Abstract
Context: The first 2 years of osteopathic medical school involve training in osteopathic principles and practice, including understanding the tenets of osteopathic medicine and developing palpatory skills for clinical application. Although this training emphasizes the link between somatic dysfunction and physiologic function, it does not include the opportunity for students to quantitatively assess the physiologic effect of osteopathic manipulative treatment (OMT) using physiologic measurements.
Objective: To evaluate an approach for integrated OMT training coupled with physiologic measurements of relevant parameters, whereby first-year osteopathic medical students assess the quantitative, real-time changes in specific physiologic signals during instruction.
Methods: During mandatory musculoskeletal and cardiovascular demonstration laboratories at a single osteopathic medical school, students were divided into small groups and performed OMT on each other while recording real-time measurements of physiologic functions such as maximum clench force, time to fatigue for the forearm flexor muscles, heart rate, and peripheral vascular flow. After data were collected, students analyzed pre- and post-OMT measurements and discussed underlying physiologic principles in a large group format. At the end of the sessions, students completed a brief survey on the usefulness of the integrated laboratories.
Results: Overall, 13 of 28 student groups (46.4%) measured a pre- to post-OMT increase in maximum clench force, and 16 (57.1%) observed an increase in time to fatigue for the forearm flexor muscles. Twenty-three of 27 student groups (85.2%) observed a reduction in heart rate and 19 (70.4%) measured an increase in peripheral vascular flow after OMT. Student satisfaction was generally favorable, with overall mean (SD) ratings of 6.38 (1.86) for the musculoskeletal laboratory and 7.81 (1.69) for the cardiovascular laboratory out of a maximum of 10 points. In open-ended comments, students deemed the combined laboratories as clinically applicable but desired more time for completing the laboratories.
Conclusion: Measurement of specific physiologic musculoskeletal and cardiovascular parameters before and after OMT enabled quantification of physiologic responses to OMT. Students' favorable feedback indicated that the quality of learning in the laboratories was enhanced by the addition of physiologic measurements. J Am Osteopath Assoc.2014;114(12):918-929 doi:10.7556/jaoa.2014.179
All osteopathic medical students are taught the tenets of osteopathic medicine
1 as part of the distinctive osteopathic principles and practice (OPP) curriculum. During the first 2 years of osteopathic predoctoral education, students learn the clinical relevance and application of these tenets in OPP laboratories, during which they develop proficiency in osteopathic palpatory diagnosis and manipulative treatment skills. A unique component of OPP training is the identification of somatic dysfunction and an appreciation of its relevance to underlying physiology and systemic complaints. This relationship of somatic dysfunction to physiology is conceptually taught as somatovisceral, somatosomatic, and viscerosomatic reflexes. Because students learn osteopathic manipulative treatment (OMT) primarily by performing it on their asymptomatic peers, OMT's potential influence on health and disease is difficult to demonstrate. Although students might occasionally encounter and treat the peer with neuromuscular complaints, their understanding of OMT for managing illness is acquired primarily through textbooks and other publications. Further, within the traditional curricular framework for osteopathic medical education, students usually learn about OMT as a tool for benefiting health through qualitative observations.
Few opportunities to practice and observe the clinical effectiveness of OMT before residency training limits students' view of OMT and thus influences these students' future use of OMT in residency and clinical practice.
2-4 Survey-based research of osteopathic family physicians and specialists has been conducted to attain a better understanding of whether OMT is becoming a “lost art.”
3 Johnson and Kurtz
2 reported that more than 50% of osteopathic physicians practiced OMT on less than 5% of their patients. Among other aspects, the training environment influences whether residents perform OMT. For example, a 2005 study
5 found that the rate of residents practicing OMT was much greater in American Osteopathic Association (AOA)–approved family medicine residencies than in Accreditation Council for Graduate Medical Education programs.
In an effort to strengthen student palpatory skills and to improve understanding of the broader spectrum of indications for OMT, a variety of strategies have been devised by osteopathic medical school faculty. For example, palpatory training models have been used to help students gauge diagnostic accuracy on premeasured lumbar and pelvic static models.
6-9 In addition, the Virtual Haptic Back simulation technology uses touch screens to give real-time feedback about digital pressures and diagnostic interpretations.
10 Some schools have incorporated clinical case discussions into the second-year osteopathic medical school curricula to enhance students' understanding of the clinical relevance of OMT.
11, 12 Mandating OPP lecture and laboratory courses during clinical clerkship rotations is another strategy to foster integration of OMT.
13, 14 Even with these strategies, trainees' use of OMT in clinical practice ranges widely, depending on preceptor availability and skill level.
