Journal of Bodywork & Movement Therapies 22 (2018) 203e208

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

REVIEW: SYSTEMATIC REVIEW

Effects of spinal manipulation and myofascial techniques on heart rate

variability: A systematic review
Bruno Luis Amoroso Borges a, Gustavo Luiz Bortolazzo a, Hugo Pasin Neto a, b, *
a
Col

egio Brasileiro de Osteopatia, Sorocaba, SP, Brazil
b
Laboratory of Human Movement Analysis, Physical Therapy Course, University of Sorocaba (UNISO), Sorocaba, SP, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Background: The analysis of heart rate variability is important to the investigation of stimuli from the
Received 24 May 2017 autonomic nervous system. Osteopathy is a form of treatment that can influence this system in healthy
Received in revised form individuals as well as those with a disorder or disease.
19 September 2017
Objectives: The aim of the present study was to perform a systematic review of the literature regarding
Accepted 27 September 2017
the effect of spinal manipulation and myofascial techniques on heart rate variability.
Methods: Searches were performed of the Pubmed, Scielo, Lilacs, PEDro, Ibesco, Cochrane and Scopus
Keywords:
databases for relevant studies. The PEDro scale was used to assess the methodological quality of each
Spinal manipulation
Spinal mobilization
study selected.
Myofascial release Results: A total of 505 articles were retrieved during the initial search. After an analysis of the abstracts,
Sympathetic nervous system nine studies were selected for the present review.
Parasympathetic nervous system Conclusion: Based on the findings, osteopathy exerts an influence on the autonomic nervous system
depending on the stimulation site and type. A greater parasympathetic response was found when
stimulation was performed in the cervical and lumbar regions, whereas a greater sympathetic response
was found when stimulation was performed in the thoracic region.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction (or normal-to-normal [NN] intervals): standard deviation of all RR

Heart rate variability (HRV) is the variation in time between
consecutive heartbeats and is predominantly dependent on the
extrinsic regulation of the heart rate (HR). HRV gives the heart the
ability to adapt to new circumstances by detecting and responding
quickly to unpredictable stimuli. This is a useful measure for un-
derstanding the status of the autonomic nervous system (ANS).
Normal HRV is due to autonomic neural regulation of the heart and
circulatory system. The balance between the sympathetic and
parasympathetic components of the ANS controls the HR. This
control involves the action of baroreceptors, chemoceptors, atrial
receptors and ventricular receptors as well as changes in the res-
piratory system, vasomotor system, renin-angiotensin-aldosterone
system and thermoregulating system.
The analysis of HRV can be linear (time and frequency domains)
or non-linear. Linear methods are obtained based on RR intervals
* Corresponding author. Rua Presidente Kennedy, 189. Ap. 52, 18040-550, Sor-
ocaba, SP, Brazil.
E-mail address: hugo.pasini@cbosteopatia.com.br (H.P. Neto).
intervals (SDNN); standard deviation of RR intervals every five
minutes (SDANN); mean of standard deviation of RR intervals every
five minutes (SDNNi); root mean square of successive differences
between RR intervals in a given period of time (rMSSD); and per-
centage of RR intervals with a greater than 50 ms difference in
duration (pNN50). The SDNN, SDANN and SDNNi indices represent
sympathetic and parasympathetic activity, whereas the rMMSD
and pNN50 indices represent parasympathetic activity (Vanderlei
et al., 2009).
The frequency domain divides HRV into high frequency (HF),
which corresponds to respiratory modulation and is an indicator of
the influence of the vagus nerve on the heart, and low frequency
(LF), which corresponds to the joint action of vagal and sympathetic
components on the heart, with a predominance of the sympathetic
component. Very low frequency (VLF) and ultra low frequency
(ULF) seem to be related to the renin-angiotensin-aldosterone
system, thermoregulation and peripheral vasomotor tone
(Vanderlei et al., 2009).
Stimuli from an increased sympathetic nervous system (SNS) or
diminished parasympathetic nervous system (PNS) result in

