OMT and the Treatment of Pneumonia

Transcription

OMT and the Treatment
of Pneumonia
Brian F. Degenhardt, D.O.
A.T. Still Research Institute, Director
Assistant Vice President for Research, ATSU
AOA 2011 Scientific Conference
www.clinicaltrials.gov, #NCT00258661
Funding Agencies
Osteopathic Heritage Foundation (OH)
Osteopathic Institute of the South (GA)
Osteopathic Founders Foundation (OK)
Quad City Osteopathic Foundation (IA)
Colorado Springs Osteopathic Foundation (CO)
Foundation for Osteopathic Health Services (MD)
Muskegon General Osteopathic Foundation (MI)
Northwest Oklahoma Osteopathic Foundation (OK)
Brentwood Foundation (OH)
Hospital Sites
Mount Clemens Regional Medical Center in Mount Clemens, Michigan
ATSU in association with Northeast Regional Medical Center in Kirksville, Missouri
UMDNJ in association with Kennedy Memorial Hospitals-University Medical Center in
Stratford, New Jersey
Doctors Hospital in Columbus, Ohio
UNTHSC in association with Osteopathic Medical Center of Texas,
Plaza, and JP Smith in Fort Worth, Texas
Multicenter Study Structure
Osteopathic
Research
Center,
Fort Worth, TX
Osteopathic
Foundations
Ohio –
Doctors
Hospital
Michigan –
Mount
Clemens
AT Still Research
Institute, Kirksville
, MO
Missouri –
NERMC
New Jersey
– Kennedy
Stratford
Texas –
OMCT, (Pl
aza &
JPS)
Research Design
Subjects
(n=406)
OMT
Group
(n=135)
OMT:
• Twice daily
• 7 days a week
• 15 min duration
LT Group
(n=136)
LT:
• Twice daily
• 7 days a week
• 15 min duration
CC Group
(n=135)
Primary Outcomes:
1. Length of Hospital Stay
2. Time to Clinical Stability
3. Rate of Symptomatic &
Functional Recovery
Secondary Outcomes:
•
Duration of IV
Antibiotic treatment
•
Hospital Complications
and Adverse Events
•
60-day Re-admission
•
Duration Leukocytosis
•
Mortality
•
Patient satisfaction
MOPSE Techniques
Thoracic and lumbar paraspinal
soft tissue
Rib Raising
Doming of the diaphragm
Cervical soft tissue
Suboccipital inhibition
Thoracic Inlet
Thoracic pump with activation
Pedal pump
Improve
rib cage mechanics,
sympathetic regulation
Improve
parasympathetic
regulation
Augment
lymphatic flow
• Twenty OMT specialists and
64 resident physicians from
12 specialties administered
the treatment protocols.
Multicenter Study Structure
Osteopathic
Research
Center,
Fort Worth, TX
Osteopathic
Foundations
Ohio –
Doctors
Hospital
Michigan –
Mount
Clemens
AT Still Research
Institute, Kirksville
, MO
Missouri –
NERMC
New Jersey
– Kennedy
Stratford
Texas –
OMCT, (Pl
aza &
JPS)
Disclaimers
• Diagnostic techniques and interpretation
was based on professional school training
• No reliability training was performed on
diagnostic skills
• Skill level quite diverse between sites
Somatic Dysfunction
Data
Analysis of Palpation Data
• Data set from first year of study
• Occurred only at the Missouri Site
• Admission data n= 50
– 25 OMT group
– 25 Light Touch group
• Admission/Discharge data n=49
– 24 OMT group
– 25 Light Touch group
MOPSE Structural Exam Data
Initial Exam
50
40
30
20
Other/Abdomen
Ribs L
Ribs R
Pelvis/Innom
Lumbar
T10-12
T5-9
T1-4
Neck
0
Pelvis/Sacrum
10
Head
Incidence of Somatic Dysfunction (Degree=1/2)
Incidence of Somatic
Dysfunction in Hospitalized
Elderly with Pneumonia (n=50)
Percentage of Somatic
Dysfunction Based on Severity
Initial Exam
100%
80%
60%
Degree 0
Degree 1
Degree 2
40%
Other/Abdomen
Ribs L
Ribs R
Pelvis/Innom
Lumbar
T10-12
T5-9
T1-4
Neck
Head
0%
Pelvis/Sacrum
20%
Percentage of Somatic
Dysfunction Based on TART
Initial Exam
100%
None
T only
80%
A/R only
60%
TTC only
40%
A/R+T
20%
TTC+T
TTC+A/R
Other/Abdomen
Ribs L
Ribs R
Pelvis/Innom
Pelvis/Sacrum
Lumbar
T10-12
T5-9
T1-4
Neck
Head
0%
TTC+A/R+T
Somatic Dysfunction Burden
(severity [1,2] x number regions)
Initial Exam
14
12
10
8
6
4
2
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Somatic Dysfunction Quotient
Neck
T1-4
T5-9
Admission
T10-12
Lumbar
Discharge
Ribs
Right
Light
Touch
OMT
Light
Touch
OMT
Light
Touch
OMT
Light
Touch
OMT
Light
Touch
OMT
Light
Touch
OMT
Light
Touch
OMT
Incidence of Somatic Dysfunction (%)
100
80
60
40
20
0
Ribs Left
Admission
Discharge
Admission
Discharge
Admission
Discharge
Admission
Discharge
Admission
Discharge
Admission
Discharge
Admission
Discharge
Admission
Discharge
Admission
Discharge
Admission
Discharge
Admission
Discharge
Admission
Discharge
Admission
Discharge
Admission
Discharge
100%
80%
60%
40%
20%
0%
OMT Light OMT Light OMT Light OMT Light OMT Light OMT Light OMT Light
Touch
Touch
Touch
Touch
Touch
Touch
Touch
Neck
T1-4
T5-9
T10-12
Degree 2
Degree 1
Lumbar
Degree 0
Ribs Right
Ribs Left
Summary
Technique Data
MOPSE Techniques
Thoracic and lumbar paraspinal
soft tissue
Rib Raising
Doming of the diaphragm
Cervical soft tissue
Suboccipital inhibition
Thoracic Inlet
Thoracic pump with activation
Pedal pump
Improve
rib cage mechanics,
sympathetic regulation
