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EMG Center of Arizona Paradise Valley

To the Editor: I read with interest the editorial by Michael M. Patterson, PhD,¹ in the January 2007 issue of JAOA—The Journal of the American Osteopathic Association. The editorial highlighted important challenges to the osteopathic medical profession regarding research protocols for osteopathic manipulative treatment (OMT).

The points raised by Dr Patterson's editorial¹ reminded me of the work by J. S. Denslow, DO,² in which he rated the severity of tissue texture abnormality with a graded index, finding that pathologic conditions could be identified between the mild and moderate grades of the index. My own research³ has led to similar findings regarding carpal tunnel syndrome (CTS). I applied a clinimetric index rating of 0 to 5 for palpatory restriction at the carpal tunnel, with level 2 (ie, moderate restriction) representing the onset of measurable abnormality.

In my research,³ I had the luxury of being able to correlate electrodiagnostic findings on nerve conduction values with palpatory findings and patients' symptom/complaint ratings. I believe that CTS represents the ideal form of somatic dysfunction for osteopathic medical research because it embodies the essential defining components—joint, nerve, skeletal, soft tissue, and vascular dysfunctions—within the diagnosis. Therefore, by measuring electrical changes in CTS, it is possible to study this type of somatic dysfunction in relative isolation, documenting resolution of specific focal restrictions that correlate with clinical improvement.

I went on to perform a reverse double-blind study involving 10 subjects with CTS and 10 without (B. M. Sucher, DO, unpublished data). In this study, we used a device that simulates OMT (Carpal Tunnel Stretch prototype; Chattanooga Group, Hixson, Tenn), as well as a sham device, in the treatment of the subjects. Each subject was treated for 2 months with one device and then switched to treatment with the other device for 2 additional months. We believed it was unethical to leave any subject untreated, so if a subject had the sham treatment first, he or she was switched to the OMT-simulation device for the second part of the trial. We noticed clinical improvement, resolution of palpatory restriction, and improved nerve conductions when the subjects received treatment with the OMT-simulation device, whereas all these conditions worsened with the sham device.

I realize that there is a greater challenge in applying the type of index used in my research³ or that of Denslow² to more generalized medical conditions, such as chronic low back pain. Still, the appeal to do so is irresistible.

The use of indexes allows osteopathic medical researchers to achieve more quantitative ratings of somatic dysfunction. Although it may be difficult to obtain interexaminer reliability with such index ratings, I have found that such reliability is possible. In the late 1990s, I conducted a workshop with second-year osteopathic medical students at the Midwestern University/Arizona College of Osteopathic Medicine in Glendale. We achieved approximately 80% agreement for one level (up or down) in a rating scale for CTS/wrist palpatory restriction (B. M. Sucher, DO, unpublished data). These results were accomplished with only a 40- to 50-minute demonstration- and-practice session, followed immediately by the testing session.

Imagine what might be achieved with more extensive training!

References
1. Patterson MM. Research in OMT: What is the question and do we understand it [editorial]? J Am Osteopath Assoc. 2007;107:8-11. Available at: http://www.jaoa.org/cgi/content/full/107/1/8. Accessed May 7, 2007.

2. Denslow JS. An approach to skeletal components in health and disease. J Am Osteopath Assoc.1951; 50:399 -403.[Medline]

3. Sucher BM. Palpatory diagnosis and manipulative management of carpal tunnel syndrome. J Am Osteopath Assoc. 1994;94:647-663. Available at: http://www.jaoa.org/cgi/reprint/94/8/647. Accessed May 7, 2007.

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