https://doi.org/10.1016/j.jbmt.2017.09.025
1360-8592/© 2017 Elsevier Ltd. All rights reserved.
204 B.L. Amoroso Borges et al. / Journal of Bodywork & Movement Therapies 22 (2018) 203e208
accelerated heart activity, whereas low SNS activity or high PNS
activity slow down the heart. The degree of HRV furnishes infor-
mation on nervous control of the HR and the response capacity of
the heart (Acharya et al., 2006).
Spinal manipulation has been used in the treatment of visceral
disorders, chronic low back pain and headache (Hurwitz et al.,
1996) and even influences autonomic aspects, such as HRV
(Pickar, 2002). This physiotherapeutic modality consists of a me-
chanical stimulus of the tissue that surrounds a vertebra or a sud-
den high-velocity, low amplitude thrust on a specific vertebra. The
therapist controls the velocity, magnitude and direction of the
thrust. Manipulation is performed at the end of the range of mo-
tion, without exceeding anatomic limits. Cavitation generally oc-
curs, which is often accompanied by a popping sound. Despite
evidence of the benefits of spinal manipulation, the physiological
mechanisms are not yet fully clarified, but this does not refute the
clinical effects (Pickar, 2002).
Different theories attempt to explain the effects of spinal
manipulation. The central theme of these theories is that anatomic,
physiologic and biomechanical changes can affect the functioning
of the nervous system. Hypothetically, a change between vertebral
segments produces a mechanical overload effect that can alter the
signaling of mechanical or chemical properties of sensory neurons
in paravertebral tissues. Such changes in sensory input can alter
neural integration or directly affect the reflex activity and/or center
of neural integration with a nociceptive or even autonomic
neuronal pool. Spinal manipulation is therefore thought to alter the
flow of sensory signals from paravertebral tissues in such a way as
to improve physiological function (Pickar, 2002). This explanation is
one of the most rational bases for the neurophysiologic mecha-
nisms underlying the effects of spinal manipulation.
Manipulation can affect the processing of pain, possibly through
a facilitated change in the central state of the spinal cord, and can
affect the motor control system. Experiments with animals have
demonstrated that sensory inputs from paravertebral tissues can
alter the neural output to the ANS. However, the effects of spinal
manipulation on this system have been investigated little (Bolton
and Holland, 1998).
Studies involving humans have been performed to measure
changes in HRV following cervical (Budgell and Hirano, 2001) and
thoracic (Budgell and Polus, 2006) manipulation. The studies cited
demonstrated changes in different HRV variables, whereas no
changes occurred in any HRV variables under simulated conditions
in the control groups. There is strong evidence that HRV is a good
marker of ANS activity (Martinma et al., 2006). Thus, the results of
these studies seem to demonstrate that spinal manipulation can
affect the ANS.
Myofascial techniques, denominated as such, due to the fact that
such techniques are directed at muscle tissue and fascia, have also
been demonstrated to act on the ANS. After interventions on the
gastrocnemius, biceps femoris, thoracic-lumber fascia and cranium,
Arroyo-Morales et al. (2008) concluded that myofascial release fa-
vors the recovery of HRV and diastolic blood pressure after high-
intensity exercise to pre-exercise levels.
Thus, the aim of the present study was to perform a systematic
review on the effect of spinal manipulation and myofascial tech-
niques on HRV.
2. Methods
Studies investigating the effects of spinal manipulation or other
manipulative and myofascial techniques on HRV were selected for
the present review using the following inclusion criteria: clinical
trials involving healthy individuals or patients with a disorder/
disease; use of manipulation with or without another intervention;
sample divided into an experimental group and control group
(sham or without treatment) or two experimental groups. Only
articles published in English in indexed journals were selected for
review. To retrieve relevant articles, the Pubmed, Scielo, Lilacs,
PEDro, Ibesco, Cochrane and Scopus databases were searched be-
tween October and December 2016 using the following key words:
heart rate variability, spinal manipulation, osteopathy, chiropractic,
manual therapy, myofascial, osteopathic.
Using the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA), two reviewers independently analyzed
the titles and abstracts of the articles retrieved during the initial
search. Pre-selected articles were then submitted to full-text
analysis. Two members of the research team independently
analyzed all pre-selected articles to identify potentially eligible
