the aao f for journalc919297.r97.cf2.rackcdn.com/znb6usqapmddjc5...page 4 the american academy of...

Melicien Tettambel, DO, FAAO, a beloved osteopathic physician specializing in obstetrics and gynecology passed away Sept. 11, 2013. Dr. Tettambel, along with Richard A. Feely, DO, FAAO, FCA, and Melvin R. Friedman, DO, presents the Founder of Osteopathy Award to Viola Frymann, DO, FAAODist, FCA, at the 2011 AAO Convocation in Colorado Springs (top right); Dr. Tettambel with James H. Gronemeyer, DO, and Angelique C. Mizera, DO (bottom left); and with Ray Hruby, DO, and Jim McGovern, PhD, after the Scott Memorial Lecture at Kirksville College of Osteopathic Medicine in 1998 (bottom right).

Osteopathic Manipulative Treatment of Pelvic Dysfuntion in a Postpartum Patient with Co-morbid Headaches...pg. 8

Forum For osteopathic thought

Official Publication of the American Academy of Osteopathy ®

tradition shapes the Future Volume 24 number 1 march 2014

JOURNALThe AAO

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.

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Forjust$5.01aweek(lessthanalargespecialtycoffeeatyourfavoritecoffeeshop)orjust71centsaday(lessthanabottleofwater),youcanbecomeamemberoftheprofessionalspecialtyorganizationdedicatedtothecoreprinciplesofyourprofession!

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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.

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JThe AAO Forum for Osteopathic Thought

Official Publication of the American Academy of Osteopathy

TRADITION SHAPES THE FUTURE • VOLUME 24 NUMBER 1 • MARCH 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

Vol. 24, No. 1, March 2014 • The American Academy of Osteopathy Journal

3500DePauwBoulevard,Ste.1100Indianapolis,IN46268

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

American Academy of Osteopathy®

DavidCoffey,DO,FAAO. . . . . . . . . . . . . . . . . . . . . . . . .PresidentKennethJ.Lossing,DO. . . . . . . . . . . . . . . . . . . . .President-ElectDianaL.Finley,CMP. . . . . . . . . . . . . . . . . . . ExecutiveDirector

Editorial Advisory Board

The AAO JournalKateMcCaffrey,DO. . . . . . . . . . . . . . . . . . . . . . . ScientificEditorKatherineA.Worden,DO,MS. . . . . . . . . . . . . .AssociateEditorDianaL.Finley,CMP. . . . . . . . . . . . . . . . . . . .SupervisingEditorLaurenGood. . . . . . . . . . . . . . . . . . . . . . . . . . . . ManagingEditor

The AAO Journal is the official publication of the AmericanAcademyofOsteopathy.® IssuesarepublishedinMarch,June,SeptemberandDecembereachyear.

The AAO Journalisnotresponsibleforstatementsmadebyanycontributor.Althoughalladvertisingisexpectedtoconformtoethicalmedicalstandards,acceptancedoesnotimplyendorsementbythisjournal.

OpinionsexpressedinThe AAO JournalarethoseoftheauthorsanddonotnecessarilyreflectviewpointsoftheeditorsorofficialpolicyoftheAmericanAcademyofOsteopathy®ortheinstitutionswithwhichtheauthorsareaffiliated,unlessspecified.

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AdvertisingratesforTheAAO Journal, officialpublicationoftheAmericanAcademyofOsteopathy®(AAO).AAOandAmericanOsteopathicAssociationaffiliateorganizationsandmembersoftheAcademyareentitledtoa20percentdiscountonadvertisinginthisjournal.CalltheAAOat(317)879-1881formoreinformation.Subscriptions:$60.00peryear.

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In this Issue:AAOCalendarofEvents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4CMECertificationofHomeStudyForms . . . . . . . . . . . . . . . . 29ComponentSocietyCalendarofEvents. . . . . . . . . . . . . . . . . . 36

Editorials:ViewfromthePyramids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Kate McCaffrey, DO; and Katherine A. Worden, DO, MSNotEveryHeroWearsaCape . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Raymond J. Hruby, DO, MS, FAAO

Book Review:HealingPainandInjury,byMaudNerman,DO,CSPOMM,CA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Anthony G. Chila, DO, FAAODist., FCA

Original Contribution:TheBioenegeticModelinOsteopathicDiagnosisandTreatment:AnFAAOThesis,Part1. . . . . . . . . . . . . . . . . . . . . . 12

Jan T. Hendryx, DO, FAAOAbstract:Second-yearOsteopathicStudentEvaluationofthePrevalenceofaPositiveThomasTestandaPsoasTenderPointBeforeandAfterTreatmentwithCounterstrainTechnique . 21

Jocelyn Young, OMS III; Sheldon C. Yao, DO; Reem Abu-Sbaith, DO; and To Shan Li, DO

Abstract:UsefulnessofVideoLearningforOsteopathicManipulativeMedicineTechniquesintheClassroomandClinicalSetting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Melissa Meghpara, OMS III; Sheldon C. Yao, DO; Theodore B. Flaum, DO; Elizabeth Caron, DO; and Michael J. Terzella, DO

OsteopathicManipulativeintheTreatmentofPrimaryNocturnalEnuresis:ARetrospectiveChartReview. . . . . . . .32

David M. Kanze, DO; and Kylie A. Kanze, DO

Case Study:OsteopathicManipulativeTreatmentofPelvicDysfunctioninaPostpartumPatientwithCo-MorbidHeadaches. . . . . . . . . 8

Rebecca Kant, OMS III; and Murray R. Berkowitz, DO, MA, MS, MPH

ResolutionofPost-traumaticTemporomandibularJointPain,HeadacheandVisionChangeswithOMMintheUnifiedField . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

James A. Lipton, DO, CSP-OMM, FAAO, FAAPMR, DAOBPMR; and ENS Matthew G. Case, MC, USNR, MS IV

DeniseK.Burns,DO,FAAOEricJ.Dolgin,DOClaireM.Galin,DOWilliamJ.Garrity,DOStephenI.Goldman,DO,FAAO

StefanL.J.Hagopian,DO,FAAO

RaymondJ.Hruby,DO,MS,FAAO

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

DavidC.Mason,DOKateMcCaffrey,DOPaulR.Rennie,DO,FAAOHallieJ.Robbins,DOMarkE.Rosen,DOKatherineA.Worden,DO,MS

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http://www.academyofosteopathy.org

The American Academy of Osteopathy Journal • Vol. 24, No. 1, March 2014

AAO Calendar of Events

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

2014

March 15-18 New Approach to Osteo-Articular Manipulations Including the Superior and Inferior Limbs(Pre-Convo),Jean-PierreBarral,DO(France);KennethJ.Lossing,DO—TheBroadmoor,ColoradoSprings,CO

March 17-18 Osteopathic Approach to Common ENT Complaints of Childhood (Pre-Convo)—HeatherP.Ferrill,DO,TheBroadmoor,ColoradoSprings,CO

March 17-18 Fascial Distortion Model(Pre-Convo)—ToddA.Capistrant,DO,TheBroadmoor, ColoradoSprings,CO

March 18 COFAAOMeeting—TheBroadmoor,ColoradoSprings,CO

March 19 BoardofTrusteesMeeting—8:00am,TheBroadmoor,ColoradoSprings,CO

March 19 BoardofGovernorsMeeting—1:00pm,TheBroadmoor,ColoradoSprings,CO

March 19-23 AAOConvocation—Trauma: An Integrated Osteopathic Approach DeniseK.Burns,DO,FAAO,ProgramChair—TheBroadmoor,ColoradoSprings,CO

March 20 AAOBusinessMeetingoftheMembership—12:00pm,TheBroadmoor,ColoradoSprings,CO

May 30-June 1 CANCELLED —Muscle Energy with Sally Sutton, DO, FAAO—RichardG.Schuster,DO—MUCOM,Indianapolis,IN

June 13-15 Sports Osteopathy—KurtP.Heinking,DO,FAAO—CCOM,DownersGrove,IL

July 18–19 Ultrasound-Guided Injections—SajidA.Surve,DO—UNTHSC-TCOM,FortWorth,TX

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]

AswelookforwardtospringandanosteopathichomecomingattheBroadmoorforConvocation,letusnotesomeofthehighlights.Thethemeforthemeetingis“Trauma:AnIntegrativeOsteopathicApproach,”chairedbyDeniseBurns,DO,FAAO.Trauma,whetheracuteorchronic,physicaloremotional,isalwaysaconsiderationasosteopathicphysiciansprovidetreatmenttoourpatients.Wehavesomefamiliarfacesandsomenewfacessteppinguptoprovidelecturesandhands-onlabsessionsonvariousfacetsofthisjewel.TherewillbesomeinternationalpresenterssuchasJeanMarieA.T.Beuckels,DO,FSc(Hons.)Osteo.Med.,Msc.Ost.Onthissideofthepond,AnthonyCapobianco,DO,hassteppedintocoverobstetricaltraumaafterthelossofDr.Tettambel.Don’tforgettostopbyandviewtheOMMResearchPosters,andpleaseconsiderattendingthenewLBORC-sponsoredResearchForumFridayafternoon.Thereareagrowingnumberofpre-Convocationcourses:NewApproachtoUpperandLowerExtremities;ENTComplaintsinChildren;andFascialDistortionModel,forthosewantingto“DigOn”further.TheconcurrentSAAOprogramforstudentscontinuestobeahugesuccessforpassingonourosteopathichandsandheartstothenextgenerationthankstomanyofyouwhohavevolunteeredyourtimeandtalents.Welookforwardtorenewingoldfriendshipsandmakingnewones.WelookforwardtoseeingyouinColorado!

Kate McCaffrey, DO; and Katherine A. Worden, DO, MS

Trauma,asencounteredinhumanexperience,isreflectedinmanywaysinthebody.Despitebestintention,resolutionisoftenelusivethroughconventionalmedical,aswellasalternative,approaches.Thepassageoftimeservesonlytomoredeeplyencodethegarbledtransmissionofabnormalmessagesthroughoutthebody’stissues.Dr.Nerman,anosteopathicphysician,hasdoneamasterfuljobofprovidingperspectiveandpatient-centeredorientationnecessarytoachievealleviationforsufferingpatients.Seeninthetraditionalviewofosteopathicmedicalpractice,itissmallwonderthatshehasbeensosuccessful.Moreimportantly,Dr.Nerman,throughoutthetext,clearlydemonstratesunderstandingandapplicabilityofscientificknowledgeinthemanagementoftheclinicalsituation.Thisisaccomplishedthroughtheuseoflanguagewhichisdigestibleforthepatient.Itcanonlybewishedthatmedicalpracticeingeneralwoulddemonstratesuchaccommodation.

Forpatientsandpractitionerswhoencounterthemanyfacesoftrauma,Healing Pain and Injuryprovidesmuchneededguidancetomorecompassionate,knowledgeableandsuccessfulinteractionwiththepatient’spathtorecovery.

Book Review—Healing Pain and Injury, by Maud Nerman, DO, CSPOMM, CACopyright © 2014 Bay Tree PublishingAnthony G. Chila, DO, FAAO Dist., FCA


View from the Pyramids


Mylong-timefriendandcolleague,Melicien(Mel)Tettambel,DO,FAAO,passedawayonSeptember11,2013.Anenergeticperson,withastrongpassionfortheosteopathicprofession,Melachievedanastoundingnumberofaccomplishmentsduringherall-too-shortlifetime.Amongherachievements:boardcertificationinObstetricsandGynecology,andalsoinNeuromusculoskeletalMedicineandOsteopathicManipulativeMedicine;anillustriousteachingcareerthatincludedteachingatseveralofourosteopathiccolleges,aswellasteachingnationallyandinternationally;PastPresidentoftheAmericanAcademyofOsteopathy(AAO),PresidentoftheSutherlandCranialTeachingFoundation(SCTF),FellowintheAAOandDistinguishedFellowintheAmericanCollegeofOsteopathicObstetriciansandGynecologists;anumberofresearchprojectsandanimpressivelistofpublications.Atthetimeofherdeath,shewasProfessorandChairoftheDepartmentofOsteopathicPrinciplesandPractice,PacificNorthwestUniversity,CollegeofOsteopathicMedicineinYakima,Washington.

ThisbrieflistingofaccomplishmentsbarelyscratchesthesurfaceanddoesnotevenremotelydojusticetoMel’smanyachievements;however,ratherthancontinuewiththislineofdiscussion,IwouldliketotalkaboutMelTettambel,thepersonthatIknew.

Ican’trememberexactlywhenIfirstmetMel.Idon’trecallbeingformallyintroducedtoher,somybestrecollectionisthatwefirstbecameacquaintedwhileworkingtogetherononeormoreAAOcommittees.Somehowitwasn’tlongbeforewebecamegreatfriends,somuchthatIcan’tseemtorememberatimewhenIdidn’tknowMel.Havingherasafriendandcolleaguewasthatcomfortable,asthoughithadalwaysbeenthatway.WhenIbecameChairoftheOMMDepartmentattheCollegeofOsteopathicMedicineofthePacific,IinvitedMelonanannualbasistobeavisitingprofessorforourstudents,andmywifeandIwouldalwayshaveherstayasaguestinourhome,allowingustogettoknowherevenbetter.InrecentyearsMelreturnedthefavorbyinvitingmetocometoYakimatoteachher

students,andIhadthepleasureofstayingwithherandherhusbandintheirbeautifulhome.

HowshouldIdescribeMelTettambel?BeforeIdothat,letmetellyouthatIhavealwayshadafascinationwithheroes,andoneofmyfavoritethingstodoistoaskpeoplewhotheirheroesareinlife.Personally,Ilearnedalongtimeagothatonecanhaveliterallythousandsofheroicfiguresinhisorherlife.Heroesarenotalwaysfamousleadersorcelebrities,butratherordinaryeverydaypeoplewithremarkablecharacteristicsthatimpressusandmakeuswanttobelikethem.Andno,noteveryherowearsacape.MelTettambelwascertainlyaherotome.Shewasanintelligent,honest,hard-workingandenergeticprofessionalwhotouchedmanylives,includingmine.Onedidn’thavetobearoundMelverylongatalltorealizethatshecareddeeplyabouteveryonearoundher:family,friends,colleagues,herstudents,andespeciallyherpatients.

Again,IcouldgoonandontryingtodescribemyimpressionsofMel.Iam,however,remindedofthepoem“Success,”writtenbyBessieAndersonStanley(andoftenerroneouslyattributedtoRobertLouisStevenson)thatIbelievesumsupinveryshortorderjustabouteverythingIcouldsayaboutMelTettambel:

Hehasachievedsuccesswhohaslivedwell,laughedoften,andlovedmuch;

Whohasgainedtherespectofintelligentmenandtheloveoflittlechildren;

Whohasfilledhisnicheandaccomplishedhistask;Whohaslefttheworldbetterthanhefoundit;Whohaslookedforthebestinothersandgiventhebesthehad;

WhoselifewasaninspirationWhosememoryisabenediction

Theworld,andallofuswhoknewher,arebetteroffbecauseMelTettambelwasinit,andwearealljustalittlediminishedbecauseofherpassing.Itwasapleasureandanhonortohaveknownsuchanamazingperson.Restinpeace,Mel.Restinpeace.

