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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)

Background: Awareness of discrepancies of renal vasculature is crucial for some medical procedures. The present study investigated origin and course of aberrant and accessory renal vessels and any associated variations. Materials and methods: Renal blood vessels of 63 cadavers were examined. Number of renal veins and arteries, arrangement, location where the vasculature attached to the kidneys, and presence of variations were recorded. Incidence of renal vasculature variations was determined, and associations were tested with age at death, sex, and cause of death and whether variations were more common on a specific side. Results: Variations were found in 7 (11%; 95% confidence interval [CI] 5–22%) cadavers. For renal veins, double, triple, and quadruple veins unilaterally (5; 8%) and veins that drained the superior pole (1; 2%) or inferior pole only (5; 8%) were found. For renal arteries, double and triple arteries unilaterally (3; 5%) and arteries attached to the superior pole only (1; 2%) or inferior pole only (2; 3%) were found. Other variations (polycystic kidney, variations in the common iliac or gonadal veins) were observed. Only renal failure as a cause of death was different between those with or without variations (4/7 [57%] vs. 1/56 [2%]; p < 0.001). Conclusions: The present study found many variations in renal vasculature. Awareness of such variations may be useful for physicians concerned with this region.

Unbalanced 3-factor design with repeated measures on 1 factor.To determine the effect of manual treatment (MT) on cytokine and pain sensations in those with and without low back pain (LBP).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.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)-1β, 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.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).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.

Context: Gastrointestinal (GI) endoscopy provides a novel means of correlating visceral abnormalities with somatic dysfunction. Objective: To assess the correlation of palpatory findings of somatic dysfunction with GI abnormalities determined by endoscopy and to identify which types of somatic dysfunction were most commonly correlated with GI abnormalities. Methods: In this observational, cross-sectional study, participants who were scheduled to receive an esophagogastroduodenoscopy (EGD), colonoscopy, or both were examined by 2 osteopathic physicians immediately prior to endoscopy for the presence of vertebral tenderness, asymmetry, restricted range of motion, and tissue texture abnormalities (TART findings); tenderness of anterior Chapman reflex points; and tenderness of visceral sphincters. Each type of somatic dysfunction and the somatic dysfunction burden (sum of findings) were compared with the type of endoscopic procedure and abnormal endoscopic findings. Results: Sixty-six adults participated: 43 received an EGD, 40 received a colonoscopy, and 17 received both. The incidence of vertebral TART findings ranged from 70% at T12 to 98% at the sacrum. Participants who received only EGD had a higher somatic dysfunction burden than those who received only colonoscopy and those who received both procedures (P=.002). The incidence of abnormal endoscopic findings ranged from 98% in the stomach to 0% at the ileocecal valve. Statistically significant positive associations were found between specific vertebral TART findings and abnormalities of the esophagus, gastroesophageal junction, pylorus, ascending colon, and sigmoid colon; specific Chapman reflex point tenderness and abnormalities of the esophagus, gastroesophageal junction, pylorus, ascending colon, descending colon, sigmoid colon, and rectum; and specific visceral sphincter tenderness and abnormalities of the duodenum, ascending colon, and sigmoid colon. Conclusions: The current study found numerous associations between somatic dysfunction and abnormal endoscopic findings. However, the high incidence of vertebral TART findings and the lack of normal controls for many GI regions made establishing meaningful relationships between specific somatic dysfunction and specific GI abnormalities challenging. Future investigations should include more participants to ensure a higher number of normal endoscopic findings and limit the physical examination to elements of somatic dysfunction with a high level of variability between vertebrae within an individual participant and between participants, such as tenderness and tissue texture abnormalities. (ClinicalTrials.gov number NCT01394198)

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.

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 (PP=.03), motion restriction (P=.04), and tenderness (PPP=.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.

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 (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.

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.

Context: In the first half of the 20th century, nearly all osteopathic physicians used osteopathic manipulative medicine (OMM) in the care of hospitalized patients. Over the past few decades, however, inpatient OMM care has declined and is more commonly provided by OMM specialists. Objective: To retrospectively evaluate the details of a specialty-level OMM inpatient consultation service. Methods: Inpatient OMM consultations that took place at Northeast Regional Medical Center in Kirksville, Missouri, between July 1998 and March 2008 were identified from billing records. Consultations were reviewed for demographic information, admission location, postoperative status, intensive care unit and mechanical ventilation usage, admission and discharge diagnoses, consultation reasons and final diagnoses, areas of somatic dysfunction treated and types of osteopathic manipulative treatment (OMT) techniques used, and hospital length of stay (LOS). Results: A total of 1509 OMM consultations were identified (580 for male patients [38%]; 929 for female patients [62%]; mean [SD] age, 54 [31] years [range, 0-99 years]), representing 11% of all inpatient consultations. Of these, 1372 consultations (91%) were initiated in the inpatient acute care facility, 87 (6%) in the inpatient acute rehabilitation facility, and 50 (3%) in the skilled nursing facility. Further, 265 consultations (18%) were for postoperative patients, 187 (12%) were for patients in the intensive care unit, and 54 (4%) were for patients receiving mechanical ventilation at the time of the consultation. The most common admission diagnoses were hypertension, routine newborn care, lower respiratory infection, chronic obstructive pulmonary disease, and gastrointestinal symptoms. The most common reasons for OMM consultation were chest/rib pain, spinal pain, lower respiratory infection (adjunctive treatment), cranial asymmetry, and infant feeding disorder. The most common types of OMT techniques used were myofascial release, balanced ligamentous tension, muscle energy, soft tissue, and inhibition. The mean (SD) LOS was 5.7 (3.3) days (range, 0-48 days), while the mean (SD) number of days the patient received OMT was 3.1 (2.2) days. Conclusion: Medical records reviewed in the current study revealed that OMM consultations were ordered primarily for musculoskeletal complaints, respiratory problems (adjunctive treatment), and newborn care. A variety of OMT techniques were used. Further retrospective study is warranted to determine if OMM had an effect on LOS.

Context:Counterstrain is 1 osteopathic manipulative treatment technique taught to osteopathic medical students, but teaching all 300 counterstrain tender points is not feasible at most colleges of osteopathic medicine (COMs) because of time limitations.Objective:To identify high-yield tender points in osteopathic medical students for teaching and to assess for correlations between tender points and demographic information, weight, and history of pain or trauma.Methods:First- and second-year osteopathic medical students at 5 COMs were surveyed regarding the presence and absence of tender points found on themselves by fellow students. Demographic information, weight, and history of pain and trauma data were collected. The McNemar test was used to compare the frequency of positive tender points between the right and left sides. Multiple logistic regression models were fit to the data to determine if participant characteristics were related to having 1 or more positive tender points in a tender point group. Wilcoxon signed rank tests were used to compare the percentage of positive anterior vs posterior tender points. Multiple logistic regression models were used to test for differences between COMs after accounting for differences in participant characteristics.Results:Frequency of 78 tender point groups was obtained. Forty tender point groups (51%) were positive for the presence of 1 or more tender points by 50% or more of the participants. Positive tender points were more common on the right side for 23 groups (allPPP≤.03). Tender points were more common in participants with a history of pain for 29 groups (allPP≤.05). Anterior tender points were more common for cervical, thoracic, rib, and lumbar body regions (PP≤.02).Conclusion:Nearly half of the tender point groups surveyed were reported positive by 50% or more of participants, and high-yield tender points were found in each body region. Ultimately, these results may guide counterstrain curricula for COMs.

