Response to “Lymphatic osteopathic manipulative treatment and soreness after receiving the COVID-19 vaccine”

To the Editor:

I appreciate the opportunity to address the concerns raised by Sookaromdee and Wiwanitkit [1]. Considering the millions of individuals receiving COVID-19 vaccines worldwide, I was interested in seeing whether osteopathic manipulative treatment (OMT) could be utilized to relieve patients of their muscle soreness, and I conducted a search to determine whether something similar had already been accomplished [2]. Although I mention that OMT has been utilized in various postvaccination settings, including in the enhancement of hepatitis B immunity [3] and in the treatment of shoulder injury related to vaccine administration (SIRVA) [4], a chronic condition that results from vaccine administration within the shoulder capsule rather than in the deltoid muscle, neither of these articles specifically mention how OMT can mitigate the severity or duration of muscle soreness. This supports my statement that “The implementation of OMT to specifically relieve vaccine-related muscle soreness”... [the local reaction caused by local cytokine infiltratation] ... “has not yet been investigated.”

The articles by Veera et al. [3] and Walkowski et al. [4] did not directly address the use of OMT for the prompt relief of the transient and self-limited muscle soreness that ensues after vaccination. Veera et al. [3] is a case study that looks at utilizing OMT for the treatment of SIRVA. This causes inflammation in various shoulder structures including ligaments, tendons, and bursae, and it can present with injuries such as bursitis or adhesive capsulitis. SIRVA begins days after injection and can last months to years [5]. The pathophysiology of SIRVA is different than the local inflammatory reaction that occurs with proper vaccine placement, and this local inflammatory reaction should not be looked at as the same process. Walkowski et al. [4] demonstrated that individuals treated with lymphatic OMT had an enhanced immune response, noted by an increase in antibody titer, an upregulation of the number of circulating leukocytes, and an increase of cytokines within the lymphatic system. Although these lab values showed significant differences with the use of OMT, this was not clinically correlated to a reduction in symptom severity or duration by these authors. To clarify, they concluded that there was uncertainty in whether OMT induced the de novo synthesis of cytokines or chemokines, but they noted that “… we were able to detect a significant increase in the plasma levels of MIP-1α in the OMT group compared with pre-treatment values … a significant increase in plasma levels of IL-8 [and] … MCP-1 were also significantly higher in the OMT group compared to sham controls” [4].

Nonetheless, there is no doubt that the mechanism underlying how OMT reduces muscle soreness requires further research. As we state, vaccines induce a local inflammatory reaction where recruited leukocytes secrete cytokines that increase nociception. Although it could be rationalized that OMT reduces muscle soreness by extrinsically clearing cytokines within infiltrated tissues, it is unclear whether this indeed is the exact mechanism. Further laboratory work could elucidate the physiological processes that underlie the use of lymphatic OMT, and a randomized controlled trial can assess whether these results are reproducible on a larger scale.