Osteopathic manipulative treatment in individuals with vertigo and somatic dysfunction: a randomized, controlled, comparative feasibility study.

CONTEXT: There is a paucity of research assessing the efficacy of osteopathic manipulative treatment (OMT) in patients with vertigo. OBJECTIVE: To assess the feasibility of conducting a randomized, controlled trial comparing OMT and vestibular rehabilitation therapy (VRT), alone or in combination, in patients with vertigo and somatic dysfunction. METHODS: Volunteers with vertigo who were also diagnosed with somatic dysfunction (SD) were prospectively enrolled in a blinded, randomized, controlled cohort comparative effectiveness study and assigned to 1 of 4 groups: OMT alone, VRT alone, a combination of OMT and VRT (OMT/VRT), or a nonintervention control group. Participants between 18 and 79 years of age were included if they had experienced symptoms of vertigo for at least 3 months' duration, demonstrated somatic dysfunction, and could participate in computerized dynamic posturography (CDP) testing, tolerate manual therapy and exercises, and communicate effectively in English or Spanish. A total of 3 treatments lasting 45 minutes each were administered 1 week apart to each participant. OMT in this study consisted of counterstrain, myofascial release, balanced ligamentous tension, soft tissue, HVLA, and articulatory techniques. Comparisons were made between composite scores (CS) assessed with computerized dynamic posturography (CDP), dizziness handicap inventory (DHI), optometric evaluation, and osteopathic structural examinations collected before the first treatment, after the third/final treatment, and 3 months after the final treatment. (ClinicalTrials.gov number NCT01529151). RESULTS: A total of 23 patients were included in the study: 7 in the OMT group, 5 in the VRT group, 6 in the OMT/VRT group, and 5 in the control group. The OMT/VRT group demonstrated significant improvement in DHI score (P=0.0284) and CS (P=0.0475) between pre- and 3-month posttreatment measures. For total severity, improvements were significant in the OMT group both from pretreatment to immediate posttreatment measures (P=0.0114) and from pretreatment to 3-month posttreatment measures (P=0.0233). There was a statistical difference between the OMT and control groups from pretreatment to 3-month posttreatment DHI scores (P=0.0332). Also, there was a statistical difference in DHI score between VRT and control from pre- to 3-month posttreatment scores (P=0.0338). OMT/VRT statistically and clinically improved visual acuity in patients' right eyes from pre- to posttreatment (P=0.0325). In all participants, vergence dysfunction was prevalent (5; 21.7%) in addition to vertical heterophoria (15; 65.2%). CONCLUSION: A combination of OMT and VRT significantly reduced vertigo and improved balance 3 months after treatment (P<0.05). There was a high prevalence in vergence and vertical heterophoria, which are not typical screening measurements used by physical therapists and physicians to assess vertigo patients. With a small sample size, this study demonstrated the feasibility of an interdisciplinary team evaluating and treating patients with vertigo in a community setting. A larger study is needed to assess the efficacy of OMT/VRT in vertigo patients.

The Role of Musculoskeletal Disorders in Chronic Disease: A Narrative Review.

Chronic diseases and musculoskeletal conditions are responsible for a significant portion of the global disease burden and are frequently comorbid, such as with low back pain in patients who also have chronic organ disease. Low back pain is the leading cause of long-term disability and is the most common reason adults seek adjunctive treatment, including osteopathic manipulative treatment (OMT). OMT has been shown to be effective in relieving low back pain and improving back-specific functioning. In this narrative review, the authors summarize literature published in the last decade and analyze the relationship between musculoskeletal disorders and systemic medical conditions such as diabetes mellitus; they also discuss the efficacy and cost-effectiveness of OMT in managing somatic dysfunction in patients with chronic diseases.

Correlation of Personal Experience and Acquired Knowledge With Intent to Recommend Adjunctive Osteopathic Manipulative Treatment or Yoga for Patients With Chronic Low Back Pain.

