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Individual Enquiry
Research Paper 2013
Title: A survey of osteopathic approaches to the evaluation, treatment and management of patients
with Type 2 Diabetes
Author: Bobby Qureshi
Supervisor: Hilary Abbey, DO, MSc
The British School of Osteopathy
275, Borough High Street, London SE1 1JE
Abstract
Objective: To explore osteopathic approaches towards the evaluation, treatment
and management of patients with type 2 diabetes.
Methods: A questionnaire was developed incorporating ideas from previous BSO
dissertations, according to guidelines by Oppenheim (2000). The questionnaire was
distributed via email to a random sample of 1000 GOSC registered osteopaths.
Results: 170 completed questionnaires were returned (17% response rate). 67% of
the practitioners reported they often alter their treatment approach for type 2 diabetic
patients compared with non-diabetic patients. Gentler soft tissue (79%), fewer high
velocity thrusts (71%), and less intense treatments (72%) were the most frequent
adaptations. Osteopaths who were more recently qualified reported evaluating
patients for neuropathy more frequently than experienced practitioners and
performed fewer high velocity thrusts. Practitioners discussed dietary issues (81%)
more frequently than exercise (58%) and considered medium intensity exercise as
most effective in DM2.
Conclusion: Participants reported differences in their management of DM2 patients
but 15% of practitioners reported never evaluating DM2 patients for neuropathy,
which is surprising considering osteopathic training and the implications of
undiagnosed neuropathy. Further research is needed to explore osteopaths’
rationales for modifying their approach, to inform education and continuing
professional development for the osteopathic management of DM2 patients.
Key words: Osteopathy, type 2 diabetes, evaluation, treatment, management,
1
Introduction
Type 2 Diabetes
Type 2 diabetes (DM2) is a metabolic condition characterised by hyperglycaemia,
peripheral insulin resistance and insulin deficiency (Merck Manual, 2010). NICE
guidelines (2008) emphasise that obesity and a sedentary lifestyle are significant in
disease aetiology, whilst polyuria, thirst, weight loss and fatigue represent a typical
presentation. The diagnostic criteria determined by the World Health Organisation
(WHO, 2011) is a 2 hour plasma glucose level of ≥ 11.1mmol/l or a glycated
haemoglobin (HbA1c) of ≥ 48 mmol/mol.
DM2 affects 2.8 million people in the UK (NHS, 2011), suggesting that osteopaths
are likely to encounter the pathology in practice. Tighe & Oakley (2008) found that
adhesive capsulitis affects approximately 20% of DM sufferers, whilst Adams (2011)
stated that carpal tunnel syndrome occurs in 6%. A cross-sectional survey by
Adeniyi et al (2010) identified that increasing duration of diabetes is associated with
reduced joint range of movement and muscle strength. The musculoskeletal nature
of these presentations are particularly relevant to osteopaths.
Evaluation
The GOsC (2012) state that osteopaths should be able to interpret clinical signs of
dysfunction and identify the presence of disease in order to inform clinical
judgement. This emphasises the awareness of osteopaths to DM2, particularly due
to its chronic implications. NICE guidelines (2008) discuss the vascular
complications that can occur including cardiovascular disease, nephropathy,
neuropathy and retinopathy. A large observational study by Stratton et al (2000)
2
identified that microvascular complications are reduced by 37% when the mean
HbA1c is reduced by 1% (P>0.0001), indicating early diagnosis to be paramount.
Urinalysis identifying the presence of glucosuria expresses sensitivity of <64%, whilst
venous blood indicates a sensitivity of <95% (Englelgau, Narayan and Herman,
2000). Although the reliability of urine testing remains questionable, the cost benefits
and ability to transfer more information to GP’s provide an efficient means of
screening for DM2.
Treatment & Management
NICE guidelines (2009) describe initial pharmacological intervention in DM2 as
metformin, followed by sulfonylurea and thiazolidinedione’s if HbA1c persists ≥ 6.5%.
Patients are advised a high fibre, low glycaemic diet combined with physical activity.
A literature review by Colberg et al (2010) sourced four recent studies to highlight
that moderate intensity exercise increases insulin sensitivity and glycaemic uptake. A
high quality study by Segerström et al (2010) supports these findings.
