Profession-based manual therapy nomenclature: exploring history, limitations, and opportunities.

OBJECTIVE: The International Consortium on Manual Therapies (ICMT) is a grassroots interprofessional association open to any formally trained practitioner of manual therapy (MT) and basic scientists promoting research related to the practice of MT. Currently, MT research is impeded by professions' lack of communication with other MT professions, biases, and vernacular. Current ICMT goals are to minimize these barriers, compare MT techniques, and establish an interprofessional MT glossary. METHODS: Practitioners from all professions with training in manual therapies were encouraged by e-mail and website to participate (www.ICMTConferene.org). Video conferences were conducted at least bimonthly for 2.5 years by profession-specific and interprofessional focus groups (FGs). Members summarized scopes of practice, technique descriptions, associated mechanisms of action (MOA), and glossary terms. Each profession presented their work to the interprofessional FG to promote dialogue, understanding and consensus. Outcomes were reported and refined at numerous public events. RESULTS: Focus groups with representatives from 5 MT professions, chiropractic, massage therapy, osteopathic, physical therapy and structural integration identified 17 targeting osseous structures and 49 targeting nonosseous structures. Thirty-two techniques appeared distinct to a specific profession, and 13 were used by more than 1. Comparing descriptions identified additional commonalities. All professions agreed on 4 MOA categories for MT. A glossary of 280 terms and definitions was consolidated, representing key concepts in MT. Twenty-one terms were used by all MT professions and basic scientists. Five terms were used by MT professions exclusive of basic scientists. CONCLUSION: Outcomes suggested a third to a half of techniques used in MT are similar across professions. Additional research is needed to better define the extent of similarity and how to consistently identify those approaches. Ongoing expansion and refinement of the glossary is necessary to promote descriptive clarity and facilitate communication between practitioners and basic scientists.

Reliability of the DIERS Formetric 4D Spine Shape Parameters in Adults without Postural Deformities.

The DIERS formetric 4D provides a safe method to monitor and track the progression of postural deformities over time. However, further evaluation of reliability is necessary. Reference values are also needed to indicate postural change. The current study examined the reliability of spine shape parameters produced by the formetric 4D in adults without postural abnormalities and established reference values to determine when real change occurs. Thirty participants were scanned during 1 week. Intraclass correlation coefficients (ICCs) were calculated for 40 spine shape parameters for scans with participants stationary between scans, scans with repositioning between scans, and between days. Within-day and between-day standard error of measurement (SEM), absolute relative SEM, and smallest detectable change (SDC) were reported. ICC for stationary scans was excellent for 29 parameters, good for 10 parameters, and fair for 1 parameter. With repositioning, ICC was excellent for 27 parameters, good for 12 parameters, and fair for 1 parameter. Between days, ICC was excellent for 26 parameters, good for 10 parameters, and fair for 4 parameters. Within-day SEM% was greater than 10% for 6 parameters. Within-day SDC ranged from 1.80 to 25.03 units for a single scan and from 0.97 to 17.93 units for 6 scans. Between-day SEM% was greater than 10% for 9 parameters. Between-day SDC ranged from 1.44 to 28.24 units for a single scan and from 1.05 to 22.2 units for 6 scans. Thirty-six of the 40 spine shape parameters from the DIERS formetric 4D reliably distinguished between participants over time. Reference values were established that can be used to track patient postural change over time. Future research should investigate the clinical relevance of these 40 spine shape parameters and determine when a clinically important change in posture occurs.

Characteristics and Treatment of Pediatric Patients in an Osteopathic Manipulative Medicine Clinic.

