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Letters to the Editor  |   August 2013
Response
Author Affiliations
  • Sherman Gorbis, DO
    Michigan State University College of Osteopathic Medicine, East Lansing
    Associate Professor
Article Information
Cardiovascular Disorders / Gastroenterology / Medical Education / Osteopathic Manipulative Treatment / Graduate Medical Education
Letters to the Editor   |   August 2013
Response
The Journal of the American Osteopathic Association, August 2013, Vol. 113, 596-597. doi:10.7556/jaoa.2013.019
The Journal of the American Osteopathic Association, August 2013, Vol. 113, 596-597. doi:10.7556/jaoa.2013.019
To the Editor: 
My colleagues and I thank Dr Noll1 for taking the time, first, to read our original contribution2 and, second, to compose such a constructively critical letter pointing out the weaknesses in our project and how potential future studies might be designed. 
We freely admit that, despite positive and encouraging results, there were limitations to our study, namely the following:
  •  
    Several osteopathic physicians (ie, DOs) and students performed osteopathic manipulative treatment (OMT) on our study's patients. We attempted to decrease the variation in OMT skills, however, by enlisting 1 physician (S.G.) to train all operators.
  •  
    The study population was limited to patients from the practice of 1 surgeon (Gary L. Roth, DO). Although we believed that this limitation worked to decrease and counter variables and to standardize the preoperative evaluation and consent process, it may have also inadvertently led to the enrollment of a smaller population of patients in our study.
  •  
    The study population was confined to patients who underwent coronary artery bypass graft surgical procedures only and thus did not include patients who also underwent other surgical interventions, such as valve replacements.
As we stated, “We are aware that these limitations in our study sample may decrease the ability to extrapolate these findings to other, more heterogeneous populations.” 
Dr Noll states that it is not correct to characterize the intervention as “beneficial, though not statistically significant.” We respectfully believe, however, that the OMT was beneficial. The following factors should be considered:
  •  
    The 17 patients in the OMT group were discharged 0.6 days sooner postoperatively than the 18 patients in the control group. Though not statistically significant, this result—if extrapolated to McLaren Greater Lansing (where Dr Roth and I practice and where the study was conducted)—could have saved our hospital at least $1000 per patient. For some hospitals, $17,000 may not seem substantial. If these savings are seen in light of 50, 100, or 400 surgical procedures per year, however, the savings quickly multiply.
  •  
    A reason for the decrease in length of stay was the return of bowel function 0.5 days sooner for patients in the OMT group than for patients in the control group. This correlation is especially relevant to general surgeons, who perform OMT—or have their residents or students perform it—postoperatively on patients to prevent or manage bowel obstruction.
  •  
    Patients in the OMT group also had the highest average total FIM (formerly known as Functional Independence Measure) score on postoperative day 3. This group's mean score was 19.3 compared with 15.4 for the placebo group and 18.6 for the control group.
We acknowledge that our study was small and “exploratory,” as described by Dr Noll. We are grateful to The Journal of the American Osteopathic Association for allowing its publication. Many people worked with the authors—including Gayle Durnin, PT—putting in many hours during and after the study to prepare it for submission. We are proud of our efforts even as we appreciate Dr Noll's comments regarding its shortcomings. Furthermore, our study has contributed to the following improvements at McLaren Greater Lansing:
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    The Osteopathic Manipulative Medicine Consultation, Treatment, and Teaching Service has been resurrected. For the past 8 years, DOs have been consulted to treat patients undergoing coronary artery bypass graft, valve repair or replacement, and thoracotomies performed by a study colleague (G.L.R.) and several of his associates, all of whom are allopathic physicians (ie, MDs). As DOs, we appreciate and respect the fact that our allopathic colleagues believe our skills to be valuable for their patients. Other DOs and MDs ask that we use our skills in osteopathic manipulative medicine, including OMT, to treat patients in other areas of our hospital with many different complaints and conditions.
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    During the course of the study, we as researchers and DOs developed a more collegial bond with the nursing staff in the intensive care unit, as well as with nurses in general medical, surgical, oncological, and labor and delivery units. We always ask permission of the intensive care unit nurses before performing OMT on patients in their wards. Nurses on other units are consulted as well. We believe that nurses have a better understanding of what DOs do and what OMT is used to accomplish, from a services' standpoint.
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    Physicians—both DOs and MDs—are cultivating osteopathic thinking, wherein OMT is considered for many patients. Osteopathic medical students and resident DOs are also encouraged to perform OMT with permission when applicable.
Dr Noll suggested that a 3-arm study should be reserved for large, well-funded, definitive projects where each group is adequately powered. We agree and indeed wrote in our article that we hoped further, larger scale investigations (preferably multicenter) would be conducted to confirm the benefits that our patients experienced. McLaren Greater Lansing would be unable to participate, however, because OMT is now part of the standard of care in the postoperative recovery of this patient population. 
References
Noll DR. The effect of OMT on postoperative medical and functional recovery of coronary artery bypass graft patients. J Am Osteopath Assoc. 2013;113(8):595-596. [CrossRef] [PubMed]
Wieting JM, Beal C, Roth GLet al. The effect of osteopathic manipulative treatment on postoperative medical and functional recovery of coronary artery bypass graft patients. J Am Osteopath Assoc. 2013;113(5):384-393. [PubMed]