This single group, randomized, cross-over study explored whether manual therapy alters motor tone of deep thoracic back muscles by examining resting electromyographic activity (EMG) after 2 types of manual therapy and a sham control intervention. Twenty-two participants with thoracic spinal pain (15 females, 7 males, mean age 28.1 ± 6.4 years) had dual fine-wire, intramuscular electrodes inserted into deep transversospinalis muscles at a thoracic level where tissues appeared abnormal to palpation (AbP) and at 2 sites above and below normal and non-tender to palpation (NT). A surface electrode was on the contralateral paraspinal mass at the level of AbP. EMG signals were recorded for resting prone, two 3-s free neck extension efforts, two 3-s resisted maximal voluntary isometric contractions (MVIC), and resting prone before the intervention. Randomized spinal manipulation, counterstrain, or sham manipulation was delivered and EMG re-measured. Participants returned 1 and 2 weeks later for the remaining 2 treatments. Reductions in resting EMG followed counterstrain in AbP (median decrease 3.3%, P = 0.01) and NT sites (median decrease 1.0%, P = 0.05) and for the surface electrode site (median decrease 2.0%, P = 0.009). Reduction in EMG following counterstrain during free neck extension was found for the surface electrode site (median decrease 2.7%, P < 0.01). Spinal manipulation produced no change in EMG, whereas counterstrain technique produced small significant reductions in paraspinal muscle activity during prone resting and free neck extension conditions. The clinical relevance of these changes is unclear.

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)

Study design The level of Tuffier's line was assessed on 200 standing and 60 prone lumbar radiographs. Sex, height, weight, and body mass index (BMI) were correlated with the radiograph findings. Objective To determine whether the level of Tuffier's line is associated with sex, height, weight, or BMI. Summary of background data Tuffier's line (intercristal line) is a commonly used landmark for identification of the L4-L5 interspace; however, multiple studies have identified that this landmark is unreliable. Methods The level of Tuffier's line was assessed retrospectively on 200 standing anteroposterior lumbar radiographs and correlated with sex. Prospectively, the level of Tuffier's line was assessed on 60 prone posteroanterior lumbar radiographs and correlated with sex, height, weight, and BMI. Results In men, the intercristal line most often intersected the L4 body or inferior endplate. In women, the intercristal line most often intersected the L5 body or superior endplate. Weight and BMI had no correlation with Tuffier's line. Subjects with a Tuffier's line through L4 were taller than those with a Tuffier's line through L5. Conclusion Tuffier's line demonstrated predictable sex-related differences: men had an intercristal line that most often intersected the L4 body or inferior endplate whereas the women's intercristal line most often intersected the L5 body or superior endplate. However, because the actual level of Tuffier's line may vary from the L4 body to the L5 body, the intercristal line is insufficient to use as the sole landmark for assessing spinal segmental level.

This study investigated depression and anxiety among students who were entering medical school prior to the onset of their medical curriculum. Entering students reported financial, day-to-day, academic, and time hassles as concerns. Interestingly, the population characteristics of gender, marital status, and ethnicity impacted the type of self-reported hassles indicated by the students. Measurements of depression and anxiety indicated that entering medical school students' emotional status resembles that of the general population. The results suggest that it is the rigors of the medical curriculum that may play an important role in the increased prevalence of depression and anxiety for students during their medical education. Further, students who are entering medical field already have concerns about medical school and are in the process of anticipating the necessary adjustment to the challenges ahead of them. Preventative programming efforts should begin early in medical education and address a wide variety of concerns from academic, to interpersonal relationships and financial worries.

Context: Identifying relationships among anatomical structures is key in diagnosing somatic dysfunction. Ultrasonography can be used to visualize anatomical structures, identify sacroiliac landmarks, and validate anatomical findings and measurements in relation to somatic dysfunction. As part of the osteopathic manipulative medicine course at A.T. Still University–Kirksville College of Osteopathic Medicine, first-year students are trained to use ultrasonography to establish relationships among musculoskeletal structures. Objectives: To determine the ability of first-year osteopathic medical students to establish sacral base position (SBP) and sacral sulcus depth (SSD) using ultrasonography and to identify the relationship of SBP and SSD to body mass index (BMI) and sex. Methods: Students used ultrasonography to obtain the distance between the skin and the sacral base (the SBP) and the distance between the skin and the tip of the posterior superior iliac spine bilaterally. Next, students calculated the SSD (the distance between the tip of the posterior superior iliac spine and the SBP). Data were analyzed with respect to side of the body, BMI, sex, and age. The BMI data were subdivided into normal (18-25 mg/kg) and overweight (25-30 mg/kg) groups. Results: Ultrasound images of 211 students were included in the study. The SBP was not significantly different between the left and right sides (36.5 mm vs 36.5 mm; P=.95) but was significantly different between normal and overweight BMI categories (33.0 mm vs 40.0 mm; PPP=.08), normal and overweight BMI categories (18.9 mm vs 19.7 mm, P=.21), or men and women (19.7 mm vs 19.0 mm; P=.24). No significant relationship was identified between age and SBP (P=.46) or SSD (P=.39); however, the age range was narrow (21-33 years). Conclusion: The study yielded repeatable and reproducible results when establishing SBP and SSD using ultrasonography. The statistically significant relationship between SBP and higher BMI and between SBP and female sex may point to more soft tissue overlaying the sacrum in these groups. Further research is needed on the use of ultrasonography to establish criteria for somatic dysfunction.

