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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)

Context Acute stress during medical school affects the health of students and is associated with burnout. The Medical Education Hassles Scale-R (MEHS-R) is designed to measure acute stress among medical students. Researchers using the MEHS-R primarily report overall hassles scores, which are unable to discriminate between different categories of hassles encountered. Objective The present study examined the factor structure of the MEHS-R to identify subscales that would be useful to categorize hassles for research and assessment purposes. Design Longitudinal, observational study. Setting Two osteopathic medical schools. Participants Five hundred six first-year medical students. Main Outcome Measure The MEHS-R was administered at orientation and 9 to 10 times throughout the first year, classified into examination, vacation, and routine medical school activity periods. Students rated the 101 items on a 4-point scale (0=none to 3=a great deal) to indicate how much of a hassle each item had been during the previous week. Demographic subgroups were males, females, married students, single students, whites, and ethnic minorities. Results Exploratory factor analysis was conducted on data collected at the first school during orientation. Seven subscales were identified: Academic and Time Pressures, Financial, Social, External Influences, Day-to-Day Functioning, Relationships With Immediate Family, and Health. Cronbach α were ≥0.75. Stability of these subscales was examined using confirmatory factor analysis. Both of the fit indices used indicated the 7-subscale model for the MEHS-R adequately fit the data obtained during examination and routine medical school activity periods, one fit index indicated adequate fit for the vacation period, and neither indicated adequate fit for the data from the second school. Of the 7 subscales, 5 had a strong correspondence with categories identified by the scale developers. Fit indices also indicated the 7-subscale model was adequately generalizable to the demographic subgroups with the exception of the ethnic minorities subgroup. Conclusions Exploratory factor analysis performed on the MEHS-R supported formation of subscales similar to categories identified during MEHS-R development. Results of the current study supported the use of the MEHS-R for the investigation of acute stress in medical students. In future research, targeted wellness interventions for medical students may be developed based on student responses to this instrument.

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.

Existing data indicate knee menisci in patients with osteoarthritis (OA) show tearing, maceration, and fragmentation, but little is known about the change in histological structure. The aim of this study was to evaluate the change in the menisci histological structure in patients with clinically diagnosed knee OA. Fourteen patients undergoing surgical treatment of knee OA (OA group) and 14 cadaveric knees (control group) were assessed. Demographic data, medical history, synovial fluid, OA severity, medial meniscus (MM) tissue, and lateral meniscus (LM) tissue were collected from the OA group. Three nonconsecutive 10 μm cross-sectional tissue slices of menisci were analyzed for percentage of tissue calcification. Exact Mann-Whitney tests and Spearman correlation coefficients tested for relationships between variables. The major change in the histological structure of the menisci in patients with OA was calcification of the matrix, which was significantly greater in the OA group compared with the control group for MM (OA: 11.9%, cadaver: 5.17%; P

Ultrasonography offers rapid, noninvasive imaging of internal anatomy for patient diagnosis, and future physicians should be competent in its use. Currently, there is no standard for assessing the sonographic skills of medical students. The purpose of the current study was to introduce ultrasound practical examinations as an innovative method of measuring the ultrasonography knowledge and proficiency of medical students. Student performance in the required ultrasound course for 3 consecutive classes of medical students was assessed by a practical examination graded by faculty and predoctoral fellows. Students were paired and instructed to find structures from a list of laboratory objectives chosen by an assigned grader. Collected data was evaluated retrospectively by analyzing grader performance and question difficulty. The class of 2018 was also given a survey to evaluate their perception of the practical examination. Overall, students performed well on the examination and liked the course and practical examination format. Significant differences were found among graders: faculty gave lower grades than predoctoral fellows, suggesting a need for standardization. Additional analysis suggested the differences between graders could be due to the laboratory objective chosen by the different graders. To eliminate grader bias and improve interrater reliability, random selection of ultrasound practical examination objectives for each student will be implemented for the class of 2020. These changes in the existing ultrasonography curriculum should improve the evaluation of student performance and student satisfaction, while providing a model for other medical education institutions to incorporate a proven ultrasound assessment method into their curricula.

