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1.  Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: The UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761] 
Background
Low back pain (LBP) is a common and costly problem. Initiatives designed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence-based clinical guidelines. The three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines. Even so, many seem unaware that such guidelines exist. Furthermore, the behaviour of at least some of these practitioners differs from that recommended in these guidelines.
Few randomised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control. All these trials have used a cluster design and most have methodological flaws. None specifically focus upon practitioner behaviour towards LBP patients. Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results. Although numerous LBP guidelines have been developed worldwide, there is a paucity of data on whether their dissemination actually changes practitioner behaviour. Primarily because of its low unit cost, sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy. The effect size of such a strategy, at an individual practitioner level, is likely to be small. However, if large numbers of practitioners are targeted, this strategy might achieve meaningful changes at a population level.
Methods
The primary aim of this prospective, pragmatic randomised controlled trial is to test the short-term effectiveness (six-months following intervention) of a directly-posted information package on the reported clinical behaviour (primary outcome), attitudes and beliefs of UK chiropractors, osteopaths and musculoskeletal physiotherapists. We sought to randomly allocate a combined sample of 1,800 consenting practitioners to receive either the information package (intervention arm) or no information above that gained during normal practice (control arm). We collected questionnaire data at baseline and six-months post-intervention. The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity, work and bed-rest, that fall within categories previously defined by an expert consensus exercise as either 'guideline-consistent' and 'guideline-inconsistent'.
doi:10.1186/1471-2474-6-41
PMCID: PMC1208895  PMID: 16033646
2.  Referrals to chiropractors and osteopaths: a survey of general practitioners in rural and regional New South Wales, Australia 
Background
Chiropractic and osteopathy form a significant part of the healthcare setting in rural and regional Australia, with national registration of practitioners, public subsidies for services and high utilisation by the Australian public. However, despite their significant role in rural and regional Australia, there has been little exploration of the interface between chiropractic and osteopathy and conventional primary health care practitioners in this area. The study aim was to examine the referral practices and factors that underlie referral to chiropractors and osteopaths by rural and regional Australian general practitioners (GPs), by drawing on a sample of GPs in rural and regional New South Wales.
Methods
A 27-item questionnaire was sent to all 1486 GPs currently practising in rural and regional Divisions of General Practice in New South Wales, Australia.
Results
A total of 585 GPs responded to the questionnaire, with 49 questionnaires returned as “no longer at this address” (response rate: 40.7%). The majority of GPs (64.1%) referred to a chiropractor or osteopath at least a few times per year while 21.7% stated that they would not refer to a chiropractor or osteopath under any circumstances. Patients asking the GP about CAM (OR=3.59; CI: 1.12, 11.55), GP’s use of CAM practitioners as a major source of information (OR=4.39; 95% CI: 2.04, 9.41), lack of other treatment options (OR=2.41; 95% CI: 1.18, 5.12), access to a wide variety of medical specialists (OR=12.5; 95% CI: 2.4, 50.0), GP’s belief in the efficacy of chiropractic and osteopathy services (OR=3.39; 95% CI: 2.19, 5.25) and experiencing positive results from patients using these services previously (OR=1.67; CI: 1.02, 2.75) were all independently predictive of increased referral to chiropractic and osteopathy services amongst the rural GPs.
Conclusions
There is a significant interface between chiropractic and osteopathy and Australian rural and regional general practice in New South Wales. Although there is generally high support for chiropractic and osteopathy among Australian GPs, this was not absolute and the heterogeneity of responses suggests that there remain tensions between the professions. The significant interface between chiropractic and osteopathy may be due in part to the inclusion of these professions in the publicly subsidised national healthcare delivery scheme. The significant impact of chiropractic and osteopathy and general practice in rural and regional Australian healthcare delivery should serve as an impetus for increased research into chiropractic and osteopathy practice, policy and regulation in these areas.
doi:10.1186/2045-709X-21-5
PMCID: PMC3599860  PMID: 23369205
Chiropractic; Osteopathy; General practice; Rural healthcare; Health services; Referral; Interdisciplinary care; Primary care
3.  The provision of chiropractic, physiotherapy and osteopathic services within the Australian private health-care system: a report of recent trends 
Background
Chiropractors, physiotherapists, and osteopaths receive training in the diagnosis and management of musculoskeletal conditions. As a result there is considerable overlap in the types of conditions that are encountered clinically by these practitioners. In Australia, the majority of benefits paid for these services come from the private sector. The purpose of this article is to quantify and describe the development in service utilization and the cost of benefits paid to users of these healthcare services by private health insurers. An exploration of the factors that may have influenced the observed trends is also presented.
Methods
A review of data from the Australian Bureau of Statistics, Australian Health Practitioner Regulation Agency, and the Australian Government Private Health Insurance Administration Council was conducted. An analysis of chiropractic, physiotherapy and osteopathic service utilisation and cost of service utilisation trend was performed along with the level of benefits and services over time.
