Volume 120, Issue 10

Context Physicians have an increased rate of depression and suicide compared with nonphysician peers. State medical licensure questions about mental health deter physicians from seeking mental health care. Several previous studies have examined state medical licensing board compliance with the Americans with Disabilities Act (ADA) of 1990, but none have included osteopathic licensing boards. Objective To evaluate compliance of state osteopathic medical licensing boards with ADA requirements regarding mental health. Methods State medical licensing applications for 51 states, including the District of Columbia (DC), and 16 states with osteopathic licensing entities were reviewed for ADA compliance in questions about mental health. In states where both osteopathic and allopathic applications were available, questions and compliance were compared. Results Fourteen of 51 states (including DC) were grossly out of compliance with ADA statutes. In states where osteopathic and allopathic licensing were both available, 7 of 16 asked different mental health questions of osteopathic physicians than their allopathic physician counterparts. Of those 7 states, 6 of the osteopathic boards were out of compliance with ADA, while their allopathic counterparts were either compliant or intermediately compliant. Conclusion To improve physician wellbeing, corrective action must be taken to create ADA-compliant language in medical licensing so physicians can seek treatment for mental health conditions without discrimination by licensing boards. Osteopathic physicians should be aware that there is a discrepancy in state licensure compliance compared with allopathic requirements in some states.

Context Osteopathy in the cranial field (OCF) is among the most controversial topics of osteopathic practice. The mechanism by which cranial movement (CM) occurs is poorly understood, but includes speculation that intracranial pressure can generate a movement of the cranial bones. If this model is valid, an increase in intracranial pressure produced by bilateral compression of internal jugular veins, or the Queckenstedt maneuver (Q-test), should be detectable. Objective To determine whether osteopaths can perceive a palpable change in CM when the Q-test is applied. Methods Blindfolded osteopaths experienced in OCF evaluated the CM of volunteers as a trained clinician applied the Q-test. The osteopaths reported any change in CM amplitude during 3 different 1-minute periods. The total number of variations perceived in each period (PV) by all osteopaths on all volunteers was analyzed. The Kruskal Wallis test was used to evaluate the differences between the test periods. The Mann-Whitney test was used for a pairwise comparison. Statistical significance was set at P ≤.05. Results Eight osteopaths participated in this study and evaluated the CM of 6 volunteers. A Kruskal-Wallis test of the PV between monitoring periods revealed a statistically significant difference ( P <.001). A Mann-Whitney Test showed there was a significant increase in PV between the compression period and the 2 other monitoring periods (base P=. 003 and expectation P =.009). Conclusion Osteopaths could detect a change in the amplitude of CM after the Q-test was applied. Although this was a small-scale pilot study, our data represent a starting point for understanding whether an intracranial or an extracranial mechanism is responsible for the CM.

Left bundle branch block complicates electrocardiogram interpretation of acute myocardial infarction (MI) because ST segment elevations, commonly used as evidence of MIs, are largely hidden by the repolarization vector. To better diagnose acute MI in cases of left bundle branch block, modified Sgarbossa criteria can be used as a clinical tool to help diagnose or exclude MI with high specificity and sensitivity. However, while clinical tools are often helpful, a clinician cannot solely rely on clinical decision-making algorithms. We describe the case of an 84-year-old man experiencing acute cardiopulmonary symptoms who was negative for modified Sgarbossa criteria, but later had a confirmed diagnosis of MI on transfer to a cardiac center. This case illustrates the necessity of good clinical judgment and a high index of suspicion for atypical presentation alongside any diagnostic algorithm.

Diabetes mellitus (DM) is a multisystem disease that affects millions of people worldwide. The vascular and cardiac effects of DM have been well-studied, but little is known about the prevalence of musculoskeletal (MSK) conditions in patients with DM. This review provides an in-depth analysis of a cross-sectional study investigating the presence of several common MSK disorders in patients with DM. This review also analyzes current literature to update health care professionals about the MSK conditions associated with DM.

Chronic diseases and musculoskeletal conditions are responsible for a significant portion of the global disease burden and are frequently comorbid, such as with low back pain in patients who also have chronic organ disease. Low back pain is the leading cause of long-term disability and is the most common reason adults seek adjunctive treatment, including osteopathic manipulative treatment (OMT). OMT has been shown to be effective in relieving low back pain and improving back-specific functioning. In this narrative review, the authors summarize literature published in the last decade and analyze the relationship between musculoskeletal disorders and systemic medical conditions such as diabetes mellitus; they also discuss the efficacy and cost-effectiveness of OMT in managing somatic dysfunction in patients with chronic diseases.