Context: The American Osteopathic Association requires the integration of osteo-pathic principles and practice in all specialty residency training programs that it accredits, but the 4 residencies with the most integration of osteopathic manipulative medicine (OMM) have differences in training and emphasis on OMM as a primary treatment modality. Objective: To study differences in OMM use for spinal pain between the neuro-musculoskeletal medicine/OMM (NMM/OMM), the family practice/osteopath-ic manipulative treatment (FP/OMT), the integrated FP/OMT and NMM/OMM (FP/NMM), and the internal medicine and NMM/OMM (IM/NMM) specialty residency training programs. Methods: Medical records were reviewed for patient encounters from September 2011 through October 2013 at NMM/OMM, FP/OMT, FP/NMM, and IM/NMM residencies in a family medicine and OMM specialty clinic. Records were screened for a diagnosis of cervicalgia, thoracalgia, lumbago, or backache. The identifed encounters were compared to determine between-specialty differences in the number of chief complaints, non–somatic dysfunction assessments, body regions with diagnosed somatic dysfunction, body regions managed with OMT, and number and type of OMT techniques used. Results: Eighteen residents had 2925 patient encounters that included 1 or more spinal pain diagnoses. Overall, 2767 patients (95%) received OMT. The probability (95% CI) of residents using OMT was 0.99 (0.98-0.99) for the NMM/OMM residents, 0.66 (0.55-0.77) for the FP/OMT residents, 0.94 (0.88-0.97) for the FP/NMM residents, and 0.997 (0.98-1.0) for the IM/NMM residents. The FP/OMT residents were less likely to manage spinal pain using OMT (PPPPP Conclusion: Although the FP/OMT residents used OMT less frequently than the other residents during spinal pain encounters, they provided care for a larger number and a wider variety of non–somatic dysfunction assessments.

Purpose: The objective of this study was to compare the responsiveness (ability to accurately detect change) of 3 self-administered questionnaires to changes produced by carpal tunnel release. Method: The Disabilities of the Arm, Shoulder and Hand (DASH), the Brigham and Women's Carpal Tunnel Questionnaire, and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) were completed by 34 subjects before surgery and at 6 and 12 weeks after carpal tunnel release. Results: The instrument most sensitive to clinical change at 12 weeks as judged by effect size and standardized response means was the Carpal Tunnel Questionnaire (effect size/standardized response means, 1.71/1.66) followed by the DASH (1.01/1.13) and the Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain (0.57/0.52) and role physical (0.39/0.39) subscales. There was good correlation between DASH and Carpal Tunnel Questionnaire change scores (Spearman correlation coefficient 0.87). Conclusions: The Carpal Tunnel Questionnaire is the most sensitive to clinical change, but the DASH is sufficiently responsive for use in outcome studies of carpal tunnel syndrome done 12 or more weeks after surgery. (J Hand Surg 2003;28A:250-254. Copyright © 2003 by the American Society for Surgery of the Hand.)

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.

Objective: To assess depressive symptoms, self-concept, and behavior in non-affected siblings of children with severe pediatric traumatic brain injury (TBI). Design: Cross-sectional study with case controls. Setting: Children's hospital tertiary care center. Participants: Twelve siblings of children consecutively admitted to an inpatient rehabilitation unit after a severe TBI. Case controls were randomly selected from the sibling's classmates. Main Outcome Measures: The Child Behavior Checklist (CBCL), the Teacher's Report Form of the CBCL (TRF-CBCL), the Self-Perception Profile for Children and the Children's Depression Inventory (CDI). Results: No statistical differences were found in depressive symptoms, self-concept, or behavior between the siblings and their classmates 3 to 18 months after injury. Poorer functional outcomes in the child with a TBI were found to correlate significantly with lower self-concept and more symptoms of depression in the siblings. Conclusions: Further research is needed to evaluate the potential impact on sibling adjustment after pediatric TBI.

Cutter NC, Scott DD, Johnson JC, Whiteneck G. Gabapentin effect on spasticity in multiple sclerosis: a placebo-controlled, randomized trial. Arch Phys Med Rehabil 2000;81:164-9. Objective: To investigate the effect of gabapentin on subject self-report and physician-administered spasticity scales in individuals with multiple sclerosis. Design: Prospective, double-masked, placebo-controlled, crossover design. Setting: The Multiple Sclerosis Center at the Denver Veterans Affairs Medical Center. Intervention: Subjects were titrated to either 900mg gabapentin orally three times a day or placebo over a 6-day period. Subjects underwent a 14-day washout and then were crossed over. No other changes were made to their medication regimen. Main Outcome Measures: The outcome measures were divided into two categories: subject self-report scales physician-administered scales. Subject self-report scales included the spasm frequency scale, spasm severity scale, interference with function scale, painful spasm scale, and global assessment scale. Physician-administered scales included the Modified Ashworth Scale, clonus scale, deep tendon reflexes, plantar stimulation response, and the Kurtzke Expanded Disability Status (EDSS) Scale. Digit Span and Digit Symbol subtests of the WAIS-R Intelligence Scale were administered to assess for possible impaired concentration. The Fatigue Impact Scale was administered to assess for changes in fatigue. The adjective generation technique was administered to assess for alterations in mood. Results: A statistically significant reduction in the impairment of spasticity was found in the gabapentin-treated subjects compared with placebo as measured by the self-report scales of the spasm severity scale, interference with function scale, painful spasm scale, and global assessment scale and by the physician-administered scales of the Modified Ashworth and plantar stimulation response. No significant difference was noted in the Digit Span, Digit Symbol, adjective generation technique, and EDSS. Conclusion: Gabapentin reduces the impairment of spasticity, compared with placebo, without the side effects of worsening concentration and fatigue. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Objective— To describe a technique for closed reduction and percutaneous insertion of a lag screw for fixation of sacroiliac fracture-luxations, and to report the success of this technique in stabilizing sacroiliac fracture-luxations. Study Design— A retrospective clinical study. Study Population— 13 consecutive client-owned dogs with sacroiliac fracture-luxations. Methods— Sacroiliac fracture-luxations were stabilized by using a closed reduction and percutaneous lag screw fixation technique. Preoperative, postoperative, and last re-examination radiographs were used to assess the location and number of pelvic injuries, other orthopedic injuries, percent reduction of the sacroiliac joint, percent sacral width screw depth, position of the screw, pelvic canal diameter ratio, hemipelvic canal width ratio, and complications. Information on signalment, weight, weight-bearing status, neurologic status, and complications was obtained from the medical record. Results— Mean percent reduction of the sacroiliac joint was 92.33%. All screws were placed within the sacral body with a mean screw depth/sacral width of 79.03%. No screw loosening occurred. Mean pelvic canal diameter ratios were 0.99, 1.20, and 1.14 preoperatively, immediately postoperatively, and at the last re-examination, respectively. Nine of 13 dogs were willing to walk on the ipsilateral rear leg the day after surgery. Conclusions— Closed reduction and percutaneous insertion of a lag screw for stabilization of fracture-luxation of the sacroiliac joint is an acceptable method of repair. Clinical Relevance— Sacroiliac fracture-luxations can be successfully reduced and stabilized using a minimally invasive technique.