Results
In 2012, the number of physiotherapists working in the private sector was 2.9 times larger than that of chiropractic, and 7.8 times that of the osteopathic profession. The total number of services provided by chiropractors, physiotherapists, and osteopaths increased steadily over the past 15 years. For the majority of this period, chiropractors provided more services than the other two professions. The average number of services provided by chiropractors was approximately two and a half times that of physiotherapists and four and a half times that of osteopaths.
Conclusions
This study highlights a clear disparity in the average number of services provided by chiropractors, physiotherapists, and osteopaths in the private sector in Australia over the last 15 years. Further research is required to explain these observed differences and to determine whether a similar trend exists in patients who do not have private health insurance cover.
doi:10.1186/2045-709X-22-3
PMCID: PMC3896731  PMID: 24428934
Chiropractic; Physiotherapy; Osteopathy; Allied health; Healthcare utilisation
4.  A COMPARISON OF THE PATIENT DEMOGRAPHICS OF VICTORIAN CHIROPRACTIC AND OSTEOPATHIC CLINICS 
COMSIG review  1994;3(2):48-53.
While there are studies that describe the patient demographics of both Australian and American chiropractic clinics, such information appears difficult to find for physiotherapy or osteopathic clinics comparative data of any kind doesn't appear to exist. This study attempted to provide this data for Australian practices and to analyse any similarities or differences between populations.
Results obtained for chiropractors and osteopaths would appear to suggest that there may be significant differences between the diagnostic profiles of the two professions. Physiotherapists withdrew from the - process during data collection.
Suggestions are made relating to possible modifications I to the survey instrument and possible directions any future study might take.
PMCID: PMC2050142
Patients; statistics and numerical dam demography; utilisation; chiropractic; osteopathy; databases
5.  RISK MANAGEMENT FOR CHIROPRACTORS AND OSTEOPATHS 
Although rare, vertebrobasilar stroke is the best known of the possible side effects of cervical manipulation. Due to the serious sequelae that may result from cervical manipulation, chiropractors and osteopaths must take the appropriate steps to ensure the risk is minimised. This article outlines how the astute practitioner can minimise this risk. Practitioners must decide on the options for treatment of a patient with neck problems. Practitioners must also advise the patient of these options as part of an appropriate informed consent.
PMCID: PMC2051301  PMID: 17987199
Chiropractic; stroke; manipulation
6.  The establishment of the Chiropractic & Osteopathic College of Australasia in Queensland (1996–2002) 
Introduction
For chiropractors and osteopaths after graduation, the learning process continues by way of experience and continuing education (CE). The provision of CE and other vocational services in Queensland between 1996 and 2002 is the subject of this paper.
Methods
The Chiropractic & Osteopathic College of Australasia (COCA) implemented a plan, which involved continuing education, with speakers from a broad variety of health provider areas; and the introduction of the concepts of evidence-based practice. The plan also involved building membership.
Results
Membership of COCA in Queensland grew from 3 in June 1996 to 167 in 2002. There were a total of 25 COCA symposia in the same period. Evidence-based health care was introduced and attendees were generally satisfied with the conferences.
Discussion
The development of a vocational body (COCA) for chiropractors and osteopaths in Queensland was achieved. Registrants in the field have supported an organisation that concentrates on the vocational aspects of their practice.
doi:10.1186/1746-1340-13-3
PMCID: PMC1151651  PMID: 15967046
Chiropractic; osteopathy; continuing education; vocational education; evidence-based practice; Queensland
7.  THE JOURNAL OF THE CHIROPRACTIC & OSTEOPATHIC COLLEGE OF AUSTRALASIA 
The first edition of the Journal of the Chiropractic and Osteopathic College of Australasia was known as COMSIG Review and was published in November, 1992 to coincide with a large conference that COCA had organised in Melbourne.
In the first few years the majority of articles were magazine style reviews, similar to these found in the Australian Family Physician. The first Editor was Bruce Walker and subsequent Editors have included John Drinkwater, Stephanie Campbell and John Reggars. The current Editors in Chief, Peter Tuchin and Henry Pollard, are staff members at Macquarie University, Centre of Chiropractic, with a strong background in science and research and both are currently undertaking post-graduate research degrees.
Over several years the magazine review style was changed in keeping with a more full journal format. An Editorial Board was formed, comprised of chiropractors, osteopaths and medical practitioners, some of whom are world renowned in their particular field of research.
By March, 1996 it was decided to change the name of the journal to Australasian Chiropractic and Osteopathy (ACO). This was a purposeful move to reflect the maturing of the journal and also the growth of the College and in the five years since November 1992, seventy-nine scientific articles have been published.
It is anticipated that the journal will continue to be widely distributed throughout the world, with current subscriptions from all Australian undergraduate chiropractic and osteopathic institutions and the vast majority of international undergraduate institutions.
