Effect of manual osteopathic treatments on physical performance

Effect of manual osteopathic treatments on physical performance | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of manual osteopathic treatments on physical performance Artur Müller, Margarete Schweizerhof, Milan Luliak This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8287443/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Manual osteopathic treatments (osteopathic manipulative treatment, OMT) are gaining importance in the field of sports medicine. However, there remains a paucity of systematic studies on the effects of these substances on the physical performance of healthy, athletically active adults. Objective The objective of the present study was to investigate the effects of a standardized series of osteopathic treatment on metabolic, cardiovascular, muscular and functional parameters in 200 healthy adults. Materials and methods In a clinical comparative study, 200 participants were assigned to either an treatment group (n = 100, four 90-minute osteopathic manipulative treatment (OMT) sessions over 8–12 weeks) or a control group (n = 100, no treatment). Pre- and post-measurements of blood lactate (levels 1–3), relative and absolute VO₂max, isometric strength (legs, trunk, grip) and mobility (cervical spine, jaw opening, finger-floor distance, splits, SIAS rotation) were performed under standardized conditions (22°C, same times of day) by test administrators who were not privy to the subjects' identities. The statistical analysis encompassed a range of methodologies, including paired and independent t-tests, ANCOVA, Pearson correlations, and multiple linear regressions, with a significance level of α = 0.05. Results The treatment group demonstrated a significant reduction in lactate levels across all three exercise levels (level 1: Δ − 0.11 mmol/l, t = − 4.41; level 3: Δ − 0.26 mmol/l, t = − 5.43; p < 0.001). The relative VO₂/kg demonstrated a significant increase of 2.58 ml/min/kg (t = 3.67; p = 0.0003; d = 0.52), while the absolute VO₂max only exhibited a tendency to increase (p = 0.065). A decrease in heart rate was observed during exercise (t = − 2.39; p = 0.0176), while blood pressure changes remained non-significant. The results demonstrated a significant increase in leg strength, with an average gain of 16.02 kilograms (t = 5.92; p 3.95; p < 0.0001). A substantial enhancement in mobility was observed in the cervical spine (t = 3.39; p = 0.0009), jaw opening (t = 3.64; p = 0.0004), finger-floor distance (t = 5.43; p < 0.0001), splits (t = 3.44; p = 0.0007) and SIAS rotation (t = − 3.61; p = 0.0004). Multiple regression explained 16% of the variance in lactate reduction through combined strength and flexibility gains; an extended model (including step position, heart rate) explained 26%. Conclusion The administration of four standardized manual osteopathic sessions has been demonstrated to result in a marked enhancement of metabolic efficiency (as indicated by a reduction in lactate levels), cardiovascular adaptation (as evidenced by a decrease in heart rate), aerobic capacity (as reflected by an increase in VO₂/kg), muscular strength, and functional mobility in healthy, physically active adults. The results of the present study underscore the potential of OMT as an integrative measure in performance and rehabilitation programmes. It is recommended that future studies direct their attention towards the investigation of long-term effects, the determination of treatment doses, and the exploration of mechanistic principles, including but not limited to neurovascular, myofascial, and immunological processes. Sports Medicine and Kinesiology Health Economics & Outcomes Research Health Economics and Outcomes Research Osteopathy manual osteopathic treatments physical performance cardiopulmonary performance diagnostics isometric strength development lactate values 1 Introduction The preservation and restoration of human health are widely acknowledged as fundamental cornerstones of social coexistence and are recognized as a universal human right. The United Nations Universal Declaration of Human Rights (UDHR) already formulates health as a fundamental right, the preservation of which benefits not only the individual but society. From an economic perspective, it is indisputable that the performance of human capital exerts a significant influence on economic productivity. Concurrently, the direct and indirect costs of medical care escalate with age, thereby imposing substantial financial challenges on healthcare systems (Schwartz et al., 2016 ). In this context, the question of whether innovative or complementary treatment approaches can be used to promote the health of the population in the long term while reducing healthcare expenditure is becoming increasingly important. One potential response to this enquiry pertains to osteopathic medicine, a field that has witnessed a consistent escalation in both acceptance and demand since its genesis over a century and a half ago. In Germany and numerous other countries, the utilization of osteopathic treatments is on the rise, encompassing not only the management of degenerative and acute musculoskeletal complaints, but also extending to the domains of prevention and general health promotion. Recent surveys conducted by the Association of Osteopaths in Germany (VOD) have indicated a consistent increase in the number of osteopathic consultations over recent years (VOD, 2018 ). The increasing utilization of osteopathic treatments for infants and children is indicative of a growing perception of osteopathy as a holistic health strategy (Anheyer et al., 2021 ). The genesis of osteopathy can be traced back to the late 1870s, when the American physician Andrew Taylor Still advanced a critique of conventional medical practices that was unorthodox for the time. The prevailing hypothesis suggests that structural dysfunctions within the musculoskeletal system and visceral organ systems play a significant role in the development of symptoms. The approach of regulating somatic structures primarily through manual mobilization and manipulation is widely considered to have marked the beginning of a separate discipline in complementary medicine (Franke et al., 2014 ). The osteopathic approach is predicated on three fundamental principles: the unity of structure and function, the inherent capacity for self-regulation in healing processes, and the significance of maintaining an undisturbed vascular and nervous system for optimal health. During the 20th century, the original mechanical concept underwent an expansion that incorporated significant findings from the disciplines of biophysics and psychosomatics. The organism's conception shifted from that of an isolated mechanical apparatus to that of a dynamic system, wherein physical, biochemical and psychosocial factors interact in a constant state. This paradigmatic expansion enabled a deeper scientific foundation for osteopathic techniques and led to the integration of neurophysiological concepts and systemic therapeutic approaches. Concurrently, there was an increase in the demand for scientific testing of osteopathic procedures. This was facilitated by clinical comparative studies and meta-analyses, which increasingly demonstrated the efficacy of manual spinal procedures and visceral mobilization. The therapeutic relationship, defined as the quality of the interaction between practitioner and patient, also became a focal point of research. This is due to the recognized role of psychosocial effects in subjective perception and treatment success (Reinhardt, 2019 ). At present, manual osteopathic therapy (OMT) comprises a broad spectrum of procedures that can be categorized into three fundamental areas of application: the visceral area, which concentrates on the mobilization of internal organs and their surrounding fascia; the parietal or biomechanical area, which addresses joint, muscle and fascia structures; and the craniosacral area, which encompasses the skull, spinal cord and nervous system facets. The techniques employed in this context range from myofascial release and neural dynamic loop mobilization to high-velocity low-amplitude (HVLA) manipulation. The combination of these techniques is intended to restore structural balance, improve neurovascular regulation and promote autoregulatory healing processes (Herring et al., 2013 ; Jonas, 2018 ). A contemporary trend in osteopathic research involves the utilization of neuroimaging techniques to visualize the effects of manual stimuli on cerebral and spinal network activity. Preliminary studies employing functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) have indicated that osteopathic mobilizations can prompt immediate alterations in brain regions implicated in pain processing, somatosensory integration, and autonomic functions (Cerritelli et al., 2020 ). The findings of this study suggest that osteopathy exerts its effects not only at the local level on tissue, but also on central regulatory mechanisms. Notwithstanding these scientific advances, the regulatory landscape for osteopathy remains inconsistent on an international level. Whilst a number of countries, including Switzerland, the United Kingdom, Belgium and Iceland, have established specific legal regulations and formally recognized osteopathy as a distinct profession with its own training requirements, many other countries have yet to implement such formal standards. It is evident that global umbrella organizations, including the Osteopathic International Alliance and the World Osteopathic Health Organisation, are endeavoring to achieve harmonization in training and professional practice. However, there is an absence of binding minimum requirements (World Health Organisation, 2010). Concurrently, the World Organisation of Traditional Medicine (WOM) advocates the establishment of a uniform minimum standard to ensure security and quality of care. In Germany, the practice of osteopathic techniques is subject to current legislation, which restricts its application to licensed doctors and alternative practitioners. The objective of this regulatory framework is twofold: firstly, to mitigate risks pertinent to patient safety and, secondly, to guarantee the standard of care provided. The practice of osteopathy that is not authorized by the relevant authorities is subject to legal sanction. Furthermore, the integration of osteopathy into the healthcare system necessitates close interdisciplinary exchange with conventional disciplines (Ehmke, 2018 ). A significant challenge that remains to be addressed is the participation of osteopathy in scientific networks and research consortia, with a view to promoting evidence-based anchoring in the national healthcare system. In the context of demographic shifts and escalating healthcare expenditures, the public health paradigm is assuming an increasingly pivotal role. The prevailing paradigm regarding health has shifted from a perspective of individual responsibility to a more collective understanding, necessitating the collection of forward-looking data, proactive prevention strategies, and interdisciplinary collaboration. In such a population protection approach, the focus is on both the management of large data sets and the consideration of individual needs. In particular, with respect to the financing of age-care-intensive population groups, it appears imperative to identify treatment methods that incur comparatively low follow-up costs and concurrently exert a preventive effect (Knecht et al., 2023 ). The concept of physical performance is pivotal in establishing a logical and methodological link between osteopathy and public health. In the domain of sports science, it encompasses all the motor skills – strength, endurance, speed, agility and coordination – that are necessary to meet specific performance requirements (Schnabel et al., 2011 ). Numerous studies have investigated the effects of training programmes on these dimensions. However, there has been no systematic evaluation of whether manual osteopathic treatments can directly influence physiological parameters without accompanying training. Specifically, data concerning lactate kinetics after exercise, changes in maximum strength and functional mobility in healthy individuals are lacking. A substantial proportion of earlier clinical studies have focused on patient groups with existing musculoskeletal complaints, chronic pain or postoperative functions. The efficacy of osteopathy in reducing pain and enhancing quality of life has been demonstrated. However, a scientific gap remains in testing these techniques beyond therapeutic indications regarding performance enhancement in healthy subjects. Consequently, there is an absence of reliable data indicating whether osteopathy serves as an independent means of performance optimization, and if so, to what extent. The present study aims to address a research gap by examining the effects of a standardized series of manual osteopathic treatments on objective performance parameters in healthy adults who exercise regularly. Contrary to the focus of preceding studies, which have chiefly examined causal effects in pain patients, the present study focuses on physiological endpoints such as blood lactate after maximum exertion, maximum strength, and functional mobility. The experimental design will be of the clinical comparison variety, with the subjects divided into two groups: an active group and a control group. The experiment will employ pre-post measurements to ascertain whether osteopathy can bring about a significant improvement in motor skills in the absence of additional training. The results of this study will provide information about direct biomechanical and metabolic effects, as well as implications for long-term cost reduction in the healthcare system. Concurrently, they will contribute to the evidence base, which is imperative for the structured integration of osteopathy into national and international healthcare systems. 2 Methodology The present study investigates the extent to which standardized manual osteopathic treatments impact the physical performance of healthy adults who engage in regular exercise. The focus of this study is a clinical comparative study that systematically compares two study arms: an active group receiving manual osteopathic treatment and a control group without therapeutic treatment. The objective of this study is to identify the causal effects of osteopathic treatments on objective performance parameters, including blood lactate, maximum strength, and functional mobility. The methodology has been meticulously devised to ensure high internal validity: all treatment procedures adhere to a comprehensive standard operating procedure, and measurements are obtained under strictly controlled conditions. The study design, participant recruitment, implementation of the treatment, measurement techniques used, data protection measures and statistical procedures have been meticulously crafted to minimize external confounding factors and ensure reliable data analysis. 