the aao forum for osteopathic thought...
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Forum for Osteopathic Thought
Official Publication of the American Academy of Osteopathy Official Publication of the American Academy of Osteopathy ®®
JOURNALJOURNALThe AAOThe AAO
Tradition Shapes the Future Volume 29 • Number 4 • December 2019
In this issue: In this issue:
View From the Pyramids: View From the Pyramids: Where Have All the Mentors Gone?Where Have All the Mentors Gone? . . . . . . 55
Impact of Predoctoral Teaching Fellows Impact of Predoctoral Teaching Fellows on Osteopathic Medical Students: on Osteopathic Medical Students: A Near-Peer Teaching ProgramA Near-Peer Teaching Program . . . . . . . . . . . . . . 99
An Osteopathic Approach to An Osteopathic Approach to Traumatically Induced Mechanical Traumatically Induced Mechanical Dyspnea: A Case ReportDyspnea: A Case Report . . . . . . . . . . . . . . . . . . . . . . . . 1919
Applying Osteopathic Manipulative Applying Osteopathic Manipulative Treatment to Postconcussion Syndrome: Treatment to Postconcussion Syndrome: A Case ReportA Case Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2525
The Cranial Rhythmic Impulse as The Cranial Rhythmic Impulse as a Measure in Patients With Bipolar a Measure in Patients With Bipolar Disorder: A Case ReportDisorder: A Case Report . . . . . . . . . . . . . . . . . . . . . . 3131
2019 2019 AAOJAAOJ Index Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3535
The American Academy of Osteopathy is your voice...in teaching, promoting, and researching the science, art, and philosophy of osteopathic medicine, with the goal of integrating osteopathic principles and osteopathic manipulative treatment in patient care.
If you are not already a member of the American Academy of Osteopathy (AAO), the AAO Membership Committee invites you to join the Academy as a 2019-20 member. The AAO is your professional organization. It fosters the core principles that led you to become a doctor of osteopathic medicine.
For $5.83 a week or just 83 cents a day, you can become a member of the professional specialty organization dedicated to you and neuromusculoskeletal medicine/osteopathic manipulative medicine (NMM/OMM).
Your membership dues provide you with:
• a national advocate for OMM, both within the profession and with health care policymakers and third-party payers.
• a champion that is monitoring closely and responding rapidly to the standards being developed for the single accreditation system for graduate medical education.
• referrals of patients through the “Find a Physician” tool at FindOMM.org.
• discounts on continuing medical education at the AAO’s annual Convocation and its weekend courses.
• access to NMM/OMM specialty-specific continuing medical education opportunities.
• networking opportunities with peers.• discounts on books in the AAO’s online store. • complimentary subscription to The AAO Journal, published
electronically 4 times annually.• complimentary subscription to the online AAO Member News,
published 8 times annually.• weekly OsteoBlast e-newsletters, featuring research on manual
medicine from peer-reviewed journals around the world.• practice promotion materials, such as the AAO-supported
“American Health Front!” segment on OMM.• discounts on advertising in AAO publications and in materials
for the AAO’s Convocation.• the fellow designation of FAAO, which recognizes DOs for
promoting OMM through teaching, writing, and professional service and which is the only earned fellowship in the osteopathic medical profession.
• promotion and grant support of research on the efficacy of OMM.
• support for the future of the profession through the Student American Academy of Osteopathy, the National Undergraduate Fellows Association, and the Resident American Academy of Osteopathy.
If you have any questions regarding membership or membership renewal, contact Bev Searcy, the AAO’s finance and membership assistant, at [email protected] or at (317) 879-1881, ext. 212.
AAOJ Call for SubmissionsTime is precious and article writing is often triaged for busy physicians. In an effort to help guide the journal and stimulate interest in academic and scholarly activity, we are providing some broad topics that can be “reserved” for you. These are by no means the only topics for the journal, but it helps to eliminate the writer’s block that so many of us may face.