Objective. To compare the effectiveness of biofeedback/relaxation, exercise, and a combined program for the treatment of fibromyalgia. Methods. Subjects (n = 119) were randomly assigned to one of 4 groups: 1) biofeedback/relaxation training, 2) exercise training, 3) a combination treatment, or 4) an educational/attention control program. Results. All 3 treatment groups produced improvements in self-efficacy for function relative to the control condition. In addition, all treatment groups were significantly different from the control group on tender point index scores, reflecting a modest deterioration by the attention control group rather than improvements by the treatment groups. The exercise and combination groups also resulted in modest improvements on a physical activity measure. The combination group best maintained benefits across the 2-year period. Conclusion. This study demonstrates that these 3 treatment interventions result in improved self-efficacy for physical function which was best maintained by the combination group.

Objective. Research in the areas of pediatric rheumatology and pediatric chronic illness has emphasized comprehensive models of adaptation involving risk and resistance factors. This study examined adaptation, within this framework, among a large sample of children with chronic illness and children without chronic illness. Methods. A comprehensive battery of adaptation measures was administered to a sample of 107 children with juvenile rheumatoid arthritis, 114 children with insulin-dependent diabetes mellitus, and 88 healthy controls. Results. Medical diagnosis was associated with mothers' depression and a composite measure of parental (mother and father) distress and passive coping. Children's emotional and behavioral functioning was not related to medical diagnosis, but mothers' depression and parental distress were associated with child behavior problems. Conclusion. Because parental distress was associated with child functioning, interventions to ameliorate parental distress may have beneficial effects on the children's behavior and on parents' reactions to their children.

Twenty-seven dogs with naturally occurring mast cell tumors were treated with weekly i.v. injections of vincristine (0.75 mg/m2) for 4 treatments. Two dogs (7%) had a partial response. Nine dogs (32%) had treatment stopped prematurely because of toxicity or a perceived deterioration in their quality of life. We conclude that vincristine is ineffective as a sole treatment for measurable mast cell tumors in dogs and produces an undesirable number of adverse reactions.

Client-owned puppies randomly were assigned to receive one of two commercially available polyvalent vaccines. The response to the parvovirus portion of each vaccine was evaluated by determining antibody titers by hemagglutination inhibition. Significant differences were found between titers produced by the vaccines. Puppies vaccinated with one of the products had a more desirable result as demonstrated by a protective antibody titer after the first vaccination (p of 0.005), a protective antibody titer at a younger age (p of 0.02), a protective antibody titer by 12 weeks of age (p of 0.001), and a protective antibody titer by 16 weeks of age (p of 0.05). Puppies vaccinated with this product also had significantly higher titers at each sampling after vaccination.

Elderly nursing home residents are generally in poor health. Many residents report pain on a daily basis, few are independent in their activities of daily living, and most take a large number of medications.To investigate the benefits elderly nursing home residents may receive from preventative osteopathic manipulative treatment (OMT) designed to optimize structure and function and enhance their bodies' homeostatic mechanisms.Volunteer nursing home residents were randomly assigned to 1 of 3 groups: (1) OMT, (2) light touch (LT), or (3) treatment as usual (TAU). The OMT group received an OMT protocol twice per month for 5 months, for a total of 10 visits. The LT group received a light-touch protocol meant to simulate OMT at the same frequency as the OMT group. The TAU group received no intervention. Participant health information from Minimum Data Set assessments was monitored during the study, along with hospitalizations, emergency room visits, and outpatient procedures. The nursing home personnel and the participants' attending physicians were blinded to treatment group assignment.Twenty-one participants completed the study: 8 in the OMT group, 6 in the LT group, and 7 in the TAU group. The OMT and LT groups had fewer hospitalizations (P=.04) and decreased medication usage (P=.001) compared with the TAU group.Twice monthly OMT and LT protocols reduced the number of hospitalizations and decreased medication usage in elderly nursing home residents.

The names of certain counterstrain tender points are incongruent with their physical locations because of an assumption that these points are reflective of dysfunction in neighboring body areas. Because the body area that is physically examined does not always match the body region in which somatic dysfunction is diagnosed for these tender points, it is not always clear which evaluation and management service codes should be used for billing physician services.To assess the attitudes of osteopathic physicians toward the billing and coding of incongruent counterstrain tender points.Physician members of the American Academy of Osteopathy who use counterstrain in clinical practice were surveyed regarding the body area that they would physically examine when assessing for incongruent tender points and, if tender points were present, the body regions to which they would assign somatic dysfunction for billing and coding purposes. Physician responses were categorized as indicating a structural approach (ie, reflective of anatomic location) or a functional approach (ie, reflective of dysfunction in neighboring body areas) to tender point examination and treatment. Associations between sex, specialty, and years in practice with the approach chosen were also examined.Of 175 physicians who responded to the survey, 156 met the study criteria. Respondents were primarily board-certified in neuromusculoskeletal medicine/osteopathic manipulative medicine (98 [63%]), special proficiency in osteopathic manipulative medicine (30 [19%]), or family practice/family practice and osteopathic manipulative treatment (94 [60%]). Ninety percent of physicians predominantly chose responses indicating a structural approach to the physical examination of tender points and 21% predominantly chose responses indicating a functional approach to somatic dysfunction diagnosis. There were inconsistencies among individual respondents regarding the type of approach chosen for a single tender point. For certain tender points, differences were seen for approach between men and women, specialty, and years in practice.Our survey respondents had clear differences in opinion regarding physical examination location and somatic dysfunction diagnosis for incongruent tender points. These results suggest inconsistency among physicians in determining the physical examination component of evaluation and management services and the International Classification of Disease, Ninth Revision, or ICD-9, diagnostic codes in the assessment of these incongruent tender points.

Identifying objective measures that correlate with somatic dysfunction palpatory findings will aid in establishing clinical relevance of the findings and provide outcome measures for future studies.To investigate the association of altered segmental lumbar vertebral mechanics (ie, somatic dysfunction) as assessed by palpation with bone mineral density (BMD) T-score variability in participants, some with chronic low back pain (CLBP) and others without low back pain (LBP).Individuals with CLBP and individuals without LBP were examined by 2 blinded examiners for the presence or absence of paraspinal tissue texture abnormalities, vertebral rotational asymmetry, anterior motion restriction, and tenderness from L1 to L4. All participants then received a dual-energy x-ray absorptiometry scan of the lumbar spine. Bone mineral density T scores were compared between the CLBP and non-LBP groups.Sixty-three individuals (16 CLBP, 47 non-LBP) participated in the study. Lumbar segments with perceivable rotational asymmetry had higher mean BMD T scores (95% confidence interval [95% CI]) than lumbar segments with no asymmetry (0.5 [0.4-0.7] vs -0.2 [-0.6 to 0.2], respectively; P=.002). Additionally, lumbar segments with anterior motion restriction had higher mean BMD T scores (95% CI) than lumbar segments with no motion restriction (0.6 [0.4-0.7] vs 0.1 [-0.2 to 0.3], respectively; P=.03). Participants with CLBP demonstrated higher regional mean lumbar BMD T scores (95% CI) than those without CLBP (0.9 [0.6-1.1] vs 0.3 [0.2-0.5], respectively; P.001). After accounting for sex and body mass index, vertebral segments with rotational asymmetry (in non-LBP participants only) and vertebral segments with motion restriction had higher mean BMD T scores than vertebral segments with no asymmetry or motion restriction.Participants with CLBP had significantly higher lumbar BMD than participants without LBP. The presence of rotational asymmetry or motion restriction was associated with elevated BMD at the affected vertebrae.

