Volume 121, Issue 4

Context Osteopathic manipulative treatment (OMT) and mindfulness-based interventions are both efficacious pain management strategies. Combining these two therapeutic approaches may offer added benefits to pain patients. Objectives To determine whether engaging in a mindfulness-based intervention before an OMT session improved OMT session outcomes. Methods Patients seeking OMT care from a single osteopathic physician at an integrative health clinic were recruited for this pilot randomized, controlled trial at an academic hospital. All patients scheduled for osteopathic structural evaluation and treatment with the provider from March 2019 to September 2019 were eligible and invited to participate during the reminder call before their visit. Participants were randomly assigned to listen to one of two audio recordings matched for length: (1) the history of osteopathic medicine, or (2) a guided mindfulness meditation practice. Patients completed surveys including numeric rating scales to measure mindfulness and embodied safety (a self-reported feeling that the patient’s body was in a safe place) immediately before and after listening to the audio recording. A global pain rating report along with a sensation manikin (a digital human figure silhouette overlaid with a grid of 786 “sensation” pixels) capturing both pleasant and unpleasant sensation were collected before and after the OMT session. Session satisfaction was also assessed with a single survey item. Results A total of 57 participants were enrolled in the study; however, 18 were unable to listen to the full audio recording and were excluded from further analysis. The final study sample consisted of 39 patients, with 19 (48.7%) randomized to the history audio recording and 20 (51.3%) randomized to the mindfulness recording. The mean age of patients was 57 years (standard deviation, 11.75 years); 25 (64.1%) were women and 14 (35.9%) were men. The most common primary pain location was the neck (16; 41.0%), followed by back (12; 30.8%) and joint (5; 12.8%). Twenty (51.3%) participants were cancer patients; 19 (48.8%) did not have a cancer diagnosis. Practicing mindfulness before OMT increased patients’ sense of mindful connection to (p=0.036) and safety within (p=0.026) their bodies as well as their overall session satisfaction (p=0.037). Additionally, OMT paired with either study condition (mindfulness vs. history) decreased pain (p<0.001) and increased the ratio of pleasant to unpleasant sensations reported by patients (p<0.001). Finally, regardless of experimental condition (mindfulness vs. history), increased safety within the body predicted greater pain relief ( β =−0.33, p=0.035) and larger sensation ratio changes ( β =0.37, p=0.030) at the OMT session’s end. Additionally, increased mindful connection to the body predicted less pain ( β =−0.41, p=0.005) at the session’s end. Conclusions This study demonstrated the feasibility of integrating a mindfulness-based intervention with OMT and results suggest that having patients listen to an audio-guided mindfulness practice while waiting for their OMT session may increase their mindful connection to and safety within their bodies as well as their session satisfaction. This study also provides empirical evidence that OMT may increase the distribution of pleasant sensations reported by pain patients while decreasing the distribution of unpleasant sensations reported.

Context Management of atrial fibrillation includes either rhythm control that aims at establishing a sinus rhythm or rate control that aims at lowering the ventricular rate, usually with atrioventricular nodal blocking agents. Another potential strategy for ventricular rate control is to induce a negative dromotropic effect by augmenting cardiac vagal activity, which might be possible through noninvasive and nonpharmacologic techniques. Thus, the hypothesis of this study was that occipitoatlantal decompression (OA-D) and transcutaneous auricular vagus nerve stimulation (taVNS) not only increase cardiac parasympathetic tone as assessed by heart rate variability (HRV), but also slow atrioventricular conduction, assessed by the PQ-interval of the electrocardiogram (EKG) in generally healthy study participants without atrial fibrillation. Objectives To test whether OA-D and/or transcutaneous taVNS, which have been demonstrated to increase cardiac parasympathetic nervous system activity, would also elicit a negative dromotropic effect and prolong atrioventricular conduction. Methods EKGs were recorded in 28 healthy volunteers on three consecutive days during a 30 min baseline recording, a 15 min intervention, and a 30 min recovery period. Participants were randomly assigned to one of three experimental groups that differed in the 15 min intervention. The first group received OA-D for 5 min, followed by 10 min of rest. The second group received 15 min of taVNS. The intervention in the third group that served as a time control group (CTR) consisted of 15 min of rest. The RR- and PQ-intervals were extracted from the EKGs and then used to assess HRV and AV-conduction, respectively. Results The OA-D group had nine participants (32.1%), the taVNS group had 10 participants (35.7%), and the CTR group had nine participants (32.1%). The root mean square of successive differences between normal heartbeats (RMSSD), an HRV measure of cardiac parasympathetic modulation, tended to be higher during the recovery period than during the baseline recording in the OA-D group (mean ± standard error of the mean [SEM], 54.6 ± 15.5 vs. 49.8 ± 15.8 ms; p<0.10) and increased significantly in the taVNS group (mean ± SEM, 28.8 ± 5.7 vs. 24.7 ± 4.8 ms; p<0.05), but not in the control group (mean ± SEM, 31.4 ± 4.2 vs. 28.5 ± 3.8 ms; p=0.31). This increase in RMSSD was accompanied by a lengthening of the PQ-interval in the OA-D (mean ± SEM, 170.5 ± 9.6 vs. 166.8 ± 9.7 ms; p<0.05) and taVNS (mean ± SEM, 166.6 ± 6.0 vs. 162.1 ± 5.6 ms; p<0.05) groups, but not in the control group (mean ± SEM, 164.3 ± 9.2 vs. 163.1 ± 9.1 ms; p=0.31). The PQ-intervals during the baseline recordings did not differ on the three study days in any of the three groups, suggesting that the negative dromotropic effect of OA-D and taVNS did not last into the following day. Conclusions The lengthening of the PQ-interval in the OA-D and taVNS groups was accompanied by an increase in RMSSD. This implies that the negative dromotropic effects of OA-D and taVNS are mediated through an increase in cardiac parasympathetic tone. Whether these findings suggest their utility in controlling ventricular rates during persistent atrial fibrillation remains to be determined.

