El dolor tiene una dimensión multidimensional que afecta a los córtices somatosensoriales primarios y secundarios del sistema nervioso central (SNC), tálamo, ínsula, corteza cingulada anterior y córtices parietales y prefrontales (Coen et al., 2008; Longe et al., 2001; Petrovic et al., 2000; Borsook, Sava and Becerra, 2010; Sator-Katzenschlager, 2014).
La migraña definida por la Sociedad Internacional del Dolor de Cabeza (IHS) tiene características específicas como ser unilateral, pulsátil con intensidad moderada o severa; incrementa con la actividad física. Es una enfermedad crónica que reduce la calidad de vida (QoL) presentando náuseas, vómitos y/o fotofobia (Society, 2013). Se argumenta el origen de la migraña, pero hay evidencia sobre una disfunción del sistema nervioso vegetativo (Pietrobon and Striessnig, 2003; Dodick and Silberstein, 2006) especialmente en relación con la sensibilización central para una alteración de los núcleos trigemino-vasculares (Goadsby, 2002) y la inflamación de las meninges (Aurora and Wilkinson, 2007). La migraña se produce en aproximadamente el 15% de la población general con un coste total anual estimado en 18.000 millones de euros en Europa, más que trastornos neurológicos como la esclerosis múltiple, la enfermedad de Parkinson y el accidente cerebrovascular o tumor cerebral (Gustavsson et al., 2011). La migraña generalmente se maneja con medicamentos, pero el manejo no farmacológico podría ser una opción de tratamiento alternativo para reducir el dolor, la discapacidad, aumentar la QoL y reducir los costes.
La osteopatía dentro de la medicina integrativa y complementaria, y también si se compara con la terapia farmacológica, es relativamente nueva y todavía carece de una práctica completa basada en la evidencia (EBP).
El tratamiento osteopático (OT) a través de la técnica de manipulación espinal (SMT) o la terapia craneosacral (CST) tiene como objetivo influir en el SNC alterando el procesamiento somatosensorial a nivel cortical mecanismos reguladores neuromusculares-autónomos para reducir el dolor (Mueller, 2007; Lelic et al., 2016).
En la práctica clínica, el OT parece ser eficaz basado en las evaluaciones realizadas y sería interesante averiguar su uso para el manejo de la migraña crónica, ayudando al paciente a conseguir una homeostasis que reduzca el dolor y la discapacidad, ayudando así a aumentar la calidad de vida.
Se ha identificado y evaluado críticamente la literatura disponible sobre la eficacia del tratamiento osteopático en pacientes afectados por migraña con respecto al dolor y la discapacidad.
Se ha llevado a cabo una revisión sistemática, examinando y revisando más de 10 databases y revistas.
|# Estudio/ Abreviatura||Título||Tipo|
|(Posadzki and Ernst, 2011)||Posadzki, P. and Ernst, E. 2011. Spinal manipulations for the treatment of migraine: a systematic review of randomized clinical trials. Cephalalgia 31(8), pp. 964-970.||Systematic Review|
|(Voigt et al., 2011)||Voigt, K. et al. 2011. Efficacy of osteopathic manipulative treatment of female patients with migraine: results of a randomized
controlled trial. J Altern Complement Med 17(3), pp. 225-230.
|Randomized Control Trial|
|(Mann et al., 2012)||Mann, J. et al. 2012. P02.55. Craniosacral therapy for migraine: a feasibility study.BMC Complement Altern Med. Vol. 12. p. P111.||Feasibility study|
|(Arnadottir and Sigurdardottir, 2013)||Arnadottir, T. S. and Sigurdardottir, A. K. 2013. Is craniosacral therapy effective for migraine? Tested with HIT-6 Questionnaire. Complement Ther Clin Pract 19(1), pp. 11-14.||Randomized Control Study|
|(Cerritelli et al., 2015)||Cerritelli, F. et al. 2015. Clinical effectiveness of osteopathic treatment in chronic migraine: 3-Armed randomized controlled trial. Complement Ther Med 23(2), pp. 149-156.||Randomized Control Trial|
Tabla 1: Revisión de la literatura
La migraña es la tercera patología sufrida por la población general según el estudio Global Burden of Disease (Vos et al., 2012); su enfoque farmacológico es hoy la primera opción.