Objective Accurate localization of vertebral segments is crucial for many treatment procedures. The objective of this study was to determine accuracy of identification of lumbar spinous process levels by palpation. Methods Three examiners independently identified the spinous processes of L1-L4 on 60 prone volunteers using multiple bony landmarks including the sacral base, L5, Tuffier's line, T12, and the 12th ribs. The spinous processes were marked with radiopaque skin markers. Location of marker placement and presence of anatomical anomalies were determined by posteroanterior lumbar radiographs. Accuracy of marker placement and interobserver reliability were assessed using weighted κ values. Generalized linear mixed models and Cochran-Mantel-Haenszel tests assessed the relationship of accuracy to training level, presence of anatomical anomalies, and participant characteristics. Results Examiners identified a spinous process in 91% of vertebral assessments. Correct identification of vertebral level occurred 69% of the time ( κ = 0.81; 95% confidence interval, 0.79-0.83). Faculty examiners were significantly more accurate in identifying the correct vertebral level than the resident examiner (67%-78% vs 51%, P ≤ .03). The presence of 12th rib anomalies decreased accuracy for all examiners ( P ≤ .05), reducing accuracy from 74% to 55%. Accuracy was higher in male participants than in female participants ( P = .01). Obesity significantly decreased accuracy ( P = .0003) at L3 (50% vs 73%) and L4 (44% vs 72%). Conclusions Identification of lumbar spinous processes using multiple landmarks was more accurate than previously reported values. However, accuracy was dependent on examiner experience, presence of anatomical anomalies, and participant characteristics.

Few studies have shown that diagnostic palpation is reliable. No studies have shown that the reliability of diagnostic palpatory skills can be maintained and improved over time.To investigate whether the reliability of selected palpatory tests used to identify lumbar somatic dysfunction was maintained during a 4-month period as part of a clinical observational study.Participants with low back pain and participants without low back pain, recruited from a rural Midwestern community, were examined during 6 separate sessions over a 4-month period. During each data collection session, two blinded examiners, who had previously completed comprehensive consensus training, evaluated the lumbar region with four tests: static segmental positional asymmetry of the transverse processes in the horizontal plane, tissue texture abnormalities, resistance to anterior springing on the spinous processes, and tenderness induced by pressure on the spinous processes. Detailed protocols for each test were defined during a previous comprehensive consensus training period and were not revised during the current study. To verify that established interobserver reliability was maintained throughout the clinical study, quality control sampling was performed on all data. When findings were inconsistent between the two examiners, focused consensus training was performed as a means of recalibration to understand why assessments were inconsistent. Interobserver reliability for determining the presence or absence of somatic dysfunction was assessed using kappa coefficients.The study enrolled 64 participants, and 14 to 33 participants were examined per session. All four tests had acceptable interobserver reliability by the final data collection session. The test for static segmental positional asymmetry of the transverse processes in the horizontal plane had moderate to substantial reliability in all 6 sessions. The test for tissue texture abnormalities had moderate reliability in 5 of the 6 sessions. The test for resistance to anterior springing on the spinous processes had moderate reliability for 3 of the 6 sessions. The test for tenderness had substantial to almost perfect reliability for all 6 sessions. In general, interobserver reliability improved over time.Examiners were able to maintain and improve interobserver reliability of four lumbar diagnostic palpatory tests over a 4-month period.

Few studies of inter- or intraobserver reliability have focused on evaluations of cranial strain patterns.To determine whether substantial intraobserver reliability can be achieved by osteopathic physicians (DOs) using common palpatory tests to diagnose cranial dysfunction.Forty-eight subjects were divided into three diagnostic groups, categorized as those with asthma, headaches, or neither asthma nor headaches (ie, healthy control group). Two blinded DO examiners separately evaluated approximately 8 subjects from each group (4 subjects per session), conducting diagnostic tests for cranial rhythmic impulse (CRI) rate, cranial strain patterns, and quadrants of restriction.Overall, among the three diagnostic procedures, cranial strain patterns showed the highest intraobserver reliability (kappa=0.67). The highest intraobserver reliability was achieved in cranial strain patterns for the control group (kappa=0.82), followed by the headache (kappa=0.67) and asthma (kappa=0.52) groups. Diagnoses of the left anterior quadrant of restriction also showed substantial intraobserver reliability for the headache and control groups (kappa=0.60 and 0.61, respectively). Diagnoses of three quadrants of restriction showed moderate overall intraobserver reliability (kappa=0.44-0.52), while the left posterior quadrant had only fair overall intraobserver reliability (kappa=0.33).Osteopathic physicians can obtain substantial intraobserver reliability when diagnosing cranial strain patterns in healthy subjects as well as those with asthma or headache. However, results are less promising for diagnoses of CRI and quadrants of restriction.

Patients with back pain make more than 14 million office visits per year to US physicians. Many of these patients have chronic low back pain (LBP) and are assumed to have more somatic dysfunction than those without chronic LBP.To investigate incidence and severity of somatic dysfunction of four lumbar vertebral segments (L1-L4).Sixteen subjects with chronic LBP and 47 subjects without chronic LBP were each evaluated by two blinded examiners using reliable osteopathic palpatory tests. The incidence and severity of somatic dysfunction for each test were then analyzed within and between the study groups.Resistance to anterior springing (P.001) and tenderness (P=.002) were found at significantly greater incidence in the chronic LBP group than in the non-LBP group, but there were no significant differences between groups for incidence of tissue texture changes or static rotational asymmetry. Significantly greater severity of tissue texture changes (P=.006), static rotational asymmetry (P=.008), resistance to anterior springing (P.001), and tenderness (P=.001) were observed in the chronic LBP group than in the non-LBP group.When compared with non-LBP subjects, chronic LBP subjects had overall greater severity for each of the four elements of somatic dysfunction evaluated, as well as greater incidence of resistance to anterior springing and tenderness. Somatic dysfunction is more severe in individuals with chronic LBP than in individuals without chronic LBP.

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.To investigate the immediate effect of OMT on pulmonary function parameters in elderly subjects with chronic obstructive pulmonary disease.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.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.Results suggest an overall worsening of air trapping during the 30 minutes immediately following one multitechnique OMT session relative to the sham group.

