Volume 110, Issue 11

Deep vein thrombosis and pulmonary embolism are clinical manifestations of venous thromboembolism, and they necessitate anticoagulant therapy in most cases. The duration of treatment is predicated on a balance between the risk of recurrent disease and the risk of bleeding inherent to anticoagulant therapy. It is important that physicians are aware of evidence-based guidelines that can enhance decision-making discussions with patients about the risks and benefits of the different durations of treatment. Keeping patients well informed as they consider these difficult choices helps them assume responsibility and may improve compliance in accordance with the tenets of osteopathic principles of care.

Context: Previous studies on the effect of mindfulness-based stress reduction (MBSR) therapy on chronic pain syndromes have been hampered by study design. Objective: To evaluate short-term efficacy of MBSR therapy for improving quality of life in adults with failed back surgery syndrome (FBSS). Design: A single-center, prospective, randomized, single-blind, parallel-group clinical trial. Patients and Setting: Participants were recruited from a multidisciplinary spine and rehabilitation center in the greater Portland, Maine, area. Interventions and Main Outcome Measures: Patients were randomly assigned at baseline to receive either MBSR therapy plus traditional therapy or traditional therapy alone for an 8-week period. Those receiving MBSR therapy completed weekly group sessions, and the control group continued with their traditional care as prescribed by their medical care providers. At study enrollment and at 12-week follow-up, all participants completed questionnaires on pain, quality of life, functionality, analgesic use, and sleep quality. Patients in the intervention group also completed questionnaires at 40-week follow-up. Results: The final analysis included 25 patients with FBSS; 15 patients were in the MBSR intervention arm, and 10 in the control group. At 12-week follow-up, patients in the intervention arm had a mean 4-point increase (on an 18-point scale) in pain acceptance and quality of life on the Chronic Pain Assessment Questionnaire, a mean 3-point decrease (on a 24-point scale) in functional limitation on the Roland-Morris Disability Questionnaire, a mean 5-point reduction (on a 30-point scale) in pain level on the Summary Visual Analog Scale for Pain, a mean 1-point reduction (on a 4-point scale) in frequency of use and potency of analgesics used for pain and recorded on logs, and a mean 1-point increase (on a 5-point scale) in sleep quality on the abridged Pittsburgh Sleep Quality Inventory. These results were statistically and clinically significant compared to outcomes for the control group. Conclusion: The results suggest that MBSR can be a useful clinical intervention for patients with FBSS.

Background: Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement conventional treatment of musculoskeletal disorders, including those that cause low back pain. Osteopathic manipulative treatment is defined in the Glossary of Osteopathic Terminology as: “The therapeutic application of manually guided forces by an osteopathic physician (US Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction. OMT employs a variety of techniques.” Somatic dysfunction is defined as: “Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment.” Previous published guidelines have been based on literature reviews and meta-analyses of spinal manipulation for low back pain. They have not specifically addressed OMT and generally have focused on spinal manipulation as an alternative to conventional treatment. The purpose of this study was to assess the efficacy of OMT for somatic dysfunction associated with low back pain by osteopathic physicians and osteopathic practitioners trained in osteopathic palpatory diagnosis and manipulative treatment. Methods: Computerized bibliographic searches of MEDLINE, OLDMEDLINE, EMBASE, AMED, MANTIS, OSTMED (OSTMED.DR), and the Cochrane Central Register of Controlled Trials were supplemented with additional database and manual searches of the literature. Six trials, involving eight OMT vs control treatment comparisons, were included because they were randomized controlled trials of OMT that involved blinded assessment of low back pain in ambulatory settings. Data on trial methodology, OMT and control treatments, and low back pain outcomes were abstracted by two independent reviewers. Effect sizes were computed using Cohen d statistic, and meta-analysis results were weighted by the inverse variance of individual comparisons. In addition to the overall meta-analysis, subgroup meta-analyses were performed according to control treatment, country where the trial was conducted, and duration of follow-up. Sensitivity analyses were performed for both the overall and subgroup meta-analyses. Results: Osteopathic manipulative treatment significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 to -0.13; P =.001). Subgroup analyses demonstrated significant pain reductions in trials of OMT vs active treatment or placebo control and OMT vs no treatment control. There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States. Significant pain reductions were also observed during short-, inter mediate-, and long-term follow-up. Conclusions: Osteopathic manipulative treatment significantly reduces low back pain. The level of pain reduction is clinically important, greater than expected from placebo effects alone, and may persist through the first year of treatment. Additional research is warranted to elucidate mechanistically how OMT exerts its effects, to determine if OMT benefits extend beyond the first year of treatment, and to assess the cost-effectiveness of OMT as a complementary treatment for low back pain.

The objective of this review is to establish the current state of knowledge on the reliability of clinical assessment of asymmetry in the lumbar spine and pelvis. To search the literature, the authors consulted the databases of MEDLINE, CINAHL, AMED, MANTIS, Academic Search Complete, and Web of Knowledge using different combinations of the following keywords: palpation, asymmetry, inter or intraexaminer reliability, tissue texture, assessment , and anatomic landmark . Of the 23 studies identified, 14 did not meet the inclusion criteria and were excluded. The quality and methods of studies investigating the reliability of bony anatomic landmark asymmetry assessment are variable. The κ statistic ranges without training for interexaminer reliability were as follows: anterior superior iliac spine (ASIS), -0.01 to 0.19; posterior superior iliac spine (PSIS), 0.04 to 0.15; inferior lateral angle, transverse plane (ILA-A/P), -0.03 to 0.11; inferior lateral angles, coronal plane (ILA-S/I), -0.01 to 0.08; sacral sulcus (SS), -0.4 to 0.37; lumbar spine transverse processes L1 through L5, 0.04 to 0.17. The corresponding ranges for intraexaminer reliability were higher for all associated landmarks: ASIS, 0.19 to 0.4; PSIS, 0.13 to 0.49; ILA-A/P, 0.1 to 0.2; ILA-S/I, 0.03 to 0.21; SS, 0.24 to 0.28; lumbar spine transverse processes L1 through L5, not applicable. Further research is needed to better understand the reliability of asymmetry assessment methods in manipulative medicine.

Cavernous hemangiomas are the most common type of benign liver tumor. Although these tumors are often asymptomatic, they can occur with an array of symptoms. The authors describe a case of a 51-year-old man who presented to the emergency department with a relentless cough, nausea, and abdominal pain. Results of a computed tomography scan suggested the patient had a giant cavernous hemangioma on his liver; microscopic evaluation confirmed this diagnosis. The hemangioma was initially deemed unresectable and the patient was treated with one session of hepatic artery embolization. The embolization was unsuccessful at easing the patient's symptoms, however, and a hepatic lobectomy and resection was performed. After surgical intervention, the patient's symptoms resolved. The present case illustrates an unusual instance in which chronic cough was cured through hepatectomy for giant cavernous hemangioma. To our knowledge, no reports of coughing as a primary symptom of giant cavernous hemangioma have been previously reported in the literature.