osteopath.For the purpose of this study, an osteopath is an osteopathic physician or osteopathic medical student overseen by an osteopathic physician.Studies where patients did not receive treatment in the post-operative period were also excluded.These exclusions were created to ensure the focus was on the improvement of post-operative patients through the usage of OMT.To achieve a scoping review, editorial papers, systematic reviews, meta-analyses, and other scoping review studies were excluded.To further ensure consistency in our review, articles that were translated into English were excluded.

Charting the Data
A data charting format was developed by authors CR, HP, and HL to determine which variables to extract from each article reviewed.The variables included the number of participants, demographics, OMT techniques utilized, time range, OMT usage in post-operative long-term complications, outcomes, and limitations.The team of 11 researchers was then divided into groups of two to analyze the remaining 30 articles.A third reviewer was implemented to resolve discrepancies.Then, CR, HP, and HL independently charted the data, discussed the results to resolve inconsistencies, and continuously updated the datacharting form in a uniform process.
Data were abstracted on article characteristics (i.e., type of study, the time frame of publication), surgical field (i.e., general, cardiothoracic, orthopedic), type of surgery performed, timeline post-surgery, OMT techniques used (i.e., HVLA, ME, MFR, CS, BLT), and results of OMT usage, including both physician assessment and patient reported outcomes.

Collating, Summarizing, and Reporting the Results
Quality analysis was utilized following the tier 2 review to assess the bias and content of each selected article.Authors CR, HP, and HL reviewed each article utilizing the Joanna Briggs Institute (JBI) Appraisal Tools.With the utilization of this resource, alongside the inclusion/exclusion criteria articles were further determined to be included or excluded.The JBI assessed the risk of bias and was able to classify articles with a high risk of bias (those scoring less than 50%), moderate bias (50%-70%), and low risk of bias (scores above 70%).Studies scoring moderate or low risk of bias were included in this study, and any scoring high risk was excluded.
Studies were grouped by time frame and surgical field to better synthesize the range of evidence answering our research questions and objectives.The information was summarized in a narrative format and described the settings, populations, and study designs, along with the measures used and broad findings.

Selection of Sources of Evidence
The initial search identified 300 citations.First, 12 duplicates were removed via automation, and another 41 duplicates were removed by reviewers.All 11 authors evaluated every title and abstract of 247 articles through the protocol criteria.Then authors CR, HP, and HL discussed the disputed articles for final inclusion in the review.From the 247 articles, 209 articles were excluded for not following the screening criteria: 33 studies were the wrong type of study, 13 studies were not published in English, 91 studies did not include OMT techniques, and 67 studies did not evaluate post-operative patients.
In conclusion, 38 articles were retrieved for analysis.The full text for one article was unable to be obtained prior to the tier 2 review.There were 37 articles assessed for eligibility during the tier 2 review and seven articles were excluded.One study was not published in English, two studies were the wrong type of study, three studies were not performed by an osteopath, and one study was a repeated study.Our protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols extension for Scoping Reviews (PRISMA-ScR) 2020 form.The screening process and flow are shown in the PRISMA flowchart in Figure 1.

Critical Appraisal Within Sources of Evidence
Each article was analyzed through the type of study and the bias relevant to that study type as seen in Tables 2-7.Articles within the moderate risk or low risk of bias were accepted, given they followed the inclusion criteria.The final inclusion and exclusion criteria yielded 30 articles.These 30 articles included nine in general surgery, six in cardiothoracic surgery, five in orthopedic surgery, four in spinal surgery, three in neurosurgery, and three others (otolaryngology, oral/maxillofacial, and gynecologic surgery).A large variety of OMT techniques were performed, as shown in Table 8.

General Surgery
In the field of general surgery, nine studies were found that evaluated the impact of OMT in post-operative patients.Three studies were case reports [16,31,34], two were case series [5,14], two were RCTs [22,29], one was a cohort study [11], and one was a qualitative study [28].While a range of OMT techniques were used across all of the studies, some of the most common were MFR, ME, and cranial manipulation [5,11,14,16,22,29,31,34].Three of the studies involved post-op ileus [11,14,16], three involved GI resections [11,29,31], and four involved laparoscopic procedures [5,16,22,29].Many of the studies evaluating the use of OMT after general surgery demonstrated positive outcomes: two demonstrated decreased length of stay in the hospital, four showed significant pain relief, one had a decrease in opioid use, and three exhibited improvements in bowel movement [5,11,14,16,22,29,31,34].
The qualitative study in hospitalized patients utilized balanced ligamentous strain, counterstrain, soft tissue, ME, FPR, and cranial techniques [28].This study administered a single OMT session during each patient's hospital stay after surgeries for appendicitis, diverticulitis, hernias, and orthopedic or gynecologic issues and demonstrated patients had less need for pain medication, less pain, decreased anxiety and stress, and improved recovery and comfort [28].The majority of the surgical procedures in this study were general; therefore, it was most appropriately designated into the general surgery category.

