Jane C. Johnson

Differences in repositioning error among patients with low back pain compared with control subjects

Study Design. Trunk repositioning error was measured in 20 patients with chronic low back pain and 20 control subjects. Objectives. To measure trunk repositioning error as a method of measuring proprioception of the low back and to compare trunk repositioning error in patients with low back pain and in control subjects. Summary of Background Data. Although many current low back pain rehabilitation programs incorporate proprioceptive training, very little research has been performed on proprioception of the low back. Methods. While standing with the legs and pelvis immobilized, the subject bent the trunk to a predetermined target position and then attempted to replicate the position. Repositioning error was calculated as the absolute difference between the actual target position and the subject-perceived target position. The multiple target positions in the frontal and sagittal planes were tested. Trunk position was measured with a 3Space Tracker, which analyzes the three-dimensional position of the body. Results. Repositioning error in patients with low back pain was significantly higher than that of control subjects in flexion, and significantly lower than that of control subjects in extension. Conclusions. The increase in repositioning error of patients with low back pain during flexion implies that some aspects of proprioception are lost in patients with low back pain. The decrease in repositioning error in patients with low back pain in extension is not as easily explained, but could possibly be caused by increased activation of mechanoreceptors in facet joints.

The effect of uncertainty of item parameter estimation on ability estimates

The conventional method of measuring ability, which is based on items with assumed true parameter values obtained from a pretest, is compared to a Bayesian method that deals with the uncertainties of such items. Computational expressions are presented for approximating the posterior mean and variance of ability under the three-parameter logistic (3PL) model. A 1987 American College Testing Program (ACT) math test is used to demonstrate that the standard practice of using maximum likelihood or empirical Bayes techniques may seriously underestimate the uncertainty in estimated ability when the pretest sample is only moderately large.

Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial

BackgroundThe Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) is a registered, double-blinded, randomized, controlled trial designed to assess the efficacy of osteopathic manipulative treatment (OMT) as an adjunctive treatment in elderly patients with pneumonia.Methods406 subjects aged ≥ 50 years hospitalized with pneumonia at 7 community hospitals were randomized using concealed allocation to conventional care only (CCO), light-touch treatment (LT), or OMT groups. All subjects received conventional treatment for pneumonia. OMT and LT groups received group-specific protocols for 15 minutes, twice daily until discharge, cessation of antibiotics, respiratory failure, death, or withdrawal from the study. The primary outcomes were hospital length of stay (LOS), time to clinical stability, and a symptomatic and functional recovery score.ResultsIntention-to-treat (ITT) analysis (n = 387) found no significant differences between groups. Per-protocol (PP) analysis (n = 318) found a significant difference between groups (P = 0.01) in LOS. Multiple comparisons indicated a reduction in median LOS (95% confidence interval) for the OMT group (3.5 [3.2-4.0] days) versus the CCO group (4.5 [3.9-4.9] days), but not versus the LT group (3.9 [3.5-4.8] days). Secondary outcomes of duration of intravenous antibiotics and treatment endpoint were also significantly different between groups (P = 0.05 and 0.006, respectively). Duration of intravenous antibiotics and death or respiratory failure were lower for the OMT group versus the CCO group, but not versus the LT group.ConclusionsITT analysis found no differences between groups. PP analysis found significant reductions in LOS, duration of intravenous antibiotics, and respiratory failure or death when OMT was compared to CCO. Given the prevalence of pneumonia, adjunctive OMT merits further study.

Palpatory Accuracy of Lumbar Spinous Processes Using Multiple Bony Landmarks

OBJECTIVE Accurate localization of vertebral segments is crucial for many treatment procedures. The objective of this study was to determine accuracy of identification of lumbar spinous process levels by palpation. METHODS Three examiners independently identified the spinous processes of L1-L4 on 60 prone volunteers using multiple bony landmarks including the sacral base, L5, Tuffiers line, T12, and the 12th ribs. The spinous processes were marked with radiopaque skin markers. Location of marker placement and presence of anatomical anomalies were determined by posteroanterior lumbar radiographs. Accuracy of marker placement and interobserver reliability were assessed using weighted κ values. Generalized linear mixed models and Cochran-Mantel-Haenszel tests assessed the relationship of accuracy to training level, presence of anatomical anomalies, and participant characteristics. RESULTS Examiners identified a spinous process in 91% of vertebral assessments. Correct identification of vertebral level occurred 69% of the time (κ = 0.81; 95% confidence interval, 0.79-0.83). Faculty examiners were significantly more accurate in identifying the correct vertebral level than the resident examiner (67%-78% vs 51%, P ≤ .03). The presence of 12th rib anomalies decreased accuracy for all examiners (P ≤ .05), reducing accuracy from 74% to 55%. Accuracy was higher in male participants than in female participants (P = .01). Obesity significantly decreased accuracy (P = .0003) at L3 (50% vs 73%) and L4 (44% vs 72%). CONCLUSIONS Identification of lumbar spinous processes using multiple landmarks was more accurate than previously reported values. However, accuracy was dependent on examiner experience, presence of anatomical anomalies, and participant characteristics.

