Who Uses Osteopathic Manipulative Treatment? A Prospective, Observational Study Conducted by DO-Touch.NET.

CONTEXT: Information about the characteristics of patients who use osteopathic manipulative treatment (OMT) is limited. OBJECTIVE: To determine the scope of conditions being managed with OMT and describe the characteristics of patients who receive OMT. METHODS: Researchers conducted a longitudinal, observational study on the use and effectiveness of OMT at 17 clinics where clinicians (ie, osteopathic and allopathic physicians and Canadian-trained osteopaths) provided OMT. Adult patients receiving OMT completed questionnaires immediately before, immediately after, and daily for 7 days after treatment. Data collected from patients included demographic information, chief complaint(s) and their severity, and health-related quality of life. Physical examination findings, treatment, and medical diagnosis documentation were extracted from medical records. Census data were used to assess whether patients were representative of the population of the county where the clinic was located. RESULTS: Data were collected from 927 patients at 1924 office visits. A majority of patients were women (690 [75%]), white (854 [96%]), and not Hispanic or Latinx (707 [95%]). The mean (SD) age was 51.9 (15.9) years. When compared with census data, the sample had higher percentages of women, people aged 65 years and older, people who identified as white, people who were high school and college graduates, and people with higher household incomes than that of the county population. The most common chief complaints from patients were pain or discomfort in the lower back (311 [34%]) and neck (277 [30%]), which corresponded with the most common medical diagnoses. Patients reported that OMT, surgery, and medications were the most helpful treatments they had used previously for their chief complaint(s). Before receiving OMT, patients' health-related quality of life was significantly worse (P≤.05) than that of the general US population. CONCLUSIONS: Adult patients receiving OMT are being treated primarily for musculoskeletal pain conditions, are not representative of the population of the county where the clinic was located, and have worse health-related quality of life than that of the general population. Information about the characteristics of patients who use OMT is important for defining osteopathic distinctiveness and identifying potential areas for increasing the use of OMT. (ClinicalTrials.gov number NCT02395965).

Characterizing Adverse Events Reported Immediately After Osteopathic Manipulative Treatment.

CONTEXT: Although adverse events in various types of manual therapy have been previously investigated, little is known about the incidence and types of adverse events that occur after osteopathic manipulative treatment (OMT). OBJECTIVE: To estimate the incidence and characterize the types of adverse events that patients report after OMT and prior to leaving the office to increase the likelihood of identifying adverse events caused by OMT. METHODS: As part of a prospective study evaluating the use and effectiveness of OMT, patients assessed how they felt immediately after OMT compared with before OMT using a 5-point ordinal rating scale (much better, better, about the same, worse, much worse). For patients who indicated they felt their condition had changed, a follow-up, open-ended question asked them to describe how it had changed. Patients who felt worse or much worse were considered to have experienced an adverse event. Two reviewers independently coded the types of adverse events based on the descriptions provided by the patients. Generalized logistic regression models were used to calculate incidence rates and 95% CIs for the types of adverse events. These models were also used to calculate the ORs and 95% CIs for associations of adverse events with demographic characteristics and with individual OMT techniques after accounting for demographic characteristics. RESULTS: Immediately after OMT, 884 patients provided data at 1847 office visits (663 [76%] women; 794 [92%] identified as white; mean [SD] age, 51.8 [15.8] years). Patients reported they felt worse or much worse immediately after OMT at 45 office visits; the incidence rate for adverse events was 2.5% (95% CI, 1.3%-4.7%). Pain/discomfort was the most commonly identified type of adverse event (16 [0.9%]; 95% CI, 0.5%-1.6%). Insufficient information was provided to determine the type of adverse event at 20 office visits. Women reported adverse events more frequently than men (OR, 13.9; 95% CI, 1.7-115.6; P=.01). CONCLUSION: The incidence of adverse events immediately after OMT, most commonly pain/discomfort, was lower than previous reports from other manual medicine disciplines. Larger studies are needed to determine the incidence of serious adverse events and to assess adverse events that occur in the days following OMT.

Tool for Predicting Medical Student Burnout From Sustained Stress Levels: Factor Analysis of the Medical Education Hassles Scale-R.

