The effectiveness of an osteopathic manual technique compared with a breathing exercise on vagal tone as indicated by heart rate variability, a crossover study.

INTRODUCTION: Parasympathetic nervous system (PSNS) function can be inferred by heart rate variability (HRV) providing indications about an individual's health. Manual therapy may influence PSNS function, however the research outcomes in this regard are equivocal. This study explored the PSNS effect of a measured breathing technique with suboccipital balanced ligamentous tension, an osteopathic manipulative therapy technique. METHODS: Healthy adult participants in this crossover study (n = 18) were randomly allocated into two groups with differing order of interventions. A 1:1 breathing rate of 6 breaths per minute maintained for 5 min was compared to the osteopathic intervention. HRV was measured for 5 min before and after each intervention and analysed using the root mean square of successive differences (RMSSD) between normal heartbeats and high frequency normalised units (HFnu). RESULTS: The RMSSD data demonstrated no significant difference between groups or within groups (p > 0.05) over time. HFnu results showed a significant between-group difference over the four time points (p = 0.004) with a medium effect size (ηp2 = 0.240), and no significant within-group difference (p > 0.05). DISCUSSION: The osteopathic intervention raised HRV to a small extent, however measured breathing lowered HRV. In the group that received the osteopathic technique first, HFnu values continued to rise post-osteopathic treatment possibly indicating an increasing parasympathetic effect over time. Recommendations for future studies include changing the breathing ratio to ensure parasympathetic response, take into account potential delayed effects of interventions, consider outcome measures less variable than HRV, and longer follow up times. CONCLUSION: This study suggests parasympathetic stimulation may occur with the application of suboccipital balanced ligamentous tension and sympathetic stimulation from measured breathing.

Overweight and obesity management in musculo-skeletal primary care: a survey of Australian health practitioners exploring ‘the elephant in the room’.

BACKGROUND: Overweight and obesity has a bi-directional association with the growing burden of musculoskeletal (MSk) dysfunction and pain. It seems inevitable that MSk practitioners will see increasing numbers of patients who are overweight and or obese and require this to be addressed as part of their management. Little evidence exists to describe the engagement of patients and their MSk practitioner in weight management as an adjunct or direct component of their intervention or therapy. METHODS: A self-administered electronic survey was constructed with 13 items to collect self-reported data from Australian practitioners who have a focus on MSk management. The target group was from a multidisciplinary MSk network of 350 members. RESULTS: A total of 204 completed surveys were analysed from respondents working in one of seven MSk- related professions. It was found that 70% of patients/clients seen by respondents were overweight or obese and that <18% of these patients had weight management included as part of their treatment. CONCLUSIONS: Sixty percent of the respondents in this survey indicated that they do not include weight management as part of their practice despite 70% of their patients/clients being overweight and or obese. With the exception of Medical Practitioners and Exercise Physiologists, in this survey, the other therapists including Chiropractors, Osteopaths, Physiotherapists and Occupational Therapists, indicated that they lacked confidence, knowledge and methods to engage a systematic approach to weight management with their patients/clients.

Common reported barriers and facilitators for self-management in adults with chronic musculoskeletal pain: A systematic review of qualitative studies.

BACKGROUND: Self-management strategies are considered a necessary component of chronic musculoskeletal pain management to address ongoing symptoms and challenges. However uptake of self-management can be impeded by a number of factors. OBJECTIVES: The aim of this study was to explore common impeding and facilitating factors of self-management strategies from the patient perspective. METHODS: An electronic search was performed between 2009 to May 2020 for the following databases: MEDLINE, AMED, PsychINFO, Cochrane Library, PubMed, CINAHL, PEDro, and Google Scholar. The search terms included peer-reviewed qualitative or mixed-method studies investigating the perspective of chronic musculoskeletal pain patients in regards to the use of self-management strategies. Study rigor and bias was assessed using the CASP (Critical Appraisal Skills Programme) questionnaire specific to qualitative studies. Qualitative data was coded using a three-stage thematic synthesis process. Confidence in findings was assessed using CERQual (The Confidence in the Evidence from Review of Qualitative Research). RESULTS: Twenty-seven studies were included with 487 participants. Six major themes were identified and divided into external and internal influencing factors. The external influencing factors were made up of the following three themes: health care practitioner role, supportive environment, accessibility. While the three internal influencing themes were: physical factors, knowledge and understanding, and psychological factors. CONCLUSION: Learning to self-manage for patients in chronic pain required ongoing support either from healthcare practitioners or from social circles. To further assist the self-management process practitioners can improve self-efficacy through increasing patient knowledge of chronic pain, utilising goal setting and finding ways an individual can access ongoing support, either from the practitioner or through group programs.

