An in-depth analysis of the polyvagal theory in light of current findings in neuroscience and clinical research.

The polyvagal theory has led to the understanding of the functions of the autonomic nervous system in biological development in humans, since the vagal system, a key structure within the polyvagal theory, plays a significant role in addressing challenges of the mother-child dyad. This article aims to summarize the neurobiological aspects of the polyvagal theory, highlighting some of its strengths and limitations through the lens of new evidence emerging in several research fields-including comparative anatomy, embryology, epigenetics, psychology, and neuroscience-in the 25 years since the theory's inception. Rereading and incorporating the polyvagal idea in light of modern scientific findings helps to interpret the role of the vagus nerve through the temporal dimension (beginning with intrauterine life) and spatial dimension (due to the numerous connections of the vagus with various structures and systems) in the achievement and maintenance of biopsychosocial well-being, from the uterus to adulthood.

The osteopath-parent-child triad in osteopathic care in the first 2 years of life: a qualitative study.

Background: Enactivism and active inference are two important concepts in the field of osteopathy. While enactivism emphasizes the role of the body and the environment in shaping our experiences and understanding of the world, active inference emphasizes the role of action and perception in shaping our experiences and understanding of the world. Together, these frameworks provide a unique perspective on the practice of osteopathy, and how it can be used to facilitate positive change in patients. Since the neonatal period is a crucial time for development, osteopaths should aim to create a therapeutic relationship. Arguably, through participatory sense-making, osteopaths can help the baby build a generative model (with positive priors) to deal with stress and needs throughout their life. Aim: Since the literature considers that interactions with the environment, which enact the patients' experiences, depending on contextual factors and communication between patient and caregiver, this research explored whether there is a correspondence between the indications in the literature and clinical practice in the management of the mother/parent-child dyad during osteopathic care on children aged 0 to 2 years old. Methods: Semi-structured interviews were conducted with a purposive sample of nine osteopaths with experience in the field of pediatrics. Interviews were transcribed verbatim, and constructivist grounded theory was used to conceptualize, collect and analyze data. Codes and categories were actively constructed through an interpretive/constructionist paradigm. Results: The core category was the idea of the pediatric osteopath as a support for the family, not only for the child. Four additional categories were identified: (1) Preparing a safe environment for both children and parents, (2) Communication, (3) Attachment and synchrony, and (4) Synchronization. Conclusion: Through participatory sense-making, osteopaths manage contextual factors to establish an effective therapeutic alliance through the osteopath-parent-child triad to facilitate the construction of the child's internal generative model to promote healthy development. The therapeutic encounter is considered an encounter between embodied subjects, occurring within a field of affordances (ecological niche) that allows the interlocutors to actively participate in creating new meanings through interpersonal synchronization. Participatory sense-making and the establishment of a therapeutic alliance through the osteopath-parent-child triad are crucial to promote healthy development in the child.

Facial functional networks during resting state revealed by thermal infrared imaging.

In recent decades, an increasing number of studies on psychophysiology and, in general, on clinical medicine has employed the technique of facial thermal infrared imaging (IRI), which allows to obtain information about the emotional and physical states of the subjects in a completely non-invasive and contactless fashion. Several regions of interest (ROIs) have been reported in literature as salient areas for the psychophysiological characterization of a subject (i.e. nose tip and glabella ROIs). There is however a lack of studies focusing on the functional correlation among these ROIs and about the physiological basis of the relation existing between thermal IRI and vital signals, such as the electrodermal activity, i.e. the galvanic skin response (GSR). The present study offers a new methodology able to assess the functional connection between salient seed ROIs of thermal IRI and all the pixel of the face. The same approach was also applied considering as seed signal the GSR and its phasic and tonic components. Seed correlation analysis on 63 healthy volunteers demonstrated the presence of a common pathway regulating the facial thermal functionality and the electrodermal activity. The procedure was also tested on a pathological case study, finding a completely different pattern compared to the healthy cases. The method represents a promising tool in neurology, physiology and applied neurosciences.