Al afectar al 15% de la población (Steiner et al., 2014), es posible enfrentarse a pacientes que toman múltiples fármacos en la práctica clínica. Un enfoque farmacológico directo no puede excluir los efectos secundarios o las contraindicaciones, por lo que debe facilitar el recurso a enfoques integrativos y complementarios como la osteopatía, entre otros. Aunque el debate sobre la causa de la migraña sigue abierto, la osteopatía con sus diferentes enfoques permitiría, después de un diagnóstico oportuno, abordar la patología con una terapia no farmacológica y no invasiva.
Los artículos analizados muestran cómo a lo largo de los años los enfoques han evolucionado de ser menos estructurales (SMT) a ser más neurológicos (SNC), mientras que los estudios han evolucionado hacia un mayor rigor científico utilizando muestras cada vez más grandes, comparaciones con placebo u otros tratamientos. Esto ha permitido que los resultados sean más fiables y válidos cada vez. Resultados que garantizan un mayor uso de la osteopatía por su eficacia; de ser algo eficaz como en el caso de los tratamientos directos y estructurales (SMT) pero con muchos riesgos de sesgo, a tener una mayor consistencia gracias a un trabajo neurológico más profundo (nervios, membranas, etc.).
En la experiencia clínica, los pacientes obtienen importantes beneficios del uso de la osteopatía como la reducción de la intensidad, frecuencia y duración de la migraña que refleja claramente un impacto positivo en su calidad de vida. Está claro que todavía hay estudios insuficientes y se necesitan más investigación y terapeutas bien formados para una aplicación confiable de técnicas osteopáticas apropiadas. En cualquier caso, la osteopatía no puede ser ignorada y debe considerarse como una posible alternativa al tratamiento farmacológico, así como fácilmente accesible y barata para reducir los gastos del servicio sanitario nacional.
Prof. Dr. Antonio Ciardo, DO, MSc, MBA
Arnadottir, T. S. and Sigurdardottir, A. K. (2013) ‘Is craniosacral therapy effective for migraine? Tested with HIT-6 Questionnaire’, Complement Ther Clin Pract, 19(1), pp. 11-4.
Aurora, S. K. and Wilkinson, F. (2007) ‘The brain is hyperexcitable in migraine’, Cephalalgia, 27(12), pp. 1442-53.
Borsook, D., Sava, S. and Becerra, L. (2010) ‘The Pain Imaging Revolution – Advancing Pain into the 21st Century’, Neuroscientist, 16(2), pp. 171-85.
Cerritelli, F., Ginevri, L., Messi, G., Caprari, E., Di Vincenzo, M., Renzetti, C., Cozzolino, V., Barlafante, G., Foschi, N. and Provinciali, L. (2015) ‘Clinical effectiveness of osteopathic treatment in chronic migraine: 3-Armed randomized controlled trial’, Complement Ther Med, 23(2), pp. 149-56.
Coen, S. J., Aziz, Q., Yaguez, L., Brammer, M., Williams, S. C. and Gregory, L. J. (2008) ‘Effects of attention on visceral stimulus intensity encoding in the male human brain’, Gastroenterology, 135(6), pp. 2065-74, 2074.e1.
Dodick, D. and Silberstein, S. (2006) ‘Central sensitization theory of migraine: clinical implications’, Headache, 46 Suppl 4, pp. S182-91.
Goadsby, P. J. (2002) ‘Pathophysiology of cluster headache: a trigeminal autonomic cephalgia’, Lancet Neurol, 1(4), pp. 251-7.