2.1 Study design and participants The study was designed as a clinical comparative study. The research team recruited a total of two hundred subjects, who were divided equally into two groups: the active group, which received four manual osteopathic treatments, and the control group, which did not undergo any therapeutic treatment. The study director was responsible for the allocation of participants to the study arms, ensuring that both groups were comparable in terms of key demographic characteristics such as age distribution, gender and performance level (distinguishing between recreational athletes and ambitious athletes). The employment of a targeted cross-sectional design facilitated the isolation of differences in treatment effects. The study encompassed an observation period of approximately twelve weeks. Prior to the commencement of the study, all participants were comprehensively informed about the procedure, time frame and obligations. Written consent forms were obtained from all participants via an online platform. The selection of test subjects was carried out in a targeted manner via various channels to generate a representative sample. The local recruitment base for the study comprised posters in physiotherapy practices at two central locations in southern Germany. These were complemented by targeted online advertising on social media channels. Furthermore, newsletters from the diagnostic center were used to directly address people who are active in sports. An integral component of the pre-selection process was the administration of online pre-screening, which interested parties were invited to complete on a designated landing page. In addition to contact details, the form requested self-reported information on physical fitness, including the ability to run at 11 km/h on a treadmill for three minutes, as well as a binding commitment to maintain the usual lifestyle during the study period. These aspects were pivotal in ruling out acute alterations in training or nutrition that could distort the results. The inclusion and exclusion criteria were meticulously delineated to ensure a homogeneous study population and to minimize potential confounding factors. The inclusion criteria encompassed individuals between the ages of 14 and 80, possessing a fundamental level of physical fitness, adequate proficiency in German or English, and the capacity to readily access the designated study locations. Furthermore, it is imperative to note that minors require the explicit consent of their legal representatives. Subjects who had been advised by their doctor not to participate in sports, had recently undergone surgery, had chronic conditions such as diabetes, were taking long-term medication with anti-inflammatory agents, or were involved in high-performance sports were systematically excluded from the study. Exclusion criteria included acute infections, clinically relevant cardiovascular diseases, and pregnancy. Prior to the commencement of the study, a thorough medical history was obtained, encompassing a medical examination, to ascertain the absence of any contraindications for the stress tests and osteopathic treatments. The defined discontinuation criteria – such as pregnancy detection, sudden onset of illness or a significant change of residence – enabled a flexible yet ethically responsible study procedure. 2.2 Treatment: Standardized osteopathic treatment The active group received four manual osteopathic treatment sessions, which were carried out according to a standard operating procedure (SOP) that had been specially developed for this purpose. Each session was scheduled to last for a duration of 90 minutes, with an approximate margin of error of ± 5 minutes. The intervals between appointments were measured in days, with a range of seven to fourteen days, to allow for the physiological adaptation processes that occur in the tissue. The treatments were administered by osteopaths who had been state-approved, with an average of eight years of professional experience and at least 1,500 hours of postgraduate training. In 86 per cent of cases, the same therapist attended all four sessions of a test subject to minimize variability due to different practitioners. In the event of unavoidable scheduling conflicts, a structured written handover was carried out using detailed findings and palpation protocols. The SOP-based procedure invariably commenced with a systematic inspection and palpation. The programme encompassed viszerofaszialer mobilization techniques, neural dynamic procedures according to Butler, myofascial release techniques, diaphragmatic mobilizations, articulating procedures and high-velocity low-amplitude (HVLA) manipulations of the pelvic ring and upper thoracic segments. The application of each individual technique was meticulously recorded with time stamps, lateralized information and written documentation in the digital case report form. Throughout the treatment period, the subjects were required to report their pain levels on a numerical pain scale ranging from 0 to 10, enabling continuous assessment of tolerability. The environment was maintained at a constant temperature (22 ± 1°C), the lighting was dimmed, and standardized positioning aids were employed to ensure reproducible starting positions in the supine or lateral position. For quality assurance, a comprehensive 'red flag' screening was performed prior to each HVLA manipulation. This evaluation utilized the Ottawa criteria, the Alar ligament test and pain progression. Adverse events were recorded immediately following treatment and subsequently via telephone communication 48 hours later. Overall, mild, self-limiting initial worsening lasting less than 24 hours was documented in 12 per cent of the sessions; no serious side effects occurred. An external video spot check of 10 per cent of all treatments revealed 92 per cent SOP compliance, meaning that treatment fidelity can be classified as high. The control group, on the other hand, did not receive any osteopathic treatment; they only underwent pre- and post-measurements at the same time intervals to reflect natural temporal changes without treatment. 2.3 Measuring instruments and outcome parameters The fundamental parameters of this study are blood lactate levels following exercise, maximum strength, and functional mobility. In order to ensure the highest possible measurement quality, established, valid and reliably tested instruments were used. Lactate spiroergometry was utilised as the integrative performance indicator. Test subjects were required to complete a standardised protocol on a treadmill (11 km/h for three minutes) under increasing stress, during which capillary blood lactate was measured immediately afterwards and at defined times after exercise. The calibration of the lactate measuring device prior to each session ensured precision and reproducibility. The lactate values obtained were utilised for both pre-post comparison within the groups and for intergroup comparison post-treatment. The measurement of maximum strength was conducted using a Baseline Hydraulic Hand Dynamometer. The test subject performed a maximum isometric contraction of the finger flexors for a duration of three seconds, commencing from a standardised starting position – unencumbered by footwear, with feet positioned shoulder-width apart on a stable surface, measuring arm relaxed and hanging down at the side, with the elbow fully extended. The adjustable handle was fixed at the narrowest grip width for all test subjects in order to ensure maximum comparability between measurements. Each hand was subjected to three distinct tests, with the highest individual value being utilised for the subsequent statistical evaluation. Regular calibration checks ruled out deviations of more than ± 1 kg. The test-retest reliability of the method is ICC > 0.95, thus confirming its status as the gold standard in clinical research. The functional mobility of the participants was assessed using a series of standardised tests. The sit-and-reach test was utilised to assess the flexibility of the dorsal muscle and fascia chain, employing the Baseline model 12-1085 as the measuring instrument. The subjects of the experiment were seated on the floor with their legs fully extended and positioned hip-width apart. They were instructed to perform a controlled forward bend. The maximum finger reach was measured using an integrated slide gauge. The experiment was conducted within an air-conditioned chamber (22 ± 1°C) during the morning hours, from 8:00 to 10:00 a.m., with the objective of eliminating the possibility of circadian fluctuations from affecting the results. Each test subject completed one trial run and two valid runs, with a 30-second break allocated between each run. The higher value was utilised as a measure of flexibility. The measurement of the maximum active mouth opening as the interincisal distance was conducted using a digital caliper from Steinle. The measurement was initially taken in an upright sitting position on a fixed wooden chair, followed by a kyphotic lumbar spine position, with the objective of investigating postural differences. Prior to each measurement, a zero calibration and a plausibility check were performed using a 50 mm gauge block. The measurement accuracy was found to be 0.01 mm, and the ICC of the double measurement was 0.93. The transfer of all values was conducted directly to an electronic case report form. The mobility of the cervical spine was determined using the three-axis Cervical Range of Motion System (CROM™ 3). The device under scrutiny consists of a headband-integrated unit that measures flexion/extension, lateral flexion and rotation on separate scales. The test subject was seated upright on a stool with 90° hip and knee flexion, and all scales were adjusted to neutral 0° prior to each measurement. Each direction of movement was tested thrice, with compensatory movements documented and repeated in case of deviations. The measurement intervals and breaks were meticulously designed to minimise muscular fatigue or learning effects. A circumference measurement was taken at the level of the anterior superior iliac spine in order to record the abdominal-thoracic respiratory excursion. The measurement of inspiratory and expiratory circumferences was conducted using a non-elastic tape measure applied horizontally, with the utmost care taken to avoid any tissue compression. The discrepancy between these values thus represented the respiratory excursion. In instances where deviations exceeded 0.5 cm, the measurements were repeated to ensure the reliability within each individual. Furthermore, fundamental parameters such as body mass index, resting blood pressure and body fat were documented. The height and weight of the subjects were determined using SECA calibrated measuring devices, and the BMI of the subjects was calculated using the internationally established formula. The measurement of resting arterial blood pressure was conducted in accordance with established methodology, employing an upper-arm sphygmomanometer as the instrument. The protocol entailed the acquisition of two measurements spaced one minute apart, with a third measurement obtained in instances of significant deviation from the mean. The determination of body fat percentage was conducted through the utilisation of the Futrex 6100/XL near-infrared interaction system. The midpoint of the ventral biceps brachii muscle was utilised as the measurement point, which was marked and measured three times with the optical probe to obtain an average value. The utilisation of these supplementary parameters was instrumental in the comprehensive characterisation of the test subjects, thereby facilitating the regulation of potential confounding variables. 2.4 Data collection and security From the initial contact onwards, all personal data was pseudonymized. Each participant was assigned a unique identification number (study ID), which was utilized to maintain a record of all survey documents and measurement data. The allocation of study identifiers to actual identities was conducted exclusively by the study director and was kept distinct from the research data. The employees of the diagnostic center and all therapists involved were bound by strict confidentiality obligations. Following the conclusion of the study, all data carriers were archived on external hard drives, password-protected, and stored in a location with restricted access. To ensure the confidentiality of the subjects, all data was anonymized for subsequent publication. The collection of data was conducted in two stages. Subjective information was obtained through the utilization of standardized online and paper questionnaires, which were completed prior to the administration of pre- and post-diagnostic assessments. In addition to contact and health data, the questionnaires included items on physical activity, lifestyle habits and psychosocial well-being. Concurrently, objective clinical measurements from the diagnostic center, conducted by trained assistants with degrees in sports science, were entered into the database. This multi-faceted approach was adopted to ensure that both the perceptual and physiological dimensions of performance could be given due consideration. 2.5 Research question and hypotheses The objective of the present study is to elucidate the impact of standardized manual osteopathic treatments on the physical performance of healthy adults who engage in regular exercise. Two overarching research questions and five associated hypotheses have been formulated: The following research question is proposed: The objective of this study is to examine the alterations in key performance parameters, specifically blood lactate accumulation, maximum power output and functional mobility, subsequent to a series of four standardized osteopathic manipulations, in comparison to an untreated control group. Descriptive statistics are utilized to address the research question, with paired and independent t-tests or ANCOVA employed to assess pre-post differences within the groups and mean differences between the groups. The following four hypotheses (α = 0.05) are derived from this research question: It is hypothesized that following the conclusion of the treatment series, the post-exercise lactate value of the active group will be significantly lower than that of the control group. The statistical implementation will be conducted using either an independent t-test or an ANCOVA with a baseline covariate. The target variable is blood lactate (mmol·l⁻¹). It is hypothesized that the active group will demonstrate a substantial increase in maximum strength (kg) in comparison to the control group. The statistical implementation of the study comprised two distinct tests: the paired t-test, which was utilized to analyze intragroup differences, and the independent t-test, which was employed for intergroup comparisons. The target variable of interest was the primary focus of the study. The first measurement taken is that of the maximum weight that can be lifted once in each of the following exercises: the bench press and the squat. The following hypothesis is proposed: The active group demonstrated a significant enhancement in functional mobility (cm) in comparison to the control group. Statistical implementation: Analogous to H2; target variables: sit-and-reach and straight-leg raise. It is evident from the findings of H4 that within the active group, there is a positive correlation between the increase in trunk strength and the increase in leg strength. Statistical implementation: Pearson's correlation coefficient, supplemented by linear regression analysis, was utilized to assess the relationship between the target variables, namely the change in trunk strength (Nm) and the change in leg strength (kg). The integration of group differences (H1–H3) and the modelling of predictive relationships (H4) within this design facilitates the documentation of causal effects of manual osteopathic treatments and the identification of potential mechanisms of action within the performance dimensions of lactate kinetics, strength and mobility. 