The authors present the case of a 24-year-old man who sustained multiple injuries during a hard landing following a parachute jump. These injuries included a right sacral fracture, bilateral femoral fractures, a separated pubic symphysis, and compression fractures of the fifth and sixth thoracic vertebrae. He was treated with a right sacroiliac joint fixation, pubic symphysis fixation, open reduction internal fixation of his bilateral femurs, and fusion of the third through seventh thoracic vertebrae. The patient experienced back pain, bilateral hip pain, and bilateral knee pain resistant to chiropractic and medical treatments. The patient presented 2 years after his aforementioned surgical procedures for treatment of persistent postoperative pain at the Physical Medicine and Rehabilitation service at the Veterans Affairs Medical Center in Hampton, Virginia. His treatment involved gait correction achieved using a left-sided heel lift and a transition to custom molded orthotics that incorporated the lift. This treatment leveled his sacral base and resulted in a simultaneous decrease in his self-reported pain scores.

Context Diagnosis of somatic dysfunction is based on subjective palpatory osteopathic assessments. This subjectivity has posed a challenge for researchers in studying osteopathic medicine. The development and use of radiological imaging techniques to objectively confirm or quantify muscle tissue stiffness associated with somatic dysfunction could be of benefit in osteopathic clinical practice, training, and further research. Objectives To investigate the feasibility of ultrasound shear wave elastography (SWE) to quantify muscle tissue stiffness in somatic dysfunction before and after osteopathic manipulative treatment (OMT). Methods In this prospective study, we assessed lumbar spine somatic dysfunction in 20 adult patients before and after a single OMT session using standard osteopathic palpatory assessments by osteopathic physician faculty members in the Department of Osteopathic Principle and Practice at Rocky Vista University College of Osteopathic Medicine (Utah campus). Shear wave velocity (SWV, m/s) was measured in lumbar paraspinal muscle tissue using a commercial ultrasonography scanner on all participants immediately before and after OMT. In this study, OMT techniques targeted the iliocostalis lumborum and included the articulatory technique, balanced ligamentous tension, facilitated positional release, high-velocity, low-amplitude technique, muscle energy, myofascial release, and the Still technique at the discretion of the osteopathic physician. The difference in SWV between muscle tissues with and without dysfunction, and differences in SWV of dysfunctional tissue before and after OMT were examined using unpaired and paired t tests, as appropriate. The correlation between SWV measurements and osteopathic assessments was examined by the Spearman rank correlation. Intra- and interobserver reliability was analyzed using intraclass correlation coefficient. Results The difference in SWV between muscle tissues with and without somatic dysfunction was significant before OMT (mean [SD], 1.93 [0.44] vs 1.69 [0.19]; P =.03) and was not significant after OMT (mean [SD], 1.69 [0.19] vs 1.53 [0.31]; P =.05). The difference in SWV in the same tissue with somatic dysfunction before and after OMT was significant (mean [SD], 1.93 [0.44] vs 1.52 [0.3]; P <.001). The SWV value highly correlated with manual osteopathic assessments ( r =0.72). Intra- and interobserver reliability for performing SWE in somatic dysfunction was good (intraclass correlation coefficient >0.80). Conclusions The results of this study show that ultrasound SWE can objectively assess muscle tissue stiffness for diagnosis of somatic dysfunctions and for muscle tissue stiffness changes after OMT.

