The effectiveness of disinfection protocols in medical school osteopathic manipulative medicine labs.

CONTEXT: In light of the COVID-19 pandemic, healthcare-associated infections have taken center stage. Healthcare has adjusted workflows to accommodate for more robust disinfecting regiments to help protect the community. This has resulted in the need for medical institutions to reevaluate the current disinfection protocols down to the student level. The osteopathic manipulative medicine (OMM) laboratory provides an optimal avenue for assessing the effectiveness of medical students' ability to clean examination tables. With OMM laboratories having a high level of interaction, adequate disinfection is important for the health and safety of students and teaching faculties. OBJECTIVES: This study will evaluate the effectiveness of the current disinfection protocols in the medical school OMM labs. METHODS: A cross-sectional, nonrandomized study was performed on 20 OMM examination tables utilized for osteopathic training. Tables were chosen based on their close proximity to the podium. Close proximity was utilized as a criteria to increase the probability of utilization by students. The sampled tables were observed to ensure their use by students during class. Initial samples were collected in the morning after disinfection by Environmental Services. Terminal samples were collected after Osteopathic medical students utilized and disinfected the OMM examination tables. Samples were collected from the face-cradle and midtorso regions and analyzed utilizing adenosine triphosphate (ATP) bioluminescence assays with an AccuPoint Advanced HC Reader. This reader provides a digital readout of the quantity of light measured in relative light units (RLUs), which is directly correlated to the amount of ATP present in the sample, providing an estimated pathogen count. For statistical analysis, a Wilcoxon signed-rank test was utilized to find statistical differences in RLUs in samples after initial and terminal disinfection. RESULTS: The face cradle showed a 40 % increase in failure rate in samples after terminal disinfection when samples were compared after initial disinfection. A Wilcoxon signed-rank test revealed an estimated pathogen level for face cradle that was significantly higher after terminal disinfection (median, 4,295 RLUs; range, 2,269-12919 RLUs; n=20) compared to initial disinfection (median, 769 RLUs; range, 29-2,422 RLUs; n=20), z=-3.8, p=0.00008, with a large effect size, d=2.2. The midtorso region showed a 75 % increase in samples after terminal disinfection when samples were compared after initial disinfection. A Wilcoxon signed-rank test revealed that the estimated pathogen levels for midtorso were significantly higher after terminal disinfecting (median, 656 RLUs; range, 112-1,922 RLUs; n=20) compared to initial disinfecting (median, 128 RLUs; range, 1-335 RLUs; n=20), z=-3.9, p=0.00012, with a large effect size, d=1.8. CONCLUSIONS: This study suggests that medical students frequently failed to disinfect high-touch regions on examination tables, such as the midtorso and the face cradle. It is recommended that the current OMM lab disinfection protocol be modified to include the disinfection of high-touch regions in order to reduce the possibility of pathogen transmission. Further research should explore the effectiveness of disinfection protocols in clinical settings such as outpatient offices.

Management of Post-Viral Postural Orthostatic Tachycardia Syndrome With Craniosacral Therapy.

Postural Orthostatic Tachycardia Syndrome (POTS) is a rare disorder of the autonomic nervous system. The number of people afflicted with this dysautonomia has increased dramatically in recent years due to the long-term effects of coronavirus disease (COVID-19); however, it is largely underdiagnosed. This case report is about a patient with post-viral neuropathic POTS. Neuropathic POTS is believed to be due to the damage of small nerve fibers that regulate the constriction of the blood vessels in the limb and abdomen, which leads to interference with vasoconstriction, and therefore causes tachycardia. Current literature emphasizes a treatment that is based on lifestyle modifications, such as increasing water and salt intake, and symptomatic pharmacological treatment. In this case, the 39-year-old male ptient was treated with osteopathic manipulative treatment (OMT), specifically the compression of the fourth ventricle (CV4), which has been associated with the production of hyperparasympathetic and anti-inflammatory effects and, hence, helps overcome the small-fiber neuropathy caused by the viral illness. We found that the CV4 technique led to the successful remission of the patient's symptoms. Therefore, we propose craniosacral therapy as a successful single management modality in patients with POTS.

