Paul J Orrock

Osteopathic intervention in chronic non-specific low back pain: a systematic review

BackgroundChronic 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.MethodsThe 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.ResultsInitial 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.ConclusionThere 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.

Developing a viva exam to assess clinical reasoning in pre-registration osteopathy students.

BackgroundClinical reasoning (CR) is a core capability for health practitioners. Assessing CR requires a suite of tools to encompass a wide scope of contexts and cognitive abilities. The aim of this project was to develop an oral examination and grading rubric for the assessment of CR in osteopathy, trial it with senior students in three accredited university programs in Australia and New Zealand, and to evaluate its content and face validity.MethodsExperienced osteopathic academics developed 20 cases and a grading rubric. Thirty senior students were recruited, 10 from each university. Twelve fourth year and 18 fifth year students participated. Three members of the research team were trained and examined students at an institution different from their own. Two cases were presented to each student participant in a series of vignettes. The rubric was constructed to follow a set of examiner questions that related to each attribute of CR. Data were analysed to explore differences in examiner marking, as well as relationships between cases, institutions, and different year levels. A non-examining member of the research team acted as an observer at each location.ResultsNo statistical difference was found between the total and single question scores, nor for the total scores between examiners. Significant differences were found between 4th and 5th students on total score and a number of single questions. The rubric was found to be internally consistent.ConclusionsA viva examination of clinical reasoning, trialled with senior osteopathy students, showed face and content validity. Results suggested that the viva exam may also differentiate between 4th and 5th year students’ capabilities in CR. Further work is required to establish the reliability of assessment, to further refine the rubric, and to train examiners before it is implemented as a high-stakes assessment in accredited osteopathy programs.

Uncritical Reverence in CM Reporting: Assessing the Scientific Quality of Australian News Media Reports

Abstract Objectives: The study is an exploratory study of a media event in Australia based on the publication of two separate systematic analyses of complementary medicine (CM) therapies. The objective of the study was to measure the scientific quality of Australian newspaper media reports about two international peer-reviewed research papers reporting results on complementary medicines published in biomedical journals during Feb/March 2007. For purposes of clarity, we refer to the papers as the ‘Antioxidant Study’ (Bjelakovic et al 2007) and the ‘Prenatal Multivitamin Study’ (Goh et al 2007). Methods: We sourced articles that were published about the two research papers in mainstream metropolitan and national Australian newspapers during February and March 2007. We then applied a model of analysis called the Index of Scientific Quality (ISQ) to measure the scientific quality of the news reports. Results: We identified 14 newspaper articles and one newswire article about the Antioxidant Study and two newspaper articles about the Prenatal Multivitamin Study. Of the seven ISQ criteria, ‘validity’ and ‘precision’ were rated the least adequate, ‘important consequences’ of the research were reported partially in the Antioxidant Study and wholly in the Prenatal Multivitamin Study, and ‘opinion from fact’ was adequate in the majority of articles. Conclusion: This exploratory study conveyed an overall inadequacy in the scientific quality of the newspaper reporting about the two CM studies in major metropolitan and national Australian newspapers. Whilst we found that journalists were careful to attribute opinions to their sources, their reports conveyed a very limited understanding of biomedical research methodologies and a subsequent incapacity to scrutinise these methodologies with rigour.

The patient experience of osteopathic healthcare

BACKGROUND Osteopathy in Australia is a primary care limited scope practice. Practitioner surveys suggest that patients present with chronic pain and receive manual therapies, exercise and lifestyle advice. Further research is required to deepen the understanding of this intervention from the perspective of patients. OBJECTIVE To explore the experience of patients receiving osteopathic healthcare. DESIGN Mixed methodology. METHOD A quantitative survey of a convenience sample of patients was followed by qualitative semi-structured interviews in a purposive sample of respondents with chronic non-specific low back pain. The transcripts were analysed using a phenomenological approach. RESULTS The survey results suggested directions of enquiry for the interviews. Eleven subjects were interviewed and reported commonalities in their clinical histories with multisystem co-morbidities. Four themes became apparent: patient decision-making, patient shared experiences of the osteopathic healthcare consultation, tailored patient-centred care, and therapeutic relationship in healthcare. CONCLUSION This data suggests that patients experience osteopathic healthcare after trying other disciplines; that there are shared aspects of the consultations, with a thorough assessment, education about their condition, multiple manual therapies and lifestyle advice; that the experience is patient-centred and tailored to their context; and that the therapeutic relationship is a key aspect of the experience. These results reflect a number of aspects of osteopathic healthcare from workplace surveys.