CONTEXT: Osteopathic manipulative medicine (OMM) is recognized as an adjunctive medical approach for the treatment of pediatric patients, but few studies have detailed the pediatric conditions that prompt the use of osteopathic manipulative treatment (OMT) or the types and frequency of OMT used. OBJECTIVE: To present descriptive data of pediatric patients receiving OMT from a neuromusculoskeletal medicine/OMM outpatient clinic. METHODS: Data were drawn from electronic health records from a single outpatient specialty clinic for pediatric clinical encounters involving OMT that took place between January 1, 2014, and December 31, 2016. Encounter notes and billing records were reviewed for demographic information, presenting complaints, clinical assessments, somatic dysfunction assessments, OMT techniques used, and payment method. Data were categorized by patient age and analyzed. RESULTS: Five hundred thirty-seven pediatric patients (321 girls, 216 boys) received OMT during the study. These patients accounted for 1688 clinical encounters (1106 for girls, 582 for boys). Mean (SD) number of encounters was 2.7 (1.3) encounters for boys and 3.5 (1.1) encounters for girls. A higher percentage of patients younger than age 2 were boys, while a higher percentage of patients older than age 2 were girls (both P=.005). Musculoskeletal complaints and assessments were the most common for children aged 6 years and older; misshapen head, feeding difficulties, and colic were the most frequently reported for children younger than 6 years. There were 8557 somatic dysfunction assessments documented; thoracic and cervical somatic dysfunction were most commonly assessed. There were 8485 OMT techniques documented, and myofascial release was most frequently used. Encounters with self-pay patients (n=72) involved fewer somatic dysfunction assessments (P<.001) than encounters with patients using private insurance (n=1060) or Medicaid (n=542). CONCLUSION: The electronic health records reviewed in the current study revealed descriptive data of pediatric patients presenting to an OMM clinic; these data were rarely documented in previous literature. They may be used by clinicians to better understand the role of OMM as a pediatric adjunctive medical approach and to identify conditions to target for future outcome studies based on common presenting complaints.

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).

Building a Collaborative Model of Sacroiliac Joint Dysfunction and Pelvic Girdle Pain to Understand the Diverse Perspectives of Experts.

BACKGROUND: Pelvic girdle pain (PGP) and sacroiliac joint (SIJ) dysfunction/pain are considered frequent contributors to low back pain (LBP). Like other persistent pain conditions, PGP is increasingly recognized as a multifactorial problem involving biological, psychological, and social factors. Perspectives differ between experts and a diversity of treatments (with variable degrees of evidence) have been utilized. OBJECTIVE: To develop a collaborative model of PGP that represents the collective view of a group of experts. Specific goals were to analyze structure and composition of conceptual models contributed by participants, to aggregate them into a metamodel, to analyze the metamodel's composition, and to consider predicted efficacy of treatments. DESIGN: To develop a collaborative model of PGP, models were generated by invited individuals to represent their understanding of PGP using fuzzy cognitive mapping (FCM). FCMs involved proposal of components related to causes, outcomes, and treatments for pain, disability, and quality of life, and their connections. Components were classified into thematic categories. Weighting of connections was summed for components to judge their relative importance. FCMs were aggregated into a metamodel for analysis of the collective opinion it represented and to evaluate expected efficacy of treatments. RESULTS: From 21 potential contributors, 14 (67%) agreed to participate (representing six disciplines and seven countries). Participants' models included a mean (SD) of 22 (5) components each. FCMs were refined to combine similar terms, leaving 89 components in 10 categories. Biomechanical factors were the most important in individual FCMs. The collective opinion from the metamodel predicted greatest efficacy for injection, exercise therapy, and surgery for pain relief. CONCLUSIONS: The collaborative model of PGP showed a bias toward biomechanical factors. Most efficacious treatments predicted by the model have modest to no evidence from clinical trials, suggesting a mismatch between opinion and evidence. The model enables integration and communication of the collection of opinions on PGP.

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.

Influence of Transverse Process Landmark Localization on Palpation Accuracy of Lumbar Spine Models.

CONTEXT: Accurate determination of transverse process displacement in the horizontal plane requires accurate transverse process landmark localization followed by accurate discrimination of asymmetry by the examiner's palpating digits. OBJECTIVE: To determine whether the accurate localization of transverse process landmarks influences overall accuracy of asymmetry determination in third-year osteopathic medical students evaluating covered lumbar spine models. METHODS: A class of third-year osteopathic medical students was split into 2 groups and asked to determine whether the right transverse processes of covered lumbar spine models were anterior or posterior relative to the left transverse process. The marked model group (group A) was provided covered models with black dots on the fabric covers over the transverse process landmarks, while the covered models given to the students in the unmarked model group (group B) had no markings. Both groups were asked to assess asymmetry differences from L1 to L5 on 2 models. Landmarks were randomized for asymmetry (ranging from 2 mm to 6 mm) and direction (anterior or posterior on the right side). The number of correct responses was modeled as a binomial random variable in a generalized linear model to compare the effects of marked vs unmarked models on accuracy of palpation. The predicted probability of correctly determining the direction of the asymmetry and 95% CIs were calculated. RESULTS: The probability of correctly identifying the direction of asymmetry was 0.89 (95% CI, 0.87-0.91) for group A and 0.74 (95% CI, 0.71-0.78) for group B, a 15 percentage point difference (OR, 1.2; 95% CI, 1.1-1.3; P<.001). Assuming accurate perception of digit asymmetry and accurate localization of landmarks are independent and correct answers are given only if both events occur, then students were more likely to accurately perceive digit asymmetry (0.89) than accurately localize landmarks (0.83=0.74/0.89). Overall, more students accurately identified the direction of asymmetry when the right transverse process was anterior (0.87; 95% CI, 0.84-0.90) than when it was posterior (0.81; 95% CI, 0.77-0.84) (OR, 1.6; 95% CI, 1.2-2.1; P=.001). CONCLUSIONS: Student palpation accuracy was better when transverse process landmark localization was provided on the lumbar spine models than when it was not. Students were more likely to accurately perceive digit asymmetry than accurately localize the landmarks. Improving palpation accuracy requires developing educational methods to improve both accurate landmark localization and accurate digit asymmetry perception.