2.6 Statistical analysis All data preparation and evaluation were performed using IBM SPSS Statistics Version 29. The central significance level was set at α = 0.05 (two-sided). The practical relevance of significant findings was assessed by reporting effect sizes according to Cohen (Cohen, 2013 ). At the commencement of the analysis, descriptive statistics were conducted. The measures of location (arithmetic mean, median) and measures of dispersion (standard deviation, interquartile range) were calculated for all dependent and independent variables. Initial indications of deviations from a normal distribution were provided by the skewness and kurtosis values. Furthermore, the creation of histograms, box-whisker plots and scatter plots was undertaken to identify outliers and heuristically visualize potential correlations. The subsequent stage of the research involved conducting a bivariate correlation analysis. In instances where the data indicated normality and linearity, the Pearson correlation coefficient was employed. Conversely, in cases where normality and linearity were not supported, the Spearman rank correlation coefficient was utilized. The present study examined the correlations between increases in trunk strength and leg strength, with a view to exploring potential mechanisms behind more effective changes. To examine the primary research questions 1 to 3, statistical group comparisons were performed. Intragroup pre-post differences were analyzed using paired t-tests, and intergroup mean comparisons after the treatment were analyzed using independent t-tests. Prior to each test, normality tests (Shapiro-Wilk) and variance homogeneity tests (Levene's test) were performed. In instances where the assumptions were violated, non-parametric alternatives such as the Wilcoxon signed-rank test or the Mann-Whitney U test were employed. A subsequent analysis of covariance (ANCOVA) was performed with baseline value as a covariate to control for initial group differences in blood lactate. Multivariate regression analysis was utilized to address the fourth and fifth research questions. Multiple linear regression was utilized in the enter procedure to estimate percentage changes in strength and mobility as predictors of post-exercise blood lactate levels. The quality of the model was assessed using the coefficient of determination R² and its adjusted form. Residual diagnostics were employed to assess linearity, homoscedasticity, normal distribution and multicollinearity. In instances where substantial deviations were observed, robust regression methods or transformation procedures were employed to ensure the estimation process remained unbiased. The present step-by-step analysis strategy – initiated with a thorough descriptive description, followed by bivariate correlation analyses, inferential statistical group comparisons and concluded with multivariate regression models – facilitates a comprehensive examination of the effects of manual osteopathic treatments on physical performance. In the process, both causal differences between the groups and possible mechanisms of action within the active group are differentiated and identified. 3 Results The present clinical comparative study investigated the extent to which a series of four standardized manual osteopathic treatments modified the physical performance of 200 healthy adults who regularly engaged in physical exercise. The subjects of the study were divided into two groups: an active group that received therapy sessions and an untreated control group. This was done to make a causal distinction between the effects. The metabolic parameters (blood lactate at three exercise levels, absolute and relative VO₂max) and functional performance parameters (isometric muscle strength in the hands, legs and back; mobility of the cervical spine, jaw opening, trunk and leg flexibility; SIAS rotation) were recorded before and after the treatment. The measurements were taken under strictly standardized laboratory conditions (22 ± 1 °C; same time of day), thereby minimizing systematic interference. The descriptive analysis demonstrated that both groups began with a very homogeneous starting position. The mean systolic blood pressure in the pre-test was 118.48 mmHg (SE 0.94), and the diastolic blood pressure was 75.01 mmHg (SE 0.62). The mean body weight was recorded as 72.46 kg (SE 1.07), with a height of 173.50 cm (SE 0.68), indicating that the body mass index fell within the normal range (see Table 1 in the appendix). Prior to the commencement of treatment, the mean values for VO2max were as follows: 2,849.83 ml/min (SE 56.88) in absolute terms and 40.12 ml/min/kg (SE 0.52) relative to body weight. As anticipated, lactate concentrations increased from 1.14 mmol/l (level 1, standard error [SE] 0.04) to 1.97 mmol/l (level 2, SE 0.08) to 3.13 mmol/l (level 3, SE 0.14), thereby indicating a physiologically plausible escalation in metabolic stress response. The average isometric hand strength was 41.75 kg on the right (SE 0.99) and 38.92 kg on the left (SE 0.94). Similarly, back strength in flexion was 48.87 Nm (SE 1.44) and in extension 57.95 Nm (SE 1.51). No outliers were observed in either case. The investigation revealed that the mobility parameters exhibited a normative distribution within the cohort of athletes (Table 1 in the appendix). The parameters included cervical spine rotation (left: 68.22° ± 0.96; right: 65.66° ± 0.96), finger-floor distance (30.68 cm ± 0.65) and splits ability (left: 128.85 cm ± 0.91; right: 129.85 cm ± 0.91). The differences between the post- and pre-values (Δ values) for the main parameters were compared between the groups using inferential statistics. The relative maximum oxygen uptake (Δ VO₂/KG) demonstrated a marked advantage for the active group (t = 3.67; p = 0.0003), with the therapeutic treatment resulting in an average increase of 2.58 ml/min/kg (see Table 2 in the appendix for details). Absolute VO2max values demonstrated a positive trend (t = 1.85; p = 0.0655), while systolic and diastolic blood pressure exhibited no significant differences (p > 0.05 in each case), emphasizing the specificity of the effect on aerobic metabolic capacity. The present study demonstrated a significant reduction in lactate accumulation after exercise in the active group across all three levels. Specifically, in level 1, the mean decrease in lactate was –0.11 mmol/l (t = –4.41; p < 0.0001). In level 2, the mean decrease was –0.19 mmol/l (t = –5.09; p < 0.0001), and in stage 3, the mean decrease was –0.26 mmol/l (t = –5.43; p < 0.0001). These findings indicate a substantial decrease in lactate levels in the active group compared to the control group (Table 3 in the appendix). This consistent series of findings indicates improved lactate utilization, an increased anaerobic threshold and increased metabolic efficiency because of the osteopathic treatment. The analysis of mobility revealed significant improvements. The difference in cervical spine mobility (a combination of flexion, extension, lateral flexion and rotation) increased significantly in the active group (t = 3.39; p = 0.0009). The CMD measurement indicated a 0.79 mm increase in jaw opening (t = 3.64; p = 0.0004), an improvement of 1.20 cm (t = 5.43; p < 0.0001) in finger-floor distance, and a 1.59 cm increase (t = 3.44; p = 0.0007) in split performance (see Table 4 in the appendix for details). Furthermore, a substantial enhancement in SIAS rotation for mapping pelvic mobility was observed (t = –3.61; p = 0.0004) (Table 5 in the appendix). The results of this study indicate not only increased muscular flexibility, but also structural harmonization of osteofascial and neuromuscular system components. A significant increase in isometric muscle strength was observed across all measurement domains. While the controlled trend in the control group remained marginal, leg strength in the active group increased by an average of 16.02 kg (t = 5.92; p < 0.0000001) (Table 10 in the appendix). The results of the study demonstrated a significant increase in hand strength, with an average gain of 0.75 kg (t = 3.95; p = 0.000108) for both hands (see Table 11 in the appendix). Additionally, back strength exhibited a notable enhancement, with an average increase of 5.32 Nm (t = 5.64; p < 0.0000001) (see Table 18 in the appendix). These homogeneous, system-wide increases in strength underscore the ability of osteopathic treatment to optimize neuromuscular recruitment patterns and strengthen muscular tension lines globally. To assess the practical significance of the findings, Cohen's d was calculated to be 0.52 for the effect on Δ VO₂/KG. As demonstrated in Table 6 in the appendix, minor effects (d < 0.3) were observed for absolute strength parameters and blood pressure changes. The mean effect size for the change in VO₂/kg indicates that the treatment results in a clinically significant enhancement in aerobic performance. Regression analyses were utilized to provide further insights into the causal relationship. A simple linear model with group membership as a predictor for Δ VO₂/KG explained 6.4% of the variance (R² = 0.064; β = 2.58; t = 3.67; p < 0.001) (Table 7 in the appendix). The multiple models, which additionally took gender, body weight and baseline VO₂max into account, increased the degree of explanation to 9.1% (R² = 0.091). While the treatment characteristic continued to exert a substantial effect (β = 2.77; t = 3.93; p < 0.001), gender emerged as a significant moderator (male: β = 2.18; t = 2.24; p = 0.026), while body weight and VO₂max remained nonsignificant (Table 8 in the appendix). The findings indicate that the observed enhancement in relative oxygen uptake is predominantly attributable to the treatment, rather than being attributable to baseline characteristics such as weight or fundamental fitness levels. Regarding the metabolic response (Δ lactate level 3), the multiple models documented a mean explanatory power of 15% (R² = 0.150). The group variable demonstrated a negative and significant effect (β = –0.58 mmol/l; t = –5.53; p < 0.001), while gender, weight and baseline VO₂max were found to be non-significant (Table 9 in the appendix). This finding indicates that the observed reduction in lactate levels is predominantly group-specific and was not influenced by demographic or physiological baseline characteristics. The fourth hypothesis proposed a positive linear relationship between the change in trunk strength and the change in leg strength. This hypothesis was confirmed with Pearson's r = 0.348 (p < 0.000001) (see Table 12 in the appendix). This moderate yet substantial correlation signifies a cross-system neuromuscular adaptation, thereby substantiating the hypothesis that enhanced trunk stability is associated with augmented leg strength. Extensive statistical analysis indicates the presence of robust, multi-causal effects of manual osteopathic treatments: targeted optimization of muscular tension lines, promotion of fascial flexibility and harmonization of neuromotor chains. These factors have been demonstrated to increase both aerobic and anaerobic performance. These findings confirm all four hypotheses and provide a robust evidence base for the integration of osteopathic treatments into performance optimization and rehabilitation programmes. It is recommended that subsequent studies examine the long-term effects, dosage parameters and potential synergies with physical training, with a view to furthering our understanding of the underlying mechanisms. 4 Discussion In this clinical comparative study, 200 healthy, physically active adults were assigned to either an treatment group or a control group in order to investigate the effects of a standardised series of osteopathic treatments on physiological performance parameters. The treatment comprised four 90-minute sessions, scheduled over a period of eight to twelve weeks. During this time, manual techniques were executed in accordance with a protocol that had previously been validated. All measurements were conducted prior to and following the treatment, with the administration of these tests conducted by an independent performance institute. This method ensured the test administrators were unaware of the subjects' performance, thereby ensuring the collected data were both objective and reliable (Andersson et al., 2024 ). Statistical analysis was performed using paired t-tests at a significance level of α = 0.05. 4.1 Metabolic efficiency A key finding is the significant reduction in blood lactate levels in all three submaximal exercise levels in the treatment group compared to the control group (level 1: t = − 4.41, p < 0.001; level 2: t = − 5.09, p < 0.001; level 3: t = − 5.43, p < 0.001). This decline in lactate levels is indicative of enhanced metabolic efficiency, which can be attributed to improved microcirculation, augmented capillary density, and elevated activity of lactate oxidation enzymes within muscle cells. To the best of the present author's knowledge, no comparable studies of osteopathic treatments in competitive sports with metabolic endpoints have been carried out to date. This finding provides new evidence for metabolic adaptations through manual techniques (Rao et al., 2022 ; Ward et al., 2012 ). 4.2 Cardiovascular adaptation In addition to the metabolic parameters, the treatment group demonstrated a significantly lower heart rate (t = − 2.39; p = 0.0176) during submaximal and maximal exercise. This reduction is indicative of a favourable shift in autonomic balance, with increased vagal influence and reduced sympathetic activity. Theoretically, these effects can be explained by improved baroreflex sensitivity as a result of thoracic and cervical mobilisations, which promote faster heart rate adaptation and stable circulatory regulation. As demonstrated in the research conducted by Jackson et al. ( 2024 ) and Cerritelli et al. ( 2020 ), a similar dose-dependent effect on blood pressure and heart rate has been observed in longer-term osteopathic studies. 4.3 Aerobic capacity The aerobic capacity of the subjects was determined on the basis of relative oxygen uptake (VO₂/kg) and absolute VO₂max. The relative VO₂/kg demonstrated a substantial increase in the treatment group, exhibiting a mean effect size of d = 0.52 (p = 0.0003). In contrast, the change in absolute VO₂max exhibited only a statistical trend, with a trend of t = 1.85 and p = 0.065. The explanatory mechanisms encompass a range of factors, including increased thoracic compliance, leading to enhanced alveolar ventilation. Additionally, increased peripheral blood flow contributes to a greater arteriovenous oxygen difference. Previous studies on the improvements of VO₂max were often limited to small samples or competitive athletes; the present study expands the understanding to include a heterogeneous cohort of healthy adults (Haberl, 2009 ). 4.4 Muscle strenght The effects on maximum muscle strength proved to be particularly pronounced. The investigation revealed a mean increase in isometric leg strength of 16.02 kilograms (t = 5.92; p < 0.00000002) subsequent to the treatment series. Additionally, a significant augmentation in trunk strength was observed (t = 5.64; p < 0.0000001), along with a 0.75-kilogram increase in the combined grip strength of both hands (t = 3.95; p = 0.0001). The enhanced systemic strength gains can be attributed to the improved neuromuscular control processes, which encompass a reduction in myofascial tension and optimised muscle-tendon control. Documented short-term strength gains after individual OMT sessions have been shown to disappear after a few minutes (Grindstaff et al., 2009 ; Monteiro et al., 2021 ). However, the effects documented here, which persist for weeks, underscore the need for repeated mechanical stimuli for sustainable strength gains. 4.5 Functional mobility The functional mobility of the subjects improved significantly in almost all areas examined. The following improvements were recorded: several degrees of increased mobility of the cervical spine (t = 3.39; p = 0.0009), an increase of approximately 2 mm in maximum vertical jaw opening (t = 3.64; p = 0.0004), an increase of 3.5 cm in finger-floor distance (t = 5.43; p < 0.0001) and a significant improvement in split ability (right and left) (e.g. an increase in front split position: t = 3.44; p = 0.0007). Furthermore, the SIAS analysis demonstrated a substantial decrease in the distance between both iliac crest points, suggesting enhanced pelvic alignment and stability (t = − 3.61; p = 0.0004). These results lend further support to the existing body of evidence pertaining to the efficacy of myofascial release and muscle energy techniques, while concomitantly extending these techniques by providing empirical data on lumbopelvic statics (Sandell et al., 2008; Ogando-Berea et al., 2024 ). Physiological mechanisms underpin the observed effects, which can be attributed to several factors. Osteopathic mobilisations have been demonstrated to release myofascial restrictions, increase tissue perfusion and compensate for mechanical imbalances. Improved tissue perfusion has been demonstrated to promote oxygen supply and accelerate lactate breakdown (Jones et al., 2022). Greater mobility has been shown to reduce biomechanical efficiency and thus alleviate metabolic stress for the same level of performance (Smith et al., 2021). Increases in strength have been shown to reduce the relative load on individual muscle groups during standardised tests, which contributes to lower lactate levels. Furthermore, enhanced vagal regulation has been demonstrated to result in heart rate attenuation and cardiovascular stabilisation. 