Evidence has shown that massage can reduce HbA1c (Pandey et al 2011; Sajedi et
al 2011). However, osteopaths offer an integrated multidimensional approach and
hence utilise a variety of manual techniques, with the patient as the focus (Ward et
al, 2002).
The only previous research on this topic were unpublished undergraduate
dissertations (Barker, 1996; Gregory, 2004) which identified contrasting approaches
to the osteopathic management of diabetic and non-diabetic patients. A recent article
by Licciardone (2008) emphasised treating vertebral levels T5-11 and T11-2. This
3
suggests that classical osteopathic concepts of treatment might still be relevant in
light of the current medical understanding of DM2.
Osteopathic considerations
A systematic review by Ezzo et al (2001) concluded that tissue fragility develops in
DM2 due to vascular dysfunction. This suggests that some types of manual therapy
might need to be adapted to prevent tissue damage and could be deemed
contraindicative. Sinclair (2007) discussed the significance of a poor peripheral blood
supply in DM2 and stated that a key aim of hydrotherapy is to improve local
vascularisation, which is congruent with osteopathic principles. A.T.Still stated that
“the rule of the artery is supreme” (Ward et al, 2002, pp.39)
Certain osteopathic treatments, such as spinal manipulation, may be contra-
indicated by DM2 related changes to micro-vasculature and bone mineral density
(BMD). An observational study by Bonds et al (2006) found that women with DM2
were 29% more likely to suffer from osteoporotic fractures and other studies
identified relationships between long-term thiazolidinedione use and reduced BMD
(Rzoncac et al 2004; Schwartz et al, 2006; Loke, Singh and Eurberg, 2009).
Study aim
This study aimed to investigate current osteopathic approaches towards the
evaluation, treatment and management of type 2 diabetic patients in the form of a
questionnaire survey, to assess whether current clinical practice appears to be in line
with knowledge and research evidence about the complications and health risk
factors for patients with DM2. It was hoped that the results would aid in directing
future osteopathic education and develop understanding of DM2 in a clinical context.
4
Methods
Participants
A systematic sample of 1000 UK based osteopaths were selected from the General
Osteopathic Council (GOsC) online register. A random number generator was used
to assist the allocation of invitations to the study. Potential participants were
contacted by e-mail, which enclosed the Participant Information Sheet (PIS)
(Appendix 1). Qualified osteopaths practising outside of the UK were excluded to
prevent including another variable and alternative patient population. The GOsC
(2012) stated that 4691 UK practitioners were registered in February 2013. Israel
(2012) reports that a response of 196 questionnaires would be necessary to maintain
a precision level of +/-7% and a confidence level of 95% considering the osteopathic
population. Recent online undergraduate questionnaire surveys by Leake (2011),
Monk (2011) and Napier (2011) received response rates of 13%, 16% and 20%
respectively and these values informed the decision to distribute 1000 invitations.
Design
An online quantitative questionnaire was used in order to reach a large proportion of
the osteopathic population to increase the validity of the results. There were no
existing standardised questionnaires that investigated the osteopathic approach to
evaluation, treatment and management of DM2. Therefore, a new questionnaire was
produced for the purposes of this project using the guidelines by Oppenheim (2000)
and based on Gregory’s (2004) undergraduate study. Furthermore, piloting of the
questionnaire was utilised to improve content validity.
5
Ethics
The research project was granted approval by the BSO Research Ethics Committee
(BSOREC). Ethical considerations included the possibility that participants might feel
their knowledge was being tested, which was addressed by clearly describing the
project aims on the PIS. Consent to take part in the study was assumed by return of
completed questionnaires and participants’ e-mail addresses were deleted following
their invitation. All data remained accessible only to the researcher and project
supervisor, securely located on the BSO’s password protected servers.
Pilot Study
Ten qualified osteopaths (six returned) who tutor at the BSO clinic were invited to
provide feedback on the questionnaire. The length of time to complete the
questionnaire stated on the PIS was adjusted from ten to five minutes according to
the feedback. The wording of question eighteen was modified to increase its clarity.
Both changes were implemented into the final questionnaire (Appendix 4).