Gustavsson, A., Svensson, M., Jacobi, F., Allgulander, C., Alonso, J., Beghi, E., Dodel, R., Ekman, M., Faravelli, C., Fratiglioni, L., Gannon, B., Jones, D. H., Jennum, P., Jordanova, A., Jonsson, L., Karampampa, K., Knapp, M., Kobelt, G., Kurth, T., Lieb, R., Linde, M., Ljungcrantz, C., Maercker, A., Melin, B., Moscarelli, M., Musayev, A., Norwood, F., Preisig, M., Pugliatti, M., Rehm, J., Salvador-Carulla, L., Schlehofer, B., Simon, R., Steinhausen, H. C., Stovner, L. J., Vallat, J. M., Van den Bergh, P., van Os, J., Vos, P., Xu, W., Wittchen, H. U., Jonsson, B. and Olesen, J. (2011) ‘Cost of disorders of the brain in Europe 2010’, Eur Neuropsychopharmacol, 21(10), pp. 718-79.
Lelic, D., Niazi, K., Holt, K., Jochumsen, M., Dremstrup, M., Yielder, P., Murphy, B., Drewes, A. and Haavik, H. (2016) ‘Manipulation of Dysfunctional Spinal Joints Affects Sensorimotor Integration in the Prefrontal Cortex: A Brain Source Localization Study.’, pp. 9 pages.
Longe, S. E., Wise, R., Bantick, S., Lloyd, D., Johansen-Berg, H., McGlone, F. and Tracey, I. (2001) ‘Counter-stimulatory effects on pain perception and processing are significantly altered by attention: an fMRI study’, Neuroreport, 12(9), pp. 2021-5.
Mann, J., Gaylord, S., Faurot, K., Suchindran, C., Coeytaux, R., Wilkinson, L., Coble, R. and Curtis, P. (2012) ‘P02.55. Craniosacral therapy for migraine: a feasibility study’, BMC Complement Altern Med: Vol. Suppl 1, pp. P111.
Mueller, L. (2007) ‘Diagnosing and Managing Migraine Headache’, The Journal of the American Osteopathic Association, 107(suppl_6).
Petrovic, P., Petersson, K. M., Ghatan, P. H., Stone-Elander, S. and Ingvar, M. (2000) ‘Pain-related cerebral activation is altered by a distracting cognitive task’, Pain, 85(1-2), pp. 19-30.
Pietrobon, D. and Striessnig, J. (2003) ‘Neurobiology of migraine’, Nat Rev Neurosci, 4(5), pp. 386-98.
Posadzki, P. and Ernst, E. (2011) ‘Spinal manipulations for the treatment of migraine: a systematic review of randomized clinical trials’, Cephalalgia, 31(8), pp. 964-70.
Sator-Katzenschlager, S. (2014) ‘Pain and neuroplasticity’, Revista Médica Clínica Las Condes, 25(4), pp. 699–706.
Society, C. o. t. I. H. (2013) ‘The International Classification of Headache Disorders, 3rd edition (beta version)’, Cephalalgia, 33(9), pp. 629-808.
Steiner, T. J., Stovner, L. J., Katsarava, Z., Lainez, J. M., Lampl, C., Lanteri-Minet, M., Rastenyte, D., Ruiz de la Torre, E., Tassorelli, C., Barre, J. and Andree, C. (2014) ‘The impact of headache in Europe: principal results of the Eurolight project’, J Headache Pain, 15, pp. 31.
Voigt, K., Liebnitzky, J., Burmeister, U., Sihvonen-Riemenschneider, H., Beck, M., Voigt, R. and Bergmann, A. (2011) ‘Efficacy of osteopathic manipulative treatment of female patients with migraine: results of a randomized controlled trial’, J Altern Complement Med, 17(3), pp. 225-30.