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)

Most current dental ethics curricula use a deontological approach to biomedical and dental ethics that emphasizes adherence to duties and principles as properties that determine whether an act is ethical. But the actual ethical orientation of students is typically unknown. The purpose of the current study was to determine the ethical orientation of dental students in resolving clinical ethical dilemmas. First-year students from one school were invited to participate in an electronic survey that included eight vignettes featuring ethical conflicts common to the health care setting. The Multidimensional Ethics Scale was used to evaluate the students’ ethical judgments of these conflicts. Students rated each vignette along 13 ethically relevant items using a 7-point scale. Nine of the thirteen items were analyzed because they represent the dominant ethical theories, including deontology. One hundred sixteen dental students successfully completed the survey. Of the analyzed items, those associated with deontology had comparatively weak associations with whether students judged the action to be ethical and whether students judged themselves likely to perform the action. Whether an action was judged to be caring had the strongest association with whether the action was judged to be ethical and whether students judged themselves likely to perform the action. These results suggest that adherence to duties or principles has weaker association with students’ ethical judgments and behavior compared to caring, which was found to be more influential in their ethical judgments and behavior. Current dental school curricula with a primary focus on deontology may not adequately prepare students to maintain ethical attitudes and behavior in practice.

ObjectiveThis study retrospectively evaluated the effect of OMT on length of stay (LOS) in hospitalized posterolateral postthoracotomy patients.MethodsInpatient medical records of patients who received posterolateral thoracotomies with lung resection between 1998 and 2011 were reviewed for demographic data, LOS, thoracotomy surgery data, consultation data excluding osteopathic manipulative medicine, discharge data, and osteopathic manipulative medicine consultation data.ResultsThirty-eight patients received posterolateral thoracotomies with lung resection; 23 patients received OMT and 15 did not. The mean (standard deviation) LOS was 11.0 (6.8) days (range, 5–29 days) for those who received OMT and 10.4 (5.5) days (range, 3–22 days) for those who did not (P = .90). Five patients developed postoperative ileus, and all had received OMT. Patients receiving 2 surgical procedures had a longer LOS than those receiving 1 surgical procedure (P = .002). Having a decortication performed during the thoracotomy increased LOS by a mean of 6.4 days (P = .005). Patients admitted directly to the intensive care unit were more likely to receive OMT than those who were not (P = .03).ConclusionWhile there was no difference in LOS, severity of illness was different between patients who received OMT and those who did not. Patients who developed postoperative ileus and most of those admitted directly to the intensive care unit received OMT, suggesting that severity of illness was greater for those who received OMT. Future studies should include a higher subject number in order to stratify for illness severity and also assess the effect of OMT on postoperative pain.

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.

Ultrasound has been integrated into a gross anatomy course taught during the first year at an osteopathic medical school. A clinical ultrasound elective course was developed to continue ultrasound training during the second year of medical school. The purpose of this study was to evaluate the impact of this elective course on the understanding of normal anatomy by second-year students. An anatomy exam was administered to students enrolled in the clinical ultrasound elective course before the start of the course and after its conclusion. Wilcoxon signed ranks tests were used to determine whether exam scores changed from the pre-test to the post-test. Scores from two classes of second-year students were analyzed. Students who took the elective course showed significant improvement in the overall anatomy exam score between the pre-test and post-test (P < 0.001). Scores for exam questions pertaining to the heart, abdomen, upper extremity, and lower extremity also significantly improved from the pretest to post-test (P < 0.001), but scores for the neck and eye showed no significant improvement. The clinical ultrasound elective course offered during the second year of medical school provided students with an important review of key anatomical concepts while preparing them for board exams. Our results suggested that more emphasis should be placed on head and neck ultrasound to improve student performance in those areas. Musculoskeletal, abdominal, and heart ultrasound labs were more successful for retaining relevant anatomical information.