Analysis
Data was obtained online using www.surveymonkey.com and then exported into an
excel spreadsheet, before being transferred to SPSS-20. Descriptive analyses were
conducted on demographic data, including years in practice and graduation
establishment. Inferential tests were used to identify relationships within the data,
using non-parametric testing that included Spearman’s Rank Correlation Coefficient
and Mann-Whitney U. The level of statistical significance was set at p<0.05.
6
Results
1000 osteopaths were contacted via e-mail with 208 questionnaires being returned,
of which 170 were complete (response rate = 17%). Demographic data are outlined
in Table 1.
Table 1 – Demographic data
Median Interquartile range (IQR)
Years in practice 9.5 11
Average patients seen per week 30 19.5
Average type 2 diabetic patients per week 2 3
This demographic data did not confirm to a normal distribution (Shapiro Wilk test
p<0.05), so non-parametric statistics were calculated. The median length of time in
practice was 9.5 years and the majority of participants (52%) graduated from the
BSO (Table 2).
Table 2 – Establishment of graduation
Frequency (n/208) Percentage (%)
The British School of Osteopathy 109 52%
The British College of Osteopathic Medicine 32 16%
The European School of Osteopathy 22 11%
Others 45 21%
7
Data from Likert scales were divided to assign the equivalent of never and rarely into
a category of used less frequently, whilst sometimes, often and always were
assigned to a ‘more frequently used’ group.
Table 3 – Evaluation of different factors in patients with Type 2 diabetes(1 = Never, 5 = Always)
Median / IQR “Always/Often/Sometimes” “Never”Neuropathy 3 (2) 73% (n=139) 15% (n=29)Urine testing 1 (0) 10% (n=19) 78% (n=150)Retina 1 (1) 17% (n=33) 56% (n=108)Nephropathy 1 (1) 21% (n=41) 62% (n=119)
Assessing neuropathy was considered most important (median=3, IQR=2), with 73%
“sometimes, often or always” evaluating this but 15% of the participants reported
“never” assessing patients for neuropathy.
Table 4 – Treatment approaches of patients with Type 2 diabetes (1 = Never, 5 = Always)
Median / IQR “always/often/sometimes”
Less intensity 3 (2) 72% (n=123)
Assess & treat T5-11 and T11-L2 3 (1) 69% (n=117)
Treatment differs 3 (2) 67% (n=114)
Expect less relief from treatment 2 (1) 46% (n=78)
Shorter treatment 2 (2) 37% (n=63)
More frequent treatment 2 (1) 21% (n=36)
67% of the practitioners agreed they would “sometimes, often or always” treat
patients with DM2 differently to non-diabetic patients.
8
Table 5 – Technique modification of patients with Type 2 diabetes (1 = Never, 5 = Always)
Median / IQR “always/often/sometimes”
Soft tissue 3 (1) 79% (n=134)
High velocity thrust (HVT) 3 (2) 71% (n=120)
Articulation 3 (1) 57% (n=97)
Visceral 2 (2) 37% (n=63)
Functional 2 (2) 27% (n=46)
Cranial 2 (1) 7% (n=11)
The most common technique modified was soft tissue (median=3, IQR=1); 79%
“sometimes, often or always” modify the technique.
Table 6 – Factors important in adapting treatment in patients with Type 2 diabetes (1 = Very unimportant, 5 = Very important)
Median / IQR
“very important/important/moderately important”
Presence of co-morbid conditions 4 (1) 94% (n=160)
Older age 4 (2) 92% (n=156)
Poor blood glucose control 4 (2) 91% (n=155)
Obesity 4 (1) 87% (n=147)
94% of participants considered the presence of co-morbid conditions to be
“moderately important, important or very important”, closely followed by older age
(92%) and poor glucose control (91%).
9
Table 7 – Contraindications to cervical spine HVT in Type 2 diabetes(1 = Never, 5 = Always)
Median / IQR “completely/very/moderately”
Neurological changes 4 (1) 86% (n=146)
Long-term thiazolidinedione use 3 (1) 77% (n=130)
Retinal changes 4 (1) 75% (n=145)
Poor blood glucose control 3 (2) 74% (n=126)
Obesity 3 (2) 62% (n=106)
86% of practitioners considered neurological changes to be “moderately important,
important or very important”.
