Does the osteopathic pedal pump reduce lower limb volume in healthy subjects?

CONTEXT: Lymphatic treatments are gentle and passive techniques believed to enhance movement of lymph back into the central circulatory system. Animal studies provide supportive evidence, yet there are few studies in humans. OBJECTIVES: The aim of this study is to investigate whether the osteopathic pedal pump protocol reduces volume in the lower limbs of healthy subjects. METHODS: A total of 30 first- and second-year medical students were recruited. Subjects were excluded from participating if they had acute asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure, active infections, fractures of the lower extremities, or metastatic cancer. A within-subjects study design with pre- and posttreatment measurement of lower limb volume was utilized. Pretreatment lower limb volume measurements were obtained utilizing a volumetric water gauge prior to myofascial thoracic inlet release and a 5 min pedal lymphatic pump protocol treatment. Posttreatment lower limb measurements were taken immediately following the protocol treatment. A telephone interview was conducted 2-3 days after the treatment to assess the participants' experience of the treatment and whether the treatment elicited a subjective change from baseline. A paired t test was utilized to determine the statistical significance of volume displacement posttreatment. RESULTS: The mean change of pretreatment to posttreatment lower limb volume was -45.63 mL with a standard deviation of 37.65 mL. The change between the pretreatment and posttreatment volume measurements was statistically significant (p<0.001). The minimum displacement was +19 mL, and the maximum displacement was -167 mL. The majority of participants perceived the treatment as effective and enjoyable, were likely to recommend it to others, and were willing to have it performed on them at routine office visits if there was a need. CONCLUSIONS: The osteopathic pedal pump technique, when utilized on those without leg lymphedema, reduces lower limb volume as measured by the volumetric water gauge. Further studies are warranted, especially in persons with excess lower-extremity edema, lymphedema or venous stasis.

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).

The Potential of Osteopathic Manipulative Treatment in Antimicrobial Stewardship: A Narrative Review.

The contemporary management of infectious diseases is built around antimicrobial therapy. However, the development of antimicrobial resistance threatens to create a post-antibiotic era. Antimicrobial stewardship attempts to reduce the development of antimicrobial resistance by improving their appropriate use. Osteopathic manipulative treatment as an adjunctive treatment has the potential for enhancing antimicrobial stewardship by enhancing the human immune system, shortening the duration of antimicrobial therapy, reducing complications, and improving treatment outcomes. The present article reviews the evidence published in the literature since this unique treatment approach was first developed more than 100 years ago. The evidence suggests that adjunctive osteopathic manipulative treatment has great potential for enhancing antimicrobial stewardship and should be further investigated.

Effective Patient-Physician Communication Based on Osteopathic Philosophy in Caring for Elderly Patients.

The objective of this article is to discuss effective communication strategies between elderly patients and their physicians from the perspective of osteopathic heritage. The patient-physician communication styles of Andrew Taylor Still, MD, DO, and early osteopathic physicians (ie, DOs) may have influenced how DOs today communicate with their patients. Historical literature describes how Still would discuss with his patients the causes of their health problems using analogies and language they would understand, and how, when caring for a patient at the end of life, he empathically provided emotional support for both patients and their families. Early DOs advocated setting clear expectations for patients regarding clinical outcomes and carefully listening to patients to build trust. The Osteopathic Oath, which calls for the DO to view the patient as a friend, may also affect patient-physician communication. Early osteopathic philosophy and culture, as modeled by Dr Still in his approach to elderly patients, should inspire today's DOs in their communication with their elderly patients.

Axioms, osteopathic culture, and a perspective from geriatric medicine.

Osteopathic medicine is a rapidly growing discipline in health care that has much to offer the wider biomedical community. A distinction of the osteopathic medical profession is the importance of an overall guiding philosophy. Despite the osteopathic medical profession's success, there remains concern about the profession's ability to maintain its unique identity. Among many factors that have contributed to the profession's success, certain axioms from its earliest days are pertinent to the profession's identity. Maintaining a knowledge and appreciation of osteopathic axioms can play an important role in safeguarding the profession's identity. These axioms encapsulate osteopathic philosophy and, moreover, are universally useful for patient care. As osteopathic geriatricians, the authors explore the value and meaning of these axioms for anyone who treats patients, but especially for the care of the elderly. The authors also propose a new axiom, derived from the experience of 2 of the authors: "First try to blame it on the medications."

Leg length discrepancy and osteoarthritic knee pain in the elderly: an observational study.

