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Building a Culture of Osteopathic Scholarship September 4, 2019

Building a Culture of Osteopathic Scholarship September 4, 2019. Jeremy A. Ginoza, DO Core Faculty Skagit Regional Health Family Medicine Residency. Survey of Programs Participating Check all that apply: Program with osteopathic recognition

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Building a Culture of Osteopathic Scholarship September 4, 2019

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  1. Building a Cultureof OsteopathicScholarshipSeptember 4, 2019 Jeremy A. Ginoza, DO Core Faculty Skagit Regional Health Family Medicine Residency

  2. Survey of Programs Participating Check all that apply: Program with osteopathic recognition Applied or plan to apply for osteopathic recognition At least one DO resident practicing with OMT At least one DO faculty practicing with OMT Have MD faculty precepting OMT

  3. Which of the following activities does not qualify as osteopathic scholarly activity for osteopathic residents? • Leading a didactic with integrated osteopathic principles & practices (OPP) • Speaking on an osteopathic topic at a regional conference • Attending a faculty-led osteopathic journal club • Leading a workshop on mind-body-spirit interactions & health • Presenting a poster abstract including OPP at a national conference

  4. Andrew Taylor Still 1828 – 1917 • Civil War-Served in Union Army • Still’s father was a physician • Driven by tragedy-loss of wife and three children to illness • Saw medical system of his day with its use of “drugs or drugging” as “a system of blind guesswork” “Andrew Taylor Still.” Brittanica. www.Britannica.com/biography/Andrew-Taylor-Still. Accessed Aug 2019. “Osteopathic Medicine celebrates 125 years.” The DO, Nov 15, 2017, thedo.osteopathic.org/2017/11/osteopathic-medicine-125-years-history/. Accessed Aug 2019

  5. Andrew Taylor Still • Began practicing osteopathy in 1874 calling himself a “lightning bonesetter” • Gained reputation from dramatic outcomes from manipulative treatments • Settled in Kirksville, Missouri • Established the first osteopathic school in 1892, infirmary in 1894 Gevitz, Norman. The DOs: Osteopathic Medicine in America. 2015.

  6. Andrew Taylor Still • Claimed to be the “founder of the science” of osteopathy • “… you begin with anatomy, and you end with anatomy, a knowledge of anatomy is all you want or need” Still AT. Philosophy of Osteopathy. Kirksville, Mo: A.T. Still; 1899.

  7. Andrew Taylor Still • Emphasized application of anatomic & physiologic knowledge over learning techniques • “We look at the body in health as meaning perfection and harmony, not in one part, but as the whole.” Chikly BJ. Manual Techniques Addressing the Lymphatic System: Origins and Development. J Am Osteopath Assoc 2005;105(10):457–464. Still AT. The Philosophy and Mechanical Principles of Osteopathy. Kansas City, Mo: Hudson-Kimberly Pub Co;1902 : 65,66.

  8. Andrew Taylor Still • Championed a system of medicine built on scientific knowledge • Advocated for its holistic application to individuals that resisted over-standardization of technical skills Chikly BJ. Manual Techniques Addressing the Lymphatic System: Origins and Development. J Am Osteopath Assoc 2005;105(10):457–464. Still AT. The Philosophy and Mechanical Principles of Osteopathy. Kansas City, Mo: Hudson-Kimberly Pub Co;1902 : 65,66.

  9. Andrew Taylor Still To find health should be the object of the doctor. Anyone can find disease. Stark JE. Quoting A.T. Still With Rigor: An Historical and Academic Review. J Am Osteopath Assoc 2012;112(6):366–373. Still AT. Philosophy of Osteopathy. Kirksville, Mo: A.T. Still; 1899:14.

  10. Andrew Taylor Still To find health should be the object of the doctor. Anyone can find disease. • Tenets of Osteopathic Medicine • The body is a unit; the person is a unit of body, mind and spirit. • The body is capable of self-regulation, self-healing, and health maintenance. • Structure and function are reciprocally interrelated. • Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function. “Tenets of Osteopathic Medicine.” AOA, osteopathic.org/about/leadership/aoa-governance-documents/tenets-of-osteopathic-medicine/. Accessed Aug 2019.

  11. Andrew Taylor Still To find health should be the object of the doctor. Anyone can find disease. • Tenets of Osteopathic Medicine • The body is a unit; the person is a unit of body, mind and spirit. • The body is capable of self-regulation, self-healing, and health maintenance. • Structure and function are reciprocally interrelated. • Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function. “Tenets of Osteopathic Medicine.” AOA, osteopathic.org/about/leadership/aoa-governance-documents/tenets-of-osteopathic-medicine/. Accessed Aug 2019.