Table 8 – Osteopathic management of patients with Type 2 diabetes(1 = Strongly disagree, 5 = Strongly agree)
Median / IQR “Strongly agree/agree/mutual”Discuss diet 4 (1) 81% (n=137)Management differs 3 (1) 80% (n=136)Advise exercise 3 (2) 58% (n=98)
81% of practitioners reported that they would be more inclined to advise about
diet with type 2 diabetic patients, whilst only 58% would advise exercise
Table 9 - Exercise Intensity advised in patient with Type 2 diabetes
Frequency (n/170) PercentageMedium intensity 102 60%Low intensity 61 36%High intensity 7 4%
Osteopaths who reported altering their treatment for patients with DM2 (n=114),
reported performing all aspects of evaluation, treatment and management more
frequently than osteopaths who reported using the same approach for diabetic and
non-diabetic patients. The two approaches that did not differ between the two groups
10
were through treating T5-11 and T11-L2 and acknowledging patients to obtain less
relief from osteopathic treatment.
The osteopaths who reported that they frequently evaluated neuropathy in patients
with DM2 had been in practice for significantly fewer years (Median year in
practice/often evaluate neuropathy = 9, median year/never evaluate neuropathy =
12, U = 3971.50, p=0.04). Furthermore, practitioners who reported that they often
modified HVT techniques had also been in practice for significantly fewer years
(Median year in practice/HVT often modified = 8, median year/HVT never modified =
12, U = 2247.00, p=0.01). Testing revealed no other significant findings relating to
years in practice. Osteopaths who more frequently treat DM2 patients did not modify
their approach to the evaluation, treatment and management of these patients.
Testing also identified no significance between osteopaths’ opinions about the relief
they expected patients to obtain from treatment.
Discussion
The aims of this study were to investigate if osteopaths reported any differences in
their treatment and management of DM2 patients and in what ways practitioners
modify treatment strategies. The study also aimed to explore the factors considered
most important in evaluation and most significant perceived contraindications to
cervical spine manipulation.
67% of participants reported that they sometimes, often or always treat DM2 patients
differently to non-diabetic patients. This finding correlates with Gregory (2004), who
found 61% of the practitioners in his sample (n=72) reported altering their treatment
for patients with DM1. The most commonly reported differences were modified soft
11
tissue techniques (79%), less intense treatments (72%), modified spinal
manipulations (71%), and treating spinal areas T5-11, T11-L2 (67%).
The modification of soft tissue suggests that these osteopaths were alert to the
tissue changes that occur in DM2, including reduced muscle capillary density (Marin
1994) and micro-vascular complications associated with hyperglycaemia which
reduces cutaneous perfusion (Kahn et al 2003). Unfortunately, further qualitative
data was not available to explore the rationale for altering treatments.
Only 5% of osteopaths in this study often performed a shorter treatment. This finding
is in agreement with strong evidence from Ezzo et al’s (2001) systematic review
which concluded there was little benefit in changing the duration of soft tissue
massage. However, this could be interpreted as a surprising outcome as tissue
fragility, outlined above, might suggest that practitioners would be more inclined to
reduce the length of treatments to prevent additional tissue damage. Unfortunately
other literature associated with shorter manual treatments is limited.
Osteopaths who reported modifying HVT techniques had been in practice for
significantly fewer years. Newly qualified practitioners might be more aware of recent
medical research, particularly regarding the safety of HVTs which have recently been
under debate (Rossetti et al, 2000; Caso et al, 2005; Haynes et al, 2012). However,
greater experience in treating DM2 patients could be significant if adjusting
technique. Gibbons & Tehan (2000) describe how experienced operators may view
certain conditions as more of a relative contraindication to HVT. However, the study
identified no significant correlation between the number of diabetic patients treated
per week and the frequency of modification of HVT. Women with DM2 are 29% more
likely to suffer from osteoporotic fractures (Bonds et al 2006) and there are
12
relationships between long-term thiazolidinedione use and reduced BMD (Rzoncac
et al 2004; Schwartz et al, 2006; Loke, Singh and Eurberg, 2009), so DM2-related
osteoporosis (Bonds et al ,2006; Rzoncac et al 2004; Schwartz et al, 2006; Loke,
Singh and Eurberg, 2009) and tissue fragility (Ezzo et al 2001) are more probable
reasons for osteopaths modifying manipulative techniques but this assumption
requires further research.