CONTEXT: Osteopathic manipulative treatment (OMT) and yoga are both recommended by systematic reviews in the evidence-based research literature for low back pain management. It is unknown, to the authors' knowledge, what the effect of personal experience with OMT or yoga, reading research articles on OMT or yoga, or both will have on medical students' recommendations for these treatment options to future patients with chronic low back pain. OBJECTIVE: To evaluate the likelihood of osteopathic medical students recommending OMT or yoga to treat patients with chronic low back pain based on their personal experience or reading research articles that recommend OMT or yoga for patients with chronic low back pain. METHODS: In this prospective cohort study, researchers administered an anonymous 18-question online survey for osteopathic medical students. The survey included a patient vignette, 2 evidence-based articles, and multiple choice, yes/no, and Likert-type questions. Participants were recruited via email from all 4 years of medical school. Between-group differences in proportions were assessed with descriptive statistics and χ2 tests; differences within groups were assessed with the McNemar test; and Fischer exact tests were used when expected cell counts were less than 5. RESULTS: A total of 180 participants (100 male, 80 female) completed the study. Personal experience increased the likelihood of osteopathic medical students recommending OMT (P<.018) or yoga (P<.001) to a future patient or to a patient in a case vignette (P<.05) with chronic low back pain. Students who read research articles were more likely to recommend OMT to the case patient and future patients before and after reading the intervention article regardless of their experience (P<.001). CONCLUSION: Personal experience and reading evidence-based research may increase the likelihood that osteopathic medical students will recommend OMT to future patients with chronic low back pain.

Effect of Table Trainer-to-Student Ratios on Outcome in Student Assessments of Cervical Muscle Energy Techniques.

CONTEXT: Improving the acquisition of osteopathic manipulative treatment (OMT) skills may increase student confidence and later use of OMT. A first step in this process is determining the optimal table trainer-to-student ratio (TTR). OBJECTIVE: To determine the effect of TTR on knowledge and skill acquisition of cervical muscle energy OMT techniques in first-year osteopathic medical students. METHODS: First-year students at 3 colleges of osteopathic medicine received instruction on cervical diagnosis and muscle energy techniques at 1 of 3 workshops, each having a different TTR (1:4, 1:8, or 1:16). Written assessments were conducted immediately before and after the workshop and again 2 weeks later to test retention of the knowledge acquired. Practical assessments were conducted immediately after the workshop and 2 weeks later to test retention of the skills acquired and were graded for technical and proficiency elements. RESULTS: Ninety-two students completed pre- and postworkshop assessments, and 86 completed the retention assessment. No difference was found between TTRs on the preworkshop, postworkshop, and retention written scores (P≥.15). Postworkshop written assessment scores were highest, followed by retention scores; preworkshop scores were lowest (P<.001). Although the mean (SD) postworkshop practical scores for the 1:4 and 1:8 TTR workshop groups (266.3 [43.1] and 250.6 [47.5], respectively) were higher than those for the 1:16 TTR groups (230.3 [62.2]), the difference was not significant (P=.06). For the retention practical assessment scores, no significant difference was found between TTRs (P=.19). A significant interaction was noted between TTR and the timing of practical assessments; scores declined from postworkshop to retention assessments for the 1:4 (P=.04) and 1:8 (P=.02) TTR workshop groups but not the 1:16 TTR workshop groups (P=.21). Student order in paired student demonstrations also had a significant effect on technical scores (P≤.03); students who demonstrated techniques second had higher scores than those who demonstrated techniques first. CONCLUSION: The TRR had no significant effect on written or practical assessment scores. Practical assessment scores for the 1:4 and 1:8 TTRs declined significantly between postworkshop and retention assessments. Future studies with more statistical power will be necessary to determine the effect of TTRs on student learning. The current study also found that student order in paired demonstrations may affect practical assessment scores, because the second-demonstrating student scored higher than the first; colleges of osteopathic medicine should therefore consider randomizing student order during practical assessments.

Somatic dysfunction and use of osteopathic manual treatment techniques during ambulatory medical care visits: a CONCORD-PBRN study.

