“More Than We Ever Imagined - Find an Osteopathic...

Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"

Exploration of the World of Lympathics Osteopathic Research (March 2013)

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“More Than We Ever Imagined …”

Michael L. Kuchera, DO, FAAOProfessor, Department OMMMarian University College of Osteopathic Medicine

2013 AAO Convocation – SAAO Program

Curiosity almost killed the cat. Canine science kept it alive.

Students Appreciate Role of Osteopathic Research



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Higher Tech - Higher TouchFocus on Lymphatics & Fluid Dynamics

Documenting: Palpatory Diagnosis, OMT, Post-OMT Change, Intra- & Inter- Examiner Reproducibility

Potential Impact: Perspective & Interpretation; Teaching; Learning; Research; Literature

Advancing Our Science & Art

Imagine DOcumentingPalpation & OMT

Several Important Objective Measures Useful in Teaching, Replicating & Documenting Procedures– Pressure / Force

– Duration & Frequency

– Direction

– Intra- & Inter- Examiner Reproducibility/Reliability

Useful in Conducting Studies of Inter-Examiner Reliabilitywww.FIMM-Online.com



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Advantages of Adding High Tech

Only then can we begin to answer …

• Is it the type of “technique” itself?

• Is it presence or absence of SD?

• Is it the amount of pressure?

• Is it the duration of the OMT?

• Documents technique & assesses intra-examiner reliability

• Outside team can replicate the study parameters

• If pilot shows trend or other result, could design study for modifying “dosage” of pressure to see if modify outcomes

Example: Replicating Lymphatic Pump Parameters – Pedal Pump Equivalent

• Lymphatic Pump as commonly taught – 120-140 per min– “slosh” observed

• Compared hands-on to machine (accelerometer)

• Parameters measured – 130-138 / minute (95% CI)– 0.24 – 0.32 G-force (95%CI)

• Report for reproducibility; permit dose-response; etc



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Alternative Line of Research on MOABiochemical Modulation?

Does lymphatic pump create shear forces/release eNOS?

“High-Tech” Enhancing “High Touch“

in Head/EENT/Cervical Research

AOA Research Convention

International Academy of MM Medicine

International Fascial Research CongressPart of 4 DO/MS Masters Theses

JAOA

Manuelle Medizin

J Bodywork & Movement Therapies

In conjunction with osteopathic students @

Philadelphia College of Osteopathic Medicine



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Profession Needs Systematic Analysis of Structure – Function Inter-Relationships

eg: Parasympathetics (?)– CN X & the OM Suture– Proposed MOA’s ?– Goal(s) of OMT ?– Application(s) of OMT ?

• Need Document BOTHProcedures & Outcomes

• Build Upon Results: New Questions or ProtocolsKuchera. Osteopathic Considerations

in HEENT Disorders. Greyden; 2011

2 Occipitomastoid Suture TechniquesBroad Application Stim (?) Psym: “Slows Heart”

V-Spread to Remove SD? Treats Bradyarrhythmia

Broad contact version: Years of informal classroom observation in healthy subjects “slows” heart

AOA Fellowship2011-12 (J. Nelson)



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Randomized, Controlled Pilot: CV Effect of OM Suture OMT

JNC 7 Pre- and Hypertensive Subjects (n=30) vs Normotensive Controls (n=30)

• Randomized 1 of 2 V-spread OMT techniques

• Rested / Supine Blinded BP, heart rate, pO2

• Wearing IsoTOUCH monitors, palpate for OM dysfunction (severity rated: 0-3) & deliver 5 minutes V-Spread (with documented pressures)

• Operator blinded to both CV & SD measures

• Blindly remeasure CV & SD parameters

• BP subject cross-over potential built in (min 4wk)

Right OM V Spread

-0.4-0.2

00.20.40.60.8

11.21.41.61.8

0 50 100 150 200 250

Time (half seconds)

Fo

rce

(lb

s)

Left Index

Left Middle

Left Thumb

Right Index

Right Middle

Right Thumb

Joint National Commission for ↑BP < 160/100; AOA/PCOM

Measuring a New Perspective:Role of CSF as “Lymphatic System” Equivalent for the Brain

• CNS Metabolites CSF Arachnoid Granulations Venous Sinuses Venous Sinus Drainage

• Gliovascular System



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Enhancing Computer Software to Gather New Insights

• Simultaneous Physiological Input

• Physiological Maneuvers Changing Certain Values Relative to Other Values

• Enhanced Computer Analysis

• Mathematical Modeling

Eg: Moskalenko MethodCranial Compliance; CSF Flow

Cranial Compliance & CSF Mobility

(Evidence Based Measures)

Director, Center for Chronic Disorders of AgingDirector, Human Performance & Biomechanics Lab

Michael L. Kuchera, DO, FAAO

Philadelphia College of Osteopathic Medicine



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Overview of This “New” Idea• High profile, high impact topic –

head trauma

• Important but controversial osteopathic approach – OCF

• Shift focus of prior research

• Employ state-of-art technology & methods

• Document impact on physiology

• Build on evolving evidence base

“High Profile – High Impact Topic”

Jan 11, 2012: Michelle Obama & Dr. Jill Biden announced JOINING FORCES @ Virginia Commonwealth University. AACOM joined AAMC leadership and member deans at the event.