The number of osteopaths who reported assessing and treating T5-11 and T11-L2
suggested that practitioners often consider the viscero-somatic reflexes associated
with the pancreas and relevant aspects of the gastrointestinal tract during treatment
(Nelson & Glonek, 2007). Licciardone et al (2007) reported finding consistent
palpatory changes on the right at T11-L2 but little other supporting research exists.
The osteopaths in this sample considered neurological changes to be the greatest
contraindication to cervical spine HVT (86%), with 73% often assessing for
neurological changes. This is fitting with Gregory et al (2004). In comparison, 75% of
participants claimed retinal changes to be contraindicative to HVT, yet only 17%
actually assessed for retinal changes. These contrasting findings could reflect
teaching emphasis in osteopathic training. Neuropathic features may be considered
as more clinically relevant to the osteopathic profession, considering their
association with peripheral tissues. The anatomical location of retinopathy and lack
of teaching emphasis may explain why these osteopaths reported limited evaluation
of this area. GOsC (2012) acknowledges the importance of interpreting clinical signs
of dysfunction and developing appropriate treatment. It is possible that retinal
changes may remain undiagnosed and therefore HVT could cause vertebra-basilar
ischaemia (Nwuga, 1986; Murtagh & Kenna, 1997) due to the increased incidence of
cardiovascular disease in retinopathy (van-Hecke et al, 2005). Obesity was
13
considered the lowest contraindication to HVT (62%), which is surprising due to its
well-recognised association with cardiovascular disease (Poirier et al, 2006; Mathew
et al, 2008).
The study identified no significant relationships between length of time in practice
and recognition of long term thiazolidinedione use as a contraindication to cervical
spine HVT. Evidence linking anti-diabetic medication and reduced BMD is a more
recent clinical research finding (Rzoncac et al 2004; Schwartz et al, 2006; Loke,
Singh and Eurberg, 2009), perhaps suggesting that osteopaths are generally aware
of relevant medical research, particularly as 77% of respondents also reported the
medication as contraindicative. Interestingly, a meta-analysis by Carnes et al (2010)
identified the relative risk of having a minor to moderate adverse event with HVT as
significantly less than medication risks, and reported the risk of a major adverse
effect following manual treatment to be 0.007%, suggesting that major adverse
events from cervical spine HVT are extremely rare in practice.
78% of participants reported never assessing urine for glucosuria, which correlates
with low frequencies identified by Gregory (2004) and Hazelwood (2007). The low
cost and easy accessibility of such equipment might suggest this to be surprisingly
low. However, it the test demonstrates an accuracy of <64% (Englelgau, Narayan
and Herman, 2000), which may be significant in osteopaths’ rationale not to use this
equipment. Interestingly, the median respondent who often assessed urine had been
in practice for 14 years, whilst participant’s not assessing urine had been in practice
for 9 years, which may reflect changes in teaching emphasis.
14
80% of practitioners reported they would alter their management for DM2 patients,
with diet (81%) being discussed more frequently than exercise (58%). This pattern is
consistent with the findings of Gregory (2004). The role of an osteopath and dietary
advice may be debated within the profession, but the GOsC (2012) states that
guidance on diet and exercise is what patients may expect from a consultation. A
small unpublished undergraduate study by Wills (2007) concluded that osteopaths
offer nutritional advice but feel inadequately trained to do so. It is encouraging that
the majority of osteopaths in this study reported they would advise medium intensity
exercise most frequently, as several studies (Chen et al, 2003; Guelfi, Jones and
Fournier, 2005; Slentz et al, 2009; Segerström et al, 2010; Colberg et al, 2010) have
identified this as the most effective for DM2 patients.
The osteopaths in this survey reported that patients with DM2 gained the same
amount of symptomatic relief from osteopathic treatment which correlates with
Barker (1996), in which 85% of practitioners observed symptomatic improvement. No
relationship was observed between the number of DM2 patients seen per week and
the amount of expected relief, suggesting that practitioners perceive osteopathic
effectiveness to be consistent, regardless of experience.
Limitations and future research
The response rate of 17% (n=170) was below the guidelines outlined by Israel
(2012) to achieve a precision level of +/-7% and confidence level of 95%. In addition,
over half of the respondents graduated from the BSO, which limits the
representativeness of these findings to the UK osteopathic population.
