Physical Medicine / OMM

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    Osteopathic Manipulative Techniques Alter Gastric Myoelectrical Activity in Healthy Subjects
    (2016-03-23) Jouett, Noah; Van den raadt, Amber; Smith, Michael; Hensel, Kendi; Shadiack, Edward
    INTRODUCTION: Osteopathic Manipulative Techniques (OMT) have been shown to alter autonomic control of heart rate. However, it is unclear if OMT affects control of gastric myoelectrical activity (GMA). HYPOTHESIS: We hypothesized that OMT significantly alters power spectral density (PSD) analyses of electrogastrography (EGG) recordings compared with sham OMT. METHODS: IRB approval was obtained for this protocol. Subjects were studied before and after sham treatment and OMT (both vagal and sympathetic directed techniques) on separate days in a cross-over design. 15 minute EGG recordings were obtained before and after each intervention and after a water challenge (WC; a standard vagal stimulus of GMA). The WC involved drinking 500 mL of 16 οC water over 5 min. Percent power in the normogastric range (PPN; 2-4 counts/min) was estimated from PSD analyses of EGG recordings. Absolute percent change of PPN (∆PPN) from baseline to post-intervention and baseline to post-WC was computed and compared using paired t-tests and two-way repeated-measures ANOVA. RESULTS: OMT significantly altered ∆PPN versus sham control (sham: 5.3%, OMT: 24.5%, P=0.015). WC significantly altered ∆PPN compared to sham control (post-sham ∆PPN: 5.3%, post-drink ∆PPN: 30.3%, P CONCLUSIONS: We conclude that (a) OMT significantly alters GMA compared to sham control and (b) that OMT produces similar changes in GMA to WC.
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    Preliminary Analysis of Effect of Body Mass Index and Health Outcomes Across the Continuum of Care Post-Traumatic Injury
    (2016-03-23) Driver, Simon; Reynolds, Megan; Bennett, Monica; Warren, Ann; Smith, Hayden
    1. Research Objectives: Examine the impact of body mass index (BMI) on health outcomes during acute care post-traumatic injury, inpatient rehabilitation, and 3-months post-discharge 2. Design: Prospective, longitudinal Setting: Level I trauma center; inpatient rehabilitation facility; community follow-up. Participants: 33 patients originally admitted to a Level I trauma center; all participants then completed inpatient rehabilitation in the same hospital system, followed by a 3-month telephonic follow-up. Interventions: Not Applicable Main Outcome Measure(s): Patients were divided into BMI categories based on admission data. Acute care data (e.g., demographic and injury-related) was collected from patient charts and hospital trauma registry. Rehabilitation data (e.g., Functional Independence Measures) was collected from eRehab and patient charts. Health outcomes included depression and post-traumatic stress disorder screens, pain levels, and return to work status. Kruskal-Wallis and Fisher’s tests compared outcomes across BMI categories. 3. Results: 12 participants were classified as being of normal weight, 11 overweight, and 10 obese. A significantly greater number of overweight patients had more severe injuries in the acute care setting (p=.001). Individuals who were overweight were significantly more likely to have a positive depression screen at baseline (p=.0011). Differences in FIM efficiency during rehabilitation approached significance (p=.0551). While no differences were found during inpatient rehabilitation or 3-month outcomes, results did indicate that overweight and obese individual’s length of stays was two days longer than people who were normal weight. 4. Conclusions: As the number of individuals considered overweight or obese now includes over two-thirds of Americans, it is critical to examine the characteristics of this population and identify strategies to achieve best outcomes. Larger samples are required to determine the relationship between BMI and health outcomes after traumatic injury.
