The AAO F For JOURNALc919297.r97.cf2.rackcdn.com/gg4lknxndzwq8jnrz4lgbaxguss1... · 2016-05-13 ·...

Lebanon, Oregon

Lobitos, Peru

4250 miles

Health Status Comparison of Lebanon, Oregon, and Lobitos, Peru...page 31

Forum For osteopathic thought

Official Publication of the American Academy of Osteopathy ®

tradition shapes the Future Volume 24 number 2 June 2014

JOURNALThe AAO

Page 2 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014

The American Academy of Osteopathy is your voice . . .in teaching, advocating, and researching the science, art, and philosophy of osteopathic medicine, emphasizing the integration of osteopathic principles, practices, and manipulative treatment in patient care.

• AccesstothemembersonlysectionoftheAAOwebsite,whichwillbeenhancedinthecomingmonthstoincludenewfeaturessuchasresourcelinks,ajobbank,andmuchmore.

• DiscountsonadvertisinginAAOpublications,ontheAAOwebsite,andattheAAO’sConvocation.

• AAO-sponsoredcoursesthatareacceptedwithoutchallengebythetheAmericanOsteopathicBoardofNeuromusculoskeletalMedicine,theonlycertifyingboardformanualmedicineinthemedicalworldtoday.

• AnearnedfellowdesignationofFAAO,whichrecognizesDOsforpromotingOMMthroughteaching,writing,andprofessionalservice.

• Promotionofresearchontheefficacyofosteopathicmedicine.

• SupportforthefutureoftheprofessionthroughtheStudentAmericanAcademyofOsteopathyonosteopathicmedicalschoolcampuses,theNationalUndergraduateFellowsAssociation,andthePostgraduateAmericanAcademyofOsteopathy.

Ifyouhaveanyquestionsregardingmembershipormembershiprenewal,contactSusanLightleat(317)879-1881orslightle@academyofosteopathy.org.ThankyouforsupportingtheAmericanAcademyofOsteopathy.

TheAAOMembershipCommitteeinvitesyoutojointheAmericanAcademyofOsteopathyasa2014-2015member.TheAAOisyourprofessionalorganization.Itfostersthecoreprinciplesthatledyoutobecomeadoctorofosteopathicmedicine.

Forjust$5.27aweek(lessthanthepriceofalargespecialtycoffeeatyourfavoritecoffeeshop)orjust75centsaday(lessthanthecostofabottleofwater),youcanbecomeamemberoftheprofessionalspecialtyorganizationdedicatedtothecoreprinciplesofyourprofession.

Yourmembershipduesprovideyouwith:• Anationaladvocateforosteopathicmanipulativemedicine

(includingappropriatereimbursementforOMMservices)withosteopathicandallopathicprofessionals,publicpolicymakers,themediaandthepublic.

• Referralsofpatientsthroughthe“SearchforaPhysician”toolontheAAOwebsiteandfromcallstotheAAOoffice.

• DiscountsonqualityeducationalprogramsprovidedbyAAOatitsannualConvocationandweekendworkshops.

• Networkingopportunitieswithyourpeers.• DiscountsonpublicationsintheAAO’sonlinestore.• FreesubscriptiontoThe AAO Journal,published

electronicallyfourtimesannually.• FreesubscriptiontotheonlineAAO Member News.

For the last three years, WVSOM has been consistently recognized as A Great College to Work For by the Chronicle of Higher Education. The school's campus is located in Lewisburg, West Virginia a picturesque community nestled in the Appalachian Mountains. In addition to being named America's Coolest Small Town in 2011, Lewisburg has an array of eclectic restaurants, outdoor activities, antique shops, art galleries, a Carnegie Hall performing art center, and a live equity theater that is supported by varied local artists and benefactors. The community is also supported by a regional medical center and excellent educational opportunities for students of all ages. To get a glimpse of this charming community, please visit www.greenbrierwv.com

Responsibilities: OPP Department duties include training first- and second-year medical students in the classroom. Academic responsibilities may include preparing and delivering lectures, instruction in OPP labs, development of test questions and small group activities. Research is supported and encouraged but not required.

Benefits: Salary and faculty rank will be commensurate with experience and includes an excellent benefits package including medical malpractice insurance, educational loan reimburse-ment and relocation expenses.

Summary: WVSOM is seeking to fill a full-time tenure track faculty position in Osteopathic Prin-ciples & Practices (OPP) Medicine. The primary job of this faculty position is to provide education in osteopathic principles and practices and assist in providing OPP integration to all phases of the WVSOM pre and post doctoral curriculum. Research opportunities are available if desired. This position provides an opportunity for a clinical practice. Successful candidates must have a D.O. degree from an accredited college/school of osteopathic medicine and be residency trained and board certified or board eligible by AOBNMM (CSPOMM and/or NMM) or other osteopathic specialty board. The successful candidate must also be eligible for licensure in the state of West Virginia.

West Virginia School of Osteopathic Medicine Osteopathic Principles and Practices Faculty Position

www.wvsom.edu/employment

Interest candidates should contact Leslie Bicksler, Associate Vice President of Human Resources at 304.647.6279; 800.356.7836; or [email protected] WVSOM is an equal opportunity employer. Applications accepted until the position is filled.

mailto:[email protected]

The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 3

3500DePauwBoulevard,Suite1100Indianapolis,IN46268-1136

(317)879-1881•Fax:(317)879-0563www.academyofosteopathy.org

The AAO JournalKateMcCaffrey,DO . . . . . . . . . . . . . . . . . . . . . . . . . ScientificeditorKatherineA.Worden,DO,MS. . . . . . . . . . . . . . . . . AssociateeditorMichaelE.Fitzgerald. . . . . . . . . . . . . . . . . . . . . . . SupervisingeditorLaurenGood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Managingeditor

Editorial Advisory Board

American Academy of OsteopathyKennethJ.Lossing,DO . . . . . . . . . . . . . . . . . . . . . . . . . . . . PresidentDorisB.Newman,DO,FAAO . . . . . . . . . . . . . . . . . . President-electMichaelE.Fitzgerald. . . . . . . . . . . . . . . . . . . . . . .ExecutivedirectorSherriL.Quarles . . . . . . . . . . . . . . . . . . .Associateexecutivedirector

The AAO JournalistheofficialpublicationoftheAmericanAcademyofOsteopathy. Issuesarepublished inMarch, June,September, andDecembereachyear.

The AAO Journalisnotresponsibleforstatementsmadebyanycontributor.Althoughalladvertisingisexpectedtoconformtoethicalmedicalstandards,acceptancedoesnotimplyendorsementbythisjournalorbytheAmericanAcademyofOsteopathy.

OpinionsexpressedinThe AAO JournalarethoseoftheauthorsanddonotnecessarilyreflectviewpointsoftheeditorsorofficialpolicyoftheAmericanAcademyofOsteopathyortheinstitutionswithwhichtheauthorsareaffiliated,unlessspecified.

[email protected].

ONTHECOVER:©iStock.com/pop_jop

AdvertisingratesforTheAAO Journal, theofficialpublicationoftheAmericanAcademyofOsteopathy(AAO).AAOmembersandorganizationsaffiliatedwiththeAAOortheAmericanOsteopathicAssociationareentitledtoa20%discountonadvertisinginthisjournal.CalltheAAOat(317)879-1881formoreinformation.SubscriptionrateforAAOnonmembers:$60.00peryear.

2014 Advertising Rates

Placed1time Placed2times Placed4times

Fullpage7.5”x10” $600 $570 $540

Halfpage7.5”x5” $400 $380 $360

Thirdpage7.5”x3.3” $300 $285 $270

Quarterpage3.75”x5” $200 $190 $180

Classified $1.00per7characters

In ThIs Issue:AAOCalendarofEvents...............................................................4CMECertificationofHomeStudyForms..................................46ComponentSocietyCalendarofEvents......................................48

edITorIals:ViewFromthePyramids:TheGamificationofMedicalSchools..5

Kate McCaffrey, DOMillenials,CranialCourses,andtheDeathoftheSlideProjector.. 6

Janice U. Blumer, DO

Book revIews:At the Still Point of the Turning WorldbyRobertLever.................7

Hollis H. King, DO, PhD, FAAOWhy Does It Hurt?byToddCapistrant,DO,MHA,WithSteveLeBeau........................................................................8

Claire M. Galin, DO

orIgInal ConTrIBuTIons:TheBioenegeticModelinOsteopathicDiagnosisandTreatment:AnFAAOThesis,Part2...............................................................9

Jan T. Hendryx, DO, FAAOOsteopathicManipulativeTreatmentinVestibularNeuritis......27

Brendan S. Ross, DO, MS; Virginia M. Johnson, DO, C-NMM/OMM

HealthStatusComparisonofLebanon,Oregon,andLobitos,Peru:APilotStudyUsingaNovelInvestigativeStudyTool....... 31

Kathryn Kimes, OMS III; David Goldman, OMS III; Megan Aabo, OMS III; Dave Aabo, MS; Katherine Peters, OMS III; Katie Zeiner, MAg; Kate McCaffrey, DO; John T. Pham, DO; Robyn Dreibelbis, DO; John Mata, PhD

IntroducingMAAP:TheModifiedASIAExaminationfor AmbulatoryPatients..............................................................40

Drew D. Lewis, DO; Jose S. Figueroa, DO; Garth K. Summer, OMS II; J.D. Polk DO

DeniseK.Burns,DO,FAAOEricJ.Dolgin,DOClaireM.Galin,DOWilliamJ.Garrity,DOStephenI.Goldman,DO,FAAOStefanHagopian,DO,FAAORaymondJ.Hruby,DO,MS,

FAAO

BrianE.Kaufman,DOHollisH.King,DO,PhD,

FAAODavidC.Mason,DOKateMcCaffrey,DOHallieJ.Robbins,DOMarkE.Rosen,DOKatherineA.Worden,DO,MS

JThe AAO Forum for Osteopathic Thought

Official Publication of the American Academy of Osteopathy® TRADITION SHAPES THE FUTURE • VOLUME 24 • NUMBER 2 • JUNE 2014

The mission of the American Academy of Osteopathy is to teach, advocate, and research the science, art, and philosophy of osteopathic medicine, emphasizing the integration of osteopathic principles, practices, and manipulative treatment in patient care.

OURNAL

Continued on page 4

https://netforum.avectra.com/eweb/shopping/shopping.aspx?site=aao&webcode=shopping&shopsearch=nerman&prd_key=6ed08dfc-4a37-4dd1-8ae8-ecd75851e4d7



July 4 IndependenceDay—AAOofficeclosed

July 11 CommitteeonFellowshipteleconference,8:30p.m.Easterntime

July 12–13 AAOBoardofTrusteesmeeting—Indianapolis

July 18–19 “Ultrasound-Guided Injections”—Sajid A. Surve, DO—University of North Texas Health Science Center—Texas College of Osteopathic Medicine, Fort Worth

aBsTraCTs:NeuralProlotherapyCanResolveNeuralgia............................... 19

Eileen Conaway, DO; Brian Browning, DOManagementofLevatorAniSyndromeWithOsteopathicManipulativeTreatment:ACaseStudy......................................20

Miho Yoshida, DO, NMM+1; Dominic Derenge, OMS IV; Katherine Worden, DO, MS

ComparisonofPatientRecordsFromtheStill-HildrethSanitoriumWithPublishedReports........................................... 21

Leslie Ching, DO, OGME 4; Harriet Shaw, DOTraumaticGroinInjuryinaFootballPlayer:ACaseStudy........22

Daniel Tsukanov, DO; Dennis Dowling, DO, FAAO; Lyn Weiss, MD

TreatmentofCommonFibularNervePalsyWithOMM...........23Bradley M. Jahnke, OMS V; Puanani Hopson, OMS V; Katherine Worden, DO, MS

ApplicationofOMTinaPediatricPostoperativeIleusCase.......24Rebecca S. Domlski, OMS III; Laura Nimkoff, MD; Sheldon C. Yao, DO; Patricia Kooyman, DO

RoleofOsteopathicManipulativeMedicineintheTreatmentof Dacrystenosis.......................................................................... 25

Theresa E. Apoznanski, OMS III; Reem Abu-Sbaib, DO; Sheldon C. Yao, DO

IsThereaPlaceforOsteopathyinParkinsonDiseaseManagement?ARetrospectiveCaseControlStudy....................26

Michael P. Catanzaro, OMS III; Kathleen M. Vazzana, OMS IV; Annie Chen, OMS II; Jayme Mancini, DO, PhD; Sheldon C. Yao, DO

AAO Calendar of Events

Mark your calendar for these upcoming Academy meetings and educational courses.

2014

Aug. 6 Birthday of Andrew Taylor Still, MD, DO

Aug. 8–9 AAO Education Committee meeting—Indianapolis

Aug. 8–9 SAAO Council meeting—Indianapolis

Table of Contents (Continued from page 3)


View From the Pyramids

@Follow the American Academy of Osteopathy online.

www.facebook.com/American.Academy.Osteopathy

@AmAcadOsteo

Playinggamesatschool?Youbet!

Luminosityisanexampleofagameinterfacewithwhichyoumayalreadybefamiliar.Afewofthemorepopularmedicalgamesarewww.prognosisapp.com,www.scrubwars.comandwww.picmonic.com.Theseappsarewidelyusedbymedicaltrainees.1

Severalstudiesnowsupportthevideogamemodelasaneffectivetoolforstudyingmedicine.Awisementortoldme,“Ifwewanttoeffectivelyteachthemillennialgeneration,thenweneedtoplayintheirsandbox.”Andweneedtofindoutwhattheyareusingtobuildsandcastles.Stayingculturallysensitiveisanotherreasontoexplorethecrossoverofusingtheir“toys”inmedicaleducationandtraining.Thedefinitionofcultureisto“maintain…conditionsforgrowth.”2Culturecanalsobedefinedas“thebeliefs,customs,arts,etc.,ofaparticularsociety,group,placeortime,”2andthemillennialgenerationfitsthisdefinitionofagroupintimewithaparticularsetofbeliefsandcustoms.Asmedicaleducators,wewillwanttogetoutourpassportsandexplorethisforeigncultureandlearnitscustomsifwewanttomakeasignificantimpactonthenextgenerationofosteopathicphysicians.Theywillbecaringforus,afterall.

Sohowdoesgamingworktoenhancelearning?Gamingincreasescomprehensionandkeepsalearner’sinterestusingamultilayeredapproach.Morrisetal,proposethatgamingusesmotivational scaffoldingsuchasfeedback,rewards,andflowstatestokeeplearnersengaged.3Aflow stateisaheightenedstateoffocusandengagementcoupledwithlowanxiety.Alsousediscognitive scaffolding,suchassimulationsandreasoningskills.Gamingmayalsochangeattitudestowardfailure.Inagame,errorsareexperiencedasconstructivefeedbackinsteadoffailure.Thissmallchangemayaltertheanxietythatfailureproduces,especiallyinmedicalschoolwherethethreatoffailingcanbeemotionallydevastating.Failurein

The Gamification of Medical SchoolKate McCaffrey, DO

medicalschoolcansometimesmeangivingup,whereasfailureinvideogamestranslatesintopersistence.

Ifyoutakestudentsorresidentsforclerkshipsorifyouteachthematthemedicalschoollevel,keepanopenmindtointegratingcreativewaysofteachinglikegamingandquizzes.Iamallforpreservingourtrainees’self-esteemandproducingintacthealerswhentheyfinallygetthroughtheirgruelingmedicaltraining.

References1. StevensonV.Thegamificationofmedicaltraining.2013;

KevinMD.com; http://www.kevinmd.com/blog/2013/12/gamification-medical-training.html. AccessedMay10,2014.

2. Culture; Merriam Webster Online; http://www.merriam-webster.com/dictionary/culture.AccessedMay10,2014.

3. MorrisBJ,CrokerS,ZimmermanC,GillD,RomigC.Gamingscience:the“Gamification”ofscientificthinking.Frontiers in Psychology.2013;4:607.



http://www.prognosisapp.com

http://www.scrubwars.com

http://www.scrubwars.com

http://www.picmonic.com

KevinMD.com

http://www.kevinmd.com/blog/2013/12/gamification-medical-training.html.

http://www.kevinmd.com/blog/2013/12/gamification-medical-training.html.

http://www.merriam-webster.com/dictionary/culture

http://www.merriam-webster.com/dictionary/culture


Photos courtesy of Louisville Convention & Visitors Bureau

Make plans now to join us for the 2015 AAO Convocation.

Louisville, Kentucky March 11-15, 2015

“Life in Motion”

Forthefirsttime,incomingosteopathicmedicalstudents,membersofthemillennialgeneration,havehadcomputertechnologyandInternetaccessfortheirentirelives.Thishaschangedthewaythiscohortlearnsandinteractswithmaterial.Labeledthe“me,me,megeneration”byTimemagazine,theyhavebeentoldtheyarespecial,andtheyhavebeengivenawardsjustforshowingup.Theyexpectasmuchintraining.Thesearemultideviceusers,andtheyarenotwithoutonetothreedevicesinhand,ofteninteractingindifferentwaysoneachdeviceorseemingly“multitasking.”

Sohowisthischangingthewayweteachosteopathiccranialmanipulativemedicine?Howdoweinteractwiththisgeneration’s“edutainment”needstomaketeachingcranial“sexy”?Howdoweslowdownthesefast-pacedstudentsenoughsotheyareabletofeelthecranialrhythmicimpulseandsotheyactuallytakethetimetolearnthepalpationinvolvedincranial?Theansweriswedon’t.

Forgenerations,osteopathiccranialmanipulativemedicinehasbeentaughtintheexactsameway:attablesidewithinterspersedlectures,usuallyinvolvingaslideprojector.Thismodel,thoughitworkedforthepreviousgenerations,ischallengingtheteachersofosteopathyinthecranialfieldwho

interactwiththisgenerationofstudents.Today’sstudentsstrugglewithslowingdownenoughtofeelthesubtlerhythmsandstrainpatterns.TheyareskepticalandgototheInternettovalidateideasbeforethelectureisdone.Intheblinkofaneyeorflashofthekeyboard,theyarealreadydismissingtheentireconceptbeforeevenachancetodefenditarises.

OfcourseIamnotinthetypicalcranialcourse,asIamanassistantprofessorinoneofthefewmedicalschoolsthatstilloffersa40-hourcoursetostudents.Mystudentscometopassthecourseandtheirnationalboards,notnecessarilybecausetheyembracetheidea.Still,Iwonderwhetherwearelosingsomebecausewemissedthememothatwhatworkedbeforeisn’tworkingwiththisgeneration.

Isittimeto“flip”thecranialcourse,ditchtheslideprojector,andmeetthetechnologygenerationsomewhereinthemiddle?Somewouldsaytechnologyitselfisahindrancetoteachingcranial,buthowdoweknowunlesswetestit?Idon’thavetheanswerstothesequestions,butIcansay,ifthesecoursesdon’tevolveinsomeway,wewilllosethisgenerationinthe“lackoftechnology”void.

Millennials, Cranial Courses, and the Death of the Slide ProjectorJanice U. Blumer, DO


Book Review—At the Still Point of the Turning World: The Art and Philosophy of Osteopathy by Robert Lever© 2013 Handspring Publishing

Hollis H. King, DO, PhD, FAAO

Nomatterwhereyouareintheworld,ifyouareanosteopathicphysician,anosteopath,apatientofoneoftheforegoing,orafacultymemberatanosteopathictraininginstitution,thephilosophyofosteopathyhasconfrontedyouatsomepoint.Forthoseinvolvedintheprofessionsofosteopathicmedicineandosteopathy,RobertLever’sbookAt the Still Point of the Turning World ismosthelpfulinrefininganddevelopingyourthoughtsaboutosteopathicphilosophy.Asonewhohastakenacrackatwritingaboutosteopathicphilosophy,Iamimpressedwithhowwelltheauthorexpressescomplexideas,andIfoundmyselflookingatideasfromnewangles.Readerswillberewardedwithanenricheddatabaseandperspectiveonosteopathicphilosophy.

Intheforeword,R.PaulLee,DO,FAAO,FCA,observesthatLeverwritesfroma“Britishperspective,”butIfoundthatLever’sisatrulyuniversalosteopathicperspective.Regardlessofthedegreeorinitialsfollowingone’snameoronwhichsideoftheAtlanticOceanoneresides,thisbookprovidesacriticalcontributiontoosteopathicphilosophyandtotheunderstandingofthecranialconceptinosteopathicmedicine.Itisnotafastread,astheintegrationofrelevantphilosophicalideasfromquantumphysicstothefivephenomenaofW. G. Sutherland’sprimaryrespiratorymechanismareplacedalongsideandmeldedintoeachother.

Juicyandthought-provokingdiscussionsdevelopthroughoutthebook.Oneofmyfavoritesisinthechaptertitled“Reciprocity,Relationship,Spaces.”Leverstates:

“…theconceptofinterconnectedness,orreciprocityoffunction,isnotanathematoconventionalmedicaltheorists.Itissimplythatsooften,thetherapeuticapproachthatisimplementedisextremelytargetedandlinear,andinthissense,thebodyisnotalwaystreatedwithrespecttoitsunity.”

Leverholdsthatosteopathy—andImaintain,osteopathicmedicine—contributesthenecessaryprofessionalservicetoimprovehealthcareinanycontextandshouldbeallowed,evenencouraged,tobetaughtwidelyinallvenuesorprofessionsthatpurporttotreatthehumancondition.

ThisreviewerrecommendsAt the Still Point of the Turning Worldtoanyphysicianorotherhealthcareprofessionalanywhereintheworld,especiallyifthatprofessionaluseshisorherhandstodeliverhealthcare.ForthediscerningAmericanAcademyofOsteopathymemberorsubscriberwhoalreadymaybeconversantwithinternationalosteopathicpublications,thisbookalreadymaybeinhisorherlibrary.


Sutherland Cranial Teaching FoundationUpcoming Courses

SCTF Basic Course:Osteopathy in the Cranial FieldJune 6–10, 2014Portland, OregonCourse Director: Dr. Duncan Soule40 hrs 1A CME anticipated

At The Double Tree Hotel at the Lloyd Center1000 NE MultnomahPortland, Oregon

direct link from the airport to the hotel via the Max Light Rail Line

2 restaurants and a fitness center available

Visit our website for enrollment forms and course details: www.sctf.com Contact: Joy Cunningham 509-758-8090Email: [email protected]

For more information on osteopathic

terminology used in The American

Academy of Osteopathy Journal, see the

Glossary of Osteopathic

Terminology

by the American Association of Colleges

of Osteopathic Medicine’s Education

Council on Osteopathic Medicine.

ToddCapistrant,DO,MHA,withthehelpofSteveLeBeauhaswrittenWhy Does It Hurt? The Fascial Distortion Model: A New Paradigm for Pain Relief and Restored Movement.Thisbookisspecificallywrittenforlaypeopleexperiencingpain.Itiseasytoreadandwellillustrated,anditiswellbalancedbetweenbeingjustscientificenoughtoexplainthefascialdistortionmodelyetnotsoscientifictobeconfusingtopeopleoutsidethemedicalprofession.Thestoriestoldandtheexplanationsgivenbecomeacompellinginvitationtoapersonsufferingpaintoseekouttreatmentinthismodel.AnditisalwaysusefultogetmaterialintothehandsofthepublicthatleadspeopletoseekoutDOswhodoosteopathicmanipulativemedicineinanyform.

However,Why Does It Hurt? hassomeobviousflaws.Multipleclaimsaremadewithnosupportingdata:Alloftheevidenceispurelyanecdotal.Therearesomeconfusingpointsmade

abouttheosteopathicmedicalprofession,includingthatitdoesnotofferanythingbutconventionalmedicineforapatientwithtenniselbow(page24)andabriefhistoryoftheprofessionthattendstowardmythology.Dr Capistrantalsomakesunsubstantiatedcommentssuchasintheoldmodelofmedicine,thedoctordidallthetalking(page41).

Icanrecommendthisbookformembersofthepublicwhoareseekinginformationontreatmentofpain,butIhopethatinhisnextedition,DrCapistrantwillsupporthisclaimswithdataand,therefore,showthetruevalueofthefascialdistortionmodel.