Cardiothoracic Surgery
The search yielded six studies that looked at the use of OMT in patients who were undergoing cardiothoracic surgeries [10,13,17,26,32,35], with three of these being coronary artery bypass (CABG) surgeries [26,32,35], one being a posterolateral thoracotomy [17], one being a thoracoabdominal resection of the esophagus [13], and one being an excision of a primary pulmonary leiomyosarcoma [10].Some of the most common OMT techniques that were used were MFR, diaphragm doming, rib raising, and ME [10,13,17,26,32,35].The study by Fleming showed no statistical difference found in length of stay after posterolateral thoracotomy [17].
The study by Arnold did not specifically address the clinical outcome after utilizing OMT but noted the rib raising and pedal lymphatic pump were used to augment lymphatic flow [10].The post-CABG study by Gert did not show statistically significant changes in pulmonary function, thoracic stiffness, quality of life, or maximum aerobic capacity between the OMT group and the control group.However, the study yielded positive results of decreased pain intensity at 12 and 52-week follow-ups post-CABG [32].The other post-CABG studies revealed beneficial hemodynamic changes in cardiac function [26], as well as decreased length of stay, earlier return of bowel function, and improved post-operative function [35].Similar positive results were found for thoracoabdominal resection of the esophagus with decreased pain, decreased thoracic stiffness, and likelihood to recommend OMT to a friend among the OMT groups [13].

Orthopedic Surgery
For the field of orthopedic surgery, four case reports and one randomized controlled trial were identified that looked at the effect of OMT in their post-operative patients.The case reports involved one focusing on upper extremity surgery of an open rotator cuff repair [27], and three focusing on lower extremity surgery of knee arthroplasty ACL repair, arthroscopic meniscectomy, and right total knee arthroplasty [19,25,33].The one randomized controlled trial involved lower extremity surgeries of knee arthroplasty, hip arthroplasty, and open-reduction internal fixation [1].The two most common overlapping OMT techniques among these orthopedic studies were ME and MFR [1,19,25,27].The randomized control trial discussed by Licciardone found significantly poorer outcomes associated with OMT in the length of stay and rehabilitation efficiency, limited to patients with knee osteoarthritis [1].Rehab efficiency was evaluated with a Function Independence Measure score [1].It also found similar outcomes among the OMT and Sham treatment groups of decreased daily analgesic use during the rehabilitation unit stay, though neither group had significantly greater improvement than the other [1].One case report focused on the improvement of post-operative ileus induced by narcotics and found through mesenteric release the patient had returned of normal bowel movement the same day of surgery [33].The majority of the studies showed an improvement in patient recovery ranging from decreased pain levels reported by the patients using visual analog score, increased range of motion assessed by physical exam via the physician, decreased swelling, improved recovery time, and improvement in post-operative complications of singultus and constipation [19,25,27,33].

Spinal Surgery
Four studies, including three randomized controlled trials [21,38,29] and one case report [20], were specific to spinal surgery, which consisted of lumbar microdiscectomies and a laminectomy.The most commonly utilized OMT techniques among the spinal cases were neuromuscular release, soft tissue, ME, and MFR [21,20,38,39].The randomized controlled trial studies were part of the same trial over a two-year period of time and looked at the outcomes through different time periods [21,38,39].The benefits found among the spinal surgery studies were decreased pain levels, reduction in residual back and leg pain, and less usage of pain medication [20,21,38,39].

Neurosurgery
In the field of neurosurgery, three case reports were identified evaluating the usage of OMT following the post-operative period with the following cases: cervical decompression laminectomy for a cervical ependymoma, Arnold Chiari Type I decompression, and a craniotomy for meningioma removal [12,23,36].Some of the OMT techniques utilized in these studies were cranial techniques, MFR, and counterstrain [12,23,36].These studies showed OMT benefits of decreased pain, increased functionality, and reduction of neurologic dysfunctions that resulted from the surgeries [12,23,36].

