Philadelphia College of Osteopathic Medicine Philadelphia, Pennsylvania
http://www.100md.com
《美国整骨期刊》
Department of Family Medicine, Director, Center for Evidence-Based Medicine University of North Texas Health Science Center at Fort Worth—Texas College of Osteopathic Medicine
I'm writing in response to the original contribution by Frederick J. Goldstein, PhD, et al, that appeared in the June issue of JAOA—The Journal of the American Osteopathic Association ("Preoperative intravenous morphine sulfate with postoperative osteopathic manipulative treatment reduces patient analgesic use after total abdominal hysterectomy." 2005;105:273–279). As a supporter of research on osteopathic manipulative treatment (OMT) and evidence-based medicine, I continually seek evidence on the effectiveness of OMT within my own practice and the osteopathic medical profession. Unfortunately, it appears that we, as a profession, continue to produce nothing more than large numbers of pilot studies on the effectiveness of OMT.
In their study of women undergoing elective total abdominal hysterectomy, Goldstein at al report that the study group receiving preoperative morphine and postoperative OMT (Group 4) used less morphine postoperatively compared with patients who received preoperative morphine and postoperative sham manipulative treatment (Group 3). However, patients' subjective pain scores—an important patient-oriented outcome—were no different between these groups.
In addition, the total postoperative dose of morphine sulfate for patients in Group 4 was no better than for those patients receiving preoperative saline and postoperative sham manipulative treatment (Group 1). These two features (ie, no change in subjective pain scores and no difference in outcomes among the two study groups) are the most revealing findings of the study.
The study had only 39 participants dispersed among four study groups, creating small group numbers: three groups had 10 participants, one group had 9. No discussion on the study's power or sample size calculations was provided for readers, like myself, to make accurate conclusions about the study results. I do not believe merely stating that the study is a pilot experiment is sufficient.
The authors did reference studies using preoperative morphine in similar patient cohorts, giving a basis for some type of sample size estimate, however.1–3
In addition, though the authors noted a statistically significant finding between Groups 3 and 4 with regard to reduced morphine use in the first 24 hours after elective total abdominal hysterectomy (P=.02), overlapping confidence intervals cast some doubt on the stability of the data and whether these findings were truly beyond chance alone.
Finally, there were no groups that received saline or morphine alone (ie, without OMT or sham manipulative treatment), and, according to extensive discussions at the Sixth Annual American Association of Colleges of Osteopathic Medicine Osteopathic Collaborative Clinical Trials Initiatives Conference, this remains a controversial methodology issue for OMT research.4
It is important for our profession to produce valid OMT research of high quality. However, we should be wary of falling prey to the lures of publication bias5; that is, only submitting and publishing findings that show that OMT "works." It is just as important to find areas in clinical practice where the use of OMT as a treatment modality is not justified—just as antibiotics are not justified for viral upper respiratory infections.6
It seems to me that among the largest concerns for today's OMT researchers is the profession's seeming inability to produce large blinded studies conducive to reproducibility and generalizability.
References
1. Richmond CE, Bromley LM, Woolf CJ. Preoperative morphine pre-empts postoperative pain. Lancet.1993; 342:73 –75.
2. Goldstein FJ, Berman MA, Jeck S, Brunvoll G. Effect of pre-operative morphine (MOR) upon postop pain after total abdominal hysterectomy (TAH) or myomectomy . J Am Osteopath Assoc. 1996:96;555 . P15.
3. Karamanlioglu B, Turan A, Memis D,Ture M. Preoperative oral rofecoxib reduces postoperative pain and tramadol consumption in patients after abdominal hysterectomy. Anesth Analg.2004; 98:1039 –1043.
4. Degenhardt BF. Reliability of osteopathic palpatory findings.Paper presented at: Sixth Annual American Association of Colleges of Osteopathic Medicine Osteopathic Collaborative Clinical Trials Initiatives Conference; April 7, 2005; Fort Worth, Tex.