ACO is currently indexed with Mantis (formerly Chirolars). The Editorial Panel continue to strive for Australasian Chiropractic and Osteopathy inclusion into Index Medicus and thereby Medline. However, it is recognised that readership of chiropractic journals is very low throughout the world and it is unlikely in the near future that any chiropractic journal other than the Journal of Manipulative and Physiological Therapeutics will be included in Index Medicus.
The lack of mainstream international indexing will not stop or prevent the College from producing a first rate journal into the future years of the professions. In fact with the now steady growth in Australian chiropractic and osteopathic research, it is envisaged that ACO will be Australia's leading professional journal. We trust our membership enjoy reading the journal and find many of its articles instructional.
We look forward to any comments from members relating to the production of the journal and any suggestions will be welcomed.
PMCID: PMC2050635  PMID: 17989763
Australasian Chiropractic Osteopathy; journal
8.  Chiropractors & Osteopaths Musculo-Skeletal Interest Group (COMSIG) 
COMSIG Review  1992;1(1):2.
The Chiropractors & Osteopaths Musculo-Skeletal Interest Group evolved from regular clinical meetings at Ringwood Clinic, a multi-disciplinary clinic in Melbourne
In 1987 the Directors of the clinic Bruce F. Walker D.C. and Alison Hogg MB.BS. (Hons), FRACGP. Decided to invite a range of guest speakers (on musculo-skeletal topics) to give an address every 6 weeks
Local practitioners of all persuasions were invited to attend these meetings. Although all groups were represented, by far the greatest interest shown by the chiropractors and osteopaths
In 1989 Peter D. Werth B.App.Sc.(Chiro) joined the team and together with the writer formulated a plan to broaden the list of invited guests to all registered chiropractors and osteopaths in Melbourne
Naturally, this required a larger venue and organisation. After several successful meetings attracting groups of 60 to 70 practitioners we formalised the COMSIG organisation and gained the invaluable assistance of David de l Harpe B.Sc., B.App.Sc.(Chiro), MB.,BS., Shane Carter B.App.Sc.(Chiro) and Simon Clement D.O. on our committee. More recently Shane Carter left for overseas and was ably replaced by Miriam Bourke B.App.Sc.(Chiro)
This year COMSIG incorporated under the name of the long established Chiropractic & Osteopathic College of Australasia
So, what is COMSIG and what are it’s objectives? COMSIG is a special interest group of the Chiropractic & Osteopathic College of Australasia. More specifically, it is an affiliation of Chiropractors and Osteopaths with interests pertaining to the musculo-skeletal system
The objectives for which COMSIG was established are: to promote knowledge of disorders of the musculo-skeletal system.to provide a forum for the interchange of ideas related to such disorders.to educate chiropractors, osteopaths and other health professionals about the diagnosis and management of such disorders.to encourage the diagnosis and management of musculo-skeletal disorders in a scientific and ethical manner.to conduct, promote, and arrange meetings, seminars, symposia, conferences, and lectures on musculo-skeletal disorders.to foster research into musculo-skeletal disorders.
Importantly, COMSIG is not a political organisation but rather an academic organisation arising from the practitioner ranks of the professions
We encourage all those with an interest in musculo-skeletal disorders to join COMSIG and participate in its development. An application form is enclosed, or available from the Secretary…
PMCID: PMC2050005  PMID: 17989738
Chiropractic; osteopathy; Australia; education
9.  Osteopathic intervention in chronic non-specific low back pain: a systematic review 
Background
Chronic Non Specific Low Back Pain (CNSLBP) is a common, complex and disabling condition that has been present for longer than three months and is not caused by a serious pathology. Osteopaths are health practitioners who commonly diagnose and treat CNSLBP patients using a complex set of interventions that includes manual therapy. The study aimed to complete a Systematic Review of clinical research into osteopathic intervention in CNSLBP using a rigorous assessment of study quality.
Methods
The literature was searched to August 2011 using the following databases: AMED, CINAHL Plus, Cochrane Central Register of Clinical Trials, MEDLINE Plus, EMBASE, MANTIS, OSTMED, PEDro, ScienceDirect. Multiple search terms were used in various combinations: osteopathy/osteopathic, osteopathic manipulative technique, OMT, Spinal Manipulative Therapy, SMT, clinical trial, back pain, chronic back pain. The inclusion criteria were papers that: reported clinical trials; had adult participants; tested the effectiveness and/or efficacy of osteopathic manual therapy intervention applied by osteopaths, and had a study condition of CNSLBP. The quality of the papers was assessed using the Cochrane Back Review Risk of Bias criteria. A meta-analysis would proceed if the studies had adequate clinical and methodological homogeneity.
Results
Initial searches revealed 809 papers, 772 of which were excluded on the basis of abstract alone. The remaining 37 trial papers were subjected to a more detailed analysis of the full text, which resulted in 35 being excluded. The two remaining trials had a lack of methodological and clinical homogeneity, precluding a meta-analysis. The trials used different comparators with regards to the primary outcomes, the number of treatments, the duration of treatment and the duration of follow-up.
