Effects of a focused training on first-year osteopathic medical students' ability to incorporate point-of-care ultrasound in assessment of the anterior knee.

CONTEXT: Patients frequently present to the outpatient clinic, urgent care, or emergency department with a painful, swollen knee. Differentiating the underlying etiology can be a challenge for both medical students and seasoned clinicians alike. Because this scenario can represent a time-sensitive emergency, developing skills to diagnose the underlying cause quickly and accurately is essential for proper management, whether the patient would benefit from osteopathic manipulation, prompt administration of antibiotics, or a more invasive procedure like joint aspiration or surgery. OBJECTIVES: The objectives are to determine the effects of a focused ultrasound training on first-year osteopathic medical students' ability to identify normal sonographic anatomy of the anterior knee and to differentiate between three common pathologies: joint effusion, prepatellar bursitis, and cellulitis. METHODS: First-year osteopathic medical students voluntarily participated in this cross-sectional study. The study protocol included a focused ultrasound training (online materials, brief didactic and single hands-on sessions) followed by a hands-on assessment. A written test and 5-point Likert scale questionnaire were administered before and after the focused training. Nine weeks later, students completed a follow-up written test. The proportion of students who correctly identified common pathologies on written tests before (pretest) and after (posttest) training and on the follow-up written test were compared utilizing the Fisher's exact test. A t test was utilized to compare data from the pretraining and posttraining questionnaires. RESULTS: Of 101 students completing the written pretest and pretraining questionnaire, 95 (94.1 %) completed the written posttest and posttraining questionnaire, and 84 (83.2 %) completed the follow-up written test. Students had limited previous experience with ultrasound; 90 (89.1 %) students had performed six or fewer ultrasound examinations before the focused ultrasound training. On written tests, students accurately identified joint effusion (22.8 % [23/101] pretest, 65.3 % [62/95] posttest, 33.3 % [28/84] follow-up test), prepatellar bursitis (14.9 % [15/101] pretest, 46.3 % [44/95] posttest, 36.9 % [31/84] follow-up test), and cellulitis (38.6 % [39/101] pretest, 90.5 % [86/95] posttest, 73.8 % [62/84] follow-up test). Differences were found between pretest and posttest for identification of all three pathologies (all p<0.001) and between the pretest and 9-week follow-up test for identification of prepatellar bursitis and cellulitis (both p≤0.001). For questionnaires, (where 1=strongly agree, 5=strongly disagree), the mean (standard deviation [SD]) confidence for correctly identifying normal sonographic anatomy of the anterior knee was 3.50 (1.01) at pretraining and 1.59 (0.72) at posttraining. Student confidence in the ability to differentiate joint effusion, prepatellar bursitis, and cellulitis utilizing ultrasound increased from 4.33 (0.78) at pretraining to 1.99 (0.78) at posttraining. For the hands-on assessment, 78.3 % (595 correct/760 aggregated responses) of the time students correctly identified specific sonographic landmarks of the anterior knee. When the evaluation combined real-time scanning with a prerecorded sonographic video clip of the anterior knee, 71.4 % (20/28) accurately identified joint effusion, 60.9 % (14/23) correctly diagnosed prepatellar bursitis, 93.3 % (28/30) recognized cellulitis, and 47.1 % (8/17) diagnosed the normal knee. CONCLUSIONS: Our focused training was effective at immediately increasing basic knowledge, as well as confidence of first-year osteopathic medical students when assessing the anterior knee with point-of-care ultrasound. However, spaced repetition and deliberate practice may be useful for learning retention.

Teaching Medical Students About Health Systems Science and Osteopathic Principles and Practice Using a Virtual World: The Envision Community Health Center.

Medical education technology initiatives can be used to prepare osteopathic medical students for modern primary care practice and to provide students with training to serve vulnerable populations. Over academic years 2014 through 2017, the authors designed and implemented 26 case studies using patient simulations through a virtual community health center (CHC). First-year students, who were preparing for clinical training in CHCs, and second-year students, who were training in CHCs, completed the simulation case studies, gaining practice in clinical reasoning, Health Systems Science, and applied osteopathic principles and practice. This article explains the project, illustrates an alignment with Health Systems Science and osteopathic competencies, and highlights findings from previous research studies.

