Publications

Anxiety disorders are one of the most common psychiatric disorders presenting to the family physician. Anxiety disorders are both biologic and psychologic in origin. Anxiety is a signal alerting the individual of ‘danger.’ This danger can be unknown, internal, conflictual and vague. The anxiety signal allows the individual to respond to, and resolve the ‘danger.’ This is to be differentiated from fear which is the emotional response to a real or perceived imminent threat. These two states overlap but differ in that fear more often triggers the physiologic response of fight or flight. Anxiety disorders result when one or both of these systems are in a chronic ‘hyper reactive’ state for either biologic or psychologic reasons. This article reviews the criteria for anxiety disorders and the range of therapeutic interventions, pharmacologic and non-pharmacologic.

CONTEXT: Assessment of the anterior superior iliac spine (ASIS) is a key component in generating the pelvic diagnosis of somatic dysfunction, but studies have shown poor reliability between examiners.

OBJECTIVE: To assess the influence of homogeneous training, years of experience, and eye dominance on the percentage of correctness, sensitivity, and specificity of ASIS evaluation.

METHODS: Osteopathic physicians, predoctoral teaching fellows, and first- and second-year osteopathic medical students from a single teaching institute assessed 3 plastic pelvic models with ASIS anatomic landmarks set at different levels: even and 5- and 10-mm descrepancies. Dominant and nondominant eyes were used independently to assess ASIS levels.

RESULTS: A total of 147 examiners (participants) participated in this study (66 first-year and 61 second-year medical students, 15 fellows, and 5 osteopathic physicians). The overall percentages of correct results were 31.0% (even levels), 82.8% (5-mm discrepancy), and 91.7% (10-mm discrepancy). Differences by level of training were statistically significant only for the 5-mm ASIS discrepancy, where participants with more experience performed better. The overall sensitivity was 82.8% (5-mm discrepancy) and 91.7% (10-mm discrepancy), and the specificity was 31.0%. No statistically significant differences were found in the percentage of correct results by eye dominance.

CONCLUSION: Assessment of ASIS is sensitive but not specific at discrepancies of 5 mm or greater. Length of experience positively influences the percentage of correct results, and eye dominance does not significantly change this outcome. This form of assessment can be used to screen for ASIS asymmetry.

Multidisciplinary fragmentation contributes to myriad medical errors and as many as 98,000 patient deaths per year. The Institute of Medicine has proposed steps to improve healthcare delivery, including providing more opportunities for interdisciplinary training. The authors describe the interprofessional education (IPE) program at Western University of Health Sciences (WesternU) in Pomona, California. In 2007, 9 colleges at WesternU-including the College of Osteopathic Medicine of the Pacific-undertook an IPE initiative that resulted in creation of a 3-phase program. Part of the IPE development process involved identifying core competencies that were nontechnical and nonclinical and common to all healthcare professions. The IPE development and implementation process and the identified competencies were analyzed for their relationship to the tenets of osteopathic medicine and the core competencies of osteopathic medical education. Although these tenets and core competencies were not intentionally used in the development process of the WesternU IPE program, the analysis revealed that the major components of the program are congruent with the framework of osteopathic principles and practice. The osteopathic medical profession's founding principles, broad-based perspective, and health-promoting tenets put the profession in a position to emerge as one of the leading forces in IPE.

OBJECTIVE: To assess the safety and feasibility of studying osteopathic manipulative treatment and its potential effectiveness for patients with vertigo.

DESIGN: A nonrandomized pilot study.

SETTING: Outpatient clinic affiliated with a teaching hospital and osteopathic medical school.

PATIENTS: The subjects were older than 18 years of age, with the diagnosis of vertigo for longer than 3 months.

INTERVENTION: The patients were treated with osteopathic manipulative treatment (OMT).

MAIN OUTCOME MEASUREMENTS: Treatment effectiveness was measured with the use of the Dizziness Handicap Inventory (DHI), a validated symptom inventory. Intensity and duration of adverse effects after OMT were used to measure study safety.

RESULTS: Of the 18 patients who were recruited all 18 (100%) met the inclusion criteria and were enrolled in the study. Sixteen patients (88.9%) completed the treatment course with OMT, and data with respect to the DHI were obtained from all 16 (100%). Significant improvement (P<.001) in total and subcomponent DHI scores was observed after completion of treatment. Of the 8 patients with moderate pretest scores, 7 (87.5%) had mild post-test scores after undergoing OMT, and of the 8 patients with severe pretest scores, 4 (50%) had mild post-test scores. Of the 18 enrolled patients, 3 (16.7%) experienced an exacerbation of their vertigo, and 5 (27.8%) experienced muscle soreness after OMT. These adverse effects were mild and transient, not lasting longer than 24 hours.