Conclusion
There are only two studies assessing the effect of the manual therapy intervention applied by osteopathic clinicians in adults with CNSLBP. One trial concluded that the osteopathic intervention was similar in effect to a sham intervention, and the other suggests similarity of effect between osteopathic intervention, exercise and physiotherapy. Further clinical trials into this subject are required that have consistent and rigorous methods. These trials need to include an appropriate control and utilise an intervention that reflects actual practice.
doi:10.1186/1471-2474-14-129
PMCID: PMC3623881  PMID: 23570655
Systematic review; Osteopathy; Osteopathic manipulative treatment; Low back pain; Chronic low back pain; Non-specific low back pain; Manual therapy; Clinical trial methodology
10.  RISK MANAGEMENT FOR CHIROPRACTORS AND OSTEOPATHS 
This article is the second in a series of articles dealing with risk management in the practise of chiropractic and osteopathy, prepared by the COCA Risk Management Subcommittee.
Background: Radiographic examination carries risks that must be weighed against the possible benefits when determining patient care.
Objective: The objective of this article is to propose guidelines for the use of imaging in chiropractic and osteopathic practice.
Discussion: Plain film radiography, CT scan, magnetic resonance imaging (MRI) and other forms of imaging are available for use in chiropractic and osteopathic practice in Australia. The astute practitioner utilises these imaging procedures for clinical decision making in order to make an accurate diagnosis that will determine a patient’s management. This article attempts to guide the practitioner in the proper use of these imaging procedures for different regions of the body.
PMCID: PMC2051318  PMID: 17987210
Chiropractic; risk management; osteopathy
11.  Primary Reasons for Osteopathic Consultation: A Prospective Survey in Quebec 
PLoS ONE  2014;9(9):e106259.
Background
Osteopathy is an increasingly popular health care modality to address pain and function in the musculoskeletal system, organs and the head region, as well as functional somatic syndromes. Although osteopathy is recommended principally in guidelines for management of back pain, osteopaths' scope of practice is wide, albeit poorly defined. In order to understand better the practice of osteopathy, this study aimed to investigate the most common reasons for osteopathic consultations in clinical settings in Quebec.
Methods
A prospective survey of members of the Registre des ostéopathes du Québec was conducted to examine demographics in osteopathic practices, as well as patients' primary reasons for consultations over a two-week period. The questionnaire was devised following a literature review and refined and verified with two stages of expert input.
Results
277 osteopaths (60.1% response rate) responded to the survey notice. 14,002 patients' primary reasons for consultations were reported in completed questionnaires and returned by practicing osteopaths. Musculoskeletal pain located in the spine, thorax, pelvis and limbs was the most common reason for consultations (61.9%), with females consulting most commonly for cervical pain and males for lumbar pain. Perinatal and paediatric (11.8%), head (9.1%), visceral (5.0%) and general concerns (4.8%) were the other most common reasons for consultations. Preventive care represented the remaining 0.3%.
Interpretation
The nature of primary reasons for osteopathic consultations, coupled with documented satisfaction of patients with this approach, suggest a future for multidisciplinary collaborative health care including osteopathy. Results of this survey may contribute to informing physicians and others pending regulation of Quebec osteopaths, and also provide direction for future clinical research and guidelines development.
doi:10.1371/journal.pone.0106259
PMCID: PMC4153609  PMID: 25184204
12.  Responding to the challenge of clinically relevant osteopathic research: efficacy and beyond 
The osteopathic profession has been challenged over the past decade to provide clinically relevant research. The conduct of evidence-based osteopathic research is imperative not only for scientific, economic, and professional reasons, but also to drive health care policy and clinical practice guidelines. This paper summarizes recent studies in response to the osteopathic research challenge, including clinical trials registered with ClinicalTrials.gov and a systematic review and meta-analysis of osteopathic manipulative treatment (OMT) for low back pain. The concept of the OMT responder is introduced and supported with preliminary data. Within the context of a pain processing model, consideration is given to genomic (e.g., the catechol-O-methyltransferase gene) and psychological (e.g., depression and somatization) factors that are associated with pain sensitivity and pain progression, and to the role that such factors may play in screening for OMT responders. While substantial progress has been made in osteopathic research, much more needs to be done.
doi:10.1016/j.ijosm.2007.01.002
PMCID: PMC2084062  PMID: 18311324
osteopathy; osteopathic medicine; osteopathic manipulative treatment (OMT); low back pain; genomics; catechol-O-methyltransferase (COMT); pain processing
13.  Effectiveness of osteopathic manipulative treatment in neonatal intensive care units: protocol for a multicentre randomised clinical trial 
BMJ Open  2013;3(2):e002187.