Context Cultural competency is a cornerstone of patient-centered health care. Religious doctrines may define appropriate consumption or use of certain animals and forbid use of others. Many medications contain ingredients that are animal-derived; these medications may be unacceptable to individual patients within the context of their religious beliefs and lifestyle choices. Knowledge of animal-derived medications as a component of cultural competency can facilitate a dialogue that shifts focus from the group to the individual, away from cultural competency toward cultural humility, and away from a paternalistic provider/patient dynamic toward one of partnership. Objectives To explore how animal-derived drug components may impact medication selection and acceptability from the perspective of patients, physicians, and religious leaders as evidenced by studies that explore the question via survey or questionnaire. A secondary objective is to use the context of animal-derived drug products as a component of cultural competency to build a framework supporting the development of cultural humility. Methods A systematic search was performed in the PubMed, CINAHL, Cochrane, and ProQuest databases using combinations of the following terms: “medication selection,” “medication,” “adherence,” “pharmaceutical preparations,” “religion and medicine,” “religion,” “animal,” “dietary,” “porcine,” and “bovine.” Studies that reported using surveys or questionnaires to examine patient, physician, or religious leader perspective on animal-derived medications published in English between 1990 and 2020 were included. Review articles, opinion pieces, case reports, surveys of persons other than patients, religious leaders, or physicians, and studies published in languages other than English were excluded. Three authors independently reviewed articles to extract information pertaining to perspectives on animal-based medication ingredients. Results Eight studies meeting the described criteria were found that queried beliefs or knowledge of patients, religious leaders, or physicians regarding medications and medical products of biologic origin. Those studies are described in full in this review. Conclusions Knowledge of animal-derived ingredients may help open conversations with patients around spiritual history and cultural competency, particularly for those patients belonging to religious sects with doctrines that define appropriate use of human- or animal-derived products. Further formal study is needed to explore more fully the extent to which religious beliefs may impact selection of animal- or human-derived medications. Guidelines developed from this knowledge may aid in identifying individual patients with whom the discussion may be particularly relevant. More studies are needed to quantify and qualify beliefs regarding animal-derived medication constituents.