  12. 1800s-1990s: Popular alternative medical systems • Homeopathic • Eclectic • Magnetic • Hydropathy • Mechanotherapy • Popular Health Movement-Sylvester Graham Gevitz, Norman. The DOs: Osteopathic Medicine in America. 2015.

  13. Louisa Burns (1870-1958) • First full-time osteopathic researcher • Went to osteopathic school after being treated by a DO • Observed visceral effects of spinal lesions induced in animal models • Headed research lab at College of Osteopathic Physicians & Surgeons in Los Angeles Jones, James, DO. “An Overview of Osteopathic Research.” Sept 27, 2006, College of Osteopathic Medicine of the Pacific.

  14. AAO Osteopathic Research Committee named in honor of Louisa Burns, DO • Research grants awarded twice yearly • Annual Research Poster Presentation for students & residents

  15. Pioneers in Osteopathic Research • J. S. Denslow, DO 1941 - Documented correlations between abnormal spinal reflex motor unit activity and palpated osteopathic lesions in human subjects using EMG Denslow J.S., Clough G.H., Electromyographic studies of structural abnormalities. 1941. J Am Osteopath Assoc. 2001 Feb;101(2):101-5. • I. M. Korr, PhD, KCOM, 1958 - Documented local sympathetic changes in areas of osteopathic lesions using electrogalvanic skin resistance Korr I.M., Thomas P.E., Wright H.M. Patterns of electrical skin resistance in man. Acta Neuroveg (Wien). 1958; 17(1-2):77-98.

  16. Pioneers in Osteopathic Research • V. M. Frymann, DO, 1971 - Record cranial bone motion by oscillography independent of arterial pulse & thoracic respiration Frymann VM. A study of the rhythmic motions of the living cranium. J Am Osteopath Assoc. 1971 May;70(9):928-45. • J. M. Cox, DO, et al, 1983 • Study of 97 patients found correlations between coronary artery disease & MSK changes consistent with osteopathic somatic dysfunction in thoracic spine Cox JM, Gorbis S, Dick LM, Rogers JC, Rogers FJ. Palpable musculoskeletal findings in coronary artery disease: results of a double-blind study. J Am Osteopath Assoc. 1983 Jul;82(11):832-6.

  17. Brief Timeline of Osteopathic Recognition • 1929 AOA voted to include pharmacology in curricula • 1938 US Congress declares DOs as physicians • 1962 California merger of MD and DO professions • 1967 DOs participate in military residency match • 1973 DO degree recognized in all 50 states and DC • 2014 Announcement of unified residency accreditation Gevitz N. The ‘little m.d.’ or the ‘Big D.O.’: The Path to the California Merger. J Am Osteopath Assoc 2014;114(5):390–402. doi: 10.7556/jaoa.2014.076. “Osteopathic Medicine celebrates 125 years.” The DO, Nov 15, 2017, thedo.osteopathic.org/2017/11/osteopathic-medicine-125-years-history/. Accessed Aug 2019.

  18. Research Gap Percentage of budget directed to research 1999 American Assoc of Colleges of Osteopathic Medicine (AACOM) Report • Public MD schools: 26%Public DO schools: 7% • Private MD schools: 32% Private DO schools: 2% Rodgers F, Dyer M. Adopting research. J Am Osteopath Assoc. 2000;100:234–7.

  19. 2003Osteopathic Manipulative Medicine Research: A 21st Century Vision-National OMM Research Synergy White Paper • First strategic plan for research • 2000-2010 number of peer-reviewed publications tripled • AOA annual budget for research- $250,000 Degenhardt BF, Standley PR. 2013-2022 Strategic Plan for Research: A Role for Everyone in Promoting Research in the Osteopathic Medical Profession. J Am Osteopath Assoc 2013;113(9):654–659. doi: 10.7556/jaoa.2013.029.

  20. 2013-2022 Research Strategic Plan for the Osteopathic Medical Profession • Calls for every member of the osteopathic medical profession to take a role in supporting research • Financial support from colleges & individuals • Setting high standards for research • Support junior researchers through funding and mentorship • Encourages AOA members to serve on national boards such as NIH Degenhardt BF, Standley PR. 2013-2022 Strategic Plan for Research: A Role for Everyone in Promoting Research in the Osteopathic Medical Profession. J Am Osteopath Assoc 2013;113(9):654–659. doi: 10.7556/jaoa.2013.029.

