Somatic Dysfunction in Osteopathic Family Medicine Table of Contents

Somatic dysfunction is divers as "impaired or altered role of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements."¹ The palpatory diagnosis of somatic dysfunction and the use of osteopathic manipulative treatment (OMT) by osteopathic physicians to relieve or amend patient discomfort and hurting are hallmarks of osteopathic principles and exercise. Nevertheless, the literature contains few published studies about the prevalence of somatic dysfunction or the frequency of its diagnosis and handling by osteopathic physicians.

The previously validated Outpatient Osteopathic SOAP Notation Grade (SNF) Serial was developed by the Louisa Burns Osteopathic Research Committee of the American Academy of Osteopathy^ii,3 to provide osteopathic physicians with a tool to objectively mensurate and record the diagnosis and handling of somatic dysfunction during patient encounters.

The standardized SNF instructions facilitate its utilize in clinical practise as well every bit during the drove of data for research studies. A previous study has demonstrated that physicians take the same corporeality of fourth dimension (ie, approximately iv minutes) to consummate the SNF equally conventional physician progress notes.³ Furthermore, the SNF appears to capture more than clinical information than do physician progress notes, especially with regard to the severity of somatic dysfunction and the response of patients with this diagnosis to OMT as a treatment modality.³

We performed a retrospective assay of SNF data to measure the prevalence and severity of somatic dysfunction encountered in the osteopathic family practice setting and to characterize doctor utilize of and patient response to OMT in this setting.

Methods

Three family exercise clinic sites affiliated with Midwestern University's Chicago College of Osteopathic Medicine (CCOM) in Downers Grove, Ill, contributed patient records for this retrospective study. Patients who presented for medical care at these family exercise clinics from March 4, 1998, through Jan 20, 1999, were eligible for inclusion in the study. Twenty osteopathic medical students, interns, and residents served as investigators for this study, completing SNF patient records under the supervision of any of seven osteopathic physicians at these family practice sites.

Effigy i.

Distribution of the number of anatomic regions diagnosed with somatic dysfunction and treated with osteopathic manipulative treatment in family do clinics.

Patient records were selected for review serially every bit patients were seen in participating clinics during regular outpatient dispensary hours. During patient encounters, investigators collected SNF data and applied diagnostic coding using the standardized course and instructions.³

Because one of the goals of this study was to capture data on somatic dysfunction and OMT at the aggregate level, the aforementioned patient may have contributed data to the report database through multiple encounters.

In addition, so that we might gauge the prevalence of somatic dysfunction and its treatment during adult patient encounters in osteopathic family practices, patients nether the age of 18 years were excluded from the report database prior to assay.

The institutional review board of Midwestern University initially approved the report protocol for gathering patients' SNF data at the three CCOM-affiliated clinics. The institutional review board of the University of N Texas Health Scientific discipline Center at Fort Worth—Texas College of Osteopathic Medicine later approved the analysis of the SNF data gathered at CCOM sites.

The master focus of the present written report involved the SNF's musculoskeletal tabular array, which is now located on the Outpatient Osteopathic Assessment and Program Form of the revised 2002 edition of this form. This table was used to collect data on the musculoskeletal evaluation of 13 anatomic regions: head, cervical, upper thoracic (T1–T4), midthoracic (T5–T9), lower thoracic (T10–T12), lumbar, sacrum/pelvis, pelvis/innominate, lower extremities (left and right), upper extremities (left and right), and ribs.

For each of the patient'south anatomic regions, the investigator "graded" the somatic dysfunction present based on the four diagnostic criteria of somatic dysfunction, commonly represented in the osteopathic medical literature by the mnemonic TART²:

• T, tissue texture abnormality (effusions, laxity, stability, tone);

• A, asymmetry (crepitation, defects, masses, misalignment);

• R, restriction of motion (contracture); and

• T, tenderness (pain).

The scoring criteria for levels of somatic dysfunction were every bit follows:

• 0—None: No somatic dysfunction present or groundwork levels of somatic dysfunction only.

• ane—Mild: More than groundwork levels of somatic dysfunction, minor TART elements present.

• ii—Moderate: Obvious TART elements, which may or may not be overtly symptomatic, with significant brake of motion and/or tenderness elements nowadays.

• 3—Severe: Key lesions with pregnant symptomatology, including restriction of motion and/or tenderness elements that "stand out" with minimal search or provocation.