studies. In cases of disagreement, a third reviewer evaluated the
articles to establish a consensus. Two researchers (authors) applied
the PEDro scale independently. Divergences were settled through
discussion until reaching a consensus.
PEDro is an evidence-based physical therapy database with
more than 16 thousand randomized clinical trials, systematic re-
views and guidelines for clinical practice. This database also pro-
vides details on citations as well as abstracts and links to full texts,
whenever available. All trials are appraised for quality and these
quality appraisals lead users quickly to trials that are more likely to
be valid and contain sufficient information to guide clinical
practice.
The PEDro database is produced by the Centre for Evidence-
Based Physiotherapy of the George Institute for International
Health and was developed to give physiotherapists and other
health professionals rapid access to bibliographic details and ab-
stracts of the best evidence of the effectiveness of treatments. Trials
are classified based on methodological quality. Each article receives
a score ranging from 0 to 10 points, depending on the number of
criteria met. A score of less than 4 points is indicative of “poor”
quality, scores of 4e5 points are indicative of “fair” quality, scores of
6e8 points are indicative of “good” quality and scores of 9e10
points are indicative of “excellent quality”.
Eleven criteria are evaluated in the PEDro scale, 10 of which are
scored:
1. Eligibility criteria were specified (not scored).
2. Subjects were randomly allocated to groups (in a crossover
study, subjects were randomly allocated an order in which
treatments were received).
3. Allocation was concealed.
4. The groups were similar at baseline regarding the most
important prognostic indicators.
5. There was blinding of all subjects.
6. There was blinding of all therapists who administered the
therapy.
7. There was blinding of all assessors who measured at least
one key outcome.
8. Measures of at least one key outcome were obtained from
more than 85% of the subjects initially allocated to the
groups.
9. All subjects for whom outcome measures were available
received the treatment or control condition as allocated or,
when this was not the case, data for at least one key outcome
was analyzed by “intention to treat”.
10. The results of between-group statistical comparisons are
reported for at least one key outcome.
11. The study provides both point measures and measures of
variability for at least one key outcome.
 B.L. Amoroso Borges et al. / Journal of Bodywork & Movement Therapies 22 (2018) 203e208
3. Results
After analysis and the selection of articles on heart rate vari-
ability and osteopathic techniques, the studies were listed in the
table, which provides data on authors, year of publication, meth-
odology used, results, conclusions and methodological quality
score based on the PEDro scale (Fig. 1 and Table 1).
4. Discussion
The aim of the present study was to analyze the effects of
techniques used in osteopathy on HRV. After an evaluation of the
pre-selected articles, ten were selected for inclusion regardless of
their methodological quality, five of which were randomized clin-
ical trials. This demonstrates that need for better methodological
criteria for studies. Among the ten articles included in the present
review, methodological quality (based on the PEDro scale) was
classified as “good” for six studies, “fair” for three studies and
“poor” for one study.
HRV describes oscillations in the intervals between consecutive
heartbeats (RR intervals), which can be used to identify phenomena
related to the ANS. Changes in HRV patterns are important in-
dicators of physiological abnormalities. High HRV is a sign of good
adaptability, characterizing a healthy individual with efficient
autonomic mechanisms, whereas low HRV is often an indicator of
impaired, inefficient adaptation of the ANS and may indicate
physiological abnormalities (Vanderlei et al., 2009).
The onset of cardiac excitation is generated in the sinus node,
which is distributed throughout the atria, promoting atrial depo-
larization represented by the P wave on the electrocardiogram
(ECG). This impulse is conducted to the ventricles through the
atrioventricular node and distributed by Purkinje fibers, resulting
in the depolarization of the ventricles represented by the Q, R and S
waves (QRS complex) of the ECG. Ventricular re-polarization is
represented by the T wave. HRV indices are obtained from the
analysis of intervals between R waves, which may be captured by
an electrocardiograph, analog-digital converter or heart rate meter
using external sensors placed on specific points of the body
(Vanderlei et al., 2009).
An analysis of variables can indicate stimuli of greater
prevalence:

R-R modulation is known as vagal firing (Martinma et al., 2006).

HF is related to parasympathetic activity and is synchronized
with the respiratory rate (Lombardi et al., 1996).
Fig. 1. Screening of studies.
205

VLF is related to variation in the activity of the sympathetic
nervous system.

LF is related to sympathetic activity and vasomotor activity
(Lombardi et al., 1996).

The SDNN, SDANN and SDNNi indices represent sympathetic
and parasympathetic activity, whereas rMMSD and pNN50
represent parasympathetic activity (Vanderlei et al., 2009).
Manipulative techniques are commonly used by osteopathic
practitioners, chiropractors and physiotherapists with or without
one of the specialties cited for use in treatment, especially the
treatment of musculoskeletal disorders (Licciardone et al., 2005).
Perry et al. used techniques that the authors denominated Grave V
(high velocity and low amplitude) at L4-L5 on both sides in lateral
decubitus. One group of volunteers (n ¼ 25) was submitted to this
technique and another group (n ¼ 25) was submitted to the
McKenzie method. The authors concluded that both techniques
have an immediate effect on the activity of the SNS, but the increase
in activity was twofold greater in the group submitted to manip-
ulation. Boal and Gillette (2004) and Bialosky et al. (2009) attribute
the immediate effect of manipulation to the modulation of the
excitability of the dorsal horn of the spinal cord, resulting in
hypoalgesia. Another factor is that manipulation is performed
passively with the patient lying down. According to Slater and
Wright (1995), the activity of the SNS may be related to a change
in body position.
Budgell and Hirano (2001) divided 25 volunteers (20 women
and five men) into two groups, but did not describe the number of
volunteers in each group. In the intervention group, the therapists
manipulated C1 and C2 without extension. In the sham group, the
thrust was performed on the skin. Immediately after the inter-
vention, a reduction in HR was found in both groups, but absolute
and normalized increases in LF as well as absolute increases in HF
and the LF/HF ratio only occurred in the manipulation group. The
authors postulate that these results may be explained by two
mechanisms: 1) the afferent input of receptors in cervical tissues;
and 2) vestibular stimulation. Vestibular stimulation can elicit a
cardiovascular response. Many neurons in the ventrolateral spinal
cord that respond to stimulation of the vestibular nerve also
respond to stimulation of the carotid sinus nerve. Coffee et al.
(2005) found that hypertension may be associated with ventro-
lateral compression of the spinal cord. It seems plausible that
manipulation at C1 significantly alters sympathetic tone.
Welch and Boone (2008) divided volunteers into one group
submitted to cervical manipulation and another submitted to
thoracic manipulation (two evaluation sessions, followed by two
206
Table 1
Results of the studies.
Authors, Year
Arroyo-Morales et al., 2008
Budgell and Hirano, 2001
Budgell and Polus, 2006
Castro-Sanchez et al., 2010
Delaney, 2002
Henley et al., 2008
Perry et al., 2011
B.L. Amoroso Borges et al. / Journal of Bodywork & Movement Therapies 22 (2018) 203e208
Subjects Methods
RCT, n ¼ 62 Both groups performed
Control group ¼ 30 warm up on stationary
Fascia group ¼ 32 bike, followed by
maximum performance
during protocol.
Myofascial induction
protocol: long J-stroke
gastrocnemus and
biceps femoris, cross
technique for thoracic-
lumbar fascia and
quadriceps, pressure
sustained on occipital
condyles, frontal V
spread, temporal ear
pull after high-intensity
cycle training
Control: sham
Evaluation: ECG
Cohort of 25 healthy Manipulation of C1 and
adults C2
Sham ¼ positioning
without thrust
Evaluation: ECG, HRV.
Controlled, cross-over Manipulation of T1 to
study, 28 healthy young T4
adults Sham ¼ positioning
Evaluation: ECG for
HRV
RCT, 92 Craniosacral therapy
Intervention ¼ 46 protocol: still point on
Sham ¼ 46 feet, diaphragmatic-
pelvic release, release
of scapular girdle,
frontal lift, parietal life,
compression-
decompression of
sphenobasilar
synchondrosis
temporal
decompression,
compression-
decompression of
temporomandibular
joint and equilibrium of
dura mater
Evaluation: ECG
RCT, n ¼ 30 (16 women Myofascial techniques
and 14 men) divided in neck region, head
into control group and shoulder in
(n ¼ 15) and intervention group
intervention group through sliding,
(n ¼ 15) compression,
percussion and deep
transverse friction
Evaluation: Polar and
HRV
N ¼ 17 Osteopathy group
submitted to
myofascial maneuver in
neck region
Sham group submitted
to only touch on neck
region
Control group not
submitted to touch in
neck region
Evaluation: ECG and
HRV
RCT, 50 healthy young Exercise e trunk
adults extension (McKenzie)
Manipulation e L4/L5
Outcomes Conclusion Quality (PEDro)
Significant reductions Myofascial release 7 (1,2,3,4,7,9,10)
in blood pressure and favors the recovery of
LF after exercise; HF HRV and diastolic blood
statistically significant pressure after high-
in fascia group after intensity exercise to
exercise; Diastolic pre-exercise levels.
pressure returned to
baseline levels in fascia
group and remained
lower in control group.
Increase in LF and HF in Manipulation can affect 5/10 (1,2,8,9,10,11)
manipulation group sympathetic-
parasympathetic
balance.
Increase in LF, HF and Thoracic manipulation 7/10 (1,2,3,4, 8,9, 10,11)
LF/HF in manipulation can affect sympathetic-
group parasympathetic
balance.
After 20 weeks Craniosacral therapy 8/10 (1, 2, 3, 4, 7, 8, 9, 10)
Intervention: reduction improves pain
in pain in 13 of 18 symptoms in the
tender points, medium term in
statistically significant patients with
difference in SDRR and fibromyalgia.
rMSDD, improvement
in clinical global
impression, prevailing
for two months and one
year after intervention
Reduction in HR in The group submitted to 6/10 (1,2,4, 8,9,10,11)
intervention group; myofascial techniques
time domain: increase exhibited an increase in
in length of RR interval, parasympathetic
SDNN, RMSSD and activity and
pNN50 only in consequently greater
intervention group; relaxation.
Frequency domain:
increase in VLF and HF
and reduction in LF/HF
ratio in intervention
group
Parasympathetic Osteopathy can exert 6/10 (1,2,4,8,9,10,11)
response in supine an influence on
position in all groups responses in the ANS. A
Vagal response in vagal response was
osteopathy group found in this study.
No differences in other
groups
Increase in activity of Spinal manipulation 5/10 (2,8,9,10,11)
SNS in both groups; has prolonged effect on
SNS activity.
 B.L. Amoroso Borges et al. / Journal of Bodywork & Movement Therapies 22 (2018) 203e208 207