Underlying mechanisms explaining the effects of osteopathic manipulative treatment (OMT) are poorly defined. The authors evaluate various nociceptive (pain) biomarkers that have been suggested as important mediators in this process.To determine if OMT influences levels of circulatory pain biomarkers.In a prospective, blinded assessment, blood was collected from 20 subjects (10 with chronic low back pain [LBP], 10 controls without chronic LBP) for 5 consecutive days. On day 4, OMT was administered to subjects 1 hour before blood collection. Blood was analyzed for levels of beta-endorphin (betaE), serotonin (5-hydroxytryptamine [5-HT]), 5-hydroxyindoleacetic acid (5-HIAA), anandamide (arachidonoylethanolamide [AEA]), and N-palmitoylethanolamide (PEA). A daily questionnaire was used to monitor confounding factors, including pain and stress levels, sleep patterns, and substance use.Increases from baseline in betaE and PEA levels and a decrease in AEA levels occurred immediately posttreatment. At 24 hours posttreatment, similar biomarker changes from baseline were observed. A decrease in stress occurred from baseline to day 5. The change in PEA from baseline to 24 hours posttreatment correlated with the corresponding changes in stress. Subgroup analysis showed that subjects with chronic LBP had significantly reduced 5-HIAA levels at 30 minutes posttreatment (P=.05) and 5-HT levels at 24 hours posttreatment (P=.02) when compared with baseline concentrations. The increase in PEA in subjects with chronic LBP at 30 minutes posttreatment was two times greater than the increase in control subjects.Concentrations of several circulatory pain biomarkers were altered after OMT. The degree and duration of these changes were greater in subjects with chronic LBP than in control subjects without the disorder.

Establishing reliable palpatory tests continues to be a critical, yet elusive, step in osteopathic medical research and evidence-based clinical practice.The authors investigated the interobserver reliability of common osteopathic palpatory tests used to evaluate the lumbar spine.Subjects (N=119) were recruited from the faculty, staff, and students of Kirksville (MO) College of Osteopathic Medicine (KCOM) of A.T. Still University of Health Sciences. Three osteopathic medical examiners residency trained in neuromusculoskeletal medicine initially evaluated lumbar segments on subjects from one subgroup (n=42) in a blinded assessment. The examiners performed palpatory tests of tenderness and tissue texture changes, as well as--in three planes--vertebral positional asymmetry and motion asymmetry. Kappa statistics (kappa) were used to evaluate interobserver reliability. Following a period of consensus training, subjects from another subgroup (n=77) were evaluated in a blinded assessment for those palpatory tests that seemed most likely to produce reliable findings. The interobserver reliability was then re-evaluated.During the initial evaluation of interobserver reliability, kappa ranged from -0.02 to 0.34, within the poor-to-fair reliability range. Following consensus training, reliability improved, rising into the moderate range for tissue texture changes (kappa=0.45) and into the substantial range for tenderness assessments (kappa=0.68). Reliability for positional asymmetry in the transverse plane (kappa=0.34) and rotational motion asymmetry (kappa=0.20) were improved but remained in the fair range.The authors concluded that consensus training improved the interobserver reliability of common osteopathic palpatory tests of the lumbar spine. In two of the four tests that were studied--tissue texture and tenderness--acceptable kappa values for clinical tests were achieved after consensus training.

Delta-9-tetrahydrocannabinol (delta-9-THC) prevents cisplatin-induced emesis via cannabinoid CB(1) receptors. Whether central and/or peripheral cannabinoid CB(1) receptors account for the antiemetic action(s) of delta-9-THC remains to be investigated. The 5-hydroxytryptamine (5-HT=serotonin) precursor, 5-hydroxytryptophan (5-HTP), is an indirect 5-HT agonist and simultaneously produces the head-twitch response (a centrally mediated serotonin 5-HT(2A) receptor-induced behavior) and emesis (a serotonin 5-HT(3) receptor-induced response, mediated by both peripheral and central mechanisms) in the least shrew (Cryptotis parva). The peripheral amino acid decarboxylase inhibitor, carbidopa, prevents the conversion of 5-HTP to 5-HT in the periphery and elevates 5-HTP levels in the central nervous system (CNS). When administered i.p. alone, a 50 mg/kg dose of 5-HTP failed to induce either behaviour while its 100 mg/kg dose produced robust frequencies of both head-twitch response and emesis. Pretreatment with carbidopa (0, 10, 20 and 40 mg/kg) potentiated the ability of both doses of 5-HTP to produce the head-twitch response in a dose-dependent but bell-shaped manner, with maximal potentiation occurring at 20 mg/kg carbidopa. Carbidopa dose-dependently reduced the frequency of 5-HTP (100 mg/kg)-induced emesis, whereas the 10 mg/kg dose potentiated, and the 20 and 40 mg/kg doses suppressed the frequency of vomits produced by the 50 mg/kg dose of 5-HTP. The peripheral and/or central antiemetic action(s) of delta-9-THC (0, 1, 2.5, 5, 10 and 20 mg/kg) against 5-HTP (100 mg/kg)-induced head-twitch response and emesis were investigated in different groups of carbidopa (0, 10 and 20 mg/kg) pretreated shrews. Irrespective of carbidopa treatment, delta-9-THC attenuated the frequency of 5-HTP-induced head-twitch response in a dose-dependent manner with similar ID(50) values. Although delta-9-THC also reduced the frequency of 5-HTP-induced emesis with similar ID(50s), at the 5 mg/kg delta-9-THC dose however, 5-HTP induced significantly less vomits in the 10 and 20 mg/kg carbidopa-treated groups relative to its 0 mg/kg control group. Moreover, increasing doses of carbidopa significantly shifted the inhibitory dose-response effect of delta-9-THC in protecting shrews from 5-HTP-induced emesis to the left. Relatively, a large dose of delta-9-THC (20 mg/kg) was required to significantly reduce the number of vomits produced by direct acting serotonergic 5-HT(3) receptor agonists, serotonin and 2-methylserotonin. Low doses of delta-9-THC (0.1-1 mg/kg) nearly completely prevented 2-methylserotonin-induced, centrally mediated, head-twitch and ear-scratch responses. The results indicate that delta-9-THC probably acts pre- and postsynaptically to attenuate emesis produced by indirect and direct acting 5-HT(3) receptor agonists via both central and peripheral mechanisms. In addition, delta-9-THC prevents 5-HTP-induced head-twitch and emesis via cannabinoid CB(1) receptors since the CB(1) receptor antagonist, SR 141716A [N-piperidino-5-(4-chlorophenyl)-1-(2,4-dichlorophenyl)-4-methylpyrazole-3-carboxamide], countered the inhibitory actions of an effective dose of delta-9-THC against both behaviours.