5. Last JM. A Dictionary of Epidemiology. 3rd ed. New York, NY: Oxford University Press; 1995.
6. Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH; Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis. Jul 152002; 35:113 –125.(ROBERTO CARDARELLI, DO, M)
I'm writing in response to the original contribution by Frederick J. Goldstein, PhD, et al, that appeared in the June issue of JAOA—The Journal of the American Osteopathic Association ("Preoperative intravenous morphine sulfate with postoperative osteopathic manipulative treatment reduces patient analgesic use after total abdominal hysterectomy." 2005;105:273–279). As a supporter of research on osteopathic manipulative treatment (OMT) and evidence-based medicine, I continually seek evidence on the effectiveness of OMT within my own practice and the osteopathic medical profession. Unfortunately, it appears that we, as a profession, continue to produce nothing more than large numbers of pilot studies on the effectiveness of OMT.
In their study of women undergoing elective total abdominal hysterectomy, Goldstein at al report that the study group receiving preoperative morphine and postoperative OMT (Group 4) used less morphine postoperatively compared with patients who received preoperative morphine and postoperative sham manipulative treatment (Group 3). However, patients' subjective pain scores—an important patient-oriented outcome—were no different between these groups.
In addition, the total postoperative dose of morphine sulfate for patients in Group 4 was no better than for those patients receiving preoperative saline and postoperative sham manipulative treatment (Group 1). These two features (ie, no change in subjective pain scores and no difference in outcomes among the two study groups) are the most revealing findings of the study.
The study had only 39 participants dispersed among four study groups, creating small group numbers: three groups had 10 participants, one group had 9. No discussion on the study's power or sample size calculations was provided for readers, like myself, to make accurate conclusions about the study results. I do not believe merely stating that the study is a pilot experiment is sufficient.
The authors did reference studies using preoperative morphine in similar patient cohorts, giving a basis for some type of sample size estimate, however.1–3
In addition, though the authors noted a statistically significant finding between Groups 3 and 4 with regard to reduced morphine use in the first 24 hours after elective total abdominal hysterectomy (P=.02), overlapping confidence intervals cast some doubt on the stability of the data and whether these findings were truly beyond chance alone.
Finally, there were no groups that received saline or morphine alone (ie, without OMT or sham manipulative treatment), and, according to extensive discussions at the Sixth Annual American Association of Colleges of Osteopathic Medicine Osteopathic Collaborative Clinical Trials Initiatives Conference, this remains a controversial methodology issue for OMT research.4
It is important for our profession to produce valid OMT research of high quality. However, we should be wary of falling prey to the lures of publication bias5; that is, only submitting and publishing findings that show that OMT "works." It is just as important to find areas in clinical practice where the use of OMT as a treatment modality is not justified—just as antibiotics are not justified for viral upper respiratory infections.6
It seems to me that among the largest concerns for today's OMT researchers is the profession's seeming inability to produce large blinded studies conducive to reproducibility and generalizability.
References
1. Richmond CE, Bromley LM, Woolf CJ. Preoperative morphine pre-empts postoperative pain. Lancet.1993; 342:73 –75.
2. Goldstein FJ, Berman MA, Jeck S, Brunvoll G. Effect of pre-operative morphine (MOR) upon postop pain after total abdominal hysterectomy (TAH) or myomectomy . J Am Osteopath Assoc. 1996:96;555 . P15.
3. Karamanlioglu B, Turan A, Memis D,Ture M. Preoperative oral rofecoxib reduces postoperative pain and tramadol consumption in patients after abdominal hysterectomy. Anesth Analg.2004; 98:1039 –1043.
4. Degenhardt BF. Reliability of osteopathic palpatory findings.Paper presented at: Sixth Annual American Association of Colleges of Osteopathic Medicine Osteopathic Collaborative Clinical Trials Initiatives Conference; April 7, 2005; Fort Worth, Tex.
5. Last JM. A Dictionary of Epidemiology. 3rd ed. New York, NY: Oxford University Press; 1995.
6. Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH; Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis. Jul 152002; 35:113 –125.(ROBERTO CARDARELLI, DO, M)