Improve
parasympathetic
regulation
Augment
lymphatic flow
Disclaimers
• From technique training sessions, data
was excluded from 11-18 physicians due
to calibration and equipment irregularities
• Up to 3 sessions of data was collected
per physician
Xsensor System
Sensor Products LLC, East Hanover, NJ
•
•
•
•
•
•
•
Thin, flexible pad
Size – 19 by 19 cm
4096 sensors/pad
11.3 sensors/cm2
Stable calibration
Mobile system
Sampling rate – 2.7/sec
Data Analysis
• Force (N) = average pressure (kg) *
contact area (kg) * 9.80665 (gravity, m/s).
• 3 ways to process data (all using low
threshold filter)
– Method 1- whole pad
– Method 2 – individual cells
– Method 3 – boxes
Rib Raising
• After diagnosing
areas of restriction,
contact ribs at rib
angles, curl fingers
and pull angles
laterally.
• “Pump” ribs by
moving hands
anteriorly as elbows
descend towards the
floor
Data Set: Rib Raising
• Number of Physicians (N) = 54
• Number of data sets = 106
• Average time of collection - 32 sec
(SD = 23 sec)
• Number of Training Sessions = 14
• Only method 2 analysis completed
Rib Raising Pressure
Processing
1
2
3
Rib Raising
11 – 15 cycles per minute
Rib Raising
Mean Force (N) (95% CI).
700
Peak
Trough
600
500
400
300
200
100
0
MI MO NJ OH TX MI MO NJ OH TX
Suboccipital Inhibition
• Finger tips identify
the base of the
occiput
• Fingers curl into the
suboccipital muscles
• Steady, gentle
outward (lateral) and
cephalad traction
Suboccipital Decompression
Average Pressure (kg/cm 2 )
Mean (95% Confidence Band).
0.90
0.85
0.80
0.75
0.70
Time Holding Steady Pressure
Mean Force (N, 95% Confidence Band)
250
225
200
175
150
0
3
6
9 12 15 18 21
Seconds Holding Steady Pressure
Force = average pressure * contact area * 9.80665 (gravity, m/s).
Within-treater variability (N, 95% CI):
Between-treater variability (N, 95% CI):
14 (13-14)
53 (46-62)
Data Set: Suboccipital Inhibition
• Number of Physicians = 66
• Number of Observations = 5707 (35.2
minutes)
• Maximum Number of Observations per
Physician = 193 (70 seconds)
• Number of Training Sessions = 14
Pressure Data
•
•
•
•
Maximum pressure
Mean pressure
Time
Contact area (determined by sensor
selection)
• Force (calculated)
– Force = average pressure x contact area x
9.80665 (gravity, m/s).
Raw Force – Method 2
Raw Force – Method 3
Predicted force – Method 2
Predicted Force – Method 3
Raw Surface Area – Method 2
Raw Surface Area – Method 3
Surface Area – Predicted – Method 2
Surface Area – Predicted – Method 3
•
•
•
•
•
•
Gradual increase in pressure over time
Gradual increase in surface area over time
Gradual increase Force over time
Sign of conscious relaxation?
Sign of local treatment response?
Sign of alteration in finger positioning?
Thoracic Pump with Activation
Hands placed on the subjects’ anterior,
superior portion of the rib cage.
During exhalation, physicians apply
rapid alternating pressure - 120
compression/relaxation cycles/minute.
Some pressure is maintained while the
patient inhales. Pressure on patients’
chest cage increases with each
successive exhalation, and sustained
with the subsequent inhalation.
At approximately the first one-third to
one half of the inhalation, the physicians
briskly remove their hands from the rib
cage.
TP Pressure Processing
1
3
2
Data Set: Thoracic Pump
• Number of physicians = 73
• Number of Observations = 7077
• Maximum Number of Observations per
physician = 141
• Number of Training Sessions=14
1,800
Peak: 1697 N (1674-1721)
1,700
1,600
Slope: 70 N/sec (59-80)
Force (N)
1,500
1,400
Midpoint: 2.7 secs (2.1-3.3)
1,300
1,200
1,100
1,000
Baseline: 982 N (932-1033)
900
Time (secs)
Standardization??
• Characteristics of the
examiner
patient
dynamic between the two
• What is therapeutic
Limitations
• Best way to isolate cells challenging since
contact area can vary throughout a
technique
• Training and testing protocols should be
better standardized
• Sampling rate not adequate to evaluate
the vibratory component of the thoracic
pump
• Current sensors are unidirectional
Conclusions
• Is standardization possible? Is it important?
• Quantification is an initial step in the long term
goal of describing techniques that are therapeutic.
• Improved interpretation of the influence of contact
area and pressure
• Determining what is therapeutic requires
simultaneous measurement of technique
performance and a measure of therapeutic
response
• Objective description is the foundation for
meaningful education
Thoracic Pump
Within-treater variability (N, 95% CI):
Between-treater variability (N, 95% CI):
287 (282-291)
629 (550-735)
2000
1750
1500
1250
1000
957 (868-1,045)
Mean Force (N, 95% CI)
2250
750
500
Rate of change: 41 N/sec (39-42)
Baseline
Peak
• Height: 11mm - 16mm
• Width: 15mm - 19mm

OMT and the Treatment of Pneumonia

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