BACKGROUND Insulin resistance (IR) is a pathological condition in which cells fail to respond normally to insulin. IR has been associated with multiple conditions, including chronic pain. Fibromyalgia (FM) is one of the common generalized chronic painful conditions with an incidence rate affecting 3% to 6% of the population. Substantial interest and investigation into FM continue to generate  many hypotheses.The relationship between IR and FM has not been explored. IR is known to cause abnormalities in the cerebral microvasculature, leading to focal hypoperfusion. IR also has been shown to cause cognitive impairment in FM patients, as in parkinsonism. As demonstrated by advanced imaging methods, similar brain perfusion abnormalities occur in the brain of patients with FM as with IR. OBJECTIVES To determine the potential association between FM and IR. SETTING Subspecialty pain medicine clinics. STUDY DESIGN Observational cross-sectional study. METHODS Laboratory data was extracted through a retrospective review of medical records from patients who had met the American College of Rheumatology (ACR) criteria for FM. The Hemoglobin A1c (HbA1c) values from 33 patients with FM were compared with the means of the glycated HbA1c levels of 2 control populations. In addition, established indices of IR [Quantitative Insulin Sensitivity Check Index (QUICKI) and the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR)] were calculated in a subgroup of patients in whom the analytes necessary for these calculations were available. To assess for confounding factors, the associations between HbA1c, QUICKI, HOMA-IR, fasting insulin levels, and glucose, after controlling for age, were explored by multiple analyses of variance with relation to gender and ethnicity. RESULTS We found an association between IR and FM that was independent of age, gender, and ethnicity. We found that patients with FM belong to a distinct population that can be segregated from the control groups by their HbA1c levels, a surrogate marker of IR. This was demonstrated by analyzing the data after introducing an age correction into a linear regression model. This strategy showed significant differences between patients with FM and control subjects (P < 0.0001 and P  = 0.0002, for 2 separate control populations, respectively). A subgroup analysis using the QUICKI and HOMA-IR showed that all patients with FM in this subgroup (100%) exhibited laboratory abnormalities pointing to IR. LIMITATIONS Small observational cross-sectional study. There are also intrinsic limitations that are attributed to cross-sectional studies. CONCLUSION The association demonstrated in this study warrant further investigation, including the pursuit of randomized, double-blind clinical trials to determine the effect of improving insulin sensitivity in FM related pain scores. Such studies could unveil a potential pathogenetic relationship between FM, central pain, and IR. Based on these initial findings, we present the hypothesis that IR may underlie pathological mechanisms leading to central pain. If confirmed, this may lead to a paradigm shift in the management of central pain.

Context: Integral to emotional intelligence (EI), empathy is frequently studied in medical students. While important, given the implications for patient safety and physician well-being, traits such as self-regard may also affect physician efficacy. Emotional intelligence offers a holistic framework from which to study empathy, allowing it to be explored with coexisting traits and offering opportunities to identify related risk factors. Objective: To identify trends in osteopathic medical student EI to help mitigate burnout, with specific attention to empathy and self-regard. Methods: Eight hundred eighty-five students at Western University of Health Sciences College of Osteopathic Medicine of the Pacific from classes 2014-2016 were offered the Emotional Quotient Inventory 2.0 (EQ-i) at the start of school, completion of their second year, and at graduation. Participants completed all 3 inventories, yielding a response rate of 16.3%. Repeated measurement analysis of variance analyses were conducted using SAS software for Windows version 9.3. Results: A total of 144 students participated. The total EI score shifted from mean (SD) 100.2 (12.4) at baseline to 96.1 (12.8) midway to 96.8 (13.3) at graduation (P=.0161) with significant decreases between baseline and midway (P<.001) and baseline and final administrations (P<.001). Empathy declined from 103 (13.1) to 99.9 (12.7) to 99.6 (12.6) (P=.0481) with significant decreases between baseline and midway (P<.001) and baseline and final administrations (P<.001). Self-regard declined from 98.6 (14.1) to 95.8 (15.1) to 95.5 (14.7) (P=.135) with significant decreases between baseline and midway (P=.0021) and baseline and final administrations (P<.001). Conclusion: This study's findings support further investigation of potential roles played by EI, empathy, and self-regard in physician burnout.