Therapeutic touch and therapeutic alliance in pediatric care and neonatology: An active inference framework.

Therapeutic affective touch has been recognized as essential for survival, nurturing supportive interpersonal interactions, accelerating recovery-including reducing hospitalisations, and promoting overall health and building robust therapeutic alliances. Through the lens of active inference, we present an integrative model, combining therapeutic touch and communication, to achieve biobehavioural synchrony. This model speaks to how the brain develops a generative model required for recovery, developing successful therapeutic alliances, and regulating allostasis within paediatric manual therapy. We apply active inference to explain the neurophysiological and behavioural mechanisms that underwrite the development and maintenance of synchronous relationships through touch. This paper foregrounds the crucial role of therapeutic touch in developing a solid therapeutic alliance, the clinical effectiveness of paediatric care, and triadic synchrony between health care practitioner, caregiver, and infant in a variety of clinical situations. We start by providing a brief overview of the significance and clinical role of touch in the development of social interactions in infants; facilitating a positive therapeutic alliance and restoring homeostasis through touch to allow a more efficient process of allostatic regulation. Moreover, we explain the role of CT tactile afferents in achieving positive clinical outcomes and updating prior beliefs. We then discuss how touch is implemented in treatment sessions to promote cooperative interactions in the clinic and facilitate theory of mind. This underwrites biobehavioural synchrony, epistemic trust, empathy, and the resolution of uncertainty. The ensuing framework is underpinned by a critical application of the active inference framework to the fields of pediatrics and neonatology.

Tidal volume optimization and heart rate response during stabilization of very preterm infants.

AIM: To verify the added value of respiratory function monitor (RFM) to assess ventilation and the heart rate (HR) changes during stabilization of preterm infants. METHODS: Preterm infants <32 weeks' gestation, bradycardic at birth and in need for positive pressure ventilation (PPV) were included. The first 15 min of stabilization was monitored with RFM. Three time points were identified according to HR values (T0 the start of mask PPV; T1 the HR rise >100 bpm; T2 the delivery of the last PPV). For each inflation, PIP, PEEP, MAP, expired tidal volume/kg (Vte/kg), and mean dynamic compliance (Cdyn) were analyzed. RESULTS: PIP and MAP values were significantly higher at T1 (27.09 ± 5.37 and 17.47 ± 3.85 cmH2 O) and at T2 (24.7 ± 3.86 and 15.2 ± 3.78 cmH2 O) compared to T0 (24.05 ± 2.27 and 15.85 ± 2.77 cmH2 O). PEEP at T1 was significantly higher (6.27 ± 2.17 cmH2 O) compared to T2 (5.61 ± 1.50 cmH2 O). Vte/kg showed significantly lower T0 values (3.57 ± 2.14 ml/kg) compared to T1 (6.18 ± 2.51 ml/kg) and T2 (6.89 ± 2.40 ml/kg). There was a significant effect of time on Cdyn. CONCLUSIONS: A clear correspondence between HR rise and adequate Vte/kg during stabilization of very preterm infants was highlighted. RFM might be useful to tailor ventilation, following real-time changes of lung compliance.

Dynamic touch induces autonomic changes in preterm infants as measured by changes in heart rate variability.

Preterm birth significantly increases the risk of developing various long-term health problems and developmental disabilities. While touch is a crucial component of many perinatal care strategies, the neurobiological underpinnings are rarely considered. C-tactile fibers (CTs) are unmyelinated nerve fibers that are activated by low-force, dynamic touch. Touch directed specifically at CTs activates the posterior insular cortex, consistent with an interoceptive function, and has been shown to reduce heart rate and increase oxygen saturation. The current research compared the effect of five minutes of CT optimal velocity stroking touch versus five minutes of static touch on autonomic markers of preterm infants between 28 and 37 weeks gestational age. CT touch induces a higher increase in heart rate variability metrics related to the parasympathetic system, which persisted for a 5-minute post-touch period. Conversely, there was no such increase in infants receiving static touch. The present findings confirmed that CTs signal the affective quality of nurturing touch, thereby arguing an additional neurobiological substrate for the evident valuable impacts of neonatal tactile interventions and improving the effectiveness of such interventions.