Osteopathic medical college deans attending: • Marc B. Hahn, DO – UNECOM• Don N. Peska, DO – UNTHSC/TCOM• Thomas A. Scandalis, DO – NYIT/NYCOM• Anthony J. Silvagni, DO – Nova/SECOM• Dixie Tooke-Rawlins, DO – EV/VCOM• Kenneth J. Veit, DO, MBA – PCOM

All 26 COMs (+4 branches) signed pledge

Major Press Coverage

Nationwide Attention

Important



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Traumatic Brain Injury (TBI) – A “Joining Forces”

Key Topic(AAO Next Year)

Example: Indiana University School of Medicine• "The IU School of Medicine has a focus on the

neurosciences, which goes hand in hand with treatment for post-traumatic stress disorder and traumatic brain injury, two of the unique health care needs of veterans cited by the Joining Forces initiative.“ – Dean D. Craig Brater

Mild Traumatic Brain Injury - Concussion

Is there a role for OMT? Osteopathic focus on somatic dysfunction of head



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Mechanism of Injury Pathophysiology

• Swelling• Metabolites• Bleeding

Body Attempts to Heal (Homeostatic Mechanisms)

• CSF-Venous Drainage • Cranial Compliance

Condition: MildSevere

FUNCTIONAL GOALS OF INTRA-CRANIAL FLUIDS

• Deliver nutrition to brain tissue• Transport nutrition in brain tissue• Maintain water balance in brain tissue• Optimize intra-cranial stroke energy for

brain nutritional supply• Distribute blood & CSF in brain under

stress situations• Evacuate wastes from brain tissue



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Problem

Too Much Intra-Cranial Fluid

Symptoms: Headache, Dizziness, Nausea/Vomiting, LethargyFatigue, Sleep Disturbances, Concentration & Memory Loss, Irritability, Visual Changes

Clinical Examples

Homeostatic Mechanisms• Increase cranial

sutural compliance• Down-regulate CSF

production by the choroid plexus

• Up-regulate absorption/drainage mechanisms viao Lymphatics (spinal

nerves & CNI [cribriform plate])

o Arachnoid granulations Venous sinuses

Improved Symptoms

&Resolution



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Measurements of Cranial Compliance & CSF Distribution of Intra-Cranial Stroke Volume

New Ideas: Switch Homeostatic Emphasis from the Container to the Fluid

Old Approach1. “Cranial bones move”

2. OMT corrects cranial SD (container)

3. We find “SD” & claim OMT removes it

4. They challenge 1-3 but if accept any, they say “no EBM that SD is clinically relevant”

New Idea/Approach 1. Head trauma is a “container –

fluid imbalance” problem

2. OMT/OCF has measurable effect on total fluid (CSF)

3. Evidence base now; underlying mechanism later

4. Oh & by the way … there is a measurable change in cranial compliance too



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/

Treatment Options For Pathophysiology

Rx for ContainerSurgical / TrephinationVentricular ShuntOMT Rx for Fluid

Ventricular ShuntMedicationsOMT

Homeostasis Overwhelmedin an Infant (Chronic)

Eg: Hydrocephalus & Shortened Life Span



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/

Homeostasis Overwhelmedin an Adult (Chronic)

Nausea/VomitingHeadache/Dizziness

Lethargy/FatigueCognitive/Memory Loss

Visual Changes

Death

Nausea/VomitingHeadache/Dizziness

Lethargy/FatigueCognitive/Memory Loss

Visual ChangesDEATH

Eg: Hydrocephalus & Shortened Life Span

Rx for ContainerSurgical/TrephinationVentricular ShuntOMT

Ventricular ShuntMedications / OMT

Rx for Fluid

Improved Symptoms

&Resolution



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Not Just For Head Trauma / TBIPre- and Post- OMT in:• Healthy MOA• Headache• Hypertension• etc

Cranial Compliance & CSF Removal of Metabolites / Waste in:• Dementia• Neurodegenerative

Disorders• etc

At PCOM, I was Clinic Director for the Center for Chronic Disorders of Aging

Healthy Aging



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Blood Flow Changes with Agebut not everyone develops dementia

CSF Mobility Changes with Age(Note After Age 50 …. Hmmmm)

• Changes with age of CSF mobility, calculated as the average of two indices — “SQ” and “T”.