Understanding and preference toward DOs and OMT before and after an osteopathic principles and practice fellow lecture series.

CONTEXT: One of the two major pathways to become a physician in the United States is the Doctor of Osteopathic Medicine (DO) degree. A major distinctive feature is often perceived as the addition of manual training in osteopathic manipulative treatment (OMT) in the DO education. However, the profession also has a distinct philosophy imbedded in the curriculum of all osteopathic medical schools. Many medical schools offer professional degrees with graduates who may choose to continue their education in medicine, such as the Master of Science in Biomedical Sciences (MSBS). At our institution, there is no formal exposure to the differences between osteopathic and allopathic medicine in the MSBS curriculum, and most of this understanding is gained through out-of-classroom conversations. During the SARS-CoV-2 pandemic, virtual learning prohibited the usual gathering and discourse that occurs when students are learning on campus. OBJECTIVES: The objective of this study is to create a curriculum in the form of a seminar series to assist premedical students in making an informed choice about which profession is the best fit for their own education and to gain an appreciation for osteopathic medicine. This appreciation could also aid in the future collaboration of premedical students with osteopathic providers, recommendations to patients, and potentially their own medical care. Questionnaires were utilized to determine if our osteopathic seminar series was effective at changing the preferences and understanding of MSBS students. We also sought to determine the effectiveness of virtual vs. in-person delivery of our curriculum. METHODS: A seminar series with pre-established objectives was developed and presented to MSBS students at an osteopathic institution during the Fall of 2020 and 2021. The 2020 seminar was delivered through a virtual conference platform, and the 2021 seminar was delivered in-person. An eight question pre-and postquestionnaire was given to participants to evaluate their preferences and understanding. Internal validity and differences between delivery formats were assessed. RESULTS: Both seminar series produced equally effective, significant changes in the preferences and perceptions of osteopathic medicine in both virtual and in-person delivery formats. Differences in pre-vs. post understanding across both seminar series were not consistently significant and were smaller than those observed in preferences and perceptions. Positive changes included an increased willingness to see a DO and to recommend a loved one see a DO as their personal physician. Preference changes between the in-person vs. virtual delivery platforms did not show significant differences; however, understanding did show some inconsistent differences. CONCLUSIONS: This study demonstrates the utility of a virtual or in-person seminar to improve the preferences and perceptions of the osteopathic profession in MSBS students. The seminar series was successful in its goal of offering formal exposure to the osteopathic profession. The improved preferences and perceptions will have potential substantial benefits to the field of osteopathic medicine in the future. Further research is warranted to determine the most effective way to increase understanding of the osteopathic profession.

COVID Impacts on Pragmatic Trials of Nonpharmacological Approaches to Pain Management: A Mixed Methods Evaluation

Methods: This 2-phase study used a sequential, mixed methods design to explore changes made to study protocols, particularly clinical interventions, in response to the evolving pandemic. A structured REDCap questionnaire queried about emerging adaptations using the periodic reflections method across 3 timepoints. Following Phase 1 analysis, brief checklists and 3 setting-specific focus groups were completed with principal investigators and key staff via video-conference to elicit information about study adaptations. Focus group interview schedules and directed content analyses were guided by the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) taxonomy. Results: Eleven PCTs completed questionnaires and 16 representatives from 10 PCTs joined focus groups. In periodic reflections, teams reported between 2 to 6 adaptations in the first 5 months of the pandemic. PCTs in the implementation stage reported delays in site/clinic onboarding, staff training, and/or patient recruitment, with 3 trials pausing intervention delivery. Intervention protocols were adapted with 6 PCTs adding/expanding virtual care. Trials testing manual therapies reported clinic closures and care restrictions. FRAME analyses of focus groups identified adaptation goals to increase trial feasibility, decrease patient/provider COVID exposures, and increasing patient engagement/retention. Context adaptations focused on virtual delivery while content adaptations included adding elements to enhance safety, tailoring/refining protocols for virtual delivery, and removing/skipping hands-on pain management interventions. Background: The COVID-19 pandemic changed the delivery of healthcare services and disrupted clinical research programs. This study evaluated adaptations made to 11 in-progress, pragmatic clinical trials (PCTs) of non-pharmacological pain management interventions in Department of Veterans Affairs and Department of Defense healthcare facilities. Conclusion: While core elements of trial interventions were retained, investigators were required to adapt study protocols for non-pharmacological pain management PCTs to address COVID-related disruptions and restrictions.