Not Every Hero Wears a CapeIn Memoriam: Melicien Tettambel, DO, FAAORaymond J. Hruby, DO, MS, FAAO


Course DirectorSajid A. Surve, DO, is a 2005 graduate of the University of Medicine and Dentistry of New Jersey–School of Osteopathic Medicine. 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 Medical Center in Long Beach, NY. He joined the faculty of UMDNJSOM in 2009 and completed an NMM/OMM residency in 2010.

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

Course TimesFriday and Saturday: 8:00 am - 5:30 pmBreakfast/lunch provided. Please contact 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 Surve, DO, course participants will be introduced to the basic principles of ultrasound, learn proper injection techniques with ultrasound guidance and learn proper billing and coding for this procedure. Cadavers will be available for practice, and table trainers will facilitate 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 completion of 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;• utilize 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 the above procedures.

CME16 hours of AOA Category 1-A credit is anticipated

Ultrasound-Guided InjectionsJuly 18–19, 2014 • UNTHSC-TCOM in Fort Worth, TX

Registration Form

Ultrasound-Guided InjectionsJuly 18–19, 2014

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Or register online at www.academyofosteopathy.org.


Abstract

Sciaticaisacommonchiefcomplaintaddressedbymedicalprofessionalsintoday’ssocietyandcanprovetobeextremelydebilitatingifleftuntreated.Themusculoskeletalchangesseeninpregnancycanoftenleadtoanexacerbationorrecurrenceofthiscondition.Osteopathicmanipulativetreatment(OMT)canprovideanadditionalmethodofmanagingthesesymptomsbytreatingsomaticdysfunctionsthatpersistintothepostpartumperiod.A28-year-oldfemalethreemonthspostpartumwasseeninourclinicforrecurrentrighthippain,right-sidedsciaticaandchronicheadaches.Usingosteopathicmanipulativetechniques,thepatient’ssomaticdysfunctionswereremovedandhersymptomsimmediatelyresolvedpost-treatment.Althoughinitiallysuccessful,thepatientreturnedtotheclinic11dayslaterreportingarecurrenceofhersymptomsandwasagaintreatedwithosteopathicmanipulativetreatment.Thiscasestudyexaminesthepersistenceofsomaticdysfunctionintothepostpartumperiodandthebenefitsoftakinganosteopathicmanipulativeapproachtowardresolvingthesymptomsofsciaticainthisspecificpopulation.

Introduction and Epidemiology

Acommonchiefcomplaintaddressedintoday’ssocietybyavarietyofphysicians,sciaticacanbeextremelydebilitatingandcandrasticallyalteranindividual’squalityoflife.Sciaticaisasymptomratherthanaconditionbyitself.Itisdefinedas“pain,tingling,ornumbnessintheback,hip,orlegcausedbycompressionorinjurytothesciaticnerve.”1Thepainexperiencedbyindividualswithsciaticaisoftensharp,shootingandconfinedtooneleg.Itcanbeexacerbatedbyeventheslightestactivity,includingsneezingorcoughingtooforcefully,orevenbysittingthewrongway.Thissymptomismostcommonlyduetodegenerationordisplacementofanintervertebraldiscleadingtocompressiononaspinalnerveroot;however,therecanbemultiplepossibleetiologies.2

Sciatica,andlowbackpainingeneral,areamongthemostcommoncomplaintsofpregnancy,with50-80%of

womenreportingexperiencingsometypeoflowbackpainduringpregnancy.3Duringtheninemonthspriortodelivery,afemaleundergoesbothgravity-inducedandhormonalchangesthatalterthemusculoskeletaldynamic.Astheuterusandfetusenlarge,acenterofgravitychangeforcesthefemaletocompensatebyleaningbackwards.Thisleadstoanincreaseinlumbarlordosisand,inturn,causesacompensatoryincreaseinthoracickyphosis.Theseslightadjustmentstendtoopenupthefacetjoints,creatingahigherdegreeofinstability.4Alongsidethesechanges,hormonalinfluencealsocontributestothestructuralalterationsseeninpregnancy.Thehormonerelaxin,producedbythecorpusluteum,isfirstexpressedaroundthetenthortwelfthweek.Appropriatelynamed,thishormonetendstosoftenand“relax”theligamentsthatholdthesacroiliacjointsandpubicsymphysisinplaceinpreparationforthebirthprocess.3

Oftenthesechangesleadinguptopregnancypersistthroughtothepostpartumperiod.Thisisthoughttobeattributedtotheprolongedamountoftimespentinthedorsallithotomypositionthroughoutdelivery.Duringthisperiod,thesciaticnervecanbestretchedandcompressedintheglutealregion.5Ininstancesofprolongedlabor,constantpressureonthelumbosacraltrunkasitcrossesthepelvicbrimcombinedwiththeinabilitytorepositionmaygreatlycontributetolastingnerveinjury.3IntheWongetalstudy,“Incidenceofpostpartumlumbosacralspineandlowerextremitynerveinjuries,”onlya0.92%incidenceofnewnerveinjurywasreportedfollowingdelivery,withnulliparityandaprolongedsecondstageoflaborbeingthemostcontributoryfactors.6However,incidenceofarecurrentnerveinjuryfollowingpregnancymaybehigherinthosewhohavepre-existingsciaticaorlowbackpain.

History

Thepatientisa28-year-oldCaucasianfemalewhopresentedtotheOMMclinicatPhiladelphiaCollegeofOsteopathicMedicine–Georgiacampuscomplainingofrighthippain,right-sidedsciaticaandchronicheadaches.Onherfirstvisittotheclinic,shewasthree

Osteopathic Manipulative Treatment of Pelvic Dysfunction in a Postpartum Patient with Co-Morbid Headaches: A Case ReportRebecca Kant, OMS III; and Murray R. Berkowitz, DO, MA, MS, MPH


monthspostpartumfromaninducedvaginaldeliveryofherfirstchild.

Thepatienthasright-sidehippainandsciatica,whichpresentedpriortoherpregnancy.Herhippainisdullandachywhilehersciaticapainissharpandshootsdownthebacksideofherrightthightoherknee.Shedescribedthispainasan8/10,andfollowingibuprofenasa5/10.Priortoherpregnancy,thepatientwenttoseeachiropractorregardingthispain,whereitwastemporarilyreducedto0/10.Followingherpregnancy,hersciaticapainhasreturnedtoitsinitiallevelof8/10withoutmedication.

Thepatienthasalonghistoryofmigrainesprecededbyavisualaurashedescribedas“acentralbrightspotfollowedbydarknessclosinginonbothsides.”Immediatelyfollowingthisaura,sheexperiencesnumbnessandaphasialeadinguptothemigraine.Thepatientdescribedthispainassharpandlocalizedtoonesideofherhead.Painisa9/10initially,butisrelievedtoa6/10upontakingImitrex.Shestatedthatshehasexperiencedtwomigrainesinthepastyear,oneoftheseepisodesbeingonemonthpriortohervisit.Thepatientalsoexperiencesheadacheswithoutanaura,occurringfairlyoftenatapproximatelytwotothreetimeseachweek.Thesehavebeenrelievedbyibuprofen400-800mgonceperday;however,thepatientdoesnotwishtocontinuetakingthisdailymedication.Shehasbeentoseeaneurologistregardingtheseheadaches,especiallyduetothestroke-likecharacteristicswhichprecedehermigraines.AlthoughthepossibilityofaCVAorTIAhasbeenruledoutsuccessfully,littlehasbeendonetosignificantlydecreasetheseverityorfrequencyoftheseepisodes.

Otherthanherhippain,sciaticaandheadaches,thepatient’sonlyotherchronicmedicalconditionisaTMJdysfunctionshehashadsincechildhood.Shehashadnoprevioussurgeriesandhasnoknowndrugallergies.HercurrentmedicationsincludeprenatalvitaminsandanOTCprobiotic.Sheismarried,hasonechild,andworksasapediatriccardiologynurse.Shedeniestheuseoftobaccoproductsorillicitdrugs,andshedrinksonlytheoccasionalglassofwine.Thepatienthasafamilyhistoryofstrokeonthematernalsideandmyocardialinfarctiononherpaternalside.Shedeniesanyfever,nausea,vomiting,diarrheaorlossofconsciousness.Shedoeshavevisionchanges;however,theseoccuronlyaspartoftheauraprecedinghermigraines.

Physical Exam

Onphysicalexam,bloodpressurewas110/70,pulsewas78,andrespiratoryratewas14.Thepatientwaswell-groomedandwell-developed,alert,awakeand

orientedtotime,personandplaceandinnoacutedistress.Herheadwasatraumaticandnormocephalic.Extraocularmuscleswereintactandpupilswereequallyroundandreactivetolight.Herneckwassuppleandnolymphadenopathyorthyromegalywereappreciated.Cardiacexamrevealedafaint1/6murmurloudestattherightsecondintercostalspace,butalsoappreciatedattheleftsecondintercostalspace.Rhythmandratewereregular,withnorubsorgallops.Lungswerecleartoauscultationbilaterally,withnowheezes,rhonchiorrales.NeurologicexamrevealedthatCNII–XIIweregrosslyintact,musclestrengthwas5/5allaroundanddeeptendonreflexeswere+2inallareaswithabilateral+3patellarreflex.Patienthadanormalgaitandnomotororsensorydeficitswereappreciated.

Thepatient’sosteopathicstructuralexamrevealedseveralsomaticdysfunctions.Boththesagittalsutureandtherightoccipitomastoidsuturewerecompressed,andtherewastendernessattheinsertionofthecapitismuscleontherightside.HercervicaldysfunctionsincludedOAERRSL,C2-C4ERRSRandC5-C6NRLSL.AArotationwasasymmetric,with80degreesofrotationtotheleftandonly60degreesofrotationtotheright.Thoracic/costaldysfunctionincludedT3-T4NRRSLandaposteriorrib5.InthelumbarregionsheexhibitedanL3-L5NRRSLdysfunction.Standingflexiontestwaspositivefollowedbyanegativelumbosacralspringtestandapositivelumbosacralligamenttest.Furtherexaminationrevealedananteriorlyrotatedinnominateboneontheright.

Treatment

Osteopathicmanipulativetreatmentwasperformedtotreatthesomaticdysfunctionsfoundduringthephysicalexamination.Inthecranialregion,thecompressedsuturesweretreatedwithasagittalsuturedecompressionandanoccipitomastoidsuturedecompressionwithaV-spread.Duetothepatient’shistoryofchronicheadaches,CV4andvault-holdandfrontallifttechniquestotreattheSBSwereperformedtohelpalleviatepotentialcausesofpain.Counterstraintechniqueswereusedforcranialtenderpoints.Treatmentofcervicaldysfunctionsconsistedofsofttissue,muscleenergy,counterstrain,Stilltechniqueandsuboccipitalrelease.BoththoracicandlumbardysfunctionsweretreatedusingmuscleenergyandHVLAtechniques,helpingtonormalizethespineandincreaserangeofmotion.Thepatient’sposteriorrib5wasalsotreatedusingmuscleenergy,decreasingtheasymmetryfoundinthisregion.Hipandpelvicsomaticdysfunctionswereaddressedusingcounterstrain,muscleenergyandHVLA.

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


Followingtreatment,thepatientreporteddecreasedtendernessinthecranialregionandincreasedrangeofmotioninthecervical,thoracicandlumbarregions.Hippainwassignificantlyimprovedwithsuccessfuladjustmentoftherightinnominatebonebacktoitsnormalposition.Nosciaticapainwasappreciatedimmediatelyfollowingthetreatment,andthepatientreportedanoverallimprovementinhersymptoms.

Thepatientwascounseledonstretchingathomeandincreasingherwaterintake.Shewasalsoinstructedtotakeibuprofen600-800mgwithfoodthreetimesdailyforfivedaysforpain/inflammationsecondarytoatreatmentreactionbeginningwithinthenext24-48hours.Shewastoldtocallinwithprogressreportsortocallinsoonerifshehadanyotherconcerns.

Thepatientreturnedtotheclinic11dayslaterduetoarecurrenceofhersymptoms.Shedescribeda“tightness”inherrightlowerback/hipandafeelingthat“herrightlegfeltlongerthanherleft.”Hippainwascharacterizedassoreandachywithsharpexacerbationswithpivoting.Backtightnessandpainwasdescribedasa7/10andmoreontherightside,butdecreasedtoa5/10withcoldpacksandstretching.Shealsodescribedhavingfrontalheadachesforthethreedaysimmediatelyfollowingherprevioustreatment.Theseheadachesoccurreduponinitiallywakingupinthemorningandimprovedthroughouttheday.Painwasan8/10,sharpandlocalizedtothebilateralfrontalregionofherhead.Shestatedthatthispaindecreasedtoa1/10withcoffeeandibuprofen.Shedeniedhavinganyotherheadachesbesidesthesethreethatwereimmediatelypost-treatment.Thepatientalsostatedthatsheexperienceda“popping”sensationinherrightkneefourdayspriortoherreturn.Painwasata9/10duringthe“popping”butsubsidedtoa2/10feelingofgeneralachinessafterwards.Shedescribedcontinuedsorenessonthebackofherrightupperthighandknee.

Onphysicalexam,thepatientwasfoundtohavenumeroussomaticdysfunctions.Therewasarecurrenceinhersagittalsuturecompression,andhercervicalsomaticdysfunctionshadcompletelyreversedfromherpreviousvisit,nowexhibitingOAERLSR,C2-C4ERLSLandC5-C6FRRSR.ATMJclickwasappreciatedontheleft,withaconcurrentleftdeviationofherjaw.ThoracicandlumbardysfunctionsincludedT4-T6NRRSLandL3-L5ERRSR.Shehadanegativestandingflexiontest,positiveseatedflexiontestontheleft,andpositivelumbosacralspringtest.Shehadarightinnominateoutflare,withherASIS,patellaandmalleolusontherightsuperiortotheleftandherILAontheleftposteriorandinferior.Shealsoexhibitedatenderpubicsymphysisandrightpiriformis.Hamstringsweretightbilaterally.