CONCLUSIONS: This study showed that OMT is generally well tolerated in patients with vertigo. It also demonstrated that it is feasible to recruit a population of patients with vertigo who can complete a course of OMT and collect data by using the DHI. A randomized control trial that examines the efficacy of OMT in patients with vertigo is warranted, given that OMT may be a reasonable treatment for vertigo and the functional impairment associated with it.

Avian influenza is an infection caused by the H5N1 virus. The infection is highly contagious among birds, and only a few known cases of human avian influenza have been documented. However, healthcare experts around the world are concerned that mutation or genetic exchange with more commonly transmitted human influenza viruses could result in a pandemic of avian influenza. Their concern remains in spite of the fact that the first United States vaccine against the H5N1 virus was recently approved. Under these circumstances the fear is that a pandemic of avian influenza could result in the kind of mortality that was seen with the Spanish influenza pandemic of 1918-1919, where the number of deaths was estimated to be as high as 40 million people. Retrospective data gathered by the American Osteopathic Association shortly after the 1918-1919 influenza pandemic have suggested that osteopathic physicians (DOs), using their distinctive osteopathic manipulative treatment (OMT) methods, observed significantly lower morbidity and mortality among their patients as compared to those treated by allopathic physicians (MDs) with standard medical care available at the time. In light of the limited prevention and treatment options available, it seems logical that a preparedness plan for the treatment of avian influenza should include these OMT procedures, provided by DOs and other healthcare workers capable of being trained to perform these therapeutic interventions. The purpose of this paper is to discuss the characteristics of avian influenza, describe the success of DOs during the 1918-1919 Spanish influenza pandemic, describe the evidence base for the inclusion of OMT as part of the preparedness plan for the treatment of avian influenza, and describe some of the specific OMT procedures that could be utilized as part of the treatment protocol for avian influenza patients.

STUDY DESIGN: A systematic review.

OBJECTIVES: To determine the quality of the research and assess the interexaminer and intraexaminer reliability of spinal palpatory diagnostic procedures.

SUMMARY OF BACKGROUND DATA: Conflicting data have been reported over the past 35 years regarding the reliability of spinal palpatory tests.

METHODS: The authors used 13 electronic databases and manually searched the literature from January 1, 1966 to October 1, 2001. Forty-nine (6%) of 797 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus or a content expert reconciled discrepancies.

RESULTS: The quality scores ranged from 25 to 79/100. Subject description, study design, and presentation of results were the weakest areas. The 12 highest quality articles found pain provocation, motion, and landmark location tests to have acceptable reliability (K = 0.40 or greater), but they were not always reproducible by other examiners under similar conditions. In those that used kappa statistics, a higher percentage of the pain provocation studies (64%) demonstrated acceptable reliability, followed by motion studies (58%), landmark (33%), and soft tissue studies (0%). Regional range of motion is more reliable than segmental range of motion, and intraexaminer reliability is better than interexaminer reliability. Overall, examiners' discipline, experience level, consensus on procedure used, training just before the study, or use of symptomatic subjects do not improve reliability.

CONCLUSION: The quality of the research on interreliability and intrareliability of spinal palpatory diagnostic procedures needs to be improved. Pain provocation tests are most reliable. Soft tissue paraspinal palpatory diagnostic tests are not reliable.

BACKGROUND: Many health care professionals use spinal palpatory exams as a primary and well-accepted part of the evaluation of spinal pathology. However, few studies have explored the validity of spinal palpatory exams. To evaluate the status of the current scientific evidence, we conducted a systematic review to assess the content validity of spinal palpatory tests used to identify spinal neuro-musculoskeletal dysfunction.

METHODS: Review of eleven databases and a hand search of peer-reviewed literature, published between 1965-2002, was undertaken. Two blinded reviewers abstracted pertinent data from the retrieved papers, using a specially developed quality-scoring instrument. Five papers met the inclusion/exclusion criteria.

RESULTS: Three of the five papers included in the review explored the content validity of motion tests. Two of these papers focused on identifying the level of fixation (decreased mobility) and one focused on range of motion. All three studies used a mechanical model as a reference standard. Two of the five papers included in the review explored the validity of pain assessment using the visual analogue scale or the subjects' own report as reference standards. Overall the sensitivity of studies looking at range of motion tests and pain varied greatly. Poor sensitivity was reported for range of motion studies regardless of the examiner's experience. A slightly better sensitivity (82%) was reported in one study that examined cervical pain.

CONCLUSIONS: The lack of acceptable reference standards may have contributed to the weak sensitivity findings. Given the importance of spinal palpatory tests as part of the spinal evaluation and treatment plan, effort is required by all involved disciplines to create well-designed and implemented studies in this area.