Below are topics available to reserve if you would like to support your portfolio with academic writing:
• Osteopathic approaches to treating patients with pelvic dysfunctions
• Osteopathic approaches for the cardiac patient• The body triune: osteopathic treatment of mind and spirit for
today’s patient• Beyond Spencer technique: OMT for shoulder overuse• Using OMT to treat patients with long-term side effects of
radiation for cancer treatment
If you are interested in any of these topics, send an email to Lauren Good and reserve your topic today. Manuscripts should be emailed
to [email protected] o m w i t h i n t h r e e months of reserving a t o p i c . S e e t h e AAOJ’s Instructions for Contributors for more in fo rmat ion o n s u b m i t t i n g manuscripts.
I n a d d i t i o n , w e are asking for peer rev iewers to a s s i s t us in producing the best journals we can, so please contact AAO Communications Specialist Lauren Good at [email protected] if you can help in this capacity. No experience is required, and training resources will be provided. Peer reviewers are expected to review at least two manuscripts per year.
If you have any questions, please email us at [email protected].
Page 2 The AAO Journal • Vol. 29, No. 4 • December 2019
The AAO JournalJanice Upton Blumer, DO, FAAO . . . . . . . . . . . . . Editor-in-chiefBrian P. Peppers, DO, PhD . . . . . . . . . . . . . . . . . Associate editorRaymond J. Hruby, DO, MS, FAAODist . . . Scientific editor emeritusLauren Good . . . . . . . . . . . . . . . . . . . . . . . . . . . Managing editor
AAO Publications Committee
American Academy of OsteopathyKendi L. Hensel, DO, PhD, FAAO . . . . . . . . . . . . . . . . PresidentPaul R. Rennie, DO, FAAO . . . . . . . . . . . . . . . . . . President-electSherri L. Quarles. . . . . . . . . . . . . . . . . . . . . . . . Executive director
The AAO Journal is the official publication of the American Academy of Osteopathy. Issues are published 4 times a year.
The AAO Journal is not responsible for statements made by any contributor. Opinions expressed in The AAO Journal are those of the authors and do not necessarily reflect viewpoints of the editors or official policy of the American Academy of Osteopathy or the institutions with which the authors are affiliated, unless specified.
Although all advertising is expected to conform to ethical medical standards, acceptance does not imply endorsement by this journal or by the American Academy of Osteopathy.
Subscription rate for AAO nonmembers: $60 per year. To subscribe, contact AAO Communications Specialist Lauren Good at [email protected].
Send all address changes to [email protected].
ISSN 2375-5717 (online) ISSN 2375-5776 (print)
The advertising rates listed below are for The AAO Journal, the official peer-reviewed publication of the American Academy of Osteopathy (AAO). AAO members and AAO component societies are entitled to a 20% discount on advertising in this journal. Call the AAO at (317) 879-1881, ext. 211, for more information.
2020 Advertising Rates
Full page (7.5” x 9.5”) $600
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Advertisements must be pre-paid and must be received by the 20th of the month preceding publication. All advertisements are printed in full-color.
Editorial
View From the Pyramids: Where Have All the Mentors Gone? ....5Janice Upton Blumer, DO, FAAO
original rEsEarch
Impact of Predoctoral Teaching Fellows on Osteopathic Medical Students: A Near-Peer Teaching Program Evaluation ...................9
Beatrice Akers, DO; Glenn Davis, MS; Jordan Keys, DO, MS; Stacey L. Pierce-Talsma, DO, MS MEdL, FNAOME; and Gregg Lund, DO, MS, FAAP
casE rEport
An Osteopathic Approach to Traumatically Induced Mechanical Dyspnea: A Case Report ............................................................. 19
David M. Kanze, DO, FAAOApplying Osteopathic Manipulative Treatment to Postconcussion Syndrome: A Case Report ........................................................... 25
Sheldon C. Yao, DO, FAAOThe Cranial Rhythmic Impulse as a Measure in Patients With Bipolar Disorder: A Case Report ................................................. 31
Teodor Huzij, DO, FACN
rEgular FEaturEs
AAOJ Submission Checklist ..........................................................4AAO Calendar of Events ..............................................................7CME Certification of Home Study ............................................. 172019 Index .................................................................................. 35Upcoming CME ........................................................................41Component Society Calendar of Events ......................................48
Raymond J. Hruby, DO, MS, FAAODist, co-chair
Polly E. Leonard, DO, MS, FNAOME, co-chair
William J. Garrity, DO, vice chair
Janice Upton Blumer, DO, FAAO
Thomas R. Byrnes Jr., DOEdward K. Goering, DO,
MSHPEKatherine L. Heineman, DO
Jodie Hermann, DOJanet M. Krettek, DO, FACOSBobby Nourani, DOBrian P. Peppers, DO, PhDNicholas Wade Salupo, DOKevin Albert Thomas, DO, MSKaren T. Snider, DO, FAAO,
Board of Trustees liaisonFrank Patrick Goodman, DO,
MS, RAAO liaisonSamantha Kari Tyler, OMS V,
SAAO liaison
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www.academyofosteopathy.org
JThe AAO Forum for Osteopathic Thought
Official Publication of the American Academy of Osteopathy®
TRADITION SHAPES THE FUTURE • VOLUME 29 • NUMBER 4 • DECEMBER 2019
The mission of The AAO Journal is to facilitate a forum, with a sense of belonging, ensuring the opportunity for the present osteopathic community and its supporters to honor the past accomplishments, promote the osteopathic tenets, and advance osteopathic research and its influence within the medical field.