Book Review—Why Does It Hurt? by Todd Capistrant, DO, MHA, With Steve LeBeauCopyright © 2014 Beaver’s Pond Press

Claire M. Galin, DO

http://www.aacom.org/resources/bookstore/Documents/GOT2011ed.pdf

http://www.aacom.org/resources/bookstore/Documents/GOT2011ed.pdf

http://www.aacom.org/Pages/default.aspx

http://www.aacom.org/Pages/default.aspx


Course DirectorSajid A. Surve, DO, is a 2005 graduate of what is now the Rowan University School of Osteopathic Medicine (RowanSOM) in Stratford, NJ. After completing a traditional rotating internship at Delaware County Memorial Hospital in Drexel Hill, Pa., he became an inaugural resident and the fi rst chief resident of the physical medicine and rehabilitation residency at Long Beach (New York) Medical Center. He joined the faculty of RowanSOM in 2009 and completed a neuromuscular medicine and osteopathic manipulative medicine residency in 2010.

Course LocationUniversity of North Texas Health Science Center—Texas College of Osteopathic Medicine3500 Camp Bowie Blvd.Fort Worth, TX 76107

Course TimesFriday and Saturday: 8 am - 5:30 pmBreakfast and lunch provided. Please contact the AAO’s Sherrie Warner with special dietary needs: (317) 879-1881 or [email protected].

Travel ArrangementsContact Tina Callahan of Globally Yours Travel at (800) 274-5975 or [email protected].

Course DescriptionThis course is designed for physicians who are novices at sonographic guidance for injections. Under the direction of physiatrist Sajid A. Surve, DO, course participants will be introduced to the basic principles of ultrasound, they will learn proper injection techniques with ultrasound guidance, and they will learn proper billing and coding for ultrasound injections. Cadavers will be available for practice, and table trainers will ensure a low faculty-to-participant ratio. The course will focus on the injection of the major joints: glenohumeral, sacroiliac, hip and knee.

Course Objectives Upon completing this course, participants will be able to:• apply the basic principles of musculoskeletal ultrasound;• comfortably navigate the necessary equipment required

for sonographic guidance of injections;• use proper injection techniques under sonographic

guidance for the glenohumeral, sacroiliac, hip and knee joints;

• bill, code and document correctly for ultrasound-guided injections; and

• avoid common pitfalls associated with ultrasound injections.

CME16 credits of AOA Category 1-A continuing medical education is anticipated.

Ultrasound-Guided InjectionsJuly 18–19, 2014 • University of North Texas Health Science Center—

Texas College of Osteopathic Medicine in Fort Worth

Registration Form

Ultrasound-Guided InjectionsJuly 18–19, 2014

Name: AOA No.:

Nickname for badge:

Street address:

City: State: ZIP:

Phone: Fax:

Email:

By releasing your fax number or email address, you have given the AAO permission to send marketing information regarding courses to your fax or email.Click here to view the AAO’s cancellation and refund policy.Click here to view the AAO’s photo release statement.

Registration Rates

On or before June 18 After June 18

AAO member $ 1,500 $ 1,600

AAO nonmember $ 1,600 $ 1,700

The AAO accepts check, VISA, MasterCard or Discover payments in U.S. dollars

Credit card No.:

Cardholder’s name:

Expiration date: 3-digit CVV No.:

Billing address (if diff erent):

I hereby authorize the American Academy of Osteopathy® to charge the above credit card for the full course registration amount.

Signature:

Register online at www.academyofosteopathy.org, or submit the registration form and payment by email to [email protected], by mail to the American Academy of Osteopathy,®

3500 DePauw Blvd., Suite 1100, Indianapolis, IN 46268-1136, or by fax to (317) 879-0563.


O’Connell82hasdescribedfascialarchitectureofthebodyasconsistingoftwofunctionalsubdivisions.Horizontal diaphragmsaremyofascialorfibrouspartitionsthatactastension-countertensionsheets.Theyincludethetentoriumcerebelli,thoracicinlet/outlet,respiratorydiaphragm,pelvicdiaphragmandplantarfascia. Longitudinal cablesrunsuperiortoinferiorinthebodyandincludevariousmuscles(psoasmajor,abdominals,quadratuslumborum),spinalduraandlongitudinalligaments(occiputtoS2),fascia(prevertebral,alar,buccopharyneal,pericardial,investingoflowerextremity)andorgans(trachea,esophagus).

TheECMhasbeenreferredtoaspartofthe“livingmatrix”byOschman.58,60Hecallsit“living”becauseitismuchmorethanapassivenetworkoffibersandgroundsubstanceholdingthebodyanditsorganstogether.TheECMisdynamicallyactiveandconnectstothemostintimatereachesofcellsthroughthecellsurface,cytoskeleton,andnuclearmatrix.Thedynamicnatureofthelivingmatrixcanbepalpatedasrhythmicinherentmotionthatcanbeinfluencedbyvariousformsofosteopathicmanipulationandbioenergeticfields.Inherent motionisdefinedasthe“spontaneousmotionofeverycell,organ,systemandtheircomponentunitswithinthebody.”67

Leehaselegantlysynthesizedinformationfromnumeroussourcestodescribepossibleoriginsoftheoscillatoryanimationofthislifeforceinthefascia,ie,the primary respiratory mechanism(PRM).52,83FirstdescribedbySutherland,thesource,or“initiativespark,”ofthePRMwaswhathetermedthe“BreathofLife.”84Hereferredtothefluidfluctuationoftheinherentmotionpalpatedinthetissuesasthe“Tide.”85RecentscientificresearchsuggeststhatthesourceoftheinherentmotionofthecranialrhythmicimpulsemaybeduetoorrelatedtotheTraube-Heringbaroreflex.86,87

Throughthebiophysicalprinciplesoftensegrityandpiezoelectricity,fasciainfluencescellphysiologyandpathophysiology.ItprovidesforinstantaneousholographicaccessandcommunicationoutsidethenervoussystemthatextendsallthewaydowntothelevelofthecellnucleusandDNA.Itservesasalargesourceofthebioenergeticfieldsthattraversethroughandextendoutsidethebody.60

Fascia and the Extracellular Matrix

AndrewTaylorStill,MD,DO,placedmuchemphasisonthefasciaanditsrelationshiptohealth.Hewrote,“Iknowofnootherpartofthebodythatequalsthefasciaasahuntingground[sicforhealthanddisease].…Byitsactionwelive,andbyitsfailure,wedie.”75

Anatomically,fasciaisdefinedasasheetoffibroustissuethatenvelopsthebodybeneaththeskinthatenclosesthemusclesandgroupsofmusclesseparatingthemintoseverallayers.76Willardetal77,78haveclassifiedtheubiquitousfasciaintofourbasicdivisions:pannicular(superficial,subcutaneous);investing(deep,axial,appendicular);visceral(pleural,pericardial,peritoneal);andmeningeal(dural).Investingfascianotonlycoversthesurfaceofskeletalmusclesbutalsobranchesdeeplyintothemuscleinteriorinwhichcaseitistermedmyofascia.

Dependingonthetypeandlocationoffascia,onefindsvariousstructures(vascular,lymphatic,neurological)traversingthroughit,aswellasacellularandcellularcomponents.Fasciaiscomposedofthreebasicfibertypes—collagen,elastic,andreticular—immersedinaseaofcolloidalproteinaminoglycans.Itisthisacellularfiber-colloidpartofthefasciathatisreferredtoastheextracellular matrix,orECM.58

Cellularfascialcomponentsincludevariousleukocytes,plasmacells,mastcells,macrophages,pluripotentialcells,fibroblastsandmyofibroblasts.Interestingly,myofibroblastscontainactinandmyosinfilamentsandcanprovideacontractileforcetofascia.79Myofibroblastcontractionwithinthefasciahasbeentheorizedtobecontributorytotissuestiffness.80,81

Fasciaperformsnumerousfunctionsinthebody,includingstructuralsupport,compartmentalization,nutritionalsupport,immunity,tissuerepairandcommunication.79Asweshallseelater,theextracellularmatrixcanmodulatecellfunctionandpathophysiology.60

The Bioenergetic Model in Osteopathic Diagnosis and Treatment: An FAAO Thesis, Part 2Jan T. Hendryx, DO, FAAO

Click here to read Part 1 of “The Bioenergetic Model in Osteopathic Diagnosis and Treatment,” published in the March 2014 issue of The AAO Journal. Part 2 concludes Dr Hendryx’s thesis.

Continued on page 11

http://files.academyofosteopathy.org/AAOJ/2014/AAOJ_March2014pp12-20.pdf


CollagenfibersintheECMattachdirectlytothecellularcytoskeletonthroughspecializedproteinsinthecellmembranecalledintegrinsandcadherins.Thesemoleculestransmitmechanicalforcesfromthefasciatoassociatedfocaladhesions,junctionalcomplexes,andultimatelythecytoskeletonintheinteriorofthecellbyaprocessknownasmechanotransduction.88,89Mechanotransductioncontrolsmanycellularprocesses,includingcelldivision,differentiation,migration,proteinsynthesis,DNAandgeneexpression,immunefunction,andevenpathologicalprocesses.90-93

TensegrityisatermcoinedbyR.BuckminsterFullerfromthewordstensional andintegritytodescribestructuremaintainedbyforcestransmittedthroughasystemofinterconnectedsolidstrutsandflexiblecables.Aclassicexampleofatensegritysystemisgeodesicdomearchitecture.89Thus,biotensegrityreferstoefficientmaintenanceofthestructuralintegrityofwholelivingsystemsorevencells.Inthehumanbeing,physicalforcesaredistributedthroughthestrut(bones)andcable(muscles,tendons,ligaments,fascia)componentsoftheneuromusculoskeletalsystem.Similarly,inthecell,thecytoskeletalcomponents(microtubules,microfilaments,microfibrils)providethestructuralsupportinboththecytoplasmandnucleus.

OneofthepioneeringresearchersinthefieldsofmechanotransductionandbiotensegrityisDonaldIngber,MD,PhD.Hehaswrittenandco-writtennumerousarticlesonthesesubjects.Fromanosteopathicperspective,Ingberhasappliedtheseprinciplesinexplaininghowvariousformsofmanualtherapiesmayinfluencestructureandfunctiondowntothecellularlevel.89-91Recently,Swanson94publishedanexcellent,thoroughreviewofbiotensegrityandmechanotransductionandtheirrelevancetoosteopathicmedicine,education,andresearch.

Communicationinthebodyoccursthroughtwomainbioelectricsystems—neurologicalandnon-neurological.Neurologicalcommunicationthroughoutthecentral,peripheralandautonomicnervoussystemsandneuromuscularcomponentshappensbecauseofthephysiologicalprocessesresultinginioniccurrents.Ioniccurrentsareproducedbyionicmovementthroughmembranesandresultantpolarityreversalthatispropagatedalongthelengthofnerves.Dependingontheextentofmyelinationofnervefibers,ioniccurrentshavevaryingconductionspeeds,andthus,thistypeofcommunicationhappensovervaryingamountsoftime.58

Non-neurologicalcommunicationoccursthroughoutthefascia.Becauseoftheirpiezoelectricnature,collagenfibersandgroundsubstancefunctiontocreateinstantaneouscommunicationoutsideofthatprovidedbythenervoussystem.Thus,electricalcurrentscanalsobecarriedalltheway

totheintracellularlevel.58Thisisaccomplishedbybioelectricsemiconductorcurrents.Semiconductorcurrentsdifferfromioniccurrentsofnervesandneuromuscularjunctionsinthattheytravelinfasciaandtheperineuriumsurroundingnervefibers.58

Themovementofelectricityalongaconductororsemiconductor(nerves,fascia)producesbioelectromagneticfieldsthatcanbedetectedwithsensitiveinstrumentationorbycertainsensoryreceptorsintheskin.Thesefieldsextendintoandoutsidethebodyindefinitely.Theymaybeinfluencedbyexternalelectromagneticfields.58,60Acompletediscussionofthetheoreticalrelationshipbetweenbioenergeticsandsomaticdysfunctioncanbefoundelsewhere.54

O’Connellhasgivenathoroughreviewofthebiomechanicsandbiophysicalpropertiesofthemyofasciainrelationtodiagnosticpalpation,myofascialrelease(MFR)techniqueandbioelectricfascialactivationandrelease.BothO’Connell49,61

andOschman60havetheorizedabioenergetic-holographicmodelforthehumanmyofascialsystembasedonthesebiophysicalproperties.Inthismodel,onecanaccessanypartofthelivingsystemfromanylocationbylightlypalpatingandapplyinggentleforcesthroughtheelaboratefascialnetworkofhorizontaldiaphragmsandlongitudinalcablesandtubes.Hollandalsohasdescribedasystemofdiagnosiscalledperceptual transferenceinwhichtheexaminerholographicallysensesinhisorherbodytheareaofkeysomaticorvisceraldysfunctioninapatient’sbodywhilegentlycontactingthepatient.74

Comparison of Dynamic Strain-Vector Release and Neurofascial Release

Twoosteopathicmanipulativetreatment(OMT)techniqueswillbediscussedtoshowhowthebioenergeticmodelmaybeusedtodiagnoseandtreatpatients.Thesearedynamicstrain-vectorrelease(SVR)andneurofascialrelease(NFR).Experientially,thisauthorhasfoundthesetechniquesextremelyeffectiveintreatingpatients,whetherthesetechniquesareusedaloneorinconjunctionwithothermanipulativemodalities.Often,SVRandNFRhavebeenintegralinenhancingtherapeuticeffectswhentraditionalbiomechanicaltechniquesarelimited.

Dynamic Strain-Vector Release

Dynamicstrain-vectorreleaseisabioenergetictechniquedevelopedbythisauthorin1999-2000.54Itsprinciplesarosefrompalpatoryexperimentationwithinherenttissuemotionsandacupuncturepointsinapatientwithchronicrefractorypain.Itwasobservedthattissuesomaticdysfunctionspossessabnormalinherentmotionsthatcanbenormalizedwithoutapplyinganydirectorindirectmechanicalforces

Continued from page 10



hand.Strain-vectorreleasepointsarelocatedbymovingthenonpalpatinghandinthedirectionofthetissuepullofthepathologicalstrain-vector.Tissueunderthepalpatinghandtightensupandreachesmaximaltensionwhenthenonpalpatinghandfindstheexactlocationofthereleasepoint.Allinherentmotionstopsbriefly(stillpoint)andrestartswhenthetissuereleases.If,afterre-evaluation,somepathologicalvectorsremain,thetechniqueisrepeateduntilnormalinherenttissuemotionisrestored.

SVRiseffectiveintreatingpatientsforacute,subacute,andchronicsomatic,visceral,neurological,andenergeticconditions,someofwhichmaynotberesponsivetootherclassicformsofOMT.Apparently,alltissuescanhavepathologicalstrain-vectorswithin.

Neurofascial Release

Neurofascial release43isabioenergetictechniquedevelopedin1987byStephenM.Davidson,DO.WithNFR,thephysicianassessesdysfunctionaltissuesforabnormaltexture,tone,rangeofmotion(fascial),andinherentmotionrestrictionsandtreatsthesebytouchingandholdinganeurofascialreleasepointlocatedonthebodyuntiltissuetextureormotionnormalizes.Neurofascialreleaseisbasedonamodelofstandingwaveformsandinterferencevibratorypatternsproduced,orheldintissues.Thesepatternsarethoughttoberesponsibleforsomaticand

tothetissues.Dynamicstrain-vectorreleaseisdirectedtowardassessingdysfunctionaltissuesforaninherentmotionabnormalityknownasadynamic strainorpathological strain-vectorandthentreatingtheabnormalitybytouchingandholdingastrain-vectorreleasepointlocatedon,inside,oroffthebodyinthebiofield.Resolutionofthepathologicalstrain-vectorresultsinresolutionofthetissuedysfunctionandre-establishmentofnormalinherenttissuemotion.

Normalinherenttissuemotionisasubtlerhythmicoscillationoccurringatafrequencyofapproximately8to14cyclesperminute.Aslightpause,or“neutralzone,”occursatthemidpointofeachbackandforthmotion,somewhatsimilartothecranialrhythmicimpulse.

Adynamic strainisdefinedas“apalpabledistortionofmotioninthetissueand/orhumanenergyfieldthatpulls‘pathologically’alongacertaindirectionwithacertainforce(vector),whilecontinuingtomovewithinherenttissuemotion.”54Thisabnormalmotionisastrongtissuepullinaspecificdirection,anditlackstheneutralzonefoundinnormalinherentmotion.

TheefficacyoftheSVRtechniquereliesonthephysician’sabilitytolayerpalpatetothelevelofthedysfunctionaltissue,assesssubtleinherenttissuemotionforpathologicaldynamicstrain-vectorslocatedinareasofdysfunction,andfindandtreatastrain-vectorreleasepointwiththenonpalpating

Honing treatment into three basic steps, this pioneering book illuminates the underlying and often mysterious causes of pain and dysfunction and charts a path to recovery.

Many suffer from terrible headaches, insomnia, weight gain, sexual dysfunction, neck and back pain, immune disorders, cognitive problems, and many other conditions. Now, with Healing Pain and Injury, Dr Nerman helps those who are suffering needlessly, letting them know that there is hope by providing critical tools for their healing.

383 pages, paperback, ISBN 978-0-9859399-0-8 AAO member: $22.46AAO nonmember: $24.95

Shipping not included in price.

Place your order on the AAO’s online store at www.academyofosteopathy.org.

Now AvailableHealing Pain and Injury

Maud Nerman, DO, CSPOMM, CA



www.academyofosteopathy.org


visceraldysfunctions.NFRisapplicabletofascial,dural,intraosseous,andvisceralstrainpatterns;painfultissue;there-establishmentofcraniosacralrhythm;andinherenttissuemotion,aswellasmental,emotional,andtoxicthemes.43,95-97

Thebiotensegrityofthefascialsystemisthemainfocus,andthepatientisexaminedandtreatedfromanintegratedwholepersonperspective.Globalandlocalfascialrestrictionsorlaxity,aswellasinherentfascialmotion,areevaluatedinanefforttofindkeydysfunctions(“keylesions”).

Neurofascialreleasepointsarethenlocatedthat1)helptonormalizeabnormaltissuetoneandreleaserestrictionsand2)restoreinherenttissuemotion.IntheNFRmodel,thereleasepointishypothesizedtoshutdownthefascialwavegeneratorthatiscreatingabnormalfascialtensionpatternsandrelatedsomaticandvisceraldysfunctions.

Fascialrestrictionsaretreatedbyfindingarelatedneurofascialreleasepointonthebodyandholdingituntilthetissuetensionnormalizes.Thisprocesscanbefacilitatedbycreatingaslightstraininthefascialrestrictivebarrier,windingupthetensionthroughoutthefasciainthebody,andmaintainingthetensionuntilthetissuereleases(ie,“recruitingthestrain”).Fortissueexhibitingabnormaltightnessorspasm,touchinganeurofascialreleasepointwillcausethetissuetorelax.Conversely,inlaxtissues,apointcanbefoundandtouchedthatactuallyincreasestone.

Thelocationsofneurofascialreleasepointscanvaryfrompatienttopatientandtreatmentsessiontotreatmentsession.Somereleasepoints,however,havebeenfoundconsistentlyinthesamelocationsamongpatients.ManyofthesecorrespondtoacupuncturepointsandlocationsthatwereusedbyFulfordintreatingpatientswiththepercussorhammer.32

Discussion

Energy,mass,andmatterareinextricablylinkedtogetherbythefamousEinsteinequationE=mc2.98Energeticexchangesandtransformationsoccuratalllevelsintheuniverseandare,thus,anintegralpartofthestructuresandfunctionsfoundinlivingsystems.60Energyexchangesalsooccurininteractionsamonglivingsystems,suchasbetweenaphysicianandpatient.58

TwoOMTtechniques,dynamicstrain-vectorreleaseandneurofascialrelease,werepresented,bothofwhichappeartoprimarilyadheretoabioenergeticdiagnosticandtreatmentmodel.Comparisonofthesetechniquesrevealssomesimilaritiesanddifferences.

InbothSVRandNFR,thepatient’stissuesareassessedforinherentmotionabnormalities.InSVR,theexaminerisfocusedonfindingapathologicalstrain-vectorindysfunctionaltissuethathasaspecificforceanddirectionofpull.54Thedirectionoftissuepullleadstheexaminer

towardthepathologicalstrain-vector“releasepoint,”whichispalpatedandheldthroughastillpointwiththenonpalpatinghand.Tissuedysfunctionresolvesandnormalinherentmotionreturnsoncethepathologicalstrain-vectororlayeredvectorsdisappear.

Dysfunctionaltissuesunderthepalpatinghandtightenwhiletheexaminermovesthenonpalpatinghandtowardtheexactlocationofthestrain-vectorreleasepoint,whichmaybelocatedon,inside,oroffthebodyinthebiofield.

InNFR,thereleasepointsaretypicallylocatedonthesurfaceofthebodyinmostlynonpredictablelocations.Inherenttissuemotion(cranialrhythmicimpulse,primaryrespiratorymechanism,visceral)isassessedprimarilyforitspresenceorabsence,althoughqualityisalsoimportant.Ifinherentmotionisabsent,itmayberestoredbytouchingareleasepoint.Iftissueistootight,suchastypicallyfoundinasomaticorvisceraldysfunction,palpationofareleasepointallowstheabnormaltissuetoloosen.Iftissueistooloose,releasepointpalpationmayactuallyallowtheloosetissuetotighten.Nopathologicalstrain-vectorsshouldbepalpatedwiththistechnique.

NFRalsocanbeusedtoreleaselargerareafascialstrainsthroughoutthebody.Inthiscase,theexaminerpassivelymovesaregionofthebodyintotherestrictivebarrierofthestrainirrespectiveofinherentmotionqualities.TheNFRreleasepointishelduntilthebodyregionmovesthroughthebarrier.

Whatisthenatureandcauseofinherenttissuemotions?Whatisthenatureofthereleasepointineachtechnique,andhowdoespalpatingandholdingitalterinherentmotionabnormalitieswithoutapplyinganymechanicalforcestothetissues?

Theoriesontheoriginandnatureofinherenttissuemotionandstillpointshavebeenpreviouslydiscussedindetail.54Inherentmotionmayoriginatefrombiodynamic(physiological)andbiokinetic(pathophysiological)energies,41yin-yangpolaritiesandqimovementsinthetissues,coaxialenergeticcorecoherentwavepropagation,99subtleenergies,65andtheTraube-Heringbaroreflex.87

Lee100hasdiscussedthecentralroleofwaterinhomeostasisandtheinterfacebetweenspiritandthelivingmaterialbodyofthehumanbeing.HesuggeststhattheoscillationspalpatedasinherenttissuemotionmaybeduetosinusoidalwavesofchangeincalciumconcentrationswithintheECM,withaccompanyingflowofwater,changesinelectricalcharges,andtissueviscosity.

Whatisthenatureofstrain-vectorandneurofascialreleasepoints?Itmaybethattheyareholographicbiofieldswitchesthatturnonorturnoffbioelectriccircuitsandinfluence




inherentbioelectromagneticactivity.Somecorrespondwithacupuncturepointsandmaybeconnectedtomeridiansystems.60

Interactionsofbioelectromagneticfieldswithfasciacouldexplaintheinstantaneousresponseofthebodytotouchingspecificreleasepointsorpalpatingtheenergyfieldoffthebody.60Tosomeextent,fascialtensionisduetosol-gelconversion.Electromagneticfieldscanaffectsol-gelconversion.Semiconductorcurrentsinducedinthefasciabydirectpassivecontact,stretching,acupunctureneedles,orinteractionwiththebiofieldmayexplainthepalpatoryphenomenaexperiencedbyboththephysicianandthepatient.54

Davidsonhassuggestedthatabnormalstandingwaveformsinthefasciaalongwithinterferencepatternsmayberesponsibleforfascialdysfunctionandtheresponseoftissuestotouchingneurofascialreleasepoints.96Oschmandiscussesholographicinterferencepatternsrelatingtowavefrontdisturbanceswithinthelivingmatrixanditsimplicationsforpotentialtherapies.60TheseconceptsarealsosupportedbydynamicalmedicineprinciplesaspresentedbyHolland.71Thus,therearemanyplausiblescientificexplanationsforwhatenergeticphenomenaarebehindpalpatoryfindingsofdysfunctionandnormaltissues,inherentmotions,andthetherapeuticresponseofthepatienttothephysician’stouch.Thescientificdisciplinecentraltotheexplorationofthesetopicsisbiophysics.