Australian osteopaths as non-medical prescribers: comparison of healthcare practitioner characteristics from a nationally representative survey.

The study aimed to compare the characteristics of Australian osteopaths who definitely agree that prescribing scheduled medicines is part of their future scope of practice with those who do not. A secondary analysis of a cross-sectional survey of osteopaths from an Australian practice-based research network was undertaken. Demographic, practice and treatment characteristics were identified using inferential statistics and backward linear regression modelling. Over one-quarter (n=257, 25.9%) of the total participants (n=992) indicated that they 'definitely' agree that osteopaths should seek prescription rights. Adjusted odds ratios (OR) suggested these osteopaths were more likely to engage in medication discussions with patients (OR 1.88), frequently manage migraines (OR 1.68) and seek increased practice rights for referrals to medical specialists (OR 2.61) and diagnostic imaging (OR 2.79). Prescribing as part of the future scope of practice for Australian osteopaths is associated with patient management (medication discussions) and practice characteristics (increased referral rights for specialists and diagnostic imaging) that warrant additional investigation. Understanding of the practice, clinical and patient management characteristics of Australian osteopaths who see prescribing as part of the future scope of practice informs the case for regulatory and health policy changes for prescribing scheduled medicines.

Prevalence and profile of Australian osteopaths treating older people.

OBJECTIVES: To explore the characteristics of the Australian osteopathy workforce who participate in the management of older patients with musculoskeletal complaints. DESIGN: Secondary analysis of a cross-sectional survey of osteopaths. SETTING: The Osteopathy Research and Innovation Network (ORION), an Australian practice-based research network. MAIN OUTCOME MEASURES: The demographic, practice and treatment characteristics of osteopaths who identify as 'always'or 'often' treating patients aged 65 years or over. RESULTS: Over half (58%) of total participants (n = 992) indicated often treating older people and this was associated with referral patterns with other health professionals and a non-urban practice location. Osteopaths providing care to older people were more likely to discuss diet/nutrition and medications, and provide pain counselling. Osteopaths who treated older adults were more likely to treat shoulder musculoskeletal disorders, degenerative spine disorders, chronic or persistent pain, and tendinopathies. CONCLUSIONS: A substantial proportion of Australian osteopaths treat older adults frequently. The potential value and impact of osteopathy in managing the health needs of an ageing population warrants close examination from both researchers and policy makers.

Reliability of a viva assessment of clinical reasoning in an Australian pre-professional osteopathy program assessed using generalizability theory.

Clinical reasoning is situation-dependent and case-specific; therefore, assessments incorporating different patient presentations are warranted. The present study aimed to determine the reliability of a multi-station case-based viva assessment of clinical reasoning in an Australian pre-registration osteopathy program using generalizability theory. Students (from years 4 and 5) and examiners were recruited from the osteopathy program at Southern Cross University, Lismore, Australia. The study took place on a single day in the student teaching clinic. Examiners were trained before the examination. Students were allocated to 1 of 3 rounds consisting of 5 10-minute stations in an objective structured clinical examination-style. Generalizability analysis was used to explore the reliability of the examination. Fifteen students and 5 faculty members participated in the study. The examination produced a generalizability coefficient of 0.53, with 18 stations required to achieve a generalizability coefficient of 0.80. The reliability estimations were acceptable and the psychometric findings related to the marking rubric and overall scores were acceptable; however, further work is required in examiner training and ensuring consistent case difficulty to improve the reliability of the examination.

Understanding clinical reasoning in osteopathy: a qualitative research approach.