Investigator utilise of OMT to treat each of the 13 anatomic regions was handled equally a dichotomous variable in our analysis. For each region treated, the investigator reported the patient'due south immediate response to OMT on the SNF'due south ordinal four-point scale²: R, somatic dysfunction is completely resolved without evidence of it having ever been nowadays; I, somatic dysfunction is improved but not completely resolved; U, somatic dysfunction is unchanged or the same afterward treatment as it was before treatment; Westward, somatic dysfunction has worsened or been aggravated afterwards treatment.

The age and sex activity of patients, prevalence and severity of somatic dysfunction, and apply of and response to OMT by anatomic region treated were summarized using standard descriptive statistics. Bones SNF information, such every bit the patient's age, sex activity, and date of encounter may not take been captured at each patient encounter because these data were bachelor elsewhere within the patient's dispensary tape and were non consistently reported in duplicate on the SNF.

We afterwards developed indices to quantify the severity and burden of somatic dysfunction and patient response to OMT by anatomic region.

The severity index for the somatic dysfunction present in whatever given anatomic region was computed as the weighted hateful severity for all patient encounters in which a somatic dysfunction was diagnosed in that particular region. This index was computed using the aforementioned grading and scoring criteria.

The brunt of somatic dysfunction was defined for each anatomic region by the production of: (1) the prevalence of somatic dysfunction diagnosed in that region in all patient encounters, and (2) the severity index rating of somatic dysfunction for that region. This metric integrates the prevalence and severity dimensions of somatic dysfunction for a population of patients in the clinical setting under investigation, yielding a blended measure of the burden of somatic dysfunction for each anatomic region.

Theoretically, a loftier burden of somatic dysfunction would be observed in anatomic regions characterized past high prevalence and severity ratings, whereas a low burden would exist observed in anatomic regions characterized by low prevalence and severity ratings. Intermediate levels of burden would be observed in anatomic regions characterized past less extreme scenarios.

The burden of somatic dysfunction for any given anatomic region may range from 0 (no prevalent dysfunction) to 300 (100% prevalence of astringent dysfunction). Because the brunt of somatic dysfunction is a continuous metric without established cutpoints, cluster assay was used to detect natural groupings of anatomic regions in the information.^iv

Figure ii.

Cluster analysis depicting the brunt of somatic dysfunction by anatomic region in patients seen in family practice clinics. C indicates cervical; H, head; L, lumbar; LLE, left lower extremity; LUE, left upper extremity; PI, pelvis/innominate; R, ribs; RLE, right lower extremity; RUE, correct upper extremity; SP, sacrum/pelvis; and T, thoracic.

Cluster analysis was used to split the anatomic regions into two to 12 clusters, in a stepwise fashion, based on prevalence and severity of somatic dysfunction. Clusters were determined past maximizing between-cluster variation relative to inside-cluster variation. The Euclidean distance metric was used for clustering, and the prevalence and severity of somatic dysfunction were standardized as z scores to adjust for dissimilar scales and skewness in the data. The optimal clustering solution was then selected based on the F ratios for each stepwise analysis.

We grouped patient records by age category (ie, eighteen–39 years, 40–59 years, and threescore years or older), sexual practice, medication use, and the number of anatomic regions with somatic dysfunction present. Contingency tables were then used to assess investigator apply of OMT by these variables. Multiple logistic regression was used to compute adapted odds ratios (ORs) and 95% confidence intervals (CIs) for the factors associated with investigator utilize of OMT.

An OMT response index was also computed every bit a weighted mean using the criteria described higher up and the following scale to describe the patient'south condition afterward treatment: one, resolved; 0.five, improved; 0, unchanged; and -0.v, worse. The underlying assumptions in the cosmos of this calibration were that:

• 0 represents the neutral point of no response (ie, unchanged),

• positive values represent improvement and negative values represent worsening,

• the responses "improved" and "worse" are of equal magnitude simply in opposite directions, and

• 1 represents resolution, though there is no comparable value or descriptor in the negative management on the SNF.

Information drove and database direction functions were performed using two software programs. Data gathered in the first database management program (SPSS for Windows; SPSS Inc, Chicago, Ill) were imported into a statistical software package (SYSTAT for Microsoft Windows; SPSS Science, Chicago, Ill) for subsequent statistical analysis. Contingency tables and the χ² exam were used to analyze categorical data. All hypotheses were tested at the .05 level of statistical significance.

Results

One family practice clinic site provided records for 704 (53%) patient encounters, another contributed records for 453 (34%), and a third site provided 174 (thirteen%) for review. Together, the three study sites contributed records for a total of 1331 patient encounters for 424 adult patients.

The mean age of patients for encounters in which this demographic data were recorded on the SNF (n=848) was 56.9 years (SD, 16.2 years; median, 57 years). For all patient encounters in which patient sexual practice was noted on the SNF (n=964), there were 686 (71%) patient visits with women and 278 (29%) with men included in the report. The median number of days betwixt repeat encounters (northward=478) was 29 days.