Further research may explore the following:
15
Rationale behind modifying osteopathic evaluation, treatment and
management of DM2 patients.
Osteopaths physiologic understanding of treatment modalities, as previously
investigated by Gregory (2004).
Do practitioners adjust the variables outlined in this study any differently for
Type 1 diabetic patients?
The signs and symptoms of a presentation that would require a referral in an
undiagnosed patient.
How qualified osteopaths feel providing advice regarding nutrition and
exercise?
The questionnaire produced for this study was non-validated and could have been
piloted more extensively. Question 11 required a response on a Likert-scale and did
not allow for practitioners to indicate whether they do not use or are unfamiliar with
some modes of treatment. It is also acknowledged that the questionnaire survey did
not capture details about how participants actually treat individual patients with DM2,
which would affect result validity.
Conclusions
This study identified significant differences in the way osteopaths report treating and
managing patients with DM2 compared with non-diabetic patients. Practitioners
reported most frequently assessing for neurological changes and considered
changes to be most contraindicative to cervical spine manipulations. The most
common way in which treatment was modified was by adjusting soft tissue and
manipulative techniques and reducing treatment intensity.
16
Interestingly, this paper has highlighted that 15% of osteopaths never test for
neuropathy. Neurological changes reflect vascular health (NICE guidelines, 2008)
and because practitioners are positioned well to evaluate the integrity of this system,
the finding in this study is surprising. GOsC (2012) states that osteopaths should
interpret clinical signs of dysfunction. A failure to examine for a peripheral
neuropathy reflects an inconsideration of the vascular health of the patient, which
should be paramount.
Another interesting finding in this paper was that 75% of participants claimed retinal
changes to be contraindicative to HVT, whilst only 17% assessed for retinal
changes. Teaching emphasis is likely to be significant, yet this finding is worrying
considering the clinical relevance of pathological changes here.
The literature presented in this paper has highlighted the importance of providing
thorough, but clinically relevant osteopathic education relating to diabetes mellitus.
The study has suggested that practitioners are generally aware of the chronic
implications of the disease and consider them through-out treatment and
management. Clinical judgement should represent a consideration of the local
musculoskeletal and broader systemic effects of such a disorder.
Word count: 3291
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Acknowledgements
I would like to thank my supervisor Hilary Abbey for her continued support and
advice through-out this project. I would also like to thank all osteopaths who
participated in this study.
25
Appendix 1: Participant Information Sheet
Study Title: Osteopathic approaches to the evaluation, management and treatment of type 2 diabetic patients. A questionnaire study
Invitation: We would like to invite you to take part in our research study. Before you decide whether you wish to participate, we would like you to understand why the research is being carried out and what it would involve for you. This document will provide you with these details.
What is the purpose of the study?
This study is being conducted as part of an osteopathic degree at the British School of Osteopathy. Type 2 diabetes is becoming an increasingly prevalent disease in modern society, affecting 2.8 million people in the UK (NHS, 2011). The aim of this study is to explore how osteopaths approach the evaluation, management and treatment of type 2 diabetic patients in clinical practice, to observe if any modifications are made compared with a non-diabetic population. It is hoped that the study may help to identify how osteopaths assess and monitor some of the complications of the condition in order to maintain safe and effective patient care.
Why have I been invited?
You have been invited because you are a practising UK osteopath. The study aims to invite a total of 1000 GOsC registered osteopaths, randomly selected from the GOsC electronic register.
Do I have to take part?
No. Whether you decide to take part, or not, will have no effect on your standing as an osteopath and is entirely voluntary. You can withdraw from the study while you are completing the questionnaire but not once it has been submitted, as it will not be possible to identify individual, anonymous questionnaires.
What will happen to me if I take part?
If you decide to take part, you will be asked to complete a questionnaire by 20 th
December 2012. There is a link to the online questionnaire at the end of this form.
What do I have to do?
To participate in this study, please complete the attached Survey Monkey questionnaire, which will take approximately 5 minutes.
What are the possible disadvantages and risks of taking part?
There are no anticipated disadvantages associated with taking part in this research, apart from the time needed to complete the questionnaire.
What are the possible benefits of taking part?