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|Glosario de terminología osteopática y sobre migraña
|Chronic:||In pain terminology, chronic denotes persistence over a period longer than three months. In headache terminology, it retains this meaning for secondary headache disorders. For primary headache disorders that are more usually episodic (qv), chronic is used whenever attacks of headache (qv) occur on more days than not over a period longer than 3 months. The trigeminal autonomic cephalalgias are the exception: in these disorders, chronic is not used until the disorder has been unremitting for more than one year.|
|Cranial rhythmic impulse (CRI):
|A palpable, rhythmic fluctuation believed to be synchronous with the primary respiratory mechanism.|
|A term used to refer to the anatomical connection between the occiput and the sacrum by the spinal dura mater.|
|A dysfunctional, persistent pattern, in some cases reversible, resulting when homeostatic mechanisms are partially or totally overwhelmed.|
|DO:||· Doctor of Osteopathy (graduate of a school accredited by the American Osteopathic Association Commission on Osteopathic College Accreditation [COCA]).
· Doctor of Osteopathic Medicine (graduate of a school accredited by the American Osteopathic Association-COCA).
· Diplomate in Osteopathy (the first degree granted by American School of Osteopathy).
· Diplomate of Osteopathy, a degree granted by some schools of osteopathy outside the United States (not accredited by the American Osteopathic Association-COCA).
|Duration of attack:||Time from onset until termination of an attack of headache (or pain) (qv) meeting criteria for a particular headache type or subtype. After migraine or cluster headache, a low-grade non-pulsating headache without accompanying symptoms may persist, but this is not part of the attack and is not included in duration. If the patient falls asleep during an attack and wakes up relieved, duration is until time of awakening. If an attack of migraine is successfully relieved by medication but symptoms recur within 48 hours, these may represent a relapse of the same attack or a new attack. Judgement is required to make the distinction (see also Frequency of attacks).|
|Frequency of attacks:||The rate of occurrence of attacks of headache (or pain) (qv) per time period (commonly one month). Successful relief of a migraine attack with medication may be followed by relapse within 48 hours. The IHS Guidelines for Controlled Trials of Drugs in Migraine, 2nd edition, recommended as a practical solution, especially in differentiating attacks recorded as diary entries over the previous month, to count as distinct attacks only those that are separated by an entire day headache-free|
|Headache days:||Number of days during an observed period of time (commonly 1 month) affected by headache for any part or the whole of the day.|
|Health:||Adaptive and optimal attainment of physical, mental, emotional, spiritual and environmental well-being.|
|High velocity/low amplitude technique (HVLA):||An osteopathic technique employing a rapid, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint, and that engages the restrictive barrier in one or more planes of motion to elicit release of restriction. Also known as thrust technique.|
|· Maintenance of static or constant conditions in the internal environment.
· The level of well-being of an individual maintained by internal physiologic harmony that is the result of a relatively stable state or equilibrium among the interdependent body functions.
|A system of control activated by negative feedback (Dorland’s).|
|Intensity of pain:||Degree of pain (qv) usually expressed in terms of its functional consequence and scored on a verbal four-point scale: 0, no pain; 1, mild pain, does not interfere with usual activities; 2, moderate pain, inhibits but does not wholly prevent usual activities; 3, severe pain, prevents all activities. It may also be expressed on a visual analogue scale.|
|Therapeutic application of manual force. See also osteopathic manipulative treatment.|
|The skillful use of the hands to diagnose and treat structural and functional abnormalities in various tissues and organs throughout the body, including bones, joints, muscles and other soft tissues as an integral part of complete medical care. This term been used interchangeably with the term manipulation. This term is not identical to manual therapy, which has originated from the German Manuelle Medizin (manual medicine) and has been used by non-physician practitioners (e.g., physical therapists).|
|Membranous articular strain:
|Any cranial somatic dysfunction resulting in abnormal dural membrane tensions.|
|The ideal physiologic state of harmonious equilibrium in the tension of the dura mater of the brain and spinal cord.|
|Models of osteopathic care:
|Five models that articulate how an osteopathic practitioner seeks to influence a patient’s physiological processes.