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CSF Mobility & Cranial Compliance Change with Age

• Changes of indices reflecting CSF mobility and CC at different ages demonstrating right and left hemisphere asymmetry.

Dementia Stratification (78-84 y/o):Note: Cranial Compliance & CSF

• Changes of CBF, CSFm, CC at rest and during voluntary breath cessation for elderly persons 78–84 yrs old, divided into 4 groups with different cognitive capabilities (Prognosis-2) irrespective of age:

Group I: mentally healthy, Gr II: initial dementia, Gr. III: moderate dementia, Gr IV: pronounced dementia. Significance ∗ p > 0.1, ∗∗ p > 0.05.



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Alzheimer Disease: Early Sign = Anosmia

Viral infection

That VooDO that You DO !?!New Opportunity to dispel

that opinion by …

• DOcumenting physiological changes made in vascular & CSF dynamics

• Calculating CSF mobility (CSFmo)

• Calculating Cranial Compliance (CC)

• DOcumenting the OMT techniques we use (site, pressure, duration, etc)



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Transcranial Doppler/Rheoencephalography

Simultaneous recordings of transcranial dopplerography (TCD); rheoencephalography (REG) (fronto-mastoid electrode position), from left & right hemispheres &intracranial pressure (ICP) in cysternamagna in quiet, comfortably awake recumbent subject

Systems & Structures Responsible for Circulatory–Metabolic Supply of Brain Activity

Central ArterialPressure

HEART ACTIVITY Central Venous Pressure

Intracranial Pressure

Pulsations ofCentral Venous

Pressure

Pulsations ofCentral Arterial

Pressure

Brain Blood Flow & Nutrition Supply

CSF-VolumeBrain Volume

Quality of Cognitive Brain Activity



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Equipment & Finding TCD “Window”



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Transcranial Doppler (TCD) Finding the Windows

(Middle Cerebral Artery)

Adjust TCD power settings to identify exact site along the MCA bilaterally

Bilateral Middle Cerebral Arteries on Transcranial Doppler



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Initial Spectrum- baseline reading of subject• Subject remains motionless with eyes closed for 1-2 minutes. • No outside stimulation

Repeated at end of treatment to see if changed or not

Rt TCD

Lt TCD

Rt REG

Lt REG

EXAMPLE: Stookey Test – Subject breathes normally while examinerapplies pressure (8 lbs.) to the abdomen – This increases venous returnand therefore increases both intra-cranial volume and pressure.



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TCD/REG Measurement Protocol --Baseline Functions : OMT : Post-OMT FunctionsFunctional Tests to Physiologically Modulate Vascular Fluid Flow• Frequency Spectrum (1 minute)

• Respiratory cessation (30+ seconds)

• 7 seconds cessation after inhalation

• 7 seconds cessation after exhalation

• Hyperventilation (20 seconds)

• Stookey test (20 seconds)

• Frequency Spectrum (1 minute)

The significant waves in the spectrum analysis are shown here. The slow fluctuation and the primary cardiac wave are most important for the analysis. The respiratory wave will be used mainly for a reference point and the 2nd harmonic is not needed for the analysis.

Slow Fluctuation wave

Respiratory wave

Primary Cardiac wave

2nd Harmonic



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Pre- CV4OMT

Doubled slow wave frequency≈ Increased blood flow to brain

Increase in Amplitude directly proportionate to increase in cranial compliance

2nd Harmonic arrival ≈ skull expansion; stems from energy increase of

the slow fluctuation

Post CV4 - Moskalenko Interpretation



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• Moskalenko Method: Intracranial volume–pressure relations by analyzing TCD & REG changes during a cardiac cycle.

• (a) Equalize amplitudes.

• (b) Isolate TCD & REG changes on ascending and descending phases of the cardiac cycle.

• (c) Transform coordinate axis from “amplitude/time” to “TCD/REG”.

• (d) Change orientation of abscissa for descendant phase of cardiac cycle and its phase in the united graphic.

• (e) Calculate

Moskalenko Method in EvaluatingCRANIAL COMPLIANCE & CSF (Mobility)



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Can measure right & left hemispheres

• Results of the calculations including cranial compliance on each hemisphere side and CSF flow for the cardiac cycle of a 26-year-old healthy man recorded at rest, in a comfortable horizontal position.

• Responses to holding breath & the Stookey test in a healthy young adult male. (Correspond to rest conditions in previous Figure.)