Osteopathicmanipulativetreatmentwasusedtoaddressthesesomaticdysfunctions,treatingcranialwithasagittalsuturedecompressionandfrontallift,cervicalwithsofttissue,counterstrainandStilltechniques,thoracicwithHVLA,andlumbarwithmuscleenergy.Hipandpelvicdysfunctionsweretreatedusinganarticulatorytechniquewithvalsalvaassistinordertospreadtheischialtuberosities.Pubicgappingmuscleenergyandsacralrocktechniqueswerealsoused.Tightnessinbothhamstringsandintherightpiriformiswasaddressedusingmuscleenergy,andTMJdysfunctionwastreatedusinganHVLAtechnique.Immediatelyfollowingthesetreatments,thepatientreportedasignificantdecreaseintendernessandanincreaseinrangeofmotion.Shewasagaininstructedtoincreaseherwaterintakeandtodogentlestretchingathomeand


counseledonthepossibilityofatreatmentreactionsimilartoherfirstvisit.Thepatientwastoldtocallinafterthreedaysandthenaftertheweekendtogiveprogressreportsonhersymptoms.

Discussion

Thepatient’spresentationofvariedsomaticdysfunctionsarelikelyapersistenceofmusculoskeletalchangesthatoccurredduringpregnancy.Sincerelaxinlevelsreturntobaselinewithinafewweeksfollowingdelivery,itisimperativetotreatanystructuraldysfunctionsearlypostpartumwhiletheligamentsremaininastateofincreasedrelaxation.Themultiplehip/pelvicsomaticdysfunctionsseeninthepatientindicatepossiblepersistenceofadysfunctiondevelopedduringthedeliveryprocess.AsdiscussedinWongetal,nulliparityandprolongedlaborarethemostsignificantfactorscontributingtopostpartumdysfunctionandcontinuedneuralinjury.6Asourpatientwasinducedandthiswasherfirstchild,bothofthesefactorsmayplayaroleintheexplanationofherhip/pelvicpresentations.

Considerationoftherelationshipbetweenthepatient’spersistenthip/pelvicdysfunctionsandconcurrentheadachesisalsosignificant.Inhisdiscussiononcraniosacralmotion,Kingexplainsthisconceptbydescribingthatthecentralnervoussystem,cerebrospinalfluid,duralmembranes,cranialbonesandsacrumareallintimatelyconnectedbyaunitknownastheprimaryrespiratorymechanism.7Theduramater,alongwithsurroundingthecentralnervoussystem,hasdirectconnectionstotheforamenmagnum,C2,C3andS2.Thisindicatesthat,inareciprocalfashion,movementinthesacralareahasadirectlinkandcaninfluencefunctionsofthecraniumandcentralnervoussystem.Asthesacrumisincloseproximitytothehip/pelvis,dysfunctionsinthisregionandtheprocessofchildbirthoverallcanstructurallyalternormalsacralmotion.7Therefore,ourpatient’spostpartumstateandmultiplehip/pelvicdysfunctionsmaybecontributingtoherfrequentheadaches.

Osteopathicmanipulativetreatmentcanbeextremelybeneficialinrestoringnormalstructureandrangeofmotionduringbothpregnancyandthepostpartumperiod.Dalyetalresearchedsacroiliacsubluxationasacommoncauseoflowbackpaininpregnancyandreportedthat“aftermanipulativetherapy,91%hadreliefofpainandnolongerexhibitedsignsofsacroiliacsubluxation.”8Anotherstudy,conductedbyLicciardoneetalin2010andpublishedintheAmerican Journal of Obstetrics and Gynecology,examinedthepotentialbenefitofusingosteopathicmanipulativetreatmentduringpregnancy.Thisstudyshowsthat

backpaindecreasedandback-specificfunctioningdeterioratedsignificantlylessinthegroupstreatedwithosteopathicmanipulativetreatmentalongsideroutineobstetriccare.9SmallwoodetalreportedtheuseandeffectivenessofOMTinreducingpainduringdelivery.10Althoughthesestudiesdemonstratethatosteopathicmanipulativetreatmentcanbeadvantageousindiminishinglowbackpainduringpregnancyandalsoduringthedeliveryitself,furtherresearchisneededtofullyexaminethebenefitsofosteopathictechniqueswhenspecificallyfocusingonthepostpartumperiod.

References1. A.D.A.M.MedicalEncyclopedia[Internet].Atlanta(GA):

A.D.A.M.,Inc.;©2013.Sciatica;[updated2013April16].Availablefrom:http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001706/

2. Katz,JN.Gettingaleguponsciatica.Harvard Health Publications. February3,2009.http://www.health.harvard.edu/healthbeat/HEALTHbeat_020309.htm#art1

3. Al-KhodairyAW,BovayP,GobeletC.Sciaticainthefemalepatient:anatomicalconsiderations,aetiologyandreviewoftheliterature.Eur Spine J. 2007;16:721–731.doi:10.1007/s00586-006-0074-3.

4. Kuchera,ML.Applyingosteopathicprinciplestoformulatetreatmentforpatientswithchronicpain.J Am Osteopath Assoc. 2007;107(suppl 6): ES28-ES38.

5. McDonald,A.Obstetricalnerveinjury.Perinatal Outreach Program.2008;31(April).

6. WongCA,ScavoneBM,DuganS.Incidenceofpostpartumlumbosacralspineandlowerextremitynerveinjuries.ObstetGynecol.2003;101(2):279-88.

7. KingHH.OsteopathyintheCranialField.InChilaAG(Ed.),Foundations of Osteopathic Medicine (3rd ed.)Philadelphia,PA:Lippincott,Williams&Wilkins;2011:728-748.

8. DalyJM,FramePS,RapozaPA.Sacroiliacsubluxation:acommon,treatablecauseoflow-backpaininpregnancy.Fam Pract Res J.1991;11(2):149-59.

9. LicciardoneJC,BuchananS,HenselKL.Osteopathicmanipulativetreatmentofbackpainandrelatedsymptomsduringpregnancy:arandomizedcontrolledtrial.Am J Obstet Gynecol. 2010;202(1):43.e1-8.doi:10.1016/j.ajog.2009.07.057.Epub2009Sep20.

10. SmallwoodCR,BorgerdingCJ,CoxMS,BerkowitzMR.Osteopathicmanipulativetreatment(OMT)duringlaborfacilitatesanatural,drug-freechildbirthforaprimigravidapatient:acasereport.International Journal of Osteopathic Medicine.2013;16:170-177.Availableonli+neathttp://dx.doi.org/10.1016/j.ijosm.2012.10.005.

Accepted for publication November 2013.

Address correspondence to:

MurrayR.Berkowitz,DO,MPHPCOM/GA–AssociateProfessorofNMM/OMM625OldPeachtreeRd.NWSuwanee,GA30024


Abstract

Theclassicfive-modelconceptofpatientfunctioning,assessmentandcareiscentraltocurrentosteopathicprinciplesandpractice.Theseprimarymodelsarebiomechanical-structural,respiratory-circulatory,neurological,metabolic-nutritionalandbehavioral-biopsychosocial.

Aseparatesixthosteopathicbioenergeticmodelexiststhatemphasizestheconceptsoflifeforceorinherentenergyflowwithinthebody,energeticcommunicationwiththeenvironment,andtissuebiophysicalandbioelectricalproperties.Thismodelhasbeenminimizedinthepast,butactuallymayprovidethebasisforallothers.

Althoughotherhealingartsdisciplines(e.g.,acupuncture,Reiki)utilizethebioenergeticmodelquiterigorously,theosteopathicprofessionhistoricallyhasbeenresistanttodiscuss,researchorembracebioenergeticsasaplausibleexplanationfortheefficacyofosteopathicmanipulativetreatment(OMT),orasacontributingetiologyofsomaticandvisceraldysfunctionandhealthanddisease.

Thisthesiswillreviewtheclassicfivemodelsandosteopathicbioenergeticmodel;explorebioenergeticpropertiesoflivingsystemsinanattempttoofferexplanationsbehindthepalpatoryexperiencesandtherapeuticresultsofOMT;discusstwobioenergetically-basedOMTtechniques;exploreanexpandedosteopathicbioenergeticmodelanddiscusswhythebioenergeticmodelshouldbeutilizedregularlyinpatientdiagnosisandcare;andoffersuggestionsforosteopathicresearchintopossiblebioenergeticcontributionstothecausesandmaintenanceofsomaticandvisceraldysfunctions.

Literature Review

The Five Osteopathic Models

Intheearly1980s,theEducationalCouncilonOsteopathicPrinciples(ECOP)developedfiveconceptualmodelsrelatedtopatientassessment,

functioning,andcare:1,2biomechanical-structural,respiratory-circulatory,neurological,metabolic-nutritionalandbehavioral-biopsychosocial.Thesemodelsaresupportedbyprinciplesofanatomy,physiology,biochemistryandpsychiatry/psychology.Eachmodelprovidesalensthroughwhichthepatientcanbeviewed,diagnosedandtreated.Thesemodelsarenottypicallyutilizedinisolationbuthavevariousdegreesofoverlapwiththeothers.

Theneuromusculoskeletalsystemisconsideredthecoreinterfaceamongthemodelsthathelpstointegrateandcoordinatebasicbodyfunctions,whileplayingaprimaryroleinapatient’sabilitytoadapttomultiplestressors(e.g.,trauma,infection,nutritional,social)andmaintainhealth.1(See Figure 1)

Thebiomechanical-structural modelviewsthepatientprimarilyfromastructuralperspective.Itemphasizestheanatomyofthemuscles,spineandextremitiesandresultantfunctionsofpostureandmotion.Osteopathicmanipulativetreatment(OMT)isdirectedtowardnormalizingbiomechanicalsomaticdysfunctions(joints,myofascia),thusrestoringnormalstructuralintegrity,physiologicalfunctioning,adaptivepotentialandhomeostasis.1Osteopathicmanipulativetechniquescommonlyutilizedtonormalizebiomechanicsincludehigh-velocitylowamplitudethrusting,muscleenergy,counterstrain,ligamentousarticularstrain,myofascialrelease,2facilitatedpositionalrelease3andStilltechnique.4

Therespiratory-circulatory modelemphasizesnormalizationofapatient’spulmonaryandcardiovascularfunctions,andthecirculationoffluids(blood,lymph,cerebrospinalfluid).2Horizontaldiaphragms(tentoriumcerebelli,respiratory,pelvic),thoracicinlet,thoraciccage,extracellularmatrix,lymphatics1andviscera5(heart,lungs,kidneys)areimportantanatomicalstructuresaddressed.Osteopathyinthecranialfield,cervical,thoracicandribmobilization,lymphaticdrainage,respiratorydiaphragmmyofascialrelease,andvisceralosteopathicmanipulativetechniquesarehelpfulinrestoringhealth

The Bioenergetic Model in Osteopathic Diagnosis and Treatment: An FAAO Thesis, Part 1Jan T. Hendryx, DO, FAAO


incombinationwithmedications,surgery,intravenousfluidsandevenventilationasappropriate.1

Themetabolic-nutritional model encouragesmaximizingtheefficiencyofthepatient’snaturalself-regulatoryandself-healingmechanisms.1,2Homeostaticadaptiveresponsesareorchestratedthroughpositiveandnegativefeedbacksystemstoregulatevariousformsofenergyexchangeandconservationthatoccurthroughmetabolicprocessesandorganfunctioning.Theneuroendocrine-immunesystemandallinternalorgansarethefocus.Lifestylechangessuchasappropriateexercise,nutritionalcounselingandstressreductionareprimarytherapeuticmodalities,asareappropriateuseofmedications.Osteopathicmanipulativetreatmentincludeslymphaticpumpandvisceraltechniques.1,2

Theneurological modeladdressesaberrationsintheperipheral,autonomicandcentralnervoussystemsthatmaycausepainanddysfunction.Theseelementscontrol,coordinateandintegratebodyfunctions.1Proprioceptivereflexandmusclestrengthimbalances,6spinalsegmentalfacilitation,7,8nervecompressionandentrapmentdisorders,autonomicreflexesandvisceraldysfunctions,8nociceptiveinfluences9andbraindysfunctions10arecommonproblems.Manipulativetreatmentmayincludeosteopathyinthecranialfield,11Chapmanreflexes,ribraising,counterstrain,muscleenergy,neuralrelease12andinhibition.9Exercisetherapy,includingproprioceptivebalancetraining,stretchingandstrengthening,6aswellasappropriateneurologicalevaluation,referral,surgeryandmedicationsmaybeappropriateinpatientmanagement.

Thebehavioral-psychosocial model addressesapatient’smental,emotional,socialand,tosomedegree,spiritualdimensionsinrelationshiptohealthanddisease.1,2Mind-bodyinteractionscanhaveahugeinfluenceonapatient’swellbeingandfunctioninginsociety.Depression,anxiety,stress,habits,addictionsandnumerousotherconditionsmustbeaddressedappropriately,ofteninconjunctionwithmedications,psychiatryorpsychotherapies,stressreduction,meditation,andsupportgroups.Osteopathic

Figure 1. Classic five models of physiological function coordinated and affected by the neuromusculoskeletal (NMS) system and adapting to external and internal environmental stressors. Osteopathic diagnosis and manipulative treatment is seen as a key modality to help restore homeostasis and facilitate health. (Adapted from Foundations of Osteopathic Medicine, 3rd edition 1)

manipulativetreatmentalsomaybehelpfulintheformofsomatoemotionalreleasewithguidedimagery13andemotionalrelease.14

The Bioenergetic Model in Osteopathic Medicine

Healersinvariouscultureshaveutilizedbioenergeticmodelsofhealingthroughoutthemillennia.Orientalmedicine,forexample,whichoriginatedinChinaatleast5,000yearsago,describestheconceptofqi(ch’i)—energyorlifeforce.Qiisthoughttomaintainhomeostasisand/orcauseaberrationsinhealth.Inotherwords,abnormalitiesinqi(excesses,deficienciesorstagnation)arethoughttobetherootcauseofillness.15

Throughoutthehistoryoftheosteopathicprofession,numerousmanipulativetechniqueshavebeendevelopedtotreatavarietyofpatientailmentsandassistinmaintaininghomeostasis.Thesetechniquesareprimarilybaseduponbiomechanical,neurophysiologicalorlymphatic/fluidmodels.1Notincludedinthefiveclassicmodelsabove,andrarelydiscussedbothinthemedicalliteratureandclinically,isthebioenergeticmodel.Bioenergeticsis,perhaps,theall-encompassingmodelthatunderliestheclassicfivemodels,aswellaslifeitself.


