Virginia Research Day 2021

OSTEOPATHIC MANIPULATION IMPROVES PATIENT PAIN SCALE REGARDLESS OF OPERATOR EXPERIENCE Jensen, Zachariah, DO, LMMG, Lynchburg, VA, PGY-3; McNichols, Courtney, 2023; Daugherty, Daniel, 2023; Judd, Trenton, 2023; Young, Amelia, 2023; Orciuolo, Jason, 2023; Sakai, Leo, 2023; Hall, Colton, 2023; Williamson, Ryan, 2023; Lockwood, Michael, DO, LUCOM, Lynchburg, VA; Joseph, Charles, MD, LUCOM, Lynchburg, VA

Abstract Osteopathic Manipulative Treatment (OMT) has been shown to be effective at treating conditions such as low back pain by reducing the amount of patient perceived pain, dependence on pain modifying drugs, and overall improvement in daily functionality. A frequent criticism of prior studies has been to have not clearly differentiated the patient response to the OMT technique itself from the skills of the operator. This is a retrospective analysis of patient response to OMT treatment at the Free Clinic of Lynchburg performed by rotating third year medical students under supervision of a preceptor. Returning patients were treated by a different student doctor at each visit, eliminating the dependence of the treatment result on the operator’s personality or expertise. The techniques employed were among the standardized treatments as taught in first and second year osteopathic medical school curriculum, and were not considered novel or advanced. This study demonstrates the direct benefit of OMT on pain reduction, regardless of the level of training. The data were analyzed to compare treatments with pain scale changes across multiple visits and body regions. Medication changes were explored to see if there was a significant change in medication usage related to patients receiving osteopathic treatments. Introduction Osteopathic Manipulative Treatment (OMT) has been shown to be effective at treating conditions such as low back pain by reducing the amount of patient-perceived pain, dependence on pain modifying drugs, and overall improvement in daily functionality. 1,3 Prior studies have frequently been criticized for their inability to differentiate independence of treatment response from provider skill level. 2 This was a retrospective analysis of patient response to OMT provided by 3rd year rotating medical students under preceptor supervision at the Free Clinic of Lynchburg. The OMT techniques performed were techniques taught in the first- and second-year curriculum of osteopathic medical schools. Returning patients were treated by a different student doctor at each visit, eliminating the dependence of the treatment result on the operator’s personality or skill level. It’s predicted that pain improvement after OMT is independent of provider skill level. Methods Data were collected by second year medical students accessing patient electronic medical records via an intake form that considered the following: patient reported pain scale, location of pain, duration of complaint, OMT provided, and improvement since last visit. Our study analyzed 53 patients ages 21-70 for a total of 576 complaints with gender ratio being 1:1. Of the 576 complaints, 466 were chronic in nature. This study used a statistical model looking at visit numbers to assess long term outcomes of patients returning for further treatment. Statistics were done using an F test for visit number and the coefficient associated with the visit number. P values <.05 were f

Results

Conclusions At follow-up after OMT treatment, patients reported better function 53.2% of the time (Table 1) . In general, each additional visit for OMT lead to a highly statistically significant decrease in patient reported pain score (Table 2) . This provides correlative evidence that patients receiving OMT have reduced average pain levels over time. Males had a greater reduction in pain from OMT than females over time (Table 3) . Male patients in all age groups besides 51-60, had a statistically significant decrease in pain upon additional visits. females in the same age group only showed a statistically significant improvement in pain. There is no control group analyzed in this retrospective study. Therefore, no conclusions can be drawn on how receiving OMT directly affects pain and functional improvement over time. It is possible that over time pain and functional improvement would have lessened without OMT. in the study returned for follow-up OMT, leading us to infer that there was some level of improved satisfaction with their pain response related to treatment. Medications changes were infrequently documented on the intake forms; therefore, they were not considered in data analysis. A prospective study needs to be performed in order to accurately quantify whether pain and functionality has truly improved in patients when compared to a control group. Going Forward There is a need to develop standardized documentation for OMT which more precisely documents pain levels before and after treatment, at each visit that OMT is performed. This documentation must address the location of the pain being documented, the treatment being performed, and the body region the treatment was performed on. Other considerations should also include medication intake before OMT treatment and if the injury being treated is acute, chronic, or an acute on chronic injury. References 1. Task Force on the Low Back Pain Clinical Practice Guidelines. American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain. J Am Osteopath Assoc 2016;116(8):536–549. doi: https://doi.org/10.7556/jaoa.2016.107. 2. John C. Licciardone. Osteopathic Manipulative Treatment for Chronic Low Back Pain: A Randomized Controlled Trial. Spine (03622436). 2003;28(13):1355. doi:10.1097/01.BRS.0000067110.61471.7D 3. Andersson, G. B. J., Lucente, T., Davis, A. M., Kappler, R. E., Lipton, J. A., & Leurgans, S. (1999). A Comparison of Osteopathic Spinal Manipulation with Standard Care for Patients with Low Back Pain. New England Journal of Medicine , 341 (19), 1426–1431.

Table 1. Frequency Distribution of Improvement of Function

Improvement of Function

Frequency

Percent

Improvement of Function

Frequency

Percent

Worse

72

15.0 31.8 53.2 100

Worse

72

15.0 31.8 53.2 100

Unchanged

153 256 481

Unchanged

153 256 481

Better

Total

Better

Total

Missing

95

Missing

95

Based on patient report post OMT follow up treatment, the most common outcome was improvement of function noted as “better” in over half of cases studied (53.2%). Only 15% of patients reported a worsening of function upon follow up examination. (Table 1)

Table 2. Coefficients for Univariate Visit Number Model

Variable

Estimate

Std. Error

t

df

p

Intercept

5.489

0.262

62.87

20.95 < 0.001

Visit Number

-0.106

0.037

264.87

-2.83

0.005

t: t-value df: degrees of freedom; p:p-value;

On average, for each additional visit that a patient received OMT, the pain score decreased by an average of 0.106 points. This was highly statistically significant (F(1, 264.87) = 8.03, p = 0.005). (Table 2) The expected pain score for a patient

on a specific visit can be predicted using the equation: Expected pain score = 5.489 - (0.106 x visit number)

Table 3. Effect of Visit Number by Sex and Age Group

Sex

Age Group Estimate Std. Error df

t

p

Male Male Male Male Male

21-30 31-40 41-50 51-60 61-70 21-30 31-40 41-50 51-60 61-70

-0.22 -1.72 -0.37 -0.15 -0.31 0.03 -1.46 -0.11 0.11 -0.06

0.07 0.65 0.13 0.11 0.11 0.13 0.65 0.07 0.07 0.10

142.54 436.77 350.25 377.76 364.90 292.94 437.28 301.77 221.91 363.55

-3.18 -2.64 -2.75 -1.41 -2.74 0.24 -2.24 -1.55 1.48 -0.55

0.002 0.009 0.006 0.161 0.006 0.813 0.025 0.122 0.139 0.581

Female Female Female Female Female

df: degrees of freedom; t: t-value; p:p-value;

There is a statistically significant decrease in pain for males in all age groups except for the 51-60 age group; however, the only statistically significant relationship of visit number to pain score for females in the 31-40 age group. On average, for any given age group, males decrease their pain scale score by 0.26 more points per visit than females, which is statistically significant. The smallest estimated decrease of both

genders is the 51-60 age group. (Table 3)

27

2 0 2 1 R e s e a r c h R e c o g n i t i o n D a y