Somatic dysfunction was diagnosed in 418 (31%) patient encounters and affected a mean of 2.9 anatomic regions per patient (SD, ane.2 anatomic regions) (Figure 1).

Somatic dysfunction was most commonly diagnosed in patients in the following anatomic regions: T1–T4 (17% of patient encounters), T5–T9 (15%), cervical (13%), lumbar (xiii%), and sacrum/pelvis (12%) (Table ane).

Table one

Diagnosis of Somatic Dysfunction in Family unit Practice: Prevalence, Severity, and Burden by Anatomic Region (n=1199) ^*

	Prevalence, No. (%)
Anatomic Region	Balmy	Moderate	Astringent	Total	Severity †	Burden ‡
▪ Head	twenty (49)	19 (46)	2 (five)	41	i.56	four.8
▪ Cervical	106 (59)	66 (37)	7 (4)	179	i.45	19.five
▪ Thoracic
□ T1–T4	107 (47)	103 (45)	19 (viii)	229	1.62	27.8
□ T5–T9	100 (51)	79 (xl)	17 (nine)	196	ane.58	23.2
□ T10–T12	48 (71)	14 (21)	vi (9)	68	i.38	seven.1
▪ Lumbar	94 (54)	64 (37)	15 (9)	173	i.54	20.1
▪ Sacrum/Pelvis	75 (47)	67 (42)	18 (xi)	160	ane.64	nineteen.8
▪ Pelvis/Innominate	17 (55)	10 (32)	4 (13)	31	1.58	iii.vii
▪ Extremities
□ Upper
– Left	7 (39)	6 (33)	v (28)	eighteen	ane.89	two.6
– Right	5 (28)	seven (39)	half-dozen (33)	18	2.06	2.eight
□ Lower
– Left	8 (33)	14 (58)	2 (8)	24	ane.75	iii.2
– Correct	11 (46)	11 (46)	two (viii)	24	i.63	2.9
▪ Ribs	ix (24)	24 (63)	5 (13)	38	ane.89	5.iv

For near patients, the severity of somatic dysfunction present was largely classified as mild or moderate (Tabular array 1). On average, the most severe somatic dysfunctions involved the upper extremities (severity indices, i.89 [left] and 2.06 [right]) and ribs (severity alphabetize, 1.89), whereas the least severe somatic dysfunctions involved T10–T12 (severity index, 1.38).

The burden of somatic dysfunction by anatomic region is presented in Table 1. Stepwise cluster-analysis results indicate that the optimal solution consisted of three groups (F _ii,10, 84.6, P<.001 for prevalence of somatic dysfunction; and F _ii,10, 15.v, P<.001 for severity of somatic dysfunction) (Effigy 2). Group I included the 5 anatomic regions with the highest burden of somatic dysfunction, primarily owing to high prevalence of somatic dysfunction (ie, T1–T4, T5–T9, lumbar, sacrum/pelvis, and cervical). Group 2 included four anatomic regions with low burden of somatic dysfunction, primarily attributable to low prevalence of somatic dysfunction (left and correct upper extremities, left lower extremity, and ribs). Group III included four anatomic regions with relatively depression burden of somatic dysfunction, primarily attributable to low severity of somatic dysfunction (correct lower extremity, pelvis/innominate, head, and T10–T12).

Investigators used OMT to care for patients in 335 (25%) patient encounters (North=1331), treating a hateful of 2.8 anatomic regions per patient encounter (SD, 1.2 anatomic regions) (Figure 1). Although somatic dysfunction was diagnosed in 313 (93%) patient encounters during which investigators used OMT, there was no diagnosis of somatic dysfunction in 22 (7%) of these encounters. When somatic dysfunction was diagnosed, during 418 patient encounters, investigators used OMT during 313 (75%) of these encounters. Among patients with somatic dysfunction, there was no statistical clan between the number of dysfunctional anatomic regions and investigator use of OMT as a handling modality (χ² _seven=ii.39, P=.94).

The frequency of OMT use by investigators was substantially lower when investigators were treating patients' upper extremities as compared with all other anatomic regions (Tabular array ii). The adjusted ORs and 95% CIs for factors associated with investigator use of OMT are presented in Tabular array 3. There was no clan between patient historic period and investigator use of OMT; yet, at that place was an clan between patient sexual practice and the utilize of OMT, with women existence more than probable than men to receive OMT (OR, 1.4; 95% CI, 1.0-2.2). Patient use of analgesics, not-steroidal anti-inflammatory agents, or muscle relaxants was also associated with utilise of OMT (OR, 2.2; 95% CI, 1.ii-4.i).