Table 1 (continued )

Authors, Year Subjects Methods Outcomes Conclusion Quality (PEDro)

N ¼ 25 (exercise) Evaluation: larger increase in

N ¼ 25 (manipulation) Neurophysiologic manipulation group
measure of skin
conductivity for
analysis of SNS (Biopac
System)
Roy et al., 2009 RCT, 51 volunteers: Manipulation at L5 with Increase in VLF in all Independent of 7/10 (1,2,3,4,5, 9, 10,11)
33 in group without activator in group groups except control technique, lumbar
pain: without pain Reduction in LF in all manipulation seems to
11 per group (control, Lumbar manipulation groups except sham stimulate the PNS.
sham and treatment) (low back row) in group group without pain
20 in group with pain: with pain
10 per group Evaluation of HRV
(treatment and sham) (Suunto heart meter)
Welch and Boone, 2008 Controlled, cross-over Cervical (n ¼ 4) and Significant reduction in Cervical stimulation led 1/10 (1,8)
clinical trial thoracic (n ¼ 3) diastolic pressure to stimulated
N ¼ 40 manipulation HRV only evaluated in 7 parasympathetic
Evaluation: BP and ECG individuals activity and thoracic
for HRV stimulation led to an
increase in sympathetic
activity.
Zhang et al., 2006 N ¼ 10, but only 8 Manipulative Reduction in HR and Manipulative 5/10 (1, 2, 8, 9, 10, 11)
underwent HRV adjustments (not increase in LF and HF in adjustments can
analysis specified) group immediately modify HRV and reduce
Evaluation: ECG e HRV, after adjustments pain.
HR and pain Increase in LF at four
weeks