Other Surgical Fields
In other surgical fields not categorized previously, there is otolaryngology, oral/maxillofacial, and gynecological surgery.There was one case report in the field of otolaryngology evaluating the use of soft tissue, articulatory, and laryngeal manipulation OMT following the excision of an obstructing granuloma after blunt trauma [15].This study showed that the use of OMT aided in the patient's recovery and return to full vocal function [15].
For the field of oral/maxillofacial surgery, there was one case report of a 30-year-old female with continued right jaw and tooth pain ten years after molar excision that was completely eliminated with the use of OMT with techniques of HVLA, intra-oral soft tissue, and cranial manipulation [24].
The one study evaluating the use of OMT in gynecologic surgery was a double-blinded RCT which utilized MFR and soft tissue techniques during the post-operative period [18].This study showed administration of post-operative OMT enhanced pre-and post-operative morphine analgesia in the immediate 48-hour period following elective total abdominal hysterectomy [18].

Summary of Evidence
A total of 30 research articles met our inclusion criteria and were analyzed.The studies were categorized based on their surgical field, and their results and methodology were evaluated.Within each subdivision, a variety of research types were studied ranging from randomized controlled trials to case reports and retrospective charts and case reviews.The most common research type was case reports, which included 14 out of the 30 studies reviewed.The next most reviewed article type was randomized controlled trials, which included nine articles in total.There were nine research articles in general surgery, six in cardiothoracic surgery, five in orthopedic surgery, four in spinal surgery, three in neurosurgery, and three others (otolaryngology, oral/maxillofacial, and gynecologic surgery).The majority of studies demonstrated the benefits utilizing OMT in post-operative patients, with the exception of one randomized controlled trial (RCT) involving OMT after knee and hip surgeries [1].Despite the lack of benefit found in the aforementioned study, the remaining articles showed a wide range of beneficial outcomes from the use of OMT in post-operative patients.
All of the studies evaluated in the field of general surgery demonstrated positive outcomes.Patients who received OMT after general surgery had decreased length of hospital stay, reduction in pain and somatic dysfunction relief, improved bowel movements, and decreased usage of pain medication post-operatively [5,11,14,16,22,28,29,31,34].
The six cardiothoracic articles also yielded positive results after post-operative implementation of OMT, which included a reduction in pain intensity and need for pain medication, reduced anxiety or stress, beneficial hemodynamic changes, improved recovery and comfort, and decreased length of hospital stay [10,13,17,26,32,35].
The studies reviewed in orthopedic and spinal surgery both showed that the use of OMT in post-operative patients demonstrated reduced pain and swelling, increased range of motion and mobility, and improvements in post-operative complications such as singultus and ileus [19][20][21]25,27,33,38].In addition, a spinal surgery study showed early post-operative functional disability showed greater improvement in OMT patients than in-home exercise [39].Another spinal surgery showed the benefits of OMT two years after the surgery [21].
In the field of neurosurgery, the three studies found showed through the usage of OMT there was correction of hemianopsia, increased cervical function, decreased pain, and reduction of structural and neurologic dysfunctions [12,23,36].
In the category of other surgical fields, which consisted of otolaryngology, oral/maxillofacial, and gynecologic surgery articles, positive effects seen included: return of normal voice after laryngeal trauma, complete resolution of long-term post-operative jaw pain, and decreased opioid use [15,18,24].As shown above, the benefits of OMT in post-operative patients are well-documented and demonstrate the amenability of OMT in a variety of medical fields from general surgery to neurosurgery.

Limitations
Some of the common limitations among the studies involved were that 14 of the 30 papers were case reports involving only one patient; therefore, a small sample size can make it unclear how those techniques would apply to a larger population [10,12,15,16,19,20,[23][24][25]27,31,33,34,36].There is also a higher risk of potential bias in case report studies.A small sample population was also an underlying limitation in the rest of the studies found with the largest sample size being 330 patients [14].
Aside from just population size, of the nine randomized controlled trials, some found it difficult to fully blind both the patients and physicians.The OMT techniques are very hands-on and specific, if a physician is blind, they would not be able to fully utilize the proper techniques [21,29,38,39].For the patients, they would need to not be exposed to OMT in the past to not be able to tell if the "hands-on technique" is truly OMT or sham treatment.While other trials were limited in who provided the OMT treatment, many had only medical students providing which were not fully trained physicians [1,21,35,38,39].
Two retrospective studies and two randomized control trials, which utilized surveys, and one randomized control trial, which had physician referrals, all had the potential for selection bias [5,11,22,28,29].The randomized control trial by Wieting, had some variation in numbers reported on their published paper on their chart versus their writing, needing the possibility of further evaluation of their data [35].
Another common limitation among many of the studies was the lack of description of the OMT utilized, which can make it difficult to reproduce that study in the future [11,14,19,36].OMT is also a very personalized technique and plays a role of variability among studies, furthering the possibility of differences in being able to replicate and utilize specific techniques among the different recovery situations.
Finally, there is a limitation with the JBI critical appraisal performed.Ideally, only studies with a low-risk of bias would be included.However, due to the small number of studies identified in the literature search (n=30), it was decided by the research team to include studies with a low risk and a moderate risk of bias.Although there are moderate risk studies included, these studies demonstrate evidence that is beneficial for review given the small amount of literature available.Furthermore, studies with a high risk of bias were not included in the review.