CONTEXT:There is a paucity of research assessing the efficacy of osteopathic manipulative treatment (OMT) in patients with vertigo.OBJECTIVE:To assess the feasibility of conducting a randomized, controlled trial comparing OMT and vestibular rehabilitation therapy (VRT), alone or in combination, in patients with vertigo and somatic dysfunction.METHODS:Volunteers with vertigo who were also diagnosed with somatic dysfunction (SD) were prospectively enrolled in a blinded, randomized, controlled cohort comparative effectiveness study and assigned to 1 of 4 groups: OMT alone, VRT alone, a combination of OMT and VRT (OMT/VRT), or a nonintervention control group. Participants between 18 and 79 years of age were included if they had experienced symptoms of vertigo for at least 3 months' duration, demonstrated somatic dysfunction, and could participate in computerized dynamic posturography (CDP) testing, tolerate manual therapy and exercises, and communicate effectively in English or Spanish. A total of 3 treatments lasting 45 minutes each were administered 1 week apart to each participant. OMT in this study consisted of counterstrain, myofascial release, balanced ligamentous tension, soft tissue, HVLA, and articulatory techniques. Comparisons were made between composite scores (CS) assessed with computerized dynamic posturography (CDP), dizziness handicap inventory (DHI), optometric evaluation, and osteopathic structural examinations collected before the first treatment, after the third/final treatment, and 3 months after the final treatment. (ClinicalTrials.gov number NCT01529151).RESULTS:A total of 23 patients were included in the study: 7 in the OMT group, 5 in the VRT group, 6 in the OMT/VRT group, and 5 in the control group. The OMT/VRT group demonstrated significant improvement in DHI score (P=0.0284) and CS (P=0.0475) between pre- and 3-month posttreatment measures. For total severity, improvements were significant in the OMT group both from pretreatment to immediate posttreatment measures (P=0.0114) and from pretreatment to 3-month posttreatment measures (P=0.0233). There was a statistical difference between the OMT and control groups from pretreatment to 3-month posttreatment DHI scores (P=0.0332). Also, there was a statistical difference in DHI score between VRT and control from pre- to 3-month posttreatment scores (P=0.0338). OMT/VRT statistically and clinically improved visual acuity in patients' right eyes from pre- to posttreatment (P=0.0325). In all participants, vergence dysfunction was prevalent (5; 21.7%) in addition to vertical heterophoria (15; 65.2%).CONCLUSION:A combination of OMT and VRT significantly reduced vertigo and improved balance 3 months after treatment (P<0.05). There was a high prevalence in vergence and vertical heterophoria, which are not typical screening measurements used by physical therapists and physicians to assess vertigo patients. With a small sample size, this study demonstrated the feasibility of an interdisciplinary team evaluating and treating patients with vertigo in a community setting. A larger study is needed to assess the efficacy of OMT/VRT in vertigo patients.

Diabetes mellitus (DM) is a multisystem disease that affects millions of people worldwide. The vascular and cardiac effects of DM have been well-studied, but little is known about the prevalence of musculoskeletal (MSK) conditions in patients with DM. This review provides an in-depth analysis of a cross-sectional study investigating the presence of several common MSK disorders in patients with DM. This review also analyzes current literature to update health care professionals about the MSK conditions associated with DM.

Chronic diseases and musculoskeletal conditions are responsible for a significant portion of the global disease burden and are frequently comorbid, such as with low back pain in patients who also have chronic organ disease. Low back pain is the leading cause of long-term disability and is the most common reason adults seek adjunctive treatment, including osteopathic manipulative treatment (OMT). OMT has been shown to be effective in relieving low back pain and improving back-specific functioning. In this narrative review, the authors summarize literature published in the last decade and analyze the relationship between musculoskeletal disorders and systemic medical conditions such as diabetes mellitus; they also discuss the efficacy and cost-effectiveness of OMT in managing somatic dysfunction in patients with chronic diseases.

Fibromyalgia (FM) is one of the most frequent generalized pain disorders with poorly understood neurobiological mechanisms. This condition accounts for an enormous proportion of healthcare costs. Despite extensive research, the etiology of FM is unknown and thus, there is no disease modifying therapy available for this condition. We show that most (if not all) patients with FM belong to a distinct population that can be segregated from a control group by their glycated hemoglobin A1c (HbA1c) levels, a surrogate marker of insulin resistance (IR). This was demonstrated by analyzing the data after introducing an age stratification correction into a linear regression model. This strategy showed highly significant differences between FM patients and control subjects (p < 0.0001 and p = 0.0002, for two separate control populations, respectively). A subgroup of patients meeting criteria for pre-diabetes or diabetes (patients with HbA1c values of 5.7% or greater) who had undergone treatment with metformin showed dramatic improvements of their widespread myofascial pain, as shown by their scores using a pre and post-treatment numerical pain rating scale (NPRS) for evaluation. Although preliminary, these findings suggest a pathogenetic relationship between FM and IR, which may lead to a radical paradigm shift in the management of this disorder.