Context: Studies of burnout among allopathic physicians have shown many deleterious effects for both physicians and patients. To our knowledge, no studies have quantified burnout among osteopathic physicians. Objective: To determine the prevalence of burnout, mentoring, and resident training satisfaction among US osteopathic otolaryngology residents compared with previously published data for allopathic otolaryngology residents. Methods: A cross-sectional, questionnaire-based, electronic survey of US osteopathic otolaryngology residents was conducted. Residents were surveyed about demographic information, personal and professional life satisfaction, professional stressors, burnout (assessed with the Maslach Burnout Inventory–Human Services Survey), and mentor-resident interactions. Burnout was measured based on levels of emotional exhaustion (EE), depersonalization (DP), and low personal accomplishment (PA). Results were compared with previously published data for allopathic otolaryngology residents. Results: Of the 102 osteopathic residents contacted, 48 (47%) responded and 47 provided complete responses in some categories. Burnout rates were low in 11 respondents (23%), moderate in 31 (66%), and high in 5 (11%), compared with published rates of 14%, 76%, and 10%, respectively, for allopathic residents (P=.18). The rates of EE and DP did not differ significantly from published data, but levels of PA were higher in osteopathic residents (P=.03). Sleep hours per night were significantly higher in osteopathic than in allopathic residents (mean, 6.6 vs 6.2; P=.04), and work hours per week were significantly lower (mean, 62 vs 71; PP=.003). Increased influence from a mentor was associated with decreased levels of burnout for all 3 components (EE: ρ=−0.54, P=.002; DP: ρ=−0.59, PP=.02). Conclusion: To our knowledge, the current study is the first to quantify burnout among osteopathic residents, and our findings suggest that osteopathic residents have lower rates of burnout than allopathic residents. Osteopathic residents reported lower rates of low PA, increased hours of sleep, and decreased overall work hours. Further study of the relationship between mentoring and decreased burnout is needed.

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: Animal models can be used to investigate manual therapy mechanisms, but testing manipulation in animal models is problematic because animals cannot directly report their pain. Objective: To develop a rat model of inflammatory joint injury to test the efficacy of manual therapy in reducing nociception and restoring function. Methods: The authors induced acute inflammatory joint injury in rats by injecting carrageenan into the ankle and then measured voluntary running wheel activity in treated and untreated rats. Treatments included manual therapy applied to the ankle and knee of the injured limb and several analgesic medications (eg, morphine, ketorolac, prednisone). Results: Intra-articular injection of carrageenan to the ankle produced significant swelling (diameter of the ankle increased by 64% after injection; P=.004) and a robust reduction in voluntary running wheel activity (running distance reduced by 91% compared with controls; P Conclusion: Voluntary running wheel activity appears to be an appropriate functional measure to evaluate the impact of an acute inflammatory joint injury. However, efforts to treat the injury did not restore running relative to untreated rats.

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)

Background and Objectives Little is known concerning the preferences for technique selection by osteopaths in the United Kingdom (UK) for the treatment of spinal, pelvic and sacroiliac dysfunction or for the methods of documentation of dysfunction in case records. Part 1 described the perception of usefulness and reported use of physical assessment procedures. This second part surveys the treatment methods reported to be commonly used by UK osteopaths. Methods A web-based questionnaire using a 5-point Likert scale and open-ended responses was developed. Invitations were e-mailed to all registrants of the General Osteopathic Council in the UK with a listed e-mail address. The available response categories (strongly disagree, disagree, etc.) were converted into numerically weighted scales. Responses in the "frequently" and "nearly always" categories were combined for summary reporting purposes. Friedman tests were used to determine if significant differences existed for the reported usage of each item. The effect of gender was analysed using Mann–Whitney tests. The effect of years of practice was examined by categorizing practice experience by decade (0–9, 10–19, 20+) and analysing using Kruskal–Wallis tests. Results 520 Osteopaths (56% male, 44% female) participated in the survey, which was a 19% response rate. Procedures for the treatment of dysfunction of the spine reported to be most commonly used were passive joint articulation (91%) and soft tissue technique (91%), followed by prescription of patient self-stretches (76%) and high velocity low amplitude thrust (HVLA, 74%, p p Conclusion Survey respondent osteopaths in the UK use a large range of manual treatment techniques, with a preference for direct techniques, such as passive joint articulation, soft tissue technique, and HVLA. Females reported more frequent use of a number of procedures, which may represent a reporting bias, but male respondents reported more frequent use of HVLA.