Asfarbackasthelate1930s,CarlPhilipMcConnell,DO,discussedhowimportantitwasforosteopathicphysicianstorecognizethekeyroleofbiophysicsinunderstandinganatomy,physiology,health,anddisease.55Inanarticletitled“TheOsteopathicApproach,”101hechallengedtheosteopathicmedicalprofessiontostretchbeyondprecedenceanddogmatolearnaboutandapplybiophysicalprinciplessothatourtreatmentswouldtrulybecomeindividualized,comprehensive,andmaximallyeffective.Ourprofessionisslowlybeginningtomakethatstretchasevidencedbythepresentationofbiophysics-relatedtopicsatrecentcontinuingmedicaleducationevents102andinosteopathicscientificliterature.30,47,51,54,61DiGiovanna,103O’Connell,61DeStefano,104andGreenman105havereintroducedthe“bioenergetic,”or“bioenergy,”modelintomainstreamosteopathicmedicaltextbooks.

Itisthisauthor’sopinionthatthestretchneedstobetransformedintoaquantumleap.Biophysicalprinciplesandapplicationstoosteopathicdiagnosisandtreatmentshouldbeintegratedintotheeducationalprocessformedicalstudentsandphysiciansalike.Why?Itispartoftherealitywithwhichwedealeverydayinthediagnosisandtreatmentofourpatients.Biophysicalprinciplesandmathematicsarebehindthefunctioningofalllivingsystems.Thephysicsofbiologicalsystemshasbeenstudiedanddocumentedformorethanacentury.Interestingly,McConnellcitesa1921referencebooktitledAn Introduction to BiophysicsbyDavidBurns.106Thiswasapparentlythefirsttimethetermbiophysicswasused

SEEKING LOCUMS OR FULL-TIME OMM/NMM/INTEGRATIVE PAIN

MANAGEMENT POSITION

Michael A. Landrum, DO, Western U ‘91, C-NMM/OMM, special proficiency certificate: Cranial Osteopathy. Currently in Maine, willing to relocate; available immediately. Contact: [email protected]; (207) 701-7168.

NMM PLUS 1 POSITIONS AVAILABLE IN SUNNY SOUTH FLORIDA

Residency program at Larkin Hospital. Contact Joel D. Stein, DO, FAAO, at (954) 563-2707 or [email protected] for more information.

NMM PLUS 1 RESIDENCY PROGRAM IN NEW YORK

NMM Plus 1 Residency at Southampton Hospital in beautiful Southampton, Long Island. Applications are currently being accepted. If interested, please contact Program Director Denise K. Burns, DO, FAAO, at [email protected] or Education Department Secretary Karen Roberts at (631) 726-0409.

GROWING FL PRACTICE SEEKS FP/DO/DERMATOLOGIST

Reliant Family Practice in Gainesville, FL, seeks specialist in Family Practice/OMM and/or Family Practice/Dermatology for its growing, close-

knit, supportive practice under the direction of Erik Schabert, DO. Call Mika Harris, Office Manager, for first contact at (352) 514-6452 or email [email protected].

PRACTICE OSTEOPATHY IN BEAUTIFUL COLORADO

Successful integrative practice seeks a board-certified/eligible NMM/ OMM physician for its busy Denver office. Preferably someone comfortable with a broad variety of techniques. Very competitive compensation. Friendly and professional atmosphere. Please call (303) 781-7862 or e-mail CV to mgentile@ cointegrative.com. Our Web site is www.cointegrative. com.

CLASSIFIED ADVERTISEMENTS




tel:%28207%29 701-7167

tel:%28207%29 701-7167

mailto:ommdoc%40aol.com?subject=


mailto:mika%40reliantfamilypractice.com?subject=

cointegrative.com

www.cointegrative


inabooktitle.107Why,then,havewenotmadethissubjectafocusinosteopathicprinciplesandpractice?

Partoftheprobleminmakingthisleapisthatbiophysicsandrelatedtopicsaretaughtsomewhatsparinglyinconventionalbiologyandinmedicalschool.Thebiochemicalnatureoflifeisemphasized,presumablybecausemedicineisfocusedonthechemicalhumanbeing.Energeticphenomenaareacknowledged,especiallyinbiochemistry,physiology,andpharmacology,buttheyarenotstressedaswaystoinfluencebiologicalsystemsfromthestandpointofhealing.

Duringthepastseveraldecades,wehaveexponentiallyincreasedourknowledgeaboutenergeticinteractionsinlivingsystemsandhowtheymayberelatedtohealingandhealth.58,60Nowemergesthesubjectof“quantumbiology”108withdescriptionsofquantumpropertiesandphenomenaoccurringinseveraldifferent“quantumbiologicalsystems.”

Anintegrativemodelofbiophysicslinksallmedicaldisciplinestogetherinaunifiedmannertoexplainanatomical-physiologicalrelationships,diagnosis,andtreatmentofpatients.Althoughitmayseemthatwearedealingwithaphysicalbody,underlyingthatphysicalityarevibratingenergiesofvarioustypesthatareconstantlybeinginterconvertedtoothertypesofenergiesinthedancewecalllife.

Six Osteopathic Models

Energeticprinciplesdescribedbymathematicsandphysicsultimatelygovernthefunctioningoflivingsystemsfromtheatomicormolecularleveltothesynthesizedwholeorganism.Energyofvarioustypesisconstantlyexchanged,transformed,andcommunicatedwithintheindividualinallaspectsofbody,mind,andspirittomaintainhomeostasisandhealth.Thus,thisauthorproposesexpandingtheclassicosteopathicfivemodelconceptintosixmodels,withbioenergyasthefoundationofall.(See Figure 2.)

Aproposeddefinitionofthebioenergeticmodelforosteopathicmedicineis:

Thebioenergetic modelseekstoaddressthebioenergeticnatureofthehumanbeinginhealthanddisease,strivingtomaintainandsupportthereturntohomeostasisthroughtheapplicationofbiophysicalprinciplesinthebiofield.Thiscanbeaccomplishedbyusingawiderangeofosteopathicmanipulativetechniquessuchasdynamicstrain-vectorrelease,neurofascialrelease,bioelectricfascialactivation

andrelease,facilitatedoscillatoryrelease,myofascialrelease,traumavectorrelease,percussortreatment,andosteopathiccranialmanipulations.Bioenergeticsservesasthefoundationandintegrationpointforallotherosteopathicmodelsofcare,andthebioenergeticmodelcanbeusedtodiagnoseandtreatalllevelsofdysfunction.

Thebioenergeticmodelbringstothetablereal-timeassessmentandtreatmentbasedonwhatishappeningwiththepatientatthevisit.Itexaminesanotherdimensionthatistypicallyignoredinmostofmedicine.Patientsmayhaveclassicpatternsofsomaticorvisceraldysfunctionsthatfromabiomechanicalstandpoint,areeasilydocumentedand,theoretically,shouldrespondtoclassicformsofOMT,butforwhateverreason,theydon’trespondcompletelyoratall.Evaluationofabnormalbioenergeticphenomenaandbiophysicalfascialabnormalitiesunderlyingthesedysfunctionsaddssignificantlytotheinformationavailabletothephysicianonhowtotreatmoreappropriately,effectively,andefficiently.

Combinationsofbioenergetictechniques,includingacupuncture,areoftenusedeffectivelyandgentlytodecreasechronicpainanddysfunctionandtoincreasehealthandhomeostasis.Giventhepotentialadverseeffectsofothercommontreatments(opiates,antidepressants,nonsteroidal

Figure 2. The classic osteopathic model is expanded to six concepts, with bioenergy serving as the foundation. Additional environmental stressors have been added (poor lifestyle, pollution, electromagnetic exposures, etc.). Energy is the primary adaptive response to stressors. The holistic view of the patient includes body, mind, and spirit.




anti-inflammatorydrugs,musclerelaxants,anxiolytics,corticosteroidinjections,epidurals,surgeries,ganglionblocks,neuro-stimulatorimplants,etc.),onemustaskwhybioenergeticevaluationandtreatmentarenotattemptedinitiallyinpatients.Therearevirtuallynoadversesideeffects.

Inpart,theanswermaylieinthefactthatthebioenergeticmodeltypicallyisnotpresentedtostudentsandphysiciansasaviablealternativetoothermodels,eventhoughbiophysicshasalonghistory,isawidelyrecognizedscientificdiscipline,andhasamassiveresearchdatabase.Biophysicsisprobablyalotmoresolidfromatheoreticalandpracticalstandpointthanarebiologyandpharmacology.

Conclusions

Dynamicstrain-vectorreleaseandneurofascialreleaseareeffectivebioenergeticallybasedmodalitiesfortreatingpatientsfortissuedysfunctionsofallkinds.Inthisauthor’sexperience,SVRandNFRcanbeusedquiteeffectivelytomovepatientstoamuchhigherleveloffunctioningwhentraditionalmanipulativeandnonmanipulativemodalitiesfail.Thisisespeciallytrueforpatientswithchronicpainwhohaveexhaustedallavenuesofconventionaltreatment,includingmedicationsandsurgery.

BothSVRandNFRcantreatmosttissuesexhibitingsomaticandvisceraldysfunctions,andemotionalandtoxicstatescanbereached.Thesetwotechniquescanbemixedandmatched,notonlywitheachotherbutalsowithanyotherOMTtechniqueandwithacupuncture.

Althoughthesebioenergetictechniquescurrentlycanbetaughttoandusedbyosteopathicmedicalstudentsandosteopathicphysicians,relativelyfewclinicianstakeadvantageofthesetreatmentmodalities.Biophysicalprinciplesshouldbeincorporatedintobothundergraduateandmedicalcurriculatobalancetheconventionalemphasisonbiology,anatomy,physiology,andbiochemistry.Thiswouldrequireosteopathicmedicalschoolstoassimilatetheseconceptsandtermsintocommonmedicalvocabulary.Theprofessionshouldconsiderintegratingbiophysicalprinciplesintothecoreosteopathiccompetencies.Thiswouldallowfortheknowledgeanditsapplicationstobespreadthroughoutthecurriculumandintograduatemedicaleducation.

Thisintegrationiscrucialtothetotalholisticapproachtopatients,whichiscentraltoosteopathicphilosophy.Additionally,wenowenteranuncertainfutureinmedicineinwhichwearemandatedtobecomemoreproficient,efficient,effective,andprevention-orientedphysicians.Patientsareawakeningtothefactthatcurrentconventionalmedicalinterventionsareoftendangerous,costly,andineffective.Thereissomethingwrongwithamedicalsystem

thatisthethird-largestcauseofdeath,laggingonlybehindcardiovasculardiseaseandcancer.109

Itis,therefore,imperativethatweprovidethemostadvancedandhighestqualityhealthcarepossible.Weshouldconsiderresearchinghowbiophysicsandthebioenergeticmodelcanbeincorporatedintoaqualityandtotallyintegratedhealthcaresystem.Thiswouldputosteopathicmedicineatthecutting-edgeofhealthcareinthe21stcentury,asitisthenaturalprogressionofourphilosophyandprinciples.

Moreresearchneedstobedoneintohowendogenousandexogenousbioelectromagneticfieldtherapies,includingOMT,affectthebodyfrompostural,gait,andbiomechanical(somaticandvisceral)dysfunctionstandpoints.Onesuggestionwouldbetousegaitandposturalanalysisvideoandcomputertechnologytodocumentspecificchangesbeforeandafterabioenergetictreatment.Thiscouldbeaccomplishedacutelyorlong-term.

Additionally,onemightuseasuperconductingquantuminterferencedevice(SQUID)magnetometertomeasurebiomagneticchangesofaspecificsomaticdysfunctionbeforeandaftertreatment.

Apreliminaryresearchprojectisunderwaybythisauthortofurtherassessrelationshipsbetweenacupuncturepointsandsomaticandvisceraldysfunctions.

References1. SeffingerMA,KingHH,WardRC,etal.OsteopathicPhilosophy.

In:ChilaAG,ed.Foundations of Osteopathic Medicine.3rded.Philadelphia,PA:Lippincott,Williams&Wilkins;2011:3-22.

2. EducationalCouncilonOsteopathicPrinciples.Glossary of Osteopathic Terminology.ChevyChase,MD:AmericanAssociationofCollegesofOsteopathicMedicine;2011:5:25-26.

3. SchiowitzS.FacilitatedPositionalRelease.In:DiGiovannaEL,SchiowitzS,DowlingDJ,eds.An Osteopathic Approach to Diagnosis and Treatment.3rded.Philadelphia,PA:Lippincott,Williams&Wilkins;2005:89-90.

4. VanBuskirkRL.The Still Technique Manual.1sted.Indianapolis,IN:AmericanAcademyofOsteopathy;1999:7-87.

5. LossingK.VisceralManipulation.In:ChilaAG,ed.Foundations of Osteopathic Medicine.3rded.Philadelphia,PA:Lippincott,Williams&Wilkins;2011:845-849.

6. DeStefanoLA.CommonClinicalSyndromes:ExercisePrinciplesandPrescriptionsfortheLowerQuarter.Greenman’s Principles of Manual Medicine.4thed.Philadelphia,PA:Lippincott,Williams&Wilkins;2011:479-485.

7. KorrIM.Proprioceptorsandsomaticdysfunction.J Am Osteopath Assoc.March1975;74:638-650.

8. KorrIM.Thespinalcordasorganizerofdiseaseprocesses:III.Hyperactivityofsympatheticinnervationasacommonfactorindisease.J Am Osteopath Assoc.Dec1979;79(4):232-7.

9. DowlingDJ,ScariatiPD.GeneralPhysiologicConsiderations.In:DiGiovannaEL,SchiowitzS,DowlingDJ,eds.An Osteopathic Approach to Diagnosis and Treatment.3rded.Philadelphia,PA:Lippincott,Williams&Wilkins;2005:38-52.




10. ChiklyB.The Inherent Motility of the Brain and Spinal Cord Part 1: Brain Parenchyma, Nuclei and Fluid.,2010;Philadelphia,PA.

11. MagounHI.EntrapmentNeuropathyintheCranium.In:FeelyRA,ed.Clinical Cranial Osteopathy: Selected Readings.Meridian,ID:TheCranialAcademy;1988:184-190.

12. BarralJP.CranialNerveManipulation,2005;AAOConvocation.Reno,NV.

13. UpledgerJE.SomatoEmotional Release and Beyond.PalmBeachGardens,FL:UIPublishing;1990:1-31.

14. LossingK.TraumaEmotionalDiagnosisandTreatment,2001;ColoradoSprings,CO.

15. HelmsJM.Acupuncture Energetics: A Clinical Approach for Physicians.Berkeley,CA:MedicalAcupuncturePublishers;1995:19-50.

16. LeeRP.Interface: Mechanisms of Spirit in Osteopathy.Portland,OR:StillnessPress;2005:175-253.

17. OschmanJL.Energy Medicine: The Scientific Basis.NewYork,NY:ChurchillLivingstone;2000:1-40.

18. OschmanJL.Energy Medicine in Therapeutics and Human Performance.NewYork,NY:Butterworth/Heinemann;2003:1-27.

19. BurrHS.Blueprint for Immortality: The Electric Patterns of Life.GreatBritain:NevilleSpearmanPublishers;1972:1-192.

20. BeckBL.Magnetichealing,spiritualism,andchiropractic:Palmer’sunionofmethodologies,1886-1895.ChiropracticHistory.The Archives and Journal for the History of Chiropractic.1991;11(2):11-15.

21. ClydeH.Medical History of Wapello County.PhotocopyofwritingsonPaulCaster’streatmentandmentoringofA.T.Stillinmagnetichealing.OsteopathicArchives,KirksvilleCollegeofOsteopathicMedicine.Kirksville,MO;c.1898.

22. StillAT.The Philosophy and Mechanical Principles of Osteopathy.KansasCity,MO:Hudson-KimberlyPublicationCo;1902:248-268.

23. LeeRP.Interface: Mechanisms of Spirit in Osteopathy.Portland,OR:StillnessPress;2005:35.

24. StillAT.The Philosophy and Mechanical Principles of Osteopathy.KansasCity,MO:Hudson-KimberlyPublishingCo;1902:296-99.

25. LittlejohnJM.Thephysiologicbasisoftherapeuticlaw.J Am Osteopath Assoc.1902;2:42-60.

26. HuletttGD.A Text Book of the Principles of Osteopathy.Kirksville,MO:JournalPrintingCo;1903:43-68.

27. SutherlandWG.The Cranial Bowl.Mankato,MN:WGSutherland;1939:8:24(ReprintedbytheOsteopathicCranialAssociation,Meridian,ID,1948).

28. MagounHI.Osteopathy in the Cranial Field.2nded.Kirksville,MO:JournalPublishingCo;1966:23-42.

29. MagounHI.Osteopathy in the Cranial Field.2nded.Kirksville,MO:JournalPublishingCo;1966:25-26.

30. ComeauxZ.Theroleofvibrationoroscillationinthedevelopmentofosteopathicthought.AAO Journal.2000;10(3):19-24.

31. Fulford,RCwithGeneStone.Dr Fulford’s Touch of Life.NewYork,NY:PocketBooks;1996:48-49:63-89.

32. FulfordRC.PercussionVibratorCourse,1989;Huntington,WV.33. ComeauxZ.Robert Fulford, DO and the Philopher Physician.Seattle,

WA:EastlandPress;2002:25-64.34. SillsF.The Polarity Process: Energy as a Healing Art.Longmead,UK:

ElementBooks,Ltd;1989:1-191.35. StoneR.Polarity Therapy: The Complete Collected Works, Vol. 1.

Sebastopol,CA:CRCSPublications;1986:1-93.

36. StoneR.Polarity Therapy: The Complete Collected Works, Vol. 2.Sebastopol,CA:CRCSPublications;1987:1-52.

37. BeckerRE.DiagnosticTouch:ItsPrinciplesandApplicationsPartI:ToFeelLivingFunction.In:BrooksRE,ed.Life in Motion.Portland,OR:RudraPress;1997:153-165.

38. BeckerRE.DiagnosticTouch:ItsPrinciplesandApplicationsPartII:WhatADiagnosticTouchCanDo.In:BrooksRE,ed.Life in Motion.Portland,OR:RudraPress;1997:166-179.

39. BeckerRE.DiagnosticTouch:ItsPrinciplesandApplicationsPartIII:PuttingaDiagnosticTouchtoWork.In:BrooksRE,ed.Life in Motion.Portland,OR:RudraPress;1997:180-202.

40. BeckerRE.DiagnosticTouch:ItsPrinciplesandApplicationsPartIV:TraumaandStress.In:BrooksRE,ed.Life in Motion.Portland,OR:RudraPress;1997:203-216.

41. BeckerRE.In:BrooksRE,ed.Life in Motion: The Osteopathic Vision of Rollin E. Becker, DO.Portland,OR:RudraPress;1997:181-182.

42. BrooksRE.Editor’sNote.In:BrooksRE,ed.Life in Motion.Portland,OR:RudraPress;1997:153.

43. DavidsonSM.Neurofascial Release: A Course in Guided Palpation and Treatment.PhoenixAZ:PracticalPublications;1990:1-20.

44. MacDonaldRC.“Theenergycyst”:Itsramificationsanduseinosteopathicmanipulativemanagement.AAO Journal.2003;13(3):16-18.

45. UpledgerJE.Craniosacral Therapy II: Beyond the Dura.Seattle,WA:EastlandPress;1987:212-214.

46. HollandEC.ViscoelasticandViscoplasticAxesofMotionintheCranium:TheBiophysicsofCranialOsteopathy[Video],1992.

47. HollandEC.TheBiophysicsofFulfordTechniques,2012;Sebastopol,CA.

48. O’ConnellJA.MyofascialReleaseApproach.In:ChilaAG,ed.Foundations of Osteopathic Medicine.3rded.Philadelphia,PA:Lippincott,Williams&Wilkins;2011:699-700.

49. O’ConnellJA.Bioelectric Fascial Activation and Release.Indianapolis,IN:AmericanAcademyofOsteopathy;2000:22-25:59-78.

50. ComeauxZJ.Facilitatedoscillatoryrelease-amethodofdynamicassessmentandtreatmentofsomaticdysfunction.AAO Journal.2003;13(3):30-35.


52. LeeRP.Spiritualityinosteopathicmedicine.AAO Journal.2000;10(4):31-36.

53. HendryxJT.Healer’s Touch: A Physician’s Journey into the Medical, Miracle, and Mystical Aspects of Healing.Mt.Jewett,PA:TransformationsPress;2006:107-108.

54. HendryxJT,O’BrienRL.DynamicStrain-VectorRelease:AnenergeticapproachtoOMT.AAO Journal.2003;10(3):19-29.

55. McConnellCP.Fundamentalfragments.Relatedness.FromJ Am Osteopathic Assoc1939.In:JordanT,SchusterR,eds.Selected Writings of Carl Phillip McConnell, DO.Columbus,OH:Squirrel’sTailPress;1994:129-130.

56. CaliforniaEnergyCommission.TheEnergyStory-Chapter1:Energy-WhatIsIt?Energy Quest.1994-2012.Availableat:http://www.energyquest.ca.gov/story/chapter01.html.AccessedJanuary12,2013.

57. OSUChemistry.1stLawofThermodynamics.The Ohio State University.Availableat:http://chemistry.osu.edu/~woodward/ch121/ch5_law.htm.AccessedJanuary12,2013.

58. OschmanJL.Energy Medicine: The Scientific Basis.NewYork,NY:ChurchillLivingstone;2000.



http://www.energyquest.ca.gov/story/chapter01.html

http://www.energyquest.ca.gov/story/chapter01.html

http://chemistry.osu.edu/~woodward/ch121/ch5_law.htm

http://chemistry.osu.edu/~woodward/ch121/ch5_law.htm


59. OschmanJL.Energy Medicine in Therapeutics and Human Performance.NewYork,NY:Butterworth/Heinemann;2003:xxvi.

60. OschmanJL.Energy Medicine in Therapeutics and Human Performance.NewYork,NY:Butterworth/Heinemann;2003.

61. O’ConnellJA.MyofascialReleaseApproach.In:ChilaAG,ed.Foundations of Osteopathic Medicine.3rded.Philadelphia,PA:Lippincott,Williams&Wilkins;2011:698-727.

62. HandollN.Anatomy of Potency.Hereford,UK:OsteopathicSuppliesLtd;2000:49-147.

63. NIH.WhatisComplementaryandAlternativeMedicine?National Center for Complementary and Alternative Medicine (NCCAM).Availableat:http://nccam.nih.gov/health/whatiscam.AccessedJune28,2012.

64. RubikB.Thebiofieldhypothesis,itsbiophysicalbasisandroleinmedicine.J Altern Complement Med.Dec2002;8(6):703-17.

65. TillerWA.Science and Human Transformation: Subtle Energies, Intentionality, and Consciousness.WalnutCreek,CA:PaviorPublishing;1997:36.

66. TillerWA.Science and Human Transformation: Subtle Energies, Intentionality, and Consciousness.WalnutCreek,CA:PaviorPublishing;1997.

67. EducationalCouncilonOsteopathicPrinciples.Glossary of Osteopathic Terminology.ChevyChase,MD:AmericanAssociationofCollegesofOsteopathicMedicine;2011:26.

68. DiGiovannaEL.SomaticDysfunction.In:DiGiovannaEL,SchiowitzS,DowlingDJ,eds.An Osteopathic Approach to Diagnosis and Treatment.3rded.Philadelphia,PA:Lippincott,Williams&Wilkins;2005:16-23.

69. StilesE.BiotensegrityandAreasofGreatestRestriction,2007;AOAConvention.SanDiego,CA.

70. ChiklyB,LossingK.LymphaticApplicationstotheViscera,2005;Glendale,AZ.

71. HollandEC.Holonomics and Relationism: The Principles of Integrative Medicine.Sebastopol,CA:TheHolonomicInstitute;2009:2-25.