The Austrian Osteopathic Practitioners Estimates and RAtes (OPERA): A cross-sectional survey.

INTRODUCTION: Since the previous survey of the osteopathic profession in Austria was almost a decade ago, an update was necessary. The Osteopathic Practitioners Estimates and RAtes (OPERA) project was developed as a Europe-based survey, whereby an updated profile of the profession not only provides new data for Austria, but also allows for a clear comparison with other European countries. METHODS: A voluntary, online-based, closed-ended survey was distributed across Austria in the period between April and August 2020. The original English OPERA-questionnaire, composed of 52 questions in seven sections, was formally translated in German and adapted to the Austrian situation. Recruitment was performed through social-media and an e-based campaign. RESULTS: The survey was completed by 338 individuals, of which 239 (71%) were female, and the median age was 40-49 years. Almost all respondents had preliminary healthcare training, mainly in physiotherapy (72%). The majority of respondents were self-employed (88%) and working as sole practitioners (54%). The median number of consultations per week was 21-25 and the majority of respondents scheduled 46-60 minutes for each consultation (69%). The most commonly used diagnostic techniques were: palpation of position/structure, palpation of tenderness and visual inspection. The most commonly used treatment techniques were cranial, visceral and articulatory/mobilisation techniques. The majority of patients estimated by respondents consulted an osteopath for musculoskeletal complaints mainly localised in the lumbar and cervical region. Although the majority of respondents experience a strong osteopathic identity, only a small proportion (17%) advertise themselves exclusively as osteopaths. CONCLUSIONS: This study represents the first published document to determine the characteristics of the osteopathic practitioners in Austria using large, national data. It provides new information on where, how, and by whom osteopathic care is delivered. The information provided may contribute to the evidence used by stakeholders and policy makers for the future regulation of the profession in Austria.

The Profile of Belgian Osteopaths: A Cross-Sectional Survey.

BACKGROUND: This study gives an update on the characteristics of Belgian osteopaths five years after the Benelux Osteosurvey. Additional new data were collected on their professional identity and views on the profession. METHODS: All Belgian osteopaths who could be contacted (n = 1473) were invited to complete a voluntary, online-based, closed-ended survey distributed between May and September 2018. The survey, composed of 52 questions and seven sections, was formally translated from English to Dutch and French and adapted from the original version. Adult, self-defined osteopaths working in Belgium were eligible. Recruitment of participants was performed through all professional associations and the InterMutualistic Agency. Descriptive statistics were used to analyse the data. RESULTS: The survey was completed by 332 osteopaths. Thirty-one per cent of the respondents were female. Almost all the respondents were self-employed (99.4%); half of them worked as part of a team (47.6%). Most respondents had a 5-year part-time training, and the majority had a previous academic degree, mainly in physical therapy (65.8%). According to respondents, most patients seek care for lumbar non-specific low back, pelvis and neck pain. Most respondents strongly define themselves as osteopaths and advertise themselves exclusively as osteopaths. CONCLUSIONS: This survey provided an update of the current characteristics of Belgian osteopathic practitioners and added new information on their professional identity and views on the profession. The information provided could contribute to the body of evidence used by stakeholders and policymakers in the future regulation of the profession in Belgium.

Postoperative Osteopathic Manipulative Treatment in Children with Esophageal Atresia: Potential Benefits on the Anthropometric Parameters.

