COVID-19 mRNA vaccine immune response to the addition of osteopathic manipulative treatment with lymphatic pumps: a randomized controlled trial

Abstract

Osteopathic manipulative treatment (OMT) has demonstrated immune augmentation in preclinical studies, but direct evidence in humans is lacking. We conducted a randomized controlled trial on the addition of OMT in subjects receiving their first Pfizer-BioNTech (BNT162b2) COVID-19 vaccination in 2021. Subjects were randomized to either receive OMT at each vaccination or not. We measured anti-spike protein, anti-nucleocapsid, and neutralizing antibodies. Primary endpoints were time-resolved and cumulative anti-SARS-CoV-2 spike protein antibody titers. Secondary endpoints were breakthrough infection symptom frequency, severity, and duration. 104 subjects were randomly assigned to control or OMT group, with 91 subjects completing the primary vaccination series. Initial antibody titers separated subjects into 51 COVID-19-naïve and 40 COVID-19-pre-exposed. COVID19-naïve subjects were selected for analysis based on data homogeneity. In this cohort, the OMT group showed significantly increased anti-SARS-CoV-2 spike protein antibody titers at 3 weeks vs controls (p = 0.038). Cumulative titers in this cohort, were significantly increased in the OMT group at 5 weeks (p = 0.046) and at 13 weeks (p = 0.009) compared to controls. An intention-to-treat (ITT) analysis of all subjects revealed significant differences in titers between the OMT group and controls at 3 weeks (p < 0.001) and at 13 weeks for AUC titers (p = 0.035) as compared to controls. The COVID-19- pre-exposed group showed no significant differences. Both groups had 10 breakthrough infections, but the OMT group experienced fewer and less severe symptoms, with symptom duration reduced from 8 days in controls to 4.5 days in the OMT group (p = 0.013). Medication duration was shorter in the OMT group, 1.5 days vs 5 days (p = 0.014). OMT-treated subjects developed quicker and stronger vaccine-induced antibody titers and had significantly shorter and less severe breakthrough symptoms, suggesting OMT may enhance immune responses to COVID19 vaccination.

Keywords: Antibody; IgG; Immunity; Manipulation, osteopathic; Vaccination; Vaccines, COVID-19.

Fig. 1a

Timeline of vaccine, OMT intervention, and blood draw schedule. Breakthroughs were analyzed from 90 days – 210 days. No breakthroughs were reported or detected in the first 90 days, as determined by negative anti-nucleocapsid IgG testing. Note that booster injections and subsequent blood draws on day 210 and day 217 were only received by participants who elected to receive booster injections. Created in BioRender. Martinez, E. (2025) https://BioRender.com/j37c808.

Fig. 1b

Timeline of variant strains and breakthrough infections. Breakthrough infections that were analyzed occurred in December 2021 and January 2022. The breakthrough infections aligned with the emergence of the Omicron variant (Omicron BA.1). Variant data adapted from previous surveillance data and CDC reports (Linton et al., 2025; Lambrou et al., 2022; Havers et al., 2022). Created in BioRender. Martinez, E. (2025) https://BioRender.com/pmq5rc7.

Fig. 2

. CONSORT trial profile. The primary analysis of adjunctive osteopathic manipulative treatment was conducted on subjects who were naïve to COVID-19 at baseline. This included the 31 subjects from the control group and the 20 from the OMT-intervention group, all of whom completed the entire vaccination protocol. This group was also selected for analysis because there were no breakthrough infections or booster vaccinations, which would further subdivide the group analysis. This selection allowed for the most reliable and valid estimation of the intervention’s effects on the primary outcome measures. Breakthrough infections were analyzed after the initial 13-week period but before booster injections were offered. There were 10 cases in each the COVID-19 naïve control and OMT intervention group.