72. MandelbrotBB.The Fractal Geometry of Nature.NewYork,NY:W.H.FreemanandCompany;1983:6-165.


74. HollandEC.Holonomic Perception: Cognitive Skills, Perceptual Physiology, and Perceptual Transference.Sebastopol,CA:TheHolonomicInstitute;2009:12-20.

75. StillAT.The Philosophy and Mechanical Principles of Osteopathy.Kirksville,MO:OsteopathicEnterprise;1892:60.

76. StedmanTL.Stedman’s Medical Dictionary.27thed.Baltimore,MD:Lippincott,Williams&Wilkins;2000:647.

77. WillardF.FascialContinuityfromtheThoracicDiaphragmtothePelvicDiaphragm,2011;AAOConvocation.ColoradoSprings,CO.

78. WillardFH,FossumC,PRStandley.TheFascialSystemoftheBody.In:ChilaAG,ed.Foundations of Osteopathic Medicine.3rded.Philadelphia,PA:LippincottWilliams&Wilkins;2011:74-92.

79. In:WarwickR,WilliamsPL,eds.Gray’s Anatomy.35thed.Philadelphia,PA:W.B.SaundersCompany;1973:32-48.

80. SchleipR,KlinglerW,Lehmann-HornF.Activefascialcontractility:Fasciamaybeabletocontractinasmoothmuscle-likemannerandtherebyinfluencemusculoskeletaldynamics.Med Hypotheses.2005;65(2):273-7.

81. SchleipR,NaylorIL,UrsuD,etal.Passivemusclestiffnessmaybeinfluencedbyactivecontractilityofintramuscularconnectivetissue.Med Hypotheses.2006;66(1):66-71.

82. O’ConnellJA.Bioelectric Fascial Activation and Release.Indianapolis,IN:AmericanAcademyofOsteopathy;2000:34-58.

83. LeeRP.Interface: Mechanisms of Spirit in Osteopathy.Portland,OR:StillnessPress;2005:149-150:153-155:265.

84. SutherlandWG.In:SutherlandAS,WalesAL,eds.Contributions of Thought: The Collected Writings of William Garner Sutherland, D.O.2nded.Portland,OR:RudraPress;1998:142-143:147.

85. SutherlandWG.In:WalesAL,ed.Teachings in the Science of Osteopathy.FortWorth,TX:SutherlandCranialTeachingFoundation;1990:166-189.

86. NelsonKE,GlonekT.Somatic Dysfunction in Osteopathic Family Medicine.Baltimore,MD:Lippincott,Williams&Wilkins;2007:130.

87. NelsonKE,SergueefN,LipinskiCM,etal.CranialrhythmicimpulserelatedtotheTraube-Hering-Mayeroscillation:Comparinglaser-Dopplerflowmetryandpalpation.J Am Osteopath Assoc.2001(101):163-173.

88. GeigerB,SpatzJP,BershadskyAD.Environmentalsensingthroughfocaladhesions.Nature Reviews: Molecular Cell Biology.2009;10(1):21-33.

89. IngberDE.Thearchitectureoflife.Scientific American.January1998:48-57.

90. IngberDE.TensegrityI.Cellstructureandhierarchalsystemsbiology.Journal of Cell Science.2003;116(7):1157-1173.

91. IngberDE.TensegrityII.Howstructuralnetworksinfluencecellularinformationprocessingnetworks.Journal of Cell Science.2003;116(8):1397-1408.

92. JaaloukDE,LammerdingJ.Mechanotransductiongoneawry.Nature Reviews: Molecular Cell Biology.2009;10(1):63-73.

93. WangN,TytellJD,IngberDE.Mechanotransductionatadistance:mechanicallycouplingtheextracellularmatrixwiththenucleus.Nature Reviews: Molecular Cell Biology.2009;10(1):75-82.

94. SwansonRL.Biotensegrity:aunifyingtheoryofbiologicalarchitecturewithapplicationstoosteopathicpractice,education,andresearch--Areviewandanalysis.J Am Osteopath Assoc.January2013;113(1):34-52.

95. DavidsonSM.NeurofascialReleaseCourse,2001;Phoenix,AZ.96. MalinaB.Neurofascial Release: An Instruction Manual.Chandler,AZ:

Selfpublished;1996:1-28.97. DavidsonSM.AdvancedNeurofascialReleaseCourse:Visceral

Manipulation,2003;Phoenix,AZ.98. TheCenterforHistoryofPhysics.EinsteinExhibit-E=mc2.

American Institute of Physics.1996-2013.Availableat:http://www.aip.org/history/einstein/emc1.htm.AccessedJanuary12,2013.

99. CriseraP.Cranio-Sacral Energetics, Volume I.Rome,Italy:S.M.I.S.R.L.;1997:13-14:48-56.

100.LeeRP.Interface: Mechanisms of Spirit in Osteopathy.Portland,OR:StillnessPress;2011:170-210:229.

101.McConnellCP.TheOsteopathicApproach.JAmOsteopathAssocJune1938.In:JordanT,SchusterR,eds.Selected Writings of Carl Philip McConnell, D.O.Columbus,OH:Squirrel’sTailPress;1994:28-32.

102.AmericanAcademyofOsteopathy.AAOConvocation2013:MechanotransductionandtheInterstitium:TheWorldInBetween,2013;Orlando,FL.



http://nccam.nih.gov/health/whatiscam

http://www.ncbi.nlm.nih.gov/pubmed/11329812






http://www.aip.org/history/einstein/emc1.htm

http://www.aip.org/history/einstein/emc1.htm


The following submission tied for first place in the residents’ case history category in the Louisa Burns Osteopathic Research Committee’s poster presentation at the AAO Convocation in Colorado Springs, Colorado, on March 21, 2014.

ATSU-KCOM has two full-time OMM faculty positions open. Responsibilities include five half days academic and five half days clinical (outpatient and inpatient OMM consultation service). Great opportunity for residents graduating July 2014 or an OMM couple looking to work together in an academic practice. Now is a great time to apply and secure a position for 2014!

Requirements:

• NMM/OMM or CSPOMM Board Certification or Board Eligibility

• Proficiency in both Direct and Indirect OMT Techniques such as HVLA, Muscle Energy, Counterstrain, Cranial, and Balanced Ligamentous Tension

• Able to work as part of a team• Eligible for Medical License in the

State of Missouri

Job Duties:

• Table training OMM skills laboratories

• Coordinating, preparing, and delivering OMM lecture and laboratory didactics

• See OMM patients in outpatient and inpatient settings

• Research opportunities available• Additional duties as directed by

Department Chair or Dean

Additional qualifications recommended:

• Experience with inpatient OMM• Proficiency in OMM for children,

infants and newborns• Experience in OMM research• Proficiency with Microsoft Word and

PowerPoint

Salary and Benefits

• Competitive salary with clinical incentives

• Full benefit package – health, life, dental, vision, retirement

• Paid sick leave, vacation, and CME money available

Apply online at http://jobs.atsu.edu/kcom-omm-assistant-associate-professor-2-positions/job/4243133.

A.T. STILL UNIVERSITY SEEKS OMM FACULTY

Introduction

Neuralgiaandperipheralneuropathiesarenotoriouslydifficultconditionstotreat.Mainstaysoftherapyareneuropharmaceuticalsandneurosurgery.

Case description

PatientNo.1:Hispanicfemale,63yearsold,complainingof13yearsofburningpainofthefaceandscalpduetoV1neuralgiaafterneurosurgicalinterventionforcerebralaneurysm.

PatientNo.2:Caucasianfemale,61yearsold,complainingofacuteonchroniclaterallegpainduetomeralgiaparasthetica.

Technique

Neuralprolotherapyisanadaptedprolotherapytechniqueinwhichsubcutaneoustissueisinjectedwitha5%dextrosesolution.Techniciansprepared3mLsyringeswithD5Wanda31g0.5inchneedle.Neuralprolotherapywasperformedforbothofthesepatientsbyinjectingtenderpointsinthesubcutaneoustissuealongtheaffectednervepaths,V1andlateralfemoralcutaneousnerves,respectively,withapproximately0.5mLofD5Wateachpointata45-degreeangle1to2cmapart.Theneedlewasinsertedtotheappropriatedepth,andthesolutionwasinjectedwhilewithdrawingtheneedletocreateaskinbleb.

Results

PatientNo.1reportedcompleteresolutionofV1neuralgiaafter3neuralprolotherapytreatments.PatientNo.2reportedsignificant,satisfactoryreliefinpainfrommeralgiaparastheticaafter8treatments.

Conclusion

Neuralprolotherapyisasimpleofficeprocedure,easilydonewithoutimaging,whichmayleadtorelieffromneuropathicpain.Themostcommonsideeffectsreportedweretemporarypainwithinjectionandlocalbruising.TheproposedmechanismofactionisagonismofTRPV1receptor.ThereareliteraturereportsofthistechniquebeingemployedforAchillestendinosis,andwehypothesizethatthistechniquecouldbeemployedforavarietyofperipheralneuralgias.

Neural Prolotherapy Can Resolve NeuralgiaEileen M. Conaway, DO; Brian L. Browning, DO


The following submission tied for first place in the residents’ case history category in the Louisa Burns Osteopathic Research Committee’s poster presentation at the AAO Convocation in Colorado Springs, Colorado, on March 21, 2014.

OMTprotocolincludedintrarectaltreatmentoflevatoraniandcoccygealmuscles.Twomonthsintohertreatment,thepatientreceivedpelvicfloorphysicaltherapy(PT)inadjuncttoOMT.Thisfacilitatedimprovementofsymptoms.Magneticresonanceimages(MRIs)ofthepelviswereobtainedpre-andpost-treatment,fivemonthsapart.

Results

Subjectively,thepatientreporteda60%reductioninsymptomssincestartingOMTafterfivemonthsoftreatment.Objectively,apost-treatmentMRIofthepelvis,takenfivemonthsafterpre-treatmentMRI,showedsignificantchangestothepubococcygeusandotherlevatoranimuscles.Improvedpalpablechangeswerefoundonexam.

Conclusions

BothobjectiveimprovementandsubjectiveimprovementwerefoundusingOMTtotreatpatientsforlevatoranisyndrome.Inthiscase,OMTincombinationwithpelvicfloorPThasbeenshowntobebeneficialintreatinglevatoranisyndrome.Thus,OMTshouldbeconsideredasthestandardofcareforpatientswiththisdisorder.

Management of Levator Ani Syndrome With Osteopathic Manipulative Treatment: A Case StudyMiho Yoshida, DO, NMM+1; Dominic Derenge, OMS IV; and Katherine Worden, DO, MS

Background

Levatoranisyndromedescribesadisorderinwhichpelvicpainisattributedtoshort,tight,andtenderpelvicfloormuscles,commonlyoccurringinconjunctionwithhypersensitivetenderpoints.Itcancausechronicpelvicpain,whichcanbesufficientlydebilitatingtoapatientbyinterferingwithdailyactivitiesandthepatient’ssenseofwell-being.Osteopathicmanipulativetreatment(OMT)canbebeneficialintreatingthisdisorder.ThiscasedescribeshowtreatingpatientswhohavelevatoranisyndromewithOMTproducespositiveresultsshownobjectivelyviaimprovementonimagingandsubjectivelythroughreassessmentbythepatient.

Material and Methods

Thepatientinthisstudycomplainedofpainwithsitting,identifiedtobecausedbyspasmofherlevatoranimuscles.ShewastreatedwithOMTforfivemonths.Theunrestricted

103.DiGiovannaEL.IntroductiontoOsteopathicMedicine.In:DiGiovannaEL,SSchiowitz,eds.An Osteopathic Approach to Diagnosis and Treatment.2nded.Philadelphia,PA:Lippincott-Raven;1997:14.

104.DeStefanoLA.TheManipulativePrescription.Greenman’s Principles of Manual Medicine.4thed.Philadelphia,PA:Lippincott,Williams&Wilkins;2011:50.

105.GreenmanPE.Principles of Manual Medicine.3rded.Philadelphia,PA:LippincottWilliams&Wilkins;2003:48.

106.BurnsD.An Introduction to Biophysics.London,UK:J.&A.Churchill;1921.

The Bioenergetic Model (Continued from page 18) 107.GratzerWB.Biophysics-whence,whither,wherefore-orHoldthathyphen.BMC Biology.2011;9:12.

108.LambertN,ChenYN,ChengYC,etal.Quantumbiology.Nat Phys.December2012:1-9.

109.StarfieldB.IsUSHealthReallytheBestintheWorld?JAMA.July2000;284(4):483-485.

Accepted for publication November 2013.

Address correspondence to:

JanT.Hendryx,DO,FAAO5401 Peach St., Suite 3400Erie, PA 16509


The following submission won first place in the residents’ clinical research category in the Louisa Burns Osteopathic Research Committee’s poster presentation at the AAO Convocation in Colorado Springs, Colorado, on March 21, 2014.

Introduction

AttheStill-HildrethSanatorium(SHS),thefirstosteopathicsanatorium,themajorityofpatientswerediagnosedwithpsychiatricdisorders,andphysiciansdesignedtreatmentsaroundtreatingthewholepatient.Thisstudyisaretrospectivechartreviewfrompatientsadmittedinthe1910stothe1930s(theonlyknownmedicalrecords)andshowsimprovementsinpyschiatircconditionsattheSHSweregreaterthannonosteopathiccontemporarystatistics.

Methods

TheMuseumofOsteopathicMedicineinKirksville,Missouri,redactedandcompiledchartsfrom1,891patients.The

Comparison of Patient Records From the Still-Hildreth Sanatorium With Published ReportsLeslie M. Ching, DO, OGME4; Harriet H. Shaw, DO

investigatorreviewedthechartinformationandcomparedittoanSHSpamphletshowingpatientstatisticsfromMarch1914toMarch1931.

Results

Ratesofhospitaladmissiondiagnosesandresultswerecompared,focusingonpatientswithpsychiatricdiagnoses.Recoveryratesintheextantrecordslargelycorrespondtopublishedreports.

Conclusion

PublisheddataofSHSmaybeconsideredgenerallycorrectwhencomparedwithextantmedicalrecords.Otherresearchavenuescouldbeconsideredfromthisdatabase.

Basic Musculoskeletal Manipulation Skills:

The 15 Minute Office Encounter

Michael P. Rowane, DO, MS, FAAFP, FAAOPaul Evans, DO, FAAFP, FACOFP

Drs. Evans and Rowane have designed this book for the primary care physician who wants a basic guide to treating patients for commonly seen clinical problems that are amenable to musculoskeletal manipulation. The assessments and techniques presented are ideal for this situation. They are rapid and efficient, and they are specifically designed for a 15-minute office visit. All chapters provide objectives, illustrative cases with answers, clear illustrations to highlight clinically important anatomic landmarks, assessment tips, treatment techniques, and key summary points. All photographs focus on critical elements of examination and treatment techniques so that they can be reviewed rapidly at the point of care, enhancing the rapid application of information.

239 pp. Hardcover. ISBN 0-940668-27-0Place your order on the AAO online store at www.academyofosteopathy.org

AAO member: $89.95AAO nonmember: $99.95

Shipping not included in price


The following submission won second place in the residents’ clinical research category in the Louisa Burns Osteopathic Research Committee’s poster presentation at the AAO Convocation in Colorado Springs, Colorado, on March 21, 2014.

History

A15-year-oldmalepatientwithnosignificanthistorypresentedtoanosteopathicmanipulationclinicfollowinganunrestrainedmotorvehicleaccidentinJuly2012.Hewasdischargedfromthehospitalwithsignificantinjuriesandrequiredcrutchesforweight-bearingsecondarypaininthegroin.Thepatientdeniedanyweakness,numbness,tingling,bowelorbladderdysfunction.Hewastostartjuniorhighschoolinthefall,andhisfootballtrainingwastoresumeinAugust.

Physical Examination

Lumbarspinerangeofmotionwas110degreesflexion,25degreesextensionwithtenderness.MildmusclespasmwasnotedovertheL4-L5ontherightside.Straightlegraisetestingwasnegative.Hiponrightnotedforswellingingroinregionnearthepubicsymphysisandadductorinsertionwithtendernesstopalpation.Thepatienthadpainoninternalrotation,adductionandflexion.Manualmuscletestingofrighthipadductionandflexion4/5waslimitedbypain.Gaitwasantalgicwithbilateralcrutches.

Differential Diagnosis

Pubicshear,pubicbonefracture,adductortear,rectusabdominustear,andinguinalherniawereruledout.

Traumatic Groin Injury in a Football Player: A Case ReportDaniel Tsukanov, DO; Dennis J. Dowling, DO, FAAO; Lyn Weiss, MD

Tests and Results

July11,2012: PelvicX-rayshowedmisalignmentofthesymphysispubiswithleftarticularsurfacedisplacedanteriorlywithrespecttotherightmeasuring6mm.

July17,2012: Pelvicmagneticresonanceimagingshoweddiastasisofsymphysispubiswithsubluxationandassociatedwithmilddiastasisofsacroiliacjoints.Thepatienthadhigh-gradestrainanddetachmentofrightadductorandexternalobturatororigin.

Aug.27,2012: Ureteralstumpevaluationshowedneutralalignmentofthepubicsymphysis.

Final Working Diagnosis

Pubicshear,rightadductor,andobturatortearwerediagnosed.

Treatment and Outcomes

Thepatientwasevaluatedinthemanipulationclinicandfoundtohavesomaticdysfunctionsinthelumbarspine,pelvic,andpubicsymphysisareas.Treatmentconsistedofmanipulation,specificallyatractiontugtotherightpubicsymphysiswasperformed,afterwhichthepatientreportedgreaterthan70%reductioninsymptomsandwasabletoambulatewithoutcrutches.Physicaltherapyandacetaminophenasneededforpainwerealsoinitiated,aswellasfollow-upmanipulationtreatments.AttheendofAugust,thepatientwasclearedbyhisorthopedicsurgeonforprogressivereturntosports,andthepatientreportedminimalgroinpain.Ureteralstumpevaluationrevealedrealignmentofthepubicsymphysis.


The following submission won first place in the students’ case study category in the Louisa Burns Osteopathic Research Committee’s poster presentation at the AAO Convocation in Colorado Springs, Colorado, on March 21, 2014.

The College of Osteopathic Medicine of the Pacific-Northwest (COMP-Northwest) is seeking an osteopathic physician for a full-time assistant/associate professor in the Department of Neuromusculoskeletal Medicine/Osteopathic Medicine. Responsibilities include teaching the OPP curriculum, subject matter, courses and methods of instruction, as well as the development and evaluation of OPP courses. Successful applicants must have a D.O. degree and be board certified by the American Osteopathic Board of Neuromusculoskeletal Medicine, or another specialty board, plus have expertise in the application of osteopathic principles and philosophy and OMT in clinical practice.

For the full job posting or to apply online, visit: http://jobs.westernu.edu and search for posting F00007.Based in Lebanon, Oregon, COMP-Northwest is part of Western University of Health Sciences (WesternU), a comprehensive graduate university of health professions. WesternU is located in Pomona, Calif., and encompasses nine colleges: medicine, dentistry, nursing, pharmacy, optometry, podiatry, allied health, biomedical sciences and veterinary medicine.

OPEN POSITION Professor (Assistant/Associate)

Department of NMM/OMMWestern University of Health Sciences,

COMP-Northwest Campus, Lebanon, Oregon

Context

Thisstudywasdesignedtopresentacaseinwhichosteopathicmanipulativemedicine(OMM)wasusedtotreatapatientforcommonfibularnerveentrapment.

Methods

Apreviouslyhealthy50-year-oldfemalepatientwitha2-monthhistoryoftrippingonflatsurfacespresentedtoanosteopathicmanipulativemedicine(OMM)clinicforosteopathicevaluationandtreatment.Electromyography(EMG)nervetestingcompletedpriortotreatmentwasconsistentwithrightcommonfibularnervepalsy.Thepatientpresentedclinicallywithrightlowerextremitypain,weakness,anddecreasedsensationoverthelateralrightlegandfoot.Osteopathicexaminationwasmostsignificantformyofascialstrainandaposteriorfibularhead.Thepatientwastreatedforthesefindingsinconjunctionwithothersignificantareasofsomaticdysfunctionusingavarietyofosteopathicmanipulativetreatment(OMT)techniques.

Treatment of Common Fibular (Peroneal) Nerve Palsy With Osteopathic Manipulative Medicine: A Case StudyBradley M. Jahnke, OMS V; Puanani Hopson, OMS V; Katherine Worden, DO, MS

Results

Overthecourseofseveraltreatments,thepatient’sresponsewasnotablefordecreasedepisodesofpainanddiscomfortofherrightlowerextremity,aswellasdecreasedfootdrop.Neurologistfollow-upandrepeatEMGafterfourmonthsofOMTfoundsomeimprovementinconductionvelocityoftherightcommonfibularnerve.

Conclusion

Ourpatientpresentedwithfootdropandpainintherightlowerextremity,andonreviewoftheliterature,thesesymptomswerefoundtocorrelatewithanosteopathicfindingofposteriorfibularhead.ThiscasedemonstratesbothclinicalimprovementandEMGalterationafterprovidingOMTforcommonfibularneuropathy.FurtherstudieswithobjectiveorneurologicresultsshouldbeconductedtodeterminetheefficacyofOMTandsupporttheuseofthistreatmentmodalityinclinicalcases.


The following submission won second place in the students’ case study category in the Louisa Burns Osteopathic Research Committee’s poster presentation at the AAO Convocation in Colorado Springs, Colorado, on March 21, 2014.

Introduction

Postoperative ileus referstothefailuretopassgasorstoolsandintoleranceoforalintakeduetodisruptionofthenormalpropulsiveactivityofthegastrointestinaltractduringthepostoperativeperiod.Postoperativeileusmayleadtoincreasedpatientpainanddiscomfortwhileprolongingthedurationofhospitalstays.2Multiplepathophysiologicmechanismscontributetopostoperativeileus.Thesuccessoftreatmentremainslimitedduetothecomplexityofneurologicandinflammatorycontrolofgastrointestinalfunction.Despitethehugecostassociatedwithpostoperativeileus,therehavebeenveryfewmedicaladvancesfortreatingpatientsforpostoperativeileus.3

Case Description

A17-year-oldHispanicfemalepatientpostlaparoscopicappendectomycomplainedofabloatingsensation,andsheconfirmedthatshehadnothadabowelmovement.Osteopathicexaminationrevealedhypertonicparaspinalmusculatureinthethoracicandlumbarspinesanddiffusebogginessoftheabdomen.Osteopathicmanipulativetreatment(OMT)techniqueswereselectedtoimpacteachcomponentofthecomplexpathophysiologyofpostoperativeileus.Thesetechniquesincludedsuboccipitalrelease,riblessribraising,myofascialtechnique,andmesentericlifts.TwentyminutesfollowingtreatmentwithOMT,thepatientreportedhavingabowelmovement.

Discussion

Inhibitoryneuralreflexesarebelievedtohavelocalactionvianoxiousspinalafferents,whichincreaseinhibitorysympatheticactivity.1OMTwasusedtohelpnormalizetheautonomicnervoussystem(ANS)withtherib/riblessribraisingtechniques.Intestinalmanipulationandtraumaleadtomacrophageactivationandaninflammatoryresponse,slowingmotility.1ThiswasaddressedwithOMTtohelpnormalizetheANSwithsuboccipitalrelease.Neurohumoralpeptidessuchasnitricoxide,vasoactiveintestinalpeptide,andpossiblysubstanceParealsothoughttoslowtransittimeinthegut.4ThiswasaddressedwithOMTbyprovidingmyofascialreleasetothethoracicandlumbarspines.OMThelpsremovestructuralrestrictiontolymphflowandpromotelymphaticflow.3Themesentericlifttechniquewasusedtodecreasevenouscongestionanddecreaseinflammationofthegut.

Conclusion

ThiscaseillustratestheeffectivenessofOMTinapostoperativeileuscase.ConsiderationshouldbegiventotheroleofOMTasanadjuvantapproachtomainstaytherapiesfortreatingpatientsforpostoperativeileus.

