Michelle Lanspa, OMS-III | Nova Southeastern University College of Osteopathic Medicine
2022 Namey/Burnett Preventive Medicine Writing Award Winner, First Place
Sponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.
Insomnia—the difficulty of initiating, maintaining or achieving quality sleep—should be a top concern among public health officials and primary care physicians for its widespread and increasing lifetime prevalence, now up to 50% of certain adult populations, and its considerable burden on mortality and morbidity.1,2,3 Insufficient sleep results in reduced quality of life, increased healthcare costs, accidents, absenteeism and increased risk of comorbidities and mental health disorders, specifically depression, hypertension, congestive heart failure, diabetes and obesity.1,4,5 It has been estimated that somewhere between $92.5 and $106.5 billion is spent annually in related medical costs.2 Osteopathic physicians are uniquely qualified to treat chronic insomnia, not only by virtue of a holistic osteopathic approach, but also by utilizing osteopathic manipulation therapy (OMT) to treat or reduce causative factors like chronic pain, somatic dysfunctions and imbalances in sympathetic and parasympathetic tone. This brief review aims to give a overview of the existing literature on osteopathic interventions in insomnia management, suggest treatment modalities that might be implemented into clinical practice upon further study, and to serve as a call to action for additional research on the utility of OMT for insomnia disorders.
A keyword search of “osteopathic” and “insomnia” was completed in the following article databases and journal websites: PubMed, Cochrane Collection Plus, Osteopathic Research Web, the Osteopathic Family Physician journal, the Journal of Osteopathic Medicine and the International Journal of Osteopathy. Inclusion criteria included all articles found, with no limitation on publication type, date or language. Exclusion criteria included relevance of the article to the study objective of evaluating OMT interventions in insomnia treatment, evaluated by reading of the publication titles and/or abstracts.
The keyword search produced 52 results, with only 10 publications being relevant to the application of OMT in the treatment of insomnia (see Figure 1: Publications on Osteopathic Treatments in Insomnia).
Limitations of the studies in Figure 1 include a lack of peer review and heterogeneity in study duration, patient population characteristics, number of treatment sessions, and OMT techniques used. Overall there were also short intervention periods, small study populations, lack of control or sham groups and a lack of documented patient studies in the English language.
|Authors||Title||Year of Publication||Journal or Publishing Institution||Study Size and Results and/or OMT Techniques Recommended
|Caicedo Acuña V, Puig Piqué P, Trujillo Hike S.||Effects of Osteopathic Treatment on Sleep Quality in Adults: A Quasi-Experimental Study||2017||Escola d’Osteopatia de Barcelona||N=30, with 2 treatment sessions over 2 months
Total body adjustments targeting individual patient needs, including structural adjustments, visceral techniques, deep and soft tissue massage, venous sinus drainage, lymphatic drainage, and cranial OMT, were used on patients in this study. The Pittsburgh Insomnia Rating Scale revealed patients with moderate clinical insomnia improved from 3.4% to 0%, patients with subclinical insomnia improved from 79.3% to 17.2% to 6.9%, and there was an overall increase of patients with absence of insomnia from 79.3% to 89.7%.
|Cuartango Oliden J, Viñas Jiménez E, Granés Cuñé A.||Effectiveness of Cranial Osteopathic Treatment in Chronic Insomnia: A Quasi-Experimental Study||2017||Escola d’Osteopatia de Barcelona||N=20, with 3 treatment sessions over 5 months
Cranial OMT techniques (CV4 compression, temporal bone rotation, synchronization of the reciprocal tension membrane and primary respiratory mechanism, pussy foot technique) applied to patients with chronic insomnia decreased the number of nighttime awakenings, Pittsburgh Insomnia Rating Scale scores, and use of hypnotic drugs and increased sleep quality and daytime motivation.
|Homistek C, Doty H.||Insomnia Diagnosis and Management: An Osteopathic Approach||2021||Osteopathic Family Physician||Describes an osteopathic approach to insomnia management, including a multifaceted evaluation and OMT to balance autonomic tone and correct associated somatic dysfunctions.