4.6 Strengths and limitations The study's merits include a substantial sample size, a standardized protocol, the blinding of the test administrators, and the utilization of objective performance parameters. This combination meets quality criteria rarely seen in osteopathic research to date (Alvarenga et al., 2018 ; Detoni et al., 2022 ). The limitations of the present study are as follows: firstly, the therapists were not blind to the treatment; secondly, there were potential expectation effects; thirdly, the training status, nutrition and recovery patterns were not controlled; and fourthly, there was an absence of follow-up measurements to assess long-term effects. Subgroup analyses, including those on vaccination status, are exploratory in nature and should be explored in greater depth in future studies with higher statistical power. In summary, the present study demonstrates that manual osteopathic treatments in healthy, physically active adults lead to significant improvements in metabolic efficiency, autonomic cardiovascular regulation, aerobic capacity, maximal muscle strength, and functional mobility. The results of the study suggest that OMT can be used as an integrative approach in competitive and recreational sports as well as in rehabilitation programmes. To establish a more comprehensive evidence base, it is recommended that future studies investigate the long-term effects, different treatment intensities and the underlying cellular mechanisms. 5 Conclusion In this clinical comparative study, a total of 200 healthy adults who regularly engage in physical activity were investigated. The influence of a series of osteopathic treatments was investigated; these treatments were standardized and consisted of four 90-minute sessions over eight to twelve weeks. The treatment had a variety of physiological performance parameters as its focus. The participants were divided into two groups: a treatment group and a control group. Only the former received osteopathic treatment. All pre- and post-treatment measures were carried out by an independent performance institute. This ensured that the test administrators were blind to the group allocation, thus ensuring objectivity and reliability (Andersson et al., 2024 ). A study was conducted to analyze body composition using bioelectrical impedance and to monitor body mass index. The results demonstrated that there were no significant changes, indicating that manual osteopathic techniques do not modulate fat percentage or macroscopic body measurements in the short term (Zago et al., 2021 ). After four sessions, blood pressure measurements demonstrated no statistically significant differences, although a slight downward trend was observed in the treatment group. This finding suggests that more prolonged or frequent treatments may be required to induce cardiac regulatory adjustments (Jackson et al., 2024 ; Cerritelli et al., 2020 ). In contrast, the treatment series induced substantial cardiovascular and metabolic adjustments. In both submaximal and maximal exercise conditions, the heart rate of the active group demonstrated a significant decrease (t = − 2.39; p = 0.0176), indicating a shift in autonomic balance towards increased vagal activity and reduced sympathetic tone. As demonstrated by Ward et al. ( 2012 ), thoracic and cervical mobilizations have been shown to promote increased baroreflex sensitivity and optimize cardiac preload and afterload. This, in turn, results in a decrease in heart rates at a constant cardiac output (Ward et al., 2012 ). Metabolic efficiency was found to improve significantly across all three submaximal exercise stages of the step test. This was accompanied by a substantial decrease in lactate levels (stage 1: t = − 4.41; p < 0.001; stage 2: t = − 5.09; p < 0.001; stage 3: t = − 5.43; p < 0.001). This phenomenon has been attributed to the optimization of microcirculation, an increase in capillary density, and elevated activity of lactate oxidizing enzymes within the muscles. To date, there have been few systematic studies on the effects of osteopathy on lactate metabolism in sport, so these results provide novel insights (Rao et al., 2022 ). Regarding the subject's aerobic capacity, a highly significant increase in relative maximum oxygen uptake (VO₂/kg) was observed, with an effect size of d = 0.52 (p = 0.0003). It has been demonstrated that enhanced thoracic compliance engenders an augmentation in alveolar ventilation. Concurrently, fascial mobilization of the extremities has been shown to increase perfused muscle mass, thereby resulting in an escalation in the arteriovenous oxygen difference. Despite the absence of a statistically significant correlation between absolute VO2max and the treatment outcomes, it is important to note that central limitations, such as cardiac output and pulmonary diffusion, presumably require longer or more intensive treatments in order to be substantially influenced (Haberl, 2009 ). The treatment had a substantial positive effect on maximal muscle strength across all domains. Isometric leg strength increased by an average of 16.02 kg (t = 5.92; p < 0.00000002), trunk strength increased significantly (t = 5.64; p < 0.0000001), and grip strength in both hands improved by approximately 0.75 kg (t = 3.95; p = 0.0001). The enhanced systemic strength gains can be attributed to several factors, including optimized neuromuscular recruitment, reduced myofascial restrictions, and increased muscle tension lines. While short-term studies following a single OMT session have been able to demonstrate effects lasting only a few minutes (Grindstaff et al., 2009 ), the present study documents, for the first time, sustained strength gains over a period of weeks (Monteiro et al., 2021 ). A marked improvement in functional mobility was observed in almost all areas that were examined. The findings revealed a substantial increase in combined cervical spine mobility (t = 3.39; p = 0.0009), accompanied by a notable augmentation in maximum vertical jaw opening of several millimeters (t = 3.64; p = 0.0004). Additionally, an average reduction of 3 millimeters was observed in finger-floor distance. Mean improvement in the ability to perform the splits, measured in both the straddle position and straight splits, was found to be significant (p < 0.0001; t = 5.43). The improvement was particularly marked in the straddle position (t = 5.24; p < 0.001) and in the straight splits (t = 3.44; p = 0.0007). The SIAS analysis demonstrated a substantial decrease in the pelvic spurs distance (t = − 3.61; p = 0.0004), suggesting optimized lumbo-pelvic statics and symmetry (Sandell et al., 2008; Rehana, 2025 ). Multiple regression analyses demonstrated that combined changes in muscle strength and flexibility already explained 16% of the variance in mean lactate reduction in the submaximal tests (strength: β = − 0.0199; p < 0.001; flexibility: β = − 0.0135; p = 0.001). In an extended model that additionally considered stride length and heart rate difference, the explained variance increased to 26% (stride length: β = − 0.0117; p = 0.032; HR difference: β = 0.0235; p < 0.001). This finding underscores the direct link between functional performance improvements and increased metabolic efficiency. In conclusion, the present study demonstrates that when osteopathic treatments are standardized and repeated in healthy athletes, there is a comprehensive enhancement of metabolic, cardiac, muscular and mobility-related performance parameters. The findings provide the first empirical evidence that OMT induces neurovegetative, vascular and neuromuscular adaptations that extend beyond the scope of short-term relaxation effects. From a clinical perspective, this development has significant potential for application in a variety of fields, including competitive sports, rehabilitation, and injury prevention. The utilization of this approach may lead to a multifaceted enhancement of key performance indicators such as strength, endurance, and mobility. Furthermore, it has the potential to mitigate the risk of injury, thereby promoting optimal physical well-being and performance. Concomitantly, methodological limitations – namely, the absence of therapist blinding, uncontrolled influencing factors such as nutrition or training status, and exclusively short-term follow-up measurements – underscore the necessity for additional large-scale, long-term studies. In such studies, different treatment doses, immunological modulations, and molecular mechanisms should be systematically investigated. Abbreviations ANCOVA analysis of covariance BMI body mass index cm centimeter et. al. et alii etc. et cetera kg kilogram le left max. maximum min minute ml milliliters N number of participants O 2 oxygen OMT osteopathic manual treatment post after pre before ri right v volume VOD Verband der Osteopathen Deutschland Declarations Ethics statement I completed my dissertation at St. Elisabeth University in the Department of Public Health in Bratislava. My supervisor was Prof. MUDr. Milan Luliak, PhD. Every study involving human subjects requires the approval of the ethics committee. I received this approval in the normal manner from St. Elisabeth University. Acknowledgements I would like to express my special thanks for the excellent guidance and support provided by Professor MUDr. Milan Luliak, PhD, who contributed his professional input to this study and supported me with efficient discussions. In addition, I would like to thank the Unique Connect practice team, especially Sophia Schwab, Jana Müller, and Alexander Haas, for their invaluable support throughout the study. References Alvarenga BAP, Fujikawa R, João F, Lara JPR, Veloso AP (2018) The effects of a single session of lumbar spinal manipulative therapy in terms of physical performance test symmetry in asymptomatic athletes: A single-blinded, randomised controlled study. 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Online unter: https://www.mynewsdesk.com/de/verband-der-osteopathen-deutschland/pressreleases/forsa-umfrage-zur-osteopathie-fast-jeder-fuenfte-war-bereits-beim-osteopathen-strich-hohe-zufriedenheit-verunsicherung-hinsichtlich-ausbildung-2572039 , abgerufen am 22.04.2025 Ward JS, Coats J, Ramcharan M, Humphries K, Tong T, Chu C (2012) Thoracolumbar spinal manipulation and the immediate impact on exercise performance. J Chiropr Med 11:233–241 World Health Organization (2010) Benchmarks for training in traditional / complementary and alternative medicine: Benchmarks for training in osteopathy . https://iris.who.int/handle/10665/44356 Zago J, Amatuzzi F, Rondinel T, Matheus JP (2021) Osteopathic Manipulative Treatment Versus Exercise Program in Runners With Patellofemoral Pain Syndrome: A Randomized Controlled Trial. J Sport Rehabilitation 30(4):609–618. https://doi.org/10.1123/jsr.2020-0108 Additional Declarations The authors declare no competing interests. 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13:56:43","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":39762,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-8287443/v1/cbc996abe8d5f6022fbee5cf.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eEffect of manual osteopathic treatments on physical performance\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eThe preservation and restoration of human health are widely acknowledged as fundamental cornerstones of social coexistence and are recognized as a universal human right. The United Nations Universal Declaration of Human Rights (UDHR) already formulates health as a fundamental right, the preservation of which benefits not only the individual but society. From an economic perspective, it is indisputable that the performance of human capital exerts a significant influence on economic productivity. Concurrently, the direct and indirect costs of medical care escalate with age, thereby imposing substantial financial challenges on healthcare systems (Schwartz et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). In this context, the question of whether innovative or complementary treatment approaches can be used to promote the health of the population in the long term while reducing healthcare expenditure is becoming increasingly important.\u003c/p\u003e\u003cp\u003eOne potential response to this enquiry pertains to osteopathic medicine, a field that has witnessed a consistent escalation in both acceptance and demand since its genesis over a century and a half ago. In Germany and numerous other countries, the utilization of osteopathic treatments is on the rise, encompassing not only the management of degenerative and acute musculoskeletal complaints, but also extending to the domains of prevention and general health promotion. Recent surveys conducted by the Association of Osteopaths in Germany (VOD) have indicated a consistent increase in the number of osteopathic consultations over recent years (VOD, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The increasing utilization of osteopathic treatments for infants and children is indicative of a growing perception of osteopathy as a holistic health strategy (Anheyer et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe genesis of osteopathy can be traced back to the late 1870s, when the American physician Andrew Taylor Still advanced a critique of conventional medical practices that was unorthodox for the time. The prevailing hypothesis suggests that structural dysfunctions within the musculoskeletal system and visceral organ systems play a significant role in the development of symptoms. The approach of regulating somatic structures primarily through manual mobilization and manipulation is widely considered to have marked the beginning of a separate discipline in complementary medicine (Franke et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe osteopathic approach is predicated on three fundamental principles: the unity of structure and function, the inherent capacity for self-regulation in healing processes, and the significance of maintaining an undisturbed vascular and nervous system for optimal health.\u003c/p\u003e\u003cp\u003eDuring the 20th century, the original mechanical concept underwent an expansion that incorporated significant findings from the disciplines of biophysics and psychosomatics. The organism's conception shifted from that of an isolated mechanical apparatus to that of a dynamic system, wherein physical, biochemical and psychosocial factors interact in a constant state. This paradigmatic expansion enabled a deeper scientific foundation for osteopathic techniques and led to the integration of neurophysiological concepts and systemic therapeutic approaches. Concurrently, there was an increase in the demand for scientific testing of osteopathic procedures. This was facilitated by clinical comparative studies and meta-analyses, which increasingly demonstrated the efficacy of manual spinal procedures and visceral mobilization. The therapeutic relationship, defined as the quality of the interaction between practitioner and patient, also became a focal point of research. This is due to the recognized role of psychosocial effects in subjective perception and treatment success (Reinhardt, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAt present, manual osteopathic therapy (OMT) comprises a broad spectrum of procedures that can be categorized into three fundamental areas of application: the visceral area, which concentrates on the mobilization of internal organs and their surrounding fascia; the parietal or biomechanical area, which addresses joint, muscle and fascia structures; and the craniosacral area, which encompasses the skull, spinal cord and nervous system facets. The techniques employed in this context range from myofascial release and neural dynamic loop mobilization to high-velocity low-amplitude (HVLA) manipulation. The combination of these techniques is intended to restore structural balance, improve neurovascular regulation and promote autoregulatory healing processes (Herring et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Jonas, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA contemporary trend in osteopathic research involves the utilization of neuroimaging techniques to visualize the effects of manual stimuli on cerebral and spinal network activity. Preliminary studies employing functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) have indicated that osteopathic mobilizations can prompt immediate alterations in brain regions implicated in pain processing, somatosensory integration, and autonomic functions (Cerritelli et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe findings of this study suggest that osteopathy exerts its effects not only at the local level on tissue, but also on central regulatory mechanisms.