Context Under the Accreditation for Graduate Medical Education (ACGME) single accreditation system, there is likely to be increasing interest and opportunity for teaching osteopathic manipulative treatment (OMT) to allopathic residents and residency faculty. When learning OMT, allopathic physicians (MDs) have distinct needs compared with osteopathic medical students. For example, MDs already have a foundation in anatomy and medical vocabulary, but incorporating an osteopathic approach to patient care may require a paradigm shift. Thus, a unique approach to osteopathic education for MDs in residency programs with osteopathic recognition (OR) is needed. Objectives To create a longitudinal OMT elective for allopathic residents and residency faculty and assess its impact on attitudes and confidence regarding osteopathic principles and treatment. Methods Drawing from standard texts used during preclinical osteopathic education, a blended online and in-person laboratory modular curriculum for the OMT elective course was developed by osteopathic residents and faculty within the Department of Family Medicine and Community Health at the University of Wisconsin in Madison. The modalities of muscle energy, counterstrain, myofascial release, and soft tissue were included; the curriculum also reviewed autonomic physiology, somatovisceral, and viscerosomatic reflexes. A quality improvement study of the course was conducted via pre- and postcourse surveys to assess its impact on perceptions and confidence regarding the theory and practice, referral, and use of OMT. A precourse survey was distributed before the first module to obtain background information and assess participants’ prior OMT exposure, among other things. Nine months after the course ended, a corresponding postcourse survey was distributed. Pre- and postcourse surveys were individually matched to improve statistical analysis, using unique identifiers. Also, following each laboratory, a postlaboratory survey was collected about the participant’s experience for that lecture and for laboratory-specific quality improvement purposes. Two years after course completion, graduates were reached via phone or email for informal interviews to assess the perceived long-term impact from the elective. Results Eleven MDs from a total potential pool of 26 residents and approximately 120 attending physicians enrolled in the course; eight (72.7%) completed all modules and pre- and postcourse evaluations. Participants reported statistically significant gains in attitudes and confidence regarding OMT (“knowledgeable regarding OMT principles”: precourse mean, 2.50 [0.76], vs. postcourse mean, 3.37 [0.52]; p=0.021; “know how to treat using OMT”: precourse mean, 2.25 [1.39], vs. postcourse mean, 3.12 [1.25]; p=0.041). Several participants (five; 62.5%) had completed prior OMT training. There was an increase, albeit nonsignificant, in the use of OMT, with more providers using OMT (precourse mean, five, vs. postcourse mean, six; p=0.171), and providers using OMT more often (precourse OMT use monthly or more often, three, vs. postcourse OMT use monthly or more often, six; p=0.131). Conclusions Implementing a longitudinal elective curriculum is a feasible way to improve attitudes and confidence in OMT for MDs involved in a family medicine residency. Whether our elective leads to competency in OMT for allopathic residents and faculty remains to be formally evaluated. Our pilot established the feasibility and led to a revision of our curriculum; the elective continues to occur yearly. Future analyses will focus on competency assessment.

Context Students enrolled in health professional (HP) programs receive varying amounts of credit hours dedicated to nutritional education, and obesity remains an issue in the United States among healthcare providers. Objectives To assess whether HP students differ in nutrition and exercise habits from non-health professional (NHP) students at a single university, and whether any gender-related differences existed in those habits. Methods From September 25, 2018 to October 10, 2019, a 16-question multiple-choice survey was distributed via e-mail or in person to HP and NHP students enrolled at Nova Southeastern University (NSU) in Fort Lauderdale, Florida. Questions targeted participant dietary and exercise habits. Each question had five multiple-choice answer options, each of which was assigned a coded value to compare similarities and differences between the HP and NHP groups. Results Of 732 responses (569 HP, 163 NHP), results showed no statistically significant difference between enrollment groups (p>0.05) in any response parameter including consumption of sweets, fast food, red meat, caffeine, water, fruit, and vegetables. Comparisons among sexes demonstrated significant differences. Women consumed less red meat, water, and protein, and women participated in less exercise compared to men. Women also consumed more sweets compared to men. Conclusions Results suggest that NSU students enrolled in HP and NHP programs have similar nutritional concepts and eating habits. This may indicate a need to strengthen nutritional education in dietary health and wellness for HP students.

Context Medical students, especially at osteopathic medical schools, have limited research exposure. Systematic instruction in research, supervised by qualified mentors, could motivate osteopathic medical students to pursue research in their careers, thereby increasing the number of future clinician-scientists. Recruiting and retaining suitable research mentors are crucial to sustaining such programs, but this task is also particularly challenging for osteopathic medical schools. Objectives To assess mentors' experiences in a voluntary student-mentor medical research program. Methods An online survey was sent to 76 university- or hospital-based participants who previously mentored 219 medical students between 2014 and 2019. The questionnaire consisted of 13 items with responses in checklist, five-point Likert scale, and categorical multiple-choice formats, assessing motivation for participation, satisfaction with the program, and interest in future participation. Data were analyzed descriptively, and responses from mentors at the university and hospital were compared using univariate logistic and ordinal regression analyses. Results Among 70 (92.1%) mentors who responded to the survey, 61 (87.1%) reported being motivated by a desire to help medical students learn research. Forty-nine (70.0%) mentors indicated that furthering their own research productivity was a motivation, and hospital-based mentors were statistically significantly more likely to endorse this source of motivation (OR=2.02; 95% CI=1.18–3.45; p=0.01). Most respondents were satisfied with the quality of the students' work (59 [84.3%]) and with the program (59 [85.5%]). However, 46 (65.7%) suggested the program could be enhanced by requiring medical students to be physically present in the clinic or laboratory for a minimum amount of time. Importantly, most (58 [84.1%]) mentors reported that they would be interested in participating in future mentored research programs. Conclusions Mentors were motivated to participate in the voluntary research program for both altruistic and professional reasons. Since most mentors reported being satisfied with the program, it is likely they would participate in future mentored research programs. Our results suggest that mentors viewed this voluntary research program as mutually beneficial.