Effectiveness of osteopathic manipulative treatment for carpal tunnel syndrome: a pilot project.

CONTEXT: Osteopathic manipulative treatment (OMT) has been recognized as a management option for carpal tunnel syndrome (CTS), although limited research exists to substantiate its effectiveness. OBJECTIVE: To evaluate the effectiveness of OMT in the management of CTS. METHODS: This single-blinded quasi-controlled trial was conducted at an academic institution. Participants with CTS underwent weekly OMT sessions for 6 consecutive weeks. The main outcome measures were the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ), a sensory symptom diagram (SSD), patient estimate of overall change, electrophysiologic testing of the median nerve (trans-carpal tunnel motor and sensory nerve conduction velocity and amplitude ratio), and carpal tunnel ultrasound imaging of the cross-sectional area of the median nerve and transverse carpal ligament length and bowing. All outcome measures were administered to participants before the first OMT session. Immediately after the first session, electrophysiologic testing of the median nerve and ultrasound imaging of the carpal tunnel were repeated. After 6 weeks of OMT, all outcome measures were readministered. RESULTS: Results of the BCTQ revealed statistically significant improvements in symptoms and function after 6 weeks of OMT (F=11.0; P=.004), and the improvements tended to be more pronounced on the treated side. The drop in SSD scores after 6 weeks of treatment was statistically significant (F=4.19; P=.0002). Patient estimate of overall improvement of symptoms was statistically significant for the treated side. No statistically significant changes in electrophysiologic function of the median nerve, cross-sectional area of the median nerve, or transverse carpal ligament bowing were observed. After treatment, the increase in transverse carpal ligament length was statistically significant, but no side-to-side difference was detected. CONCLUSION: Osteopathic manipulative treatment resulted in patient-perceived improvement in symptoms and function associated with CTS. However, median nerve function and morphology at the carpal tunnel did not change, possibly indicating a different mechanism by which OMT acted, such as central nervous system processes.

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.

Use of real-time physiologic parameter assessment to augment osteopathic manipulative treatment training for first-year osteopathic medical students.

CONTEXT: The first 2 years of osteopathic medical school involve training in osteopathic principles and practice, including understanding the tenets of osteopathic medicine and developing palpatory skills for clinical application. Although this training emphasizes the link between somatic dysfunction and physiologic function, it does not include the opportunity for students to quantitatively assess the physiologic effect of osteopathic manipulative treatment (OMT) using physiologic measurements. OBJECTIVE: To evaluate an approach for integrated OMT training coupled with physiologic measurements of relevant parameters, whereby first-year osteopathic medical students assess the quantitative, real-time changes in specific physiologic signals during instruction. METHODS: During mandatory musculoskeletal and cardiovascular demonstration laboratories at a single osteopathic medical school, students were divided into small groups and performed OMT on each other while recording real-time measurements of physiologic functions such as maximum clench force, time to fatigue for the forearm flexor muscles, heart rate, and peripheral vascular flow. After data were collected, students analyzed pre- and post-OMT measurements and discussed underlying physiologic principles in a large group format. At the end of the sessions, students completed a brief survey on the usefulness of the integrated laboratories. RESULTS: Overall, 13 of 28 student groups (46.4%) measured a pre- to post-OMT increase in maximum clench force, and 16 (57.1%) observed an increase in time to fatigue for the forearm flexor muscles. Twenty-three of 27 student groups (85.2%) observed a reduction in heart rate and 19 (70.4%) measured an increase in peripheral vascular flow after OMT. Student satisfaction was generally favorable, with overall mean (SD) ratings of 6.38 (1.86) for the musculoskeletal laboratory and 7.81 (1.69) for the cardiovascular laboratory out of a maximum of 10 points. In open-ended comments, students deemed the combined laboratories as clinically applicable but desired more time for completing the laboratories. CONCLUSION: Measurement of specific physiologic musculoskeletal and cardiovascular parameters before and after OMT enabled quantification of physiologic responses to OMT. Students' favorable feedback indicated that the quality of learning in the laboratories was enhanced by the addition of physiologic measurements.

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

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