References1. BaltazarG,BetlerMP,AkellaK,etal.EffectofOsteopathic

ManipulativeTreatmentonincidenceofpostoperativeileusandhospitallengthofstayingeneralsurgicalpatients.J Am Osteopath Assoc.2013;113(3):204-9.

2. CagirB.IleusTreatmentandManagement.Medscape.14Feb.2014.3. CrowWT,GorodinskyL.DoesOMTimproveoutcomeinpatients

whodeveloppostoperativeileus:aretrospectivechartreview.IJOM.2009;12(1):32-37.

4. LitkouhiB.Postoperativeileus.UptoDate.1August2013.

Application of OMT in a Pediatric Postoperative Ileus CaseRebecca S. Domalski, OMS III; Laura Nimkoff, MD; Sheldon C. Yao, DO; Patricia S. Kooyman, DO


The following submission won third place in the students’ case study category in the Louisa Burns Osteopathic Research Committee’s poster presentation at the AAO Convocation in Colorado Springs, Colorado, on March 21, 2014.

This textbook is designed for the interested physician and for the beginning to intermediate student of this topic. It can be easily used as an accompanying manual for a first or second course in osteopathy in the cranial field, and some topics are useful for more advanced study. Exploring Osteopathy in the Cranial Field would be especially suitable for use in a 40-hour first or second level course on this topic. 164 pages, spiral bound, ISBN 978-0-9887511-0-1

AAO member: $53.95AAO nonmember: $59.95

Shipping not included in price.

Place your order on the AAO’s online store at www.academyofosteopathy.org.

Now Available

Exploring Osteopathy in the Cranial Field

Raymond J. Hruby, DO, FAAO

withstandardtreatments.Osteopathicexaminationrevealedseveralcranialandcervicalsomaticdysfunctions,andtheywereaddressedwithcranialandcervicaltechniques.Thepatient’sepiphoraimprovedimmediately,anditcontinuedtoimproveduringthefollowingweeksandmonths.At6monthspost-treatment,thepatientnolongerneededsurgicalprobing.Thiscasesuggeststhatosteopathicmanipulativemedicine(OMM)canhelprelievenasolacrimalductstenosisbyaddressingthesomaticdysfunctionsofthecranialbones,improvingcranialbonearticulation,andaugmentingthedrainageofthelymphaticsoftheheadandneck.Inturn,thismaydecreaseepiphoraanddacryocystitis,ultimatelydecreasingpatientdiscomfortandtheneedforinvasiveandexpensiveprocedures.

Reference1. WagnerRS.Managementofcongenitalnasolacrimalductobstruction.

Pediatr Ann. 2001;30:481.

The Role of Osteopathic Manipulative Medicine in the Treatment of DacryostenosisTheresa E. Apoznanski, OMS III; Reem Abu-Sbaih, DO; Sheldon C. Yao, DO

Abstract

Dacryostenosisisfoundinupto20%ofnewbornsandupto6%aresymptomatic.While90%ofcasesresolvespontaneouslywithin6months,therateofspontaneousresolutiondecreasesafter6months,andinvasivetreatmentmaybenecessary.1Thestandardofcareforsymptomaticpatientsyoungerthan6monthsisnasolacrimalmassageandtopicalantibioticsasneeded.After6monthsofage,nasolacrimalprobingunderanesthesiamayberequired.Theauthorspresentacaseofpersistentdacryostenosisina9-month-oldmalepatientwithrecurrentepiphoraandoculardischargesincebirth.Hewasscheduledforsurgicalnasolacrimalprobingbecauseheshowedlittleimprovement

www.academyofosteopathy.org

http://www.uptodate.com/contents/nasolacrimal-duct-obstruction-dacryostenosis-in-children/abstract/4

http://www.uptodate.com/contents/nasolacrimal-duct-obstruction-dacryostenosis-in-children/abstract/4


The following submission won first place in the students’ clinical research category in the Louisa Burns Osteopathic Research Committee’s poster presentation at the AAO Convocation in Colorado Springs, Colorado, on March 21, 2014.

IRB approval: NYIT-IRB-BHS-957. May 21, 2013.

Context

Parkinsondisease(PD)isasevereneurodegenerativediseasewhosetreatmentinvolvesamultifacetedapproach.Osteopathicmanipulationmedicine(OMM)mayplayanimportantroleinPDmanagement.

Objectives

ThisstudywasdesignedtodeterminethedifferenceinthepresenceofsomaticdysfunctionsandthetreatmentapproachwithOMMbetweenPDcasesandmatchedcontrolcases.

Methods

ThisretrospectivecasecontrolstudywasconductedattheAcademicHealthCareCenterattheNewYorkInstituteofTechnologyCollegeofOsteopathicMedicine(NYIT-COM)usingchartsofpatientsseenfromJanuary1,2010,toAugust1,2013.AsearchoftheelectronicmedicalrecordsystemeClinicalWorks©wasperformedusingInternationalClassificationofDisease9th(ICD-9)codes.TheICD-9codesforPD(332.0)andthoracicsomaticdysfunction(739.2)weresearched,yielding322chartsofpatientswithParkinsondisease.Ofthese,80metourinclusioncriteria.ThecontrolgroupwasidentifiedbyICD-9codesforthoracicsomaticdysfunction(739.2)andamusculoskeletalcomplaint:lowbackpain(724.2),backpain(724.5),thoracicbackpain

Is There a Place for Osteopathy in Parkinson Disease Management? A Retrospective Case Control StudyMichael P. Catanzaro, OMS III; Kathleen M. Vazzana, OMS IV; Annie Chen, OMS II; Jayme D. Mancini, DO, PhD; Sheldon C. Yao, DO

(724.1),cervicalgia(723.1),andsacrococcygealdisorders(724.6).Thecaseswerematchedtocontrolsbyage,gender,andtreatingphysician.OutcomesweremeasuredbycomparingthepresenceofsomaticdysfunctionsofeachbodyregionbetweenthegroupsusingMcNemar’stestwithalphasetat0.05.Thenumberofbodyregionstreatedineachgroupandthefrequencyofuseofactiveandpassivetechniqueswerealsorecorded,andtheywerecomparedusingpairedt-tests.

Results

Parkinsondiseasecaseshadsignificantlymorehead/cranial(p <0.01,or=0.21)andcervicalsomaticdysfunctions(p = 0.01,or=0.28).Thecontrolcaseshadsignificantlymorepelvicsomaticdysfunctions(p <0.01,or=3.14).PDcasesreceivedOMMtreatmentsinsignificantlymorebodyregionsthanthematchedcontrolcases(p <0.01,CI[-1.184,1.466]).Therewasnosignificantdifference betweenthefrequencyofuseofdifferentpassive(p =0.148,CI[-0.0690,0.4487])andactive(p =0.242,CI[-0.0516,2016])treatmenttechniquesbetweenPDcasesandcontrolcases.

Conclusion

Head/cranialandcervicalsomaticdysfunctionsweresignificantlygreaterintheParkinsondiseasecases,indicatingthatpatientswithPDmaybemoresusceptibletodysfunctionsintheseregions.PDcasesalsoreceivedtreatmentinsignificantlymorebodyregionsthanthecontrolcases.ThesefindingscanhelptoestablishaPDOMMprotocol.AdditionalstudiesshouldbeaimedatcorrelatingsuccessfultreatmentoftheseregionswithimprovedqualityoflifeinpatientswithPD.


Osteopathic Manipulative Treatment in Vestibular Neuritis: A Case ReportBrendon S. Ross, DO, MS; Virginia M. Johnson, DO, C-NMM/OMM

Abstract

Vestibularneuritisisabenign,self-limiteddiseaseprocesscharacterizedbynew-onsetvertigowithsymptomspersistingfordaysormonths.Currentmedicalmanagementwithmedicationandvestibularrehabilitationexerciseshasshownlimitedsuccess.Thefollowingcasereporthighlightstheuseofosteopathicmanipulativetreatment(OMT)ina56-year-oldmalepatientwhodevelopedvestibularneuritisfollowingdentaltrauma.Thepatientreportedasignificantimprovementinhisvertigosymptomsinbothfrequencyanddurationfollowingmultiplesessionsofosteopathicmanipulationtargetingthecraniocervicalregionsandtemporalmandibularjoint(TMJ).Osteopathicevaluationandmanipulativetreatmentshould,therefore,beconsideredinthetreatmentofpatientsdiagnosedwithvestibularneuritis.

Introduction

Currentunderstandingofthepathophysiologicmechanismsandappropriatetreatmentofpatientsforvestibularneuritisremainsincomplete.Disablingvertigoisthehallmarksymptomofthisdiseaseprocess.Mostcurrenttreatmentsaimtomanagetheautonomicsymptomsassociatedwiththecondition—nausea,vomiting,andvertigo—byusinganticholinergics,antihistamines,orantidopaminergicagents.Thesetreatmentshavehadminimalsuccess.Corticosteroidshavebeenshowntosignificantlyimprovevestibularfunctioninpatientsata1yearfollow-upcomparedtopatientstakingplacebo,butvalacycloviraloneorincombinationwithcorticosteroidsprovidedlittlebenefit.1Recentresearchindicatesthatvestibularrehabilitation

exerciseprescription,specificallyCawthorneCookseyexercises(Table A)andbalancetrainingusingtheNintendoWiimayaidintherecoveryprocessfromthiscondition.2,3Giventhesuccessofosteopathicmanipulativetreatmentinothertypesofvertigo,adistinctiveosteopathicapproachinthetreatmentofthisdiseaseprocessshouldalsobeexplored.

Vestibularneuritisisdefinedasabenign,self-limiteddiseasecharacterizedbynewonsetvertigo—thephysicalsensationofmotioninone’sselforenvironment—withassociatedautonomicsymptoms,primarilynauseaandvomiting.4ThissyndromewasfirstdescribedbyDixandHallpikeasadistinctivedisturbanceofthevestibularfunctionleadingtovertigowithoutassociateddeafnessortinnitus.5Thepersistenceofsymptomsfromdaystomonths—alongwiththeabsenceofhearingloss—differentiatesthisdiseaseprocessfromMenieredisease(Table B, page 28).Thevertigomaybesosevereastooftenrequireimmobilitytocopewiththeattacks.


In bed or sittingEyemovements(firstslowly,thenquickly):upanddown,sidetoside,focusingonfinger

movingfrom3feetto1footawayfromfaceHeadmovements(firstslowly,thenquicklywitheyesopenandthenwitheyesclosed)BendingforwardandbackwardTurningfromsidetoside

SittingEyemovementsandheadmovementsasaboveShouldershruggingandcirclingBendingforwardandpickingupobjectsfromtheground

StandingEye,head,andshouldermovementsasbeforeChangefromsittingtostandingpositionwitheyesopenandthenclosedThrowingasmallballfromhandtohand(aboveeyelevel)ThrowingaballfromhandtohandunderkneeChangingfromsittingtostandingandturningaroundinbetween

Moving aboutWalkacrosstheroomwitheyesopenandthenclosedWalkupanddownslopewitheyesopenandthenclosedWalkupanddownstepswitheyesopenandthenclosedAnygameinvolvingstooping,stretching,andaiming,suchasbowlingorbasketball

Table A. Vestibular Rehabilitation Exercises


righthandforfourmonths.Thepatientdeniedanytraumaticincidentsormotorvehicleaccidentsassociatedwiththeonsetofsymptoms.Uponfurtherquestioning,thepatientstatedthatmostofthesesymptomsstartedafterbeingimmobileinbedforprolongedperiodsoftimesecondarytosevereattacksofvertigo.Reviewofsymptomsrevealedringinginhisrightearoccasionallybutwasotherwisenegative.

History

Sixmonthspreviously,thepatienthadanuppertoothabscessrequiringextensivedentalwork,includingdentalextractionandsubsequentimplantsoftemporarycrownsplacedinhisupperleftmaxillarymolarregion.Itwasafterthepatientunderwentdentalextractionrelatedtotheabscessthathesufferedthefirstterribleattackofdizzinessandnauseadescribedasacutevertigo.Heunderwenttestingatalocalemergencydepartmenttoruleoutemergentconditionscausinghisacutevertigo,allofwhichwerenegative.Thepatientwaslaterseenbyseveralphysiciansforthiscondition,andhehasundergoneextensiveimagingstudies,includingcomputedtomographyandmagneticresonanceimagingofthehead,neck,andinnerearwithunremarkableresults.Hiscurrentneurologistprovidedthediagnosisofvestibularneuritis.Thepatienthadbeentreatedwithcorticosteroidsandantihistamineswithnoappreciablesuccess.

Theepisodesofvertigohadbeenrecurrentsincetheinitialattack,restrictinghisdailyactivitiesaswellasputtinghiminbed,immobilizedforlongperiodsoftime.Thedentalworkwasstillongoingwithhiscurrentdentist.Pastmedical,family,andsurgicalhistoriesarenoncontributory.Thepatienthadnoknowndrugorseasonalallergies.Thepatienthassmoked10cigarettesperdayonaverageformorethan10years.Thepatientdeniesusingalcohol,caffeine,orrecreationaldrugs.

Physical Examination

Vitalsignswerewithinnormallimitsforthispatient.Physicalexaminationwassignificantfortissuetexturechangesandtendernesstopalpationinthesubocciptalmusclesandtemporalmandibularjointsbilaterally,aswellasinthethoracicinletbilaterally.Atemporarydentalcrownwasnoted

Vestibularneuritisisthoughttoberelatedtoanantecedentviralupperrespiratorytractinfection,althoughthistheoryhasyettobevalidated.Thisdiseasehasbeenreportedtooccurinmultiplefamilymembersaffectedbyanupperrespiratorytractinfectionandhasseasonalvariation,whichstrengthenstheviralprodromaltheory.6Vestibularneuritisisassociatedwithselectivedamagetothesuperiorpartofthevestibularlabyrinth(horizontalandanteriorsemicircularcanalsandutricle).7Thesubsequenthypofunctioningofthevestibularapparatusinmaintainingbalanceresultsinvertigo,whichmaylastforweeksormonthsafterthefirstacuteepisode.Clinically,thisdisordertendstoaffectyoungtomiddle-agedadults,anditseemstohavenosexpreference.

Researchonincorporatingosteopathicmanipulativetreatment(OMT)intothetreatmentplanofpatientssufferingfromvertigoandbalanceissuesisgrowingconsiderably.TheabilityofthegrowingelderlypopulationoftheUnitedStatestomaintainbalanceisofparamountconcerninthepreventionoffalls.8,9Inarecentstudy,Fraixdemonstratedthatpatientssufferingfrombenignparoxysmalpositionalvertigo(BPPV)whoreceivedOMTshowedstatisticallysignificantimprovementinthedizzinesshandicapinventoryandinthephysical,functional,andemotionalsubscales.10

Thisreportpresentsthecaseofa56-year-oldmalepatientwithonsetofvestibularneuritisfollowingextensivedentalinterventionwithprobablemechanicaleffectsonthestructuralandfunctionalintegrityofthetemporalmandibularjointandthetemporalbone.AfterreceivingOMTforsixweeks,thepatientreportedsignificantimprovementinhisvertigoandassociatedmusculoskeletaldysfunction.

Report of Case

Presentation

A56-year-oldCaucasianmanpresentedtotheOMMclinicatWesternUniversityofHealthSciencesPatientCareCenterinPomona,California,foranosteopathicevaluationregardingachiefcomplaintoftinglingandoccasionalnumbnessinhisrightarm,affectingmostlythefourthandfifthdigitsofhis

Seconds Hours Days Months

• perilymphaticfistula• cervicalvertigo• diplopia• positioningvertigo• BPPV

• Menieredisease• syphilis• vestibularmigraine

• vestibularneuronitis• labyrinthitis• headtrauma

• acousticneuroma• cerebellartumor• multiplesclerosis• ototoxicity• ateriovenous

malformation

Table B. The persistence of symptoms from days to months along with the absence of hearing loss differentiates vestibular neuritis from Meniere disease.




patient’supperextremitycomplaintsandsomaticdysfunction.Asegmentofthepatient’sOMTtargetedthesuboccipitalmuscles,whichareintegralinthereflexarcsaffiliatedwithoureyemovements,balance,andthevestibularsystem.12Therestorationofnormalstructureandfunctionoftheheadandoccipito-atlantalregionsusingosteopathiccranialmanipulativemedicine,however,remainedtheprimaryfocusoftreatmentforthispatient,givenhishistoryofdevelopingvertigoafterhisinitialdentalprocedures.

Post-treatment,thepatientreportednoadverseeffects.Thepatientwasinstructedtomonitorhissymptomsandthefrequencyofvertigoattacks.Counselingonsmokingcessationwasperformed,givenhissmokinghistory.Thepatientwasalsoinstructedtodrinkplentyofwater,andhewaseducatedregardinganytransienttreatmentreactionssuchassorenessandmildmyalgiathatmaydevelop24to48hourspost-treatment.

Clinical Follow-up

Thepatientwasfollowedonaweeklybasisandreceivedosteopathicmanipulationbasedonhissubjectivecomplaintsandstructuralexaminations.Thecontinuedprimaryfocusoftreatmentwasontherestorationofnormalstructureandfunctionoftheheadandoccipito-atlantalregions.Atthefifthfollow-upvisit,thepatientreportedalmostacompleteresolutionofhisupperextremitycomplaints,withinfrequenttinglingandnumbnessinhisrightupperextremityandhand.

Onthesixthfollow-upvisit,thepatientreportedreduceddizzinessrelativetowhenhewasfirstseenintheclinicsixweeksprior.Hestillhadoccasionalflaresofvertigo,morenoticeableintheafternoon,butthetimingandfrequencydecreasedappreciablyoverall.Therightupperextremitycomplaintsremainednearresolution,withinfrequentepisodesofnumbnessandtingling.Thepatientwaspracticingpilatesdaily,andaftersixweeks,hewaspleasedwiththeoverallprogressofhissymptomsrelatedtohisvestibularneuritisandthoracicoutletsyndrome.

Discussion

Thedentaltraumaandproceduresourpatientenduredrequiredextensivetimewithhismandibleopen,leavingthemandibleandtemporalbonesusceptibletomalalignmentduetotheeffectonligamentsandmusclesintheregion.Bothofthesebonesshareanintricaterelationshipwiththemuscular,ligamentous,andbonycomplexoftheTMJandassociatedtemporalbones.MagoundescribedhowmalalignmentofthesebonystructurescausesassociatedmuscularspasmssurroundingtheTMJfromdentaltrauma,causingmyoduralandmembranousstrainscomprisingtemporalbonemotion.13,14ThispatienthadbilateralTMJdysfunction,tenderness,andtemporalishypertonicitysecondarytohis

ontheleftuppersecondmolar,andtheabsenceoftheleftlowersecondmolarwasnoted.Nystagmuswaselicitedonthelateralgaze,andthetympanicmembraneswereclearwithreflectiveconesoflight.Cardiovascularandrespiratoryauscultationandexaminationwerenoncontributory.Abdomenwassoft,nondistended,andnontendertopalpationwithequalbowelsoundsinallfourquadrants.Lumbarspinerevealedropytissuetexturechangeswithmilddecreaseinoverallrangeofmotion.NeurologicalexaminationrevealednogrossdeficitsincranialnervesII-XII,normalstrengthandreflexesintheupperandlowerextremities,butdiminishedsensationtolighttouchinthelateralaspectoftheleftthighandproximallowerleg.VertigosymptomswerenotelicitedwiththeDix-Hallpikemaneuver.

Osteopathic Structural Examination

Osteopathicstructuralexaminationrevealedarightlateralstrainatthesphenobasilarsynchondrosiswithassociatedrightoccipitomastoidsutureandrightcondylarcompressioninthecranialregion.Therewashypertonicitybilaterallyinthetemporalismuscles.ThecervicalvertebraewerecompressedatC2/C3withC2rotatedright,andribs1and2ontherightwereelevatedandrestrictedininhalation.ThethoracicspinehadadecreasedkyphoticcurvaturewithT2andT5havingFSRrandESRrdiagnoses,respectively,andthethoracicdiaphragmwasheldininhalation.Lumbarspineexaminationrevealedlumbosacralcompression.Examinationofthepelvicandsacralstructuresrevealedbilateralhipmotionrestrictionwithaleftleglengthdiscrepancyof1mmto2mm.Arightposteriorlyrotatedinnominatewasalsodiagnosedinthepelviswithanassociatedrightonleftbackwardsacraltorsion.

Diagnoses

Diagnosesincludedvestibularneuritisandthoracicoutletsyndrome,giventheneurologicalcomplaintsthepatienthaduponinitialpresentation.Somaticdysfunctionofthehead,cervicalspine,ribcage,thoracicspine,lumbarspine,pelvis,andsacrumwerealsodiagnosedinthispatient.Thereweredistinctstrainpatternsthatmostlikelydevelopedinresponsetohisdentalworkinthecranium,andtherewerenotablefascialstrainsinthelumbosacralregionandhips.

Treatment

Theperiodsofimmobilitysecondarytothevertigomayhavecontributedtocompensatorychangesinthestructureandfunctionofhisbody,whichwereconsideredthelikelycauseofthethoracicoutletsyndrome.TheapplicationofvariousOMTtechniques,suchasbalancedligamentoustensionandmyofascialrelease,11tospecificanatomicalstructuresrestoredadegreeofstructuralbalanceandsymmetryforthispatient.Forexample,theshouldergirdle,scalenemuscles,thoracicinlet,andcervicalspinetreatmentsfocusedonaddressingthe




dentalhistory.Furthermore,anychangestoocclusionthatmayhavebeenintroducedbytheextractionortheplacementofhistemporarycrownmayhavedisruptedlong-establishedmechanicalrelationshipsintheregionoftheTMJandthetemporalbone,whichhousesthevestibularapparatusalongwithitsarterialandnervesupply,aswellasthelymphaticandendolymphaticsystems.

Themotionofaxisforthetemporalbonerunsalongthepetrousridgefromthejugularsurfacetothepetrousapexandengagesininternalandexternalrotationduringnormalphysiologicmotion.15Thepetrousridgeisalsoamajorareaofattachmentforboththeupperandlowerportionsoftheduralmeninges.ThevestibularportionofCNVIII,whichisresponsibleforequilibrium,passesthroughthefacialcanaltotheinternalauditorymeatusofthetemporalbone.Anydiscrepancybetweenthecoordinatedmotionsofthetemporalbonesandvestibularfiringpatterns,whichmayoccurafterdentaltrauma,couldcausethecentralnervoussystemtointerpretthissignalabnormally,andvertigoanddizzinessmaydevelop.13MagounhypothesizedthatduraltensionsurroundingCNVIIIcanalsoleadtoloweredresistancetoinfection,afactorthatmayhavesignificancegiventheviralprodromethoughttobeassociatedwithvestibularneuritis.14Additionally,earlydiscoveriesbyYoungrevealedthatpharyngotympanicbackwashandincreasesinlabrynthinefluidpressurescanleadtoendolymphaticdistortionsresultinginvertigo.16Restoringnormalfunctionofthepatient’sjawmuscles,mandible,maxilla,andtemporalbonesusingbalancedmembranousandligamentoustensionwasemployedtoattempttorestoretemporalbonemotionandCNVIIIfunction.

Sphenoidalmotionwillalsobeinfluencedbyaffectingthe“strut-like”Vomerthroughmaxillarymanipulationandbyaffectingtheconnectionstomandibularmotionthroughthepterygoidplatesandsphenomandibularligament.Normalmotionofthesphenoidwillassistinrestoringphysiologicmotionandmechanicaltensionacrossthevariousduralattachmentsinthereciprocaltensionmembranesystem,allthewaydowntothesuperiororanteriorportionofS2andthecoccyx.17

Conclusion

Ballesterosetaldescribehowtheendolymphaticsystemoftheinnerear,whichiskeyinvestibularfunctioning,sharesindirectbutimportantembryonicandstructuralrelationshipswiththesurroundingcraniocervicalregionandtheTMJ.16Magounisquotedassaying,“Intheauthor’sexperiencebyfarthecommonestcause[ofvertigo]isanincreaseincraniocervicaltensionandaconsequentshiftintemporalbonepositionfromtheunequalpullofmusclesorfromtrauma.”18Disruptionandasymmetryincraniocervical

biomechanicswillprecipitatechallengesinothersystems,suchasmetabolic,respiratory,circulatory,biopsychosocial,and—mostimportantlyinthiscase—neurologicfunctioning,namelythevestibularsystem.