Context Previous literature has demonstrated the prevalence and socioeconomic impact of postoperative pain in surgery patients. Somatic dysfunction has been demonstrated as a cause, but literature documenting osteopathic manipulative treatment (OMT) in surgery patients is lacking. Objective To describe typical patterns of and common treatments for somatic dysfunction in patients following laparoscopic cholecystectomy. Methods The authors retrospectively reviewed the billing records of all patients over 18 years of age who underwent laparoscopic cholecystectomy by a single surgeon and had postoperative outpatient OMT for right-side pain linked to somatic dysfunction between 2006 and 2018 at a community hospital in Grand Rapids, Michigan. Patients who underwent open cholecystectomy, who did not have documented somatic dysfunction, or had somatic dysfunction unrelated to their biliary disease were excluded. Results Nine patients were selected for inclusion in this retrospective case series. All patients in the study demonstrated anterior right lower rib pain corresponding to posterior lower rib dysfunctions and rotated right and side-bent left thoracic spine dysfunctions between T5 and T11. Pain was successfully managed with muscle energy, high-velocity, low-amplitude, or soft tissue OMT. Conclusion Postoperative pain following laparoscopic cholecystectomy can be related to right-sided thoracic and rib dysfunctions. This is important for early diagnosis of surgical patients with somatic dysfunction and initiation of appropriate OMT to decrease morbidity related to pain, functional status, and quality of life.

Vincristine-induced constipation is a common side effect in pediatric oncology patients. We report the case of an infant with histologic diagnosis of infantile fibrosarcoma who developed significant constipation because of ongoing vincristine administration. She was treated with osteopathic manipulative treatment and had significant improvement in symptoms. She was able to stop her home lactulose bowel regimen without signs or symptoms of constipation. This case demonstrates the benefit of osteopathic manipulative treatment for chemotherapy-induced constipation as an effective and simple supportive care option without added adverse events.

Context The first exposure to opioids for many women of reproductive age follows childbirth. Current data show a significant correlation between the number of days supplied and continued use/abuse of opioids. The number of women with opioid dependency in pregnancy is steadily increasing, and opioid use is directly linked to an increase in maternal and neonatal morbidity and mortality. However, there are no clear opioid-prescribing guidelines for the postpartum period. Objective To compare the number of opioid pills prescribed with the number used by patients in the postpartum period. Methods Patients were recruited to this pilot study at the time of admission to the labor and delivery unit at a community hospital in Oklahoma City, Oklahoma; 84 patients gave informed consent to participate. Medical records were reviewed to determine the number of opioids prescribed. Phone surveys were conducted 4 to 6 weeks after discharge to identify the number of opioids used during the postpartum period. Welch t test was used to determine P values. Results After exclusion criteria were applied, records of 23 patients with vaginal deliveries and 14 patients with cesarean sections were included in the study. Patients who were prescribed opioids after a vaginal delivery were prescribed significantly more pills than were used ( P <.001); a mean of 10 opioid pills per patient remained unused. Patients prescribed opioids after cesarean section were also often prescribed more opioid pills than used ( P <.05); a mean of 7.5 opioid pills per patient remained unused. Of 37 patients, only 2 disposed of unused opioid pills. Conclusion The data in this study show a clear example of overprescribing opioids after vaginal and cesarean deliveries leading to increased opioid pill availability within the community.

Context Doppler sonography is a noninvasive method to evaluate the hemodynamic status of the kidney, and its parameters are used as direct and indirect predictors of certain parenchyma and renovascular diseases. However, the effect of hydration on kidney hemodynamics has not been explored via Doppler sonography. Objective To examine differences in arterial Doppler velocities of normal adult kidney before and after hydration. Methods A total of 60 native kidneys in 30 normal adult participants (mean age, 26 years) were assessed using Doppler sonography. Quantitative ultrasound Doppler parameters of peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI) of the main renal artery and the intrarenal (interlobar) arteries were measured immediately before and 1 hour after ingestion of 500 mL of water. We tested differences in Doppler parameters before and after hydration using a paired t test, analyzed the correlation of the increase in PSV to the increase in EDV after hydration using Pearson correlation coefficient (PCC), and examined intraobserver reliability using intraclass correlation coefficient (ICC). Results Statistical analyses revealed that the differences in PSV and EDV values before and after hydration at the main renal artery and interlobar arteries of the kidney were significant ( P <.001), whereas the RI at the main renal artery and interlobar arteries were not ( P >.05). PCC for the correlation of the increase in PSV to the increase in EDV was greater than 0.80. ICC for intraobserver repeatability in performing kidney Doppler sonography was 0.92. Conclusion Our results suggest that Doppler sonography is able to demonstrate changes in kidney hemodynamics within 1 hour after hydration. The normal kidney reflects proportional increases in PSV and EDV at the main renal artery and interlobar arteries, while maintaining vascular resistance. Doppler flow velocities of renal arteries can be considered as noninvasive quantitative markers for evaluating the response of kidney hemodynamics to hydration.