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.

In 2000, a rural consortium of health care education and service providers established a geriatric mental health outreach program (ElderLynk) for the underserved elderly (aged 65 and older) in ten rural counties in northeast Missouri. ElderLynk evaluated the efficacy of an integrated community-based treatment model through the creation and evaluation of a clinical database. Ten rural counties in northeast Missouri were chosen because they were designated as mental health shortage areas (MHSAs) and because their elderly population approximates the projected level of elderly in the USA in 2020. All patients were managed by a geriatric nurse with treatment planning and oversight provided by a community-based interdisciplinary team which included a psychiatrist, geriatrician, psychologist, and social worker. Using the Geriatric Depression Scale (GDS); the Government Performance and Results Act data (GPRA) to assess life satisfaction, independence/autonomy, psychosocial functioning, and overall health; the Instrumental Activities of Daily Living (IADL); the Mini-Mental Status Examination (MMSE); and patterns of service usage (number of hours of case management and number of counseling sessions), ElderLynk patients improved significantly in overall psychological functioning, level of depression, and reported life satisfaction despite significant declines in mental status, daily function, and overall health.

Transient fluctuations in immune function after heavy exercise have been linked to an increased incidence of infection in athletes. Several parameters of immunity, including salivary immunoglobulin A (IgA), are affected by heavy exercise in the laboratory setting. However, few observations have been made during true competition. We tested the hypothesis that salivary IgA levels will be decreased after a collegiate rugby game. Saliva samples obtained from 16 men's college rugby players before and after an 80-minute regulation rugby game were analyzed for total volume, IgA, total protein content, and osmolality. Salivary IgA was expressed relative to secretion rate (s-IgA), osmolality (IgA-Osm), and total protein (IgA-Pro). No significant pregame-postgame changes in salivary IgA were observed (s-IgA: -13%, IgA-Osm: -16%, IgA-Pro: +10%). These data indicate that strenuous physical activity, such as a competitive rugby game, does not affect IgA levels. More study on the immune response to athletic competition is needed.

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: Improving the acquisition of osteopathic manipulative treatment (OMT) skills may increase student confidence and later use of OMT. A first step in this process is determining the optimal table trainer–to-student ratio (TTR). Objective: To determine the effect of TTR on knowledge and skill acquisition of cervical muscle energy OMT techniques in first-year osteopathic medical students. Methods: First-year students at 3 colleges of osteopathic medicine received instruction on cervical diagnosis and muscle energy techniques at 1 of 3 workshops, each having a different TTR (1:4, 1:8, or 1:16). Written assessments were conducted immediately before and after the workshop and again 2 weeks later to test retention of the knowledge acquired. Practical assessments were conducted immediately after the workshop and 2 weeks later to test retention of the skills acquired and were graded for technical and proficiency elements. Results: Ninety-two students completed pre- and postworkshop assessments, and 86 completed the retention assessment. No difference was found between TTRs on the preworkshop, postworkshop, and retention written scores (P≥.15). Postworkshop written assessment scores were highest, followed by retention scores; preworkshop scores were lowest (PP=.06). For the retention practical assessment scores, no significant difference was found between TTRs (P=.19). A significant interaction was noted between TTR and the timing of practical assessments; scores declined from postworkshop to retention assessments for the 1:4 (P=.04) and 1:8 (P=.02) TTR workshop groups but not the 1:16 TTR workshop groups (P=.21). Student order in paired student demonstrations also had a significant effect on technical scores (P≤.03); students who demonstrated techniques second had higher scores than those who demonstrated techniques first. Conclusion: The TRR had no significant effect on written or practical assessment scores. Practical assessment scores for the 1:4 and 1:8 TTRs declined significantly between postworkshop and retention assessments. Future studies with more statistical power will be necessary to determine the effect of TTRs on student learning. The current study also found that student order in paired demonstrations may affect practical assessment scores, because the second-demonstrating student scored higher than the first; colleges of osteopathic medicine should therefore consider randomizing student order during practical assessments.