Is the outcome of hands-on treatment interventions different for people with high compared to low pain self-efficacy? A secondary analysis

Keywords: Physiotherapy;Interactional analysis;Treatment Purpose: High pain self-efficacy at the start of treatment is a significant predictor of a better outcome for people attending physiotherapy for the management of musculoskeletal shoulder pain. The mechanisms by which pain self-efficacy is associated with outcome are uncertain. One possibility is that pain self-efficacy moderates the relationship between some treatment modalities and outcome. Our aim is to investigate whether there is a statistically significant difference in outcome between participants with high compared to low pain self-efficacy for the following treatments categories: (i) manual therapy, acupuncture, or electrotherapy, (ii) manual therapy, (iii) spine and/or shoulder joint mobilisations. Methods: Six-month outcome and treatment data were available for 804 of 1030 participants at baseline for this secondary analysis of a multicentre longitudinal cohort study. Pain and disability at outcome were measured using the Shoulder Pain and Disability Index (SPADI). Pain self-efficacy was measured using the pain self-efficacy questionnaire (PSEQ). Participants were dichotomised into the following groups: (i) high or low baseline SPADI, (ii) high or low pain self-efficacy, (iii) received or did not receive categorised treatments. Descriptive analysis compared mean (±standard deviation) SPADI at 6 months for 4 groups: pain self-efficacy (high or low) and treatment modality (received, yes or no). Inferential statistics were performed in stages to investigate: (i) Does treatment category have an effect? (ii) Does the treatment effect (if significant) differ by PSEQ level? A significant Difference of Difference (p ≤ 0.05) represented an interaction effect between treatment category and PSEQ level for outcome. Results: Six-month SPADI scores were lower (less pain and disability) for those who did not receive manual therapy, acupuncture, or electrotherapy compared to those who did. This was statistically significant in 7 of 24 models. However, although higher PSEQ predicted a better outcome, it did not moderate the relationship between treatment and outcome (p > 0.05). Conclusion(s): Pain self-efficacy did not moderate the effect of treatment on outcome. Surprisingly, participants receiving manual therapy, acupuncture, electrotherapy in addition to advice and exercise consistently had an equal or worse 6-month outcome compared to those not receiving these treatments. However, this study was not designed to assess treatment effectiveness and participants were not randomly allocated to treatment. The decision to use a specific treatment may be affected by several unknown factors. The results of our analysis should therefore be interpreted with caution but do indicate the need for further appropriately designed research. Impact: As COVID-19 continues to limit face-to-face consultations between clinicians and participants, our results suggest that patient outcomes may not be compromised by the absence of the hands-on treatments we analysed. We currently recommend clinicians and researchers consider the following: (i) the harms as well as benefits of these treatments, (ii) for which patients’ hands-on treatment should or should not be advocated. We recommend future randomised controlled trials of these treatments include measures of baseline pain, disability, and pain self-efficacy to further investigate this potential interaction. We continue to recommend the assessment of pain self-efficacy as a predictor of outcome and that management should monitor and facilitate higher levels of pain self-efficacy. Funding acknowledgements: The study was performed as part of a MSc dissertation, no funding was received.