  21. State of Evidence in MSK Medicine • 2014 Review of 32 most common orthopedic surgeries - 3 had at least one supporting RCT with low risk of bias • 2017 Review of RCTs with Sham Orthopedic Surgery - Sham procedures similarly effective for pain & function Knee arthroscopy with lavage and debridement Vertebroplasty for osteoporotic fracture Lateral epicondylitis-excision of degenerated tendon Lim HC, Adie S, Naylor JM, Harris IA. Randomised trial support for orthopaedic surgical procedures. PLoS One 2014;9:e96745. Adriaan Louw, Ina Diener, César Fernández-de-las-Peñas, Emilio J. Puentedura, Sham Surgery in Orthopedics: A Systematic Review of the Literature, Pain Medicine, Volume 18, Issue 4, April 2017, Pages 736–750, https://doi.org/10.1093/pm/pnw164

  22. State of Evidence in MSK Medicine • 2019 Review of 283 Cochrane Reviews of Physical Therapy • 4.7% of Cochrane Reviews of PT showed conclusive results based on size and strength of evidence Momosaki R, Tsuboi M, Yasufuku Y, Furudate K, Kamo T, Uda K, Tanaka Y, Abo M. Conclusiveness of CochraneReviews in physiotherapy: a systematicsearch and analytical review. Int J Rehabil Res. 2019 Jun;42(2):97-105. doi: 10.1097/MRR.0000000000000338.

  23. Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) • RCT across 7 hospitals • 387 patients aged 50 years or older assigned to OMT, light touch or conventional care • Length of stay 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). • Mortality rates were lower for both the OMT and LT groups. Noll, DR, Degenhardt BF, Johnson JC: Multicenter Osteopathic Pneumonia Study in the Elderly: Subgroup Analysis on Hospital Length of Stay, Ventilator-Dependent Respiratory Failure Rate, and In-hospital Mortality Rate. J Am Osteopath Assoc. 2016;116(9):574-587.

  24. OMT for Post-operative Ileus • 2003-2006 Retrospective study 655 patients • OMT patients had shorter length of stay • Adjust mean 11.8 days vs 14.6 days in non-treatment group F (1,308)=4.81, p=0.029. • 2013 Retrospective Cohort Study • 55 patients • 17 pts receiving OMT had shorter LOS-6.1 days vs 11.5 days Does osteopathic manipulative treatment (OMT) improves outcomes in patients who develop postoperative ileus: A retrospective chart review. Crow, W. Thomas et al. International Journal of Osteopathic Medicine, Volume 12, Issue 1, 32 – 37. Baltazar GA, Betler MP, Akella K, Khatri R, Asaro R, Chendrasekhar A. Effect of Osteopathic Manipulative Treatment on Incidence of Postoperative Ileus and Hospital Length of Stay in General Surgical Patients. J Am Osteopath Assoc 2013;113(3):204–209.

  25. Manipulation for Neck pain:short term benefit • Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Syst Rev. 2015;(9):CD004249. • Gross AR, Hoving JL, Haines TA, et al.; Cervical overview group. Manipulation and mobilisation for mechanical neck disorders. Cochrane Database Syst Rev. 2004;(1):CD004249. • Gross A, Miller J, D’Sylva J, et al. Manipulation or mobilisation for neck pain. Cochrane Database Syst Rev. 2010;(1):CD004249. • Hurwitz EL, Acker PD, Adams AH, et al: Manipulation and mobilization of the cervical spine: A systematic review of the literature. Spine. 21:1746–1760, 1996.

  26. RCT: OMT for neck pain in an ER • OMT compared to single dose 30 mg IM ketorolac • 58 patients with acute neck pain • OMT was similarly effective and reduced pain intensity significantly better than ketorolac McReynolds TM, Sheridan BJ. Intramuscular Ketorolac Versus Osteopathic Manipulative Treatment in the Management of Acute Neck Pain in the Emergency Department: A Randomized Clinical Trial. J Am Osteopath Assoc 2005;105(2):57–68.

  27. Manipulation for Headache • 2016 Review of 10 RCTs • Concluded cervical spine manipulation and mobilization are more beneficial than placebo and traditional physical therapy in lessening intensity and frequency of symptoms in patients with cervicogenic headache.  • High velocity low amplitude (HVLA) outperformed mobilization plus exercise in reducing duration and frequency of headache Garcia J, Arnold S, Tetley K, Voight K, Frank RA. Mobilization and manipulation of the cervical spine in patients with cervicogenic headache: any scientific evidence? Front Neurol. 2016;7:40. doi:10.3389/fneur.2016.00040 Seffinger MA, Tang MY. Spinal Manipulation and Mobilization Therapy for Cervicogenic Headache. J Am Osteopath Assoc 2017;117(1):58–59. doi: 10.7556/jaoa.2017.010. 