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.

Background Castlio and Ferris-Swift conducted a series of experiments in the 1930s testing the scientific basis for using splenic pump manipulation to stimulate the immune system. Their work is still cited as evidence that the splenic pump technique is beneficial. However, they only reported case summaries of the data, indicating what percent of the cases increased or decreased relative to baseline and, therefore, limiting the certainty of their conclusions. To our knowledge, no one has published research confirming their findings. Objective Our hypothesis is that an updated analysis of the raw data will support the original conclusions that splenic pump manipulation does increase leukocyte counts, lower the erythrocyte counts, not change the leukocyte differentials, and increase the opsonic index. Methods Wilcoxon signed rank tests were used to determine whether there was a significant change in blood cell counts, leukocyte percent differentials, and the opsonic index following splenic pump manipulation. Using Mann–Whitney U -tests, the change from baseline in leukocyte and erythrocyte counts for the first 23 cases managed by an honorary fraternity were compared to the cases managed by Castlio and Ferris-Swift. P values ≤0.05 were considered significant. Results Consistent with Castlio and Ferris-Swift's original conclusions, there was a statistically significant rise in the mean leukocyte counts, a decrease in the mean erythrocyte counts, no change in the leukocyte differentials, and an increase in the opsonic index following splenic pump treatment. However, subgroup analysis shows that most of the mean increase in the leukocyte count came from the first 23 subjects processed by a fraternity. The erythrocyte counts were less affected by this variable while the differential and opsonic index tests were unaffected because Castlio and Ferris-Swift performed these. Discussion Statistical analysis of Castlio and Ferris-Swift's published raw data lends support to their original conclusions. However, subgroup analysis showed a distinct difference, relative to the rise in serum leukocytes, between subjects managed by the fraternity and those managed by the Castlio and Ferris-Swift research team. Conclusion Modern, well-designed studies which incorporate demographic information, blinding methods to limit measurement bias, and a control group are needed to clarify the effect of the splenic pump on blood cell counts and other immune parameters.

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: During the first 2 years of osteopathic medical school, osteopathic manipulative medicine (OMM) courses use an objective professionalism score to measure student timeliness and appropriate dress for learning activities. Objective: To assess for correlations between this score and the numeric course grades of all first- and second-year basic science and clinical courses at a single osteopathic medical school. Methods: The professionalism scores obtained for each of the 7 quarters of the OMM course (2007-2012) were compared with the students' numeric final course grades and combined grade point average (GPA) of all courses in the corresponding quarter. Spearman correlation coefficients were used to determine the strength of the relationship between the professionalism score and the final course grades and the combined GPA. Results: The mean (SD) professionalism score was 98.6% (3.3%), and scores ranged from 23.1% to 100%. Excluding the OMM course, the professionalism score was positively correlated with 29% of first-year course grades and 65% of second-year course grades. The professionalism score was predictive of academic performance in 16 of 23 clinical courses with the highest correlation for Principles of Medicine and Dermatology (ρ=0.28 and ρ=0.25, respectively). The OMM professionalism score was positively associated with GPA for quarters 1, 6, and 7 (P=.006, PPPConclusion: Objective measures of professionalism correlated with academic performance in many first- and second-year osteopathic medical school courses, particularly clinical courses in the second-year curriculum. J Am Osteopath Assoc. 2014;114(11):850-859 doi: 10.7556/jaoa.2014.171

Ultrasound has been integrated into a gross anatomy course taught during the first year at an osteopathic medical school. A clinical ultrasound elective course was developed to continue ultrasound training during the second year of medical school. The purpose of this study was to evaluate the impact of this elective course on the understanding of normal anatomy by second-year students. An anatomy exam was administered to students enrolled in the clinical ultrasound elective course before the start of the course and after its conclusion. Wilcoxon signed ranks tests were used to determine whether exam scores changed from the pre-test to the post-test. Scores from two classes of second-year students were analyzed. Students who took the elective course showed significant improvement in the overall anatomy exam score between the pre-test and post-test (P0.001). Scores for exam questions pertaining to the heart, abdomen, upper extremity, and lower extremity also significantly improved from the pretest to post-test (P0.001), but scores for the neck and eye showed no significant improvement. The clinical ultrasound elective course offered during the second year of medical school provided students with an important review of key anatomical concepts while preparing them for board exams. Our results suggested that more emphasis should be placed on head and neck ultrasound to improve student performance in those areas. Musculoskeletal, abdominal, and heart ultrasound labs were more successful for retaining relevant anatomical information.