Bioenergeticsisauniquefieldofresearchthatfallsunderthecategoryofbiophysics,andisnotemphasized,perse,asanimportantpartoftraditionalbiologyorclinicalmedicine.Itisthestudyofhowendogenousandexogenousenergysources/formsinfluenceandcontrollivingsystemsandtheirenvironment.Scientificstudyofbioenergeticsofbothplantsandanimals,includinghumans,hasbeenprolificandongoingforatleastacentury.16,17,18,19

Bioenergeticconceptsactuallyhavebeenapartofthelanguageandpracticeofosteopathicmedicinefromtheearlybeginnings.AndrewTaylorStilladvertisedandpracticedasamagnetichealerpriortofoundingourprofession.20,21InhisbookThe Philosophy and Mechanical Principles of Osteopathy,hediscussedtheconceptof“biogen”22asvital(energetic)forceoperatingthroughprotoplasmtoproducelivingmatter.23Heacknowledgedthatelectricandmagneticforcesinthebodyarelikelyimportantinhealth.24

In1902J.M.Littlejohn,DO,25definedthevital forceasaunionofspiritandmatteroperatingthroughitsbasicprinciple—thepowerofvibration.Henotedthatoscillatoryrhythmsexistinalllivingtissuesinoneformoranother,andsurmisedthatvariouslevelsof“vibratility”correlatewithnormalandabnormalfunctioning,i.e.,healthanddisease.Fromhisperspective,encouragingrestorationofnormalvibratoryactivityinthebodywasanimportantphysiologicalprinciplebehindosteopathictherapeutics.

In1903Hulett26presentedadetailedosteopathicenergymodel.Heconjectured,“anormalconditionofhealthisdependentonapropercoordinationofenergies,andthatdiseaserepresentsastateoflivingmattersuchthatincoordinationresults.”

Aroundthissametime,W.G.Sutherlandwasjustbeginninghislifelongjourneytodevelopthecranialconcept,amodelforosteopathictreatmentinthecranialfield.Inordertoexplainrhythmicmotionsofthecranium,sacrumandothertissuesthathewaspalpating,heeventually(1939)definedwhathecalledtheprimary respiratory mechanismandpotency.27Theprimaryrespiratorymechanismhasfivecomponents,twoofwhichmaycontributetheinherentdrivingforcesbehindtheflexion-extensionphasesofmovement.Thesearetheinherentmotilityofthebrainandspinalcord;andfluctuationofthecerebrospinalfluid.28

Magoun29statedthatfluctuationofthecerebrospinalfluidexhibitedtwocharacteristicswhichaffectthewholebody:potency,anenergeticforce,actingthroughahydrodynamicmechanism;andelectricalpotentials

actinginpositiveandnegativephases.Hesuggestedthatelectricalenergymightbegeneratedbythecoilinganduncoilingoftheneuraltube.Additionally,hewrote,“Inthecranialconcept,humanelectrobiologyistremendouslyaffectedbyitsenvironmentasitcarriesoutasimilartransmutationthroughoutthebody.”

OneofthegreatestchampionsforthebioenergeticmodelwasRobertFulford,DO.Throughoutmuchofhiscareer,hereliedonhisunderstandingofbioenergytoexplainhishands-ontechniquesanduseofthepercussionhammer.30,31,32Hecontinuallyquestionedandsoughtanswerstothetruenatureandgreaterscopeofhealingandosteopathicprinciples.Hehadawide-ranginginterestinresearchandtherapiesrelatedtotheenergeticlifeforce,includingpolaritytherapy.33

Polarity therapyisanenergetically-basedsystemofhealth,diagnosisandtreatmentfoundeduponEasterntraditions(yogic/AyurvedicandChinesemedicine).34DevelopedbyRandolphStone,DO,DC,itaddressesmind-body-spiritissuesbytherapeuticallytouchingthebodyto(theoretically)affectelectromagneticwaveandpolarityimbalances.35,36

Duringthe1960s,RollinBecker,DO,soughttodefine,explainandteachaboutvariouspalpableenergiesthatheexperiencedwhiletreatingpatientswithosteopathyinthecranialfield. Inaseriesoffourarticles(1964-65)37,38,39,40hedescribedanddiscussedbioenergy fields,biodynamicandbiokinetic intrinsic energiesandforcesandtheirrelationshipstopotency,fulcrums,diagnosticandtherapeutictouch,health,diseaseandtrauma.Biodynamic intrinsic forces/potenciesweredefinedasthe“physiologicalenergyfoundinthehealthwithinthepatient.”Biokinetic intrinsic forces/potenciesweredefinedasthe“pathological-physiologicalenergies…foundindiseaseandtraumaticstateswithinthepatient.”41In1969,heabandonedthesetermsandconceptswhenheperceivedtheywerenotbeingappreciatedandunderstoodbycolleagues.42

In1987StephenM.Davidson,DO,developedanosteopathicdiagnosisandtreatmentmodelwhichhecalledneurofascial release.43Basedonaparadigmofstandingwaveformsandinterferencevibratorypatternsintissues,thistechniquecanbeappliedtomusculoskeletal,visceral,cranialandevenemotionaldysfunctions.Neurofascialreleasewillbediscussedinmoredetaillaterinthispaper.

Asimilarmodelofabnormalinterferencetissuewavepatternsisthoughttoexplainthe“energycyst”conceptoriginatingwithElmerGreen,PhD,anddescribedbyMacDonald44andUpledger..45Energy cystsaredefinedasenergeticallyencapsulatedareasofthebodywhich


containincreasedenergyentropyordisorganizationwithinthecysts.Theoretically,theseresultfromphysical,mental,emotionalorspiritualtrauma,andaresimilartotheconceptofstagnantorblockedqiintheacupuncturemeridiansystem.Theycanbedetectedbyanumberofmethodsandtreatedbymyofascialunwindingofthecystareawithsubsequentmobilizationofrelatedfacilitatedspinalsegmentsandtheduraltube.44

Inthelate1980sandearly1990s,CarlisleHolland,DO,ponderedthehumanbodyfromabiophysicsstandpoint.Withauniqueeducationalbackgroundinaerospaceengineering,molecularbiologyandosteopathicmedicine,hebegandiscussingthecolloidalnatureoftissuesandtheirpropensitytomovebetweensolidorgelstates.Sol-gelinterconversionincolloidsoccurswhencertainenergeticorphysicalstressesareapplied.Thus,changesinviscoelasticandviscoplasticpropertiesofthedura(andtissuesingeneral)occurasaresultoftrauma/dysfunction,andcannormalizebyappropriatetreatmentwithosteopathyinthecranialfieldandothertechniques.46Hollandwentontoexpandtheseconceptswithdynamicalsystemstheory,chaostheory,andfractalprinciples.47Hiscontributiontotheosteopathicbioenergeticsmodelalsowillbediscussedsubsequently.

Alsoduringthe1990s,O’Connellresearchedandappliedbioenergeticsandbiophysicsprinciplestothetreatmentoffascia.48Shedevelopedthebioelectricfascialactivationenergyandholographicmodelsforanosteopathicmanipulativetechniqueshetermedbioelectric fascial activation and release(BFAR).49Thisbioenergeticparadigmsupportshomeostasisthroughthesynthesisoffascialbioresponsiveelectricalpotentials,continuityandinterfacewiththeECF,compensatorypatternandenvironmentalcommunication.Treatmentisaccomplishedthroughholographicpalpationandenergeticfascialactivation.48

Overthepastdecadeorso,theinterestinbioenergeticsinosteopathicmedicineappearstohaveincreased.In2003Comeauxdescribedamethodofdiagnosisandtreatmenthetermedfacilitated oscillatory release (FOR).50Thetheoreticalbasisofwhichisthemechanicalfacilitationofcoherentvibrationsinthetissuesresultinginnormalizationoffunction.HecharacterizesthetechniqueasamergerofprinciplesfromFulford’spercussormodel,fascialreleaseandmuscleenergy.50

OtherphysiciansalsoprovidingmorerecentinsightandexperiencetothebioenergeticmodelincludeLee(Spirit/extracellularmatrixbiophysics),51,52Chikly(traumavectorrelease),10andHendryx53andO’Brien

(dynamicstrain-vectorrelease).54Thecontributionsoftheseauthorswillbediscussedinmoredetaillater.

In1939C.P.McConnell,DO,wrote,“keepinmindthatosteopathicpathogenesisispre-eminently(essentiallyfundamental)afieldofbeginningpathologyfirmlygroundedonbiophysics.Hereinarisesthesoundnessandcomprehensivenessofosteopathicscience.”55

Energy Medicine and the Scientific Basis of the Bioenergetic Model

Energyisdefinedscientificallyastheabilitytodowork.56Thefirstlawofthermodynamicsmaintainsthatenergycanbeneithercreatednordestroyed.Itcanonlybeconvertedtootherformsofenergy.57

Somefamiliarformsofenergyincludekinetic(motion),potential(stored),chemical,electromagnetic,heat,elastic,gravityandsound.Anyformofenergycanbeabsorbedbyandaffectlivingsystems.Livingsystemsalsoproduceenergyandinteractwitheachotherandtheenvironmentthroughenergyexchange.58

Energy medicinecanbedefinedsimplyastheuseofenergeticprinciplesandphenomenatodiagnoseandtreatpatients.Oschmanhasmadetheargument,“allmedicineisenergymedicineandthattheenergeticperspectiveholdsthekeytothefutureoftheentiremedicalenterprise.”59Hehasthoroughlyreviewedthehistoricalbackground,measurements,biophysicsandtherapeuticusesofenergeticphenomenainmedicine(includingosteopathic)andhumanperformance.58,60Holland,47Lee,16,52O’Connell,61Comeaux,30,50Davidson,43HendryxandO’Brien54andHandoll62haveexpandedandintegratedtheseconceptstoexplainpalpatoryfindingsofinherentbodymotions,somaticdysfunctionandmanipulativetherapeuticsintheosteopathichealingmodel.

Biophysicsandbioenergeticprinciplesareutilizedeverydayinmedicinefordiagnosisandtreatment.DiagnosticinstrumentationthatemployenergeticmeasurementsincludeX-rays,computerizedtomography(CT),magneticresonanceimaging(MRI),positronemissiontomography(PET),electrocardiography(ECG),electroencephalography(EEG),electromyography(EMG),evokedpotentials,infraredthermographicimaging,magnetoencephalography(MEG),magnetocardiography(MCG),ultrasound(US),superconductingquantuminterferencedevice(SQUID)magnetometry(biomagnetometry),pulseoximetryandskinsurfacepotentialmeasuringdevices.

“Conventional”treatmentmodalitiesthatutilizevariousformsofenergyincludeultrasound,electricalstimulation,electric/magneticbonestimulation,


diathermy,X-irradiation,gamma-irradiation,lighttherapy(fullspectrum,ultraviolet,laser,infrared),electrocautery,pacemaker,defibrillator,neurofeedbackandmusictherapy.Osteopathicmanipulativetreatmentsofvarioustypesutilizemechanicalenergy,attheleast.

TheNationalCenterforComplementaryandAlternativeMedicine(NCCAM/NIH)hasdesignatedandissupportingresearchintoeightcategoriesofcomplementaryandalternativemedicine:63

1. Alternativesystems2. Botanicals/herbalmedicines3. Biofieldtherapies(energymedicine/

bioelectromagnetics)4. Manipulative/manual/therapeuticbodywork5. Movementtherapies6. Mind-bodyinteractions7. Pharmacologic/biologic8. Diet/nutrition/lifestylechanges

Categoriesthreeandfourobviouslyapplytothecentralthemeofthisthesis.Atthispoint,itisimportanttodefinevarioustermsrelatedtothebioenergeticmodelasthesetermsdonotappearinconventionalosteopathicresourceliterature.

BeverlyRubik,PhD,hasdefinedthebiofieldas“thecomplex,extremelyweakelectromagneticfieldoftheorganismhypothesizedtoinvolveelectromagneticbioinformationforregulatinghomeodynamics.”64The

biofieldhasbeenmeasuredbyanumberofdevices58andisconcentratedwithinandimmediatelysurroundsthephysicalbody,althoughitsboundariesarelimitless.Allcells,organs,organsystemsandtheextracellularmatrixcontributeenergytothebiofield,withtheheartandbrainproducingthetwolargesteffects,respectively.58,60Biofield therapycanbedefinedasanytherapeuticmodalitywhichinteractsandchangesthebiofieldanditsmanifestations.64

Bioenergyisenergyproducedendogenouslybylivingsystems.58,60 Thenatureandsourcesofbioenergyareknowninsomeinstances,unknowninothers.Muchofitappearstomanifestintheelectromagneticspectrumfromextralowfrequencyfields(ELF)(<100Hz)through1015Hz(visiblelight).58Bioenergyiscreatedandtransmittedbyanumberofbioelectromagneticandphysiologicalactivitiesinsidelivingtissuesandcells.Sourcesofbioenergyincludebiochemicalreactions,ioninflux/effluxthroughmembranes(gatingmechanisms),piezoelectricphenomena,mechanotransduction,electricalconductionthroughtheneuromusculoskeletalsystem,bloodcirculationandelectromechanicalactivityoftheheart.58,60Someunknownsourcesandtypesofbioenergyhavetodowithinherentmotionofthecraniosacralsystem(cranialrhythmicimpulse)andprimaryrespiratorymechanism,acupuncturemeridiansystems,qi,healingbiofields,andsubtleenergy.60,65 Biofieldenergiesmaybedirectedandcontrolledthroughconsciousnessandintention.60,66

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Bioelectromagneticsisthestudyoftheinteractionbetweenelectromagneticfieldsandbiologicallivingsystems.Bioelectromagnetismdescribestheinherentabilityoflivingcells,tissuesandorganismstoproduceandemitelectricalandmagneticfields,andtheresponseofcellstoelectromagneticfields.60

Oschmanconsidersthehumanbodytobeatissue-tensegritypiezoelectricmatrixorliquidcrystalundertension.60Fromabiophysicsstandpoint,thischaracteristicallowsthebodytoreacttoandcreatevariousfrequenciesandfieldsofenergy.Thehumanbodyalsocreatesotherformsofenergyincludingheat,sonic,photic(light/photons),chemicalandmechanical.60

The Bioenergetic Nature of Somatic Dysfunction

Toanosteopathicphysician,thoroughevaluationoftheneuromusculoskeletalsystemiskeyinaccuratelydiagnosingandappropriatelytreatingapatient.Intelligentpalpationofchangesintheposition,motion,texture,tensionandtemperatureoftissuesgivesimportantcluesastothestatusofapatientandresponsetotreatment.Abnormaltissuetexturechanges,asymmetryandrestrictionofmotion,andtenderness(i.e.,T.A.R.T.)arethehallmarksofsomaticdysfunction.Somatic dysfunctionisclassicallydefinedas“impairedoralteredfunctionofrelatedcomponentsofthesomatic(bodyframework)system;skeletal,arthrodialandmyofascialstructures,andtherelatedvascular,lymphaticandneuralelements.”67Commonlyconsideredunderlyingetiologiesofsomaticdysfunctionincludepoorbodymechanicsandposture,muscleimbalances,abnormalneurologicalreflexes,facilitation,emotionalstressors,compensationfromotherareasofbodyorvisceraldysfunctions,leglengthdiscrepancies,localizedstrainsandsprains,responsetotraumaandpainandothers.68Abnormaltissuetexturechangespalpatedintissuesaregenerallyassumedtobemaintainedbyvariousreflexesintheneuromusculoskeletalsystemandalsobybiotensegrityabnormalities.68,69

Becauseoftheenergeticnatureoflivingsystems,severalimportantquestionsarise.Canenergeticdysfunctionsinthebodyorbiofieldcauseorcontributetosomaticdysfunctionandotherhealthissues?Ifso,howmightthesemanifest?Canbioenergeticosteopathicmanipulativetechniquesbeutilizedtoactuallytreatsomatic,visceralorpsychologicaldysfunctions?Whataretheenergeticmechanismsbehindthesetechniques?