\u003c/p\u003e\u003cp\u003eNotwithstanding these scientific advances, the regulatory landscape for osteopathy remains inconsistent on an international level. Whilst a number of countries, including Switzerland, the United Kingdom, Belgium and Iceland, have established specific legal regulations and formally recognized osteopathy as a distinct profession with its own training requirements, many other countries have yet to implement such formal standards. It is evident that global umbrella organizations, including the Osteopathic International Alliance and the World Osteopathic Health Organisation, are endeavoring to achieve harmonization in training and professional practice. However, there is an absence of binding minimum requirements (World Health Organisation, 2010). Concurrently, the World Organisation of Traditional Medicine (WOM) advocates the establishment of a uniform minimum standard to ensure security and quality of care.\u003c/p\u003e\u003cp\u003eIn Germany, the practice of osteopathic techniques is subject to current legislation, which restricts its application to licensed doctors and alternative practitioners. The objective of this regulatory framework is twofold: firstly, to mitigate risks pertinent to patient safety and, secondly, to guarantee the standard of care provided. The practice of osteopathy that is not authorized by the relevant authorities is subject to legal sanction. Furthermore, the integration of osteopathy into the healthcare system necessitates close interdisciplinary exchange with conventional disciplines (Ehmke, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). A significant challenge that remains to be addressed is the participation of osteopathy in scientific networks and research consortia, with a view to promoting evidence-based anchoring in the national healthcare system.\u003c/p\u003e\u003cp\u003eIn the context of demographic shifts and escalating healthcare expenditures, the public health paradigm is assuming an increasingly pivotal role. The prevailing paradigm regarding health has shifted from a perspective of individual responsibility to a more collective understanding, necessitating the collection of forward-looking data, proactive prevention strategies, and interdisciplinary collaboration. In such a population protection approach, the focus is on both the management of large data sets and the consideration of individual needs. In particular, with respect to the financing of age-care-intensive population groups, it appears imperative to identify treatment methods that incur comparatively low follow-up costs and concurrently exert a preventive effect (Knecht et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe concept of physical performance is pivotal in establishing a logical and methodological link between osteopathy and public health. In the domain of sports science, it encompasses all the motor skills \u0026ndash; strength, endurance, speed, agility and coordination \u0026ndash; that are necessary to meet specific performance requirements (Schnabel et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Numerous studies have investigated the effects of training programmes on these dimensions. However, there has been no systematic evaluation of whether manual osteopathic treatments can directly influence physiological parameters without accompanying training. Specifically, data concerning lactate kinetics after exercise, changes in maximum strength and functional mobility in healthy individuals are lacking.\u003c/p\u003e\u003cp\u003eA substantial proportion of earlier clinical studies have focused on patient groups with existing musculoskeletal complaints, chronic pain or postoperative functions. The efficacy of osteopathy in reducing pain and enhancing quality of life has been demonstrated. However, a scientific gap remains in testing these techniques beyond therapeutic indications regarding performance enhancement in healthy subjects. Consequently, there is an absence of reliable data indicating whether osteopathy serves as an independent means of performance optimization, and if so, to what extent.\u003c/p\u003e\u003cp\u003eThe present study aims to address a research gap by examining the effects of a standardized series of manual osteopathic treatments on objective performance parameters in healthy adults who exercise regularly. Contrary to the focus of preceding studies, which have chiefly examined causal effects in pain patients, the present study focuses on physiological endpoints such as blood lactate after maximum exertion, maximum strength, and functional mobility. The experimental design will be of the clinical comparison variety, with the subjects divided into two groups: an active group and a control group. The experiment will employ pre-post measurements to ascertain whether osteopathy can bring about a significant improvement in motor skills in the absence of additional training. The results of this study will provide information about direct biomechanical and metabolic effects, as well as implications for long-term cost reduction in the healthcare system. Concurrently, they will contribute to the evidence base, which is imperative for the structured integration of osteopathy into national and international healthcare systems.\u003c/p\u003e"},{"header":"2 Methodology","content":"\u003cp\u003eThe present study investigates the extent to which standardized manual osteopathic treatments impact the physical performance of healthy adults who engage in regular exercise. The focus of this study is a clinical comparative study that systematically compares two study arms: an active group receiving manual osteopathic treatment and a control group without therapeutic treatment. The objective of this study is to identify the causal effects of osteopathic treatments on objective performance parameters, including blood lactate, maximum strength, and functional mobility. The methodology has been meticulously devised to ensure high internal validity: all treatment procedures adhere to a comprehensive standard operating procedure, and measurements are obtained under strictly controlled conditions. The study design, participant recruitment, implementation of the treatment, measurement techniques used, data protection measures and statistical procedures have been meticulously crafted to minimize external confounding factors and ensure reliable data analysis.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study design and participants\u003c/h2\u003e\u003cp\u003eThe study was designed as a clinical comparative study. The research team recruited a total of two hundred subjects, who were divided equally into two groups: the active group, which received four manual osteopathic treatments, and the control group, which did not undergo any therapeutic treatment. The study director was responsible for the allocation of participants to the study arms, ensuring that both groups were comparable in terms of key demographic characteristics such as age distribution, gender and performance level (distinguishing between recreational athletes and ambitious athletes). The employment of a targeted cross-sectional design facilitated the isolation of differences in treatment effects. The study encompassed an observation period of approximately twelve weeks. Prior to the commencement of the study, all participants were comprehensively informed about the procedure, time frame and obligations. Written consent forms were obtained from all participants via an online platform.\u003c/p\u003e\u003cp\u003eThe selection of test subjects was carried out in a targeted manner via various channels to generate a representative sample. The local recruitment base for the study comprised posters in physiotherapy practices at two central locations in southern Germany. These were complemented by targeted online advertising on social media channels. Furthermore, newsletters from the diagnostic center were used to directly address people who are active in sports. An integral component of the pre-selection process was the administration of online pre-screening, which interested parties were invited to complete on a designated landing page. In addition to contact details, the form requested self-reported information on physical fitness, including the ability to run at 11 km/h on a treadmill for three minutes, as well as a binding commitment to maintain the usual lifestyle during the study period. These aspects were pivotal in ruling out acute alterations in training or nutrition that could distort the results.\u003c/p\u003e\u003cp\u003eThe inclusion and exclusion criteria were meticulously delineated to ensure a homogeneous study population and to minimize potential confounding factors. The inclusion criteria encompassed individuals between the ages of 14 and 80, possessing a fundamental level of physical fitness, adequate proficiency in German or English, and the capacity to readily access the designated study locations. Furthermore, it is imperative to note that minors require the explicit consent of their legal representatives. Subjects who had been advised by their doctor not to participate in sports, had recently undergone surgery, had chronic conditions such as diabetes, were taking long-term medication with anti-inflammatory agents, or were involved in high-performance sports were systematically excluded from the study. Exclusion criteria included acute infections, clinically relevant cardiovascular diseases, and pregnancy. Prior to the commencement of the study, a thorough medical history was obtained, encompassing a medical examination, to ascertain the absence of any contraindications for the stress tests and osteopathic treatments. The defined discontinuation criteria \u0026ndash; such as pregnancy detection, sudden onset of illness or a significant change of residence \u0026ndash; enabled a flexible yet ethically responsible study procedure.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Treatment: Standardized osteopathic treatment\u003c/h2\u003e\u003cp\u003eThe active group received four manual osteopathic treatment sessions, which were carried out according to a standard operating procedure (SOP) that had been specially developed for this purpose. Each session was scheduled to last for a duration of 90 minutes, with an approximate margin of error of \u0026plusmn;\u0026thinsp;5 minutes. The intervals between appointments were measured in days, with a range of seven to fourteen days, to allow for the physiological adaptation processes that occur in the tissue. The treatments were administered by osteopaths who had been state-approved, with an average of eight years of professional experience and at least 1,500 hours of postgraduate training. In 86 per cent of cases, the same therapist attended all four sessions of a test subject to minimize variability due to different practitioners. In the event of unavoidable scheduling conflicts, a structured written handover was carried out using detailed findings and palpation protocols.\u003c/p\u003e\u003cp\u003eThe SOP-based procedure invariably commenced with a systematic inspection and palpation. The programme encompassed viszerofaszialer mobilization techniques, neural dynamic procedures according to Butler, myofascial release techniques, diaphragmatic mobilizations, articulating procedures and high-velocity low-amplitude (HVLA) manipulations of the pelvic ring and upper thoracic segments. The application of each individual technique was meticulously recorded with time stamps, lateralized information and written documentation in the digital case report form. Throughout the treatment period, the subjects were required to report their pain levels on a numerical pain scale ranging from 0 to 10, enabling continuous assessment of tolerability. The environment was maintained at a constant temperature (22\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u0026deg;C), the lighting was dimmed, and standardized positioning aids were employed to ensure reproducible starting positions in the supine or lateral position.\u003c/p\u003e\u003cp\u003eFor quality assurance, a comprehensive 'red flag' screening was performed prior to each HVLA manipulation. This evaluation utilized the Ottawa criteria, the Alar ligament test and pain progression. Adverse events were recorded immediately following treatment and subsequently via telephone communication 48 hours later. Overall, mild, self-limiting initial worsening lasting less than 24 hours was documented in 12 per cent of the sessions; no serious side effects occurred. An external video spot check of 10 per cent of all treatments revealed 92 per cent SOP compliance, meaning that treatment fidelity can be classified as high. The control group, on the other hand, did not receive any osteopathic treatment; they only underwent pre- and post-measurements at the same time intervals to reflect natural temporal changes without treatment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Measuring instruments and outcome parameters\u003c/h2\u003e\u003cp\u003eThe fundamental parameters of this study are blood lactate levels following exercise, maximum strength, and functional mobility. In order to ensure the highest possible measurement quality, established, valid and reliably tested instruments were used.\u003c/p\u003e\u003cp\u003eLactate spiroergometry was utilised as the integrative performance indicator. Test subjects were required to complete a standardised protocol on a treadmill (11 km/h for three minutes) under increasing stress, during which capillary blood lactate was measured immediately afterwards and at defined times after exercise. The calibration of the lactate measuring device prior to each session ensured precision and reproducibility. The lactate values obtained were utilised for both pre-post comparison within the groups and for intergroup comparison post-treatment.\u003c/p\u003e\u003cp\u003eThe measurement of maximum strength was conducted using a Baseline Hydraulic Hand Dynamometer. The test subject performed a maximum isometric contraction of the finger flexors for a duration of three seconds, commencing from a standardised starting position \u0026ndash; unencumbered by footwear, with feet positioned shoulder-width apart on a stable surface, measuring arm relaxed and hanging down at the side, with the elbow fully extended. The adjustable handle was fixed at the narrowest grip width for all test subjects in order to ensure maximum comparability between measurements. Each hand was subjected to three distinct tests, with the highest individual value being utilised for the subsequent statistical evaluation. Regular calibration checks ruled out deviations of more than \u0026plusmn;\u0026thinsp;1 kg. The test-retest reliability of the method is ICC\u0026thinsp;\u0026gt;\u0026thinsp;0.95, thus confirming its status as the gold standard in clinical research.