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.

Traumatic brain injury (TBI) is among the most devastating of injuries leading to death and disability among young people today. The major cause of TBI is motor vehicle crashes. One way to reduce the rates of such crashes and thus TBI is through prevention programs. This article analyzes a study conducted for assessing a 1-day educational traffic injury prevention program for young traffic offenders with speeding violations. The obtained data include information about traffic convictions for speeding violations on a group of 16- to 23-year-old drivers. A common method for analyzing such studies is to use simple two-sample rank tests on summary statistics. But this approach ignores the detailed conviction process information and can assess only the long-term overall effect of the program. In this article, we treat the data as recurrent event data and apply a novel approach based on counting processes to evaluate the program. Our approach makes use of the information ignored by the rank tests and allows the...

Objective To test whether change in cognitive–behavioral variables (such as self-efficacy, coping strategies, and helplessness) is a mediator in the relation between cognitive behavior therapy and reduced pain and depression in persons with rheumatoid arthritis (RA). Methods A sample of patients with RA who completed a stress management training program (n = 47) was compared to a standard care control group (n = 45). A path analysis testing a model including direct effects of comprehensive stress management training on pain and depression and indirect effects via change in cognitive–behavioral variables was conducted. Results The path coefficients for the indirect effects of stress management training on pain and depression via change in cognitive–behavioral variables were statistically significant, whereas the path coefficients for the direct effects were found not to be statistically significant. Conclusion Decreases in pain and depression following stress management training are due to beneficial changes in the arenas of self-efficacy (the belief that one can perform a specific behavior or task in the future), coping strategies (an individual's confidence in his or her ability to manage pain), and helplessness (perceptions of control regarding arthritis). There is little evidence of additional direct effects of stress management training on pain and depression.

The Missouri Arthritis Rehabilitation Researchand Training Center’s (MARRTC) website was devel-oped to provide better public access to informationabout arthritis (1). The authors recently describedthe website and reported extensive use of its servicesduring its first 18 months (1). While visits to the sitecontinue at about 30,000 visits per month, the au-thors noted that a future challenge would be to eval-uate the MARRTC site’s efficacy to users and to usethis information to improve services (1).There are several options to assess audience use ofa website. The tracking of how many persons visit isone indicator of efficacy. However, in terms of mak-ing editorial improvements, the authors noted that itmight be more useful to understand the underlyingmotivations why persons visit a website about topicsrelated to arthritis (1). The history of mass mediascholarship strongly suggests that audiences usemass media for a range of purposes, which includeboth informational and complex emotional needs(2,3). The literature about audience use of mass me-dia also suggests that users may be interested injoining an interactive community of persons withcommon interests (3–8).For about 40 years, a uses and gratifications ap-proach to audience research has been a prevailingframework in understanding the range of motiva-tions why persons converge on mass media. Theuses and gratifications approach was developed fromaudience research during the middle of the 20thcentury and was characterized by a series of assump-tions (3,9,10): 1) the media have to be “read” throughthe perceptions of its audience, which constructsmeanings and pleasure from the media texts offered(and these are never fixed or predictable); 2) the veryprocess of media use as a set of practices and the wayin which it unfolds are the central objects of interest;3) audiences for particular genres often comprise“interpretive communities” that share much of thesame experience, forms of discourse, and frame-works for making sense of media; 4) audiences arenever passive, nor are their members all equal, sincesome will be more experienced or more active fansthan others.The term “uses” has evolved to broadly representthe mass media’s utilitarian and social learning ca-pacities, or the extent media is perceived to provideuseful information, give useful advice, help onelearn about local, national, and international events,and, in the process, provide helpful insights aboutlife and work (11–15). The term “gratifications” hasevolved to broadly represent the mass media’s emo