intervention sessions and a final evaluation session). The authors
only described the position of the volunteers during the in-
terventions e the cervical group (C1, n ¼ 4) was in supine position,
whereas the thoracic group (T1, n ¼ 1 and T4, n ¼ 2) was in the
prone position. Although 40 individuals were recruited for the
study, HRV was only evaluated in seven. After manipulation, an
increase in parasympathetic dominance was found, as demon-
strated by the reduction in the LF/HF ratio. In contrast, an increase
was found in the LF/HF ratio in the group submitted to thoracic
manipulation, which indicates an increase in sympathetic activity.
Zhang et al. (2006) performed manipulation on 10 individuals,
but did not specify the type of manipulation and HRV was evalu-
ated in only eight individuals. Statistically significant changes were
found. Mean HR was reduced from 76 to 74, SDNN increased from
57.4 to 61.5, HF increased from 448 to 485 and LF increased from
446 to 448. The authors conclude that manipulation can exert an
influence on HRV, but long-term studies are needed.
For the lumbar region, Roy et al. (2009) divided the sample into
two groups, each with three subgroups. The group without pain
(n ¼ 11) was subdivided into a treatment, sham and control group.
Treatment involved the use of a chiropractic device denominated
the Activator IV (174.75 N) applied to L5. The group with pain
(n ¼ 10) was subdivided in the same way and used the lumbar roll
method. In the group with pain, differences were found among the
subgroups with regard to HF and VLF. In the group without pain,
differences among subgroups were found for mean RR and HF. The
reduction in HF in all groups except the control was considered to
be representative of the parasympathetic response, which is also
linked to respiratory activity. VLF also increased in all groups except
the control and LF diminished in all groups except the sham sub-
group without pain. This represents the sympathetic response and
is related to vasomotor activity. The prevalence of HF over LF was
also found in all groups except the control, suggesting a change in
sympathovagal balance toward parasympathetic predominance.
Thus, lumbar manipulation seems to stimulate the para-
sympathetic system.
Osteopathy is not restricted to spinal manipulation. Myofascial
techniques are also employed for the treatment of different disor-
ders. In the study conducted by Arroyo-Morales et al. (2008),
healthy volunteers were allocated to a fascia group (n ¼ 32) and
control group (n ¼ 30). Following warm up and three minutes of
recovery, both groups performed the Wingate test on a stationary
bike. The volunteers were encouraged to give their maximum
performance and were then placed in the supine position for
analysis. The fascia group was submitted to the following tech-
niques for a total of 40 min: long J-stroke for the gastrocnemius and
biceps femoris muscles for three minutes each; technique with
hand crossed over the thoracolumbar fascia for 12 min and over the
quadriceps for eight minutes; sustained pressure on the occipital
condyles for five minutes; frontal V spread for five minutes; and ear
pull of the temporal muscles for four minutes. These myofascial
techniques favored the normalization of blood pressure and HRV
after the high-intensity exercise. It is likely that such techniques
favor parasympathetic effects, with type 3 and 4 mechanoreceptors
stimulated by the myofascial movements activating a para-
sympathetic vegetative response. A specific group of these
mechanoceptors are responsible for this type of cardiovascular
response through the stimulus of traction.
Castro-Sanchez et al. (2010) allocated volunteers with fibro-
myalgia to an intervention group (n ¼ 46) and sham group (n ¼ 46).
After the algometric and HRV analyses, the intervention group was
submitted to the still point technique on the feet, diaphragmatic-
pelvic release, scapular girdle release, frontal lift, parietal lift,
compression-decompression of sphenobasilar synchondrosis,
decompression of the temporal muscle, compression-
decompression of the temporomandibular joint and equilibrium
of the dura mater. After 20 weeks of treatment, the intervention
group exhibited a significant reduction in 13 of the 18 tender points,
significant differences in SDRR and rMSDD and an improvement
the clinical global impression, prevailing for two months and one
year after the intervention.
Henley et al. (2008) allocated 17 volunteers to an osteopathy
208 B.L. Amoroso Borges et al. / Journal of Bodywork & Movement Therapies 22 (2018) 203e208
group, sham group and control group, but did not describe the
number of volunteers in each group. The osteopathy group was
submitted to a myofascial technique in the cervical region, but the
authors did not describe how the technique was performed. In the
sham group, the researchers placed their hands in the same posi-
tion as in the osteopathy group, but without performing any
intervention, and the control group was only submitted to the
evaluation procedures. Increases in HR, LF and the LF/HF ratio as
well as a decrease in HF were found in all groups in the tilt position.
In the inter-group comparisons, the increase in LF and the LF/HF
ratio were significantly lower in the osteopathy group when
compared to the other groups and HF was significantly higher in
comparison to the other groups. The authors demonstrated that the
tilt position causes a change in sympathetic tone, with the return to
parasympathetic tone after returning to the horizontal supine po-
sition. It is possible that the change in sympathovagal balance from
the sympathetic to parasympathetic response was more evident in
the osteopathy group than the other groups. The authors hypoth-
esize that these data were the result of cervical afference to
vestibular nuclei.
Delaney (2002) used myofascial techniques to determine the
influence on HRV. The sample was divided into an intervention
group (n ¼ 15) and a control group (n ¼ 15). Myofascial techniques
(sliding, compression, percussion and transverse friction) were
performed for 20 min. In comparison to the control group, in-
creases were found in the RR interval, RR, SDNN, RMSSD and
pNN50 and a reduction was found in HR in the time domain. In the
frequency domain, increases occurred in HF and VLF and a decrease
occurred in the LF/HF ratio only in the intervention group. The
author concluded that an increase occurred in the parasympathetic
response and a decrease occurred in sympathetic activity. These
findings seem to be related to an increase in relaxation and a
reduction in the defense excitation response (stress).
One important point was the concern the authors had regarding
the analysis of HRV, instructing the volunteers to avoid consuming
certain foods and beverages, such as coffee, and not to perform
physical activity during the procedures to avoid any change in the
ANS due to other agents.
5. Conclusion
With regard to the influence of osteopathic modalities on heart
rate variability, the following factors can facilitate sympathetic and
parasympathetic responses:

Stimulus in the upper cervical region stimulates the para-
sympathetic response whether through vestibular stimulation
or the afference of cervical receptors (Budgell and Hirano, 2001).

The manipulation site can exert an influence on the response
(Zhang et al., 2006). When manipulation is performed in the
cervical region, the parasympathetic nervous system is activated
due to the response to the vagus nerve. When lumbosacral
manipulation is performed, parasympathetic activation is due to
the occurrence of parasympathetic nerves in this region (Perry
et al., 2011; Welch and Boone, 2008; Roy et al., 2009). When
thoracic manipulation is performed, there is an increase in the
sympathetic response, since sympathetic roots are located on
this level (Welch and Boone, 2008).

Relaxation promoted by myofascial techniques may facilitate
the parasympathetic response (Delaney, 2002; Arroyo-Morales
et al., 2008; Henley et al., 2008; Castro-Sanchez et al., 2010).

Cranial techniques tend to stimulate the parasympathetic
response through the stimulus of mechanoreceptors, which
mediate the response when stimulated by myofascial
movements, thereby activating a parasympathetic vegetative
response, as some mechanoreceptors are responsible for this
type of cardiovascular response through the stimulus of traction
(Arroyo-Morales et al., 2008).
Conflict of interest
The authors declare no conflicts of interest.
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