Introduction
Neonatal care has been considered as one of the first priorities for improving quality of life in children. In 2010, 10% of babies were born prematurely influencing national healthcare policies, economic action plans and political decisions. The use of complementary medicine has been applied to the care of newborns. One previous study documented the positive effect of osteopathic manipulative treatment (OMT) in reducing newborns’ length of stay (LOS). Aim of this multicentre randomised controlled trial is to examine the association between OMT and LOS across three neonatal intensive care units (NICUs).
Methods and analysis
690 preterm infants will be recruited from three secondary and tertiary NICUs from north and central Italy and allocated into two groups, using permuted-block randomisation.
The two groups will receive standard medical care and OMT will be applied, twice a week, to the experimental group only. Outcome assessors will be blinded of study design and group allocation. The primary outcome is the mean difference in days between discharge and entry. Secondary outcomes are difference in daily weight gain, number of episodes of vomit, regurgitation, stooling, use of enema, time to full enteral feeding and NICU costs. Statistical analyses will take into account the intention-to-treat method. Missing data will be handled using last observation carried forward (LOCF) imputation technique.
Ethics and dissemination
Written informed consent will be obtained from parents or legal guardians at study enrolment. The trial has been approved by the ethical committee of Macerata hospital (n°22/int./CEI/27239) and it is under review by the other regional ethics committees.
Results
Dissemination of results from this trial will be through scientific medical journals and conferences.
Trial registration
This trial has been registered at http://www.clinicaltrials.org (identifier NCT01645137).
doi:10.1136/bmjopen-2012-002187
PMCID: PMC3586056  PMID: 23430598
Complementary Medicine; Paediatrics; Preventive Medicine
14.  Extending ICPC-2 PLUS terminology to develop a classification system specific for the study of chiropractic encounters 
Background
Typically a large amount of information is collected during healthcare research and this information needs to be organised in a way that will make it manageable and to facilitate clear reporting. The Chiropractic Observation and Analysis STudy (COAST) was a cross sectional observational study that described the clinical practices of chiropractors in Victoria, Australia. To code chiropractic encounters COAST used the International Classification of Primary Care (ICPC-2) with the PLUS general practice clinical terminology to code chiropractic encounters. This paper describes the process by which a chiropractic-profession specific terminology was developed for use in research by expanding the current ICPC-2 PLUS system.
Methods
The coder referred to the ICPC-2 PLUS system when coding chiropractor recorded encounter details (reasons for encounter, diagnoses/problems and processes of care). The coder used rules and conventions supplied by the Family Medicine Research Unit at the University of Sydney, the developers of the PLUS system. New chiropractic specific terms and codes were created when a relevant term was not available in ICPC-2 PLUS.
Results
Information was collected from 52 chiropractors who documented 4,464 chiropractor-patient encounters. During the study, 6,225 reasons for encounter and 6,491 diagnoses/problems were documented, coded and analysed; 169 new chiropractic specific terms were added to the ICPC-2 PLUS terminology list. Most new terms were allocated to diagnoses/problems, with reasons for encounter generally well covered in the original ICPC 2 PLUS terminology: 3,074 of the 6,491 (47%) diagnoses/problems and 274 of the 6,225 (4%) reasons for encounter recorded during encounters were coded to a new term. Twenty nine new terms (17%) represented chiropractic processes of care.
Conclusion
While existing ICPC-2 PLUS terminology could not fully represent chiropractic practice, adding terms specific to chiropractic enabled coding of a large number of chiropractic encounters at the desired level. Further, the new system attempted to record the diversity among chiropractic encounters while enabling generalisation for reporting where required. COAST is ongoing, and as such, any further encounters received from chiropractors will enable addition and refinement of ICPC-2 PLUS (Chiro). More research is needed into the diagnosis/problem descriptions used by chiropractors.
doi:10.1186/2045-709X-21-4
PMCID: PMC3563572  PMID: 23311664
Chiropractic; International classification of primary care; Classification; Clinical coding
15.  A profile of osteopathic practice in Australia 2010–2011: a cross sectional survey 
Background
There is limited evidence available to describe a profile of osteopathic practice in Australia. The purpose of this study was to describe the current activities of Australian osteopaths, using an internationally-developed standardised data collection tool.
Methods
A voluntary national paper-based survey using a modified UK-developed standardised data collection tool was distributed to and completed by osteopaths across Australia between June 2010 and June 2011.
Results
Fifty four osteopaths participated in this study and returned a total of 799 patient records. Two thirds of patients were female, with a median age of 39 years and age range of 7 days - 89 years. Almost three quarters of people seeking osteopathic care were employed and the largest source of referral was by word-of-mouth.
The majority of presenting complaints were acute musculoskeletal in nature. Approximately 38% of patients presented with a coexisting condition; the highest incidences were found in the cardiovascular and respiratory systems, along with mental health disorders.
Main treatment approaches were soft tissue (22.3%), muscle energy technique (14.6%), articulation techniques (14.3%) and education/advice (11.9%). Improvement or resolution of the complaint was experienced by 96.2% of patients within a small number of treatments. Complications of treatment were minor and of low frequency.