Energeticphenomenainthebodythatcanbepalpatedandusedintreatmentofsomaticorvisceral

dysfunctionsandpsychosomaticconditionshavebeenpreviouslydescribedandreviewedindepth.54Theseincludepalpationofinherentmotions(nervoussystem,cranialrhythmicimpulse/primaryrespiratorymechanism,visceral,myofascial),stillpoints,therapeuticpulses,thermalprojections,vibratoryfields,biodynamicandbiokineticenergyfields,“energycysts,”“listening,”fascialinterferencepatterns,pathologicalstrain-vectors54andheadtraumavectors.10Osteopathicmanipulativetechniquesthatemployprimarilyabioenergeticmodelintreatmentinclude,butarenotlimitedto,Fulfordpercussortreatment,32myofascialrelease,61bioelectricfascialactivationandrelease,49neurofascialrelease,43dynamicstrain-vectorrelease,54lymphofascialrelease70andheadtraumavectorrelease.10

Holland71makesacompellingargumentforabiophysicsandmathematicallybasedsystemofintegrativemedicinewhichheterms“DynamicalMedicine.”Dynamicalmedicinefollowsamathematicalmodelandisnamedforitsoriginindynamicalsystemstheory,abranchofscienceconcernedwithchaosandfractals.Dynamicalsystemstheoryappliestoalllivingsystemsinalldimensionsanddescribesbiologicalshapesandprocessesmathematically.

Physiologicalfunctioninginadynamiclivingsystemiscomplex,andvariousparameters(bloodpressure,bloodchemistriesandcellcounts,heartandrespiratoryrates,bodytemperature,etc.),tendtohoverwithincertain“normalranges,”butneverremainfixed.Thedomainsoffluctuatingparametervaluesweregiventhenameof“strangeattractors”byLorenz.71

Throughthelensofdynamicalmedicine,thehumanbeingisseenasanenergeticvibratingsystemexhibitingfractalgeometryinalldimensions.Fractalsaremathematicalprocessesthatexhibitrepeatingpatterns(waveforms)andoccurinallofnature.71,72Inhumans,fractalsmaybeseeninthebranchingpatternsofnerves,bloodvessels,lymphatics,fascia,muscles,ligaments,bonesandinthetissueorganizationofallorgansinthebody.Innormaltissue,energyflowsunhinderedthroughthefractalsystem,andnormalfunctionensues(i.e.,strangeattraction).Indysfunctionalsystems,energyflowthroughfractalsisblocked.Blockageoccursatwhatisknownasa“catastrophicbifurcation”ofthefractalwherethewaveformcollapses.71

Thepointwherethiscatastrophicbifurcationemergesismathematicallyknownasa“pointattractor.”Pointattractorsmaybe“trivial”or“non-trivial.”Trivialpointattractorsarereversibleintheirstressoreffectsonasystem.Thelivingsystemcanrevertbacktonormal


functioningwithfullfractalexpressiononcethetrivialpointattractorisremoved.71Hollandhasdescribedsomaticdysfunctionasa“mattedfractal”wheretheenergyflowisinterrupted.47Thus,reversiblesomaticdysfunctionisanexampleofatrivialpointattractorinthedynamicalmedicinemodel.71

Non-trivialpointattractorsresultinirreversiblechangesinthesystem.Theseproducepermanentblocksintheenergyflowandcommunicationinthesystemand,ifsevereenough,willcausetotalcollapseoftheenergyflowandfractalgeometryofthesystemanddeath.Examplesmightincludeacerebrovascularaccident,fatalcardiacarrhythmia,liverorkidneyfailure.71

Sol-gelinterconversionshavebeenpostulatedtounderliepalpatoryfindingsofabnormaltissuetexturechangesassociatedwithsomaticdysfunction.54,73,74Hollandemphasizesthatalltissues,includingthemyofasciaandextracellularmatrix,arecolloidal(anon-precipitatingsuspension)innatureand,assuch,mustfollowcolloidalphysicsprinciples.71Colloidshavephysicalpropertiesofbothliquids(sol)andsolids(gel),andareabletoabsorbandstoreenergythroughtheirintermolecularbonds.Physicalenergyintheformoftraumaandevenelectromagneticenergyandfields(i.e.,pointattractors)cancausesol-gelinterconversions.54

Part two of Dr. Hendryx’s thesis will appear in the next issue of the American Academy of Osteopathy Journal.

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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


Editor’s Note: This abstract was presented as part of the Louisa Burns Osteopathic Research Committee poster competition at the 2013 AAO Convocation in Orlando, FL.

Objectives

Psoasmuscledysfunctionscancauselowbackpain.Osteopathicphysiciansusecounterstraintotreatthetenderpointthatcanoccurwhenthereisamusclecontractionorspasminthepsoas.TheThomastestisaspecialtestutilizedtodiagnosisapsoasspasm,andtherehavebeenseveralstudieswhichestablishedtheThomastestasaneffectivemeanstodiagnosethesedysfunctions.However,therehavenotbeenanystudiesthatlookedforarelationshipbetweenapositiveThomastestandpsoastenderpointpresence.Wehadthreeobjectivesinthisstudy:

1. toestablishthatsubjectswithapositiveThomastestwouldhavehigheroddsofapositivepsoastenderpoint;

1. tolookforanimprovedThomastestfollowingtreatmentwiththeappropriatecounterstraintechnique(ifthetenderpointwaspresent);and

1. tocollectdatatodeterminetheeffectivenessofcounterstraintreatmentforthepsoasmuscleasperformedbystudents.

Methods

Second-yearmedicalstudentsatNewYorkInstituteofTechnologyCollegeofOsteopathicMedicine(NYIT-COM)utilizedanosteopathicmanipulativemedicine(OMM)labworksheetwhichaskedstudentstoworkinpairsandperformaThomastest,lookforapsoas

Abstract: Second-year Osteopathic Student Evaluation of the Prevalence of a Positive Thomas Test and a Psoas Tender Point Before and After Treatment with Counterstrain TechniqueJocelyn Young, OMS III; Sheldon C. Yao, DO; Reem Abu-Sbaih, DO; and To Shan Li, DONew York Institute of Technology College of Osteopathic Medicine. 2013.

tenderpoint,andifitwaspresent,gradeitonapainscaleof0to10,treatitwithcounterstrainandthenreassessthetendernessandThomastest.Studentsrecordedallresponsesontheirworksheets,whichwerecollectedattheendofthelaboratorysession.Thestudentresponseswereanalyzedasdata.

Results

StudentswithapositiveThomastesthadapsoastenderpointinastatisticallysignificanthigherproportionthanthosewithanegativeThomastest(p=.04).IfthesubjectwithapositiveThomastestalsohadapsoastenderpointthatwastreated,wefoundthat68.2%hadanimprovedThomastest,definedasdecreasedhipflexionoftheaffectside.Ofallpsoastenderpointsstudentsfoundandtreated,3.4wastheinitialmeannumberreportedonthepainscale.Aftertreatmentthemeanwasreducedto0.6,suggestingeffectivetreatmentofthepsoastenderpoint(p<.001).

Conclusions

Ourresultshaveshownthatinahealthypopulationofsecond-yearmedicalstudents,thefindingofapositiveThomastestincreasestheprobabilityapsoastenderpointispresenttwofold.Theresultsalsodemonstratedthatsecond-yearstudentswereeffectiveinutilizingcounterstraintechniquetotreatapsoastenderpointwhenfound.Whilenotstatisticallysignificant,wealsoshowedthatalargepercentageofpositiveThomastestscanbeimprovedwithcounterstraintreatmenttothepsoas.


The views in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense or the United States Government.

Abstract

Thisisareportofacaseofapatientwithsymptomsoftemporomandibularjointpain(TMJP),trismus,migraineheadachesandassociatedlefteyeblurredvisiondailyforyears.Previouslyseenandtreatedbynon-osteopathicproviders,thispatientreportedfailedtreatmentsincludingdentalguards,musclerelaxers,over-the-counteranalgesicsandnarcotics.Followingasingletreatmentwithosteopathicmanipulativemedicine(OMM)thepatientreportedresolutionofhersymptoms,allowinghertodiscontinuetheuseofspeciallymadeglasseswithalefteyecorrectivelens.

Key Words: osteopathicmanipulativemedicine(OMM),osteopathicmanipulativetreatment(OMT),craniosacral,cranial,manualmedicine,posttraumaticheadaches,migraine,tensionheadache,cervicogenicheadache,temporomandibularjointdysfunction,traumaticvisionloss,zygomatictrauma,somaticdysfunctionandunifiedfield.

Introduction

Variousheadachesduetoheadandnecktraumaareamongthemostreportedsymptomsfollowinginjury.1-3AccordingtotheInternationalHeadacheSociety’sICHD-3b,adistinguishingfeatureofposttraumaticheadachesisthetemporalrelationtoaknowntraumaticincident.4Posttraumaticheadachesarenotfullyunderstood;aspecificdiagnosisisnotoftenassignedandanoptimalcourseoftreatmentisnotalwaysprovidedforthosewhoseektreatment.5

Posttraumaticheadachescanbesimilartonon-traumaticheadaches.4,6-8Traumaticheadachesinathletescanhavesymptomssimilartotension,migraine,clusterandmixedposttraumaticheadachesregardlessoftheseverityoftheheadtrauma.4,5BasedonICHD-3bcriteria,newonsetheadacheswithinsevendaysofheadtraumaarediagnosedasacute posttraumatic headachewhilecontinuedheadache

Resolution of Post-traumatic Temporomandibular Joint Pain, Headache and Vision Changes with OMM in the Unified Field: A Case ReportJames A. Lipton, DO, CSP-OMM, FAAO, FAAPMR, DAOBPMR; and ENS Matthew G. Case, MC, USNR, MSIV

afterthreemonthsistermedpersistent posttraumatic headache.4,8,9,77Evenmildheadtraumawithoutlossofconsciousnessorobjectivefindingscancausenewonsetorexacerbationofheadachesnecessitatinglong-termmanagement.4-6,9

Diagnosingapatientwithamigrainefollowingaposttraumaticinjurycanbelinkedtoapatient’smedicalhistoryandreportedsymptoms.6,9Typicalcharacteristicsarephonophobia,photophobiaandincreasedpainwithphysicalexertion.4,5,9-11Thethreemostpredictivecharacteristicsformigrainediagnosisaredisability,nauseaandphotophobiaalthoughnoisolatedcharacteristicisnecessarytomakethediagnosisofmigraine.9

Treatmentforheadachescanbebasedonthedescriptionoftheheadache,forexample,tensiontype,cluster,cervicogenicormigraine.Headachescanbemanagedwithmedication,butsomepatientsdon’ttoleratemedicationsduetothesideeffects,can’ttakethemduetothecontraindications,mayneedadditionaltreatmentorchoosealternativetreatments.1,12-18Pharmacologicaltreatmentsformigraineheadachescanincludenon-steroidalanti-inflammatorydrugs,anticonvulsants,tricyclics,calciumchannelblockersandtriptans.6,9,12,16,19Despiteadvanceddrugtherapies,therecanremainsuffererswithrefractoryheadachewhofailtorespondtocurrentpharmacologictreatmentsorreturntobaselinesymptomsoncemedicationsarestopped.Pharmacologicaltreatmentsarenotsuitableforallpatients,noraretheyuniversallyeffective.1,13,14,20

Manipulativemedicinemaybeusefulasatreatmentforheadaches.11,14,15,18,20-30Manipulativemedicinehasbeendescribedasbeingusedtoimprovecirculation,releaserestrictionsinjoints,reducetensioninmuscles,fasciaandduramater,decreasenociceptiveinputandpromotethenormalizationofthecentralnervoussystem.26,31-34

Theliteratureonosteopathictreatmentofposttraumaticheadacheswithvisionrestorationissparse.Wingfieldetal,35Gorman,36,37andStephens


etal38,39describevisualimpairmentssuccessfullytreatedwithmanualmanipulationinpatientswithoutposttraumaticheadaches.AsurveypublishedbyJonsonetalreportsosteopathicphysiciansusingOMMtotreatheadaches,concussionsanddiplopia.27ElectronicliteraturesearcheswerecarriedoutonGoogleScholar,theNationalLibraryofMedicine(MEDLINE)andtheCochraneDatabasesforpublishedmaterialintheEnglishlanguage.Literatureaddressingthediagnosisandtreatmentofposttraumaticheadaches,temporomandibularjointpainanddysfunction,andblurryvisiontreatedwithosteopathicmanualmanipulationwasreviewedandincludedinthiscasereport.

Report of Case

A27-year-oldfemalepresentedtophysicalmedicineandrehabilitationforevaluationofchronicright-sidedTMJP,trismusanddailymigraineswithassociatedblurryvisionofthelefteye.Thepatientstatedhersymptomsweretheaccumulationoftwoseparatetraumaticincidents.Followingaphysicalaltercationfiveyearspriortotreatment,thepatientwasstruckontherightsideofherheadjustanteriortoherear.Threeyearspriortotreatmentthepatientreportedafallaboardshipwhereshestruckherheadagainstmetalframingandinjuredherrightshoulder,requiringaBankartrepair.

Followingthefirstincident,thepatientbegantoexperienceintermittentheadachesthatwereunlikeanypreviousheadacheshehadexperienced.Followingthesecondincident,thepatientstatestheheadachesbecamemorefrequent,occurringeverydaywithincreasedpain.Temporomandibulardiscomfortwitheatingandtrismusalsobeganfollowingthesecondincident.

Overthecourseoffouryears,thepatientwastreatedfortemporomandibularjointdysfunction(TMJD),migrainesandnewonsetblurryvisionthroughvariousallopathicproviders.ThepatientwasfittedwithdentalguardstoaddressherTMJP,buttheyprovidednorelief.Thepatientwasalsoevaluatedandtreatedbyneurologyforherheadaches,resultinginmedicationwithnosuccess.

ImagingobtainedthroughherprevioustreatmentincludedanormalMRIofherheadandanormalPanorexfilmofherjaw.