Implications for Research
Future post-operative patients could benefit from additional OMT research in this field of study.This review identified limitations including the lack of comparison, potential selection bias, lack of description for OMT techniques, utilization of medical students, and lack of fully blinding participants.When conducting future research, it would be beneficial to include a detailed description of control groups and the process of patient selection to rule out selection bias and ensure patients have not had prior exposure to OMT before the study.It would also be valuable to describe which OMT techniques are utilized on each patient in detail so that a protocol can be established and utilized by other providers.In addition, uniform reporting of adverse events would be useful as this would allow providers to compare OMT to traditional standards of care utilized in the post-operative setting.
A large randomized controlled trial demonstrating the use of OMT in various surgical fields, while following the above-mentioned variables, could have immense implications for the use of OMT for post-operative patients.Demonstrating the effectiveness of OMT in these patients could also give evidence to the insurance companies that it is a beneficial treatment for post-operative patients, in comparison to traditional standards of care.

Conclusions
Prior studies have demonstrated numerous examples of OMT effectiveness in various surgical fields, including decreased length of hospital stay, reduction in pain, reduction in pain medication usage, and overall improved recovery and increased comfort.However, there are few studies available in this field, and the studies identified have several limitations, as noted previously.OMT can be beneficial to patients during the post-operative period, and more investigations and literature would further legitimize its implementation into patient care.In addition, patients could benefit from future studies being performed with detailed methodology, descriptions of OMT techniques utilized, and selection biases removed.Providing a guideline for physicians to use with future post-operative patients would be beneficial and would provide patients with the best possible post-operative care.

Appendices
Funding Source Type # of Articles (%)

FIGURE 1 :
FIGURE 1: PRISMA flow diagram PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