CONTEXT: Acute stress during medical school affects the health of students and is associated with burnout. The Medical Education Hassles Scale-R (MEHS-R) is designed to measure acute stress among medical students. Researchers using the MEHS-R primarily report overall hassles scores, which are unable to discriminate between different categories of hassles encountered. OBJECTIVE: The present study examined the factor structure of the MEHS-R to identify subscales that would be useful to categorize hassles for research and assessment purposes. DESIGN: Longitudinal, observational study. SETTING: Two osteopathic medical schools. PARTICIPANTS: Five hundred six first-year medical students. MAIN OUTCOME MEASURE: The MEHS-R was administered at orientation and 9 to 10 times throughout the first year, classified into examination, vacation, and routine medical school activity periods. Students rated the 101 items on a 4-point scale (0=none to 3=a great deal) to indicate how much of a hassle each item had been during the previous week. Demographic subgroups were males, females, married students, single students, whites, and ethnic minorities. RESULTS: Exploratory factor analysis was conducted on data collected at the first school during orientation. Seven subscales were identified: Academic and Time Pressures, Financial, Social, External Influences, Day-to-Day Functioning, Relationships With Immediate Family, and Health. Cronbach α were ≥0.75. Stability of these subscales was examined using confirmatory factor analysis. Both of the fit indices used indicated the 7-subscale model for the MEHS-R adequately fit the data obtained during examination and routine medical school activity periods, one fit index indicated adequate fit for the vacation period, and neither indicated adequate fit for the data from the second school. Of the 7 subscales, 5 had a strong correspondence with categories identified by the scale developers. Fit indices also indicated the 7-subscale model was adequately generalizable to the demographic subgroups with the exception of the ethnic minorities subgroup. CONCLUSIONS: Exploratory factor analysis performed on the MEHS-R supported formation of subscales similar to categories identified during MEHS-R development. Results of the current study supported the use of the MEHS-R for the investigation of acute stress in medical students. In future research, targeted wellness interventions for medical students may be developed based on student responses to this instrument.

Acute electromyographic responses of deep thoracic paraspinal muscles to spinal manual therapy interventions. An experimental, randomized cross-over study.

This single group, randomized, cross-over study explored whether manual therapy alters motor tone of deep thoracic back muscles by examining resting electromyographic activity (EMG) after 2 types of manual therapy and a sham control intervention. Twenty-two participants with thoracic spinal pain (15 females, 7 males, mean age 28.1 ± 6.4 years) had dual fine-wire, intramuscular electrodes inserted into deep transversospinalis muscles at a thoracic level where tissues appeared abnormal to palpation (AbP) and at 2 sites above and below normal and non-tender to palpation (NT). A surface electrode was on the contralateral paraspinal mass at the level of AbP. EMG signals were recorded for resting prone, two 3-s free neck extension efforts, two 3-s resisted maximal voluntary isometric contractions (MVIC), and resting prone before the intervention. Randomized spinal manipulation, counterstrain, or sham manipulation was delivered and EMG re-measured. Participants returned 1 and 2 weeks later for the remaining 2 treatments. Reductions in resting EMG followed counterstrain in AbP (median decrease 3.3%, P = 0.01) and NT sites (median decrease 1.0%, P = 0.05) and for the surface electrode site (median decrease 2.0%, P = 0.009). Reduction in EMG following counterstrain during free neck extension was found for the surface electrode site (median decrease 2.7%, P < 0.01). Spinal manipulation produced no change in EMG, whereas counterstrain technique produced small significant reductions in paraspinal muscle activity during prone resting and free neck extension conditions. The clinical relevance of these changes is unclear.

Changes in Cytokines, Sensory Tests, and Self-reported Pain Levels After Manual Treatment of Low Back Pain.