  28. OMT for Primary Headache • 2017 Review of 5 studies, 265 pts • Concluded that there is low level evidence that OMT is effective for headache; reduces frequency of migraine • Studies did not meet Cochrane Collaboration’s standard of low risk of bias Cerritelli F., Lacorte E., Ruffini N., Vanacore N. (2017b). Osteopathy for primary headache patients: a systematic review. J. Pain Res. 10 601–611. 10.2147/JPR.S130501 

  29. OMT for Newborn Feeding Difficulty 2016-17 RCT of 97 mother-infant pairs P=.001 Herzhaft-Le Roy J, Xhignesse M, Gaboury I. Efficacy of an Osteopathic Treatment Coupled With Lactation Consultations for Infants' Biomechanical Sucking Difficulties. J Hum Lact2017;33:165–72. 10.1177/0890334416679620

  30. OMT for Newborn Feeding Difficulty Retrospective Cohort Study in Italy (published Jan 2019) L. Vismaraa,b,c , A. Manzottic,d , A.G. Tarantinob,c,⁎ , G. Bianchia , A. Nonise , S. La Roccac,d , E. Lombardic,d , G. Listad , M. Agostia. Timing of oral feeding changes in premature infants who underwent osteopathic manipulative treatment. Complementary Therapies in Medicine 8 Jan 2019. https://doi.org/10.1016/j.ctim.2019.01.003

  31. Osteopathic Journal Club E. Chris Vincent, MD September 4, 2019

  32. Objectives • Examine the evidence for osteopathic manipulative treatment (OMT) of nonspecific low back pain (nLBP) • Identify strengths and weaknesses of current systematic reviews of OMT and spinal manipulative therapy (SMT) for nLBP • Think about possible research opportunities (within the UW Family Medicine Residency Network (UW Network) for OMT and other osteopathic treatments

  33. Why examine the evidence for OMT for nLBP? • nLBP is a common problem in family medicine • We are encouraging providers to use nonpharmacologic methods (especially avoiding opioids) to treat nLBP • There is a fair amount of evidence in support of OMT and SMT for nLBP • OMT for nLBP seems to be recommended (or at least accepted) by most family physicians as a first-line option for nLBP treatment [my own opinion – anecdotal evidence!] • There is a specific and recent (2016) American Osteopathic Association guideline for OMT for LBP

  34. OMT for nLBP evidence I examined • Systematic review with of without meta-analysis (6) • Practice guidelines (2) • Narrative review (1) • I will discuss in some detail 3 systematic reviews and 1 guideline • I will briefly discuss the other 5 articles (honorable mentions)

  35. Why examine systematic reviews / meta analyses? Pros Cons Selection of studies may involve some subjective decision making by authors, so some possible bias in inclusion/exclusion process Authors may attempt to group together treatments that are substantially different (OMT ≠ SMT) Magnitude of the effect may be swayed by small number of studies • Able to look at many studies at once • If done well, inclusion/exclusion process will cull out poorly done studies and assure some homogeneity in studies (all RCTs) • More studies = more data, more data = more power (able to detect real differences when they exist)

  36. Why examine practice guidelines? Pros Cons Quality of evidence supporting guideline may be poor Process for creating the guideline may not be transparent Recommendations may be more consensus-based than evidence-based Guideline developer may be biased • Define the current “standard of care” • Often used by third-party payers to define what is reimbursed • Most recently developed guidelines are based on scientific evidence

  37. SR #1

  38. SR #1

  39. SR #1: Osteopathic manipulative treatment for nonspecific low back pain* • “Best” of 3 systematic reviews (in terms of OMT) • Published in 2014 (oldest of the 3 SRs) • Included any RCT of OMT for nLBP – even non-published (”gray literature”) and non-English language • Searched the following electronic databases: • Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PEDro, OSTMED.DR, and Osteopathic Web Research • Adhered to PRISMA** guidelines (standardized reporting for SRs) *Ref: Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC MusculoskeletDisord. 2014 Aug 30;15:286. PMID: 25175885. **Preferred Reporting Items for Systematic Reviews and Meta-Analyses (http://www.prisma-statement.org/)