Table ii

Osteopathic Manipulative Treatment in Family Do: Frequency of Investigator Employ by Patient Anatomic Region (n=952) ^*

Anatomic Region	Frequency, No. (%)
▪ Caput	37 (90)
▪ Cervical	142 (79)
▪ Thoracic
□ T1–T4	173 (76)
□ T5–T9	153 (78)
□ T10–T12	63 (93)
▪ Lumbar	144 (83)
▪ Sacrum/Pelvis	128 (80)
▪ Pelvis/Innominate	27 (87)
▪ Extremities
□ Upper
– Left	ix (50)
– Right	10 (56)
□ Lower
– Left	20 (83)
– Correct	17 (71)
▪ Ribs	29 (76)

Table 3

Osteopathic Manipulative Treatment in Family Practice: Associated Multivariate Factors (North=1331) ^*

	OMT Used, No. (%)
Factor	Yes	No	Odds Ratio	95% Confidence Interval
▪ Age, y
□ xviii–39†	44 (34)	85 (66)	ane	...
□ 40–59	157 (46)	185 (54)	1.3	0.7–2.two
□ ≥sixty	97 (26)	280 (74)	0.9	0.5–1.v
▪ Sexual activity
□ Men†	95 (34)	183 (66)	ane	...
□ Women	236 (34)	450 (66)	1.four	1.0–ii.2
▪ Medication ‡
□ No†	287 (32)	610 (68)	one	...
□ Aye	48 (62)	29 (38)	two.ii	one.ii–four.1

Data on patients' immediate responses to OMT were recorded for 779 (82%) of the total number of anatomic regions treated (n=952). Overall, symptoms associated with patients' diagnosed somatic dysfunctions were reported to take resolved or improved after handling in 747 (96%) anatomic regions, remained unchanged in 32 (4%) regions, and worsened in no regions (χ² ₂=1114, P<.001). By and large, similar anatomic region–specific findings were also observed (Tabular array 4). Consequently, the OMT response indices did non differ substantially among most anatomic regions. The everyman levels of beneficial response to OMT were observed for patients with somatic dysfunction in the right lower extremity and pelvis/innominate regions, whereas the anatomic region almost probable to reply favorably to this treatment modality was the ribs.

Table four

Osteopathic Manipulative Treatment in Family Practise: Immediate Patient Response to Treatment by Anatomic Region (n=779) ^*

	Response, No. (%) †
Anatomic Region	Resolved	Improved	Unchanged	Total	Response Index ‡
▪ Head	iii (x)	24 (83)	ii (seven)	29	0.52
▪ Cervical	fifteen (xiii)	92 (82)	5 (iv)	112	0.54
▪ Thoracic
□ T1–T4	16 (11)	123 (85)	5 (3)	144	0.54
□ T5–T9	18 (14)	99 (79)	8 (6)	125	0.54
□ T10–T12	vi (12)	42 (84)	2 (4)	fifty	0.54
▪ Lumbar	7 (half dozen)	102 (xc)	4(4)	113	0.51
▪ Sacrum/Pelvis	12 (xi)	91 (87)	2 (2)	105	0.55
▪ Pelvis/Innominate	1 (6)	15 (83)	two (11)	eighteen	0.47
▪ Extremities
□ Upper
– Left	2 (17)	9 (75)	one (8)	12	0.54
– Right	1 (8)	11 (92)	0 (0)	12	0.54
□ Lower
– Left	2 (10)	eighteen (90)	0 (0)	twenty	0.55
– Right	0 (0)	16 (94)	1 (6)	17	0.47
▪ Ribs	four (18)	18 (82)	0 (0)	22	0.59

Comment

The results of our retrospective analysis of SNF data draw the "epidemiology" of somatic dysfunction also equally investigator use of—and patient response to—OMT in the family practice setting. In our study, investigators diagnosed somatic dysfunction in well-nigh one-tertiary of developed patient encounters. The somatic dysfunction diagnosed often involved multiple anatomic regions for each patient.

The burden of somatic dysfunction, a novel composite mensurate based on prevalence and severity, served as the ground for grouping anatomic regions using cluster analysis. The three anatomic region groups that emerged tin can generally be labeled as i of the following:

• I: high prevalence of somatic dysfunction (thoracic T1–T4 and T5–T9, lumbar, sacrum/pelvis, and cervical);

• II: low prevalence of somatic dysfunction (left and right upper extremities, left lower extremity, and ribs); and

• Iii: low severity of somatic dysfunction (right lower extremity, pelvis/innominate, head, and thoracic T10–T12).