Risk factors for depression in rheumatoid arthritis

OBJECTIVE To identify risk factors for the development of depression in persons with rheumatoid arthritis (RA). METHODS Subjects were divided into depressed versus nondepressed groups on the basis of the Center for Epidemiologic Studies-Depression Scale; a range of psychological, pain-related, disease-related, and demographic variables were analyzed to predict depression. Both cross-sectional and longitudinal predictive models were examined. RESULTS A series of analyses, including multiple logistic regression, found that the optimal predictors of depression in RA were average daily stressors, confidence in ones ability to cope, and degree of physical disability. The model was successfully cross-validated on separate data sets (i.e., same subjects at different time points). CONCLUSION All of the identified risk factors for depression in RA are preventable to some extent and, therefore, should be addressed in comprehensive, rheumatology team care.

Stress Management in Rheumatoid Arthritis: What Is the Underlying Mechanism?

OBJECTIVE To test whether change in cognitive-behavioral variables (such as self-efficacy, coping strategies, and helplessness) is a mediator in the relation between cognitive behavior therapy and reduced pain and depression in persons with rheumatoid arthritis (RA). METHODS A sample of patients with RA who completed a stress management training program (n = 47) was compared to a standard care control group (n = 45). A path analysis testing a model including direct effects of comprehensive stress management training on pain and depression and indirect effects via change in cognitive-behavioral variables was conducted. RESULTS The path coefficients for the indirect effects of stress management training on pain and depression via change in cognitive-behavioral variables were statistically significant, whereas the path coefficients for the direct effects were found not to be statistically significant. CONCLUSION Decreases in pain and depression following stress management training are due to beneficial changes in the arenas of self-efficacy (the belief that one can perform a specific behavior or task in the future), coping strategies (an individuals confidence in his or her ability to manage pain), and helplessness (perceptions of control regarding arthritis). There is little evidence of additional direct effects of stress management training on pain and depression.

Impact of the clinical ultrasound elective course on retention of anatomical knowledge by second-year medical students in preparation for board exams.

Ultrasound has been integrated into a gross anatomy course taught during the first year at an osteopathic medical school. A clinical ultrasound elective course was developed to continue ultrasound training during the second year of medical school. The purpose of this study was to evaluate the impact of this elective course on the understanding of normal anatomy by second‐year students. An anatomy exam was administered to students enrolled in the clinical ultrasound elective course before the start of the course and after its conclusion. Wilcoxon signed ranks tests were used to determine whether exam scores changed from the pre‐test to the post‐test. Scores from two classes of second‐year students were analyzed. Students who took the elective course showed significant improvement in the overall anatomy exam score between the pre‐test and post‐test (P < 0.001). Scores for exam questions pertaining to the heart, abdomen, upper extremity, and lower extremity also significantly improved from the pretest to post‐test (P < 0.001), but scores for the neck and eye showed no significant improvement. The clinical ultrasound elective course offered during the second year of medical school provided students with an important review of key anatomical concepts while preparing them for board exams. Our results suggested that more emphasis should be placed on head and neck ultrasound to improve student performance in those areas. Musculoskeletal, abdominal, and heart ultrasound labs were more successful for retaining relevant anatomical information. Clin. Anat. 28:156–163, 2015.