increasing function in postpartum women. Mean differences

manipulative intervention (P<.001 and P<.05). One of these 2 studies noted that this finding was only observed in the group that received manipulation followed by an exercise regimen, while no significant change was noted in the manipulation-only group. The study that evaluated pain catastrophizing found a significant association between pain sensitivity in patients who received spinal manual therapy (P<.02). Among the 7 studies assessing health-related quality of life, 5 found significant postintervention improvements (P<.001 to P<.043). Among the 4 trials reporting quality of life, 3 found significant improvements among the intervention groups (P<.001 to P<.05). The study was limited by the heterogeneous patient populations and overall poor quality of data reviewed. The pain conditions varied (ie, back pain, neck pain, shoulder pain), as did the age and sex of participants sampled. For example, among the UK BEAM, Moustafa et al, and Castro-Sanchez et al trials, the mean age differed from 43 to 52.5 years, and the percentage of male participants ranged from 4.6% to 57%. Nevertheless, the results suggest that osteopathic interventions may positively affect the biopsychosocial factors related to patients with chronic pain. More work is needed to appraise outcomes, and standardized tools for biopsychosocial assessment should be integrated into all studies of osteopathic interventions and pain. (doi:10.7556/jaoa.2018.067)

Context: Osteopathic manipulative treatment (OMT) and yoga are both recommended by systematic reviews in the evidence-based research literature for low back pain management. It is unknown, to the authors' knowledge, what the effect of personal experience with OMT or yoga, reading research articles on OMT or yoga, or both will have on medical students' recommendations for these treatment options to future patients with chronic low back pain. Objective: To evaluate the likelihood of osteopathic medical students recommending OMT or yoga to treat patients with chronic low back pain based on their personal experience or reading research articles that recommend OMT or yoga for patients with chronic low hack pain. Methods: In this prospective cohort study, researchers administered an anonymous 18-question online survey for osteopathic medical students. The survey included a patient vignette, 2 evidence-based articles, and multiple choice, yes/no, and Liken-type questions. Participants were recruited via email from all 4 years of medical school. Between-group differences in proportions were assessed with descriptive statistics and chi(2) tests; differences within groups were assessed with the McNemar test; and Fischer exact tests were used when expected cell counts were less than 5. Results: A total of 180 participants (100 male, 80 female) completed the study. Personal experience increased the likelihood of osteopathic medical students recommending OMT (P<.018) or yoga (P<.001) to a future patient or to a patient in a case vignette (P<.05) with chronic low back pain. Students who read research articles were more likely to recommend OMT to the case patient and future patients before and after reading the intervention article regardless of their experience (P<.001). Conclusion: Personal experience and reading evidence-based research may increase the likelihood that osteopathic medical students will recommend OMT to future patients with chronic low back pain.

instrumental intervention was not found to be statistically different between the 2 groups, and there were no negative outcomes associated with peanut ball use. The decrease in the length of both first and second stages of labor, along with the reduced cesarean surgery rates, support the efficacy of the peanut ball during active labor over current practices. Limitations of this study include the small study size and a significant difference between groups when it came to women’s parity and cervical dilation. Osteopathic manipulative treatment (OMT) has been found to be effective for pregnancy-related pain and dysfunction when compared with standard intervention. Manual therapies have also shown promise as effective methods for pain relief during labor. However, there is a lack of studies examining OMT to improve labor progression. This study demonstrates the opportunity to improve labor length and outcomes by optimizing the shape of a laboring women’s pelvis, which can also be targeted by several OMT techniques (eg, sacroiliac balanced ligamentous tension, muscle energy for somatic dysfunction in the pelvic region). Additional studies are needed to investigate the potential benefits of OMT in labor progress. (doi:10.7556/ jaoa.2018.110)