CONTEXT: Osteoarthritic knee pain is very common, as are leg length discrepancies (LLDs). The relationship between LLDs and osteoarthritic knee pain is not well understood. OBJECTIVE: To confirm a clinical impression that osteoarthritic knee pain is more common in the short (ie, superior-presenting) leg, as measured by supine physical examination of 3 bony landmarks: the medial malleoli, the anterior superior iliac spines, and the iliac crests. The secondary objective was to measure the relative positions of the 3 bony landmarks to better understand functional contributions to LLD. METHODS: A prospective single-occasion observational design was used. Patients who reported osteoarthritic knee pain during an office visit were recruited, and data were collected on 3 bony landmarks and which knee was usually most painful. RESULTS: Of the 32 participants who were recruited, 28 were women and 4 were men. Of the 17 participants who reported having right knee pain, 10 had a short right leg and 7 had a short left leg. Of the 15 participants who reported having left knee pain, 13 had a short left leg, 1 had a short right leg, and 1 had equal leg lengths. Knee pain was most severe in the short leg for 23 of 32 participants (71.9%). The most common pattern was for both iliac crests to be equal and the short leg to be concordant with a superior anterior superior iliac spine, which occurred in 23 of 32 participants (71.9%). In the present study population, the magnitude of LLD ranged from 0 to 2.1 cm. CONCLUSION: Osteoarthritic knee pain was more common in the apparent short leg. More sophisticated studies, including investigations into the role of pelvic torsion in knee pain, as well as investigations for interoperator reliability and validity, are needed to build on the findings reported in this observational study.

The short-term effect of a lymphatic pump protocol on blood cell counts in nursing home residents with limited mobility: a pilot study.

CONTEXT: Lymphatic pump techniques have the potential to alter blood cell counts and thus enhance immune function in elderly adults with diminished mobility. OBJECTIVE: To test whether an osteopathic manipulative treatment (OMT) protocol designed to enhance immune function will have an effect on lymphocyte and lymphocyte subset counts compared with a sham control group. DESIGN: The study design was a single-session, randomized, controlled clinical trial comparing a standardized lymphatic pump protocol with a light-touch protocol. Participants were assigned to 1 of 2 groups by using a 1:1 allocation ratio. SETTING: The study was conducted in 2 rural long-term care facilities in Missouri. PARTICIPANTS: Residents in the long-term care facilities who were aged 60 years or older and who were confined to a bed or wheelchair for most of their waking hours. Twenty residents were recruited to participate in the study, and 10 were randomly assigned to each group. INTERVENTIONS: Baseline blood samples were obtained. Then each patient received a 6-minute study protocol treatment. Thirty minutes after completion, posttreatment blood samples were obtained. The OMT protocol consisted of 3 osteopathic techniques: myofascial release to the thoracic inlet, the splenic pump, and the pedal lymphatic pump. The light touch protocol was applied to the same body areas as the OMT protocol for 6 minutes. OUTCOME MEASURES: A pretreatment and posttreatment lymphocyte subset panel, complete blood cell count, and automated white blood cell count differential was obtained from each participant. RESULTS: There was a statistically significant between-group difference in mean change for platelet counts: counts in the OMT group decreased by a mean (standard deviation) of 15,400 (7947) platelets per microliter and the light touch group increased by 4,700 (17,857) platelets per microliter (P=.004). The between-group differences for the mean (standard deviation) absolute lymphocyte cell count, red blood cell count, hemoglobin level, and hematocrit measures all decreased, but the changes were not statistically significant relative to the control group. CONCLUSION: The OMT protocol used in this pilot study modestly reduced platelet counts in nursing home residents with limited mobility.

Developing osteopathic competencies in geriatrics for medical students.

CONTEXT: Minimum core competencies for allopathic medical students in the specialty area of geriatrics have been developed, comprising 26 competencies divided into 8 topical domains. These competencies are appropriate for osteopathic medical students, but they do not include competencies relating to osteopathic principles and practice (OPP) in geriatrics. There remains a need within the osteopathic profession to develop specialty-specific competencies specific to OPP. OBJECTIVE: To develop more specific and comprehensive minimum competencies in OPP for osteopathic medical students in the field of geriatric medicine. METHODS: The Delphi technique (a structured communication technique that uses a panel of experts to reach consensus) was adapted to generate new core competencies relating to OPP. Osteopathic geriatricians and members of the Educational Council on Osteopathic Principles (ECOP) of the American Association of Colleges of Osteopathic Medicine participated in a breakout session and 2 rounds of surveys. Proposed competencies with 80% of the participants ranking it as "very important and should be added as a competency" were retained. Participants were also asked if they agreed that competencies in OPP should include specific types of osteopathic manipulative treatment techniques for the elderly. RESULTS: Responses were received from 26 osteopathic physician experts: 17 ECOP members and 9 geriatricians. Fourteen proposed competencies were developed: 7 related to the existing topic domains, and 7 were placed into a new domain of osteopathic manipulative medicine (OMM). Six proposed competencies were retained, all of which were in the new OMM domain. These competencies related to using OMM for gait and balance assessment, knowing adverse events and contraindications of OMM, using OMM for pain relief and end-of-life care, using OMM in the hospital and nursing home setting, adapting OMM to fit an elderly individual, and using OMM to address limited range of motion and ability to perform activities of daily living. Thirteen of 22 participants (59%) agreed that OPP competencies should include specific osteopathic manipulative treatment techniques. CONCLUSIONS: The Delphi consensus building process was used to create 6 new minimum competencies in OMM for osteopathic medical students for the specialty area of geriatrics. Using data from this consensus, medical schools, residencies, and fellowships can create standards and expectations for osteopathic physicians regarding the best care of geriatric patients.