1. Structural model, the goal of the structural model is biomechanical adjustment and the mobilization of joints. This model also seeks to address problems in the myofascial connective tissues, as well as in the bony and soft tissues, to remove restrictive forces and enhance motion. This is accomplished by the use of a wide range of osteopathic manipulative techniques such as high velocity-low amplitude, muscle energy, counterstrain, myofascial release, ligamentous articular techniques and functional techniques.
2. Respiratory-circulatory model, the goal of the respiratory-circulatory model is to improve all of the diaphragm restrictions in the body. Diaphragms are considered to be “transverse restrictors” of motion, venous and lymphatic drainage and cerebrospinal fluid. The techniques used in this model are osteopathy in the cranial field, ligamentous articular strain, myofascial release and lymphatic pump techniques.
3. Metabolic model, the goal of the metabolic model is to enhance the selfregulatory and self-healing mechanisms, to foster energy conservation by balancing the body’s energy expenditure and exchange, and to enhance immune system function, endocrine function and organ function. The osteopathic considerations in this area are not manipulative in nature except for the use of lymphatic pump techniques. Nutritional counselling, diet and exercise advice are the most common approaches to balancing the body through this model.
4. Neurologic model, the goal of the neurologic model is to attain autonomic balance and address neural reflex activity, remove facilitated segments, decrease afferent nerve signals and relieve pain. The osteopathic manipulative techniques used to influence this area of patient health include counterstrain and Chapman reflex points.
5. Behavioral model, the goal of this model is to improve the biological, psychological and social components of the health spectrum. This includes emotional balancing and compensatory mechanisms. Reproductive processes and behavioral adaption are also included under this model.
|The therapeutic use of anatomic and physiologic mechanisms to facilitate the body’s response toward homeostasis and improved health.|
|A person who has achieved the nationally recognized academic and professional standards within her or his country to independently practice diagnosis and treatment based upon the principles of osteopathic philosophy. Individual countries establish the national academic and professional standards for osteopaths practicing within their countries (International usage).
Considered by the American Osteopathic Association to be an archaic term when applied to graduates of U.S. schools.
|Osteopathic manipulative medicine (OMM):||The application of osteopathic philosophy, structural diagnosis and use of OMT in the diagnosis and management of the patient.|
|Osteopathic manipulative therapy (OMTh):||The therapeutic application of manually guided forces by an osteopath (nonphysician) to improve physiological function and homeostasis that has been altered by somatic dysfunction.|
|Osteopathic manipulative treatment (OMT):
|The therapeutic application of manually guided forces by an osteopathic physician (U.S. usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction. OMT employs a variety of techniques.|
|The preferred term for a complete system of medical care practiced by physicians with an unlimited license that is represented by a philosophy that combines the needs of the patient with the current practice of medicine, surgery and obstetrics. Emphasizes the interrelationship between structure and function, and has an appreciation of the body’s ability to heal itself.|
|Osteopathic musculoskeletal evaluation:
|The osteopathic musculoskeletal evaluation provides information regarding the health of the patient.
Utilizing the concepts of body unity, self-regulation and structure-function interrelationships, the osteopathic physician uses data from the musculoskeletal evaluation to assess the patient’s status and develop a treatment plan.
|A concept of health care supported by expanding scientific knowledge that embraces the concept of the unity of the living organism’s structure (anatomy) and function (physiology). Osteopathic philosophy emphasizes the