Submitted January 29, 2018; accepted January 30, 2018. T he safety and effectiveness of medical procedures and treatments are the concern of all health care professionals, payers, policy makers, and public consumers of these services. Even before the 2001 report from the Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century, the American Osteopathic Association (AOA) had promoted and fostered documentation of the quality, safety, and effectiveness of osteopathic medicine, including osteopathic manipulative treatment (OMT), in its accredited colleges, in hospitals, and in the private practices of its members. In 1999, the National Quality Forum (NQF) formed as a private, not-for-profit membership organization to use a consensus-based process to develop and implement a national strategy for health care quality measurement and reporting. In 2002, based on the available literature and expert opinion at the time, and because of OMT’s documented record of safety, the NQF accepted the AOA’s recommendation to list disability or death from spinal manipulation as a reportable serious adverse event (SAE), as it is unexpected, unintended, measurable, and preventable. Many organizations and states have used the information and recommendations gathered by the Institute of Medicine and NQF to institute policies, statutes, and laws pertaining to patient safety, standard quality measures, and reporting of SAEs. In 2004, the state of New Jersey, for example, passed the Patient Safety Act, which “requires every health care facility licensed by the Department of Health and Senior Services to report every serious preventable adverse event, defined as an adverse event that is preventable and results in a patient death, loss of a body part, disability, or loss of bodily function lasting for more than seven days or still present at the time of discharge.” In California, legislation (SB 1301) was enacted in July 2007 based on the NQF recommendations. One of the 28 adverse events defined by the Health and Safety Code, Section 1279.1, is “A patient death or serious disability due to spinal manipulative therapy performed at the health facility.” However, not only has there been a paucity of SAEs from spinal manipulation reported by states and other health care facilities, but in 2011, the NQF recommended to remove this SAE because it “targets a specific group of healthcare providers” and “is related to individual provider behavior rather than facility safety systems.” To ensure that all osteopathic physicians are competent in using OMT safely and appropriately, the American Association of Colleges of Osteopathic Medicine and the National Board of Osteopathic Medical Examiners include documentation of competency in OMT by all osteopathic medical students and all physicians who elect to pursue osteopathic licensure and board certification. In addition, osteopathic physicians who pursue further training in OMT can access continuing medical education courses through local, regional, and national osteopathic conferences and specialty groups, such as the American Academy of Osteopathy. Because of the safety and effectiveness of OMT, 2 AOA position papers, one of which has become a national clinical practice guideline, promote the use of OMT for neck and back pain, respectively. In addition, several large prospective clinical trials have demonstrated the safety and effectiveness of OMT as an adjunct to standard medical care. Based on a review of articles over 6 decades, SAEs from OMT are estimated to be so rare that a prospective, randomized, placebo-controlled clinical trial to evaluate the actual incidence in clinical practice would be cost prohibitive, requiring thousands of OMT patient encounters. Thus, gathering data on SAEs is more pragmatic through a practice-based research network (PBRN). The DO-Touch.NET PBRN, which was established in 2010 and is centered at the A.T. Still University Kirksville College of Osteopathic Medicine in EDITORIAL

rheumatoid or inflammatory arthritis, or autoimmune disease; significant psychiatric disease or dementia; substance abuse in past 6 months; and breastfeeding or pregnancy. Participants were randomly assigned to 1 of 3 groups: gabapentin only (900 mg/d), OMT only, or combined gabapentin and OMT. Participants had weekly visits for 6 weeks and a follow-up visit at 8 weeks. Outcome measures included Wong-Baker FACES Pain Rating Scale, Clinical Global Impression of Health, Fibromyalgia Impact Questionnaire, and number of tender points. Twenty-nine of 35 participants completed the trial: 8 received gabapentin only, 11 received OMT only, and 10 received combined OMT and gabapentin. The OMT was administered by “advanced” osteopathic medical students under supervision for 30 minutes, and the OMT techniques used included myofascial release, muscle energy, counterstrain, facilitated positional release, articular ligamentous, high-velocity/lowamplitude, and osteopathic cranial manipulative medicine. These techniques were administered based on structural examination findings at each visit. Participants who received OMT alone or combined OMT and gabapentin displayed clinical improvements in the pain scale scores (P<.01 and P=.03, respectively), whereas the change for the gabapentin-only group was insignificant. The OMT-only group was the only group to have a significant decline in scores on the Clinical Global Impressions of Health scale (P<.01). Changes in scores on the Fibromyalgia Impact Questionnaire and number of tender points were insignificant. No differences across groups were statistically significant, which was not surprising given the small sample size of this feasibility study. The authors note that gabapentin, an offlabel but commonly used intervention, and OMT were safe and clinically efficacious in this population. (doi:10.7556/jaoa.2018.071)