Context Evidence has shown that spinal mobilization with leg movement (SMWLM) and progressive inhibition of neuromuscular structures (PINS) are individually effective in the management of lumbar radiculopathy. However, previous evidence reported data for only a short-term study period and did not investigate the effect of the combined manual therapy techniques. Objectives To compare the combined effects of two manual therapy techniques (SMWLM and PINS) with the individual techniques alone (SMWLM or PINS) in the management of individuals with lumbar radiculopathy. Methods A total of 60 patients diagnosed with unilateral lumbar radiculopathy secondary to disc herniation were randomly allocated into three groups: 20 participants each in the SMWLM, PINS, and combined SMWLM + PINS groups. Each group attended two treatments per week for 30 min each, for three months. Participants were assessed at baseline, immediately posttreatment, and then at three, six, and nine months follow-up using the Visual Analog Scale (VAS), Rolland-Morris Disability Questionnaire (RMDQ), and Sciatica Bothersomeness Index (SBI). Results Between-groups analyses using a two-way repeated-measures analysis of variance indicated significant interactions between groups and follow-up times for all outcomes (p=0.001). Participants receiving combined SMWLM + PINS treatment experienced greater improvement in leg pain, back pain, disability, and sciatica at all timelines (immediately posttreatment, and three, six, and nine months follow-up) than the participants receiving SMWLM or PINS alone (p<0.05). However, participants receiving SMWLM alone showed better improvement than the participants receiving PINS alone at all timelines (p<0.05). Conclusions A combined SMWLM + PINS treatment protocol showed greater improvement than the individual techniques alone in the management of individuals with LR in this study.

Context The parasympathetic-mediated inflammatory reflex inhibits excessive proinflammatory cytokine production. Noninvasive techniques, including occipitoatlantal decompression (OA-D) and transcutaneous auricular vagus nerve stimulation (taVNS), have been demonstrated to increase parasympathetic tone. Objectives To test the hypothesis that OA-D and taVNS increase parasympathetic nervous system activity and inhibit proinflammatory cytokine mobilization and/or production. Methods Healthy adult participants were randomized to receive OA-D (5 min of OA-D followed by 10 min of rest; n=8), taVNS (15 min; n=9), or no intervention (15 min, time control; n=10) on three consecutive days. Before and after these interventions, saliva samples were collected for determination of the cytokines interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor α (TNF-α). Arterial blood pressure and the electrocardiogram were recorded for a 30-min baseline, throughout the intervention, and during a 30-min recovery period to derive heart rate and blood pressure variability markers as indices of vagal and sympathetic control. Results OA-D and taVNS increased root mean square of successive RR interval differences (RMSSD) and high frequency heart rate variability, which are established markers for parasympathetic modulation of cardiac function. In all three groups, the experimental protocol was associated with a significant increase in salivary cytokine concentrations. However, the increase in IL-1β was significantly less in the taVNS group (+66 ± 13 pg/mL; p<0.05) than in the time control group (+142 ± 24 pg/mL). A similar trend was observed in the taVNS group for TNF-α (+1.7 ± 0.3 pg/mL vs. 4.1 ± 1.3 pg/mL; p<0.10). In the OA-D group baseline IL-6, IL-8, and TNF-α levels on the third study day were significantly lower than on the first study day (IL-6: 2.3 ± 0.4 vs. 3.2 ± 0.6 pg/mL, p<0.05; IL-8: 190 ± 61 vs. 483 ± 125 pg/mL, p <0.05; TNF-α: 1.2 ± 0.3 vs. 2.3 ± 0.4 pg/mL, p<0.05). OA-D decreased mean blood pressure from the first (100 ± 8 mmHg) to the second (92 ± 6 mmHg; p<0.05) and third (93 ± 8 mmHg; p<0.05) study days and reduced low frequency spectral power of systolic blood pressure variability (19 ± 3 mmHg 2 after OA-D vs. 28 ± 5 mmHg 2 before OA-D; p<0.05), a marker of sympathetic modulation of vascular tone. OA-D also increased baroreceptor-heart rate reflex sensitivity from the first (13.7 ± 3.0 ms/mmHg) to the second (18.4 ± 4.3 ms/mmHg; p<0.05) and third (16.9 ± 4.2 ms/mmHg; p<0.05) study days. Conclusions Both OA-D and taVNS elicited antiinflammatory responses that were associated with increases in heart rate variability-derived markers for parasympathetic function. These findings suggest that OA-D and taVNS activate the parasympathetic antiinflammatory reflex. Furthermore, an antihypertensive effect was observed with OA-D that may be mediated by reduced sympathetic modulation of vascular tone and/or increased baroreceptor reflex sensitivity.