|Mazzeo S, Silverberg C, Oommen T, Moya D, Angelo N, Zwibel H, Mancini J, Leder A, Sheldon Y.||Effects of Osteopathic Manipulative Treatment on Sleep Quality in Student Athletes After Concussion: A Pilot Study||2020||Journal of the American Osteopathic Association (Journal of Osteopathic Medicine)||N=30, with 3 treatment sessions over 2 weeks
The Sport Concussion Assessment Tool (SCAT-5) was used to evaluate sleep quality of student athletes with concussions pre- and post-OMT. The 16 participants who received OMT showed overall 80% and 76% improvement in sleep quality after the 2nd and 3rd visits respectively, versus 36% and 46% improvements in the group that received an educational intervention only.
|McConkey K.||Osteopathy in Insomnia: A Review of the Literature of, Diagnosis and Treatment of Insomnia, the Processes Involved in the Sleep Mechanism and the Intervention of CV4 as a Treatment Option||2010||Escola d’Osteopatia de Barcelona||Literature review of osteopathy and CV4 keywords revealed a positive autonomic response to CV4 treatment and one pilot study that resulted in improved sleep latency.
|Mecko K, Berkey F, Jeffrey M.||Insomnia: How OMT Can Help||2021||Osteopathic Family Physician||Identifies how to rebalance the autonomic nervous system by assessing and treating incorrect positioning, pain and restricted movement in the bones, muscles and other tissues in and around the spine, skull and ribs.
|Nobles T, Bach A, Boesler D. ||Case Report of Osteopathic Treatment of Insomnia and Traumatic Anhidrosis||2016||International Journal of Osteopathic Medicine||N=1, with 3 treatment sessions over 6 months
Case study of a patient with subacute insomnia and chronic anhidrosis secondary to trauma that resolved after 1 treatment session of various OMT techniques, followed by maintenance visits at 1 and 6 months.
|Quilez E, Nenni M.||Effect of Cranial Osteopathic Treatment on Patients Suffering From Insomnia, A Case Study||2018||Escola d’Osteopatia de Barcelona||N=15, 3 treatment sessions over 2 months
CV4 cranial OMT technique was used with the objective of rebalancing the autonomic nervous system. The Pittsburgh Insomnia Rating Scale was used for analysis and, while self-reported sleep quality showed an improvement, the small size resulted in a large margin of error.
|Torti A. ||The Effectiveness of Hydrotherapy and Suboccipital Inhibition in the Treatment of Insomnia||2018||British College of Osteopathic Medicine||N=30, with 3 treatment sessions per treatment modality over 2 months
The insomnia severity index questionnaire (ISI) and visual analogue scale (VAS) revealed no statistically relevant improvements in the ISI and VAS after sessions of hydrotherapy at 41ºC–43ºC (105.8°F–109°F) and of suboccipital inhibition OMT.
|Yoojin Jung J.||Osteopathic Approach to Insomnia||2019||National Academy of Osteopathy ||Outlines an osteopathic treatment approach to insomnia that targets the neurovegetative system. Techniques discussed included: soft tissue therapy (to optimize neuro-vascular flow), articular techniques (to reduce chronic pain and neurological irritations, and to improve mobility), muscle energy techniques (to release tension and to increase range of motion), visceral manipulation (to improve organ mobility and neuro-vascular flow) and cranial osteopathy (to optimize central nervous system function).
