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The study materials shall be self-instructional. There will be use of limited face-to-face contact during the residential sessions.
Face-to-face delivery mode shall not exceed one third of the instructional time. Counselling and guidance shall be provided using multi-media approach. The module will run for a minimum of eight semesters of 24 weeks each and a maximum of 24 semesters from the date of registration. The minimum semester load shall be two course units and the maximum shall be six course units. Each course unit in the programme has a loading of a minimum of 70 hours. And a terrible, black emptiness.
If he was to become a good physician, he had to overcome his sensibilities and aversions. Francine Rivers Publisher: The other lioness sprang, and the two rolled and clawed at one another. The Egyptian stared at him, his dark eyes unbelieving. Citations are based on reference standards.
How many times have you overseen this done, Troas? Worldcat source edition See also WorldCat this item.
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Delaware County District Library Ohio. If data was still non-normally distributed, then it was finally rejected. The next step was to test normality along M patterns, which are randomly selected from a set of sequences of length L Porta et al. To test the stability of the variance, Barlett test was used if data was normally distributed otherwise Levene's test using the median was adopted.
A descriptive analysis of the population was performed at the baseline using arithmetic means, medians, standard deviations and standard errors. Univariate statistical tests used chi square test for establishing differences among categorical variables, such as gender, OMT, and smoking.
Results were expressed in percentage. Mixed effect regression MER model considering random effect for osteopath and a fixed effect for period was used to determine dependent variables differences between groups. Post-hoc pairwise analysis adjusted by Holm-Bonferroni correction was used to explore any statistical difference resulted from MER.
Sensitivity analyses were performed according to smoking and session. Effect size was computed using Cohen's d to show any clinical effect of OMT compared to sham therapy and control group. Statistical significance was based on a probability level at less than 0. All analyses were performed using R v 2. Out of 97 volunteers, 66 were included in the study and randomized. None of the subject enrolled recorded less than cardiac cycles at any study condition.
The RWS revealed a stationarity of mean and variance. Among the 38 participants receiving sham and OMT interventions, the percentage of subjects able to correctly guess which treatment they received did not differ session 1: Heart rate variability HRV findings for: C, control; O, osteopathic manipulative treatment; S, sham therapy. Effect sizes were small OMT vs. Sensitivity analyses were performed taking into account smoking and sessions.
Sham therapy and time control groups did not demonstrate any valuable change. Sensitivity analysis stratified by smoking. Each figure shows HRV data recorded during the three steps of the each session: Sensitivity analysis stratified by non-smoking. Sham therapy and time control group did not reveal variations compared to baseline values.
Sensitivity analysis stratified by session 1. Sensitivity analysis stratified by session 2.
The present trial showed that OMT modifies ANS activity through modulating the parasympathetic functioning of healthy subjects compared to sham therapy and control groups. Statistically significant changes were revealed during the treatment period.
This clinical study used a larger sample size to confirm previous findings showing that OMT can globally influence the tonic activity of ANS Henley et al.
However, several differences can be highlighted between former studies and this trial. Henley used an additional tilt test to evaluate HRV variations in response to an environmental stress. Then, both Henley and Giles limited the OMT intervention to anatomical areas cervical spine and sub-occipital area directly connected with parasympathetic and sympathetic heart rate control.
The present trial used a patients' need-based treatment to improve the clinical generalizability of findings. In non-smokers, HRV-values of the final 5 min record remained unchanged compared to the HRV-values of the treatment phase.
In contrast, smokers presented a difference, although not statistical significant, of the HRV-values between the final 5 min and the treatment phase, showing an influence of smoking on HRV changes after OMT. Overall, we suggest that the treatment of an osteopathic dysfunction, independently from its location, could modify autonomic activity of both smokers and non-smokers.
Interestingly, other OMT mediated improvements in clinical outcomes such as reduction of pain grade and frequency and improvement of the range of motion, may correlate to the decrease of sympathetic activity resulting from this study. As a matter of fact, parasympathetic branch of ANS has anti-inflammatory and anti-nociceptive actions. Tracey demonstrated that the release of acetylcholine by vagal endings binds to alpha-7 nicotinic receptors of macrophages selectively inhibiting pro-inflammatory cytokines production Tracey, Sympathetic branch has instead an opposite pro-inflammatory action, potentially increasing pain grade.
Clinical effects following osteopathic treatment could also be referred to the trophotropic tuning of the patient's organism, due to the shift of ANS tonic activity toward the parasympathetic functioning.
According to Hess , the trophotropic tuning is characterized by a decrease in frequency and an increase in amplitude of brain waves, a decrease in heart and respiratory rate, an increase in skin temperature, a decrease in muscle tension and anxiety.
Several strengths and limitations have to be considered for the present trial. No changes to methods and outcomes were applied after trial commencement. It was based on rigorous methodology, controlling for allocation, detection, sequence generation biases.
Attention was paid to confounding factors like temperature, humidity of the room, smoking, and circadian rhythms. It included a large sample size and a patients' need-based treatment. Limitations are in terms of incomplete emptiness of the bladder that was not systematically asked to participants, difficulty to control for subjects emotional conditions and daily habits before the trial started.
The present study focused on healthy subjects. Future studies are warranted to further explore the extent to which OMT can change ANS activity in pathological conditions and comparing its effect with usual care, hypothesizing that OMT could be used as a supportive care in addition to traditional methods.
LC supervised the experiment, exported the data and reviewed the paper, FC run the statistical analysis, supervised the research and reviewed the paper for intellectual content.
All authors approved the final version. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Authors sincerely thank Luca Righetto for his technical support and Dr. Michael Hicks for reviewing the paper. National Center for Biotechnology Information , U. Journal List Front Neurosci v. Front Neurosci. Published online Aug 4.
Author information Article notes Copyright and License information Disclaimer. Reviewed by: Millar, University of Guelph, Canada. Vespucci , Pescara, Italy moc. This article was submitted to Autonomic Neuroscience, a section of the journal Frontiers in Neuroscience.
Received Apr 16; Accepted Jul The use, distribution or reproduction in other forums is permitted, provided the original author s or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. This article has been cited by other articles in PMC. Abstract Context: Introduction Heart rate, one of the most variable organism's phenomena, corresponds to a number of heart beats per minute.
Materials and methods Primary outcome of this randomized placebo controlled within subject cross-over single blinded study was to explore the extent to which OMT changed nu HF-value, compared to sham therapy and control group. Population Asymptomatic healthy adults, of either gender, were considered eligible for the study. Open in a separate window. Figure 1. Data analyses Data was collected through a socio-demographic form and a HRV detector system Flexcomp http: HRV records were performed at 1 , 3 , and 4.
Statistical analysis Sample size was computed considering a correlation coefficient among repeated measure of 0. Results Out of 97 volunteers, 66 were included in the study and randomized.
Numbers in table are: Figure 2. Sensitivity analysis Sensitivity analyses were performed taking into account smoking and sessions.