\u003c/p\u003e\u003cp\u003eThe functional mobility of the participants was assessed using a series of standardised tests. The sit-and-reach test was utilised to assess the flexibility of the dorsal muscle and fascia chain, employing the Baseline model 12-1085 as the measuring instrument. The subjects of the experiment were seated on the floor with their legs fully extended and positioned hip-width apart. They were instructed to perform a controlled forward bend. The maximum finger reach was measured using an integrated slide gauge. The experiment was conducted within an air-conditioned chamber (22\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u0026deg;C) during the morning hours, from 8:00 to 10:00 a.m., with the objective of eliminating the possibility of circadian fluctuations from affecting the results. Each test subject completed one trial run and two valid runs, with a 30-second break allocated between each run. The higher value was utilised as a measure of flexibility. The measurement of the maximum active mouth opening as the interincisal distance was conducted using a digital caliper from Steinle. The measurement was initially taken in an upright sitting position on a fixed wooden chair, followed by a kyphotic lumbar spine position, with the objective of investigating postural differences. Prior to each measurement, a zero calibration and a plausibility check were performed using a 50 mm gauge block. The measurement accuracy was found to be 0.01 mm, and the ICC of the double measurement was 0.93. The transfer of all values was conducted directly to an electronic case report form.\u003c/p\u003e\u003cp\u003eThe mobility of the cervical spine was determined using the three-axis Cervical Range of Motion System (CROM\u0026trade; 3). The device under scrutiny consists of a headband-integrated unit that measures flexion/extension, lateral flexion and rotation on separate scales. The test subject was seated upright on a stool with 90\u0026deg; hip and knee flexion, and all scales were adjusted to neutral 0\u0026deg; prior to each measurement. Each direction of movement was tested thrice, with compensatory movements documented and repeated in case of deviations. The measurement intervals and breaks were meticulously designed to minimise muscular fatigue or learning effects. A circumference measurement was taken at the level of the anterior superior iliac spine in order to record the abdominal-thoracic respiratory excursion. The measurement of inspiratory and expiratory circumferences was conducted using a non-elastic tape measure applied horizontally, with the utmost care taken to avoid any tissue compression. The discrepancy between these values thus represented the respiratory excursion. In instances where deviations exceeded 0.5 cm, the measurements were repeated to ensure the reliability within each individual.\u003c/p\u003e\u003cp\u003eFurthermore, fundamental parameters such as body mass index, resting blood pressure and body fat were documented. The height and weight of the subjects were determined using SECA calibrated measuring devices, and the BMI of the subjects was calculated using the internationally established formula. The measurement of resting arterial blood pressure was conducted in accordance with established methodology, employing an upper-arm sphygmomanometer as the instrument. The protocol entailed the acquisition of two measurements spaced one minute apart, with a third measurement obtained in instances of significant deviation from the mean. The determination of body fat percentage was conducted through the utilisation of the Futrex 6100/XL near-infrared interaction system. The midpoint of the ventral biceps brachii muscle was utilised as the measurement point, which was marked and measured three times with the optical probe to obtain an average value. The utilisation of these supplementary parameters was instrumental in the comprehensive characterisation of the test subjects, thereby facilitating the regulation of potential confounding variables.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Data collection and security\u003c/h2\u003e\u003cp\u003eFrom the initial contact onwards, all personal data was pseudonymized. Each participant was assigned a unique identification number (study ID), which was utilized to maintain a record of all survey documents and measurement data. The allocation of study identifiers to actual identities was conducted exclusively by the study director and was kept distinct from the research data. The employees of the diagnostic center and all therapists involved were bound by strict confidentiality obligations. Following the conclusion of the study, all data carriers were archived on external hard drives, password-protected, and stored in a location with restricted access. To ensure the confidentiality of the subjects, all data was anonymized for subsequent publication.\u003c/p\u003e\u003cp\u003eThe collection of data was conducted in two stages. Subjective information was obtained through the utilization of standardized online and paper questionnaires, which were completed prior to the administration of pre- and post-diagnostic assessments. In addition to contact and health data, the questionnaires included items on physical activity, lifestyle habits and psychosocial well-being. Concurrently, objective clinical measurements from the diagnostic center, conducted by trained assistants with degrees in sports science, were entered into the database. This multi-faceted approach was adopted to ensure that both the perceptual and physiological dimensions of performance could be given due consideration.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Research question and hypotheses\u003c/h2\u003e\u003cp\u003eThe objective of the present study is to elucidate the impact of standardized manual osteopathic treatments on the physical performance of healthy adults who engage in regular exercise. Two overarching research questions and five associated hypotheses have been formulated:\u003c/p\u003e\u003cp\u003eThe following research question is proposed: The objective of this study is to examine the alterations in key performance parameters, specifically blood lactate accumulation, maximum power output and functional mobility, subsequent to a series of four standardized osteopathic manipulations, in comparison to an untreated control group.\u003c/p\u003e\u003cp\u003eDescriptive statistics are utilized to address the research question, with paired and independent t-tests or ANCOVA employed to assess pre-post differences within the groups and mean differences between the groups.\u003c/p\u003e\u003cp\u003eThe following four hypotheses (α\u0026thinsp;=\u0026thinsp;0.05) are derived from this research question:\u003c/p\u003e\u003cp\u003eIt is hypothesized that following the conclusion of the treatment series, the post-exercise lactate value of the active group will be significantly lower than that of the control group. The statistical implementation will be conducted using either an independent t-test or an ANCOVA with a baseline covariate. The target variable is blood lactate (mmol\u0026middot;l⁻\u0026sup1;).\u003c/p\u003e\u003cp\u003eIt is hypothesized that the active group will demonstrate a substantial increase in maximum strength (kg) in comparison to the control group. The statistical implementation of the study comprised two distinct tests: the paired t-test, which was utilized to analyze intragroup differences, and the independent t-test, which was employed for intergroup comparisons. The target variable of interest was the primary focus of the study. The first measurement taken is that of the maximum weight that can be lifted once in each of the following exercises: the bench press and the squat.\u003c/p\u003e\u003cp\u003eThe following hypothesis is proposed: The active group demonstrated a significant enhancement in functional mobility (cm) in comparison to the control group. Statistical implementation: Analogous to H2; target variables: sit-and-reach and straight-leg raise.\u003c/p\u003e\u003cp\u003eIt is evident from the findings of H4 that within the active group, there is a positive correlation between the increase in trunk strength and the increase in leg strength. Statistical implementation: Pearson's correlation coefficient, supplemented by linear regression analysis, was utilized to assess the relationship between the target variables, namely the change in trunk strength (Nm) and the change in leg strength (kg).\u003c/p\u003e\u003cp\u003eThe integration of group differences (H1\u0026ndash;H3) and the modelling of predictive relationships (H4) within this design facilitates the documentation of causal effects of manual osteopathic treatments and the identification of potential mechanisms of action within the performance dimensions of lactate kinetics, strength and mobility.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Statistical analysis\u003c/h2\u003e\u003cp\u003eAll data preparation and evaluation were performed using IBM SPSS Statistics Version 29. The central significance level was set at α\u0026thinsp;=\u0026thinsp;0.05 (two-sided). The practical relevance of significant findings was assessed by reporting effect sizes according to Cohen (Cohen, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAt the commencement of the analysis, descriptive statistics were conducted. The measures of location (arithmetic mean, median) and measures of dispersion (standard deviation, interquartile range) were calculated for all dependent and independent variables. Initial indications of deviations from a normal distribution were provided by the skewness and kurtosis values. Furthermore, the creation of histograms, box-whisker plots and scatter plots was undertaken to identify outliers and heuristically visualize potential correlations.\u003c/p\u003e\u003cp\u003eThe subsequent stage of the research involved conducting a bivariate correlation analysis. In instances where the data indicated normality and linearity, the Pearson correlation coefficient was employed. Conversely, in cases where normality and linearity were not supported, the Spearman rank correlation coefficient was utilized. The present study examined the correlations between increases in trunk strength and leg strength, with a view to exploring potential mechanisms behind more effective changes.\u003c/p\u003e\u003cp\u003eTo examine the primary research questions 1 to 3, statistical group comparisons were performed. Intragroup pre-post differences were analyzed using paired t-tests, and intergroup mean comparisons after the treatment were analyzed using independent t-tests. Prior to each test, normality tests (Shapiro-Wilk) and variance homogeneity tests (Levene's test) were performed. In instances where the assumptions were violated, non-parametric alternatives such as the Wilcoxon signed-rank test or the Mann-Whitney U test were employed. A subsequent analysis of covariance (ANCOVA) was performed with baseline value as a covariate to control for initial group differences in blood lactate.\u003c/p\u003e\u003cp\u003eMultivariate regression analysis was utilized to address the fourth and fifth research questions. Multiple linear regression was utilized in the enter procedure to estimate percentage changes in strength and mobility as predictors of post-exercise blood lactate levels. The quality of the model was assessed using the coefficient of determination R\u0026sup2; and its adjusted form. Residual diagnostics were employed to assess linearity, homoscedasticity, normal distribution and multicollinearity. In instances where substantial deviations were observed, robust regression methods or transformation procedures were employed to ensure the estimation process remained unbiased.\u003c/p\u003e\u003cp\u003e The present step-by-step analysis strategy \u0026ndash; initiated with a thorough descriptive description, followed by bivariate correlation analyses, inferential statistical group comparisons and concluded with multivariate regression models \u0026ndash; facilitates a comprehensive examination of the effects of manual osteopathic treatments on physical performance. In the process, both causal differences between the groups and possible mechanisms of action within the active group are differentiated and identified.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eThe present clinical comparative study investigated the extent to which a series of four standardized manual osteopathic treatments modified the physical performance of 200 healthy adults who regularly engaged in physical exercise. The subjects of the study were divided into two groups: an active group that received therapy sessions and an untreated control group. This was done to make a causal distinction between the effects. The metabolic parameters (blood lactate at three exercise levels, absolute and relative VO₂max) and functional performance parameters (isometric muscle strength in the hands, legs and back; mobility of the cervical spine, jaw opening, trunk and leg flexibility; SIAS rotation) were recorded before and after the treatment. The measurements were taken under strictly standardized laboratory conditions (22 ± 1 °C; same time of day), thereby minimizing systematic interference.\u003c/p\u003e\n\u003cp\u003eThe descriptive analysis demonstrated that both groups began with a very homogeneous starting position. The mean systolic blood pressure in the pre-test was 118.48 mmHg (SE 0.94), and the diastolic blood pressure was 75.01 mmHg (SE 0.62). The mean body weight was recorded as 72.46 kg (SE 1.07), with a height of 173.50 cm (SE 0.68), indicating that the body mass index fell within the normal range (see Table 1 in the appendix).\u003c/p\u003e\n\u003cp\u003ePrior to the commencement of treatment, the mean values for VO2max were as follows: 2,849.83 ml/min (SE 56.88) in absolute terms and 40.12 ml/min/kg (SE 0.52) relative to body weight. As anticipated, lactate concentrations increased from 1.14 mmol/l (level 1, standard error [SE] 0.04) to 1.97 mmol/l (level 2, SE 0.08) to 3.13 mmol/l (level 3, SE 0.14), thereby indicating a physiologically plausible escalation in metabolic stress response. The average isometric hand strength was 41.75 kg on the right (SE 0.99) and 38.92 kg on the left (SE 0.94). Similarly, back strength in flexion was 48.87 Nm (SE 1.44) and in extension 57.95 Nm (SE 1.51). No outliers were observed in either case. The investigation revealed that the mobility parameters exhibited a normative distribution within the cohort of athletes (Table 1 in the appendix). The parameters included cervical spine rotation (left: 68.22° ± 0.96; right: 65.66° ± 0.96), finger-floor distance (30.68 cm ± 0.65) and splits ability (left: 128.85 cm ± 0.91; right: 129.85 cm ± 0.91).\u003c/p\u003e\n\u003cp\u003eThe differences between the post- and pre-values (Δ values) for the main parameters were compared between the groups using inferential statistics. The relative maximum oxygen uptake (Δ VO₂/KG) demonstrated a marked advantage for the active group (t = 3.67; p = 0.0003), with the therapeutic treatment resulting in an average increase of 2.58 ml/min/kg (see Table 2 in the appendix for details).\u003c/p\u003e\n\u003cp\u003eAbsolute VO2max values demonstrated a positive trend (t = 1.85; p = 0.0655), while systolic and diastolic blood pressure exhibited no significant differences (p \u0026gt; 0.05 in each case), emphasizing the specificity of the effect on aerobic metabolic capacity.\u003c/p\u003e\n\u003cp\u003eThe present study demonstrated a significant reduction in lactate accumulation after exercise in the active group across all three levels. Specifically, in level 1, the mean decrease in lactate was –0.11 mmol/l (t = –4.41; p \u0026lt; 0.0001). In level 2, the mean decrease was –0.19 mmol/l (t = –5.09; p \u0026lt; 0.0001), and in stage 3, the mean decrease was –0.26 mmol/l (t = –5.43; p \u0026lt; 0.0001). These findings indicate a substantial decrease in lactate levels in the active group compared to the control group (Table 3 in the appendix). This consistent series of findings indicates improved lactate utilization, an increased anaerobic threshold and increased metabolic efficiency because of the osteopathic treatment.\u003c/p\u003e\n\u003cp\u003eThe analysis of mobility revealed significant improvements. The difference in cervical spine mobility (a combination of flexion, extension, lateral flexion and rotation) increased significantly in the active group (t = 3.39; p = 0.0009). The CMD measurement indicated a 0.79 mm increase in jaw opening (t = 3.64; p = 0.0004), an improvement of 1.20 cm (t = 5.43; p \u0026lt; 0.0001) in finger-floor distance, and a 1.59 cm increase (t = 3.44; p = 0.0007) in split performance (see Table 4 in the appendix for details).\u003c/p\u003e\n\u003cp\u003eFurthermore, a substantial enhancement in SIAS rotation for mapping pelvic mobility was observed (t = –3.61; p = 0.0004) (Table 5 in the appendix). The results of this study indicate not only increased muscular flexibility, but also structural harmonization of osteofascial and neuromuscular system components.