Volume 114, Issue 5

Context: Osteopathic manual treatment (OMT) of somatic dysfunction is a unique approach to medical care that may be studied within a practice-based research network. Objective: To measure patient characteristics and osteopathic physician practice patterns within the Consortium for Collaborative Osteopathic Research Development–Practice-Based Research Network (CONCORD-PBRN). Design: Cross-sectional card study. Setting: Eleven member clinics within the CONCORD-PBRN coordinated by The Osteopathic Research Center. Patients: A total of 668 patients seen between January and March 2013. Main Study Measures: Patient age and sex; primary diagnoses; somatic dysfunction as manifested by tenderness, asymmetry, restricted motion, or tissue texture changes; and use of 14 OMT techniques. Results were stratified by anatomical region and adjusted for clustering within member clinics. Clustering was measured by the intracluster correlation coefficient. Results: Patient ages ranged from 7 days to 87 years (adjusted mean age, 49.2 years; 95% confidence interval [CI], 43.3-55.1 years). There were 450 females (67.4%) and 508 patient visits (76.0%) involved a primary diagnosis of disease of the musculoskeletal system and connective tissue. Structural examination was performed during 657 patient visits (98.4%), and 649 visits (97.2%) involved OMT. Restricted motion and tenderness were the most and least common palpatory findings, respectively. Cranial (1070 [14.5%]), myofascial release (1009 [13.7%]), muscle energy (1001 [13.6%]), and counterstrain (980 [13.3%]) techniques were most commonly used, accounting for more than one-half of the OMT provided. Pediatric patients were more likely than adults to receive OMT within the head (adjusted odds ratio [OR], 9.53; 95% CI, 1.28-71.14). Geriatric patients were more likely than adults to receive a structural examination (adjusted OR, 1.83; 95% CI, 1.09-3.07) and OMT (adjusted OR, 1.62; 1.02-2.59) within the lower extremity. Females were more likely than males to receive a structural examination (adjusted OR, 2.44; 95% CI, 1.44-4.16) and OMT (adjusted OR, 2.11; 95% CI, 1.26-3.52) within the sacrum and OMT within the pelvis (adjusted OR, 1.79; 95% CI, 1.12-2.88). Intracluster correlation coefficients for the 4 most commonly used OMT techniques ranged from 0.34 to 0.72. Conclusion: This study provides proof of concept of the feasibility of studying osteopathic medical practice on a national level by developing and growing the CONCORD-PBRN.

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 ( P <.001), as was the severity for tissue texture abnormalities ( P =.03), motion restriction ( P =.04), and tenderness ( P <.001). Of the 316 vertebrae assessed, 31 (10%, all in the chronic LBP group) had moderate/severe tenderness. The vertebral somatic dysfunction burden score, the total somatic dysfunction burden score, the vertebral somatic dysfunction severity score, and the total somatic dysfunction severity score were higher in the chronic LBP group (all P <.001). The vertebral BMD T score was significantly higher for vertebrae demonstrating moderate/severe rotational asymmetry compared with those demonstrating mild or no rotational asymmetry ( P =.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: Since its launch in 2001, Wikipedia has become the most popular general reference site on the Internet and a popular source of health care information. To evaluate the accuracy of this resource, the authors compared Wikipedia articles on the most costly medical conditions with standard, evidence-based, peer-reviewed sources. Methods: The top 10 most costly conditions in terms of public and private expenditure in the United States were identified, and a Wikipedia article corresponding to each topic was chosen. In a blinded process, 2 randomly assigned investigators independently reviewed each article and identified all assertions (ie, implication or statement of fact) made in it. The reviewer then conducted a literature search to determine whether each assertion was supported by evidence. The assertions found by each reviewer were compared and analyzed to determine whether assertions made by Wikipedia for these conditions were supported by peer-reviewed sources. Results: For commonly identified assertions, there was statistically significant discordance between 9 of the 10 selected Wikipedia articles (coronary artery disease, lung cancer, major depressive disorder, osteoarthritis, chronic obstructive pulmonary disease, hypertension, diabetes mellitus, back pain, and hyperlipidemia) and their corresponding peer-reviewed sources ( P <.05) and for all assertions made by Wikipedia for these medical conditions ( P <.05 for all 9). Conclusion: Most Wikipedia articles representing the 10 most costly medical conditions in the United States contain many errors when checked against standard peer-reviewed sources. Caution should be used when using Wikipedia to answer questions regarding patient care.

Context: Attention-deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder most commonly affecting children and teenagers. It is characterized by the coexistence of attention problems and impulsivity and hyperactivity. Although several studies have been conducted on the efficacy of conventional and alternative therapies in children with ADHD, few studies have specifically investigated the efficacy of osteopathic manipulative therapy (OMTh). Objective: To evaluate the efficacy of OMTh in the treatment of children with ADHD. Methods: Children aged 5 to 15 years with a primary diagnosis of ADHD who were admitted to a single neuropsychiatry unit from November 2008 to September 2009 were randomly assigned to an intervention group (OMTh + conventional care) or a control group (conventional care only). Biancardi-Stroppa Modified Bell Cancellation Test accuracy and rapidity scores were recorded for both groups at baseline and after 10 weeks. Statistical analyses included univariate tests and multivariate linear regressions. Results: A total of 28 participants were included in the study: 14 in the OMTh group and 14 in the control group. Univariate statistical analysis showed no statistically significant differences between the intervention and control groups in terms of characteristics measured at baseline, except for psychosocial intervention ( P =.05). Multivariate linear regression showed that OMTh was positively associated with changes in the Biancardi-Stroppa Test accuracy (β=7.948 points; P =.04) and rapidity (β=9.089 points; P =.03) scores. Conclusion: Participants who received OMTh had greater improvement in Biancardi-Stroppa Test scores than participants who received conventional care only, suggesting that OMTh can potentially increase performances of selective and sustained attention in children with ADHD. To confirm these findings, studies of larger and more diverse populations are warranted.

In the second of 5 articles on the management of injuries and illnesses caused by ionizing radiation, the authors discuss nontherapeutic radiologic/nuclear incidents: use of a radiologic exposure device, use of a radiologic dispersal device, nuclear power plant safety failure, and detonation of an improvised nuclear device. The present article focuses on how such incidents—whether involving deliberate or accidental methods of radiation exposure—produce casualties and how physicians need to understand the pathologic process of injuries caused by these incidents. To identify the diagnoses associated with nontherapeutic exposure in time to improve morbidity and mortality, physicians must maintain a high index of suspicion when faced with a specific constellation of symptoms. In some scenarios, the sheer number of uninjured, unaffected persons who might present to health care institutions or professionals may be overwhelming. Public health and safety issues may seriously disrupt the ability to respond to and recover from a radiologic and nuclear incident, especially a nuclear detonation.

In the years following the American Osteopathic Association's sanctioning of the broad teaching of chemical and biological agents, osteopathic physicians moved closer to allopathic physicians with respect to diagnosis and treatment. In the 1930s, osteopathic colleges began to adopt standards and improve their basic science and clinical training, which allowed them to produce graduates who did substantially better in passing external examinations to become licensed as physicians and surgeons. Nevertheless, many state legislatures refused to grant DOs unlimited licenses and osteopathic physicians were unable to obtain medical commissions during the Second World War. In California, despite significant accomplishments on the social and legislative fronts, a growing number of osteopathic physicians believed that their DO degree and independent status as a separate medical profession was an impediment to achieving equality with their allopathic counterparts, and they worked toward a merger or amalgamation with their long-time opponents.