Insomnia Is a Public Health Concern: Definitions and Epidemiology
Approximately 50–70 million U.S. adults suffer from sleep disorders, within insomnia ranking number one in prevalence.12 Sleep disorders have been categorized by the third edition of the International Classification of Sleep Disorders (ICSD-3) into the following seven categories: (1) insomnia (short-term, chronic, other); (2) sleep-related breathing disorders (central and obstructive sleep apnea disorders, sleep-related hypoventilation or hypoxemia); (3) central disorders of hypersomnolence (narcolepsy, idiopathic, Kleine-Levin, insufficient sleep syndrome); (4) circadian rhythm sleep-wake disorders (shift work, jet lag, delayed sleep-wake disorders); (5) parasomnias (REM and non-REM disorders of arousal including sleepwalking, sleep terrors, sleep-related eating disorders, sleep paralysis, exploding head syndrome, sleep enuresis); (6) sleep-related movement disorders (restless leg syndrome, bruxism); and (7) other disorders that overlap categories, including fatal familial insomnia, parasitic sleeping sickness, or sleep-related epilepsy, headaches, gastroesophageal reflux disease or myocardial ischemia, psychiatric condition-related sleep disorders like mood disorders, anxiety, panic, depression and substance use.12,13
Insomnia is defined by the American Academy of Sleep Medicine as the “subjective perception of difficulty with sleep initiation, duration, consolidation or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime impairment.”2 The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the ICSD-3 have both eliminated diagnoses of primary and secondary insomnia and have defined acute insomnia as sleep difficulties present at least three nights a week for one to three consecutive months, chronic insomnia as difficulties lasting three or more months, and recurrent insomnia as two or more episodes per year.2 Also of increasing concern, but requiring distinction from insomnia, is the growing problem of insufficient sleep syndrome, a voluntary sleep disorder.3,14 Insomnia is caused by a variety of mechanisms including increased sympathetic tone and stress responses, which result in a breakdown of biobehavorial mechanisms and circadian rhythms.1,15,16
Insomnia is the most common sleep disorder, with an approximate lifetime prevalence of 20%–40% for chronic insomnia among adults overall.17,18,19 Certain populations show even higher rates: 50% of adults over age 65, pregnant women, and women experiencing premenstrual syndrome (PMS), 75% of adult patients with depression, and over 90% of military combat-related PTSD report suffering from insomnia.17,18 A 2021 systematic review and meta analysis by Kocevska et al. studying sleep characteristics in the Netherlands, the United Kingdom and the United States further revealed that insomnia symptoms were 1.5–2.9 times higher in the United States.17
Moreover, chronic insomnia is vastly under-diagnosed and under-treated; only 5% of patients with chronic insomnia seek treatment directly, and only 26% mention it when addressing other medical concerns.1 Current treatment modalities include problematic pharmaceutical interventions including sedative hypnotics, benzodiazepines and benzodiazepine agonists, which—while effective in the treatment of acute insomnia—have been shown to have no long-term benefits and to cause problems like dependency and withdrawal.1,2,5 First-line therapy is cognitive behavioral therapy for insomnia (CBT-I); however, it does not totally address the physiological processes that are key in the pathophysiology of this disease, and the importance of resolving autonomic nervous system (ANS) dysfunction.2 Therapies like yoga, stress management and traditional Chinese medicine practices show promise but require additional study to verify effectiveness.2 Self-treatment options include beneficial mind-body relaxation techniques, but many patients also engage in potentially harmful, self-directed medication with over-the-counter supplementation and alcohol use, which present acute and chronic risks to patients.1
Summary of Suggested OMT Techniques in the Treatment of Insomnia
The studies explored in this review demonstrate that specific OMT techniques and protocols may have the ability to improve sleep quality while concurrently reducing sleep latency in patients suffering from chronic insomnia. The techniques explored and recommended in the studies from Figure 1 are listed below. Both clinical and non-clinical studies included in this review recommended two over-arching models of treatment: cranialsacral work and ANS rebalancing, namely by decreasing sympathetic tone. The following lists have been made from the current review to provide a starting point for osteopathic physicians and researchers interested in developing a more studied and proven insomnia OMT protocol.