\u003c/p\u003e\n\u003cp\u003eA significant increase in isometric muscle strength was observed across all measurement domains. While the controlled trend in the control group remained marginal, leg strength in the active group increased by an average of 16.02 kg (t = 5.92; p \u0026lt; 0.0000001) (Table 10 in the appendix). The results of the study demonstrated a significant increase in hand strength, with an average gain of 0.75 kg (t = 3.95; p = 0.000108) for both hands (see Table 11 in the appendix). Additionally, back strength exhibited a notable enhancement, with an average increase of 5.32 Nm (t = 5.64; p \u0026lt; 0.0000001) (see Table 18 in the appendix). These homogeneous, system-wide increases in strength underscore the ability of osteopathic treatment to optimize neuromuscular recruitment patterns and strengthen muscular tension lines globally.\u003c/p\u003e\n\u003cp\u003eTo assess the practical significance of the findings, Cohen's d was calculated to be 0.52 for the effect on Δ VO₂/KG. As demonstrated in Table 6 in the appendix, minor effects (d \u0026lt; 0.3) were observed for absolute strength parameters and blood pressure changes. The mean effect size for the change in VO₂/kg indicates that the treatment results in a clinically significant enhancement in aerobic performance.\u003c/p\u003e\n\u003cp\u003eRegression analyses were utilized to provide further insights into the causal relationship. A simple linear model with group membership as a predictor for Δ VO₂/KG explained 6.4% of the variance (R² = 0.064; β = 2.58; t = 3.67; p \u0026lt; 0.001) (Table 7 in the appendix). The multiple models, which additionally took gender, body weight and baseline VO₂max into account, increased the degree of explanation to 9.1% (R² = 0.091). While the treatment characteristic continued to exert a substantial effect (β = 2.77; t = 3.93; p \u0026lt; 0.001), gender emerged as a significant moderator (male: β = 2.18; t = 2.24; p = 0.026), while body weight and VO₂max remained nonsignificant (Table 8 in the appendix). The findings indicate that the observed enhancement in relative oxygen uptake is predominantly attributable to the treatment, rather than being attributable to baseline characteristics such as weight or fundamental fitness levels.\u003c/p\u003e\n\u003cp\u003eRegarding the metabolic response (Δ lactate level 3), the multiple models documented a mean explanatory power of 15% (R² = 0.150). The group variable demonstrated a negative and significant effect (β = –0.58 mmol/l; t = –5.53; p \u0026lt; 0.001), while gender, weight and baseline VO₂max were found to be non-significant (Table 9 in the appendix). This finding indicates that the observed reduction in lactate levels is predominantly group-specific and was not influenced by demographic or physiological baseline characteristics.\u003c/p\u003e\n\u003cp\u003eThe fourth hypothesis proposed a positive linear relationship between the change in trunk strength and the change in leg strength. This hypothesis was confirmed with Pearson's r = 0.348 (p \u0026lt; 0.000001) (see Table 12 in the appendix). This moderate yet substantial correlation signifies a cross-system neuromuscular adaptation, thereby substantiating the hypothesis that enhanced trunk stability is associated with augmented leg strength.\u003c/p\u003e\n\u003cp\u003eExtensive statistical analysis indicates the presence of robust, multi-causal effects of manual osteopathic treatments: targeted optimization of muscular tension lines, promotion of fascial flexibility and harmonization of neuromotor chains. These factors have been demonstrated to increase both aerobic and anaerobic performance. These findings confirm all four hypotheses and provide a robust evidence base for the integration of osteopathic treatments into performance optimization and rehabilitation programmes. It is recommended that subsequent studies examine the long-term effects, dosage parameters and potential synergies with physical training, with a view to furthering our understanding of the underlying mechanisms.\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eIn this clinical comparative study, 200 healthy, physically active adults were assigned to either an treatment group or a control group in order to investigate the effects of a standardised series of osteopathic treatments on physiological performance parameters. The treatment comprised four 90-minute sessions, scheduled over a period of eight to twelve weeks. During this time, manual techniques were executed in accordance with a protocol that had previously been validated. All measurements were conducted prior to and following the treatment, with the administration of these tests conducted by an independent performance institute. This method ensured the test administrators were unaware of the subjects' performance, thereby ensuring the collected data were both objective and reliable (Andersson et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Statistical analysis was performed using paired t-tests at a significance level of α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Metabolic efficiency\u003c/h2\u003e\u003cp\u003eA key finding is the significant reduction in blood lactate levels in all three submaximal exercise levels in the treatment group compared to the control group (level 1: t = \u0026minus;\u0026thinsp;4.41, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; level 2: t = \u0026minus;\u0026thinsp;5.09, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; level 3: t = \u0026minus;\u0026thinsp;5.43, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This decline in lactate levels is indicative of enhanced metabolic efficiency, which can be attributed to improved microcirculation, augmented capillary density, and elevated activity of lactate oxidation enzymes within muscle cells. To the best of the present author's knowledge, no comparable studies of osteopathic treatments in competitive sports with metabolic endpoints have been carried out to date. This finding provides new evidence for metabolic adaptations through manual techniques (Rao et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ward et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Cardiovascular adaptation\u003c/h2\u003e\u003cp\u003eIn addition to the metabolic parameters, the treatment group demonstrated a significantly lower heart rate (t = \u0026minus;\u0026thinsp;2.39; p\u0026thinsp;=\u0026thinsp;0.0176) during submaximal and maximal exercise. This reduction is indicative of a favourable shift in autonomic balance, with increased vagal influence and reduced sympathetic activity. Theoretically, these effects can be explained by improved baroreflex sensitivity as a result of thoracic and cervical mobilisations, which promote faster heart rate adaptation and stable circulatory regulation. As demonstrated in the research conducted by Jackson et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and Cerritelli et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), a similar dose-dependent effect on blood pressure and heart rate has been observed in longer-term osteopathic studies.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Aerobic capacity\u003c/h2\u003e\u003cp\u003eThe aerobic capacity of the subjects was determined on the basis of relative oxygen uptake (VO₂/kg) and absolute VO₂max. The relative VO₂/kg demonstrated a substantial increase in the treatment group, exhibiting a mean effect size of d\u0026thinsp;=\u0026thinsp;0.52 (p\u0026thinsp;=\u0026thinsp;0.0003). In contrast, the change in absolute VO₂max exhibited only a statistical trend, with a trend of t\u0026thinsp;=\u0026thinsp;1.85 and p\u0026thinsp;=\u0026thinsp;0.065. The explanatory mechanisms encompass a range of factors, including increased thoracic compliance, leading to enhanced alveolar ventilation. Additionally, increased peripheral blood flow contributes to a greater arteriovenous oxygen difference. Previous studies on the improvements of VO₂max were often limited to small samples or competitive athletes; the present study expands the understanding to include a heterogeneous cohort of healthy adults (Haberl, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Muscle strenght\u003c/h2\u003e\u003cp\u003eThe effects on maximum muscle strength proved to be particularly pronounced. The investigation revealed a mean increase in isometric leg strength of 16.02 kilograms (t\u0026thinsp;=\u0026thinsp;5.92; p\u0026thinsp;\u0026lt;\u0026thinsp;0.00000002) subsequent to the treatment series. Additionally, a significant augmentation in trunk strength was observed (t\u0026thinsp;=\u0026thinsp;5.64; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0000001), along with a 0.75-kilogram increase in the combined grip strength of both hands (t\u0026thinsp;=\u0026thinsp;3.95; p\u0026thinsp;=\u0026thinsp;0.0001). The enhanced systemic strength gains can be attributed to the improved neuromuscular control processes, which encompass a reduction in myofascial tension and optimised muscle-tendon control. Documented short-term strength gains after individual OMT sessions have been shown to disappear after a few minutes (Grindstaff et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Monteiro et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, the effects documented here, which persist for weeks, underscore the need for repeated mechanical stimuli for sustainable strength gains.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Functional mobility\u003c/h2\u003e\u003cp\u003eThe functional mobility of the subjects improved significantly in almost all areas examined. The following improvements were recorded: several degrees of increased mobility of the cervical spine (t\u0026thinsp;=\u0026thinsp;3.39; p\u0026thinsp;=\u0026thinsp;0.0009), an increase of approximately 2 mm in maximum vertical jaw opening (t\u0026thinsp;=\u0026thinsp;3.64; p\u0026thinsp;=\u0026thinsp;0.0004), an increase of 3.5 cm in finger-floor distance (t\u0026thinsp;=\u0026thinsp;5.43; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and a significant improvement in split ability (right and left) (e.g. an increase in front split position: t\u0026thinsp;=\u0026thinsp;3.44; p\u0026thinsp;=\u0026thinsp;0.0007). Furthermore, the SIAS analysis demonstrated a substantial decrease in the distance between both iliac crest points, suggesting enhanced pelvic alignment and stability (t = \u0026minus;\u0026thinsp;3.61; p\u0026thinsp;=\u0026thinsp;0.0004). These results lend further support to the existing body of evidence pertaining to the efficacy of myofascial release and muscle energy techniques, while concomitantly extending these techniques by providing empirical data on lumbopelvic statics (Sandell et al., 2008; Ogando-Berea et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePhysiological mechanisms underpin the observed effects, which can be attributed to several factors. Osteopathic mobilisations have been demonstrated to release myofascial restrictions, increase tissue perfusion and compensate for mechanical imbalances. Improved tissue perfusion has been demonstrated to promote oxygen supply and accelerate lactate breakdown (Jones et al., 2022). Greater mobility has been shown to reduce biomechanical efficiency and thus alleviate metabolic stress for the same level of performance (Smith et al., 2021). Increases in strength have been shown to reduce the relative load on individual muscle groups during standardised tests, which contributes to lower lactate levels. Furthermore, enhanced vagal regulation has been demonstrated to result in heart rate attenuation and cardiovascular stabilisation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e4.6 Strengths and limitations\u003c/h2\u003e\u003cp\u003eThe study's merits include a substantial sample size, a standardized protocol, the blinding of the test administrators, and the utilization of objective performance parameters. This combination meets quality criteria rarely seen in osteopathic research to date (Alvarenga et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Detoni et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The limitations of the present study are as follows: firstly, the therapists were not blind to the treatment; secondly, there were potential expectation effects; thirdly, the training status, nutrition and recovery patterns were not controlled; and fourthly, there was an absence of follow-up measurements to assess long-term effects. Subgroup analyses, including those on vaccination status, are exploratory in nature and should be explored in greater depth in future studies with higher statistical power.\u003c/p\u003e\u003cp\u003eIn summary, the present study demonstrates that manual osteopathic treatments in healthy, physically active adults lead to significant improvements in metabolic efficiency, autonomic cardiovascular regulation, aerobic capacity, maximal muscle strength, and functional mobility. The results of the study suggest that OMT can be used as an integrative approach in competitive and recreational sports as well as in rehabilitation programmes. To establish a more comprehensive evidence base, it is recommended that future studies investigate the long-term effects, different treatment intensities and the underlying cellular mechanisms.\u003c/p\u003e\u003c/div\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eIn this clinical comparative study, a total of 200 healthy adults who regularly engage in physical activity were investigated. The influence of a series of osteopathic treatments was investigated; these treatments were standardized and consisted of four 90-minute sessions over eight to twelve weeks. The treatment had a variety of physiological performance parameters as its focus. The participants were divided into two groups: a treatment group and a control group. Only the former received osteopathic treatment. All pre- and post-treatment measures were carried out by an independent performance institute. This ensured that the test administrators were blind to the group allocation, thus ensuring objectivity and reliability (Andersson et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). A study was conducted to analyze body composition using bioelectrical impedance and to monitor body mass index. The results demonstrated that there were no significant changes, indicating that manual osteopathic techniques do not modulate fat percentage or macroscopic body measurements in the short term (Zago et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). After four sessions, blood pressure measurements demonstrated no statistically significant differences, although a slight downward trend was observed in the treatment group. This finding suggests that more prolonged or frequent treatments may be required to induce cardiac regulatory adjustments (Jackson et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Cerritelli et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn contrast, the treatment series induced substantial cardiovascular and metabolic adjustments. In both submaximal and maximal exercise conditions, the heart rate of the active group demonstrated a significant decrease (t = \u0026minus;\u0026thinsp;2.39; p\u0026thinsp;=\u0026thinsp;0.0176), indicating a shift in autonomic balance towards increased vagal activity and reduced sympathetic tone. As demonstrated by Ward et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2012\u003c/span\u003e), thoracic and cervical mobilizations have been shown to promote increased baroreflex sensitivity and optimize cardiac preload and afterload. This, in turn, results in a decrease in heart rates at a constant cardiac output (Ward et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMetabolic efficiency was found to improve significantly across all three submaximal exercise stages of the step test. This was accompanied by a substantial decrease in lactate levels (stage 1: t = \u0026minus;\u0026thinsp;4.41; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; stage 2: t = \u0026minus;\u0026thinsp;5.09; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; stage 3: t = \u0026minus;\u0026thinsp;5.43; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This phenomenon has been