CONTEXT: Osteopathic manual treatment (OMT) of somatic dysfunction is a unique approach to medical care that may be studied within a practice-based research network. OBJECTIVE: To measure patient characteristics and osteopathic physician practice patterns within the Consortium for Collaborative Osteopathic Research Development-Practice-Based Research Network (CONCORD-PBRN). DESIGN: Cross-sectional card study. SETTING: Eleven member clinics within the CONCORD-PBRN coordinated by The Osteopathic Research Center. PATIENTS: A total of 668 patients seen between January and March 2013. MAIN STUDY MEASURES: Patient age and sex; primary diagnoses; somatic dysfunction as manifested by tenderness, asymmetry, restricted motion, or tissue texture changes; and use of 14 OMT techniques. Results were stratified by anatomical region and adjusted for clustering within member clinics. Clustering was measured by the intracluster correlation coefficient. RESULTS: Patient ages ranged from 7 days to 87 years (adjusted mean age, 49.2 years; 95% confidence interval [CI], 43.3-55.1 years). There were 450 females (67.4%) and 508 patient visits (76.0%) involved a primary diagnosis of disease of the musculoskeletal system and connective tissue. Structural examination was performed during 657 patient visits (98.4%), and 649 visits (97.2%) involved OMT. Restricted motion and tenderness were the most and least common palpatory findings, respectively. Cranial (1070 [14.5%]), myofascial release (1009 [13.7%]), muscle energy (1001 [13.6%]), and counterstrain (980 [13.3%]) techniques were most commonly used, accounting for more than one-half of the OMT provided. Pediatric patients were more likely than adults to receive OMT within the head (adjusted odds ratio [OR], 9.53; 95% CI, 1.28-71.14). Geriatric patients were more likely than adults to receive a structural examination (adjusted OR, 1.83; 95% CI, 1.09-3.07) and OMT (adjusted OR, 1.62; 1.02-2.59) within the lower extremity. Females were more likely than males to receive a structural examination (adjusted OR, 2.44; 95% CI, 1.44-4.16) and OMT (adjusted OR, 2.11; 95% CI, 1.26-3.52) within the sacrum and OMT within the pelvis (adjusted OR, 1.79; 95% CI, 1.12-2.88). Intracluster correlation coefficients for the 4 most commonly used OMT techniques ranged from 0.34 to 0.72. CONCLUSION: This study provides proof of concept of the feasibility of studying osteopathic medical practice on a national level by developing and growing the CONCORD-PBRN.

Use of the SMART Balance Master to quantify the effects of osteopathic manipulative treatment in patients with dizziness.

CONTEXT: Dizziness is the third most common complaint among outpatients and the most common complaint in patients aged 75 years or older. It can be incapacitating for patients, affecting both productivity and quality of life. OBJECTIVE: To evaluate the effect of osteopathic manipulative treatment (OMT) for spinal somatic dysfunction in patients with dizziness lasting longer than 3 months. DESIGN: A prospective clinical cohort study that took place in 2011. SETTING: Department of Physical Therapy laboratory at the Western University of Health Sciences College of Osteopathic Medicine in Pomona, California. PATIENTS: Sixteen participants (2 male, 14 female; mean [range] age, 49 [13-75] years) with dizziness lasting at least 3 months (mean duration of symptoms, 84 months) and spinal somatic dysfunction, but no history of known stroke or brain disease, were recruited from the local community and evaluated for postural balance control before, immediately after, and 1 week after OMT. INTERVENTION: Four osteopathic physicians board certified in neuromusculoskeletal medicine/osteopathic manipulative medicine provided OMT, including muscle energy; high-velocity, low-amplitude; counterstrain; myofascial release; balanced ligamentous release; and cranial OMT techniques. MAIN OUTCOME MEASURES: Outcomes were assessed with the SMART Balance Master (NeuroCom), a validated instrument that provides graphic and quantitative analyses of sway and balance, and the Dizziness Handicap Inventory (DHI), a self-assessment inventory designed to assess precipitating physical factors associated with dizziness and functional and emotional consequences of vestibular disease. RESULTS: Paired t tests, performed to assess changes in mean composite scores for all challenge tests, revealed that balance was significantly improved both immediately and 1 week after OMT (both P<.001), with no significant difference between immediate and 1-week post-OMT scores (P=.20). The DHI scores, both total and subscale, improved significantly after OMT (P<.001), and changes in composite and DHI scores were correlated with each other (P=.047). CONCLUSION: Osteopathic manipulative treatment for spinal somatic dysfunction improved balance in patients with dizziness lasting at least 3 months.

Trainer-to-student ratios for teaching psychomotor skills in health care fields, as applied to osteopathic manipulative medicine.

The hallmark of osteopathic medical education is the inclusion of hands-on instruction in osteopathic manipulative medicine (OMM), which includes palpatory diagnosis and osteopathic manipulative treatment (OMT). This OMM training typically involves a primary instructor presenting theory and techniques with step-by-step demonstrations to a large group of first- and second-year osteopathic medical students. Additional instructors, referred to as table trainers, assist the primary instructor by supervising the students as they practice the presented techniques. To the authors' knowledge, there is no currently accepted standard for a table trainer-to-student ratio in OMM skills laboratories within osteopathic medical schools in the United States. However, through a Google Web search and PubMed literature review, the authors identified published trainer-to-student ratios used in other health care skills training curricula. Psychomotor skills training courses in health care fields typically have a table trainer-to-student ratio of 1 trainer to 8 or fewer students. On the basis of these findings and psychomotor skills learning theory, the authors conclude that this ratio is likely sufficient for OMM skills training.