Reliability of Tuffierʼs Line as an Anatomic Landmark

Study Design. The level of Tuffiers line was assessed on 200 standing and 60 prone lumbar radiographs. Sex, height, weight, and body mass index (BMI) were correlated with the radiograph findings. Objective. To determine whether the level of Tuffiers line is associated with sex, height, weight, or BMI. Summary of Background Data. Tuffiers line (intercristal line) is a commonly used landmark for identification of the L4–L5 interspace; however, multiple studies have identified that this landmark is unreliable. Methods. The level of Tuffiers line was assessed retrospectively on 200 standing anteroposterior lumbar radiographs and correlated with sex. Prospectively, the level of Tuffiers line was assessed on 60 prone posteroanterior lumbar radiographs and correlated with sex, height, weight, and BMI. Results. In men, the intercristal line most often intersected the L4 body or inferior endplate. In women, the intercristal line most often intersected the L5 body or superior endplate. Weight and BMI had no correlation with Tuffiers line. Subjects with a Tuffiers line through L4 were taller than those with a Tuffiers line through L5. Conclusion. Tuffiers line demonstrated predictable sex-related differences: men had an intercristal line that most often intersected the L4 body or inferior endplate whereas the womens intercristal line most often intersected the L5 body or superior endplate. However, because the actual level of Tuffiers line may vary from the L4 body to the L5 body, the intercristal line is insufficient to use as the sole landmark for assessing spinal segmental level.

The immediate effect of individual manipulation techniques on pulmonary function measures in persons with chronic obstructive pulmonary disease

BackgroundThe use of manipulation has long been advocated in the treatment of chronic obstructive pulmonary disease (COPD), but few randomized controlled clinical trials have measured the effect of manipulation on pulmonary function. In addition, the effects of individual manipulative techniques on the pulmonary system are poorly understood. Therefore, the purpose of this study was to determine the immediate effects of four osteopathic techniques on pulmonary function measures in persons with COPD relative to a minimal-touch control protocol.MethodsPersons with COPD aged 50 and over were recruited for the study. Subjects received five, single-technique treatment sessions: minimal-touch control, thoracic lymphatic pump (TLP) with activation, TLP without activation, rib raising, and myofascial release. There was a 4-week washout period between sessions. Protocols were given in random order until all five techniques had been administered. Pulmonary function measures were obtained at baseline and 30-minutes posttreatment. For the actual pulmonary function measures and percent predicted values, Wilcoxon signed rank tests were used to test within-technique changes from baseline. For the percent change from baseline, Friedman tests were used to test for between-technique differences.ResultsTwenty-five subjects were enrolled in the study. All four tested osteopathic techniques were associated with adverse posttreatment changes in pulmonary function measures; however, different techniques changed different measures. TLP with activation increased posttreatment residual volume compared to baseline, while TLP without activation did not. Side effects were mild, mostly posttreatment chest wall soreness. Surprisingly, the majority of subjects believed they could breathe better after receiving osteopathic manipulation.ConclusionIn persons with COPD, TLP with activation, TLP without activation, rib raising, and myofascial release mildly worsened pulmonary function measures immediately posttreatment relative to baseline measurements. The activation component of the TLP technique appears to increase posttreatment residual volume. Despite adverse changes in pulmonary function measures, persons with COPD subjectively reported they benefited from osteopathic manipulation.

Preventing traumatic brain injury: an innovative approach to outcomes assessment

The purpose of this study was to investigate the usefulness of the state traffic violations database as an outcome measure for the Young Traffic Offenders Programme, a 1-day educational injury prevention programme for young people with speeding offences. The database provided a fine-grained, cumulative record of each drivers traffic offences and sanctions applied. A comparison of 92 programme participants and 87 non-treated individuals showed no significant between-group difference in rate of convictions after the target programme date, but each group declined significantly in rate of convictions over time. Younger males and individuals with a higher number of convictions initially were more likely to have higher conviction rates after the target date. These findings underscore the need to improve prevention programmes and highlight the potential usefulness of existing public datasets for outcome evaluation.The purpose of this study was to investigate the usefulness of the state traffic violations database as an outcome measure for the Young Traffic Offenders Programme, a 1-day educational injury prevention programme for young people with speeding offences. The database provided a fine-grained, cumulative record of each drivers traffic offences and sanctions applied. A comparison of 92 programme participants and 87 non-treated individuals showed no significant between-group difference in rate of convictions after the target programme date, but each group declined significantly in rate of convictions over time. Younger males and individuals with a higher number of convictions initially were more likely to have higher conviction rates after the target date. These findings underscore the need to improve prevention programmes and highlight the potential usefulness of existing public datasets for outcome evaluation.