TargetingOMTtorestorecraniocervicalandtemporalbonestructuralsymmetryhelpeddiminishthedisablingvertigointhispatientandnormalizedthesensorineuralfiringofthevestibularsystemafter6OMTsessions.ThiscasedemonstratestheinfluenceOMTcanhaveoutsideofthemusculoskeletalorbiomechanicalsystem,anditdemonstratesthatOMTshouldbeanappropriatemodalitytoconsiderwhenencounteringvestibularneuritisclinically.

References1. StruppM,ZinglerVC,ArbusowV,NiklasD,MaagKP,DieterichM,

etal.Methylprednisolone,valacyclovir,orbothforvestibularneuritis.N Engl J Med.2004Nov25;351(22):2344-5.Availableat:http://www.nejm.org/doi/full/10.1056/NEJMoa033280.AccessedApril7,2014.

2. SparrerI,DuongDinhTA,IlgnerJ,WesthofenM.VestibularrehabilitationusingtheNintendo®WiiBalanceBoard–auser-friendlyalternativeforcentralnervouscompensation.Acta Otolaryngol.2013,133:239-245.Availableat:http://informahealthcare.com/doi/abs/10.3109/00016489.2012.732707.AccessedApril7,2014.

3. CornaS,NardoneA,PrestinariA,GalanteM,GrassoM,SchieppatiM.ComparisonofCawthorne-Cookseyexercisesandsinusoidalsupportsurfacetranslationstoimprovebalanceinpatientswithunilateralvestibulardeficit.Arch Phys Med Rehabil.2003Aug;84(8):1173-84.Availableat:http://www.sciencedirect.com/science/article/pii/S0003999303001308.AcessedApril7,2014.

4. HalmagyiGM,WeberKP,CurthoysIS.Vestibularfunctionafteracutevestibularneuritis.Restor Neurol Neurosci.2010;28(1):37-46

5. AllanH.Ropper,MartinASamuels.Adams&Victor’sPrinciplesofNeurology.Chapter 15-Deafness, Dizziness, and Disorders of Equilibrium: Vestibular Neuritis [Neuronitis], 9e.Copyright2009.

6. BalohRW.Clinicalpractice.Vestibularneuritis.N Engl J Med.2003Mar13;348(11):1027-32.Availableat:http://www.nejm.org/doi/full/10.1056/NEJMcp021154.AccessedApril7,2014.

7. GoebelJA,O’MaraW,GianoliG.Anatomicconsiderationsinvestibularneuritis.Otol Neurotol.2001;22:512-8

8. Fraix,M.Roleofthemusculoskeletalsystemandthepreventionoffalls[Evidence-BasedClinicalReview].J Am Osteopath Assoc.2012;112(1):17-21.Availableat:http://www.jaoa.org/content/112/1/17.long.AccessedApril7,2014.

9. NollDR.ManagementofFallsandBalanceDisordersintheElder.J Am Osteopath Assoc.2013;113(1):17-22.Availableat:http://www.jaoa.org/content/113/1/17.long.AccessedApril7,2014.

10. FraixM.Osteopathicmanipulativetreatmentandvertigo:apilotstudy.PM R.2010Jul;2(7):612-8.Availableat:http://www.sciencedirect.com/science/article/pii/S1934148210003060.AccessedApril7,2014.

11. O’ConnellJA.Myofascial Release Approach. In:AnthonyG.Chila,DO,ed.Foundations of Osteopathic Medicine, 3rd Edition.AmericanOsteopathicAssociation.Philadelphia,PA:LippincottWilliams&Wilkins;2011:698-727.

12. BoltonP.Thesomatosensorysystemoftheneckanditseffectsonthecentralnervoussystem.J Manipulative Physiol Ther.1998;21:553-563.



http://www.nejm.org/doi/full/10.1056/NEJMoa033280

http://www.nejm.org/doi/full/10.1056/NEJMoa033280

http://informahealthcare.com/doi/abs/10.3109/00016489.2012.732707

http://informahealthcare.com/doi/abs/10.3109/00016489.2012.732707

http://www.sciencedirect.com/science/article/pii/S0003999303001308


http://www.nejm.org/doi/full/10.1056/NEJMcp021154

http://www.nejm.org/doi/full/10.1056/NEJMcp021154

http://www.jaoa.org/content/112/1/17.long







Abstract

Astheglobalburdenofdiseaseshiftsawayfromcommunicablediseasestowardnoncommunicablediseases,newmodelsforsurveillancewillimproveinterventionstrategies.Apilotstudywasdesignedtotestthehypothesisthatasinglesurveymodelwithdirecthomeinterviewsandcollectionofhealth-relatedmeasurementscouldbeappliedglobally.Thestudy’sgoalwastodeterminetheutilityofthismodelintwodivergentcommunitiesasameansofassessingthegeneralhealthstatusandbasicmedicalknowledgeofthecommunity.Lebanon,Oregon,andLobitos,Peru,aretworuralcommunitiescontinentsapartthatwerechosenbecausetheyareeasilyaccessible,representativeofsmallunderservedcommunities,andsafe.Healthquestionnaireresponseswerecompiledandanalyzedascontingencytables,usingtwo-tailedFisherexacttests.Statisticalresultsrevealedthattheanswerstoquestionspertainingtoeducation,preventivehealthcare,andlifestyledifferedsignificantlybetweentheLebanonandLobitoscommunities.Limitationstothestudyreflectintrinsicallyflawedaspectsofthedoor-to-doorsurveymethod,questiondesign,andflowofthesurveyquestions.However,theresultssuggestthatthismodelmaybeusefulforidentifyinggapsinmedicalknowledgeandcareaccess.Further,thishealthdatacollectionmodelavoidsinherentbiasesinself-reportingofcurrenthealthstatus.Thisstudyallowsforfurtherdevelopmentofacollectiveanddigitizedcommunityassessmentsurveymodelthatcouldbeimplementedwithinanyglobalcommunity.

Introduction

Advancesintechnology,communication,andeconomicshaveledtoagradualshiftintheglobalburdenofdiseasefromcommunicabletononcommunicablediseases.1,2Cardiovasculardisease,respiratorydisease,cancer,andtype2diabetesmellitusarethefourmostcommonnoncommunicablediseases,andtheyareresponsiblefor36milliondeathsworldwideeachyear.3-6Amongthemostcommonnoncommunicablediseases,80%sharefourcommonriskfactors:tobaccouse,physicalinactivity,harmfuluseofalcohol,andpoordiet,4clearlyillustratingthatthe

mostcommoncausesofdeathworldwidearepreventable.Whentargetingtheareasofgreatestneedforimprovement,globaleffortstowarddiseasepreventionmustbeunifiedtounderstandandintegrateintoeachcommunity’sculture,beliefs,andvaluesystems.2,7-10Developingauniversalassessmenttoolthatcanbeimplementedanywhereintheworldtoobjectivelymeasurecommunityhealthwillgreatlyimprovedecisionmakingandquantifytheimpactofapublichealthinterventionorprogram.2,11,12

ThesiteschosentoimplementthecommunityassessmentsurveytoolwereLebanon,Oregon,andLobitos,Peru.Thesetwocommunitiesdifferinregardtogeographiclocation,culture,socioeconomicstatus,availableresources,andaccesstohealthcare.13-16Apilotstudyinthesetwolocationswasconductedtotestamodelofcommunityhealthscreening.Thegoalofthisworkistodevelopanassessmenttoolthatcanbeappliedinavarietyofsettingstobettercharacterizehealthstatusandidentifypotentialareasofintervention.12,17

LobitosisasmallfishingvillagelocatedinthenorthwestdistrictofTalara,withintheprovinceofPiura.16,18AccordingtoPeru’sMinistryofHealth,1,624individualsliveinLobitos,andthereiscurrentlyonlyonehealthcareworkertoservethecommunity.15,16Lebanon,population15,305,isaruralcitywithinLinnCounty.14Itsbeginningsarebasedinthetimberandsawmillindustries,andmorerecently,ithasbecomehometolightindustrialandmanufacturingcompanies.13,19

In2015,LebanonwelcomeditsfirstclassofosteopathicmedicalstudentstotheNorthwestcampusoftheWesternUniversityofHealthSciencesCollegeofOsteopathicMedicineofthePacific.20Medicalstudentsarerequiredtotakeaservicelearningcoursethatlinksmedicalstudentswithcommunityprogramsandprovidesmentorshipopportunitiesforlocalstudents.21ThearrivalofthenewmedicalstudentsandtheirworkwithinthecityofLebanonhavefocusedattentionontheneedforclearmeasurablebaselinedataregardinghealthstatus,healthinformation,andadoptionofhealthylifestyles.Collectingsuchdatawillallowfuture

Health Status Comparison of Lebanon, Oregon, and Lobitos, Peru: A Pilot Study Using a Novel Investigative Study ToolKathryn E. Kimes, OMS III; David F. Goldman, OMS III; Meghan Aabo, OMS III; Dave Aabo, MS; Katherine Peters, OMS III; Katie Zeiner, MAg; Kate McCaffrey, DO; John T. Pham, DO; Robyn Dreibelbis, DO; John Mata, PhD



assessmentsoftheimpactfromtheinfluxofosteopathicmedicalstudentsinvolvedwiththeircommunity.22,23

CommunityhealthassessmentsareoftenconductedintheUnitedStatesbycountypublichealthdepartments;however,dataarereportedforentirecountiesratherthanforindividualcitiesandtowns.24Ruralcommunities,suchasLebanon,facecircumstancesthatdifferfromothercitieswithinLinnCounty,Oregon,andthusthecountydataarenotnecessarilyrepresentative.

Methods

Thestudydesignisacross-sectionalsurvey.Themethodology,surveyquestions,andconsentformswereapprovedbytheInstitutionalReviewBoardoftheWesternUniversityofHealthSciencesinPomona,California.Designatedgroupsoftwotothreetrainedmedicalstudentvolunteersadministeredthedoor-to-doorcommunityassessmentsurvey.Eachsitewasdividedintodistricts,andteamsadministeredsurveys.Eachteamofsurveyadministratorswasassignedtoadistrict.Therandomsamplingprocedureconsistedofdeterminingthegeographiccenterofeachdistrictandchoosingadirectioninwhichtheteamwouldbeginthedoor-to-doorsurveyatrandom.Asamplingintervaloffourwasselectedpriortocommencementofsurveyadministration.Everyfourthhousewasvisitedtominimizeselectionbias.Inclusioncriteriaforstudyenrollmentwereasfollows:59monthsofageorolderandcurrentresidentofLebanonorLobitos.Exclusioncriteriaofenrollmentwereasfollows:tooillorunabletoproviderequiredinformation,absentfromhomeonmorethan3occasions,refusaltoparticipate,orrefusaltosigntheinformedconsent.Uponmeetinginclusioncriteria,participantswereregisteredwiththeirname,sex,address,anddateofenrollment.Eachparticipantwasassignedastudynumberbasedondistrict,householdnumber,andnumberofindividualswithinthehousehold.Thisuniqueidentifier

ensuredeachparticipantanonymityandprotectionofpersonalhealthinformationduringdataentryandanalysis.

Thecommunityassessmentsurveywasconductedwithintheparticipants’homes.Surveyadministratorsreadeachquestionaloud,andtheparticipantsprovidedverbalresponsestoberecorded.DuetolanguagebarriersinLobitos,eachteamhadanassignedtranslatortoassistthisprocess.Surveyquestionsweredividedintodifferentcategoriesforassessment.Categoriesincludeddemographicsandhealthstatusconsistingofeducation,generalhealth,lifestyle,behavioralhealth,recentmedicalconditions,andimmunizationhistory.Afterallcommunityassessmentsurveyquestionswerecompleted,vitalsignswerecollected,includingheight,weight,pulse,respirationrate,andbloodpressure.Thesamethreeleadinvestigatorstrainedeachmedicalstudentvolunteerininterviewtechniquesandvitalsigncollection.

Aftercompletingthesurvey,datawerecompiledandenteredintocontingencytablesforallnominalandordinaldata.Contingencytableswerecreatedusinglocation(LebanonorLobitos)astheindependentvariableintherows.Dependentvariableswereplacedinthecolumns.All2x2contingencytableswereanalyzedwithGraphPadPrism6.01™,usingatwo-tailedFisherexactteststatisticalanalysistoattaindirectpvalues.Contingencytableslargerthan2x2wereanalyzedwithRversion3.0.1statisticalsoftware.Thesignificancelevelforthisstudywassetasplessthanorequalto0.01(p value≤0.01).

Results

Education

LevelofeducationattainedandemploymentstatusquestionswereaskedofboththeLebanonandLobitoscommunities.LevelofeducationattainedandemploymentstatusweresignificantlydifferentbetweenLebanonandLobitos.AllrespondentsinLebanonhadcompletedprimaryschool,



OMM in Vestibular Neuritis (Continued from page 30)13. MagounHI.Thetemporalbone:Troublemakerinthehead.J Am

Osteopath Assoc.1974;73(10):825.14. MagounHI.Osteopathicapproachtodentalenigmas.Boardof

Fellowship,AcademyofAppliedOsteopathyThesis.DepartmentofNeuromusculoskeletalMedicine/OsteopathicManipulativeMedicine,CollegeofOsteopathicMedicineofthePacific,WesternUniversityofHealthSciences.CourseManualforTheExpandingOsteopathicConcept.2014;43-49.

15. AristeguietaL,OrtizG,BallesterosLE.TheoriesonOticSymptomsinTemporomandibularDisorders:PastandPresent.Int J Morphol.2005;23(2):141-156.

16. DepartmentofNeuromusculoskeletalMedicine/OsteopathicManipulativeMedicine,CollegeofOsteopathicMedicineofthePacific,WesternUniversityofHealthSciences.CourseManualforTheExpandingOsteopathicConcept.2014;3583-104.

17. MagounHI.Thetemporalbone:Troublemakerinthehead.J Am Osteopath Assoc.1974;73(10):825-835.

18. PapeschM.http://www.entcare.co.uk/cawthorne_cooksey_excercises.html

Accepted for publication April 2014.

Address correspondence to:BrendanS.Ross,DOWesternUniversityofHealthSciencesCollegeofOsteopathicMedicineofthePacificDepartmentofNeuromusculoskeletalMedicineandOsteopathicManipulativeMedicine309E.SecondSt.Pomona,CA91766-1854

http://www.entcare.co.uk


Figure 1. Comparison of percent of responders in Lobitos, Peru, and Lebanon, Oregon, for survey questions focused on (a) tobacco use, (b) regular primary care physician (PCP) visits, (c) surgeries, (d) dental exams, (e) eye exams, (f) Pap smears, (g) mammograms, and (h) prostate exams. ** Denotes a significant difference between the two locations (p ≤ 0.01).

Incidence of tobacco use Incidence of regular PCP visits

Incidence of at least one dental exam Incidence of at least one surgery

Incidence of at least one mammogram

Incidence of at least one eye exam Incidence of at least one Pap smear

Incidence of at least one prostate exam


andthemajorityhadcompletedsecondaryeducation.ThemajorityofthoseinLobitoshadnotprogressedpastprimaryschool.NorespondentsinLobitoshadattainedbachelor’sdegreesorhigher,whileonethirdofrespondentsinLebanonhadbachelor’sdegreesorhigher.

AlthoughthelevelofeducationofrespondentswashigherinLebanon,therewassignificantlymoreunemployment.OfthepeoplesurveyedinLebanon,46%wereunemployedcomparedwith3.2%inLobitos.Thereweremanymorestudentsandself-employedpeopleinLobitosthaninLebanon.NoneoftherespondersfromLebanonworked“inhome,”whilethemajorityofworkersinLobitosworked“inhome.”OfworkerssurveyedinLebanon,83%worked“outsidethehome.”

General Health

Thegeneralhealthsectionincludedquestionsonsleep,substanceuse,dentalhealth,screeningexams,andpastmedicalhistory.TherewerenosignificantdifferencesobservedbetweentobaccoorrecreationaldruguseinLebanonandLobitos.Whilesmokingisavaluableindicatorofhealthstatus,only5%ofrespondentsinLobitosreportedsmoking,while12%ofthoseinLebanondid.Notasingleresponderineithercommunityreportedrecreationaldruguse.

Thereportednumberofprimarycareprovider(PCP)visitsdifferedsignificantlybetweentheLebanonandLobitosrespondents.AsshowninFigure 1Bonpage33,morethan80%ofthosesurveyedinLebanonsaidthattheyregularlyseetheirPCPs,comparedwithonly19%ofthoseinLobitos.ThesestatisticsaresupportedbythesignificantdifferenceinthenumberofPCPvisitsinthelastyear.Onlyonerespondent(3.8%)inLebanonhadnotbeentoaPCPinthelastyearcomparedwith32%ofrespondersinLobitos.InadditiontothedifferencesinPCPvisits,thesurveyrevealedasignificantdifferenceinthenumberofsurgeriesbetweenLebanonandLobitos,whilethenumberofhospitalizationsinthepreviousyearwasnotsignificantlydifferent.Morethan80%ofthesurveypopulationinLebanonhadsurgerycomparedwith25%inLobitos(Figure 1C).

Thedentalhealthquestionsrevealedsignificantdifferencesinbrushing,flossing,anddentalexamincidence(Figure 1D).SignificantlymorerespondentsinLebanonhadhaddentalexamsatleastonceandflosstheirteethmorethanthoseinLobitos.However,respondentsinLobitosbrushtheirteethsignificantlymoreoftenthanthosesurveyedinLebanon.Infact,49%ofrespondentsinLobitosbrushtheirteeth3timesormoreperdaycomparedwithonly12%inLebanon.Thisisintriguinginthecontextthat100%ofrespondentsinLebanonhavehadadentalexamcomparedwith40%inLobitos.

PreventivehealthscreeningsweresignificantlymorecommonintheLebanonrespondergroup,withmorepeoplereceivingeyeexams,Papsmears,mammograms,andprostateexams,asseeninFigures 1E, 1F, 1G, and 1H,respectively.

Familyhistoryquestionsfocusedonheartdisease,highcholesterol,diabetes,cancer,andhighbloodpressure.InLebanon,65%ofrespondentshadfamilyhistoriesofcancer,62%hadfamilyhistoriesofhighbloodpressure,50%hadfamilyhistoriesofheartdisease,46%haddiabetes,and38%reportedfamilyhistoriesofhighcholesterol.OnlyoneLebanonrespondent(4%)reportednofamilieshistoryofdisease.InLobitos,50%ofrespondentsreportednofamilyhistoriesofdisease,while20%reportedfamilyhistoriesofhypertension;20%,highcholesterol;17%,cancer;16%,diabetes;and6%,heartdisease.

Lifestyle

Thesurveycollecteddataonthenumberofmeals,thekindoffoodpeopleate,andphysicalactivitylevels.

Withregardtonutritionalintakeonadailybasis,respondentsinLebanonconsumesignificantlymoresupplements,eatmoreservingsofvegetables,andeatmoreservingsofmeatordairythanthoseinLobitos.Fruitconsumptionandnumberofmealsperdaywerenotsignificantlydifferentbetweenthetwocommunities.

ThedatasuggestthatrespondentsinLebanongetsignificantlymorephysicalactivitythanthoseinLobitos.OfthosesurveyedinLebanon,73%gotmorethan5hoursofphysicalactivityperweekcomparedwith39%inLobitos.Therewasnosignificantdifferenceintheamountoftimespentonsedentarybehavior.

Behavioral Health

Thesurvey’sbehavioralhealthquestionsattemptedtoassesssatisfactionlevels,interpersonalrelationships,andstresslevels.Thementalhealthquestionsdidnotshowanysignificantdifferencesbetweenthetwocommunities.Overall,mostpeopleweresatisfiedwiththeircurrentsituations,hadatrustedpersontotalkto,andweresplitwhenitcametocurrentstresslevelsandwhetherstresshadimpactedtheirhealth.CurrentstresslevelswerehigherinLebanonandapproachedsignificance(p=0.03),buttheydidmeetthep value≤0.01thresholdforthisstudy.

Recent Medical Conditions

Atotalof38differentmedicalconditionswereassessed.Whenquestionedaboutsymptomsinthepreviousmonth,onlypainandstuffynoseweresignificantlydifferentfromrespondersinthetwolocations,asshowninFigures 2A and 2Bonpage35,respectively.InLebanon,77%ofpeoplehadsomesortofchronicoracutepaininthepreviousmonth




Figure 2. Comparison of percent of responders in Lobitos, Peru, and Lebanon, Oregon, for survey questions focused on (a) pain in last month, (b) stuffy nose in last month, (c) influenza immunization, (d) influenza immunization knowledge, (e) polio immunization, (f) polio immunization knowledge, (g) measles or MMR immunization, and (h) measles or MMR immunization knowledge. ** Denotes a significant difference between the two sites (p ≤ 0.01).

Incidence of pain in the last month

Incidence of influenza immunization

Incidence of polio immunization

Incidence of measles or MMR immunization

Incidence of influenza immunization knowledge

Incidence of polio immunization knowledge

Incidence of measles or MMR immunization knowledge

Incidence of stuffy nose in the last month


comparedwith23%inLobitos.Discriminationbetweenthetypesorcausesofpainwasnotrecorded.StuffynosewasmorecommoninLebanonthaninLobitos.

Whenaskedaboutsymptomsduringthepreviousthreemonths,onlytype2diabetesmellitus(T2DM)showedsignificance.Theresultsrevealedthat19%ofrespondentsinLebanonhavebeendiagnosedwithT2DMcomparedwithnorespondentsinLobitos.

Immunizations

Immunizationstatusandknowledgeamongstudyrespondentswasassessed.Lebanonhadsignificantlyhigherimmunizationstatusforinfluenza,polio,andmeaselsormeasles,mumps,andrubella(MMR)asshownonpage35inFigures 2C, 2E, 2G,respectively.Lobitoshadahigherimmunizationstatusforhepatitis(datanotshown).Knowledgeofimmunizationstatuswassignificantlyhigherforinfluenza,polio,measles/MMRinLebanonresponderscomparedtothoseinLobitos.Similardatawereobtainedforneisseria meningitidisandtetanustoxoid(Td/TTdatanotshown).Whiletheresultswerenotsignificant,respondentsinLobitoshadmoreknowledgeofimmunizationstatusforhepatitisBthandidrespondentsinLebanon(datanotshown).

Vital Signs

Therewasnosignificantdifferenceinbodymassindex(BMI)orbloodpressurebetweenstudysites.However,therewere10underweightindividualsinLobitoscomparedwithnoneinLebanon.ThemajorityofpeopleinbothcommunitieshadBMIsabovethenormalrange,yetveryfewpeopleineithercommunityreportedfeelingoverweightorobeseintheprevious30days(Figures 3A and 3C onpage37).Incontrast,theobservedandself-reporteddatarelatedtohypertensionwerecloselyalignedinbothcommunities.

Discussion

Education

ThetrendamongLobitosrespondentstobelesseducatedthanthoseinLebanonmaybepartiallyaresultofayoungersamplingpopulationinLobitos.However,someusefultrendsstillemerge.Mostapparentwasthelackofanybachelor’sdegreesorhighereducationinLobitos.Thismaybeduetoadifferenceinopportunityoraccesstohighereducation.Ifthistrendheldtrueinalargersampling,itmayrepresentaneedfortheLobitoscommunity.25

TheaverageageofthesampledpopulationinLebanonwas53.5yearswhereastheaverageageinLobitoswas33.8.ThissuggeststhatthedatamaybebiasedtohavefewerstudentsandmoreretireesinLebanon.Asaresult,retiredmaybeagoodoptiontoaddinfutureiterationsofthesurveybecause

inthecurrentsurvey,retiredindividualswerecountedasunemployed.Furthermore,individualswhoself-identifiedasemployedstudentsalsocreatedinconsistenciesinthedata,astherewereonlyselectionsdenotedforstudentoremployed.Infuturesurveys,itmaybebettertoremoveworks in homeandemployed outside the homeandinsteadlookatself-employedoremployedtodifferentiatebetweenthetwoeconomiesandincreasetheclarityofthequestion.