Cranial techniques included in the above clinical studies:
- Compression of the fourth ventricle (CV4)1,7,8,11,15
- Temporal bone treatment7
- Synchronization of the reciprocal tension membrane and primary respiratory mechanism7
- Pussy foot technique7
- Cranial lifts8
- Occipitoatlantal decompression8
- Venous sinus drainage (VSD)8
ANS techniques to reduce sympathetic tone and/or improve neuro-lymphatic function included in the above studies:
- Seated rib raising8,10
- Paraspinal inhibition10
- Collateral ganglion inhibition10
- Thoracolumbar OMT10
- Soft tissue OMT5,10
- Myofascial release to include heart rate variability10
- Thoracic inlet release8
- Abdominal diaphragm doming8
A common thread among the studies was evaluation and recommendation of the CV4 cranial technique. This technique is routinely used to reduce anxiety, pain, sleep latency and sympathetic activity.7,20 The fourth ventricle, like the other ventricles of the brain, subarachnoid space, and central canal of the spinal cord, contains cerebral spinal fluid, which is the vehicle for providing nutrition and waste disposal to the nervous system.1 Alterations in chemical composition, or pressure via venous or lymphatic congestion will affect the functioning of this closed hydraulic system.1 Dr. WJ Sutherland first proposed the CV4 compression technique due to the fourth ventricle’s role as a “primary physiological control center of respiration.”1,16 The fourth and third ventricles provide sensory feedback mechanisms regarding temperature regulation, electrolyte balance, hypothalamic-pituitary axis (HPA) function, and cardiovascular and respiratory functions.1,16 When the fourth ventricle is compressed, the surrounding periaqueductal gray tissue, which is is lined with opioid and cannabinoid neuroreceptors, releases endorphins and endocannabinoids.1,16 Insomnia has been associated with increased adrenocorticotropic hormone (ACTH) and cortical secretions and with increased HPA axis activation.1,10,21 The CV4 technique down regulates the the HPA axis and sympathetic nervous system response, and has been shown to improve sleep latency.1,15
Four overarching goals can be developed from this review for an osteopathic approach to the treatment of chronic insomnia treatment: (1) Treat chronic pain which may be disturbing the patient’s ability to sleep comfortably; (2) Treat somatic dysfunctions to optimize digestive, cardiovascular, neural, lymphatic and respiratory functions; (3) Rebalance parasympathetic and sympathetic tone and correct any musculoskeletal dysfunctions which may impact the automatic nervous system, for example, vertebral misalignment; and (4) Utilize cranial evaluation and treatment methods to optimize function of the central nervous system and rebalance the HPA axis. Given the large public health impact of insomnia disorders, and the relative lack of of peer-reviewed studies and publications that address osteopathic techniques useful in the treatment of insomnia, it would be of great benefit to both patients and healthcare systems for osteopathic physicians and researchers to complete additional studies that compare and contrast the effectiveness of OMT with the current first-line insomnia therapy and other treatment modalities.
- McConkey KJ. Osteopathy in insomnia: A review of the literature of, diagnosis and treatment of insomnia, the processes involved in the sleep mechanism and the intervention of CV4 as a treatment option. Fundació Escola d’Osteopatia de Barcelona. 2010. https://www.osteopathic-research.com/s/orw/item/2141
- Homistek C, Doty H. Insomnia diagnosis and management: an osteopathic approach. Osteopathic Family Physician. 2021;31-36. https://doi.org/10.33181/13055
- Short sleep duration among US adults. Centers for Disease Control and Prevention website. Updated May 2, 2017. https://www.cdc.gov/sleep/data_statistics.html