4
Preceptor-based, hands-on OPP training has been described by Gevitz
15 as “a craft model of education” whereby “[t]he master teaches the student how he or she performs a particular task, and the student imitates the master until gaining the desired degree of proficiency.” He also proposed that students can gain greater insight into systemic and functional influence of OMT when their instruction is paired with physiologic measurements.
15 This type of teaching approach can help demonstrate to students the physiologic influence of OMT, such as findings reported in studies by Denslow
16, 17 and Korr.
18
We describe one osteopathic medical school's approach to integrate physiologic measurements with OMT training during mandatory first-year OPP laboratories. Distinct from training using simulated mannequins and models, the training used in the present laboratories involved students performing OMT on fellow students while continuously monitoring specific physiologic parameters, thereby obtaining immediate human-response feedback to OMT.
In the present study, 2 aspects of this integrated physiologic measurement-OPP model were assessed: (1) whether noninvasive physiologic measurement during specified OMT enabled quantification of physiologic responses and (2) whether student perception of the quality of the laboratory experience was positive.
After institutional review board approval, 5 mandatory physiology demonstration laboratories were integrated into the first-year OPP curriculum at A.T. Still University–School of Osteopathic Medicine in Arizona (Mesa) between 2010 and 2012. During the beginning of the academic year, the first laboratory sessions were used to fine-tune the teaching approach, logistics, allocation of appropriate student group size per station, and student feedback forms. In the present study, we analyzed data from 2 laboratory sessions in 2012 that occurred later in the academic year, during which the instruction sessions could be successfully completed and all information recorded.
To evaluate the success of these laboratories, we (1) compared student-recorded pre- and post-OMT physiologic measurements to assess whether noninvasive physiologic measurement during OMT enabled quantification of physiologic responses and (2) administered a survey to students after completion of the new laboratories to assess student perception of the quality of the laboratory experience.
For the musculoskeletal demonstration laboratory, students recorded baseline and post-OMT measurements in real time using electromyography (EMG) for forearm muscle electrical activity and a clench force transducer for hand grip strength.
22,23
In the laboratory, faculty guided the students in identifying and treating specific forearm tender points using the strain-counterstrain OMT procedure.
24 Surface electrodes were placed on the forearm of the test participant (
Figure 1). Clench force was measured by using a dynamometer within the same set up.
At the end of the session, students used the Biopac software to analyze post-OMT changes in the forearm of the test participant. For this signal, the peak force as well as the time to fatigue was assessed. Time to fatigue was defined as the time it took to reach 50% of the maximum force during a sustained clench of the dynamometer. Results were recorded on a worksheet, and each group gave an oral report of their findings, including pre- to post-OMT changes in muscle electrical activity (surface EMG, peak-peak amplitude), hand-grip strength (maximum clench force), and endurance (time to fatigue), as well as differences in performance between men and women. The anticipated result was to achieve an increase in forearm EMG activity and a longer duration of handgrip strength after OMT.
At the end of the sessions, students were administered a 9-item survey that asked them to rate the following items using a 10-point Likert scale, with 1 indicating “poor” and 10 indicating “excellent”: presentation and instructional materials, time allowed to practice, amount of provided material, complexity of the material, organization of the laboratory, and faculty. In addition, students were asked to provide comments regarding the strong points of laboratory, the clinical applicability of the laboratory, and suggestions to improve the laboratory. The survey was administered during the afternoon musculo-skeletal laboratory session and during the morning and afternoon cardiovascular laboratory sessions.
Data were obtained from student laboratory worksheets and student satisfaction forms. Statistical comparison (using SPSS statistical software, version 22) of the pre- and post-OMT musculoskeletal and cardiovascular parameters for the 2 different laboratories was conducted using dependent samples t tests. For the musculoskeletal performance laboratory, data by sex of participants were evaluated using a repeated measures analysis of variance. For the student satisfaction survey, an independent samples t test was performed. Descriptive statistics in each case were counts, mean, and SD. For all tests, a was set at .05, 2-tailed.
Our study revealed that (1) noninvasive muscle activity and cardiovascular parameter physiologic measurements during specified OMT enabled quantification of physiologic responses and (2) overall student perception of laboratories that incorporated this learning approach was positive. Physiologic changes have been measured in scientific studies to demonstrate the effects of OMT,
28-31 and the quantitative measurement of these changes during OPP training has been proposed before.
15 To our knowledge, however, the present study is the first to describe the measurement of physiologic changes in combination with OMT in a hands-on teaching environment for osteopathic medical students.
The anticipated responses for the musculoskeletal demonstration laboratory were an increase in forearm EMG activity and a longer duration of hand-grip strength after OMT. In our study population, these responses were reported in approximately half of the 28 groups, and changes were not statistically significant (Table 2).
The use of OMT for modulating the autonomic nervous system is a fundamental concept of osteopathic medicine. For example, treatment of upper cervical and upper thoracic vertebral segments can help achieve vagal stimulation as well as sympathetic inhibition.