From the Brody School of Medicine/ East Carolina University, Greenville, North Carolina (JBW, DPM); the Missouri Arthritis Rehabilitation Research and Training Center, Harry S. Truman Memorial Veterans Hospital, Columbia, Missouri (JCP); and the Kirksville College of Osteopathic Medicine, Kirksville, MO Objective: To investigate the research activity and perspectives, and the predictors and barriers to research activity, in a cohort of individuals completing a research enrichment program for physiatrists. Design: A retrospective cohort study design was utilized. Data collection was accomplished with a mailed survey, which was sent to 68 individuals who had completed the Research Enrichment Program for Physiatrists between 1991 and 1998. Data analysis was performed using both descriptive and inferential statistical methods. Results: Eighty-five percent (58 of 68) of surveys were completed and returned. The majority of respondents were in academic-based practice (83%) at the assistant professor level (59%). Sixty-nine percent of the group reported spending no time in research, and 64% reported having no protected time for research. The mean number of peer-reviewed journal publications was 2.4, and the average number of research grants was 1.6, with 57% of the cohort reporting no grant funding. Departmental PhD, statistical, and secretarial support for research were all noted to be inadequate or not available for >50% of the cohort. High demand for clinical productivity, lack of protected research time, and lack of research funding were all identified as major barriers to research activity. Cluster analysis found greater research time and support to be associated with measures of research productivity. Conclusion: Long-term research success seems to require ongoing support, funding, and mentorship at the departmental and institutional level. Despite adequate training and motivation for research, research support was perceived as inadequate for many Research Enrichment Program graduates.

The research objectives of this study were to evaluate the effects of osteopathic manipulative treatment (OMT) combined with maximal-effort exercise (MEE) on strength, coordination, endurance, and fatigue in female patients with multiple sclerosis (MS). Seven female subjects with MS participated in the 12-week study, which included intervention with OMT and MEE twice per week. Standardized tests for progression of MS and fatigue were used. Strength (maximal effort and impulse) was measured with the IsoPump exercise machine (IsoPump USA, Cleveland, Miss) during the three phases of the exercise protocol. Significant changes occurred in all but one measure of strength and on the 25-foot walk (P.05), but not on the block-and-box test. The change in fatigue scores was not significantly different. Findings indicate that OMT combined with MEE significantly increases strength and ambulatory levels while not increasing fatigue in female patients with MS who have low to medium impairment. Qualitative data show that this intervention also produces beneficial effects in activities of daily living.

Clinically ill feline leukemia virus (FeLV)-infected cats, treated with Staphylococcus protein A (SPA) or oral interferon alpha (IFN), or both, were compared with cats treated with saline (SAL). Nine cats received SPA/SAL, nine received SPA/IFN, 10 received SAL/IFN, and eight received SAL/SAL. Twelve cats survived and completed the 100-week therapy. Significantly more owners of cats treated with SPA/SAL thought their cat's health improved during treatment compared to owners of cats treated with SAL/SAL (P=0.05, pair-wise comparison) or SPA/IFN (P=0.05, pair-wise comparison). No significant differences in body weight, temperature, hematocrit, red blood cell counts, mean corpuscular hemoglobin concentration, reticulocyte counts, white blood cell or neutrophil numbers, lymphocyte concentrations, bone-marrow cytopathology, FeLV status, survival time, activity, or appetite scores were observed. No significant differences in the owners' subjective assessment of their cat's health following treatment with SAL/IFN, SPA/IFN, or SAL/SAL were seen. Therapy with SPA as a single agent results in the owners' subjective impression of improved health of their FeLV-infected cats.

Newcomer K, Laskowski ER, Yu B, Johnson JC, An K-N. The effects of a lumbar support on repositioning error in subjects with low back pain. Arch Phys Med Rehabil 2001;82:906-10. Objective: To determine whether a lumbar support improves trunk repositioning error (RE), an aspect of proprioception. Design: RE was measured with and without a lumbar support. Setting: Outpatient clinic. Participants: Twenty subjects with chronic low back pain (LBP) and 20 control subjects. Interventions: Subjects wore the lumbar support for 2 hours and then testing was repeated. Main Outcome Measures: Standing with legs and pelvis immobilized, subjects moved to a predetermined target position and then attempted to replicate the position. The 3-dimensional position of the trunk was measured with a 3Space Tracker. RE was calculated as the absolute difference between the actual target position and the subject-perceived target position. Testing was performed with and without a lumbar support both before and after wearing the support for 2 hours. Results: In subjects with LBP, RE was significantly lower with a support in flexion, extension, and right lateral bending. In control subjects, RE was significantly lower when wearing the support in left bending only, and RE was significantly higher in control subjects after wearing the support for 2 hours. Conclusion: A lumbar support improves trunk RE. In subjects with LBP, this result was significant in the sagittal plane and in right lateral bending, whereas in control subjects, it was significant only in left lateral bending. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Study design Trunk repositioning error was measured in 20 patients with chronic low back pain and 20 control subjects. Objectives To measure trunk repositioning error as a method of measuring proprioception of the low back and to compare trunk repositioning error in patients with low back pain and in control subjects. Summary of background data Although many current low back pain rehabilitation programs incorporate proprioceptive training, very little research has been performed on proprioception of the low back. Methods While standing with the legs and pelvis immobilized, the subject bent the trunk to a predetermined target position and then attempted to replicate the position. Repositioning error was calculated as the absolute difference between the actual target position and the subject-perceived target position. The multiple target positions in the frontal and sagittal planes were tested. Trunk position was measured with a 3Space Tracker, which analyzes the three-dimensional position of the body. Results Repositioning error in patients with low back pain was significantly higher than that of control subjects in flexion, and significantly lower than that of control subjects in extension. Conclusions The increase in repositioning error of patients with low back pain during flexion implies that some aspects of proprioception are lost in patients with low back pain. The decrease in repositioning error in patients with low back pain in extension is not as easily explained, but could possibly be caused by increased activation of mechanoreceptors in facet joints.

The purpose of this study was to investigate the usefulness of the state traffic violations database as an outcome measure for the Young Traffic Offenders Programme, a 1-day educational injury prevention programme for young people with speeding offences. The database provided a fine-grained, cumulative record of each driver's traffic offences and sanctions applied. A comparison of 92 programme participants and 87 non-treated individuals showed no significant between-group difference in rate of convictions after the target programme date, but each group declined significantly in rate of convictions over time. Younger males and individuals with a higher number of convictions initially were more likely to have higher conviction rates after the target date. These findings underscore the need to improve prevention programmes and highlight the potential usefulness of existing public datasets for outcome evaluation.