BACKGROUND: Clinical reasoning has been described as a process that draws heavily on the knowledge, skills and attributes that are particular to each health profession. However, the clinical reasoning processes of practitioners of different disciplines demonstrate many similarities, including hypothesis generation and reflective practice. The aim of this study was to understand clinical reasoning in osteopathy from the perspective of osteopathic clinical educators and the extent to which it was similar or different from clinical reasoning in other health professions. METHODS: This study was informed by constructivist grounded theory. Participants were clinical educators in osteopathic teaching institutions in Australia, New Zealand and the UK. Focus groups and written critical reflections provided a rich data set. Data were analysed using constant comparison to develop inductive categories. RESULTS: According to participants, clinical reasoning in osteopathy is different from clinical reasoning in other health professions. Osteopaths use a two-phase approach: an initial biomedical screen for serious pathology, followed by use of osteopathic reasoning models that are based on the relationship between structure and function in the human body. Clinical reasoning in osteopathy was also described as occurring in a number of contexts (e.g. patient, practitioner and community) and drawing on a range of metaskills (e.g. hypothesis generation and reflexivity) that have been described in other health professions. CONCLUSIONS: The use of diagnostic reasoning models that are based on the relationship between structure and function in the human body differentiated clinical reasoning in osteopathy. These models were not used to name a medical condition but rather to guide the selection of treatment approaches. If confirmed by further research that clinical reasoning in osteopathy is distinct from clinical reasoning in other health professions, then osteopaths may have a unique perspective to bring to multidisciplinary decision-making and potentially enhance the quality of patient care. Where commonalities exist in the clinical reasoning processes of osteopathy and other health professions, shared learning opportunities may be available, including the exchange of scaffolded clinical reasoning exercises and assessment practices among health disciplines.

The patient experience of osteopathic healthcare.

BACKGROUND: Osteopathy in Australia is a primary care limited scope practice. Practitioner surveys suggest that patients present with chronic pain and receive manual therapies, exercise and lifestyle advice. Further research is required to deepen the understanding of this intervention from the perspective of patients. OBJECTIVE: To explore the experience of patients receiving osteopathic healthcare. DESIGN: Mixed methodology. METHOD: A quantitative survey of a convenience sample of patients was followed by qualitative semi-structured interviews in a purposive sample of respondents with chronic non-specific low back pain. The transcripts were analysed using a phenomenological approach. RESULTS: The survey results suggested directions of enquiry for the interviews. Eleven subjects were interviewed and reported commonalities in their clinical histories with multisystem co-morbidities. Four themes became apparent: patient decision-making, patient shared experiences of the osteopathic healthcare consultation, tailored patient-centred care, and therapeutic relationship in healthcare. CONCLUSION: This data suggests that patients experience osteopathic healthcare after trying other disciplines; that there are shared aspects of the consultations, with a thorough assessment, education about their condition, multiple manual therapies and lifestyle advice; that the experience is patient-centred and tailored to their context; and that the therapeutic relationship is a key aspect of the experience. These results reflect a number of aspects of osteopathic healthcare from workplace surveys.

Developing a viva exam to assess clinical reasoning in pre-registration osteopathy students.

BACKGROUND: Clinical reasoning (CR) is a core capability for health practitioners. Assessing CR requires a suite of tools to encompass a wide scope of contexts and cognitive abilities. The aim of this project was to develop an oral examination and grading rubric for the assessment of CR in osteopathy, trial it with senior students in three accredited university programs in Australia and New Zealand, and to evaluate its content and face validity. METHODS: Experienced osteopathic academics developed 20 cases and a grading rubric. Thirty senior students were recruited, 10 from each university. Twelve fourth year and 18 fifth year students participated. Three members of the research team were trained and examined students at an institution different from their own. Two cases were presented to each student participant in a series of vignettes. The rubric was constructed to follow a set of examiner questions that related to each attribute of CR. Data were analysed to explore differences in examiner marking, as well as relationships between cases, institutions, and different year levels. A non-examining member of the research team acted as an observer at each location. RESULTS: No statistical difference was found between the total and single question scores, nor for the total scores between examiners. Significant differences were found between 4th and 5th students on total score and a number of single questions. The rubric was found to be internally consistent. CONCLUSIONS: A viva examination of clinical reasoning, trialled with senior osteopathy students, showed face and content validity. Results suggested that the viva exam may also differentiate between 4th and 5th year students' capabilities in CR. Further work is required to establish the reliability of assessment, to further refine the rubric, and to train examiners before it is implemented as a high-stakes assessment in accredited osteopathy programs.