STUDY DESIGN: Unbalanced 3-factor design with repeated measures on 1 factor. OBJECTIVE: To determine the effect of manual treatment (MT) on cytokine and pain sensations in those with and without low back pain (LBP). SUMMARY OF BACKGROUND DATA: Evidence suggests that MT reduces LBP but by unknown mechanisms. Certain cytokines have been elevated in patients with LBP and may be affected by MT. METHODS: Participants aged 20-60 years with chronic LBP or without LBP were recruited and randomly assigned to MT, sham ultrasound treatment, or no treatment groups. Venous blood samples were collected and pain levels assessed at baseline, 1 hour later, and 24 hours later. Blood was analyzed for interleukin (IL)-1ß, IL-6, tumor necrosis factor-α, and C-reactive protein. Pain levels were measured by pressure pain threshold (PPT), mechanical detection threshold (MDT), dynamic mechanical allodynia, and self-report. RESULTS: Forty (30 women, age 36±11 y) participants completed the study, 33 with LBP (13 MT, 13 sham ultrasound treatment, and 7 no treatment) and 7 without LBP. Participants with or without LBP could not be differentiated on the basis of serum cytokine levels, PPT, or MDT (P≥0.08). There were no significant differences between the groups at 1 hour or 24 hours on serum cytokines, PPT, or MDT (P≥0.07). There was a significant decrease from baseline in IL-6 for the no treatment (LBP) group (P=0.04), in C-reactive protein for the sham ultrasound treatment group (P=0.03), in MDT for all 3 LBP groups (P≤0.02), and in self-reported pain for the MT and sham ultrasound treatment groups (P=0.03 and 0.01). CONCLUSIONS: Self-reported pain was reduced with MT and sham ultrasound treatment 24 hours after treatment, but inflammatory markers within venous circulation and quantitative sensory tests were unable to differentiate between study groups. Therefore, we were unable to characterize mechanisms underlying chronic LBP.

Histological characteristics of knee menisci in patients with osteoarthritis.

Existing data indicate knee menisci in patients with osteoarthritis (OA) show tearing, maceration, and fragmentation, but little is known about the change in histological structure. The aim of this study was to evaluate the change in the menisci histological structure in patients with clinically diagnosed knee OA. Fourteen patients undergoing surgical treatment of knee OA (OA group) and 14 cadaveric knees (control group) were assessed. Demographic data, medical history, synovial fluid, OA severity, medial meniscus (MM) tissue, and lateral meniscus (LM) tissue were collected from the OA group. Three nonconsecutive 10 µm cross-sectional tissue slices of menisci were analyzed for percentage of tissue calcification. Exact Mann-Whitney tests and Spearman correlation coefficients tested for relationships between variables. The major change in the histological structure of the menisci in patients with OA was calcification of the matrix, which was significantly greater in the OA group compared with the control group for MM (OA: 11.9%, cadaver: 5.17%; P < 0.001) and LM tissues (OA: 11.1%, cadaver: 4.2%; P < 0.001). A correlation between percent calcification of the MM and LM tissues existed in the OA group (ρ = 0.56, P = 0.04) but not the control group (P = 0.20). The most pronounced pathological change in the histology of menisci was calcification of the cartilage matrix, significantly greater in the OA group than the control group. A strong correlation between percent calcification of MM and LM tissues in patients with OA indicates changes in fibrocartilage matrix of menisci progress similarly in the medial and lateral compartments of the knee. Clin. Anat. 30:805-810, 2017. © 2017Wiley Periodicals, Inc.

Multicenter Osteopathic Pneumonia Study in the Elderly: Subgroup Analysis on Hospital Length of Stay, Ventilator-Dependent Respiratory Failure Rate, and In-hospital Mortality Rate.

CONTEXT: Osteopathic manipulative treatment (OMT) is a promising adjunctive treatment for older adults hospitalized for pneumonia. OBJECTIVE: To report subgroup analyses from the Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) relating to hospital length of stay (LOS), ventilator-dependent respiratory failure rate, and in-hospital mortality rate. DESIGN: Multicenter randomized controlled trial. SETTING: Seven community hospitals. PARTICIPANTS: Three hundred eighty-seven patients aged 50 years or older who met specific criteria for pneumonia on hospital admission. INTERVENTIONS: Participants were randomly assigned to 1 of 3 groups that received an adjunctive OMT protocol (n=130), a light touch (LT) protocol (n=124), or conventional care only (CCO) (n=133). MAIN OUTCOME MEASURES: Outcomes for subgroup analyses were LOS, ventilator-dependent respiratory failure rate, and in-hospital mortality rate. Subgroups were age (50-74 years or ≥75 years), Pneumonia Severity Index (PSI) class (I-II, III, IV, or V), and type of pneumonia (community-acquired or nursing-home acquired). Data were analyzed by intention-to-treat and per-protocol analyses using stratified Cox proportional hazards models and Cochran-Mantel-Haenszel tests for general association. RESULTS: By per-protocol analysis of the younger age subgroup, LOS was shorter for the OMT group (median, 2.9 days; n=43) than the LT (median, 3.7 days; n=45) and CCO (median, 4.0 days; n=65) groups (P=.006). By intention-to-treat analysis of the older age subgroup, in-hospital mortality rates were lower for the OMT (1 of 66 [2%]) and LT (2 of 68 [3%]) groups than the CCO group (9 of 67 [13%]) (P=.005). By per-protocol analysis of the PSI class IV subgroup, the OMT group had a shorter LOS than the CCO group (median, 3.8 days [n=40] vs 5.0 days [n=50]; P=.01) and a lower ventilator-dependent respiratory failure rate than the CCO group (0 of 40 [0%] vs 5 of 50 [10%]; P=.05). By intention-to-treat analysis, in-hospital mortality rates in the PSI class V subgroup were lower (P=.05) for the OMT group (1 of 22 [5%]) than the CCO group (6 of 19 [32%]) but not the LT group (2 of 15 [13%]). CONCLUSION: Subgroup analyses suggested adjunctive OMT for pneumonia reduced LOS in adults aged 50 to 74 years and lowered in-hospital mortality rates in adults aged 75 years or older. Adjunctive OMT may also reduce LOS and in-hospital mortality rates in older adults with more severe pneumonia. Interestingly, LT also reduced in-hospital mortality rates in adults aged 75 years or older relative to CCO. (ClinicalTrials.gov number NCT00258661).