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

Creaminess is used by consumers to describe the texture of many food products. The overall objective of this study was to investigate the underlying sensations to the acceptance of textural creaminess. Eight puddings varying in thickness, mouthcoating, rate of melt and smoothness were developed by altering the amount and type of starch, amount of milk-fat and amount of sodium salts. Puddings were evaluated by descriptive analysis for appearance, texture and flavor characteristics. Concurrently, consumers evaluated the puddings for “liking of creamy texture”. Sensory descriptive data were subjected to principal component analysis, resulting in a multidimensional product space that was related to the consumer acceptance data using the AUTOFIT selection strategy. More than 90% of consumer responses were selected and validated by AUTOFIT. A dimension related to thickness seemed important to consumer acceptance of creamy texture. In general, hedonic scores for creamy texture were higher for samples that were smoother and had more dairy flavor, although, hedonic scores for creamy texture varied considerably on dimensions related to dairy flavor and smoothness.

Objective To determine the long-term clinical and immunologic outcomes in a well-characterized cohort of 47 patients with mixed connective tissue disease (MCTD), including reactivity with U small nuclear RNP (snRNP) polypeptides. Methods Patients were followed up over a period of 3–29 years with immunogenetic and systematic clinical and serologic analysis. Sera were analyzed for reactivity with snRNP polypeptides U1–70 kd, A, C, B/B′, and D, for anti–U1 RNA, and for anticardiolipin antibodies (aCL). Results The typical core clinical features of MCTD tended to develop over time; features of inflammation as well as Raynaud's phenomenon and esophageal hypomotility diminished, while pulmonary hypertension, pulmonary dysfunction, and central nervous system disease persisted, following treatment. A favorable outcome was observed in 62% of patients; 38% had continued active disease or had died, with death associated with pulmonary hypertension and aCL. All patients had autoantibodies to the U1–70 kd polypeptide of snRNP, and most were positive for anti–U1 RNA. An orderly progression of intramolecular spreading of autoantibody reactivity against snRNP polypeptides was observed, as was the novel finding of “epitope contraction” followed by disappearance of anti-snRNP autoantibodies during prolonged remission. Conclusion These patients demonstrated the typical immunogenetic, clinical, and serologic findings of MCTD, and the condition rarely evolved into systemic lupus erythematosus or systemic sclerosis. The majority of patients had favorable outcomes, with pulmonary hypertension being the most frequent disease-associated cause of death. Intramolecular spreading of autoantibody reactivity against snRNP polypeptides was observed, followed by “epitope contraction” and ultimate disappearance of anti-snRNP autoantibodies during prolonged disease remission.

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.

A test is presented for testing equality of two multivariate populations versus the alternative that the component wise differences between the two populations are ordered. A bootstrap estimate of the variance of the test statistic is proposed and the limiting distribution of the standardized form of the test statistic is shown to be N(0,1). Methods for conducting two-stage tests and an interim analysis are also presented. The joint null limiting distributions for the two-stage test statistics and the interim analysis test statistics are each shown to be bivariate normal.

Objective To examine a range of variables potentially associated with rheumatoid arthritis (RA)-related fatigue and to determine which variables best predict subjective fatigue. Methods Measures of fatigue, disease activity, pain, and various psychosocial factors were gathered from 73 individuals with RA. Correlations between fatigue and other variables were examined, and the “best” predictors of fatigue were determined with multiple regression analyses. Results Many of the variables that were significantly correlated with fatigue had a psychosocial character. Moreover, the “best” predictors of increased fatigue were higher levels of pain, more depressive symptoms, and female sex. Longer symptom duration, less perceived adequacy of social support, and less disease activity were significant predictors of fatigue, over and above the “best” model. Conclusion RA-related fatigue appears to be strongly associated with psychosocial variables, apart from disease activity per se. Correspondingly, treatment of fatigue may be enhanced by interventions that address relevant cognitive and behavioral dimensions.

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.