Tobacco and Drug Use

Interview-basedquestioningpertainingtodruguseisnotablyunreliable.26Plusthegroupinterviewsettingcreatedasituationinwhichsensitiveandprivateinformationcouldhavebeenrevealedtootherhouseholdoccupants,thusviolatingtheconfidentialityofparticipants.Additionally,thesequestionswereplacedatthebeginningofthesurvey,leavinglittletimefortheinvestigatorstobuildrapportwiththeinterviewees.Thesequestionsarebettersuitedforthelifestylesectionlaterinthesurvey,astheymightfitbetterforstudyorganizationandcadence.Finally,therewasnoquestionaboutalcoholuse.Suchaquestionshouldbeincludedinfuturesurveys,asithasbeenshownthatalcoholuseisalargecontributingfactortotheincidenceandprevalenceofnoncommunicablediseases.4

General Health

ConsideringthelackoforalhealthprofessionalsinLobitos,itisinterestingthattherespondentsindicatedahigherfrequencyofbrushingperdayincomparisonwithrespondentsinLebanon.However,Lebanonrespondentsreportedagreateramountofflossing.15ThehigherfrequencyofbrushinginLobitosmaybeattributabletolocalnongovernmentalorganizationsandgovernmenthealthprogramsinthearea.27Afollow-upquestionastohowresidentsobtaindentalhealthcareknowledgemaybeappropriate.

Allofthequestionspertainingtopreventivehealthscreeningsrevealedsignificantdifferencesbetweensites.AgreaternumberofparticipantsinLebanonregularlyvisitedprimarycarephysiciansandobtainedeyeexams,Papsmears,mammograms,andprostateexamscomparedwiththeLobitossample.Itiswellestablishedthatearlyscreeningisparamounttobetteroutcomesforbreastcancer,cervicalcancer,andprostatecancer,aswellasforensuringorimprovingqualityoflife.28ThelowerincidenceofvisitstoprimarycarephysiciansandscreeningexamsinLobitosmaysuggestaneedforpreventivehealthprogrammingwithinthecommunity.Thelackofprimarycareandpreventivescreeningsmaydirectlycontributetothelackofknowledgeofdiseasestatus,whichinturnmaycontributetothediscrepanciesinreportedfamilymedicalhistoriesbetweenLebanonandLobitos.Thesurveydidnotstandardizethequestioningaboutfamilyhistory.




Infuturestudies,forreliability,thisquestionshouldonlyaskaboutthemedicalhistoriesoftherespondents’children,siblings,parents,andgrandparents.

Lifestyle

Althoughbothsiteshadthesamenumberofmealsperday,respondentsinLebanonhadmoreservingsofvegetablesandmeatand/ordairyperday.Inafutureexpansionofthisstudy,itmaybeimportanttoseparatethesequestionstoallowformorespecificdata,assomestudyrespondentshaddifficultydiscussingmeatanddairytogether.Thequestionnairedidnotaskaboutservingsofgrains,whichmaybevaluableinformationforobtainingatruecomparisonoffoodhabits.Futureversionsofthequestionnaireshouldprobablyhaveonefruitcategorytominimizeconfusioncreatedbyaskingaboutservingsoffruitsandservingsofwholefruitsperday.Supplementuseisaverybroadlabel,andafollow-upquestionregardingspecificsupplementswouldallowforgreaterunderstandingofthedifferencesbetweencommunities.

Behavioral Health

Thebehavioralhealthquestionsaddressedsomeofthebasicindicatorsofmentalhealthandwell-being.Expandingon

thesequestionstoinvestigatewhetherpeoplehaveeverfeltdepressedandthenfollowingupwithaquestionaboutclinicaldiagnosesofdepressionmayprovidegreaterinsightintothementalhealthstatusofcommunities.Thismayprovidevaluableinformationforgroupstryingtoprovidecareinthesecommunities.

Recent Medical Conditions

Questionsregardingacuteorchronicpaininthepreviousmonthelicitedabroadspectrumofresponses.Itcouldnotbedeterminedwhetherthepainwasduetoamedicalconditionoranaccident.Takenliterally,thequestionwouldlikelyhavea100%responserate,indicatingsomeepisodeofpaininthepreviousmonth.Asaresult,thisquestiongivesmoreinsightontheculturalperceptionofpain.Withregardtothisstudy,itwouldappearthatrespondentsinLebanonhadalowerthresholdforpain.However,itisalsopossiblethattheresultsareduetoadifferenceintranslationalmeaning,ortheymaybeduetowhichinvestigatoraskedthequestion.Asaresult,thisquestionshouldlikelybesplitintotwoquestions,askingaboutacutepainandchronicpainseparately.Infuturestudies,afollow-upquestionpertainingtothesourceofpainwouldgeneratemorespecificinformation.



Figure 3. Comparison of perception of being overweight (panels A,C) with calculated BMI > 24.9 (Panels B,D) in Lobitos, Peru (A,B) and Lebanon, Oregon (C,D). ** Denotes a significant difference between perception of being overweight with a BMI of 24.9 (p ≤ 0.01).

Lobitos, Peru

Lebanon, Oregon


Theresultsforprevalenceoftype2diabetesmellitus(T2DM)withintherespondentgroupsrevealedthat19%ofLebanonrespondentshavethisdiagnosiscomparedwithnorespondentsinLobitos.Althoughwefeelthisisasignificantnumber,thedataarelikelyskewedbecauseoftheagedifferencebetweenthesampledpopulations.Conversely,thelackofhealthscreeningsinLobitosmaycontributetothelownumberofresponsesforT2DM.Theadditionofaglucosetestinfuturestudieswouldyieldveryinterestingresultsandpotentiallyhelpcommunitiesidentifytheprevalenceof T2DM.

Immunizations

Oneofthemorechallenginggroupsofsurveyquestionsisrelatedtoimmunizationsbecausemanypeopledonotknowordonotrememberwhatimmunizationstheyhaveobtainedintheirlifetime.Somegeneraltrendsemerged.Forinstance,thoseinLebanonreceivedmoreimmunizationsandrememberedgettingthemmoreoftenthandidthoseinLobitos.ThiswastrueformostimmunizationswiththeexceptionofthehepatitisBimmunization.NotonlywererespondentsinLobitosmorelikelytobeimmunizedforhepatitisBthanforanyotherdisease,buttheyalsoknewtheirimmunizationstatusforhepatitsBbetterthandidrespondentsinLebanon.HepatitisBwasalsotheonlyimmunizationforwhichLobitosrespondershadahigherimmunizationstatusthanLebanonresponders.Thereasonforthisresultisnotapparentbutwouldbeaninterestingtopicforfurtherinvestigation.

Vital Statistics

Above-normalbodyweightisanissueamongrespondersinbothsites,asthemajorityofthosesurveyedhadaBMIabovethenormalrange.Whilethisisnotsurprisinggiventheobesitypandemic,itisinterestingtoobservethatthemajorityofrespondentsdidnotfeeloverweight.Ourdatarevealedthattheperceptionofbeingoverweightwassignificantlylowerthanthevitalstatisticscollected(Figures 3A, 3B, 3C, and3D onpage37).GiventhedirectcorrelationbetweenincreasedBMIandtheprevalenceofcardiovasculardisease,diabetes,andcancer,29thisfindingissignificantbecauseasimplesurveywithoutmeasuringvitalstatisticswouldnotrevealthedisparitybetweentheperceptionofobesityandanobjectivemeasureofobesity.

Study Assessment

Theassessmenttoolwasfoundtobeusefulinseveralaspects.QuestionsthatelicitedsignificantdifferencesinresponsesbetweenLebanonandLobitosidentifiedareasthatmaybearesultofdifferencesinhealthcareinfrastructureandculturalnorms.Furthermore,responsesrevealedsimilaritiesbetween

thetwocommunitiesinriskfactorsthatcontributetononcommunicablediseases.

Strongattributesofthedesignofthiscommunityassessmentsurveywerespecificquestionsregardinglifestyleandrecentmedicalconditionsthatarenotcurrentlyavailableviacountycommunityhealthassessments.Thisassessmenttoolcouldallowacommunitytoidentifysubclinicaldiseasesandailmentsanddevelophealthprogrammingandinterventionstopreventortreatspecifiedsymptoms.

Thereareintrinsicaspectstothestudydesignthatcontributedtolowparticipationandskewedresults.First,mostofthedatacollectedreliedonself-reportingfromparticipants.Specifically,surveyquestionspertainingtolifestylechoices,suchasdiet,exercise,tobacco,anddruguse,wereaskedbymedicalstudents,whichmayhavecontributedtoinaccuratereportingofthesedata.26Modifyingthesurveytoallowtheparticipantstoreadandrecordtheirownresponsescouldaddresstheissueofreliabilityandbiasedreporting.30However,ifthesurveyweretoaccommodateself-administeredresponses,wordingofthesurveymusttakeintoconsiderationtheeducationlevelofthestudiedpopulation.

Increasingthenumberofparticipantsisofhighimportancefordatatobecompleteandgeneralizabletothepopulation.Onaverage,thesurveytook1hourtocomplete.Thelackofaforeseenbenefitorincentiveforparticipationcombinedwiththetimecommitmentledtodecreasedstudyenrollment.Paringdownthenumberofquestionsinthesurveywouldmitigatethetimecommitmentandpossiblyleadtogreaterenrollment.

Thelackofinterestonthepartofvolunteerinvestigatorswasdetrimentalbecausethestudyhadtorelyonhighnumbersofinvestigatorstoblanketthetwocommunities.Thelowvolunteerturnoutresultedinadecreasednumberofvisitedhouseholdsand,thus,alowstudyenrollment.Creatinganincentiveformedicalstudentstovolunteerbyincorporatingthesurveyadministrationintotherequisiteservicelearningcourseinthemedicalschoolcurriculumwouldeasilyrectifythisobstacle.

Theusefulnessofthecollecteddataislimitedinthattheresultsofthisassessmentsurveycanbeusedasabaselineonlyiffuturesurveyorsfollowthesameparticipantswithoutenrollingnewparticipants.Ifthesurveyweretocontinuetobeconductedintheoriginalmannerwithenrollmentofnewparticipants,informationcouldnotbeanalyzedtodirectlymeasuretheimpactofhealthprogramsandinterventions.However,continuouscross-sectionalsurveyscouldbeadministeredtoobtainageneralpictureofhealthstatusaslongasinvestigatorsarecarefultonotreportinformationasahealthbaseline.




Conclusions

Thepurposeofthispilotsurveywastoidentifythecurrenthealthstatus,healthmaintenancebehavior,andlifestylechoicesofcitizensinLebanon,Oregon,andLobitos,Peru.Thecollecteddatadidprovidevaluableinsightintothehealthstatusofthetwocommunities,andthedataprovidedinsightintothesurveydesignandprotocol.Thenecessaryinfrastructureforadministeringthissurveyinthefuturemustincludeasetofinstitutionalgoalssothatthesurveycanbeoptimizedtotrackthosegoals.Withsignificantmodification,theimpactofhealthprograms,interventions,andinstitutionscouldbemeasuredandfollowedwiththissurveytool.

Acknowledgments

Theauthorswishtoacknowledgethemedicalstudentvolunteerswhoparticipatedinthecollectionofdata.

References1. CampbellT,CampbellA.Emergingdiseaseburdensandthepoor

incitiesofthedevelopingworld.J Urban Health. May2007;84(3Suppl):i54-64.

2. MaherD,FordN,UnwinN.Prioritiesfordevelopingcountriesintheglobalresponsetonon-communicablediseases.Global Health. 2012;8:14.

3. WorldHealthOrganization.NoncommunicableDiseases.http://www.who.int/mediacentre/factsheets/fs355/en/.

4. WorldHealthOrganization.NewWHOreport:deathsfromnoncommunicablediseasesontherise,withdevelopingworldhithardest.2011;http://www.who.int/mediacentre/news/releases/2011/ncds_20110427/en/index.html.AccessedSeptember3,2013.

5. DeCockKM,SimonePM,DavisonV,SlutskerL.Thenewglobalhealth.Emerg Infect Dis.Aug2013;19(8):1192-1197.

6. KohlerS.CanInternetaccessgrowthhelpreducetheglobalburdenofnoncommunicablediseases?J Public Health Inform.2013;5(2):221.

7. GoodstadtMS,SimpsonRI,LorangerPO.Healthpromotion:aconceptualintegration.Am J Health Promot. Winter1987;1(3):58-63.

8. HillPS,DoddR,BrownS,HaffeldJ.Developmentcooperationforhealth:reviewingadynamicconceptinacomplexglobalaidenvironment.Global Health. 2012;8:5.

9. OliveiraCruzV,McPakeB.Globalhealthinitiativesandaideffectiveness:insightsfromaUgandancasestudy.Global Health. 2011;7:20.

10. StokolsD.Translatingsocialecologicaltheoryintoguidelinesforcommunityhealthpromotion.Am J of Health Promot. Mar-Apr1996;10(4):282-298.

11. PalermoC,RobinsonC,RobertsonK,HiiS.Approachesforprioritisingthenutritionalneedsofrefugeecommunities.Aust J Prim Health. 2012;18(1):11-16.

12. YangH,DuvallS,RatcliffeA,JeffriesD,StevensW.ModelinghealthimpactofglobalhealthprogramsimplementedbyPopulationServicesInternational.BMC Public Health. 2013;13Suppl2:S3.

13. CityofLebanon.FactsSheet.2012;http://www.ci.lebanon.or.us/Modules/ShowDocument.aspx?documentid=2811.AccessedSeptember4,2013.

14. BureauUSC.SexbyagebynativityandcitizenshipstatusforLebanoncity,Oregon.2010;http://www.census.gov/easystats/.AccessedAugust20,2013.

15. InformáticaMdS-OGdEe.PersonaldelMinisteriodeSaludyGobiernosRegionalesporGruposeOcupacionalesDepartamentodePiura-Año2012.2012;http://www.minsa.gob.pe/estadisticas/estadisticas/recursos/RRHHMacros.asp?20.AccessedAugust29,2013.

16. InformáticaMdS-OGdEe.PoblaciónEstimadaporGruposdeEdades,SegúnProvinciayDistritoDepartamentodePiura-Año2013.2013;http://www.minsa.gob.pe/estadisticas/estadisticas/Poblacion/PoblacionMarcos.asp?20.AccessedAugust29,2013.

17. LuotoJ,MaglioneMA,JohnsenB,etal.Acomparisonofframeworksevaluatingevidenceforglobalhealthinterventions.PLOS Medicine. Jul2013;10(7):e1001469.

18. GoddenNJ.GenderandDecliningFisheriesinLobitos,Perú:BeyondPescadorandAmaDeCasa.In:MargaretAlstonKW,ed.Research, Action and Policy: Addressing the Gendered Impacts of Climate Change: SpringerNetherlands;2013:251-263.

19. DuganAK.WhyLebanon?answer:landavailable.Lebanon Express.August03,2011.

20. MedicalSchoolleasesigned.Lebanon Express. May13,2009.21. WUHS.CommunityEngagement&ServiceLearningEducation.

2013;https://www.westernu.edu/northwest-community-engagement.AccessedSeptember5,2013.

22. CarneyJK,MaltbyHJ,MackinKA,MaksymME.Community-academicpartnerships:howcancommunitiesbenefit?Am J Prev Med. Oct2011;41(4Suppl3):S206-213.

23. LandriganPJ,RippJ,MurphyRJ,etal.Newacademicpartnershipsinglobalhealth:innovationsatMountSinaiSchoolofMedicine.Mt Sinai J Med. May-Jun2011;78(3):470-482.

24. LinnCountyPublicHealthCommunityHealthStatusAssessment.LinnCountyHealthServices;2012.http://www.co.linn.or.us/Health/pdf/ph/Community_Health_Assessment_2012.pdf.

25. FernaldLC,KarigerP,HidroboM,GertlerPJ.Socioeconomicgradientsinchilddevelopmentinveryyoungchildren:evidencefromIndia,Indonesia,Peru,andSenegal.Proceedings of the National Academy of Sciences of the United States of America. Oct162012;109Suppl2:17273-17280.

26. RogersSM,MillerHG,TurnerCF.Effectsofinterviewmodeonbiasinsurveymeasurementsofdruguse:dorespondentcharacteristicsmakeadifference?Subst Use Misuse. Aug1998;33(10):2179-2200.

27. WAVESfordevelopment.communityoutreach.2007;http://www.wavesfordevelopment.org/programs/community-outreach/.AccessedAugust28,2013.

28. PaciE,QuagliaA,PannelliF,BudroniM.Theimpactofscreeningandearlydiagnosisonsurvival—resultsfromtheItaliancancerregistries.Epidemiologia e prevenzione.2001;25(3Suppl):9-14.

29. HjellvikV,SelmerR,GjessingHK,TverdalA,VollsetSE.Bodymassindex,smoking,andriskofdeathbetween40and70yearsofageinaNorwegiancohortof32,727womenand33,475men.European Journal of Epidemiology. Jan.2013;28(1):35-43.

30. RamoDE,HallSM,ProchaskaJJ.Reliabilityandvalidityofself-reportedsmokinginananonymousonlinesurveywithyoungadults.Health Psychol. Nov2011;30(6):693-701.

Accepted for publication May 2014.

Address correspondence to:KathrynKimes,[email protected]


http://www.who.int/mediacentre/factsheets/fs355/en/

http://www.who.int/mediacentre/factsheets/fs355/en/

http://www.who.int/mediacentre/news/releases/2011/ncds_20110427/en/index.html

http://www.who.int/mediacentre/news/releases/2011/ncds_20110427/en/index.html

http://www.ci.lebanon.or.us/Modules/ShowDocument.aspx?documentid=2811

http://www.ci.lebanon.or.us/Modules/ShowDocument.aspx?documentid=2811

http://www.census.gov/easystats/

http://www.minsa.gob.pe/estadisticas/estadisticas/recursos/RRHHMacros.asp?20

http://www.minsa.gob.pe/estadisticas/estadisticas/recursos/RRHHMacros.asp?20

http://www.minsa.gob.pe/estadisticas/estadisticas/Poblacion/PoblacionMarcos.asp?20

http://www.minsa.gob.pe/estadisticas/estadisticas/Poblacion/PoblacionMarcos.asp?20

http://www.westernu.edu/northwest-community-engagement

http://www.co.linn.or.us/Health/pdf/ph/Community_Health_Assessment_2012.pdf

http://www.co.linn.or.us/Health/pdf/ph/Community_Health_Assessment_2012.pdf

http://www.wavesfordevelopment.org/programs/community-outreach/

http://www.wavesfordevelopment.org/programs/community-outreach/



Introducing MAAP: The Modified ASIA Examination for Ambulatory PatientsDrew D. Lewis, DO; Jose S. Figueroa, DO; Garth K. Summers, OMS II; J.D. Polk, DO

ofpaingreaterthanonemonth,painwhilesleeping,andunresponsivenesstoprevioustherapies.4,5

Wealsocanconsiderred-flagphysicalexaminationfindingssuchasneurologicalabnormalitiesleadingtosensoryandmotorimpairment,reflexabnormalities,duraltensionsigns,capsularpatternrestrictions,painuponpalpation,andsuchsignificantfunctionimpairmentsasambulatorylimitationsrelatedtoneurogenicclaudication.4,6

Despiteadvancedimagingandotherdiagnostictools,athoroughhistoryandphysicalexamarenecessaryandsignificantcomponentsofanaccuratemusculoskeletaldiagnosis.7

Anappropriateassessmentofmanypatientswithmusculoskeletalpresentationsshouldincludeacorrespondingevaluationforcausativeorconcurrentneurologicdeficits.

WepresentthemodifiedAmericanSpinalCordInjuryAssociation(ASIA)examinationforambulatorypatients(MAAP)indetail.Intheexperienceoftheauthors(DL,JF),thisexaminationisextremelybeneficial,notonlyforproperlydiagnosingpatients’conditionsbutalsoforidentifyingconditionsinwhichanuntowardoutcomemayresultwithoutaMAAPprecedingmanipulativetreatment.

MAAP and the Osteopathic Physician

Asoneofthecoreprinciplesoftheosteopathicmedicalprofession,theinterrelationshipofstructureandfunctionhaslongbeenemphasizedforproperosteopathichealthcare.6(p3)

Inadditiontoprovidingapatientwithstandardmedicalcare,theosteopathicphysicianfocusesonthehostenvironment(structure)whichthepatient’sdiseaseorconditionisinhabiting.6(p12)Theosteopathicphysicianistrainedtoprovideathoroughstructuralexaminationforanddiagnosisofsomaticdysfunctions,withtheexpectationofprovidingosteopathicmanipulativetreatment(OMT)directedatthepatient’sunderlyingcondition.InadvocatingOMTtotreatpatientsforsomaticdysfunctions,textbooksonosteopathicmanipulativemedicine(OMM)pointtoparticulartreatmentapproachesthatmayberelativeorabsolutecontraindications

Abstract

Forthepracticingclinicianevaluatingapatientformusculoskeletalcondition,themodifiedASIAexaminationforambulatorypatients(MAAP)introducedhereisavaluableassessmenttooltohelpidentifyneurologicalred-flagfindingsbeforemakingdecisionsregardingtreatment,especiallyosteopathicmanipulativetreatment(OMT).ThisnewtoolisbasedonandincorporatestheguidingprinciplesusedintheAmericanSpinalInjuryAssociation(ASIA)examination.

PerformingtheMAAPasapartofthethoroughevaluationofpatientsformusculoskeletalconditionscanbeanextremelyusefulguidetoidentifytheappropriateuse,orrestraint,ofOMTinpatientswhomaybeneurologicallycompromised.Itmayalsoidentifypreviouslyundiagnosedneurologicdisease,preventuntowardoutcomes,andhelpphysiciansavoidlitigationfrommissedneurologicdisease.

Wepresentthismodifiedexamination,whichhasbeentailoredtotheambulatorysetting.

Introduction

Recentreportshaveshownadecreaseinskillfulperformanceofthemusculoskeletalexambymedicalstudents.1

Simultaneously,successfullitigationconcerningspinaldiseaseisontheriseinboththeUnitedStatesandtheUnitedKingdom.2Whilethesestatisticsmaybemultifactorial,itisparticularlyconcerningconsideringthewell-documentedhighfrequencyofprimarypatientswithmusculoskeletalconditionsseekingcareinoutpatientclinicsandtheneedforaccuratediagnosis.3

Asphysicians,ourroleistoassesspatientsforconditionsthatmaycausethetheirsymptomsandtoscreenforbothcommonandpotentiallyseriousissuesthatmaybesubclinicalorasymptomatic(preventivehealthcare).Achiefinitialfocusinevaluatingpatientsformusculoskeletalconditionsisassessingforredflagsinhistoriesandphysicalexaminations.4

Forinstance,inthecaseofapatientwithlowbackpain,red-flaghistoryfindingsincludehistoryofcancer,ageolderthan50years,unexplainedweightloss,bowelorbladderincontinenceorretention,impotence,duration



thatusingOMTis“advisabletoachievethemaximumpossiblefunctionalcapacity”ofapatientafterthediagnosisofaneurologicdeficit.9(p52,484)

Thisarticleintroducesaneurologicexamthatcanbeusefulforimprovingtheclinicaldiagnosesofpatientswithneurologiclesions,includingidentifyingsignificantred-flagfindings.Thisexamalsowillserveasaguidetohelpidentifytheappropriateuse,orrestraint,ofOMTinapatientwhoisneurologicallycompromised.