- Torti A. The effectiveness of hydrotherapy and suboccipital inhibition in the treatment of insomnia. British College of Osteopathic Medicine. 2018. https://www.osteopathic-research.com/s/orw/item/2141
- Yoojin Jung J. Osteopathic Approach to Insomnia. National Academy of Osteopathy website. December 2019. https://nationalacademyofosteopathy.com/wp-content/uploads/2019/12/Osteopathic-Approach-to-Insomnia.pdf
- Caicedo Acuña V, Puig Piqué P, Trujillo Hike S. Effects of osteopathic treatment on sleep quality in adults: a quasi-experimental study. Escola d’Osteopatia de Barcelona. 2017. https://www.osteopathic-research.com/s/orw/item/404
- Cuartango Oliden J, Viñas Jiménez E, Granés Cuñé A. Effectiveness of cranial osteopathic treatment in chronic insomnia: a quasi-experimental. Escola d’Osteopatia de Barcelona. 2017. https://www.osteopathic-research.com/s/orw/item/394
- Mazzeo S, Silverberg C, Oommen T, Moya D, Angelo N, Zwibel H, Mancini J, Leder A, Sheldon Y. Effects of osteopathic manipulative treatment on sleep quality in student athletes after concussion: A pilot study. Journal of the American Osteopathic Association. 2020;120(9). https://doi.org/10.7556/jaoa.2020.100
- Mecko K, Berkey F, Jeffery M. Insomnia: How OMT can help. Osteopathic Family Physician. 2021;30(5):45. https://ofpjournal.com/index.php/ofp/article/view/775
- Nobles T, Bach A, Boesler D. Case report of osteopathic treatment of insomnia and traumatic anhidrosis. International Journal of Osteopathic Medicine. 2016;21:58-61. http://dx.doi.org/10.1016/j.ijosm.2016.01.006
- Quílez Esteve S, Nenni M. Effect of cranial osteopathic treatment on patients suffering from insomnia. Escola d’Osteopatia de Barcelona. 2018. https://www.osteopathic-research.com/s/orw/item/289
- Sleep and Sleep Disorder Statistics. American Sleep Association website. February 16, 2018. https://www.sleepassociation.org/about-sleep/sleep-statistics/
- Judd B, Sateia M. Classification of sleep disorders. UpToDate website. Updated May 19, 2021. https://www.uptodate.com/contents/classification-of-sleep-disorders#H13423686
- Skiba V, Matsumura A. What is insufficient sleep syndrome? American Academy of Sleep Medicine website. December 2020. https://sleepeducation.org/sleep-disorders/insufficient-sleep-syndrome/
- Cutler MJ, Holland BS. Cranial manipulation can alter sleep latency and nerve activity in humans; a pilot study. Journal of Alternative and Complementary Medicine. 2005;11:103-8. https://doi.org/10.1089/acm.2005.11.103
- Magnoun HT. Osteopathy in the cranial field. 3rd ed. The Cranial Academy; 1976
- Kocevska D, Lysen TS, Dotinga A, et al. Sleep characteristics across the lifespan in 1.1 million people from the Netherlands, United Kingdom and United States: a systematic review and meta-analysis. Natural Human Behavior. 2021;5(1):113-122. https://doi.org/10.1038/s41562-020-00965-x
- Suni E, Truong K. Sleep statistics. Sleep Foundation website. Updated November 12, 2021. https://www.sleepfoundation.org/how-sleep-works/sleep-facts-statistics
- Cicolin A, Giordano A. Cognitive behavioral and pharmacological treatments for insomnia: a combined approach. Clinical Management Issues. 2020;14(1):27-28. http://dx.doi.org/10.7175/cmi.v14i1.1474
- Jäkel A, Von Hauenschild P. Therapeutic effects of cranial osteopathic manipulative medicine: a systematic review. Journal of the American Osteopathic Association. 2011;111(12):685-693.
- Vgontzas A, Bixler E, Lin HM, Prolo P, Mastorakos G, Vela-Bueno A, Kales A, Chrousos GP. Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: Clinical implications. Journal of Clinical Endocrinology & Metabolism. 2001;86(8):3787-3794. https://doi.org/10.1210/jcem.86.8.7778
- Lande G, Gragnani C. Nonpharmacolotic approaches to the management of insomnia. Journal of the American Osteopathic Association. 2010;110(12):695-701. https://doi.org/10.7556/jaoa.2010.110.12.695
- Schwarz R. A guide to treating the symptoms of menopause. Osteopathic Family Physician. 2017;9(5):20-25. https://ofpjournal.com/index.php/ofp/article/view/517