Investigator use of OMT for somatic dysfunction comprised a substantial portion of the exercise at the three clinic sites providing data to the authors for assay. In approximately one-fourth of patient encounters, investigators used OMT. Treatment was often perceived by the investigator to have immediately improved patients' somatic dysfunction. For somatic dysfunction of the upper extremities, OMT was used less frequently fifty-fifty though patient response to handling in these anatomic regions appeared to exist comparable to the response noted in other regions.

Multivariate analysis revealed that women were more likely than men to receive OMT. This finding is consistent with data on lifetime use of OMT reported in the Osteopathic Survey of Health Care in America, a random national telephone survey of the adult population.^five

Furthermore, we found that when patients used analgesics, nonsteroidal anti-inflammatory agents, or muscle relaxants, they were more likely to receive OMT from investigators. This clan suggests that osteopathic physicians in family unit practice may exist more likely to use OMT to complement medication rather than equally an culling to it. Superficially, this finding appears to contradict those of a well-known clinical trial of OMT in patients with subacute low back hurting, in which the osteopathic treatment group used less medication than the standard care grouping.⁶ However, in the present retrospective report, the patients who did not receive OMT may non stand for an advisable comparing group because few of them were diagnosed with somatic dysfunction. Although patient response to OMT was largely favorable in our written report, these results should be interpreted with caution, every bit explained below, because of the potential for biased measurement of response.

We admit potential limitations of the electric current study. Some of these potential limitations are attributable to a methodology based on retrospective analysis of bachelor patient meet data rather than on a formal, prospectively planned research pattern. Thus, unlike a randomized clinical trial, for example, it is possible that the patients nigh likely to reply to OMT were selected to receive it or that the patients in this population may accept requested OMT.

Also, the investigator who provided OMT to a given patient was the same one given the job of assessing the patient'due south immediate response to treatment. Therefore, such assessments were not blinded and may take been vulnerable to biased measurement. For instance, in the 779 anatomic regions treated with OMT past investigators, there was non even one reported case of a patient's condition worsening immediately later OMT.

In addition, we institute investigators used OMT in 22 (7%) patient encounters for which the presence of diagnosed somatic dysfunction was not indicated in the SNFs. For these 22 patient encounters, it is unclear if OMT represents: (1) the use of OMT during a follow-up session in response to previously diagnosed somatic dysfunction, (two) a "preventive" use of OMT, or (3) but erroneous documentation. Even if this number entirely represents the latter, its infrequent occurrence should not materially affect the validity or interpretation of our findings.

The ability of clinicians and researchers to employ our findings to other clinical settings should also be addressed. Because patients were evaluated and treated by osteopathic trainees, it is unclear if our results can be generalized to experienced osteopathic physicians. Nevertheless, recent findings suggest that greater feel in providing OMT does not appear to result in substantially improve clinical outcomes or greater patient satisfaction.^vii

Finally, it is unclear if the patients seeking medical care in academy-based family unit practice clinics are representative of patients visiting osteopathic physicians in community-based settings.

Our results were based on all bachelor SNF data, including multiple and unequal numbers of encounters for many patients. Although, at the private level, the methodology nosotros accept called has the disadvantage of giving greater weight to patients with many encounters (ie, relative to those with i or few encounters), at the amass level, our written report blueprint has the reward of more accurately reflecting the frequency of somatic dysfunction and clinician apply of OMT in a family unit dispensary setting.

Finally, cluster analysis allows for more objective identification of natural groupings in the data for the brunt of somatic dysfunction and its component dimensions of prevalence and severity of somatic dysfunction. Although many of the groupings by anatomic region using this statistical method likewise make "clinical sense," some may not. The disparate grouping of the left and right lower extremities is perhaps the almost obvious example of a statistical observation that cannot exist interpreted readily in terms of clinical plausibility.

Conclusion

Despite the potential limitations noted, we believe our analysis of SNF data provides a unique perspective on clinician use of and patient response to OMT in the treatment of somatic dysfunction in the family unit dispensary setting. It is our promise that this data will provide the necessary impetus for researchers to behave and publish additional studies on somatic dysfunction and OMT using the SNF in a multifariousness of clinical settings. It is only through such studies that the osteopathic medical profession volition acquire a better understanding of the epidemiology of somatic dysfunction and the effectiveness of OMT in gimmicky osteopathic medical practice.

This work is licensed under the Artistic Commons Attribution-NonCommercial-NoDerivatives iv.0 International License.

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Source: https://www.degruyter.com/document/doi/10.7556/jaoa.2005.105.12.537/html

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