Why We Modified the ASIA Exam

TheAmericanSpinalInjuryAssociation(ASIA)examinationisastandardizedexaminationdevelopedtodocumentimpairmentinpatientswithspinalcordinjuries.TheexamandisendorsedbytheInternational Standards for Neurological Classification of Spinal Cord Injury.10TheASIAexaminationiswellknowntophysicalmedicineandrehabilitation(PM&R)physicians,asphysiatristsareexpectedtobecomehighlyproficientwithitduringtheirresidencies.Theexamination(seeFigure 2onpage42)wasdesignedtobeperformed

incasesinwhichthereareknownorsuspectedneurologicconditions.8

However,manyneurologicdiseasesandimpingementscanmimicorexhibitmusculoskeletalfindings,andtheycanbeconfusedwithanoverusesyndromeorsomaticcomplaint.Withthisinmind,thereisarecognizedneedforanin-depthneurologicexaminationasapartofacompleteassessmentpriortoprovidingOMT.6(p987),9(p300,390,433)

MAAP and OMT

WhenconsideringOMTasapartofthetherapeuticapproach,itisimperativetorelyonanexaminationthatincludesanefficientandeffectiveneurologicalscreentoidentifyredflags.RedflagshelpdictatedecisionsregardinginitiatingOMT,othercommontreatmentoptions,furtherdiagnosticevaluation,andconsultations(seeFigure 1).

Inhistext,GreenmanemphasizesthatthegoalofOMTistorestorethemaximumfunctionalcapacityapatient’sanatomywillallow.Greenmanhighlightedtheimportanceofevaluatingpatientsforneurologicdeficits,andhereported

Figure 1. Proposed algorithm for management of patients presenting with spine pain.

Acute or Chronic Lumbar or Cervical Spine Pain Algorithm



http://files.academyofosteopathy.org/AAOJ/2014/MAAP%20flow%20chart.jpg


ofneurologiclesion,abnormallystrongreflexesareassociatedwithacentralnervoussystemlesion.Centralnervoussystemlesionscanbefurtherevaluatedforthepresenceofhyper-reflexiaorotherpathognomonicresponseswithsuchmeansastheextensorplantarresponseandHoffman’ssign(seeFigure 3).6(p519)Therefore,itbecomesclinicallyrelevanttouse

thereflexassessmentinadditiontopatternrecognitionofmotorandsensoryneurologicabnormalitiestodifferentiatebetweencentralandperipheralnervoussystemlesions.

predominantlyasanacutein-patientspinalcordassessment.Itiscomposedofsensoryandmotorcomponents,anditisdesignedtobeperformedwithpatientsinthesupineposition.TheMAAP,inturn,wasdevelopedfortheoutpatientambulatorysettingemployingASIA’sguidingprinciples.

OurmodifiedversionoftheASIAexamcanbereadilyperformedonambulatorypatientsprimarilyintheseatedpositionduringoutpatientclinicalassessments.

ThegoaloftheMAAPistoscreenforandidentifyanyneurologicmanifestationsorpotentialdiagnosesthatwouldbecontraindicationstomanipulativetreatmentorforwhichmanipulativetreatmentwouldotherwisehavedeleteriousoutcomes.Ifsuchasign,symptom,orlesionisidentified,thenextstepintheneurologicevaluationistoidentifywhetherthemanifestationismorelikelytobeinthecentralnervoussystemortheperipheralnervoussystem.Whilesensationabnormalitiesandmotorweaknessmaybeseenineithertype

Figure 3. Hoffman’s Sign

Figure 2. American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2013; Atlanta, Georgia. Reprinted with permission 2014.10




Important caveats with the examination

Whenevaluatingdeeptendonreflexes,thegoalistoensurereproducibilityofthemaximumresponse.Trytoensurecompleterelaxationofthemusclegroupbeingassessed.

Distractioncanbeusedfordeeptendonreflexes(eg,Jendrassikmaneuver)withoutchangingthegradingoftheresponse.However,ifyouneedtoaugmentareflex(eg,mildlycontractthemuscle),thiswouldrequiredowngradingtheresponse(eg,a2outof4becomesa1outof4).

Averyeffectiveconventionformotortestingisfullcontractionandtryingto“breakit.”

Sensorytestingistypicallyperformedwithlighttouchandpinprick.Askthepatient,“Doyoufeelthisonbothsides,anddoesitfeelnormal?”

Whenpossible,thephysicianshouldusethesamemuscleforsensorytestingasforthemotortesting(eg,abductordigitiminimi).

Ankleplantarflexionmotortestingneedstobedonewithsinglelegcalf-raisewith10repetitions.Gradedownifunabletocomplete.

Conclusion

Inthethoroughevaluationofmanypatientswithpainormusculoskeletalpresentations,itisprudenttoevaluatepatientsforcausativeandconcurrentneurologicissues.RoutinelyperformingastandardizedneurologicexamsuchastheMAAPinconjunctionwiththemusculoskeletalexam,improvesqualityofcarebyscreeningforsignificantconditionsthatmaybecausingorcontributingtopatients’conditions.InpatientstowhomyouareconsideringofferingOMT,usingtheMAAPcanidentifyconditionsforwhichcertaintreatmentapproachesmaybecontraindicated(eg,high-velocity,low-amplitudetechniqueinapatientwithsuspectedradiculopathyofunknowncause).Inaddition,withusingaroutinescreeningneurologicexam,physicianscanexpecttodecreasetheirliabilityandnegativeoutcomesbyimprovingtheiridentificationofconditionswithriskofsignificantmorbidityandmortality.

TheMAAPprovidesaclinicallyusefulscreeninginstrumentformusculoskeletalconditions.Intheexperienceoftheauthors(DL,JF),MAAPis:

• asensitivetooltoscreenforcommonandimportantneurologicconditionssuchascervicalandthoracicmyelopathy,radiculopathy,andperipheralneuropathy;

• arapidwaytohelpdiscriminateconcernofnervoussystemlesiontoanuppermotorneuronorlowermotorneuronlesion.

Introducing MAAP

Lower Quarter (Lumbar Spine or Below)

Inadditiontotheotherphysicalexaminations(rangeofmotion,inspection,palpation,abdominalexam,etc.),itisimportanttoperformneurologictestingonthelowerextremity,inparticulartheL2-S2nerverootsforpatientswithmusculoskeletalsymptomsinthelowerhalfofthebody(lumbarspineandbelow).Theoutcomeofthisexammaynecessitateafurtherorsubsequentfollow-upneurologicexamination.Forinstance,briskreflexesunilaterallyinthelowerextremityoraplantarextensorresponseraisetheconcernthatthepatientmayhaveanuppermotorneuronlesion,inwhichcasetheneurologicexamshouldbeexpandedtoincludetheupperextremity.

Thelowerquarterexamshouldconsistofthefollowing:

Reflexes:patellar(L4),hamstrings(optional)(L5),Achilles’(S1).

Motor:hipflexion(L2),kneeextension(L3),ankledorsiflexion(L4),extensorhallucislongus(L5),ankleplantarflexion(S1).

Sensation:Forrootleveldermatomeassessment,werecommendtheASIApointsforspecificdermatomeassessment.Lighttouchandpinprickcanbeusedforsensorytesting.(See Figure 4 on page 44.)

Upper Quarter (Neck, Shoulder Girdle, Upper Extremity)

Inadditiontotheothertypicalexaminations(rangeofmotion,inspection,auscultation,palpation,etc.),itisimportanttoperformneurologicscreeningontheupperandlowerextremities,inparticulartheC5-T1andL2-S2nerverootsforpatientswithmusculoskeletalsymptomsintheneck,upperextremities,ortrunk.Alesionintheupperthoracicspinalcordmayproduceabnormalneurologicfindingsonlyinthelowerextremities.Findingsmayrangefromobviouslyabnormaluppermotorneuronsignstoonlymildhyper-reflexiaonpatellarandAchillesresponses.SuchfindingsshouldwarrantexaminationbeyondtheMAAPscreen(eg,expandedsensoryevaluationofthetrunk).

Inadditiontotheabove,theupperquarterexamshouldconsistofthefollowing:

Reflexes: biceps(C5),brachioradialis(C6),triceps(C7).

Motor:elbowflexion(C5),wristextension(C6),elbowextension(C7),longfingerflexion(C8),abductordigitiminimi(T1).

Sensation: ForrootleveldermatomeassessmentwerecommendtheASIApointsforspecificdermatomeassessment(seeFigure 4).




Figure 4. ASIA sensory dermatomes.10 American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2013; Atlanta, Georgia. Reprinted with permission 2014.

C3. In the supraclavicular fossa, at the midclavicular line.C4. Over the acromioclavicular joint.

L2. On the anterior-medial thigh, at the midpoint drawn on an imaginary line connecting the midpoint of the inguinal ligament and the medial femoral condyle.L3. At the medial femoral condyle above the knee.C6. On the dorsal

surface of the proximal phalanx of the thumb.C7. On the dorsal surface of the proximal phalanx of the middle finger.C8. On the dorsal surface of the proximal phalanx of the little finger.

C3

C4

L2

L3

C8C7

C6

L4

L5

S1

S2 S2

S1. On the lateral aspect of the calcaneus.S2. At the midpoint of the popliteal fossa.

C5. On the lateral (radial) side of the antecubital fossa just proximal to the elbow.T1. On the medial (ulnar) side of the antecubital fossa, just proximal to the medial epicondyle of the humerus.

T1

C5

L4. Over the medial malleolus.L5. On the dorsum of the foot at the third metatarsal phalangeal joint.


ConTInuIng MedICal eduCaTIon QuIz

Thepurposeofthequiz—foundonpage46—istoprovideaconvenientmeansofself-assessingyourcomprehensionofthescientificcontentin“IntroducingMAAP:TheModifiedASIAExamforAmbulatoryPatients”byDrewD.Lewis,DO;JoseS.Figueroa,DO;GarthK.Summers,OMSII;andJ.D.Polk,DO.

Pleaseanswereachquestionlisted.ThecorrectanswerswillbepublishedinthenextissueoftheAAOJ.

ToapplyfortwocreditsofAOACategory2-BCMEcredit,recordyouranswerstotheAAOJCMEquizapplicationformanswersheetonpage46.TheAAOwillnotethatyousubmittedtheformandforwardyourresultstotheAOADivisionofContinuingMedicalEducationfordocumentation.Youmustscorea70%orhigheronthequiztoreceiveCMEcredit.

AbnormalfindingsintheMAAPmayindicatethelossofneurologicfunctionandcanalertphysicianstothepresenceofmorecriticalpathologicconditions.

Forphysiciansevaluatingpatientsformusculoskeletalconditions,theMAAPisanextremelyvaluableassessmenttousebeforemakingdecisionsregardingtreatment,especiallyOMT.

References: 1. RamaniS,RingB,LoweR,HunterD.Apilotstudyassessing

knowledgeofclinicalsignsandphysicalexaminationskillsinincomingmedicineresidents.Journal of Graduate MedicalEducation.2010;2(2):232-235.http://www.jgme.org/doi/abs/10.4300/JGME-D-09-00107.1.AccessedOctober29,2013.

2. QurasihiNA,HammettTC,ToddBD,BhuttaMA,KapoorV.Malpracticelitigationandthespine:theNHSperspectiveon235successfulclaimsinEngland.Eur Spine J.2012;21(2):196-199.http://www.ncbi.nlm.nih.gov/pubmed/22367360.AccessedNovember12,2013.

3. USBurdenofDiseaseCollaborators,MurrayCL,AbrahamJ,etal.TheStateofUSHealth,1990-2010:BurdenofDiseases,Injuries,andRiskFactors. JAMA. 2013;310(6):591-608.doi:10.1001/jama.2013.13805.AccessedOctober29,2013.

4. Approachtothediagnosisandevaluationoflowbackpaininadults.UpToDatewebsite.http://www.uptodate.com/contents/approach-to-the-diagnosis-and-evaluation-of-low-back-pain-in-adults.AccessedOctober11,2013.

5. DominoF,BaldorR,GrimesJ,GoldingJ.The 5-Minute Clinical Consult. 19thed.Baltimore,MD:LippincottWilliams&Wilkins;2011.

6. ChilaAG,executiveed. Foundations of Osteopathic Medicine.3rded.Baltimore,MD:LippincottWilliams&Wilkins;2011:3,12,519,987.

7. MusculoskeletalExam.LoyolaUniversityChicagoStritchSchoolofMedicinewebsite.http://www.meddean.luc.edu/lumen/MedEd/medicine/pdx1/muscle/handout.htm.AccessedOctober30,2013.

8. NicholasAS,NicholasEA.Atlas of Osteopathic Techniques.2nded.Baltimore,MD:LippincottWilliams&Wilkins;2012:80,112,141,374.

9. DeStefanoL.Greenman’s Principles of Manual Medicine. 4thed.Baltimore,MD:LippincottWilliams&Wilkins;2011:52,300,390,433,484.

10. AmericanSpinalInjuryAssocation:International Standards for Neurological Classification of Spinal Cord Injury,revised2013;Atlanta,GA.

Accepted for publication May 2014.Address correspondence to:Drew D. Lewis, DODes Moines University College of Osteopathic Medicine3500 Grand AveDes Moines, IA 50312-4326


http://www.jgme.org/doi/abs/10.4300/JGME-D-09-00107.1

http://www.jgme.org/doi/abs/10.4300/JGME-D-09-00107.1



10.1001/jama

10.1001/jama

http://www.uptodate.com/contents/approach-to-the-diagnosis-and-evaluation-of-low-back-pain-in-adults

http://www.uptodate.com/contents/approach-to-the-diagnosis-and-evaluation-of-low-back-pain-in-adults

http://www.meddean.luc.edu/lumen/MedEd/medicine/pdx1/muscle/handout.htm

http://www.meddean.luc.edu/lumen/MedEd/medicine/pdx1/muscle/handout.htm


AnswerstoThe AAOJ’sMarch2014quiz:

1. A2. E3. D4. D

AnswerstotheJune2014AAOJCMEquizwillappearintheSeptember2014issue.

CMECERTIFICATIONOFHOMESTUDYFORMThisistocertifythatI,___________________________ Pleasetypeorprintname

ReadthefollowingarticleforAOACMEcredits.

Name of Article:“IntroducingMAAP:TheModifiedASIAExamforAmbulatoryPatients”

Authors: DrewD.Lewis,DO;JoseS.Figueroa,DO;GarthK.Summers,OMSII;andJ.D.Polk,DO

Publication: The AAO Journal,Volume24,No.2,June2014,pages40-45

Mailthispageto:AmericanAcademyofOsteopathy3500DePauwBlvdSuite1100Indianapolis,IN46268-1136

AOACategory2-Bcreditmaybegrantedforthisarticle.00____________ AOAnumberFullname:______________________________________ (Pleasetypeorprint)

Streetaddress:___________________________________

City,state,ZIP:__________________________________

Signature:______________________________________

aMerICan osTeopaThIC assoCIaTIon—ConTInuIng MedICal eduCaTIon

ThisCMECertificationofHomeStudyFormisintendedtodocumentindividualreviewofarticlesinTheAmerican Academy of Osteopathy JournalunderthecriteriaforAOACategory2-Bcontinuingmedicaleducationcredit.

Completethequiztotherightbycirclingthecorrectanswers.MailyourcompletedanswersheettotheAmericanAcademyofOsteopathy.TheAAOwillforwardyourresultstotheAmericanOsteopathicAssociation.Youmustanswer70%ofquestionscorrectlytoreceiveCMEcredits.

1. WhyisperformingtheMAAPexambeneficialpriortoprovidingosteopathicmanipulativetreatment?

a. Itcanhelpdetectneurologiclesionscontributingtoapatient’ssymptoms.

b. Itcanhelpyoudecideiffurtherdiagnosticevaluationiswarranted.

c. Itcanhelpidentifyconditionsthatmayhavesignificantmorbidityormortalityrisk.

d. Itmaypreventuntowardoutcomesandpreventlitigation.

e. Alloftheabove.

2. BasedontheMAAPmotorrootlevels,whichmotion(manualmuscletest)isassignedtotheL5nerverootandappropriatefora45-year-oldmalepatientwithsuspectedL5radiculopathy?

a. Ankledorsiflexion(notthetoes)b. Ankleplantarflexionc. Bigtoeextension(EHL)d. Hipadductione. Kneeextension

3. Whichofthebelowfindingswasnotdiscussedinthearticleasared-flagphyscialexamfindingforlowbackpain?

a. Decreasedsensationb. Duraltensionsignsc. Motorweaknessd. Painuponpinchinge. Reflexabnormalities

4. Whichportionoftheneurologicalexaminationparticularlyhelpstodiscriminatebetweenuppermotorneuronlesions(centralnervoussystem)andlowermotorneuron(peripheralnervoussystem)lesions?

a. Duraltensionsignsb. Motorexaminationsc. Reflexexaminationd. Sensoryexamination

FOROFFICEUSEONLYCategory2-B Credits:_________Date:____________


AAOJ Submission ChecklistManuscript Submission

☐ SubmissionemailedtoAAOJ scientificeditorateditoraaoj@gmail.comormailedonaflashdriveorCDtotheAAOJ managingeditor,AmericanAcademyofOsteopa-thy,3500DePauwBoulevard,Suite1100,Indianapolis,IN46268-1136

☐ ManuscriptformattedinMicrosoftWordforWindows(.doc),textdocumentformat(.txt)orrichtextformat(.rtf )

Manuscript Components

☐ CoverletteraddressedtotheAAOJ ScientificEditorKateMcCaffrey,DO,withanyspecialrequests(e.g.,rapidreview)notedandjustified

☐ Titlepage,includingtheauthors’fullnames,financialandotheraffiliations,anddisclosureofthefinancialsupportrelatedtooriginalresearchdescribedinthemanuscript

☐ “Abstract”(see“Abstract”sectionin“AAOJ InstructionsforContributors”foradditionalinformation)

☐ “Methods”section

• thenameofthepublicregistryinwhichthetrialislisted,ifapplicable

• ethicalstandards,therapeuticagentsordevices,andstatisticalmethodsdefined

☐ Fourmultiple-choicequestionsforthecontinuingmedicaleducationquizandbriefdiscussionsofthecorrectanswers

☐ Editorialconventionsadheredto

• unitsofmeasuregivenwithalllaboratoryvalues• onfirstmention,allabbreviationsotherthan

measurementsplacedinparenthesesafterthefullnamesoftheterms,asin“AmericanAcademyofOsteopathy(AAO)”

☐ Numberedreferences,tables,andfigurescitedsequentiallyinthetext

• journalarticlesandothermaterialcitedinthe“References”sectionfollowtheguidelinesdescribedinthemostcurrenteditionoftheAMA Manual of Style: A Guide for Authors and Editors.

• referencesincludedirect,open-accessURLstoposted,full-textversionsofthedocuments

• photocopiesprovidedforreferenceddocumentsnotaccessiblethroughURLs

☐ “Acknowledgments”sectionwithaconcise,comprehensivelistofthecontributionsmadebyindividualswhodonotmerit

authorshipcreditandpermissionfromeachindividualtobenamedinprint

☐ Formanuscriptsbasedonsurveydata,acopyoftheoriginalvalidatedsurveyandcoverletter

Graphic Elements

☐ Graphicsshouldbeformattedasspecifiedinthe“GraphicElements”sectionof“AAOJ InstructionsforContributors”

☐ Graphicsshouldnotbeincludedwithtextbutsentasseparategraphicfiles(e.g.jpg,tiff,pdf )

☐ Eachgraphicelementcitedinnumericalorder(e.g.,Table 1,Table 2andFigure 1,Figure 2)withcorrespondingnumericalcaptionsinthemanuscript

☐ Forreprintedoradaptedtables,figures,andillustrations,afullbibliographiccitationgiven,providingappropriateattribution

Required Legal Documentation

☐ Forreprintedoradaptedtables,figures,andillustrations,copyrightholders’permissiontoreprintintheAAOJ’s printandonlineversions,accompaniedbyphotocopiesoftheoriginalwork

☐ Forphotographsinwhichpatientsarefeatured,signedanddated“Patient-ModelRelease”forms

☐ Fornamedsourcesofunpublisheddataandindividualslistedinthe“Acknowledgments”section,writtenpermissiontopublishtheirnamesintheAAOJ

☐ ForauthorsservingintheUSmilitary,thearmedforces’writtenapprovalofthemanuscriptandinstitutionalormilitarydisclaimers

Financial Disclosure and Conflict of Interest

Authorsarerequiredtodiscloseallfinancialandnonfinancialrelationshipsrelatedtothesubmission’ssubjectmatter.Alldisclosuresshouldbeincludedinthemanuscript’stitlepage.Seethe“TitlePage”sectionof“AAOJInstructionstoContributors”forexamplesofrelationshipsandaffiliationsthatmustbedisclosed.Thoseauthorswhohavenofinancialorotherrelationshipstodisclosemustindicatethatonthemanuscript’stitlepage(eg,“DrJoneshasnoconflictofinterestorfinancialdisclosurerelevanttothetopicofthesubmittedmanuscript”).

Publication in the JAOA

PleaseincludepermissiontoforwardthemanuscripttoTheJournal of the American Osteopathic AssociationiftheAAOJ’sscientificeditordeterminesthatthemanuscriptwouldlikelybenefitosteopathicmedicinemoreiftheJAOA agreedtopublishit.

Questions? Contact AAOJ Scientific Editor Kate McCaffrey, DO, at [email protected].


http://files.academyofosteopathy.org/AAOJ/AAOJSubmissionGuidelines2014.pdf


http://www.amamanualofstyle.com/view/10.1093/jama/9780195176339.001.0001/med-9780195176339-chapter-3

http://www.amamanualofstyle.com/view/10.1093/jama/9780195176339.001.0001/med-9780195176339-chapter-3





Component Societies and Affiliated Organizations Calendar of Upcoming Events

June 19-22, 2014 The Osteopathic Cranial Academy

Annual Conference Beyond Sutherland’s Minnow:

Anatomy, Perception and Treatment Conference director: Melvin R. Friedman, DO

Sheraton Indianapolis City Centre, Indianapolis, Indiana (317) 581-0411 • Fax: (317) 580-9299

[email protected] • www.cranialacademy.org

July 14–18, 2014 American Academy of Pediatric Osteopathy

with Osteopathy’s Promise to Children Expanding the Osteopathic Concept Into the Cranial Field

Program chair: Raymond J. Hruby, DO, FAAODist Hilton Doubletree San Diego-Mission Valley,

San Diego, California CME: 40 credits of AOA Category 1-A anticipated

(619) 548-8815 [email protected] • www.the-promise.org

July 18–20, 2014

The Holonomic Institute of Integrative Medicine – Northern California Academy of Osteopathy

Level One Fulford Percussion Program chair: Richard W. Koss, DO

Sebastopol, California Co-sponsored by the AAO

CME: 24 credits of AOA Category 1-A anticipated Contact Kate Price at (707) 824-8764

July 19–21, 2014 American Academy of Pediatric Osteopathy

with Osteopathy’s Promise to Children Intensive Course in Pediatric Osteopathy

Program chair: Shawn Kristian Centers, DO Hilton Doubletree San Diego-Mission Valley,

San Diego, California CME: 24 credits of AOA Category 1-A anticipated

(619) 548-8815 [email protected] • www.the-promise.org

September 19-21, 2014

The Osteopathic Cranial Academy Cranial Base Course

Course director: James W. Binkerd, DO Associate director: Paul E. Dart, MD, FCA

Renaissance Suites O’Hare, Chicago, Illinois (317) 581-0411 • Fax: (317) 580-9299

[email protected] • www.cranialacademy.org

October 5-6, 2014 American FDM Association Sixth FDM World Congress

Hotel Contessa, San Antonio, Texas CME: 24 credits of AOA Category 1-A anticipated

www.orthopathy.com/worldcongress.html

October 31-November 2, 2014 Michigan Osteopathic Association 10th Annual Autumn Convention

Devos Place, Grand Rapids, Michigan (800) 657-1556

https://www.mi-osteopathic.org/ 2014AutumnConvention

November 7-9, 2014

The Osteopathic Cranial Academy Midline Course

Course director: Eliott S. Blackman, DO, FCA Doubletree San Francisco Airport, Burlingame, California

(317) 581-0411 • Fax: (317) 580-9299 [email protected] • www.cranialacademy.org


www.cranialacademy.org


www.the

-promise.org


www.the

-promise.org



www.orthopathy.com/worldcongress.html

https://www.mi-osteopathic.org



Date post:	13-Jun-2020
Category:	Documents
Upload:	others
View:	3 times
Download:	0 times