the aao f for journalc919297.r97.cf2.rackcdn.com/gg4lknxndzwq8jnrz4lgbaxguss1... · 2016-05-13 ·...
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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.
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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.
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.
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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
Page 4 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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)
The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 5
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.
Page 6 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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
The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 7
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.
Page 8 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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
The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 9
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
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Registration Rates
On or before June 18 After June 18
AAO member $ 1,500 $ 1,600
AAO nonmember $ 1,600 $ 1,700
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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.
Page 10 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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.
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The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 11
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
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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
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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
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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
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CLASSIFIED ADVERTISEMENTS
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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.
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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.
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The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 19
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
Page 20 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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 American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 21
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
Page 22 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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 American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 23
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.
Page 24 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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 American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 25
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
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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.
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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.
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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
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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.
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The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 29
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
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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.
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The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 31
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
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Page 32 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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,
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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
The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 33
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
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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
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The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 35
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
Page 36 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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.
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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.
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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
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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.
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Conclusions
Thepurposeofthispilotsurveywastoidentifythecurrenthealthstatus,healthmaintenancebehavior,andlifestylechoicesofcitizensinLebanon,Oregon,andLobitos,Peru.Thecollecteddatadidprovidevaluableinsightintothehealthstatusofthetwocommunities,andthedataprovidedinsightintothesurveydesignandprotocol.Thenecessaryinfrastructureforadministeringthissurveyinthefuturemustincludeasetofinstitutionalgoalssothatthesurveycanbeoptimizedtotrackthosegoals.Withsignificantmodification,theimpactofhealthprograms,interventions,andinstitutionscouldbemeasuredandfollowedwiththissurveytool.
Acknowledgments
Theauthorswishtoacknowledgethemedicalstudentvolunteerswhoparticipatedinthecollectionofdata.
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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]
Continued from page 38
Page 40 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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
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The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 41
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
Continued from page 40
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Page 42 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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
Continued from page 41
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The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 43
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).
Continued from page 42
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Page 44 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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.
The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014 Page 45
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
Continued from page 44
Page 46 The American Academy of Osteopathy Journal • Vol. 24, No. 2, June 2014
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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
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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