26
There are no direct benefits for you in taking part in this study, but you would be contributing your clinical experience to osteopathic research about the care of patients with diabetes.
What if there is a problem?
If you have any complaints regarding the study or feel harmed in any way, please feel free to contact the researcher or study supervisor using the contact details listed at the end of this document.
Will my taking part in the study remain confidential?
The questionnaires are completely confidential and anonymous. The e-mail addresses of selected participants were deleted immediately after being sent details of the study. Data obtained will be kept on the British School of Osteopathy’s (BSO) secure servers and in a locked metal cabinet. After 6 years following completion of the study, data will be destroyed.
What will happen to the results from the study?
A copy of the completed study will be available in the BSO library after completion of the study in July 2013. Please note that due to the anonymity of this study, no individuals will be identifiable in any written material or reports. Should you wish to obtain a copy of the results after July 2013, please contact the researcher using the contact details at the end of this document.
Who is organising the research?
The principal researcher is Bobby Qureshi; a third year BSO undergraduate student. The study is being conducted as part of a dissertation project for an M.Ost. degree course. The study supervisor is Paul Blanchard, a senior BSO clinic tutor and member of the CAE team.
Thank you for taking the time to read the information sheet. Our contact details are given below should you have any questions or want further information.
Researcher contact details Supervisor contact details
Bobby Qureshi
275 Borough High Street, London SE1 1JE
020 7407 0222
Hilary Abbey
275 Borough High Street, London SE1 1JE
020 7407 0222
27
Appendix 2: Email Invitation
Dear colleague,
My name is Bobby Qureshi, I am a fourth year student at the British School of Osteopathy. I am conducting a questionnaire study in order to explore how osteopaths evaluate, manage and treat patients suffering from type 2 diabetes. I would like you to participate in this research project that would take approximately 5 minutes to complete.
Should you wish to take part, please click the following link: http://www.surveymonkey.com/s/osteopathyandtype2diabetes.
A participation information sheet has been attached to this e-mail explaining details of the study.
Thank-you very much,
Bobby Qureshi
28
Appendix 3: Initial questionnaire
A questionnaire survey of osteopathic evaluation, treatment and management of patients with Type 2 diabetes
1. Years in practice: years
2. What establishment did you graduate from? (Mark as appropriate)
The British College of Osteopathic Medicine, London
The British School of Osteopathy, London
The College of Osteopaths, validated by Middlesex University, Hertfordshire
The College of Osteopaths, validated by Keele University, Staffordshire
The European School of Osteopathy, Kent
Leeds Metropolitan University, Leeds
The London College of Osteopathic Medicine
The London School of Osteopathy, London
Oxford Brookes University, Oxford
The Surrey Institute of Osteopathic Medicine, Surrey
Other – please specify: _____________________________________________________
The following questions relate to patients with Type 2 Diabetes, a condition characterised by hyperglycaemia, peripheral insulin resistance and insulin deficiency (Merck Manual, 2010)
3. Approximately, how many patients do you see per week in practice?
4. Approximately, how many of these patients have Type 2 diabetes?
29
5. How often do you assess these factors in patients who patients who are suspected and are diagnosed with Type 2 diabetes?
Always Often Sometimes Rarely Never
a. Urine testing
b. Retinal changes
c. Peripheral neuropathy
d. Nephropathy
6. My treatment of patients with type 2 diabetes differs from non-diabetic patients
7. I treat patients with type 2 diabetes for a shorter length of time
8. I treat type 2 diabetic patients more frequently than non-diabetic patients
9. I treat patients with type 2 diabetes with less intensity (i.e lighter treatment)
10. I assess and treat vertebral levels T5-11 and T11-L2 in type 2 diabetic patients
11. Would you modify any of the following techniques in a patient with type 2 diabetes?
a. Soft tissue
b. High velocity thrust
c. Functional technique
d. Visceral technique
e. Joint articulation
f. Cranial techniques
30
12. How important are these factors in adapting treatments for a type 2 diabetic patient:
Very Important
Important Moderately important
Unimportant
Very unimportant
a. Older age
b. Poor blood glucose control
c. Presence of co-morbid conditions e.g. peripheral neuropathy
d. Obesity
13. In your clinical experience, would any of the following be relative contra-indications to high velocity thrust techniques to the cervical spine?