Esophageal atresia (EA) is a congenital malformation that affects the normal esophageal development. Surgical treatment, although restoring the integrity of the alimentary tract, may lead to long-term sequelae-like developmental abnormalities and musculoskeletal deformities. We evaluated the effects of osteopathic manipulative treatment (OMT) on the recovery of the range of the right upper limb movement and on the rise of the auxological parameters. A case series of five children affected by type C EA were described. Six OMT sessions were performed over a 4-month period. At each treatment, height, weight, body mass index (BMI) and range of motion (ROM) in elevation of the right upper limb were assessed. OMT was applied to improve scar, larynx, rib cage, and sternum mobility. An average change of 2.3 cm in height and an average increase of 8° in the ROM of the upper limb in the period of study were detected. Additionally, OMT could improve the anthropometric data and the mobility of the right upper limb of children surgically treated for EA. Further studies that evaluate the effectiveness of OMT in post surgical treatment of congenital malformations of the thorax can be considered in the future.

Newborns' clinical conditions are correlated with the neonatal assessment manual scorE (NAME).

Objective: To investigate the relationship between the Neonatal Assessment Manual scorE (NAME) and newborns' clinical condition on a large number of infants. The NAME model was developed as an instrument to assess the infant's general conditions, especially in NICUs, by evaluating how the infant's body responds to an external stressor such as static touch. Previous studies, employing experienced assessors, showed good validity indices as well as high inter-rater reliability. Study design: Newborns were recruited at the "Vittore Buzzi" Pediatric Hospital NICU ward in Milan and their clinical conditions were collected through a standardized form-the complexity index. Two manual practitioners assessed all eligible newborns using the NAME scores. Data was analyzed using Kendall's τ correlation and odds ratio (OR) to assess the relationship between the NAME scores and the complexity index. Results: Two hundred two newborns (46% female; 34.1 w ± 4.3; birth weight of 2,093.4 gr ± 879.8) entered the study. The Kendall's correlation between the clinical conditions (complexity index) and the NAME score was -0.206 [95% CI: (-0.292, -0.116), p-value < 0.001], corresponding to an OR of 0.838 [95% CI: (0.757, 0.924), p-value < 0.001]. Further exploratory analyses showed significant correlation between gestational age, birth weight and NAME scores. Conclusion: The present paper adds evidence to the NAME model validity by demonstrating its applicability in the clinical neonatological context.

The Role of Osteopathic Care in Gynaecology and Obstetrics: An Updated Systematic Review.

BACKGROUND: Many efforts are made to find safer and more feasible therapeutic strategies to improve gynaecological care. Non-pharmacological treatments, such as osteopathic interventions, could be used as complementary strategies to better manage different gynaecological conditions. This review aims to report the effectiveness of osteopathic treatment in the gynaecology and obstetrics field, updating the previous review published in 2016. The secondary aim was to elucidate the role of somatic dysfunction (SD) in osteopathic assessment and treatment procedures, as well as their health and economic implications. METHODS: An electronic search was conducted in the following databases: Embase, MEDLINE (PubMed), and Science direct. All types of clinical studies published between May 2014 and December 2021 have been included: randomised controlled trial (RCT), controlled before/after, interrupted time series quasi RCT, case controls, case reports, case series, observational, clinical studies involving any type of osteopathic treatment, (standardised, semi-standardised or patients' need-based treatment) performed alone or in combination with other treatments, were included). RESULTS: A total of 76,750 were identified through database searching and other sources. After the removal of duplicates, 47,655 papers were screened based on title and abstract. A total of 131 full-text articles were consequently assessed for eligibility. Twenty-one new articles were included in the synthesis. A total of 2632 participants with a mean age of 28.9 ± 10.5 years were included in the review. CONCLUSIONS: Results showed an effectiveness of osteopathic care in gynaecology and obstetrics, but the studies were too heterogeneous to perform quantitative analysis and make clinical recommendations. Nevertheless, osteopathic care could be considered a safe complementary approach to traditional gynaecological care.

Differences between experimental and placebo arms in manual therapy trials: a methodological review.