Understanding clinical reasoning in osteopathy: a qualitative research approach

BackgroundClinical reasoning has been described as a process that draws heavily on the knowledge, skills and attributes that are particular to each health profession. However, the clinical reasoning processes of practitioners of different disciplines demonstrate many similarities, including hypothesis generation and reflective practice. The aim of this study was to understand clinical reasoning in osteopathy from the perspective of osteopathic clinical educators and the extent to which it was similar or different from clinical reasoning in other health professions.MethodsThis study was informed by constructivist grounded theory. Participants were clinical educators in osteopathic teaching institutions in Australia, New Zealand and the UK. Focus groups and written critical reflections provided a rich data set. Data were analysed using constant comparison to develop inductive categories.ResultsAccording to participants, clinical reasoning in osteopathy is different from clinical reasoning in other health professions. Osteopaths use a two-phase approach: an initial biomedical screen for serious pathology, followed by use of osteopathic reasoning models that are based on the relationship between structure and function in the human body. Clinical reasoning in osteopathy was also described as occurring in a number of contexts (e.g. patient, practitioner and community) and drawing on a range of metaskills (e.g. hypothesis generation and reflexivity) that have been described in other health professions.ConclusionsThe use of diagnostic reasoning models that are based on the relationship between structure and function in the human body differentiated clinical reasoning in osteopathy. These models were not used to name a medical condition but rather to guide the selection of treatment approaches. If confirmed by further research that clinical reasoning in osteopathy is distinct from clinical reasoning in other health professions, then osteopaths may have a unique perspective to bring to multidisciplinary decision-making and potentially enhance the quality of patient care.Where commonalities exist in the clinical reasoning processes of osteopathy and other health professions, shared learning opportunities may be available, including the exchange of scaffolded clinical reasoning exercises and assessment practices among health disciplines.

Reliability of a viva assessment of clinical reasoning in an Australian pre-professional osteopathy program assessed using generalizability theory

Clinical reasoning is situation-dependent and case-specific; therefore, assessments incorporating different patient presentations are warranted. The present study aimed to determine the reliability of a multi-station case-based viva assessment of clinical reasoning in an Australian pre-registration osteopathy program using generalizability theory. Students (from years 4 and 5) and examiners were recruited from the osteopathy program at Southern Cross University, Lismore, Australia. The study took place on a single day in the student teaching clinic. Examiners were trained before the examination. Students were allocated to 1 of 3 rounds consisting of 5 10-minute stations in an objective structured clinical examination-style. Generalizability analysis was used to explore the reliability of the examination. Fifteen students and 5 faculty members participated in the study. The examination produced a generalizability coefficient of 0.53, with 18 stations required to achieve a generalizability coefficient of 0.80. The reliability estimations were acceptable and the psychometric findings related to the marking rubric and overall scores were acceptable; however, further work is required in examiner training and ensuring consistent case difficulty to improve the reliability of the examination.

Criticality in osteopathic medicine: exploring the relationship between critical thinking and clinical reasoning

Critical thinking is an important graduate attribute that is universally cultivated in university courses, including professional entry courses in health. Osteopathic medicine is undergoing considerable change as it reevaluates its traditional foundations in the context of the evidence-based demands of contemporary health care (Fryer 2008; Licciardone, Brimhall, and King 2005) and thus offers a timely opportunity for practitioners and students to engage in critical thinking both within and about the field. This chapter discusses the relationship between critical thinking and clinical reasoning and what criticality means in osteopathic medicine, which may shed light on the relationship between critical thinking and clinical reasoning in health care more generally. We argue that critical thinking and clinical reasoning are primarily distinguished by context and by the metaskills that practitioners call on in the course of clinical practice.