Correlation of Somatic Dysfunction With Gastrointestinal Endoscopic Findings: An Observational Study.

CONTEXT: Gastrointestinal (GI) endoscopy provides a novel means of correlating visceral abnormalities with somatic dysfunction. OBJECTIVE: To assess the correlation of palpatory findings of somatic dysfunction with GI abnormalities determined by endoscopy and to identify which types of somatic dysfunction were most commonly correlated with GI abnormalities. METHODS: In this observational, cross-sectional study, participants who were scheduled to receive an esophagogastroduodenoscopy (EGD), colonoscopy, or both were examined by 2 osteopathic physicians immediately prior to endoscopy for the presence of vertebral tenderness, asymmetry, restricted range of motion, and tissue texture abnormalities (TART findings); tenderness of anterior Chapman reflex points; and tenderness of visceral sphincters. Each type of somatic dysfunction and the somatic dysfunction burden (sum of findings) were compared with the type of endoscopic procedure and abnormal endoscopic findings. RESULTS: Sixty-six adults participated: 43 received an EGD, 40 received a colonoscopy, and 17 received both. The incidence of vertebral TART findings ranged from 70% at T12 to 98% at the sacrum. Participants who received only EGD had a higher somatic dysfunction burden than those who received only colonoscopy and those who received both procedures (P=.002). The incidence of abnormal endoscopic findings ranged from 98% in the stomach to 0% at the ileocecal valve. Statistically significant positive associations were found between specific vertebral TART findings and abnormalities of the esophagus, gastroesophageal junction, pylorus, ascending colon, and sigmoid colon; specific Chapman reflex point tenderness and abnormalities of the esophagus, gastroesophageal junction, pylorus, ascending colon, descending colon, sigmoid colon, and rectum; and specific visceral sphincter tenderness and abnormalities of the duodenum, ascending colon, and sigmoid colon. CONCLUSIONS: The current study found numerous associations between somatic dysfunction and abnormal endoscopic findings. However, the high incidence of vertebral TART findings and the lack of normal controls for many GI regions made establishing meaningful relationships between specific somatic dysfunction and specific GI abnormalities challenging. Future investigations should include more participants to ensure a higher number of normal endoscopic findings and limit the physical examination to elements of somatic dysfunction with a high level of variability between vertebrae within an individual participant and between participants, such as tenderness and tissue texture abnormalities. (ClinicalTrials.gov number NCT01394198).

Feasibility of Using Ultrasonography to Establish Relationships Among Sacral Base Position, Sacral Sulcus Depth, Body Mass Index, and Sex.