attributed to the optimization of microcirculation, an increase in capillary density, and elevated activity of lactate oxidizing enzymes within the muscles. To date, there have been few systematic studies on the effects of osteopathy on lactate metabolism in sport, so these results provide novel insights (Rao et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRegarding the subject's aerobic capacity, a highly significant increase in relative maximum oxygen uptake (VO₂/kg) was observed, with an effect size of d\u0026thinsp;=\u0026thinsp;0.52 (p\u0026thinsp;=\u0026thinsp;0.0003). It has been demonstrated that enhanced thoracic compliance engenders an augmentation in alveolar ventilation. Concurrently, fascial mobilization of the extremities has been shown to increase perfused muscle mass, thereby resulting in an escalation in the arteriovenous oxygen difference. Despite the absence of a statistically significant correlation between absolute VO2max and the treatment outcomes, it is important to note that central limitations, such as cardiac output and pulmonary diffusion, presumably require longer or more intensive treatments in order to be substantially influenced (Haberl, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe treatment had a substantial positive effect on maximal muscle strength across all domains. Isometric leg strength increased by an average of 16.02 kg (t\u0026thinsp;=\u0026thinsp;5.92; p\u0026thinsp;\u0026lt;\u0026thinsp;0.00000002), trunk strength increased significantly (t\u0026thinsp;=\u0026thinsp;5.64; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0000001), and grip strength in both hands improved by approximately 0.75 kg (t\u0026thinsp;=\u0026thinsp;3.95; p\u0026thinsp;=\u0026thinsp;0.0001). The enhanced systemic strength gains can be attributed to several factors, including optimized neuromuscular recruitment, reduced myofascial restrictions, and increased muscle tension lines. While short-term studies following a single OMT session have been able to demonstrate effects lasting only a few minutes (Grindstaff et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), the present study documents, for the first time, sustained strength gains over a period of weeks (Monteiro et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA marked improvement in functional mobility was observed in almost all areas that were examined. The findings revealed a substantial increase in combined cervical spine mobility (t\u0026thinsp;=\u0026thinsp;3.39; p\u0026thinsp;=\u0026thinsp;0.0009), accompanied by a notable augmentation in maximum vertical jaw opening of several millimeters (t\u0026thinsp;=\u0026thinsp;3.64; p\u0026thinsp;=\u0026thinsp;0.0004). Additionally, an average reduction of 3 millimeters was observed in finger-floor distance. Mean improvement in the ability to perform the splits, measured in both the straddle position and straight splits, was found to be significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001; t\u0026thinsp;=\u0026thinsp;5.43). The improvement was particularly marked in the straddle position (t\u0026thinsp;=\u0026thinsp;5.24; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and in the straight splits (t\u0026thinsp;=\u0026thinsp;3.44; p\u0026thinsp;=\u0026thinsp;0.0007). The SIAS analysis demonstrated a substantial decrease in the pelvic spurs distance (t = \u0026minus;\u0026thinsp;3.61; p\u0026thinsp;=\u0026thinsp;0.0004), suggesting optimized lumbo-pelvic statics and symmetry (Sandell et al., 2008; Rehana, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMultiple regression analyses demonstrated that combined changes in muscle strength and flexibility already explained 16% of the variance in mean lactate reduction in the submaximal tests (strength: β = \u0026minus;\u0026thinsp;0.0199; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; flexibility: β = \u0026minus;\u0026thinsp;0.0135; p\u0026thinsp;=\u0026thinsp;0.001). In an extended model that additionally considered stride length and heart rate difference, the explained variance increased to 26% (stride length: β = \u0026minus;\u0026thinsp;0.0117; p\u0026thinsp;=\u0026thinsp;0.032; HR difference: β\u0026thinsp;=\u0026thinsp;0.0235; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This finding underscores the direct link between functional performance improvements and increased metabolic efficiency.\u003c/p\u003e\u003cp\u003eIn conclusion, the present study demonstrates that when osteopathic treatments are standardized and repeated in healthy athletes, there is a comprehensive enhancement of metabolic, cardiac, muscular and mobility-related performance parameters. The findings provide the first empirical evidence that OMT induces neurovegetative, vascular and neuromuscular adaptations that extend beyond the scope of short-term relaxation effects. From a clinical perspective, this development has significant potential for application in a variety of fields, including competitive sports, rehabilitation, and injury prevention. The utilization of this approach may lead to a multifaceted enhancement of key performance indicators such as strength, endurance, and mobility. Furthermore, it has the potential to mitigate the risk of injury, thereby promoting optimal physical well-being and performance. Concomitantly, methodological limitations \u0026ndash; namely, the absence of therapist blinding, uncontrolled influencing factors such as nutrition or training status, and exclusively short-term follow-up measurements \u0026ndash; underscore the necessity for additional large-scale, long-term studies. In such studies, different treatment doses, immunological modulations, and molecular mechanisms should be systematically investigated.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eANCOVA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;analysis of covariance\u003c/p\u003e\n\u003cp\u003eBMI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;body mass index\u003c/p\u003e\n\u003cp\u003ecm\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;centimeter\u003c/p\u003e\n\u003cp\u003eet. al.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;et alii\u003c/p\u003e\n\u003cp\u003eetc.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;et cetera\u003c/p\u003e\n\u003cp\u003ekg\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;kilogram\u003c/p\u003e\n\u003cp\u003ele\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;left\u003c/p\u003e\n\u003cp\u003emax.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;maximum\u003c/p\u003e\n\u003cp\u003emin\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;minute\u003c/p\u003e\n\u003cp\u003eml\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;milliliters\u003c/p\u003e\n\u003cp\u003eN\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;number of participants\u003c/p\u003e\n\u003cp\u003eO\u003csub\u003e2\u003c/sub\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;oxygen\u003c/p\u003e\n\u003cp\u003eOMT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;osteopathic manual treatment\u003c/p\u003e\n\u003cp\u003epost\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;after\u003c/p\u003e\n\u003cp\u003epre\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;before\u003c/p\u003e\n\u003cp\u003eri\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;right\u003c/p\u003e\n\u003cp\u003ev\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;volume\u003c/p\u003e\n\u003cp\u003eVOD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Verband der Osteopathen Deutschland\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics statement I completed my dissertation at St. Elisabeth University in the Department of Public Health in Bratislava. My supervisor was Prof. MUDr. Milan Luliak, PhD. Every study involving human subjects requires the approval of the ethics committee. I received this approval in the normal manner from St. Elisabeth University.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eI would like to express my special thanks for the excellent guidance and support provided by Professor MUDr. Milan Luliak, PhD, who contributed his professional input to this study and supported me with efficient discussions.\u003c/p\u003e\u003cp\u003eIn addition, I would like to thank the Unique Connect practice team, especially Sophia Schwab, Jana M\u0026uuml;ller, and Alexander Haas, for their invaluable support throughout the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlvarenga BAP, Fujikawa R, Jo\u0026atilde;o F, Lara JPR, Veloso AP (2018) The effects of a single session of lumbar spinal manipulative therapy in terms of physical performance test symmetry in asymptomatic athletes: A single-blinded, randomised controlled study. 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Urban \u0026amp; Fischer in Elsevier\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVOD (2018) Forsa-Umfrage zur Osteopathie: Fast jeder F\u0026uuml;nfte war bereits beim Osteopathen / Hohe Zufriedenheit \u0026ndash; Verunsicherung hinsichtlich Ausbildung. VOD - Verband der Osteopathen Deutschland e.V. Online unter: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mynewsdesk.com/de/verband-der-osteopathen-deutschland/pressreleases/forsa-umfrage-zur-osteopathie-fast-jeder-fuenfte-war-bereits-beim-osteopathen-strich-hohe-zufriedenheit-verunsicherung-hinsichtlich-ausbildung-2572039\u003c/span\u003e\u003cspan address=\"https://www.mynewsdesk.com/de/verband-der-osteopathen-deutschland/pressreleases/forsa-umfrage-zur-osteopathie-fast-jeder-fuenfte-war-bereits-beim-osteopathen-strich-hohe-zufriedenheit-verunsicherung-hinsichtlich-ausbildung-2572039\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, abgerufen am 22.04.2025\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWard JS, Coats J, Ramcharan M, Humphries K, Tong T, Chu C (2012) Thoracolumbar spinal manipulation and the immediate impact on exercise performance. J Chiropr Med 11:233\u0026ndash;241\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2010) \u003cem\u003eBenchmarks for training in traditional / complementary and alternative medicine: Benchmarks for training in osteopathy\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/handle/10665/44356\u003c/span\u003e\u003cspan address=\"https://iris.who.int/handle/10665/44356\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZago J, Amatuzzi F, Rondinel T, Matheus JP (2021) Osteopathic Manipulative Treatment Versus Exercise Program in Runners With Patellofemoral Pain Syndrome: A Randomized Controlled Trial. J Sport Rehabilitation 30(4):609\u0026ndash;618. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1123/jsr.2020-0108\u003c/span\u003e\u003cspan address=\"10.1123/jsr.2020-0108\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"ST. ELIZABETH UNIVERSITY OF HEALTH AND SOCIAL WORK IN BRATISLAVA","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Osteopathy, manual osteopathic treatments, physical performance, cardiopulmonary performance diagnostics, isometric strength development, lactate values","lastPublishedDoi":"10.21203/rs.3.rs-8287443/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8287443/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eManual osteopathic treatments (osteopathic manipulative treatment, OMT) are gaining importance in the field of sports medicine. However, there remains a paucity of systematic studies on the effects of these substances on the physical performance of healthy, athletically active adults.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eThe objective of the present study was to investigate the effects of a standardized series of osteopathic treatment on metabolic, cardiovascular, muscular and functional parameters in 200 healthy adults.\u003c/p\u003e\u003ch2\u003eMaterials and methods\u003c/h2\u003e\u003cp\u003eIn a clinical comparative study, 200 participants were assigned to either an treatment group (n\u0026thinsp;=\u0026thinsp;100, four 90-minute osteopathic manipulative treatment (OMT) sessions over 8\u0026ndash;12 weeks) or a control group (n\u0026thinsp;=\u0026thinsp;100, no treatment). Pre- and post-measurements of blood lactate (levels 1\u0026ndash;3), relative and absolute VO₂max, isometric strength (legs, trunk, grip) and mobility (cervical spine, jaw opening, finger-floor distance, splits, SIAS rotation) were performed under standardized conditions (22\u0026deg;C, same times of day) by test administrators who were not privy to the subjects' identities. The statistical analysis encompassed a range of methodologies, including paired and independent t-tests, ANCOVA, Pearson correlations, and multiple linear regressions, with a significance level of α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe treatment group demonstrated a significant reduction in lactate levels across all three exercise levels (level 1: Δ \u0026minus;\u0026thinsp;0.11 mmol/l, t = \u0026minus;\u0026thinsp;4.41; level 3: Δ \u0026minus;\u0026thinsp;0.26 mmol/l, t = \u0026minus;\u0026thinsp;5.43; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The relative VO₂/kg demonstrated a significant increase of 2.58 ml/min/kg (t\u0026thinsp;=\u0026thinsp;3.67; p\u0026thinsp;=\u0026thinsp;0.0003; d\u0026thinsp;=\u0026thinsp;0.52), while the absolute VO₂max only exhibited a tendency to increase (p\u0026thinsp;=\u0026thinsp;0.065). A decrease in heart rate was observed during exercise (t = \u0026minus;\u0026thinsp;2.39; p\u0026thinsp;=\u0026thinsp;0.0176), while blood pressure changes remained non-significant. The results demonstrated a significant increase in leg strength, with an average gain of 16.02 kilograms (t\u0026thinsp;=\u0026thinsp;5.92; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0000001). Additionally, trunk and hand strength exhibited a notable enhancement (t\u0026thinsp;\u0026gt;\u0026thinsp;3.95; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). A substantial enhancement in mobility was observed in the cervical spine (t\u0026thinsp;=\u0026thinsp;3.39; p\u0026thinsp;=\u0026thinsp;0.0009), jaw opening (t\u0026thinsp;=\u0026thinsp;3.64; p\u0026thinsp;=\u0026thinsp;0.0004), finger-floor distance (t\u0026thinsp;=\u0026thinsp;5.43; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), splits (t\u0026thinsp;=\u0026thinsp;3.44; p\u0026thinsp;=\u0026thinsp;0.0007) and SIAS rotation (t = \u0026minus;\u0026thinsp;3.61; p\u0026thinsp;=\u0026thinsp;0.0004). Multiple regression explained 16% of the variance in lactate reduction through combined strength and flexibility gains; an extended model (including step position, heart rate) explained 26%.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe administration of four standardized manual osteopathic sessions has been demonstrated to result in a marked enhancement of metabolic efficiency (as indicated by a reduction in lactate levels), cardiovascular adaptation (as evidenced by a decrease in heart rate), aerobic capacity (as reflected by an increase in VO₂/kg), muscular strength, and functional mobility in healthy, physically active adults. The results of the present study underscore the potential of OMT as an integrative measure in performance and rehabilitation programmes. It is recommended that future studies direct their attention towards the investigation of long-term effects, the determination of treatment doses, and the exploration of mechanistic principles, including but not limited to neurovascular, myofascial, and immunological processes.\u003c/p\u003e","manuscriptTitle":"Effect of manual osteopathic treatments on physical performance","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-16 13:56:39","doi":"10.21203/rs.3.rs-8287443/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ba49ca0c-45d4-43d3-8842-e53f478f00f5","owner":[],"postedDate":"December 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":59151737,"name":"Sports Medicine and Kinesiology"},{"id":59151738,"name":"Health Economics \u0026 Outcomes Research"},{"id":59151739,"name":"Health Economics and Outcomes Research"}],"tags":[],"updatedAt":"2025-12-16T13:56:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-16 13:56:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8287443","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8287443","identity":"rs-8287443","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}