Conclusions
In this study, Australian osteopaths mainly see patients with acute or sub-acute musculoskeletal problems which are predominantly spinal conditions. A significant proportion of these patients have one or more co-existing condition, largely of the cardiovascular and respiratory systems, along with mental health disorders. The majority of patients have a significant improvement within few treatments, with infrequent and minor adverse events reported. These findings should be tested through multi-centred pragmatic trials of osteopathic practice.
doi:10.1186/1471-2474-14-227
PMCID: PMC3733950  PMID: 23915239
Osteopathy; Osteopathic medicine; Cross-sectional survey; Scope of practice; Clinical presentations
16.  The nature of the informed consent doctrine and the chiropractor 
This paper examines in part, the doctrine of informed consent for chiropractic treatment. The roles of the chiropractor and the patient are discussed as related to verbal consent, written consent, informed consent and implied consent. Is it the responsibility of the rational patient to provide consent or is it the role of the chiropractor to seek it? As well, some of the fundamental rights of the patient are discussed and the applicable sections of the Canadian Chiropractic Association Code of Ethics and standards of practice are reviewed. The concepts of material disclosure and the criteria for valid patient consent are presented.
PMCID: PMC2484849
chiropractic; informed consent; code of ethics
17.  The DREEM, part 2: psychometric properties in an osteopathic student population 
BMC Medical Education  2014;14:100.
Background
The Dundee Ready Educational Environment Measure (DREEM) is widely used to assess the educational environment in health professional education programs. A number of authors have identified issues with the psychometric properties of the DREEM. Part 1 of this series of papers presented the quantitative data obtained from the DREEM in the context of an Australian osteopathy program. The present study used both classical test theory and item response theory to investigate the DREEM psychometric properties in an osteopathy student population.
Methods
Students in the osteopathy program at Victoria University (Melbourne, Australia) were invited to complete the DREEM and a demographic questionnaire at the end of the 2013 teaching year (October 2013). Data were analysed using both classical test theory (confirmatory factor analysis) and item response theory (Rasch analysis).
Results
Confirmatory factor analysis did not demonstrate model fit for the original 5-factor DREEM subscale structure. Rasch analysis failed to identify a unidimensional model fit for the 50-item scale, however model fit was achieved for each of the 5 subscales independently. A 12-item version of the DREEM was developed that demonstrated good fit to the Rasch model, however, there may be an issue with the targeting of this scale given the mean item-person location being greater than 1.
Conclusions
Given that the full 50-item scale is not unidimensional; those using the DREEM should avoid calculating a total score for the scale. The 12-item ‘short-form’ of the DREEM warrants further investigation as does the subscale structure. To confirm the reliability of the DREEM, as a measure to evaluate the appropriateness of the educational environment of health professionals, further work is required to establish the psychometric properties of the DREEM, with a range of student populations.
doi:10.1186/1472-6920-14-100
PMCID: PMC4050100  PMID: 24884704
18.  Patients’ expectations of private osteopathic care in the UK: a national survey of patients 
Background
Patients’ expectations of osteopathic care have been little researched. The aim of this study was to quantify the most important expectations of patients in private UK osteopathic practices, and the extent to which those expectations were met or unmet.
Methods
The study involved development and application of a questionnaire about patients’ expectations of osteopathic care. The questionnaire drew on an extensive review of the literature and the findings of a prior qualitative study involving focus groups exploring the expectations of osteopathic patients. A questionnaire survey of osteopathic patients in the UK was then conducted. Patients were recruited from a random sample of 800 registered osteopaths in private practice across the UK. Patients were asked to complete the questionnaire which asked about 51 aspects of expectation, and post it to the researchers for analysis.
The main outcome measures were the patients-perceived level of expectation as assessed by the percentage of positive responses for each aspect of expectation, and unmet expectation as computed from the proportion responding that their expectation “did not happen”.
Results
1649 sets of patient data were included in the analysis. Thirty five (69%) of the 51 aspects of expectation were prevalent, with listening, respect and information-giving ranking highest. Only 11 expectations were unmet, the most often unmet were to be made aware that there was a complaints procedure, to find it difficult to pay for osteopathic treatment, and perceiving a lack of communication between the osteopath and their GP.
Conclusions
The findings reflected the complexity of providing osteopathic care and meeting patients’ expectations. The results provided a generally positive message about private osteopathic practice. The study identified certain gaps between expectations and delivery of care, which can be used to improve the quality of care. The questionnaire is a resource for future research.
doi:10.1186/1472-6882-13-122
PMCID: PMC3679882  PMID: 23721054
Questionnaires; Survey; Expectations; Musculoskeletal manipulations; Osteopathic medicine
19.  CHIROPRACTIC AND OSTEOPATHIC EDUCATION AT ROYAL MELBOURNE INSTITUTE TECHNOLOGY 
Objective: To assess the attitudes of undergraduate chiropractic and osteopathic students at Royal Melbourne Institute of Technology (RMIT) in 1992 on the education they are receiving and on the effectiveness of chiropractic and osteopathic care.