CONTEXT: Identifying relationships among anatomical structures is key in diagnosing somatic dysfunction. Ultrasonography can be used to visualize anatomical structures, identify sacroiliac landmarks, and validate anatomical findings and measurements in relation to somatic dysfunction. As part of the osteopathic manipulative medicine course at A.T. Still University-Kirksville College of Osteopathic Medicine, first-year students are trained to use ultrasonography to establish relationships among musculoskeletal structures. OBJECTIVES: To determine the ability of first-year osteopathic medical students to establish sacral base position (SBP) and sacral sulcus depth (SSD) using ultrasonography and to identify the relationship of SBP and SSD to body mass index (BMI) and sex. METHODS: Students used ultrasonography to obtain the distance between the skin and the sacral base (the SBP) and the distance between the skin and the tip of the posterior superior iliac spine bilaterally. Next, students calculated the SSD (the distance between the tip of the posterior superior iliac spine and the SBP). Data were analyzed with respect to side of the body, BMI, sex, and age. The BMI data were subdivided into normal (18-25 mg/kg) and overweight (25-30 mg/kg) groups. RESULTS: Ultrasound images of 211 students were included in the study. The SBP was not significantly different between the left and right sides (36.5 mm vs 36.5 mm; P=.95) but was significantly different between normal and overweight BMI categories (33.0 mm vs 40.0 mm; P<.001) and between men and women (34.1 mm vs 39.0 mm; P<.001). The SSD was not significantly different between left and right sides (18.9 mm vs 19.8 mm; P=.08), normal and overweight BMI categories (18.9 mm vs 19.7 mm, P=.21), or men and women (19.7 mm vs 19.0 mm; P=.24). No significant relationship was identified between age and SBP (P=.46) or SSD (P=.39); however, the age range was narrow (21-33 years). CONCLUSION: The study yielded repeatable and reproducible results when establishing SBP and SSD using ultrasonography. The statistically significant relationship between SBP and higher BMI and between SBP and female sex may point to more soft tissue overlaying the sacrum in these groups. Further research is needed on the use of ultrasonography to establish criteria for somatic dysfunction.

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.

Variations in the diagnosis and treatment of somatic dysfunction between 4 osteopathic residency programs.

CONTEXT: The American Osteopathic Association requires the integration of osteo-pathic principles and practice in all specialty residency training programs that it accredits, but the 4 residencies with the most integration of osteopathic manipulative medicine (OMM) have differences in training and emphasis on OMM as a primary treatment modality. OBJECTIVE: To study differences in OMM use for spinal pain between the neuro-musculoskeletal medicine/OMM (NMM/OMM), the family practice/osteopath-ic manipulative treatment (FP/OMT), the integrated FP/OMT and NMM/OMM (FP/NMM), and the internal medicine and NMM/OMM (IM/NMM) specialty residency training programs. METHODS: Medical records were reviewed for patient encounters from September 2011 through October 2013 at NMM/OMM, FP/OMT, FP/NMM, and IM/NMM residencies in a family medicine and OMM specialty clinic. Records were screened for a diagnosis of cervicalgia, thoracalgia, lumbago, or backache. The identifed encounters were compared to determine between-specialty differences in the number of chief complaints, non-somatic dysfunction assessments, body regions with diagnosed somatic dysfunction, body regions managed with OMT, and number and type of OMT techniques used. RESULTS: Eighteen residents had 2925 patient encounters that included 1 or more spinal pain diagnoses. Overall, 2767 patients (95%) received OMT. The probability (95% CI) of residents using OMT was 0.99 (0.98-0.99) for the NMM/OMM residents, 0.66 (0.55-0.77) for the FP/OMT residents, 0.94 (0.88-0.97) for the FP/NMM residents, and 0.997 (0.98-1.0) for the IM/NMM residents. The FP/OMT residents were less likely to manage spinal pain using OMT (P<.001) and documented fewer somatic dysfunction assessments and fewer musculoskeletal assessments (P<.001), but they documented significantly more non-somatic dysfunction assessments (P<.001). When using OMT, the FP/OMT residents diagnosed somatic dysfunction in fewer mean (95% CI) body regions (2.9 [2.4-3.5]) than the NMM/OMM (5.5 [4.9-6.2]), the FP/NMM (5.5 [4.8-6.3]), or the IM/NMM (4.6 [3.4-6.0]) residents (P<.001). The FP/OMT residents also managed fewer mean (95% CI) body regions with OMT (3.5 [3.0-4.1]) than the NMM/OMM (5.7 [5.2-6.3]), the FP/NMM (5.6 [5.0-6.3]), or the IM/NMM (4.7 [3.7-6.0]) residents (P<.001). CONCLUSION: Although the FP/OMT residents used OMT less frequently than the other residents during spinal pain encounters, they provided care for a larger number and a wider variety of non-somatic dysfunction assessments.

Impact of the clinical ultrasound elective course on retention of anatomical knowledge by second-year medical students in preparation for board exams.