Promoting successful aging through effective prevention and management of osteoporosis.

Successful aging has been described as having 3 components: a low probability of disease and disease-related disability, a capacity for high cognitive and physical function, and active engagement with social and productive activities. Osteopathic physicians play a critical role in the promotion of successful aging through the prevention, early detection, and management of osteoporosis. Not many years ago, osteoporosis was viewed as an age-related disorder for which there was a lack of effective approaches for early intervention and management. Now, that view has changed.

Management of falls and balance disorders in the elderly.

Falls, gait disturbances, and balance disorders are common clinical problems for the elderly, and these problems are associated with considerable morbidity. However, the literature reports relatively few effective treatment options, such as vitamin D replacement, exercise and physical therapy, and tai chi. Because of the limited number of available effective interventions, there is a need to explore other approaches, such as osteopathic manipulative treatment. The author reviews the limited body of literature relating to the use of manipulation for reducing fall events and improving gait and balance in the elderly. At this time, there are new opportunities for clinical and basic science research to investigate emerging uses of osteopathic manipulative treatment for managing falls, gait disturbances, and balance disorders.

Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial.

BACKGROUND: The Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) is a registered, double-blinded, randomized, controlled trial designed to assess the efficacy of osteopathic manipulative treatment (OMT) as an adjunctive treatment in elderly patients with pneumonia. METHODS: 406 subjects aged >/= 50 years hospitalized with pneumonia at 7 community hospitals were randomized using concealed allocation to conventional care only (CCO), light-touch treatment (LT), or OMT groups. All subjects received conventional treatment for pneumonia. OMT and LT groups received group-specific protocols for 15 minutes, twice daily until discharge, cessation of antibiotics, respiratory failure, death, or withdrawal from the study. The primary outcomes were hospital length of stay (LOS), time to clinical stability, and a symptomatic and functional recovery score. RESULTS: Intention-to-treat (ITT) analysis (n = 387) found no significant differences between groups. Per-protocol (PP) analysis (n = 318) found a significant difference between groups (P = 0.01) in LOS. Multiple comparisons indicated a reduction in median LOS (95% confidence interval) for the OMT group (3.5 [3.2-4.0] days) versus the CCO group (4.5 [3.9-4.9] days), but not versus the LT group (3.9 [3.5-4.8] days). Secondary outcomes of duration of intravenous antibiotics and treatment endpoint were also significantly different between groups (P = 0.05 and 0.006, respectively). Duration of intravenous antibiotics and death or respiratory failure were lower for the OMT group versus the CCO group, but not versus the LT group. CONCLUSIONS: ITT analysis found no differences between groups. PP analysis found significant reductions in LOS, duration of intravenous antibiotics, and respiratory failure or death when OMT was compared to CCO. Given the prevalence of pneumonia, adjunctive OMT merits further study.

The immediate effect of individual manipulation techniques on pulmonary function measures in persons with chronic obstructive pulmonary disease.

BACKGROUND: The use of manipulation has long been advocated in the treatment of chronic obstructive pulmonary disease (COPD), but few randomized controlled clinical trials have measured the effect of manipulation on pulmonary function. In addition, the effects of individual manipulative techniques on the pulmonary system are poorly understood. Therefore, the purpose of this study was to determine the immediate effects of four osteopathic techniques on pulmonary function measures in persons with COPD relative to a minimal-touch control protocol. METHODS: Persons with COPD aged 50 and over were recruited for the study. Subjects received five, single-technique treatment sessions: minimal-touch control, thoracic lymphatic pump (TLP) with activation, TLP without activation, rib raising, and myofascial release. There was a 4-week washout period between sessions. Protocols were given in random order until all five techniques had been administered. Pulmonary function measures were obtained at baseline and 30-minutes posttreatment. For the actual pulmonary function measures and percent predicted values, Wilcoxon signed rank tests were used to test within-technique changes from baseline. For the percent change from baseline, Friedman tests were used to test for between-technique differences. RESULTS: Twenty-five subjects were enrolled in the study. All four tested osteopathic techniques were associated with adverse posttreatment changes in pulmonary function measures; however, different techniques changed different measures. TLP with activation increased posttreatment residual volume compared to baseline, while TLP without activation did not. Side effects were mild, mostly posttreatment chest wall soreness. Surprisingly, the majority of subjects believed they could breathe better after receiving osteopathic manipulation. CONCLUSION: In persons with COPD, TLP with activation, TLP without activation, rib raising, and myofascial release mildly worsened pulmonary function measures immediately posttreatment relative to baseline measurements. The activation component of the TLP technique appears to increase posttreatment residual volume. Despite adverse changes in pulmonary function measures, persons with COPD subjectively reported they benefited from osteopathic manipulation.