Context Reviews exploring harm outcomes such as adverse effects (AE), all cause dropouts (ACD), dropouts due to inefficacy, and dropouts due to AE associated with osteopathic manipulative treatment (OMT) or osteopathic manual therapy (OMTh) are scant. Objectives To explore the overall AE, ACD, dropouts due to inefficacy, and AE in chronic noncancerous pain (CNCP) patients receiving OMTh through a systematic review of previous literature. Methods For this systematic review and meta-analysis, the authors searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Physiotherapy Evidence Database (PEDro), EMCare, and Allied and Complementary Medicine Database (AMED), and Ostmed.Dr, as well as the bibliographical references of previous systematic reviews evaluating OMTh for pain severity, disability, quality of life, and return to work outcomes. Randomized controlled trials with CNCP patients 18 years or older with OMTh as an active or combination intervention and the presence of a control or combination group were eligible for inclusion. In this sub-study of a previous, larger systematic review, 11 studies (n=1,015) reported data that allowed the authors to perform meta-analyses on ACD and dropouts due to AE. The risk of bias (ROB) was assessed with the Cochrane ROB tool and the quality of evidence was determined with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Results The pooled analysis showed that ACD was not significantly different for visceral OMTh (vOMTh) vs. OMTh control (odds ratio [OR]=2.66 [95% confidence interval [[CI]], 0.28, 24.93]) or for OMTh vs. standard care (OR=1.26 [95% CI, 0.84, 1.89]; I 2 =0%). Single study analysis showed that OMTh results were nonsignificant in comparison with chemonucleolysis, gabapentin, and exercise. OMTh in combination with gabapentin (vs. gabapentin alone) and OMTh in combination with exercise (vs. exercise alone) showed nonsignificant ACD. Dropouts due to AE were not significantly different, but the results could not be pooled due to an insufficient number of studies. Conclusions Most articles did not explicitly report AEs, ACD rates, or dropouts due to AEs and inefficacy. The limited data available on dropouts showed that OMTh was well tolerated compared with control interventions, and that the ACD and dropouts due to AEs were not significantly different than comparators. Future trials should focus on explicit reporting of dropouts along with beneficial outcomes to provide a better understanding of OMTh efficacy.

The national vaccination effort for novel coronavirus 2019 (COVID-19) is among the greatest operational challenges America has ever faced, the success of which depends upon reaching communities across the United States. In this Commentary, the Executive Dean of Ohio University’s Heritage College of Osteopathic Medicine (OUHCOM) describes the logistics and processes of vaccine delivery at OUHCOM, both on campus and beyond. Among those logistical considerations is a partnership with the local health department and hospital system, as well as student involvement in vaccination efforts.

Context Type 2 diabetes (T2D) mellitus, which was once considered a disease affecting adults, is a growing problem among youths. Research now shows that T2D in youths is more progressive and associated with earlier onset of complications than adult-onset T2D. Objectives To update practicing clinical physicians on what is currently known about pediatric T2D and share current guidelines to care for these patients. Methods The authors conducted a literature review through the MEDLINE/PubMed, Google Scholar, and clinicaltrials.gov databases in July 2019 using the following search phrases: “youth-onset type 2 diabetes,” “pediatric type 2 diabetes,” “diabetes in youth,” and “FDA-approved pediatric diabetes medications.” Items published between 2010 and 2019 and written in English were included. Results A total of 65 items were included after database review, including 44 articles, 10 FDA product inserts, six clinicaltrials.gov listings, three position statements/guideline documents, one website, and one FDA announcement. Conclusions There are very limited treatment options available to manage pediatric T2D. Prevention of pediatric T2D is paramount, which requires a high index of suspicion, routine screening of children and adolescents, and willingness to engage in family-based interventions for those at risk for prediabetes and T2D. Osteopathic physicians have a unique opportunity to help by applying the osteopathic principles to the whole person – including environmental, societal, and lifestyle factors – to help patients achieve their health and wellness goals.