Ultrasound has been integrated into a gross anatomy course taught during the first year at an osteopathic medical school. A clinical ultrasound elective course was developed to continue ultrasound training during the second year of medical school. The purpose of this study was to evaluate the impact of this elective course on the understanding of normal anatomy by second-year students. An anatomy exam was administered to students enrolled in the clinical ultrasound elective course before the start of the course and after its conclusion. Wilcoxon signed ranks tests were used to determine whether exam scores changed from the pre-test to the post-test. Scores from two classes of second-year students were analyzed. Students who took the elective course showed significant improvement in the overall anatomy exam score between the pre-test and post-test (P < 0.001). Scores for exam questions pertaining to the heart, abdomen, upper extremity, and lower extremity also significantly improved from the pretest to post-test (P < 0.001), but scores for the neck and eye showed no significant improvement. The clinical ultrasound elective course offered during the second year of medical school provided students with an important review of key anatomical concepts while preparing them for board exams. Our results suggested that more emphasis should be placed on head and neck ultrasound to improve student performance in those areas. Musculoskeletal, abdominal, and heart ultrasound labs were more successful for retaining relevant anatomical information.

Professionalism score and academic performance in osteopathic medical students.

CONTEXT: During the first 2 years of osteopathic medical school, osteopathic manipulative medicine (OMM) courses use an objective professionalism score to measure student timeliness and appropriate dress for learning activities. OBJECTIVE: To assess for correlations between this score and the numeric course grades of all first- and second-year basic science and clinical courses at a single osteopathic medical school. METHODS: The professionalism scores obtained for each of the 7 quarters of the OMM course (2007-2012) were compared with the students' numeric final course grades and combined grade point average (GPA) of all courses in the corresponding quarter. Spearman correlation coefficients were used to determine the strength of the relationship between the professionalism score and the final course grades and the combined GPA. RESULTS: The mean (SD) professionalism score was 98.6% (3.3%), and scores ranged from 23.1% to 100%. Excluding the OMM course, the professionalism score was positively correlated with 29% of first-year course grades and 65% of second-year course grades. The professionalism score was predictive of academic performance in 16 of 23 clinical courses with the highest correlation for Principles of Medicine and Dermatology (ρ=0.28 and ρ=0.25, respectively). The OMM professionalism score was positively associated with GPA for quarters 1, 6, and 7 (P=.006, P<.001, and P<.001, respectively). Professionalism scores were significantly lower in the second year (P<.001). CONCLUSION: Objective measures of professionalism correlated with academic performance in many first- and second-year osteopathic medical school courses, particularly clinical courses in the second-year curriculum.

Burnout among osteopathic otolaryngology residents: identification during formative training years.

CONTEXT: Studies of burnout among allopathic physicians have shown many deleterious effects for both physicians and patients. To our knowledge, no studies have quantified burnout among osteopathic physicians. OBJECTIVE: To determine the prevalence of burnout, mentoring, and resident training satisfaction among US osteopathic otolaryngology residents compared with previously published data for allopathic otolaryngology residents. METHODS: A cross-sectional, questionnaire-based, electronic survey of US osteopathic otolaryngology residents was conducted. Residents were surveyed about demographic information, personal and professional life satisfaction, professional stressors, burnout (assessed with the Maslach Burnout Inventory-Human Services Survey), and mentor-resident interactions. Burnout was measured based on levels of emotional exhaustion (EE), depersonalization (DP), and low personal accomplishment (PA). Results were compared with previously published data for allopathic otolaryngology residents. RESULTS: Of the 102 osteopathic residents contacted, 48 (47%) responded and 47 provided complete responses in some categories. Burnout rates were low in 11 respondents (23%), moderate in 31 (66%), and high in 5 (11%), compared with published rates of 14%, 76%, and 10%, respectively, for allopathic residents (P=.18). The rates of EE and DP did not differ significantly from published data, but levels of PA were higher in osteopathic residents (P=.03). Sleep hours per night were significantly higher in osteopathic than in allopathic residents (mean, 6.6 vs 6.2; P=.04), and work hours per week were significantly lower (mean, 62 vs 71; P<.001). Increased EE scores were negatively associated with hours of sleep (ρ=-0.42, P=.003). Increased influence from a mentor was associated with decreased levels of burnout for all 3 components (EE: ρ=-0.54, P=.002; DP: ρ=-0.59, P<.001; PA: ρ=0.44, P=.02). CONCLUSION: To our knowledge, the current study is the first to quantify burnout among osteopathic residents, and our findings suggest that osteopathic residents have lower rates of burnout than allopathic residents. Osteopathic residents reported lower rates of low PA, increased hours of sleep, and decreased overall work hours. Further study of the relationship between mentoring and decreased burnout is needed.