Design: Cross-sectional descriptive survey.
Participants: Undergraduate chiropractic and osteopathic students enrolled at RMIT School of Chiropractic and Osteopathy in 1992.
Results: This study surveyed 272 students, 196 who were chiropractic students and 76 who were osteopathic students from RMIT School of Chiropractic and Osteopathy in Melbourne, Australia. The students that responded represented 73.4% of chiropractic students and 85.4% of osteopathic students currently enrolled in their respective courses. Chiropractic and osteopathic students entered their respective courses from non-chiropractic/non-osteopathic families. More chiropractic students than osteopathic students (1.3:1.0) had their respective course as their first choice when applying for tertiary education. A majority (95.8 chiropractic students and 94.8% osteopathic students) of both groups surveyed were pleased with their choice of course. Students from both disciplines held considerable respect for each other in the care of certain conditions, but did not see the other profession’s care as effective as their own. A greater percentage of osteopathic students believed there was sufficient difference between chiropractic and osteopathy to justify two separate professions (57.6% compared to 97.2%).
Discussion: High quality education is a major aim in our schools and colleges. For this standard to be maintained it requires continual re-evaluation and assessment. Surveys such as this should be performed regularly as a method of evaluating student attitude and how these attitudes change during the course. This would also allow administrators to determine whether they are achieving their academic intentions. An immediate follow up survey asking the same questions is suggested to ascertain whether the same attitudes exist today.
PMCID: PMC2051086  PMID: 17987188
Chiropractic; osteopathic medicine; education; students; attitude
20.  Introducing an osteopathic approach into neonatology ward: the NE-O model 
Background
Several studies showed the effect of osteopathic manipulative treatment on neonatal care in reducing length of stay in hospital, gastrointestinal problems, clubfoot complications and improving cranial asymmetry of infants affected by plagiocephaly. Despite several results obtained, there is still a lack of standardized osteopathic evaluation and treatment procedures for newborns recovered in neonatal intensive care unit (NICU). The aim of this paper is to suggest a protocol on osteopathic approach (NE-O model) in treating hospitalized newborns.
Methods
The NE-O model is composed by specific evaluation tests and treatments to tailor osteopathic method according to preterm and term infants’ needs, NICU environment, medical and paramedical assistance. This model was developed to maximize the effectiveness and the clinical use of osteopathy into NICU.
Results
The NE-O model was adopted in 2006 to evaluate the efficacy of OMT in neonatology. Results from research showed the effectiveness of this osteopathic model in reducing preterms’ length of stay and hospital costs. Additionally the present model was demonstrated to be safe.
Conclusion
The present paper defines the key steps for a rigorous and effective osteopathic approach into NICU setting, providing a scientific and methodological example of integrated medicine and complex intervention.
doi:10.1186/2045-709X-22-18
PMCID: PMC4046173  PMID: 24904746
Complementary and alternative medicine; Integrated medicine; Neonatology intensive care unit; Newborns; Osteopathic manipulative treatment
21.  Spinal and sacroiliac assessment and treatment techniques used by osteopathic physicians in the United States 
Background
Osteopathic manipulative medicine texts and educators advocate a range of approaches for physical assessment and treatment, but little is known about their use by osteopathic physicians in the United States.
Methods
A web-based survey using a 5-point Likert scale was developed and e-mailed to 777 practicing osteopathic physician members of the American Academy of Osteopathy. Responses in the "frequently" and "always" categories were combined for reporting purposes. Friedman tests were used to analyze the reported usage of each item. The effect of gender was analyzed using Mann-Whitney tests.
Results
One hundred seventy-one osteopathic physicians completed the survey (22%). For the assessment of spinal somatic dysfunction, paraspinal tissue texture (98%), transverse process asymmetry (89%), and tenderness (85%) were most commonly reported. Myofascial release (78%), soft tissue technique (77%), and patient self-stretches (71%) were most commonly used for treatment of the spine. For assessment of pelvic landmark asymmetry, the anterior superior iliac spine (ASIS, 87%), sacral base (82%), posterior superior iliac spine (81%), sacral sulci (78%), iliac crests (77%), and inferior lateral angle of the sacrum (74%) were commonly palpated. For assessment of sacroiliac joint motion, ASIS compression (68%) was most commonly used. Sacroiliac pain provocation tests were also employed although their use was less common than asymmetry or motion tests. Muscle energy (70%), myofascial release (67%), patient self-stretches (66%), osteopathy in the cranial field (59%), muscle strengthening exercises (58%), soft tissue technique (58%), and articulatory technique (53%) were most commonly used for treatment of the pelvis and sacroiliac. The effect of gender was significant for many of the treatment procedures, with females using more soft tissue and muscle energy and males more high-velocity techniques. The majority of respondents document the types of osteopathic manipulative techniques used (83%), document somatic dysfunction with Fryette nomenclature (64%), and bill for osteopathic manipulative treatment (92%).