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CSF mobility in response to voluntary breath holding for 30-seconds (27 y/o)

VOLUNTARY BREATH HOLDING

Research Protocol & Materials for CV4 Gathering Data for Moskalenko Method



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Reproducibility Built Around IsoTOUCH® Pressure Sensitive Monitoring System

50 100 150 200

IsoTOUCH® Pressure SensorPalpation Monitor System

Non-invasive, pressure deformation sensors on finger pads & thenar eminences

Bluetooth data to computer for realtime graphic display of measured forces used during manual diagnosis and treatment of somatic dysfunction.

Better understanding of tissue loading, end-feel test impulses and OMT activation forces to diagnose or treat somatic dysfunction.



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Volunteers experienced in palpation & MM

“High Tech” -- Sensitive 4 grams to 10 poundsLimitations: Direction - Traction

How does our touch compare?

Is my touch

anywhere near close?

I just can’t believe I’m

touching“the” Dr. Frymann!



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TCD/REG Measurement Protocol --Baseline Functions : OMT : Post-OMT Functions

Repeat Functional Tests to Physiologically Modulate Vascular Fluid Flow

OMT selected with potential to modulate physiology:

• CV4

• Venous Sinus Drainage

• OM Suture Release

• Occipital Decompression

• Sub-Occipital Release

• Sham

-0.5

0

0.5

1

1.5

2

2.5

3

3.5

4

0 200 400 600 800 1000 1200

Time (sec)

Fo

rce

(lb

s)

CV4 Hold

Forc

e (l

bs)

1min 2min 3min 4min 5min

Still Point

CV4 Pressure measured using IsoTOUCH® Pressure Monitoring Sensor System (Thenar Pads bilaterally).

Only one pad displayed above. Report specifics in methods section to enhance reproducibility.



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Right OM V Spread

-0.4-0.2

00.20.40.60.8

11.21.41.61.8

0 50 100 150 200 250

Time (half seconds)

Fo

rce

(lb

s)

Left Index

Left Middle

Left Thumb

Right Index

Right Middle

Right Thumb

Fluid direction 20-30 grams: left index-middle, Extension pulse toward Rt OM

V-Spread Pressure 0.5-0.8 lbsLateral fluctuation (peak=valley)

Right HandInitial 1.5 lb

V-SpreadNo waves

“Release” notedPhase restored

Synchronybtwn hands

etc

Rate CRI8/minute

PCOM 2005

Palpation Monitors

Example:

Plan of Action: First Show in Normal Population

• Write full protocol & grant application

• Recruit and train clinical research teams in TCD/REG

• Train in standardized OMM protocol

• Conduct & publish study data / results

• Share findings – AAO– Cranial Academy– ECOP– JAOA– Mainline basic

science journal

• Apply for larger externally funded study



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Then Collaborative Research

Cranial Compliance &

CSF Flow

• Transcranial Doppler & Rheoencephalography

• Moskalenko Method

• CC: Altered in Dementia? In Multiple Sclerosis? In Head Trauma? In ADHD?

• See if ΔPre-Post OMT

Collegial DiscussionResearch Thoughts

Looking forward to further discussionPlease feel free to poke holes in any weak aspects of our new

ideas to make them (and us) stronger



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Journal of Integrative Neuroscience, Vol. 10, No. 2 (2011) 131–160Imperial College Press DOI: 10.1142/S021963521100266X (Useful Synopsis Article of Method)

CHANGES OF CIRCULATORY–METABOLIC INDICES AND SKULL BIOMECHANICS WITH BRAIN ACTIVITY DURING AGING

Y. E. MOSKALENKO, N. A. RYABCHIKOVA, G. B. WEINSTEIN, P. HALVORSON and T. C. VARDY

Sechenov Institute of Evolutionary Physiology and Biochemistry of the Russian Academy of Sciences (Thorez Prosp. 44, St. Petersburg 194223, Russian Federation)

Dept. of Higher Nervous Activity, Biology Faculty; Lomonosov Moscow State University, Vorobyevi Gory (Moscow 119899, Russian Federation)

[email protected] 22 September 2010; Accepted 25 April 2011

Thanks & Acknowledgements Grant &/or equipment support• American Osteopathic Association• Bodiflo (equipment)• Neuromuscular Engineering grants and equipment• Non-Invasive Monitoring Systems (equipment)• Sigma Corporation (equipment)• USA Department of DefenceStudents & research coordinators of the Human

Perfomance & Biomechanics Laboratory at PCOM Pre- AND Post- OMT to Base of Skull, Upper Cervical & Venous Sinus



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Interpret Research Correctly!

Excellent health statistics … smokers are less likely to die of age-related illnesses!

Questions?

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