BACKGROUND: To measure the specific effectiveness of a given treatment in a randomised controlled trial, the intervention and control groups have to be similar in all factors not distinctive to the experimental treatment. The similarity of these non-specific factors can be defined as an equality assumption. The purpose of this review was to evaluate the equality assumptions in manual therapy trials. METHODS: Relevant studies were identified through the following databases: EMBASE, MEDLINE, SCOPUS, WEB OF SCIENCE, Scholar Google, clinicaltrial.gov, the Cochrane Library, chiloras/MANTIS, PubMed Europe, Allied and Complementary Medicine (AMED), Physiotherapy Evidence Database (PEDro) and Sciencedirect. Studies investigating the effect of any manual intervention compared to at least one type of manual control were included. Data extraction and qualitative assessment were carried out independently by four reviewers, and the summary of results was reported following the PRISMA statement. RESULT: Out of 108,903 retrieved studies, 311, enrolling a total of 17,308 patients, were included and divided into eight manual therapy trials categories. Equality assumption elements were grouped in three macro areas: patient-related, context-related and practitioner-related items. Results showed good quality in the reporting of context-related equality assumption items, potentially because largely included in pre-existent guidelines. There was a general lack of attention to the patient- and practitioner-related equality assumption items. CONCLUSION: Our results showed that the similarity between experimental and sham interventions is limited, affecting, therefore, the strength of the evidence. Based on the results, methodological aspects for planning future trials were discussed and recommendations to control for equality assumption were provided.

Neonatal Early Onset Sepsis (EOS) Calculator plus Universal Serial Physical Examination (SPE): A Prospective Two-Step Implementation of a Neonatal EOS Prevention Protocol for Reduction of Sepsis Workup and Antibiotic Treatment.

Current neonatal early-onset sepsis (EOS) guidelines lack consensus. Recent studies suggest three different options for EOS risk assessment among infants born ≥35 wks gestational age (GA), leading to different behaviors in the sepsis workup and antibiotic administration. A broad disparity in clinical practice is found in Neonatal Units, with a large number of non-infected newborns evaluated and treated for EOS. Broad spectrum antibiotics in early life may induce different short- and long-term adverse effects, longer hospitalization, and early mother-child separation. In this single-center prospective study, a total of 3002 neonates born in three periods between 2016 and 2020 were studied, and three different workup algorithms were compared: the first one was based on the categorical risk assessment; the second one was based on a Serial Physical Examination (SPE) strategy for infants with EOS risk factors; the third one associated an informatic tool (Neonatal EOS calculator) with a universal extension of the SPE strategy. The main objective of this study was to reduce the number of neonatal sepsis workups and the rate of antibiotic administration and favor rooming-in and mother−infant bonding without increasing the risk of sepsis and mortality. The combined strategy of universal SPE with the EOS Calculator showed a significant reduction of laboratory tests (from 33% to 6.6%; p < 0.01) and antibiotic treatments (from 8.5% to 1.4%; p < 0.01) in term and near-term newborns. EOS and mortality did not change significantly during the study period.

Therapeutic Alliance as Active Inference: The Role of Therapeutic Touch and Biobehavioural Synchrony in Musculoskeletal Care.

Touch is recognised as crucial for survival, fostering cooperative communication, accelerating recovery, reducing hospital stays, and promoting overall wellness and the therapeutic alliance. In this hypothesis and theory paper, we present an entwined model that combines touch for alignment and active inference to explain how the brain develops "priors" necessary for the health care provider to engage with the patient effectively. We appeal to active inference to explain the empirically integrative neurophysiological and behavioural mechanisms that underwrite synchronous relationships through touch. Specifically, we offer a formal framework for understanding - and explaining - the role of therapeutic touch and hands-on care in developing a therapeutic alliance and synchrony between health care providers and their patients in musculoskeletal care. We first review the crucial importance of therapeutic touch and its clinical role in facilitating the formation of a solid therapeutic alliance and in regulating allostasis. We then consider how touch is used clinically - to promote cooperative communication, demonstrate empathy, overcome uncertainty, and infer the mental states of others - through the lens of active inference. We conclude that touch plays a crucial role in achieving successful clinical outcomes and adapting previous priors to create intertwined beliefs. The ensuing framework may help healthcare providers in the field of musculoskeletal care to use hands-on care to strengthen the therapeutic alliance, minimise prediction errors (a.k.a., free energy), and thereby promote recovery from physical and psychological impairments.