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Eight patients (88%) verbally reported symptoms improvement following treatment with OMT at their post-operative appointment -One patient did not experience significant relief after treatment and was referred for a gastroenterology evaluation of persistent symptoms -Three patients without full relief of pain, but with improvement in somatic dysfunction, were referred to an OMT specialist clinic for recurrent dysfunction following intitial treatment -One patient initially reported partial relief of symptoms after OMT but was treated with additional supportive care and stretching exercises without specialist referral -No complications 1al.Cureus 16(2): e54233.DOI 10.7759/cureus.No significant difference in times to bowel movement and clear liquid diet between the OMT and non-OMT groups -Mean time to flatus was 3.1 days in the OMT group and 4.7 days in the non-OMT group -Post-operative mean length of stay was significantly different -6.1 days for the OMT group and 11.Shorter length of stay in OMT group -"My patients do better when your team treats them.''-quotefrom MD surgeon who usually referred for OMT treatment on post-Patient reported having a bowel movement 20 minutes after treatment -Post-operative ileus was resolved 1. Population size 2. occurred in the OMT group and 18 complications in the control group -For the first 5 post-operative days, in the OMT group, intra-individual pain decreased by a median of 2 on the Numeric Rating Scale (NRS), while pain in the control group remained the same -At the end of the vists, patients in the OMT group had less pain than those in the control group on each postoperative day -Median length of stay was 11.3 days in OMT group and 17.4 days in control group -Time to first stool was 55.2 hours in OMT group compared to 62.8 hours in control group -Patients in the OMT group also had first flatus on post-operative day 1 (POD) and those in the control group on POD 2 -No difference was seen with regard to vomitting in the first 5 post-operative days and post-operative quality of life (PQL) did not differ significantly before surgery, after surgery or on the day of discharge 1Less opioid consumption in OMT group 26.9±16.4mgcompared to Control 35.1±23.4mg,but it was not statistically 1. Population size 2. Lack of detailed population demographics within 2024 Randall et al.Cureus 16(2): e54233.DOI 10.7759/cureus.(45%)had less need for pain medications -71 patients (76%) had less pain -83 patients (88%) had decreased anxiety/stress -90 patients (96%) indicated improved recovery -90 patients (96%) Lower pain intensity at 12 and 52 weeks in OMT group -No significant change in pulmonary function, thoracic stiffness, quality of life or maximum aerobic capacity between groups at 12 weeks or 52 weeks 1had decreased length of stay (p=0.72), earlier return of bowel function (p=0.19),& improved post-operative function (Significantly increased range of motion in the thorax -Positive change in pain -Expiratory vital capacity was only minimally affected by OMT -Participants were generally positive towards OMT 1. Population size 2. Low generalizability 3. Differences in time from procedure 1. Population size low 2024 Randall et al.Cureus 16(2): e54233.DOI 10.7759/cureus.No statistical difference in length of stay between OMT and non-OMT patients -OMM consultation was more common with pts who had 2 procedures performed during surgery (8 of 12) and with those who were directly admitted to ICU (22 of 23 OMT pts in ICU and 10 of 15 non OMT in ICU) Significantly poorer outcomes associated with OMT in the length of stay and rehabilitation efficiency, limited to patients with knee osteoarthritis.Rehab efficiency evaluated with a Function Independence Measure score -Similar outcomes among the OMT and Sham Treatment groups of decreased daily analgesic use during the rehabilitation unit stay, though neither group had significantly greater improvement than the other 1Patient able to return to full sports activity in 6 months with OMT -Patient had increased Somatic dysfunctions were resolved with treatment -Decreased swelling and improved range of motion reported during the 1 week follow-up -Improved ambulation, complete normal range of motion, and no return of swelling reported at 1 month followhad improved all postoperative outcomes at 2 year follow-up -All post-surgical outcomes in the control group had worsened during the same period -Postoperative physical disability was more improved in the OMT rehabilitation group than in the control group (63% vs. −423%, p<0.05) -Post-operative residual low back pain improved in the OMT rehabilitation group showing a 26% reduction -Low back residual pain had intensified by 5% in the control group -Intensity of post-operative leg pain was reduced by 57% in patients who had received OMT rehabilitation -Leg residual pain had increased by 8% in the control group 1pain after the lumbar discectomy decreased in the OMT group with a 53% reduction from baseline compared to the exercise group which had a 17% reduction -Residual low back pain also decreased with 37% reduction in the OMT group and a Early post-operative functional disability was more improved by individualised rehabilitation with OMT than active control with self-home exercise (55% vs. −5%, p<0.05) -Reduction in medication use went down 93% in the OMT rehabilitation group and 38% in the Neck pain resolved by 50% -Patient was able to regain much of her range of motion lost 1assist patients to adapt, compensate, and continue to optimize their functional recovery -OMT can be provided to reduce the patient's structural and neurologic dysfunction -Patient's jaw pain was completely eliminated with the use of OMM -OMM began on her third visit (pain 7/10) and at the 4th visit (second OMM treatment) her pain 2024 Randall et al.Cureus 16(2): e54233.DOI 10.7759/cureus.Pain returned at the 5th visit (third OMM treatment) at 3/10, but by the 7th visit (fifth OMM treatment) the patient's pain was a 0/10 and remained resolved for four months and she was subsequently discharged There were no differences in either pain, or nausea and vomitting scores among the four study groups -Patients in the Morphine + OMT group used less morphine than the Morphine + Sham group for the first 24 hours and from 25-48 hours -Morphine blood concentrations in the Morphine + OMT group were also lower after 24 hours compared to the Saline + OMT group -Patients in the Morphine + OMT group weighed more than those in any of the other three study groups -No significant differences detected among the four groups regarding patient demographics such as age and duration of surgery -Administration of post-operative OMT enhanced pre-and post-operative morphine analgesia in the immediate 48-hour period following elective total abdominal hysterectomy -OMT can be a therapeutic adjunct in pain management following elective total abdominal hysterectomy 1. Population Size

TABLE 4 : JBI critical appraisal checklist for case series
JBI -Joanna Briggs InstituteArticle Is it clear in the study what is the 'cause' and what is the 'effect' (i.e.

TABLE 7 : JBI critical appraisal checklist for qualitative studies
JBI -Joanna Briggs Institute