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.

Appraisal of the DIERS method for calculating postural measurements: an observational study.

BACKGROUND: Surface topography is increasingly used with postural analysis. One system, DIERS formetric 4D, measures 40 defined spine shape parameters from a 6-s scan. Through system algorithms, a set of spine shape parameter values from 1 of 12 recorded images obtained during a scan becomes the DIERS-reported value (DRV) for postural assessment. The purpose of the current study was to compare DRV with a standard average value (SAV) calculated from all 12 images to determine which method is more appropriate for assessing postural change. METHODS: One mannequin and 30 human participants were scanned over 5 days. Values from each image and the DRV for 40 defined spine shape parameters were exported, and mean DRV, mean SAV, mean DRV, and within-scan variance were calculated. Absolute difference and percent change between mean DRV and mean SAV were calculated for the mannequin and humans. Inter-method reliability was calculated for humans. Within-scan variance for each parameter was tested for significant variability. RESULTS: For all spine shape parameters on the mannequin, absolute difference (< 0.6 mm, 0.1°, or 0.1%) and percent change (< 2.90%) between mean DRV and mean SAV for each parameter were small. Nine parameters on human participants had a large percent change (> 7%). Absolute difference between mean DRV and mean SAV for those nine parameters was small (≤ 0.87 mm or 0.61°). Absolute difference for all other parameters ranged from 0.02 to 6.98 mm for distance measurements, from 0.01 to 1.21° for angle measurements, and from 0.15 to 0.22% for percentage measurements. Inter-method reliability between DRV and SAV was excellent (0.94-1.00). For the mannequin, within-scan variance was small (< 1.62) for all parameters. For humans, within-scan variance ranged from 0.05 to 36.04 and was different from zero for all parameters (all P < 0.001). CONCLUSIONS: The minimal variability observed in the mannequin suggested the DIERS formetric 4D instrument had high within-scan reliability. The DRV and SAV provided comparable spine shape parameter values. Because within-scan variability is not reported with the DRV, the clinical usefulness of current DRV values is limited. Establishing an estimate of variance with the SAV will allow clinicians to better identify a clinically meaningful change.

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.

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).

Effects of pressure applied during standardized spinal mobilizations on peripheral skin blood flow: A randomised cross-over study.

BACKGROUND: Peripheral skin blood flow (SBF) changes during and after spinal mobilization (SM), evaluated with laser Doppler flowmetry, may document physiological responses associated with SM. OBJECTIVES: To document variations in SBF during and after application of an SM and evaluate influence of pressure on SBF by applying the same standardized SM with 3 different nonnoxious pressures. DESIGN: Cross-over design with 4 interventions on 4 different days: control (no touch) and 3 SMs applied rhythmically at 5%, 40%, or 80% of pain pressure threshold (sham SM, low-pressure SM, or high-pressure SM, respectively). METHOD: Thirty-two individuals participated. The inspiratory gasp (IG) test was our positive control of vasoconstriction through excitation of the skin sympathetic nervous activity (SSNA). Each session comprised 5 phases: (1) baseline at the end of a 20-min acclimatization, (2) IG test, (3) post-IG phase, (4) SM phase or no manual contact for control, and (5) post-SM phase. A Biopac MP36 system collected SBF data, and a Novel Pliance-X system recorded pressure data. RESULTS/FINDINGS: Equal and significant bilateral vasodilation occurred during application of unilateral sham SM, low-pressure SM, and high-pressure SM. Post-SM significant vasodilation persisted after high-pressure SM. CONCLUSIONS: The current study is the first to describe bilateral peripheral SBF changes occurring during and 5 min after application of standardized SMs. Our post-SM vasodilation suggests involvement of mechanisms other than the putative SSNA-excitatory mechanism proposed with skin conductance measurements. Persistence of post-SM vasodilation following only high-pressure SM suggests possible pressure-dependent mechanisms. However, further research is warranted to clarify our findings.