An Active Inference Account of Touch and Verbal Communication in Therapy.

This paper offers theoretical explanations for why "guided touch" or manual touch with verbal communication can be an effective way of treating the body (e.g., chronic pain) and the mind (e.g., emotional disorders). The active inference theory suggests that chronic pain and emotional disorders can be attributed to distorted and exaggerated patterns of interoceptive and proprioceptive inference. We propose that the nature of active inference is abductive. As such, to rectify aberrant active inference processes, we should change the "Rule" of abduction, or the "prior beliefs" entailed by a patient's generative model. This means pre-existing generative models should be replaced with new models. To facilitate such replacement-or updating-the present treatment proposes that we should weaken prior beliefs, especially the one at the top level of hierarchical generative models, thereby altering the sense of agency, and redeploying attention. Then, a new prior belief can be installed through inner communication along with manual touch. The present paper proposes several hypotheses for possible experimental studies. If touch with verbal guidance is proven to be effective, this would demonstrate the relevance of active inference and the implicit prediction model at a behavioral level. Furthermore, it would open new possibilities of employing inner communication interventions, including self-talk training, for a wide range of psychological and physical therapies.

An Enactive-Ecological Model to Guide Patient-Centered Osteopathic Care.

Osteopaths commonly face complexity and clinical uncertainty in their daily professional practice as primary contact practitioners. In order to effectively deal with complex clinical presentations, osteopaths need to possess well-developed clinical reasoning to understand the individual patient's lived experience of pain and other symptoms and how their problem impacts their personhood and ability to engage with their world. We have recently proposed (En)active inference as an integrative framework for osteopathic care. The enactivist and active inference frameworks underpin our integrative hypothesis. Here, we present a clinically based interpretation of our integrative hypothesis by considering the ecological niche in which osteopathic care occurs. Active inference enables patients and practitioners to disambiguate each other's mental states. The patients' mental states are unobservable and must be inferred based on perceptual cues such as posture, body language, gaze direction and response to touch and hands-on care. A robust therapeutic alliance centred on cooperative communication and shared narratives and the appropriate and effective use of touch and hands-on care enable patients to contextualize their lived experiences. Touch and hands-on care enhance the therapeutic alliance, mental state alignment, and biobehavioural synchrony between patient and practitioner. Therefore, the osteopath-patient dyad provides mental state alignment and opportunities for ecological niche construction. Arguably, this can produce therapeutic experiences which reduce the prominence given to high-level prediction errors-and consequently, the top-down attentional focus on bottom-up sensory prediction errors, thus minimizing free energy. This commentary paper primarily aims to enable osteopaths to critically consider the value of this proposed framework in appreciating the complexities of delivering person-centred care.

Osteopathic Manipulative Treatment Regulates Autonomic Markers in Preterm Infants: A Randomized Clinical Trial.

Osteopathic manipulative treatment (OMT) has been found to be effective in the context of premature infants. Nonetheless, no studies have investigated the immediate effects of OMT on heart rate variability (HRV). As altered HRV reflects poor or worsening newborn's clinical conditions and neurodevelopment, should OMT improve HRV fluctuations, it could become a relevant intervention for improving the care of preterm newborns. Therefore, this study aimed to evaluate whether OMT could affect HRV. The study was carried out at the Buzzi Hospital in Milan. From the neonatal intensive care unit, ninety-six preterm infants (41 males) were enrolled and were randomly assigned to one of two treatment groups: OMT or Static Touch. The infants were born at 33.5 weeks (±4.3) and had a mean birth weight of 2067 g (±929). The study had as primary outcome the change in the beat-to-beat variance in heart rate measured through root mean square of consecutive RR interval differences (RMSSD); other metrics were used as secondary and exploratory analyses. Despite the lack of statistically significant results regarding the primary outcomeand some study limitations, compared to static touch, OMT seemed to favor a parasympathetic modulation and improved HRV, which could reflect improvement in newborn's clinical conditions and development.