Clinical and research protocol for osteopathic manipulative treatment of elderly patients with pneumonia.

Pneumonia in elderly patients is a major public health concern because of greater morbidity and mortality and longer hospital stays relative to younger populations. Based on the premise that osteopathic manipulative treatment (OMT) is beneficial in the management of pulmonary infections, the Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) was designed as a prospective randomized controlled trial to evaluate the efficacy of OMT as an adjunct to the current pharmacologic treatment of elderly patients hospitalized for pneumonia. The protocol developed for MOPSE has its origins in early osteopathic medical literature at a time when effective antibiotic therapy was unavailable and osteopathic physicians relied on physical examination and empiric reasoning to develop treatment strategies and OMT techniques to improve host defenses against pneumonia. The present paper reviews the early osteopathic medical literature to identify the reasoning behind the OMT techniques that are the basis for the design of the MOPSE protocol. Likewise, the contemporary medical literature relevant to the protocol is reviewed. Finally, a description of the study design and the OMT and light touch (sham) protocols used in MOPSE are provided.

Immediate effects of osteopathic manipulative treatment in elderly patients with chronic obstructive pulmonary disease.

CONTEXT: Osteopathic manipulative treatment (OMT) has long been advocated for patients with respiratory disorders, but little definitive evidence exists to support its use in this population. OBJECTIVE: To investigate the immediate effect of OMT on pulmonary function parameters in elderly subjects with chronic obstructive pulmonary disease. METHODS: Subjects aged 65 years or older with a forced expiratory volume in 1 second to forced vital capacity ratio of less than 70% were recruited and randomly assigned to receive either OMT or sham therapy. The OMT protocol consisted of seven standardized osteopathic manipulative techniques, while the sham therapy protocol comprised light touch applied to the same anatomic regions and for the same duration (20 min). All subjects received baseline and posttreatment pulmonary function testing. A telephone survey was conducted 1 day after the intervention to collect subjective feedback and assess the success of blinding protocols. RESULTS: Of the 35 study participants, 18 were randomly assigned to the OMT group and 17 to the sham group. Compared with the sham group, the OMT group showed a statistically significant decrease in the forced expiratory flow at 25% and 50% of vital capacity and at the midexpiratory phase; the expiratory reserve volume; and airway resistance. The OMT group also had a statistically significant increase in the residual volume, total lung capacity, and the ratio of those values compared with the sham group. Most subjects (82%, OMT group; 65%, sham group) reported breathing better after receiving their treatment. Only 53% of subjects in the OMT group and 41% in the sham group correctly guessed their group assignment. CONCLUSION: Results suggest an overall worsening of air trapping during the 30 minutes immediately following one multitechnique OMT session relative to the sham group.

Revisiting Castlio and Ferris-Swift's experiments on direct splenic stimulation in patients with acute infectious disease.

BACKGROUND: In 1934, Yale Castlio, DO, and Louise Ferris-Swift, DO, published the results of a within-subjects experiment on direct splenic stimulation in patients with acute infectious disease (N=100). Their results, which used rudimentary statistical analyses, are still cited as evidence that osteopathic manipulative treatment augments immunity. OBJECTIVE: To retest the validity of Castlio and Ferris-Swift's conclusions by applying contemporary statistical methods to their raw data. METHODS: Castlio and Ferris-Swift's original 1934 data were not normally distributed and sample sizes were small. Therefore, the authors of the present study reanalyzed the data using several nonparametric statistical methods: Wilcoxon signed rank, Friedman, and Kruskal-Wallis tests. RESULTS: Contemporary statistical analysis confirms a modest posttreatment increase in leukocytes, a decrease in erythrocytes, a decrease in the Arneth index, and an increase in reticulocytes after the application of direct splenic stimulation for patients diagnosed with acute infectious disease. Contemporary reanalysis also confirms statistically significant posttreatment changes in the immune function tests. Findings were less conclusive for the leukocyte differential cell counts and for the effect of varying the number of splenic compressions. CONCLUSIONS: Analysis of Castlio and Ferris-Swift's 1934 data using contemporary statistical methods supports many of their original conclusions. However, faults in study design common to that era limit the article's applicability for modern researchers. Additional research on splenic pump techniques using contemporary study designs and statistical methods is recommended.