Investigation into factors influencing roles, relationships, and referrals in integrative medicine.

INTRODUCTION: Integrative medicine (IM) is a recent phenomenon within primary care practice. It is defined variously as a process of integration or convergence of complementary and alternative medicine (CAM) with mainstream medicine or as the incorporation of alternative therapies into mainstream medical practice. Little is known about the attitude of complementary medicine practitioners regarding their place within this model or the factors that influence referral between them and medical practitioners. OBJECTIVES: The aim of this research was to explore practitioners' perspectives of the theory and practice of the IM model, relevant to factors influencing referral among them. DESIGN: This research applied a qualitative method with semi-structured interviews to determine practitioner perspectives of factors influencing referral in the IM setting. One family practice physician (called a general practitioner [GP] in Australia), one osteopath, and one naturopath were interviewed at each of two IM clinics in regional Australia. Thematic analysis was used to identify themes and concepts. RESULTS: Thematic analysis of the transcribed data allowed for an in-depth understanding of themes and concepts surrounding practitioner perceptions of IM. Predominant themes centered on the notion of interpractitioner relationships and collaborations. Insight into these relationships within IM revealed concepts of interpractitioner trust and respect. In addition, sharing a philosophy of care and a common understanding pertaining to scope of practice and area of expertise appeared to support the IM framework. These concepts and themes were determined as important factors influencing referrals between GPs, osteopathic physicians, and naturopathic practitioners in the IM clinics studied. CONCLUSION: This research has highlighted the significance of interprofessional relationships and multidisciplinary referral networks as pivotal in the efficacy of the IM clinics represented in this sample. Further research is needed to define the practitioner roles and the factors influencing referrals within IM.

Osteopathic intervention in chronic non-specific low back pain: a systematic review.

BACKGROUND: Chronic Non Specific Low Back Pain (CNSLBP) is a common, complex and disabling condition that has been present for longer than three months and is not caused by a serious pathology. Osteopaths are health practitioners who commonly diagnose and treat CNSLBP patients using a complex set of interventions that includes manual therapy. The study aimed to complete a Systematic Review of clinical research into osteopathic intervention in CNSLBP using a rigorous assessment of study quality. METHODS: The literature was searched to August 2011 using the following databases: AMED, CINAHL Plus, Cochrane Central Register of Clinical Trials, MEDLINE Plus, EMBASE, MANTIS, OSTMED, PEDro, ScienceDirect. Multiple search terms were used in various combinations: osteopathy/osteopathic, osteopathic manipulative technique, OMT, Spinal Manipulative Therapy, SMT, clinical trial, back pain, chronic back pain. The inclusion criteria were papers that: reported clinical trials; had adult participants; tested the effectiveness and/or efficacy of osteopathic manual therapy intervention applied by osteopaths, and had a study condition of CNSLBP. The quality of the papers was assessed using the Cochrane Back Review Risk of Bias criteria. A meta-analysis would proceed if the studies had adequate clinical and methodological homogeneity. RESULTS: Initial searches revealed 809 papers, 772 of which were excluded on the basis of abstract alone. The remaining 37 trial papers were subjected to a more detailed analysis of the full text, which resulted in 35 being excluded. The two remaining trials had a lack of methodological and clinical homogeneity, precluding a meta-analysis. The trials used different comparators with regards to the primary outcomes, the number of treatments, the duration of treatment and the duration of follow-up. CONCLUSION: There are only two studies assessing the effect of the manual therapy intervention applied by osteopathic clinicians in adults with CNSLBP. One trial concluded that the osteopathic intervention was similar in effect to a sham intervention, and the other suggests similarity of effect between osteopathic intervention, exercise and physiotherapy. Further clinical trials into this subject are required that have consistent and rigorous methods. These trials need to include an appropriate control and utilise an intervention that reflects actual practice.