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    Pituitary Dysfunction and Hormone Replacement Therapy in Traumatic Brain Injury Rehabilitation
    (2016-03-23) Smith, Michael PhD; Royston, Alexa
    1. Purpose: Pituitary dysfunction is an exceedingly predominant complication of traumatic brain injury (TBI) with a prevalence of up to 30%. Symptoms of a pituitary disorder, such as fatigue, concentration difficulties, depression, and hormone deficiencies, can often appear nonspecific and consequently are overlooked. Such profound deficits may impose a negative impact on patients' recovery and ultimate quality of life. Currently no protocol exists for the screening of pituitary function or hormone replacement therapy (HRT) due to critical research gaps in the area of brain injury rehabilitation. The purpose of this project was to draft a set of evidence-based recommendations regarding pituitary screening and hormone replacement therapy in TBI patients. 2. Methods: A multidisciplinary team of research personnel and clinicians who specialize in treating TBI was established to include physiatry, neuropsychology, physical therapy (PT), occupational therapy (OT), speech language pathology (SLP), and therapeutic recreation (TR). Clinicians created a research question in PICO format (Population, Intervention, Comparison, Outcome). Next, research staff conducted a systematic review using the key terms "brain injuries, pituitary screen, pituitary testing, pituitary evaluation, hormone replacement therapy." PubMed, CINAHL, PSYCInfo, and Allied Health Evidence databases were utilized. The multidisciplinary team reconvened to assess quality of evidence for each article using a modified-Oxford scale and created draft recommendations using a modified-GRADE format. 3. Results: 20 articles were assessed and deemed to have good quality of evidence in support of pituitary screening, particularly in patients with severe TBI and within the first 12 months of injury. 6 articles were assessed for hormone replacement therapy and deemed to have fair quality of evidence surrounding HRT, particularly growth hormone. 4. Conclusion: We strongly recommend that pituitary screening should be routinely performed on all patients with TBI, especially moderate to severe TBI. While further study of HRT is warranted, the available research supports a weak conditional recommendation for growth hormone replacement.
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    Comparative Accuracy of Physician Palpation of Sacral Anatomical Landmarks versus Musculoskeletal Ultrasound Evaluation
    (2016-03-23) Surve, Sajid DO; Lee, Yein
    Comparative Accuracy of Physician Palpation of Sacral Anatomical Landmarks versus Musculoskeletal Ultrasound Evaluation. Introduction Ultrasonography is useful for visualizing musculoskeletal structures due to its safety and capacity for real-time imaging. A recent publication shows the validity of ultrasonography to establish sacral base position and sacral sulcus depth. Our study will compare the palpatory examination of sacral landmarks by osteopathic physicians to sonographic findings. Methods This study has received institutional review board approval (#2015-188). Our enrollment goal is 40-60 subjects and we have currently recruited and collected data with 16 subjects. Each subject had an initial ultrasound measurement of each sacral sulcus and inferior lateral angle (ILA), both in a prone and extended (sphinx) position. Then 5 examiners comprised of 3 senior osteopathic physicians and 2 osteopathic residents, palpated and evaluated each landmark for symmetry, again in prone and sphinx positions. Finally, another ultrasound evaluation was performed to see if there was a change in the sacrum following the repeated examinations. Results The preliminary data collected with 16 enrolled subjects were analyzed thus far. Ultrasound measurements revealed mean left to right depth difference ranging from 0.38-0.26cm between the designated sacral bony landmarks. When the subjects were transitioned from prone to sphinx position, the mean depth difference ranged from 0.23-0.06cm (±0.46-0.68). Sonography before and after physician palpation showed a depth difference of the designated landmark range from 0.37-0.07cm (±0.6-0.42). Physician palpation data have not shown a high degree of interrator reliability with the 16 subjects studied. Comments/ Conclusions Our study is on going, but so far we are able to validate that ultrasound can identify depth differences of the sacral sulcus and the ILA. Sonography also has demonstrated that depth of the sacral landmarks change from prone to sphinx position. It is important to note that the ultrasound measurements we collected so far show that there may be relative anterior movement of the sacrum at both the sacral sulcus and ILA when the subjects are in a sphinx position. This is important to study further as standard osteopathic texts maintain that the sphinx position causes the sacral base to move anterior while the ILAs move posterior. Comparing ultrasound measurements before and after physician palpation demonstrated that repeated palpation of bony landmarks may change sacral positioning. Further data collection will be needed to adequately understand physician palpatory experience.
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    Development of a Visualization Tool to Understand Gait
    (2016-03-23) Patterson, Rita; Le, David
    Objective: The aim of this study was to create a visualization tool that illustrates the motion of specific joint angles during gait cycles. An example of how this tool would be beneficial to understanding gait will be presented by comparing a patient’s joint angle before and after application of Osteopathic manipulative medicine (OMM) and heel lift therapy to improve back pain. Design: A V-gait CAREN system was used to create realistic virtual environments in order to test functional gait and balance in situations that resemble real life. Reflective markers were placed on the head, arms, legs and torso. A 12-camera Motion Analysis System (Motion Analysis Corp., Santa Rosa, CA) tracked reflective markers placed on the body, allowing precise calculation of kinematics, gait parameters, and joint range of motion during movements using the GRAIL (Gait Real-Time Analysis interactive lab) and GOAT (Grail offline analysis tool). A list of 17 joint parameters were compiled and separated into left and right joints on an excel sheet. For each parameter, 50 cycles of gait were analyzed. Sample data from a preliminary subject that has gone through gait analysis via the V-gait CAREN system (Computer Assisted Rehabilitation Environment Network, Motek Medical, The Netherlands) were inputted into the list and each cycle was graphed Results: Graphs for joint parameters up to 50 gaits cycles were automatically generated using the excel tool and proved to be effective for visualizing gait motion. Conclusions: Presentation of one possible way to utilize this tool looks at data from one of our existing studies that compares gait changes of a patient before and after OMM and heel lift therapy to investigate improvements in back pain. Other potential uses for this tool that is not presented would be to visualize the motion of specific joints and compare a subject with a pathologic joint to a subject with a non-pathologic joint. In addition, left and right side joint angles could be compared within one subject. Lastly, pre-treatment and post-treatment analysis can be done for patients using this tool.