Assessing palpation thresholds of osteopathic medical students using static models of the lumbar spine.

CONTEXT: Although spinal somatic dysfunction diagnosis is taught at all colleges of osteopathic medicine, few objective measures have been used to evaluate student accuracy. OBJECTIVE: To assess the palpatory skills of osteopathic medical students in evaluating positional asymmetry in the transverse plane using static block transverse process and lumbar spine models. METHODS: For this observational study, first-year osteopathic medical students completed 3 palpatory assessments using uncovered and covered block transverse process and lumbar spine models to simulate a range of positional asymmetries of the transverse processes. With use of logistic regression, 80%, 90%, and 95% thresholds were defined as the magnitude of asymmetry for which the predicted probability of students correctly determining the direction of asymmetry exceeded a specified amount (.80, .90, or .95). RESULTS: A total of 346 students completed the assessments. For the uncovered block transverse process model (assessment 1), students correctly identified the direction of asymmetry with .89 probability at 1 mm of asymmetry (80% threshold), .94 probability at 2 mm (90% threshold), and .95 probability at 3 mm (95% threshold). For the covered block transverse process model, students correctly identified the direction of asymmetry with .80 probability at 1 mm (80% threshold), .92 probability at 2 mm (90% threshold), and .98 probability at 3 mm (95% threshold) by the third assessment. For the uncovered lumbar spine model (assessment 2), students correctly identified the direction of asymmetry with .93 probability at 2 mm (80% and 90% thresholds) and .95 probability at 3 mm (95% threshold). For the covered lumbar spine model (assessments 2 and 3), students correctly identified the direction of asymmetry with .87 probability at 4 mm (80% threshold); 90% and 95% thresholds were not reached with the range of asymmetries tested. CONCLUSION: Most first-year osteopathic medical students were able to discern the direction of positional asymmetry of transverse processes on static models. Depending on the model type, student performance improved (block transverse process models) or declined (lumbar spine models) over time. Future studies should evaluate whether accuracy of palpating lumbar spine models translates to accuracy of palpating human lumbar spines.

Association of low back pain, somatic dysfunction, and lumbar bone mineral density: reproducibility of findings.

CONTEXT: Somatic dysfunction as diagnosed by palpation should be associated with an objective measure. Bone mineral density (BMD) has been shown to be elevated in lumbar vertebrae with somatic dysfunction and in the lumbar region of individuals with chronic low back pain (LBP). OBJECTIVE: To investigate the association of lumbar somatic dysfunction and BMD T-score variability in participants with chronic LBP and without LBP (non-LBP) and to determine the reproducibility of previously published results. METHODS: Two examiners, blinded to symptom history, evaluated participants for tissue texture abnormalities, rotational asymmetry, anterior motion restriction, and tenderness at vertebral levels L1 to L4. Participants also underwent dual-energy x-ray absorptiometry of vertebral levels L1 to L4 for the assessment of BMD T scores. Generalized linear models were used to compare the chronic LBP and non-LBP groups on the presence and severity of somatic dysfunction and to test whether group and the presence and severity of somatic dysfunction were related to BMD T scores. RESULTS: Forty-three chronic LBP (54%) and 36 non-LBP participants (46%) completed the study. Although the presence of somatic dysfunction in the 2 groups was not significantly different, the presence of tenderness was significantly more common in the chronic LBP group (P<.001), as was the severity for tissue texture abnormalities (P=.03), motion restriction (P=.04), and tenderness (P<.001). Of the 316 vertebrae assessed, 31 (10%, all in the chronic LBP group) had moderate/severe tenderness. The vertebral somatic dysfunction burden score, the total somatic dysfunction burden score, the vertebral somatic dysfunction severity score, and the total somatic dysfunction severity score were higher in the chronic LBP group (all P<.001). The vertebral BMD T score was significantly higher for vertebrae demonstrating moderate/severe rotational asymmetry compared with those demonstrating mild or no rotational asymmetry (P=.01) and for vertebrae demonstrating moderate/severe tenderness compared with those demonstrating no tenderness (P=.04). CONCLUSION: Study results suggest that somatic dysfunction was more significant in chronic LBP participants. Although the correlation between the presence of somatic dysfunction and segmental BMD T scores was not reproduced, BMD T scores were higher for vertebrae demonstrating moderate/severe rotational asymmetry and tenderness.

Preliminary findings on the use of osteopathic manipulative treatment: outcomes during the formation of the practice-based research network, DO-Touch.NET.