Completely Very Moderate Slightly Not at all
a. Poor blood glucose control
b. Retinal changes
c. Neurological changes e.g. Neuropathy
d. Obesity
e. Long-term thiazolidinedione use
Strongly agree
Agree Neither agree nor disagree
Disagree
Strongly disagree
31
14. Type 2 diabetic patients tend to get less relief from osteopathic treatment than non-diabetic patients
15. My management of a type 2 diabetic patient differs to that of a non-diabetic patient
16. I am more likely to discuss dietary issues with a type 2 diabetic patient than a non-diabetic patient
17. I am more likely to advise type 2 diabetic patients about exercise than non-diabetic patients.
18. Which of these forms of exercise would you be more likely to advise for a patient with Type 2 diabetes? (Please tick one).
High intensity exercise
Moderate intensity exercise
Low intensity exercise
32
Thank you very much for your help by completing this questionnaire.
If you would like a copy of the final paper, or a summary of the results, please email the researcher ([email protected]) once the project is completed in
June 2013.
Appendix 4: Final Questionnaire
A questionnaire survey of osteopathic evaluation, treatment and management of patients with Type 2 diabetes
3. Years in practice: years
4. What establishment did you graduate from? (Mark as appropriate)
The British College of Osteopathic Medicine, London
The British School of Osteopathy, London
The College of Osteopaths, validated by Middlesex University, Hertfordshire
The College of Osteopaths, validated by Keele University, Staffordshire
The European School of Osteopathy, Kent
Leeds Metropolitan University, Leeds
The London College of Osteopathic Medicine
The London School of Osteopathy, London
Oxford Brookes University, Oxford
The Surrey Institute of Osteopathic Medicine, Surrey
Other – please specify: _____________________________________________________
The following questions relate to patients with Type 2 Diabetes, a condition characterised by hyperglycaemia, peripheral insulin resistance and insulin deficiency (Merck Manual, 2010)
3. Approximately, how many patients do you see per week in practice?
4. Approximately, how many of these patients have Type 2 diabetes?
33
5. How often do you assess these factors in patients who patients who are suspected and are diagnosed with Type 2 diabetes?
Always Often Sometimes Rarely Never
e. Urine testing
f. Retinal changes
g. Peripheral neuropathy
h. Nephropathy
6. My treatment of patients with type 2 diabetes differs from non-diabetic patients
7. I treat patients with type 2 diabetes for a shorter length of time
8. I treat type 2 diabetic patients more frequently than non-diabetic patients
9. I treat patients with type 2 diabetes with less intensity (i.e lighter treatment)
10. I assess and treat vertebral levels T5-11 and T11-L2 in type 2 diabetic patients
11. Would you modify any of the following techniques in a patient with type 2 diabetes?
a. Soft tissue
b. High velocity thrust
c. Functional technique
d. Visceral technique
e. Joint articulation
f. Cranial techniques
34
12. How important are these factors in adapting treatments for a type 2 diabetic patient:
Very Important
Important Moderately important
Unimportant
Very unimportant
e. Older age
f. Poor blood glucose control
g. Presence of co-morbid conditions e.g. peripheral neuropathy
h. Obesity
13. In your clinical experience, would any of the following be relative contra-indications to high velocity thrust techniques to the cervical spine?
Completely Very Moderate Slightly Not at all
f. Poor blood glucose control
g. Retinal changes
h. Neurological changes e.g. Neuropathy
i. Obesity
j. Long-term thiazolidinedione use
Strongly agree
Agree Neither agree nor disagree
Disagree
Strongly disagree
35
14. Type 2 diabetic patients tend to get less relief from osteopathic treatment than non-diabetic patients
15. My management of a type 2 diabetic patient differs to that of a non-diabetic patient
16. I am more likely to discuss dietary issues with a type 2 diabetic patient than a non-diabetic patient
17. I am more likely to advise type 2 diabetic patients about exercise than non-diabetic patients.
18. What intensity of exercise would you be more likely to advise for a patient with Type 2 diabetes?
High intensity exercise
Moderate intensity exercise
Low intensity exercise
36
Thank you very much for your help by completing this questionnaire.
If you would like a copy of the final paper, or a summary of the results, please email the researcher ([email protected]) once the project is completed in
June 2013.