I. The human being is a dynamic unit of function.
II. The body possesses self-regulatory mechanisms that are self-healing in nature.
III. Structure and function are interrelated at all levels.
IV. Rational treatment is based on these principles.
|Osteopathic physician:||A person with full unlimited medical practice rights who has achieved the nationally recognized academic and professional standards within his or her country to practice diagnosis and treatment based upon the principles of osteopathic philosophy. Individual countries establish the national academic and professional standards for osteopathic physicians practicing within their countries.|
|Refers to an osteopath, an osteopathic physician or an allopathic physician who has been trained in osteopathic principles, practices and philosophy.|
|Osteopathic structural examination:
|The examination of a patient by an osteopathic practitioner with emphasis on the neuromusculoskeletal system including palpatory diagnosis for somatic dysfunction and viscerosomatic change within the context of total patient care. The examination is concerned with finding somatic dysfunction in all parts of the body, and is performed with the patient in multiple positions to provide static and dynamic evaluation.|
|Osteopathy in the Cranial Field (OCF),
|A system of diagnosis and treatment by an osteopathic practitioner using the primary respiratory mechanism and balanced membranous tension.|
|Archaic usage. No longer a preferred term in the United States. See Osteopathic Medicine.|
|Pain:||An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage|
|Primary machinery of life:
|The neuromusculoskeletal system. A term used to denote that body parts act together to transmit and modify force and motion through which man acts out his life. This integration is achieved via the central nervous system acting in response to continued sensory input from the internal and external environment.|
|Primary respiratory mechanism:
|A conceptual model that describes a process involving five interactive, involuntary functions: (1). The inherent motility of the brain and spinal cord. (2). Fluctuation of the cerebrospinal fluid. (3). Mobility of the intracranial and intraspinal membranes. (4). Articular mobility of the cranial bones. (5). Mobility of the sacrum between the ilia (pelvic bones) that is interdependent with the motion at the sphenobasilar synchondrosis.
This mechanism refers to the presumed inherent (primordial) driving mechanism of internal respiration as opposed to the cycle of diaphragmatic respiration (inhalation and exhalation). It further refers to the innate interconnected movement of every tissue and structure of the body. Optimal health promotes optimal function and the inherent function of this interdependent movement can be negatively altered by trauma, disease states or other pathology. The mechanism is thought to affect cellular respiration and other body processes. In the original definition, the following descriptions were given: primary, because it is directly concerned with the internal tissue respiration of the central nervous system; respiratory, because it further concerns the physiological function of the interchange of fluids necessary for normal metabolism and biochemistry, not only of the central nervous system, but also of all body cells; mechanism, because all the constituent parts work together as a unit carrying out this fundamental physiology.
|Reciprocal tension membrane:
|The intracranial and spinal dural membrane including the falx cerebri, falx cerebelli, tentorium and spinal dura.|
|Hypothetically, a short lived (minutes or hours) increase in central nervous system (CNS) response to repeated sensory stimulation that generally follows habituation.|
|Soft tissue (ST):
|A system of diagnosis and treatment directed toward tissues other than skeletal or arthrodial elements.|
|Somatic dysfunction:||Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment. The positional and motion aspects of somatic dysfunction are best described using at least one of three parameters: 1). The position of a body part as determined by palpation and referenced to its adjacent defined structure, 2). The directions in which motion is freer, and 3). The directions in which motion is restricted.|
|1. The maintenance of a pool of neurons (e.g., premotor neurons, motor neurons or preganglionic sympathetic neurons in one or more segments of the spinal cord) in a state of partial or subthreshold excitation; in this state, less afferent stimulation is required to trigger the discharge of impulses.
2. A theory regarding the neurophysiological mechanisms underlying the neuronal activity associated with somatic dysfunction.
3. Facilitation may be due to sustained increase in afferent input, aberrant patterns of afferent input, or changes within the affected neurons themselves or their chemical environment. Once established, facilitation can be sustained by normal central nervous system (CNS) activity.
|An oscillation that has been measured in association with blood pressure, heart rate, cardiac contractility, pulmonary blood flow, cerebral blood flow and movement of the cerebrospinal fluid, and peripheral blood flow including venous volume and thermal regulation. This whole-body phenomenon, which exhibits a rate typically slightly less than and independent of respiration, bears a striking resemblance to the primary respiratory mechanism.|
|Visceral manipulation (VIS):
|A system of diagnosis and treatment directed to the viscera to improve physiologic function. Typically, the viscera are moved toward their fascial attachments to a point of fascial balance.|
Source: Medicine (2011) and Society (2013).