25 Hence, for the cardiovascular demonstration laboratory, anticipated responses included a reduction in heart rate and an increase in peripheral vascular flow in the upper extremity after OMT. These expected responses were reported in the majority of our student groups, and changes were found to be statistically significant
(Table 3).
Although the musculoskeletal demonstration laboratory results were not statistically significant for peak force and time to fatigue, the students had the opportunity to observe physiologic trends pertinent to muscle performance after the application of strain-counterstrain. The heart rate and peak-peak PPG changes in the reported test groups were statistically significant. However, more importantly, the combination of vascular measurements during OMT procedures at the occipitoalantal junction enabled students to observe physiologic changes first hand. The overall student survey results from both the musculoskeletal and cardiovascular laboratories were relatively positive at 64% and 78%, respectively.
Our findings are preliminary, but they demonstrate the practical usefulness of employing OMT to affect physiologic change. In addition, in this combined approach to learning the use of OMT and bioinstrumentation, osteopathic medical students had an opportunity to become familiar with the use of clinically relevant instrumentation and physiologic measurements early in their medical training. Both scaled survey responses and student comments reflected the value of working in small groups, observing the biophysiologic effects of OMT, and optimizing OMT procedures (
Table 4 and
Figure 3). No differences in survey responses were observed between the morning and afternoon sessions, indicating no change in instructor readiness or student familiarity with the steps as the day progressed.
During the implementation stage of the current integrative teaching approach, workflow in the laboratories evolved, and the worksheets and expectations from the students were revised. Instructions were simplified, and student group sizes were reduced. Initially, the learning groups were 10 students per station, which was determined to be too large for optimum participation. Students were also not required to formally report their acquired data, explain their results, or submit their laboratory records. Students are now expected to scientifically interpret their outcomes and submit a worksheet. The current 3- to 5-person group size ensures greater student participation in the exercises. In addition, the present laboratory structure provides precise, easy-to-follow instructions for operating instrumentation, acquiring data accurately, and analyzing post-OMT data efficiently.
Since completion of the current study, A.T. Still University–School of Osteopathic Medicine in Arizona has continued to include 5 physiologic demonstrations as part of its 25 mandatory first-year OPP laboratory sessions. The sessions are timed to integrate within curriculum content and are designed to be appropriate for the student skill level. For example, the musculoskeletal demonstration laboratory coincides with the neuromusculoskeletal coursework that covers upper extremity muscle anatomy and physiology, and the cardiovascular demonstration laboratory coincides with coursework on the cardiovascular system and the basics of ECG. In addition, the OMT procedures selected for the laboratories are safe and appropriate for a novice level. In contrast to the complex designs of detailed research protocols from studies related to recording musculoskeletal and cardiovascular function with OMT,
28-31 the laboratories described in the present study are simple, noninvasive, and easy to implement into first-year osteopathic medical student training.
Despite differences in students' familiarity with instrumentation and computer skill level, most students are able to successfully complete the laboratories using the Biopac software. The laboratories are time-limited and must be run efficiently to ensure that all groups finish their OMT exercises, collect and report their data, and allow sufficient time for large-group discussion. We have found that for the optimum laboratory experience, all supervising faculty and fellows must be trained in using the equipment, troubleshooting technical glitches, and carefully guiding the students' use of OMT.
In the large-group discussions, instructors emphasize that the observed findings illustrate the relationship of OPP with physiologic responses. The students are reminded that these demonstration laboratories are not intended as research studies because they lack a detailed, formal study design and proper controls. However, the laboratories do introduce students to basic research questions and provide an opportunity for faculty to discuss double-blind, randomized control designs, as well as the role of placebos and sham procedures, in osteopathic clinical research. After completing the demonstration laboratories, a few students have been motivated to design and seek funding for their own clinical research studies.
The current study has a number of limitations, weaknesses, and confounding factors. First, it included a small number of physiologic performance data sets from EMG and cardiovascular measurements after OMT. A greater number of student data sets must be analyzed before definitive conclusions can be made about the efficacy of particular OMT procedures in producing the corresponding physiologic output. In addition, more student feedback is needed to fully understand the value of combining OMT with physiologic signal monitoring. Confounding factors include students' ability to operate computer-based instrumentation, perform OMT, and understand certain physiologic concepts, as well as the lack of a controlled scientific experimental environment. Despite these limitations, the success of the present combined approach for training first-year osteopathic medical students is promising. The aforementioned limitations will be addressed in future laboratories by further simplifying instructions and obtaining more student feedback. In addition, future research is needed to correlate students' OMT skill level to measureable physiologic responses as they acquire further training. Future studies are also needed to investigate whether integrated OPP training affects students' readiness to use OMT in clinical practice.