Conclusion
Respondents reported the use of a broad range of assessment and treatment approaches. Results suggest a higher use of myofascial release and cranial technique and lower use of high-velocity techniques in this group of physicians compared to previous studies.
doi:10.1186/1750-4732-3-4
PMCID: PMC2676310  PMID: 19366458
22.  Avian influenza: an osteopathic component to treatment 
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.
doi:10.1186/1750-4732-1-10
PMCID: PMC1939852  PMID: 17620133
23.  Time for the osteopathic profession to take the lead in musculoskeletal research 
Musculoskeletal conditions, such as low back pain, are prevalent in the United States. These conditions exact an enormous toll on society, both in terms of their detrimental impact on quality of life and on the costs of treatment and lost productivity. Osteopathic physicians, as common providers of primary care services and spinal manipulation, are ideally positioned to lead future research efforts in this field. The emergence of data and standards relevant to osteopathic manipulative treatment outcomes, refinement of research methodologies to enhance evidence-based medicine, and investments in developing osteopathic research infrastructure are all critical elements in moving this field of research forward.
doi:10.1186/1750-4732-3-6
PMCID: PMC2724431  PMID: 19624819
24.  Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis 
Background
Nonspecific back pain is common, disabling, and costly. Therefore, we assessed effectiveness of osteopathic manipulative treatment (OMT) in the management of nonspecific low back pain (LBP) regarding pain and functional status.
Methods
A systematic literature search unrestricted by language was performed in October 2013 in electronic and ongoing trials databases. Searches of reference lists and personal communications identified additional studies. Only randomized clinical trials were included; specific back pain or single treatment techniques studies were excluded. Outcomes were pain and functional status. Studies were independently reviewed using a standardized form. The mean difference (MD) or standard mean difference (SMD) with 95% confidence intervals (CIs) and overall effect size were calculated at 3 months posttreatment. GRADE was used to assess quality of evidence.
Results
We identified 307 studies. Thirty-one were evaluated and 16 excluded. Of the 15 studies reviewed, 10 investigated effectiveness of OMT for nonspecific LBP, 3 effect of OMT for LBP in pregnant women, and 2 effect of OMT for LBP in postpartum women. Twelve had a low risk of bias. Moderate-quality evidence suggested OMT had a significant effect on pain relief (MD, -12.91; 95% CI, -20.00 to -5.82) and functional status (SMD, -0.36; 95% CI, -0.58 to -0.14) in acute and chronic nonspecific LBP. In chronic nonspecific LBP, moderate-quality evidence suggested a significant difference in favour of OMT regarding pain (MD, -14.93; 95% CI, -25.18 to -4.68) and functional status (SMD, -0.32; 95% CI, -0.58 to -0.07). For nonspecific LBP in pregnancy, low-quality evidence suggested a significant difference in favour of OMT for pain (MD, -23.01; 95% CI, -44.13 to -1.88) and functional status (SMD, -0.80; 95% CI, -1.36 to -0.23), whereas moderate-quality evidence suggested a significant difference in favour of OMT for pain (MD, -41.85; 95% CI, -49.43 to -34.27) and functional status (SMD, -1.78; 95% CI, -2.21 to -1.35) in nonspecific LBP postpartum.
Conclusion
Clinically relevant effects of OMT were found for reducing pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women at 3 months posttreatment. However, larger, high-quality randomized controlled trials with robust comparison groups are recommended.
doi:10.1186/1471-2474-15-286
PMCID: PMC4159549  PMID: 25175885
Low back pain; Spinal manipulation; Osteopathic manipulative treatment; Systematic review
25.  Osteopathic manipulative treatment for pneumonia 
The pneumonias due to infection continue to be a meaningful threat to the health and viability of persons, particularly those in high risk groups: children, the aged and the debilitated. Noll and colleagues provide us with the results of a well-designed and well-executed multi-institutional controlled clinical trial to evaluate the efficacy of osteopathic manipulative treatment (OMT) in the treatment of pneumonia. The data obtained indicate that by intention-to-treat analysis, the addition of OMT to conventional care did not improve the designated outcomes when compared to conventional care only. A disappointing but important finding. However, by per-protocol analysis, the addition of OMT or of light touch decreased length of hospital stay, the duration of intravenous antibiotics and the incidence of respiratory failure and death relative to conventional care only. Further study is called for to explain these surprising results.
Meeting the need for randomized clinical trials of the role and efficacy of OMT is a responsibility of high priority for the osteopathic profession in this age of evidence-based medicine. The American Osteopathic Association (AOA) needs to consider reinstating a dues-generated financial set-aside both to increase its support of osteopathic research and to initiate a program of physician-investigator career development awards to recruit and help establish osteopathic clinical investigators in a career in translational and clinical research.
doi:10.1186/1750-4732-4-3
PMCID: PMC2845139  PMID: 20302620

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