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    Utilization of Osteopathic Manipulative Treatment within an Academic Practice Setting
    (2016-03-23) Jamrog, Jennifer DO; Fernando, Shane PhD; Crow, Thomas; Willingham, Krista
    Introduction: Osteopathic manipulative treatment (OMT) has historically been the foundation of treatment used by osteopathic physicians. This study assesses the utilization of OMT across multiple specialties in an academic practice setting. Hypothesis: OMT is underutilized in multiple clinics within an osteopathic academic institution. Methods: Electronic medical records for all clinics at the University of North Texas Health Science Center (UNTHSC) were retrospectively reviewed. All patient records which were billed with CPT codes 98925-98929, indicating use of OMT, from September 2004 through September 2015 were included. The multiple specialty clinics within the UNTHSC system were combined into seven categories. The number of office visits in which OMT was utilized in each specialty was compared to the total number of office visits within the same specialty over the same time period. Results: A total of 35,333 records that included billing codes for OMT during the specified time period were reviewed. These encounters were found to represent 7,148 unique patients, ranging in age from 0 to 98. Females made up 67% of patients, while 33% were male. Caucasians made up nearly 74% of the patient population, accompanied by 9% African Americans and 2% Asians. In neuromusculoskeletal medicine, 74.93% of total office visits included billing for OMT; in family medicine, 0.52%; in sports medicine, 1.61%; in obstetrics, 0.01%; in pediatrics, 0.03%; in internal medicine 0.34%; and in surgical specialties, 0.01%. Conclusions: This study shows that the vast majority of OMT in this academic clinic setting is provided by osteopathic neuromusculoskeletal specialists, with sports medicine and family medicine as distant runners-up. This was not unexpected, due to the unique skill set acquired by osteopathic neuromusculoskeletal specialists. However, this study does highlight the lack of OMT provided in the primary care setting, and shows even lower use among specialists and surgeons. This presents a need for ongoing education and support to encourage osteopathic physicians outside of an OMT specialty to integrate the use of musculoskeletal manipulation into their practices.
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    Safety of Osteopathic Manipulative Treatment on Labor and Delivery Outcomes
    (2016-03-23) Roane, Brandy; Smith-Barbaro, Peggy; Hensel, Kendi; Chaphekar, Anita V.
    1. Objective: Osteopathic Manipulative Treatment (OMT) has been used in pregnant women since its beginning, but little quality data exists on its safety. The Pregnancy Research in Osteopathic Manipulation Optimizing Treatment Effects (PROMOTE) study was a NIH-funded, randomized controlled clinical trial with the objective of evaluating the safety and efficacy of OMT during third-trimester pregnancy. 2. Materials and Methods: In PROMOTE, 400 study subjects were randomly assigned to one of three study groups: Usual Care Only (UCO), Usual Care plus Placebo Ultrasound Treatment (PUT) or Usual Care plus OMT (OMT). The primary objective of the current analysis was to evaluate safety of OMT on labor and delivery by comparing the incidence of high-risk status of pregnant women; labor and delivery outcomes such as length of labor, perineal lacerations, operative vaginal delivery, meconium-stained amniotic fluid; and APGARs of infants born to mothers in each of the three study groups. 3. Results: Data from this study showed that the application of the OMT protocol does not result in increased risk of high-risk status, in fact, women who received OMT were less likely to develop high risk status. The OMT protocol also did not increase risk of precipitous labor, conversion to caesarian section, perineal laceration, meconium-stained amniotic fluid, or requiring the use of forceps or a vacuum device. In all the maternal outcomes examined, no difference was reported among the three study groups with the exception of incidence of prolonged labor. Women receiving OMT were able to successfully labor longer and vaginally deliver with no increased incidence of complications, including perineal laceration, episiotomy, and use of forceps or vacuum device. 4. Conclusion: These results suggest that the OMT protocol as applied in PROMOTE is a safe intervention during the third trimester.