  40. SR #1: Osteopathic manipulative treatment for nonspecific low back pain • [P] Studies of adults (> 18 y/o) w/ nonspecific LBP • Acute (≤3 mo), chronic (> 3 mo), pregnant, postpartum) • [I] “Authentic” OMT intervention - treating practitioner was osteopath or osteopathic physician • Clinical judgment used to determine the treatment performed • If co-interventions used, had to also be performed in controls • Excluded studies with just a single intervention technique (eg, only high-velocity manipulation) • [C] Any type of comparison intervention • manual therapy, usual care, sham treatment, untreated • [O] Patient-oriented – measured at 3 months after Rx onset • Pain rated on 100-point visual analog scale (VAS); 10 pts = meaningful diff • Function (various scales) reported as Standardized Mean Difference (SMD) • Small = 0 – 0.5 (<10%), Medium = 0.5 – 0.8 (10%-20%), Large = >0.8 (>20%)

  41. SR #1: Osteopathic manipulative treatment for nonspecific low back pain • 15 RCTs; N = 1502; 18 comparison groups • 6 unpublished, all in German (5 DO theses, 1 presentation) • 9 published (1985 – 2012); 5 US, 2 UK, 2 Italy • LBP: 6 chronic, 3 chronic & acute, 1 acute, 3 pregnancy, 2 postpartum • Median 4 OMT treatments (range 1 – 8) over 8 weeks (range 1 – 22) • 13 of 15 felt to be low risk of bias, however… • None were able to blind provider to the intervention • Only 5 were deemed unclear risk of bias for patient blinding (4 used sham OMT as control), other 10 were deemed high-risk of bias due to lack of patient blinding • As the patient was the “outcome assessor,” same 10 studies were high-risk of assessor bias due to lack of patient blinding, other 5 had unclear risk

  42. SR #1: Osteopathic manipulative treatment for nonspecific low back pain • Acute & chronic LBP • Pain relief* (10 trials, N = 1083; mean diff. [MD] -12.9 points; 95% CI, -20 to -5.8) • Functional status* (9 trials, N = 1046; SMD -0.36; 95% CI, -0.58 to -0.14) • Heterogeneity** (I2) = 86% for pain [substantial], 57% for function [moderate] • Moderate-quality evidence; 2 unpublished • Chronic LBP • Pain relief* (6 trials, N = 769; MD -14.9; 95% CI, -25.2 to -4.7) • Functional status* (6 trials, N = 771; SMD -0.32; 95% CI, -0.58 to -0.07) • Heterogeneity** (I2) = 89% for pain [considerable], 49% for function [moderate] • Moderate-quality evidence; 1 unpublished * For pain, a MD ≥ 10 is clinically meaningful; for function, 0 – 0.5 is small , 0.5 – 0.8 is medium, >0.8 is large ** For heterogeneity, ≤ 30% not important; 30-60% moderate; 50-90% substantial; 75-100% considerable

  43. SR #1: Osteopathic manipulative treatment for nonspecific low back pain • Pregnancy LBP • Pain relief* (3 trials, N = 242; MD -23.0; 95% CI, -44.1 to -1.9) • Functional status* (3 trials, N = 242; SMD -0.80; 95% CI, -1.36 to -0.23) • Heterogeneity** (I2) = 91% for pain [considerable], 76% for function [substantial] • Low-quality evidence; 2 unpublished • Postpartum LBP • Pain relief* (2 trials, N = 119; MD -41.9; 95% CI, -49.4 to -34.3) • Functional status* (2 trials, N = 119; SMD -1.78; 95% CI, -2.21 to -1.35) • Heterogeneity** (I2) = 0% for both pain and function [not important] • Moderate-quality evidence; both trials unpublished * For pain, a MD ≥ 10 is clinically meaningful; for function, 0 – 0.5 is small , 0.5 – 0.8 is medium, >0.8 is large ** For heterogeneity, ≤ 30% not important; 30-60% moderate; 50-90% substantial; 75-100% considerable

  44. SR #1: Osteopathic manipulative treatment for nonspecific low back pain • Author conclusion: • “Clinically relevant effects of OMT were found for reducing pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women at 3 months posttreatment. However, larger, high-quality randomized controlled trials with robust comparison groups are recommended.” • My thoughts: • Very thorough, easy to follow, transparent (excellent description of methods) • Results believable • Inclusion of a funnel plot (to look for publication bias, and possible suppression of “negative” studies) would have helped to be more believable • Inclusion of unpublished studies may be a plus; however, I would like to have seen a sensitivity analysis (ie, remove outliers from pooled analysis) or subgroup analysis without the unpublished studies

  45. SR #1: Osteopathic manipulative treatment for nonspecific low back pain Forest plot for magnitude of the effect of OMT on pain [subgroup - acute & chronic LBP]:

  46. SR #1: Osteopathic manipulative treatment for nonspecific low back pain 2 unpublished RCTs account for a significant amount of the magnitude of the effect of OMT on acute & chronic LBP:

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