Fig. 3a

Changes from baseline to week 13 in log10 Immunoglobulin G titers. Changes in Log₁₀-transformed Immunoglobulin G (IgG) levels among all subjects measured over a 13-week period before breakthrough infections. IgG titers were measured in arbitrary units per milliliter (AU/mL) and estimated from mixed linear models that adjusted for age. Toeplitz covariance matrices were assumed to have time-lag dependent (constant) correlations/covariance between each measurement. Error bars indicate the 95 % confidence interval. Each box plot depicts the median and the interquartile range. Circular dots on the box plots indicate individual data points for IgG titers in both groups. At week 3 post-enrollment, there is a statistically significant difference in IgG titers between the Control and OMT-treated group, indicated by *** (p-value < 0.001); 95 %CI [3.57,3.79]; 86 % increase.

Fig. 3b

Mean area under the curve changes of anti-SARS-CoV-2 spike protein IgG titers over time (0 to 13 weeks) for each subject. Mean Area Under the Curve (AUC) of anti-SARS-CoV-2 spike protein Immunoglobulin G (IgG) titers from baseline to week 13. The AUC for IgG was calculated using the Trapezoidal rule, providing a cumulative measure of the overall effect of OMT treatment on IgG over time. The estimated AUC showed significant differences at 0 to week 13 (average ctrl AUC: 303,532 AU vs average OMT AUC: 422,772 AU; 39.28 % increase; * p-value: 0.035).

Fig. 4a

Changes from baseline to week 13 in log10 Immunoglobulin G titers. Changes in Log₁₀-transformed Immunoglobulin G (IgG) levels among subjects who were not infected with SARS-CoV-2 prior to joining the study were measured over a 13-week period before any breakthrough infections occurred. At week 3 post-enrollment, there is a statistically significant difference in IgG titers between the Control and OMT-treated group, indicated by * (p-value:0.038); 95 %CI [0.0387,1.3542]; 62 % increase; t-value: 2.09.

Fig. 4b

Mean area under the curve changes of anti-SARS-CoV-2 spike protein IgG titers over time (0 to 13 weeks) for each subject. Mean Area Under the Curve (AUC) of anti-SARS-CoV-2 spike protein Immunoglobulin G (IgG) titers from baseline to week 13. AUC of IgG titer levels are presented among subjects without prior SARS-CoV-2 infection. The estimated AUC showed significant differences at 0 to week 5 (average ctrl AUC: 42,389 AU vs average OMT AUC: 63,819 AU; 50.56 % increase; t-value:2.05; * p-value:0.046) and 0 to week 13 (average ctrl AUC: 171,249 AU vs average OMT AUC: 272,711 AU; 59.25 % increase; t-value:2.71; ** p-value:0.009).

Fig. 5

Breakthrough infection symptomology frequency, severity, and duration. Breakthrough infections were self-reported by subjects and confirmed via PCR or rapid antigen testing. In addition, breakthrough infections were monitored and confirmed via spikes in anti-SARS-CoV-2 spike protein and anti-SARS-CoV-2 nucleocapsid protein. The analysis focused on the COVID-19 naïve cohort between blood draw 6 (day 90) and blood draw 7 (day 210), before booster injections were introduced. Panel A: Frequency of symptoms in the post-vaccination period breakthrough cases. Symptoms were classified into five subcategories: Respiratory, Nervous, Musculoskeletal, Immune, and Gastrointestinal symptoms. Panel B: Symptom severity score was self-reported by subjects on a scale of 0–3 (0-None present, 1-Mild, 2-Moderate, 3-Severe). Significant differences in severity scores were observed for cough (p = 0.036), body aches (p < 0.001), and chills (p = 0.025). Panel C: Duration of symptoms, reported in days by subjects with breakthrough infections. Subjects in the OMT intervention group reported fewer days of symptoms compared to the control group (p = 0.013). Panel D: Duration of medication usage, reported in days by subjects with breakthrough infections. The OMT intervention group also reported fewer days of medication usage compared to the control group (p = 0.014).