Lead has been reported to be an immunosuppressive agent in animal systems at levels far below those recognized as overtly toxic. Little data exist on lead’s effects on the human immune system, especially in young children who are at greatest risk for exposure to this environmental hazard. The effects of environmental lead exposure on the human immune system were examined in a population of young children, age 9 months–6 years, from the urban population of Springfield–Greene County, Missouri. Reported here are data from 279 children with blood lead levels ranging from 1 to 45 μg/dl. White blood cell populations have been enumerated and examined for cell–surface expression of activation markers. Serum has been analyzed for IgE, specific titers to Rubella vaccine, sCD25 (the soluble form of the IL2 receptor), sCD27 (the soluble form of the lymphocyte specific member of the tumor necrosis factor receptor family), and IL4 (the cytokine interleukin 4). Variation of these assays with age of the child was considered in statistical analysis of data. A statistically significant relationship of IgE and blood lead level was found in this population; as blood lead (PbB) level increases, IgE level increases. No other statistically significant differences between risk categories or other associations with blood lead level were found. The exact mechanism for this apparent stimulus of IgE-producing B cells remains to be elucidated. The development of allergic symptoms is often preceded by an increase in IgE. These data indicate that ingested lead could play a role in this process by stimulating IgE production.

We examined a number of patient variables, including three different scales of preprocedure patient anxiety, to determine which best predicted patient cooperation and satisfaction with gastrointestinal endoscopy. We prospectively evaluated 251 patients undergoing outpatient diagnostic esophagogastroduodenoscopy and colonoscopy under conscious sedation. All were given a questionnaire on arrival to our endoscopy center that included three measures of preprocedure anxiety: (a) a single question asking how anxious the patient was (termed "Anxiety I" scale); (b) a visual linear analog scale of anxiety; and (c) the Hospital Anxiety and Depression scale. Patient cooperation during the procedure was rated by the attending endoscopist. Patients were telephoned the next day to complete a questionnaire assessing their endoscopic experience. Logistic regression analysis was used to construct models for predicting which patients were most likely to have difficulty during their procedures from both the endoscopists' and the patients' standpoint. Statistical analysis identified three parameters that by themselves significantly correlated with patient cooperation during endoscopy: age (p = 0.008), Anxiety I scale (p = 0.03), and visual linear analog anxiety score (p = 0.02). When used together, age, type of procedure, and Anxiety I scale were the best predictors of patient cooperation from the standpoint of the endoscopist. Age, type of procedure, Anxiety I scale, and education level were the best predictors of satisfaction with endoscopy from the perspective of the patient. Good cooperation during endoscopy was associated with greater patient satisfaction.

Objective. Family resources and coping skills are important to adaptation to pediatric chronic illness. Psychological and educational interventions have been found to enhance the coping skills of children with juvenile rheumatic disease (JRD) and their families. We examined the efficacy of a 3-day family retreat as a multidisciplinary, comprehensive treatment. Methods. Children with JRD and their caregivers completed questionnaires assessing the children's behavioral and emotional functioning, pain, strain on caregivers' work and leisure activities, and caregivers' psychological distress before and 6 months after the family retreat. Principal caregivers were both parents for 16 children, mothers only for 10 children, and an aunt for 1 child. Results. Improvements were found in children's emotional functioning, strain on caregivers' work, and strain on caregivers' leisure activities. Reductions in reported pain were not consistently revealed. Conclusions. Family retreats are an efficacious, multidisciplinary approach to helping families of children with JRD cope with the disease and its manifestations. Importantly, retreats offer a comprehensive intervention package that might not be available to families on an individual basis.

Objective. To examine the effects of stress-management training on clinical outcomes in persons with rheumatoid arthritis (RA). Methods. Patients with RA (n = 141) were randomly assigned to 1 of 3 groups: a stress management group, an attention control group, or a standard care control group. The stress management and the attention control groups received a 10-w eek intervention followed by an additional 15-m onth maintenance phase. Results. The stress management group showed statistically significant improvements on measures of helplessness, self-efficacy, coping, pain, and health status. Selected beneficial effects were still detectable at the 15-m onth followup evaluation. Conclusion. The data indicated that stress management interventions are capable of producing important clinical benefits for persons with RA.

Purpose. The purpose of this study was to examine the effects of self-efficacy on self-report pain and physical activities among subjects with fibromyalgia (FM). In addition, descriptive statistics of the Arthritis Impact Measurement Scale (AIMS), a measure developed for use with arthritis patients, were reported. Methods. Seventy-nine subjects with FM, as classified by the American College of Rheumatology (ACR) criteria, completed the Visual Analogue Scale for Pain, the AIMS, and the Arthritis Self-Efficacy Scale. A myalgic score was obtained during a tender point evaluation. Hierarchical multiple regression analyses were used to assess the effect of self-efficacy on self-report pain and physical activities measures after controlling for demographic variables (age, education, and symptom duration), disease severity (myalgic scores), and psychological distress (negative affect from the AIMS). Results. Higher self-efficacy was associated with less pain and less impairment on the physical activities measure after controlling for demographic and disease severity measures. Conclusions. This study underscores the unique importance of self-efficacy in understanding pain and physical activities impairment.

Objective. To determine if neurologic impairment is related to progressive autoimmune disease in 3 murine models of systemic lupus erythematosus (SLE): MRL/lpr, NZB, and NZB/WF1 Methods. Sensorimotor function, learning, and memory were tested within strains at specific ages, before and after the appearance of SLE. These parameters were also compared between strains for young and older lupus mice and their congenic controls with reduced autoimmune disease (MRL/lpr versus MRL/+; NZB versus NZB/xid). Results. Abnormal neurologic features were present at a much higher frequency in MRL/lpr mice than in age-matched MRL/+ control mice, and sensorimotor function deficits were also seen in NZB/WF1 mice. Strains that develop lupus showed deficits on a water-escape, distal cue discrimination task and on a food-rewarded, proximal cue discrimination task, but the cognitive impairments were not global. Conclusion. MRL/lpr, NZB, and NZB/WF1 mice differed in terms of which behaviors were impaired as well as when those impairments appeared.

Anger expression styles are associated with psychological and physical well-being among adults. Little is known about the role of anger expression in children's functioning. This lack of knowledge has resulted, in part, from a lack of validated tools for anger expression measurement. The Pediatric Anger Expression Scale-3rd edition (PAES-III; Jacobs, Phelps, & Rohrs, 1989; Jacobs & Kronaizl, 1991) has been proposed as a reliable and valid assessment instrument of anger expression styles. The PAES-III includes three scales that measure anger turned inward, anger expressed outwardly, and anger controlled cognitively or behaviorally. We evaluated the psychometric properties of this instrument when it is administered verbally to children with juvenile rheumatoid arthritis, children with juvenile diabetes mellitus, and healthy children. Internal consistency was adequate for anger-in and anger-out, but marginal for anger-control. Concurrent validity was supported for the total sample. A principal components analysis suggested a four-factor model of anger expression. Overall, the PAES-III was found to have psychometric limitations. Use of a modified PAES-III may facilitate pediatric behavioral medicine research addressing risk factors for maladjustment among children with chronic illnesses.