CONTEXT: Few studies have assessed the use of osteopathic manipulative treatment (OMT) and subsequent patient-reported outcomes. OBJECTIVE: To assess the current use of OMT and associated patient-reported outcomes. DESIGN: A retrospective medical record review and a prospective observational study. SETTING: Two university-based sites and their clinics associated with the practice-based research network DO-Touch.NET. PARTICIPANTS: Patients aged 18 years or older who received OMT. MAIN OUTCOME MEASURES: Medical records from 2007 were retrospectively reviewed to identify conditions being managed with OMT. From 2008 to 2010, patients were recruited before seeing their physicians. Questionnaires were distributed to patients and physicians, and information including demographics, chief complaints, symptom severity, current and past treatments, interference of symptoms with quality of life, physical examination findings, diagnoses, OMT performed, and immediate patient response to OMT was collected. A subset of patients provided data on symptom severity and frequency and other treatments daily for the 7 days after OMT. On day 7, symptom interference with quality of life was reassessed. RESULTS: Retrospective data were collected from 2569 office visits, and prospective data were collected from 299 office visits (patient age range, 18-93 years). In the medical record review, 17 of the top 25 diagnoses (68%) were related to musculoskeletal conditions. In the prospective study, 18 of the top 24 medical diagnoses (75%) were related to musculoskeletal conditions. Immediately after OMT, patients at 271 of 296 office visits (92%) felt better or much better; those at 5 (<2%) felt worse. After 7 days, patients at 126 of 175 office visits (72%) felt better or much better, and those at 10 (6%) felt worse. Average and worst symptom severity decreased until post-OMT days 4 and 5, respectively, when severity leveled off. There was decreased interference of symptoms with quality of life from before OMT to 7 days after OMT in usual/general activities, sleep, mood, and relationships (all P≤.05). CONCLUSION: These preliminary results suggest that for adults, OMT is predominantly used for managing musculoskeletal pain conditions and is effective for short-term symptom relief. Continued surveillance of DO-Touch.NET member practice outcomes may help identify priorities for osteopathic research and define evidence-based standards for OMT practice and training.

The persistence of lumbar somatic dysfunction and its association with bone mineral density.

CONTEXT: Clinically meaningful somatic dysfunction, if left untreated, should persist over time and be associated with objective measurable findings. OBJECTIVE: To investigate the persistence of lumbar somatic dysfunction over 8 weeks and the association of that persistence with lumbar bone mineral density (BMD) T scores. METHODS: Individuals were assessed at 0, 4, and 8 weeks for the presence and severity of paraspinal tissue texture abnormalities (TTA), vertebral rotational asymmetry, anterior motion restriction, and tenderness from L1 to L4. Participants underwent dual-energy x-ray absorptiometry of the lumbar spine at 0 and 8 weeks. Persistent somatic dysfunction findings from all 3 examinations were compared with BMD T scores obtained at 8 weeks and to changes in the BMD T scores from 0 to 8 weeks. RESULTS: Forty-eight individuals (38 women [79%] and 10 men [21%]) participated in the study. The mean (standard deviation [SD]) age was 30.1 (6.4) years (range, 20.0-40.8 years), and the mean (SD) body mass index was 26.3 (5.2). The percentage of vertebrae with persistent somatic dysfunction varied by vertebral level and ranged from 44% to 83% for TTA, 63% to 79% for rotational asymmetry, 10% to 56% for motion restriction, and 2% to 10% for tenderness. Vertebral segments with persistent motion restriction had higher mean BMD T scores (95% confidence interval [CI]) than those without persistent motion restriction (0.6 [0.4 to 0.8] vs 0.2 [0.1 to 0.4], respectively; P=.02). There was a significant increase in the vertebral BMD T scores for those vertebrae that demonstrated persistent TTA (P=.02) and for those vertebrae that demonstrated persistent moderate/severe TTA (P=.02). A significant difference was found in the initial to final vertebral BMD T-score change between vertebrae that demonstrated persistent tenderness and those that did not (mean [95% CI] change, -0.2 [-0.4 to 0.1] vs 0.1 [0.0 to 0.1], respectively; P=.04). CONCLUSION: A persistence of predominantly left lumbar rotation was observed. Persistent vertebral motion restriction was shown to have an association with final lumbar BMD T scores, and persistent TTA and tenderness were associated with changes in the BMD T scores over 8 weeks.