Duringherhistoryoftreatment,thepatientwasprovidedmultipledrugs,includingmusclerelaxers(cyclobenzaprine),narcotics(hydrocodonewithacetaminophenandoxycodonewithacetaminophen),

nonsteroidalanti-inflammatory(naproxen)andtramadol.Thepatientexplainedthatshehasahistoryofbeingverysensitivetomedicationsandfoundoxycodonetobetoosedating;thehydrocodoneandnaproxenresultedinitching,andnoreliefwasprovidedfromthecyclobenzaprineortramadol.

Thepatient’sreviewofsystemsincludedright-sidedjawpain,reducedoralopeningandacorrectivelensforherlefteyeblurredvision.Thepatientreportedhavingpersistentjawpainwith8/10painmostnotablywhileshewaseating.Thepatientreportedthatherheadachesweredailyandcouldlastbetween45minutesto24hoursandcouldrangeinseverityfrom4/10to8/10.

Onphysicalexamthepatient’sC3wasERLSL,andC4wasERRSR.Straight-lineopeningofthejawwithdiminishedopeningwasnotedwithlateralpterygoidrestriction,markedrightsphenoidtorsionandtemporalrestriction.Atoruspalatinuswasnoted.

TreatmentwasbasedonosteopathicprinciplesandpracticeandchosenasaresultofclinicalexperiencewiththeuseofOsteopathyintheunifiedfield.40TreatmentinvolvedOMMtechniquesincludingmyofascialrelease,muscleenergy(ME),high-velocitylow-amplitude(HVLA)andcranialtechniquesdirectedtowardinvolvingintraoralandextraorallocations,therectuscapitisposteriorminor,associatedmyoduralbridge21andcranialbonestospecificallyaddressthispatient’sindividualresponsetotreatment.

Immediatelyfollowingthefirsttreatment,thepatientreportedcompleteresolutionofhersymptomsandimprovementwasnotedinthepatient’sstraight-lineopeningofthejaw.

Thepatientfolloweduptwoandthreeweeksafterherinitialtreatmentandreportedherpainwas0/10.ShehadnotexperiencedanymigrainesfollowingherfirsttreatmentandnolongerexperiencedTMJP.Shealsohadnotusedhercorrectivelenssinceherfirsttreatment.Twenty-fourdaysfollowingherfirsttreatment,shewaswithoutrestrictioninanyofhercranialbones.HerC4wasERLSLandwastreatedwithfacilitatedpositionalrelease.Shewasa0/10pre-treatmentand0/10post-treatmentwithresolutionofhersomaticdysfunction.Phonecommunicationatthirty-fivedayspost-treatmentrevealedshewasstillsymptomfree.

Discussion

Inthefallof1994,“TheCranialRhythmicImpulseandHeadache,ASynthesisforCliniciansandScientistsWorkingTowardMutualEducation”waspublished.Numerousareasoffurtherstudywereproposed,


includingsuggestionsforfurtheringourunderstandingofanatomicrelationshipsinregardtoheadache.12Amongthetopicscoveredinthepaperwerethedura,emissaryveins,scalptension,thepalpationofexternalheadandbodytissues,intervertebraldiscspacesandtheirrelationshiptoproprioception,bloodflow,cerebrospinalfluidflow,cranialrhythmicimpulseandhormonesastheyrelatetoheadache.12

WorkingindependentlyinapilotstudyinDecember1994,Hallgren,GreenmanandRechtien41lookedattheMRIimagingofsixpatientsinregardtofindingatrophyoftherectuscapitismajorandminormusclesinsomesubjectswithchronicheadandneckpain.

AgainworkingindependentlyinMay1995,Hack,Koritzer,Robinson,HallgrenandGreenmanidentifiedconnectionsbetweentherectuscapitisposteriorminor(RCPMi)andspinalduramaterattheatlanto-occipitaljunction.42

Thetermunified field hasbeendiscussedinphysicsforyearsandhasbeeninusesinceatleastthemid-nineteenthcentury.Inphysicsmanyscientistsworkedtodescribetheinter-relationshipbetweenthefundamentalforcesofnatureandparticlebehaviorwithinasingleframework.43InOctober1995theauthorarticulatedtheconceptoftheUnifiedFieldinOsteopathy,whichheoriginated,inapresentationgiventotheAmericanAcademyofOsteopathyattheAmericanOsteopathicAssociationmeetingheldinOrlando,Florida.40Inthispresentationtheauthornamedthemyoduralbridge.Theclinicalimplicationsofacervicalmyoduralbridgewerepublishedinthewinterof1997byHallgren,HackandLipton,againdocumentingtheabove.21Numerousarticleshavementionedthesetopicssince.9,44-51

ThisunifiedfieldinvolvesOsteopathyintheUnifiedField.40TheunderstandingoftheunifiedfieldisbasedonconceptsofOsteopathyfirstenunciatedbyAndrewTaylorStill,52thefounderoftheosteopathicprofessionandcarriedforwardbyWilliamGarnerSutherland,53HaroldMagoun,54ViolaFrymann,55RobertFulford56andcountlessotherskilledosteopathicpractitioners.Thisunifiedfieldisasynthesisofbasicscience,allopathic,dentalandosteopathicthoughtregardingtheanatomyanditsclinicalimplications,bothwithrespecttodiagnosisandtreatment40—inotherwords,theunifiedrelationshipbetweenthemanycentralandperipheralmechanismsthatinteractindynamichomeostasis.TheliteratureonandtheacceptanceoftheunifiedfieldinosteopathycontinuestogrowtosuchanextentthatitwasthetopicoftheAmericanAcademyofOsteopathy’sannualconvocationinLouisville,Kentucky,March2012.57,58

Atenetofosteopathystatesthatstructureandfunctionarereciprocallyinterrelated.59Abnormalitiesofthemusculatureortheosseousjointcomplexesofthecervicalspinehavebeenimplicatedinheadpain.9,11,15,23,26,29,44,60,61,62,63Painfulstimulicanelicitaheightenedsympatheticresponsethatcancausevasoconstriction,chemicalchanges,andmoremusclecontraction.26,32Increasedmuscletensioncantranslatethroughextra-cranialconnectionslikemyoduralbridgesintheuppercervicalspine.9,12,21,29,46,47,64Dysfunctionoftheuppercervicalregionfollowinginjuryhasalsobeenimplicatedinabnormalfunctionofthejaw.44SeverinssonetalreportanincreasedriskofdevelopingTMJDinwomenwithcranialcervicalsymptomsfollowingneckinjuriesandposttraumaticstress.65OsteopathictreatmentresultedintheuseoflessmedicineinonestudycomparingthetreatmentofTMJDtonon-manipulativetreatment.66

CranialOMMinvolvesthetreatmentofcraniumanditsinterrelationshipwiththebodyasawhole,includingasystemofdiagnosticandtherapeuticmodalitieswithapplicationintreatingdisease.12,67,68Sandhouseetalstudiedmyopiaandhyperopiaanddeterminedthatpatientswhounderwentcranialtreatmenthadimprovementintheirvisualacuityfollowingasingletreatment.Theirtreatmentwassaidtoinvolvemanipulationofthesphenoidboneandwasdirectedatreleasingfascialandbonyrestrictions,therebynormalizingtheinnervationandsubsequentfunctionoftheeyes.67,69,70

Therearetimeswhensurgeryisnecessarytotreatthebody.ExamplesofsurgeryinaconditionthatmightbefavorablytreatedwithOMMwouldbewithrespecttopiriformissyndrome71andwithrespecttoacasereportonchronicheadachereliefaftersectionofsuboccipitalduralconnectionsbyHackandHallgren.72

Theuseofmanipulativemedicineisaneffectivealternativetopharmacologicalandsurgicaltreatmentswithrespecttoheadaches.Manipulationasatreatmentformigraines,cervicogenicandtensionheadacheshasbeenreportedtobeeffectiveatreducingthefrequencyandseverityofheadaches.1,14,17,18,20-22,25,27,28,30,32,73Therearereportsofimmediateresultsafterasingletreatment.14,30Studieshavereportedthelong-termeffectsofOMMtreatmentsstillbeingefficacious12monthsorgreaterfollowingmanipulativetreatment.15,24,30Addressingdysfunctionofthemusculatureorthejointcomplexesofthecervicalregion,wherepainmayoriginate,couldexplaintheresolutionofpatients’symptomsfollowingtreatmentofthatsamearea.9,11,15,23,26,29,44,60,61,72Physicalattemptsattreatmentofheadachebyaccessingseemingly


unrelatedperipherallocationsarenotconfinedtomanipulationoftheneck.Osteopathicphysicians’approachtopatientcareisrootedinindividualizedtreatmentwithrespecttoeachpatientasaresultofacomprehensiveexamination.74,75Examplesmightbetheanecdotaluseofpressureinthehandinthewebspacebetweenthefirstandseconddigitandnumerousstudiesreviewedinevaluatingtheevidencefortheuseofacupunctureforreliefofheadache.76

Yet,thereismoretoexamineinthecloseclinicalcorrelationbetweensymptomandstructureinvolvedinheadaches,particularlyintensionheadaches.Itiscommonclinicalknowledgethataheadacheisoftendescribedbypatientsasstartingatthebaseoftheskull(RCPMi,myoduralbridgelocationandduralconnections)andprogressingtoscalptension(frontaliscontractionandacombinedfeelingofabandofstricturearoundthehead).Perhapsinterruptionoftheheadacheisachievedbymanipulatingtissue,causingaresetofthemyoduralconnectionfunctioningasastraingauge?Perhapswithrapidvasodilationofarteriolescommonlydescribedinmigraineheadachetheoryasirritatingdura,thebody’sattemptatbloodflowregulationmayinvolvetheemissaryveins?Oneinterestingreviewnotedthatthermoregulationcouldreversevenousflowthroughemissaryveinsoftheskull.49Nontraumaticheadachescanbeginwithathought,theconsequencesofwhicharefeltintheunifiedfield.IfthescalptensionisinitiatedbyastraingaugemechanismresponsivetoOMM,thenseveringtherelationshipmightnotbethefirstconsideration.Theclinicianmaybeabletomanipulatetheunifiedfieldinsupportofthebody’sefforttorestorehomeostasis.40Acommonknowledgeconcepttaughtinmedicalschoolsacrossthecountryistherelationshipbetweenheadtraumaandtheneedforreductionofintracranialpressurethroughtheuseofhyperventilationtoprotectbrainfunction.Thisisanexampleofusingthesecondaryrespiratorymechanismtoinfluencetheinternalbiochemistryofcerebralspinalfluidfarafieldwiththeaidofchemoreceptorsonthefloorofthefourthventricle.InterestingthattheOMMsuccessfullyappliedinthiscaseinvolvesanatomysoclosetothecerebrospinalfluid,thedura,theattachedmyoduralbridgeandthechangesinrespirationweasclinicianstreatingheadachesooftenwitnessourpatientsundergoduringapplicationofOMM.AndrewTaylorStillasasurgeonthoughtlongandhardonalternativestosurgerywhereappropriate.Asaresult,osteopathicphysiciansandsurgeonsworkinconcertwithcolleaguesacrossmanydisciplinestofurtherourunderstandingofhowthehumanbodyworksinsuchawondrousway.

Conclusion

Followingasinglein-officeOMMtreatment,thepatientwasprovidedwithcompleteresolutionofhercomplaintsofTMJP,dailymigraines,trismusandblurryeyesightthathadbeenpresentdailyforyears.

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Course DescriptionThis course is designed for participants with intermediate to advanced skills in OMM and those who have taken intermediate-level Cranial courses. We will take an in-depth look at the anatomical and structural influences of the pediatric ENT patient, taking a close look at the cranial and facial anatomy and its influences on health and function of the middle ear, sinuses and temporomandibular joint.CME16 hours of AOA Category 1-A credit are anticipated.Course TimesMonday and Tuesday: 8:00 am - 5:30 pmBreakfast and lunch on your own, coffee provided.Course LocationThe Broadmoor1 Lake Avenue, Colorado Springs, CO 80906Reservations: 7am to 9pm (MT), seven days a week.(800) 634-7711 (Mention AAO event.) https://resweb.passkey.com/go/aao14

Osteopathic Approach to Common ENT Complaints of Children

Heather P. Ferrill, DO, Program ChairDr. Ferrill, a 2000 Michigan State University College of Osteopathic Medicine graduate, is an Associate Professor of Osteopathic Manipulative Medicine (OMM) at the Rocky Vista University College of Osteopathic Medicine (RVUCOM). Board-certified in Family Practice and Neuromusculoskeletal Medicine/OMM, her practice emphasizes Osteopathic Manipulative Treatment in the pediatric population. She serves on the AAO Board of Governors and the Education Committee.

March 17–18, 2014

Register online at www.academyofosteopathy.org. For travel arrangements, Contact Tina Callahan of Globally Yours Travel at (800) 274-5975 or [email protected].

Click here to register

online.

Early registration extended to March 11!


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51. ElliottJ,etal.Fattyinfiltrationinthecervicalextensormusclesinpersistentwhiplash-associateddisorders:amagneticresonanceimaginganalysis.Spine.2006;31(22):E847-E855.

52. StillAT.Philosophy of Osteopathy. Indianapolis,IN:AmericanAcademyofOsteopathy;1986.

53. BraybrookJE.Anexplorationoftheinfluencesthatshapetheopinionsandpracticesofosteopathsinrelationtoosteopathyinthecranialfield:aresearchprojectsubmittedinpartialrequirementforthedegreeofmasterofosteopathy.UnitecInstituteofTechnology[i.e.,UnitecNewZealand].Diss.2010.

54. MagounHI.Osteopathy in the Cranial Field.Kirksville,MO:JournalPrintingCompany;1976.

55. FrymannVM,KingHH.The Collected Papers of Viola M. Frymann: Legacy of Osteopathy to Children.Indianapolis,IN:AmericanAcademyofOsteopathy;1998.

Osteopathic Considerations in Sports Medicine

June 13–15, 2014 • MWU/CCOM, Downers Grove, IL

Course DescriptionThis course will outline a manipulative approach to common sports medicine injuries and conditions of the spine, upper extremity and lower extremity. The program will have a balanced content of didactic material and hands-on OMT workshops.CME20 hours of AOA Category 1-A CME credit are anticipated.Course TimesFriday, 8:00 am to 5:30 pmSaturday, 8:00 am to 5:30 pmSunday, 8:00 am to 12:30 pmCourse LocationMWU/Chicago College of Osteopathic Medicine555 31st StreetDowners Grove, IL 60515

Program ChairKurt P. Heinking, DO, FAAO, is a 1994 graduate of Chicago College of Osteopathic Medicine, where he currently serves as Chair of the Department of Osteopathic Manipulative Medicine. He is board certified in Osteopathic Manipulative Medicine, Family Medicine and Sports Medicine, and has a private musculoskeletal medicine practice in Willowbrook, IL. Dr. Heinking is Program Chair of the AAO Sports Medicine course and serves on the Awards Committee.FacultyMark McKeigue, DO, graduated from Chicago College of Osteopathic Medicine in 1977 and completed internship and residency programs at Chicago Osteopathic Hospital. He is currently in family practice in Orland Park, IL.