Assessment of skin blood flow following spinal manual therapy: a systematic review.

Skin blood flow (SBF) indexes have been used to describe physiological mechanisms associated with spinal manual therapy (SMT). The aims of the current review were to assess methods for data collection, assess how investigators interpreted SBF changes, and formulate recommendations to advance manual medicine research. A database search was performed in PubMed, Cochrane Library, the Physiotherapy Evidence Database, and the Cumulative Index to Nursing and Allied Health Literature through April 2014. Articles were included if at least 1 outcome measure was changes in 1 SBF index following SMT. The database search yielded 344 records. Two independent authors applied the inclusion criteria. Twenty studies met the inclusion criteria. Selected studies used heterogeneous methods to assess short-term post-SMT changes in SBF, usually vasoconstriction, which was interpreted as a general sympathoexcitatory effect through central mechanisms. However, this conclusion might be challenged by the current understanding of skin sympathetic nervous activity over local endothelial mechanisms that are specifically controlling SBF. Evaluation of SBF measurements in peripheral tissues following SMT may document physiological responses that are beyond peripheral sympathetic function. Based on the current use of SBF indexes in clinical and physiological research, 14 recommendations for advancing manual medicine research using laser Doppler flowmetry are presented.

Laser Doppler flowmetry in manual medicine research.

Laser Doppler flowmetry (LDF) is commonly used in combination with reactivity tests to noninvasively evaluate skin sympathetic nerve activity and skin microvascular function. In manual medicine research, LDF has been used as a marker for global peripheral sympathetic nervous system function, but these results should be considered with caution because skin sympathetic nerve activity physiology is often overlooked. Another limitation of LDF in manual medicine research is the processing of LDF recordings. Two methods have been suggested: the time-domain analysis and the frequency-domain analysis. Standardization is required for data collection and processing in either domain to accurately interpret these changes in skin blood flow that occur after manual procedures. For physiologic studies using LDF, the authors recommend the use of noninvasive reactivity tests (positive controls) to evaluate the different mechanisms involved in overall skin blood flow changes and to compare the magnitude of these changes with those specifically elicited by manual procedures.

Changes in rat spinal cord gene expression after inflammatory hyperalgesia of the joint and manual therapy.

CONTEXT: Mobilization of a joint affects local tissue directly but may also have other effects that are mediated through the central nervous system. OBJECTIVE: To identify differential gene expression in the spinal cords of rats with or without inflammatory joint injury after manual therapy or no treatment. METHODS: Rats were randomly assigned to 1 of 4 treatment groups: no injury and no touch (NI/NT), injury and no touch (I/NT), no injury and manual therapy (NI/MT), and injury and manual therapy (I/MT). We induced acute inflammatory joint injury in the rats by injecting carrageenan into an ankle. Rats in the no-injury groups did not receive carrageenan injection. One day after injury, rats received manual therapy to the knee of the injured limb. Rats in the no-touch groups were anesthetized without receiving manual therapy. Spinal cords were harvested 30 minutes after therapy or no touch, and spinal cord gene expression was analyzed by microarray for 3 comparisons: NI/NT vs I/NT, I/MT vs I/NT, and NI/NT vs NI/MT. RESULTS: Three rats were assigned to each group. Of 38,875 expressed sequence tags, 755 were differentially expressed in the NI/NT vs I/NT comparison. For the other comparisons, no expressed sequence tags were differentially expressed. Cluster analysis revealed that the differentially expressed sequence tags were over-represented in several categories, including ion homeostasis (enrichment score, 2.29), transmembrane (enrichment score, 1.55), and disulfide bond (enrichment score, 2.04). CONCLUSIONS: An inflammatory injury to the ankle of rats caused differential expression of genes in the spinal cord. Consistent with other studies, genes involved in ion transport were among those affected. However, manual therapy to the knees of injured limbs or to rats without injury did not alter gene expression in the spinal cord. Thus, evidence for central nervous system mediation of manual therapy was not observed.

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.