Click here to register.


56. FulfordRC,FulfordR.Dr. Fulford’s Touch of Life: The Healing Power of the Natural Life Force. SimonandSchuster.com;1997.

57. HartmannC,PöttnerM.Classical Osteopathy: Field Theory as a Paradigm and a Fundamental Principle.

58. LossingKJ.TheUnifiedOsteopathicFieldTheory.Proc.of2012AAOConvocation,TheGaltHouseHotel,Louisville,KY.March21-252012

59. NelsonKE.Osteopathicdistinctiveness.Somatic Dysfunction in Osteopathic Family Medicine.2007:6.

60. HumphreysBK,etal.Investigationofconnectivetissueattachmentstothecervicalspinalduramater.Clinical Anatomy.2003;16(2):152-159.

61. TreleavenJ,JullG,AtkinsonL.Cervicalmusculoskeletaldysfunctioninpost-concussionalheadache.Cephalalgia.1995;14(4):273-279.

62. ZitoG,JullG,StoryI.Clinicaltestsofmusculoskeletaldysfunctioninthediagnosisofcervicogenicheadache.Manual Therapy.2006;11(2):118-129.

63. KempIIIWJ,TubbsRS,Cohen-GadolAA.Theinnervationofthecranialduramater:neurosurgicalcasecorrelatesandareviewoftheliterature.World Neurosurgery.2012;78(5:505-510.

64. RadanovBP,StefanoG,AugustinyKF.Symptomaticapproachtoposttraumaticheadacheanditspossibleimplicationsfortreatment.European Spine Journal.2001;10(5):403-407.

65. SeverinssonY,BunketorpO,WennebergB.Jawsymptomsandsignsandtheconnectiontocranialcervicalsymptomsandpost-traumaticstressduringthefirstyearafterawhiplashtrauma.Disability & Rehabilitation.2010;32(24):1987-1998.

66. CucciaAM,etal.Osteopathicmanualtherapyversusconventionalconservativetherapyinthetreatmentoftemporomandibulardisorders:arandomizedcontrolledtrial.Journal of Bodywork and Movement Therapies.2010;14(2):179-184.

67. JäkelA,vonHauenschildP.Therapeuticeffectsofcranialosteopathicmanipulativemedicine:asystematicreview.JAOA.2011;111(12):685-693.

68. JäkelA,vonHauenschildP.Asystematicreviewtoevaluatetheclinicalbenefitsofcraniosacraltherapy.Complementary Therapies in Medicine.2012.

69. SandhouseME,etal.Effectofosteopathyinthecranialfieldonvisualfunction—apilotstudy.JAOA.2010;110(4):239-243.

70. WolfAH.Osteopathicmanipulativeprocedureindisordersoftheeye.Academy Of Applied Osteopathy.1970:75.

71. BartonPM.Piriformissyndrome:arationalapproachtomanagement.Pain.1991;47(3):345-352.

72. HackGD,HallgrenRC.Chronicheadachereliefaftersectionofsuboccipitalmuscleduralconnections:acasereport.Headache: The Journal of Head and Face Pain.2004;44(1):84-89.

73. MilleaPJ,BrodieJJ.Tension-typeheadache.American Family Physician.2002;66(5):797-806.

74. DuncanB,etal.Effectivenessofosteopathyinthecranialfieldandmyofascialreleaseversusacupunctureascomplementarytreatmentforchildrenwithspasticcerebralpalsy:apilotstudy.JAOA.2008;108(10):559-570.

75. GoldbergPM.Osteopathicmedicine’sholisticapproachismoreimportantthanever.JAOA.2010;110(12):741-743.

76. ManiasP,TagarisG,KarageorgiouK.Acupunctureinheadache:acriticalreview.The Clinical Journal of Pain.2000;16(4):334-339.

Accepted for publication January 2014.

Address correspondence to:JamesA.Lipton,DO,CSP-OMM,FAAO,FAAPMR,DAOBPMRDepartmentofRehabilitativeMedicineServicesVeteransAdministrationHospitalHampton,VA,23667

ENSMatthewG.Case,MC,USNR,MSIVVirginiaCollegeofOsteopathicMedicineBlacksburg,VA,24073


December2013AAO Journal CMEquizanswers:

1. A2. D3. D4. A

AnswerstotheMarch2014AAOJCMEquizwillappearintheJune2014issue.

CMECERTIFICATIONOFHOMESTUDYFORMThisistocertifythatI,___________________________ Pleaseprintname

READthefollowingarticleforAOACMEcredits.

Name of Article:ResolutionofPost-traumaticTemporomandibularJointPain,HeadacheandVisionChangeswithOMMintheUnifiedField:ACaseReport

Authors: JamesA.Lipton,DO,CSP-OMM,FAAO,FAAPMR,DAOBPMR,andENSMatthewG.Case,MC,USNR,MSIV

Publication: AAOJ,Volume24,No.1,March2014,pp.22-28

Mailthispageto:AmericanAcademyofOsteopathy3500DePauwBlvd.Suite1100Indianapolis,IN46268

Category2-Bcreditmaybegrantedforthesearticles.00____________ AOANumberFullname:______________________________________ (Pleaseprint)

Streetaddress:___________________________________

City,state,zip:__________________________________

Signature:______________________________________

FOROFFICEUSEONLYCategory:2-B Credits:_________Date:____________

American Osteopathic Association Continuing Medical Education

ThisCMECertificationofHomeStudyFormisintendedtodocumentindividualreviewofarticlesintheAmerican Academy of Osteopathy JournalunderthecriteriadescribedforCategory2-BCMEcredit.

Completethequiztotherightbycirclingthecorrectanswers.MailyourcompletedanswersheettotheAAO.TheAAOwillforwardyourresultstotheAOA.Youmusthave70percentaccuracyinordertoreceiveCMEcredits.

1. Amyoduralbridgeexistsbetweentheduraandwhatmuscle?

a. Rectuscapitusposteriorminorb. Trapeziusc. Levatorscapulaed. Bicepse. Alloftheabove

2. Theremaybearelationshipbetween:

a. Headacheandtraumab. Scalptensionandscalpbloodflowc. OMMtreatmentandOMMoutcomed. Suboccipitalmusclesandheadachee. Alloftheabove

3. Post-traumaticheadachecanbecharacterizedbythefollowingsymptoms:

a. Photophobiab. Phonophobiac. Agorophobiad. AandBe. Arachnophobia

4. TheUnifiedFieldinOsteopathyinvolves

a. Adynamicdistinctionbetweentheperipheryandthecentralnervoussystem

b. Alackofstructuralrelationshipbetweenstructureandfunction

c. AnappreciationoftheinterrelationshipbetweenOsteopathicPrincipleandPracticeandThirdPartyBillers

d. Osteopathicprinciplesandpracticeusedinmanipulatingstructureandrelatedfunctioninsupportofdynamichomeostasis

e. Thetheorydescribingsubatomicparticlebehaviorobservedfromcollidingacceleratedlattemolecules


Editor’s Note: This abstract was presented as part of the Louisa Burns Osteopathic Research Committee poster competition at the 2013 AAO Convocation in Orlando, FL.

Context

Thecurrentmethodsofteachingosteopathicmanipulativemedicine(OMM)toosteopathicmedicalstudents(OMS)maybeimprovedbytheincorporationofvideolearningintoschoolcurricula.MannandElandhavedemonstratedthatstudentself-efficacyevaluationswerehigherwithvideolearningandinstructorfeedbackversusinstructordemonstrationandpairedpracticefortheSpencertechnique.1Dilulloetalhavealsodemonstratedtheuseofvideolearningasausefultoolinanatomydissectionpreparationandunderstanding;however,itisnecessarytoexpandtheassessmentofvideolearningtoallOMMtechniquesaswellastheusefulnessofthesevideosintheclassroomandclinicalsettingsinordertoimprovethetechnicalskillsofOMS.2,3

Objectives

TomeasurestudentperceptionoftheusefulnessofOMMvideosasalearningtoolintheclassroomandclinicalsetting.

Methods

ThestudyemploysanonlinesurveytoevaluatetheusefulnessofOMMvideostoimproveunderstandingofosteopathictreatmenttechniquesforallcurrentNewYorkInstituteofTechnologyCollegeofOsteopathicMedicine(NYIT-COM)studentsinboththeclassroomandclinicalsettings.ThestudyisconductedattheNYIT-COMinOldWestbury,NY.AllcurrentNYIT-COMstudentsareincludedinthestudy.Any

Abstract: Usefulness of Video Learning for Osteopathic Manipulative Medicine Techniques in the Classroom and Clinical SettingMelissa Meghpara, OMS III; Sheldon C. Yao, DO; Theodore B. Flaum, DO; Elizabeth Caron, DO; and Michael J. Terzella, DONew York Institute of Technology College of Osteopathic Medicine. 2013.

studentnotcurrentlyenrolledatNYIT-COMwillbeexcluded.OutcomemeasurementsarebasedupontheinterpretationofLikertscaleresponsesbytheparticipantsofthissurvey.

Results

Datacollectionandanalysisarepending.(Editor’s note: Please see AAOJ, Vol. 23, No. 3, pp. 24–30, for final analysis.)

Conclusion

Weexpecttheresultsofthisstudywillprovideinformationthatcouldinfluenceboththeclassroomandclinicalsettings.Intheclassroomsetting,weanticipatethattheuseofvideolearningforOMMtechniqueswillbeintegratedintoosteopathicmedicalschoolcurriculaasanadditionallearningtool.Intheclinicalsetting,theadditionofvideolearningtothecurriculumwillalsopromotetheuseofosteopathicmanipulativetechniques.Additionally,thestudycouldprovideavalidrationaleforofferingaccesstoOMMvideosforresidentsandattendingphysiciansinordertopromotetheuseofOMMinclinicalpractice.

References1. Mann,DDetal.(2005).Self-efficacyinmasterylearningto

applyatherapeuticpsychomotorskill.Perceptual and Motor Skills.2005;100:77-84.

2. DiLullo,C.etal.(2006).Anatomyinanewcurriculum:Facilitatingthelearningofgrossanatomyusingwebaccessstreamingdissectionvideos.Journal of Visual Communication in Medicine.2006;29(3):99-108.doi:10.1080/01405110601080738

3. Browning,S.(2009).Teachingosteopathicstudentstechnique;usingresearchtoidentifygoodteachingpractice.International Journal of Osteopathic Medicine.2009;13:70-73.doi:10.1015/j.ijosm.2009.10.004


Book Signings at ConvocationAAO Booth in the Exhibit Hall (Broadmoor Hall B)

C O M P E N D I U M E D I T I O N

Clinical Application of

C O U N T E R S T R A I N

H A R M O N L . M Y E R S , D . O .

C O N T R I B U T I N G A U T H O R S

William H. Devine, D.O.

C-NMM OMM,C-FM OMT, Medical Editor

Christian Fossum, D.O. (UK)

John C. Glover, D.O., F.A.A.O.

Michael Kuchera, D.O., F.A.A.O.

Randall S. Kusunose, P.T., O.C.S.

Richard Van Buskirk, D.O., PhD., F.A.A.O.

Foreword by Andrew Weil, M.D.

Raymond J. Hruby, DO, MS, FAAO

Exploring Osteopathy in the

Cranial Field

Thursday, March 20 • 4:00–4:30 pm

Osteopathy and Swedenborg: The Influence of Emanuel Swedenborg on the Genesis and Development of Osteopathy, Specifically on Andrew Taylor Still and William Garner Sutherland

DavidB.Fuller,DO,FAAOThisbookdemonstratestheinfluenceofSwedenborg’sideasonthecreationanddevelopmentofosteopathicmedicine,especiallyinregardstobody/mind/spiritandtheanatomicalinter-relationshipofthenervoussystem,fasciaandfluidsthroughoutthebody.ThisincludesastudyofcranialosteopathyandSwedenborg’sparadigmofthebrainandsoul-bodyinteraction,comparingconceptssuchasSwedenborg’sspirituousfluidandSutherland’sPrimaryRespiratoryMechanism.Intheprocess,thebooktracestheinfluenceofSwedenborg’sideasacross19th-c.America,specificallythroughthemetaphysical/healingmovementsoftranscendentalism,spiritualism,newthoughtandtheosophy.

$65.00;607pp.,Hardcover,ISBN:978-0-910557-82-5

Friday, March 21 • 10:00–10:30 am

Clinical Applications of Counterstrain: Compendium EditionbyHarmonL.Myers,DO

WilliamH.Devine,DO;ChristianFossum,DO(UK);JohnC.Glover,DO,FAAO;MichaelL.Kuchera,DO,FAAO;RandallS.Kusunose,PT,OCS;RichardL.VanBuskirk,DO,FAAO(ContributingAuthors)Apowerfultooltotreatchronicandacutepain,Counterstrain’sgentlebutlogicalmanipulationscaneffectimmediate,oftenlastingrelief,andhelpmaximizethebody’snaturalinclinationtowardhealth.Casehistoriesandstandardized,muscle-specifictreatmentpositionsbringtheauthor’sexpertisetobeginnersandadvancedpractitionersalike.Inthisat-a-glancepresentation,HarmonL.Myers,DO,sharesalifetimeofinsight,andastep-by-stepapproachforcliniciansofalldisciplinestoquicklyandeffectivelydiagnoseandtreatmuchofwhatailsus.Thisbookisacomprehensiveresourceforstudents,instructors,cliniciansandpractitionersinosteopathicmanipulation,physicaltherapyandintegratedmedicaldisciplines.

$142.95;234pp.,Sprial-bound,ISBN:0978-0-9633658-1

Thursday, March 20 • 9:10–9:40 am

Basic Musculoskeletal Manipulation Skills: The 15-Minute Office Encounter

MichaelP.Rowane,DO,FAAFP,FAAO;PaulEvans,DO,FAAFP,FACOFPThisbookisfortheprimarycareproviderwhowantsabasicguidetomanagingcommonlyseenclinicalproblemsthatareamenabletomusculoskeletalmanipulation.Theassessmentsandtechniquespresentedrapid.efficient,andspecificallydesignedforuseduringa15-minuteofficevisit.Chaptersincludeobjectives,illustrativecaseswithanswers,clearillustrationstohighlightclinicallyimportantanatomiclandmarks,assessmenttips,treatmenttechniques,andkeysummarypoints.

$99.95;339pp.,Hardcover,ISBN:0-940668-27-0

Friday, March 21n • 3:30–4 pmExploring Osteopathy in the Cranial Field RaymondJ.Hruby,DO,FAAOThistextbookisdesignedfortheinterestedpractitioner,andforthebeginningtointermediatestudentofthistopic.Itcanbeeasilyusedasanaccompanyingtextormanualforafirstorsecondcourseinosteopathyinthecranialfield,andsometopicsareusefulformoreadvancedstudy.Itwouldbeespeciallysuitableforuseina40-hourfirstorsecondlevelcourseinthistopic.

$59.95;164pp.,Sprial-bound,ISBN:978-0-9887511-0-1

Abstract

Context

Enuresiscancausesignificantstressandembarrassmentforchildrenandtheirparents.Spontaneousresolutionratesofprimarynocturnalenuresis(PNE)decreaseaschildrenincreaseinage.

Objective

Toexaminetheefficacyofosteopathicmanipulativetreatment(OMT)asatreatmentformonosymptomaticPNE.

Method

AretrospectivechartreviewwasconductedofpatientswithadiagnosisofPNEorenuresistreatedwithOMTinaprimarycareofficefromSeptember2010throughMay2012.

Results

Chartsofsixpatients,ageseightto14,wereincluded.Outofsixchildrentreated,onewaslosttofollow-up,onedidnotrespondtothefollow-upinquiryaboutparticipationinthestudy,twofullyresolvedandtwosignificantlyimproved.Ofthetwowhoimproved,oneimprovedgreatlywhenhefinishedplayingfootball,acollisionsport,fortheseason.

Conclusion

OMTisaneffectivemodalitytoreduceorresolveenuresisinchildren.Duetothesmallsamplesize,thenumbersarenotstatisticallysignificant.However,thissuccessfulpilotstudyindicatestheneedforastudywithalargersamplesizetoyieldmoreinformationontheeffectivenessoftreatingPNEwithOMT.

Introduction

Primarynocturnalenuresis(PNE)isdefinedasbedwettinginachildfiveyearsorolderwhohasnotbeendryovernightforaperiodofsixormoreconsecutivemonths.3,11PNEisdividedintotwocategories,monosymptomaticandnon-monosymptomaticenuresis,thelatterofwhichwill

Osteopathic Manipulation in the Treatment of Primary Nocturnal Enuresis: A Retrospective Chart Review David M. Kanze, DO; and Kylie A. Kanze, DO

notbediscussedinthisstudy.TheprevalenceofPNE(Figure 1)variesslightlyfromcountrytocountrybutisconsistentasitdecreaseswithageandismorecommoninboysthangirls.3,4,7,10,11,12,14,17Onaverage,theyearlyrateofspontaneousresolutionofmonosymptomaticenuresisis15%;althoughthisratedecreasesthelongertheenuresisispresent.3,4,7,10,11,12,14,17Bladdermaturationinvolvesautonomicandsomaticnervesthatsynapseatmultiplelocationswithinthebrainandspinalcord.Normalfunctionincludesabilitytohaveurinestorageatlowpressurewithhighoutletresistanceandvoidingwithlowoutletresistanceandsustaineddetrusorcontraction.Newbornbladdersfillwithoutresistance,andvoidingresultsfromuninhibitedcontraction.Thisfunctionisthoughttobecoordinatedviathelowerspinalcordand/orthebrain,andthus,neurologicallystimulatingactivitieswillcausevoidinginthisagegroup.Bladdercapacityincreasesoverthenextthreetofouryearsinadisproportionaterelationshiptothesurfaceareaofthebody.Bladdercontrolisachievedslowly.Thechildfirstbecomesawareofbladderfilling,thengainstheabilitytovoluntarilyinhibitdetrusorcontractions,andlastlycoordinatessphincteranddetrusorfunction.Daytimecontrolisusuallyachievedbyapproximatelyfouryearsofage,andnighttimecontrolusuallydevelopsmonthstoyearslaterbutisexpectedbyfivetosevenyearsofage.Causesof

Figure 1. Prevalence of Primary Nocturnal Enuresis


PNEincludeoneoracombinationofthefollowing:maturationaldelay,genetics,smallbladdercapacity,nocturnalpolyuria,abnormalsecretionofantidiuretichormone(ADH),abnormaldetrusoractivity,disturbedsleepand/orpsychologicaldisorders.15

StandardtreatmentforPNEincludesmotivationaltherapyincludingsmile/starcharts,bladdertraining,alarms,dry-bedtraining,biofeedbackandmedication,includingbutnotlimitedtoDDAVP(desmopressin).1,10,17Ifstandardandcomplementarytreatmentsfail,orifthereisasuggestionofanorganicorpsychologicalcauseforPNE,thechildcanbereferredtotheappropriatespecialist.Guidelinesforreferralstoapediatricurologistcomefromamyriadofsources.10Referraltoapediatricurologistshouldbeconsideredifanyofthefollowingconditionsexistoraresuspected:Type1diabetesmellitus,constipation,urinarytractinfection,developmentaldelay,emotionalproblems,psychologicalproblems,learningdifficultiesorrecurrentenuresis.ComorbiditiesforPNEincludedecreasedweight,decreasedgrowth,shorterstature,anxiety,interpersonalconflictswithparents,siblingsandpeers,andthestigmaofbeingabedwetter,especiallyinolderchildrenandadolescents.1,7,10WehypothesizethatOMTcanbeaneffective,complementarytreatmentoptionforchildren.

Methods

Followinginstitutionalreviewboardapproval,aretrospectivechartreviewwasconductedonpatientsseenatRockyVistaHealthCenter(RVHC)inParker,CO,fromSeptember2010throughMay2012whohadthediagnosisofPNEandreceivedOMT.Thechartsofsixchildrenwerereviewedbytwoosteopathicphysicians,apediatricianandafamilypractice/neuromuscularmedicinespecialistforinformationpertainingtothediagnosis,thetreatmentmodalitiesandthesubjectiveeffectivenessofsuchtreatment.ManyofthesepatientspresentedtotheclinicforstandardpediatriccareorforOMTofotherbodyregions.Severalofthepatientswereonthestandard

regimenofDDAVP(desmopressin),nighttimefluidrestrictionandbedwettingalarms,oracombinationthereof.NonehadreceivedOMTinthepast.NospecificOMTprotocolwasfollowed,asthetreatmentplanwasindividualizedforeachpatient.Thechildrenrangedinagefromeightto14years,onegirlandthreeboys,threeofwhomwereCaucasianandonewasofmixedrace.ThenumberofOMTtreatmentsrangedfromthreeto15sessionsoveraperiodoffiveto12months,withanaverageofseventreatmentsessionsperpatient(Chart1).Basedonfindingsdeterminedduringthesession’sexaminationandassessment,OMTwasappliedtoeachpatient’sregionsrequiringtreatment.Themostcommonareastreatedwerethepelvis,sacrum,thoracicspineandlumbarspine.Themostcommontechniqueutilizedwasligamentousarticularstrain.Otherareasaddressedincludedthecranium,tohelptreattheparasympatheticcontroltothekidneysviathevagusnerve;thesacralplexusviathesacrum,toaddresstheparasympatheticcontroltothebladderitself;andtheribheadsandthoracicandlumbarvertebraefromT10toL2,whichregulatesympatheticcontroltothekidneys,uretersandurinarybladderrespectively.

Results

Chartsfromsixpatients,ageseightto14,withadiagnosisofPNEwhoweretreatedwithOMT,wereincludedintheretrospectiveanalysis.Ofthesixchildrentreated,onewaslosttofollow-up,onedidnotrespondtotheinquiryaboutparticipationinthestudy,twofullyresolvedandtwosignificantlyimproved,oneofwhichimprovedgreatlywhenhewasfinishedplayingfootball,acollisionsport,fortheseason.

Discussion

Therearemultiplestudiesonmanyofthetreatmentmodalitiesmentionedabovewithvaryingresults.ThereislittleresearchpublishedonmanualtherapiesforPNEitself.Twowerefoundduringareviewoftheliterature,oneastudybyaGermanosteopathonOMTforenuresis11andtheotherastudyusingOsteopathically-

basedmanualphysicaltherapyforpediatricdysfunctionvoiding.8Bothstudies,ofsmallsamplesize,showsymptomaticimprovement.Thesestudiescombinedwiththischartreviewshouldprovideafoundationforalarger,multicenterclinicaltrialofOMTforprimarynocturnalenuresis.

Chart 1. Treatments and results by patient.


Conclusion

ThisretrospectivechartreviewsuggestsOMTmaybeaneffectivetreatmentforchildrenwithPNE,augmentingthebenefitsofconventionalmedicationandbehavioralmanagementofmonosymptomaticenuresis.FurtherstudywithalargersamplesizewouldyieldmoreinformationregardingtheusefulnessofOMTintreatingPNE.

Acknowledgements

ThankyoutoFrankRitchelAmes,PhD;JasonWells,PhD;JillPitcher,DO;AmberHeck,PhD;andKayKelts,OMSV,fortheirassistance.

References1. RamakrishnanK.EvaluationandTreatmentofEnuresis.

American Family Physician.Aug.15,2008;78(4):489-496.2. MakariJ,RushtonHG.NocturnalEnuresis.American Family

Physician.2006;73(9):1611-1614.3. CendronM.PrimaryNocturnalEnuresis:CurrentConcepts.

American Family Physician.1999;59(5)::1205-1214.4. YeungCK,SneedharB,SihoeJD,etal.Differencesin

characteristicsofnocturnalenuresisbetweenchildrenandadolescents:acriticalappraisalfromalargeepidemiologicalstudy.BJU International.2005;97,1069-1073.

5. WillardF.AutonomicNervousSystem.In:Chila,AG,executiveeditor.Foundations of Osteopathic Medicine.3rdEdition.Baltimore,MD:Lippincott,WilliamsandWilkins;2011:136-140.

6. CarineA,MillsM,FrymannV.APediatricPerspectiveonOsteopathicMedicine.In:CulbertTandOlnessK,executiveeditors.Integrative Pediatrics. 1stEdition.NewYork,NY:OxfordPress;2010:340-366.

7. GhahramaniM,MahdiB,GhahramaniAA.NocturnalEnuresisanditsImpactonGrowth.Iran Journal of Pediatrics.2008;18(2):,167-170.

8. FrankeH,HoeselK.Osteopathicmanipulativetreatment(OMT):forlowerurinarytractsymptoms(LUTS)inwomen;Journal of Bodywork and Movement Therapies.2013;17(1):11-18.

9. NemettDR,FivushBA,MatthewsR,etal.Arandomizedcontrolledtrialoftheeffectivenessofosteopathy-basedmanualphysicaltherapyintreatingpediatricdysfunctionalvoiding.Journal of Pediatric Urology.2008;4:100-106.

10. Nocturnalenuresisinchildrenandyoungpeople:NICEclinicalguideline. National Institute for Health and Clinical Excellence.London,England.October2010.

11. KarglD.Osteopathy with Enuresis.(Germany).12. FoxmanB,ValdezRB,BrookRH.ChildhoodEnuresis:

Prevalence,PerceivedImpact,andPrescribedTreatments. Pediatrics.1986;77(4):482.

13. RobsonWL,LeuingAK,VanHoweR.PrimaryandSecondaryNocturnalEnuresis:SimilaritiesinPresentation.Pediatrics.2005;115(4):956-959.

14. HazzaI.PrimaryNocturnalEnuresisamongSchoolChildreninJordan.Saudi Journal of Kidney Disease and Transplantation.2002;13(4)::478-480.

15. TuND,BaskinLS,ArnhymAM.Etiologyandevaluationofnocturnalenuresisinchildren.UpToDate.Dec.4,2012.AccessedMarch28,2013.

16. NeppleKG,CooperCS.Evaluationanddiagnosisofbladderdysfunctioninchildren.UpToDate.May13,2013.AccessedMay28,2013.

17. TuND,BaskinLS.Managementofnocturnalenuresisinchildren.UpToDate.December15,2012.AccessedMarch28,2013.



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Component Societies and Affiliated Organizations Calendar of Upcoming Events

April 10-13, 2014Orthopedic Neurology

Course Director: Maurice Bensoussan, MD, DO, FCAAssociate Director: R. Paul Lee, DO, FAAO, FCA

Doubletree San Francisco Airport Hotel, Burlingame, CAPhone: (317) 581-0411 Fax: (317) 580-9299

Email: [email protected]: www.cranialacademy.org

April 30–May 3, 2014Pennsylvania Osteopathic Medical Association

106th Annual Clinical Assembly and Scientific SeminarValley Forge Convention Center, King of Prussia, PA

CME: 34 Category 1-A and 6 Category 1-B AOA credits anticipated

Phone: (800) 544-7662 Fax: (717) 939-7255 Email: [email protected]: www.poma.org

May 1, 2014Indiana Academy of Osteopathy Preconference OMT

Workshop: “The Principles of Muscle Energy Diagnosis”French Lick Resort, French Lick and West Baden, IN

CME: 8 Category 1-A hours anticipatedPhone: (317) 926-3009

Website: www.inosteo.org

May 2 - 4 2014Indiana Osteopathic Association 117th Annual Convention

French Lick Resort, French Lick and West Baden, INCME: 25 Category 1-A hours anticipated

Phone: (317) 926-3009Website: www.inosteo.org

May 8–10, 2014The American Osteopathic Association of Prolotherapy Regenerative Medicine’s Spring 2014 Training Seminar

Marriott Country Club Plaza, Kansas City, MOCME: 34 Category 1-A AOA credits anticipated

Phone: (302) 530-2489Email: [email protected]

Website: www.prolotherapycollege.org/Training.html#Fall

May 14-17, 2014Michigan Osteopathic Association 115th Annual Spring

Scientific Convention COBO Center, Detroit, MICME: 30 Category 1-A Credits Anticipated

(1 hour for AOBNMM)Phone: (800) 657-1556

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

June 14-18, 2014June Introductory Course in Osteopathy in the Cranial Field

Course Director: Eric J. Dolgin, DO, FCASheraton Indianapolis City Centre, Indianapolis, IN

Phone: (317) 581-0411 Fax: (317) 580-9299Email: [email protected]

Website: www.cranialacademy.org

June 19-22, 2014Osteopathic Cranial Academy Annual Conference: Beyond

Sutherland’s Minnow: Anatomy, Perception and TreatmentConference Director: Melvin R. Friedman, DO

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

Email: [email protected]: www.cranialacademy.org

July 14–July 18, 2014Expanding Osteopathy into the Cranial

Field: Viola M. Frymann Basic CourseProgram Chair: Ray Hruby, DO

American Academy Of Pediatric Osteopathy with Osteopathy’s Promise to Children, San Diego, CA

CME: 40 Category 1-A AOA credits anticipatedWebsite: www.the-promise.org

July 19–21, 2014Intensive Course in Pediatric OsteopathyProgram Chair: Shawn K. Centers, DO

American Academy Of Pediatric Osteopathy with Osteopathy’s Promise To Children, San Diego, CA

CME: 24 Category 1-A AOA credits anticipatedWebsite: www.the-promise.org

http://www.inosteo.org

http://www.inosteo.org

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