OURNAL
On the cover: iStock photo ID Mumemories/1042891754
The AAO Journal • Vol. 29, No. 4 • December 2019 Page 3
AAOJ Submission Checklist
Questions? Contact [email protected].
Manuscript Submission
� Submission emailed to [email protected] or mailed on a flash drive or CD to the AAOJ managing editor, American Academy of Osteopathy, 3500 DePauw Blvd, Suite 1100, Indianapolis, IN 46268-1136
� Manuscript formatted in Microsoft Word for Windows (.doc, .docx), text document format (.txt), or rich text format (.rtf )
Manuscript Components
� Cover letter addressed to the AAOJ’s editor-in-chief with any special requests (eg, rapid review) noted and justified
� Title page, including the authors’ full names, financial and other affiliations, and disclosure of financial support related to the original research or other scholarly endeavor described in the manuscript
� “Abstract” (see “Abstract” section in “AAOJ Instructions for Contributors” for additional information)
� “Methods” section
• the name of the public registry in which the trial is listed, if applicable
• ethical standards, therapeutic agents or devices, and statis-tical methods defined
� Four multiple-choice questions for the continuing medical education quiz and brief discussions of the correct answers
� Editorial conventions adhered to
• terms related to osteopathic medicine used in accordance with the Glossary of Osteopathic Terminology
• units of measure given with all laboratory values
• on first mention, all abbreviations other than measure-ments placed in parentheses after the full names of the terms, as in “American Academy of Osteopathy (AAO)”
� Numbered references, tables, and figures cited sequentially in the text
• journal articles and other material cited in the “Refer-ences” section follow the guidelines described in the most current edition of the AMA Manual of Style: A Guide for Authors and Editors
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• photocopies provided for referenced documents not acces-sible through URLs
� “Acknowledgments” section with a concise, comprehensive list of the contributions made by individuals who do not merit
authorship credit, as well as permission from each individual to be named
� For manuscripts based on survey data, a copy of the original validated survey and cover letter
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� Graphics formatted as specified in the “Graphic Elements” sec-tion of “AAOJ Instructions for Contributors”
� Graphics as separate graphic files (eg, jpg, tiff, pdf )
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� For reprinted or adapted tables, figures, and illustrations, a full bibliographic citation given, providing appropriate attribution
Required Legal Documentation
� For reprinted or adapted tables, figures, and illustrations, copyright holders’ permission to reprint in the AAOJ’s online and print versions, accompanied by photocopies of the origi-nal published graphic designs
� For photographs in which patients are featured, signed and dated patient-model release forms
� For named sources of unpublished data and individuals listed in the “Acknowledgments” section, written permission to pub-lish their names in the AAOJ
� For authors serving in the US military, the armed forces’ writ-ten approval of the manuscript, as well as military or other institutional disclaimers
Financial Disclosure and Conflict of Interest
Authors are required to disclose all financial and nonfinancial rela-tionships related to the submission’s subject matter. All disclosures should be included in the manuscript’s title page. See the “Title Page” section of “AAOJ Instructions to Contributors” for examples of relationships and affiliations that must be disclosed. Those authors who have no financial or other relationships to disclose must indicate that on the manuscript’s title page (eg, “Dr. Jones has no conflict of interest or financial disclosure relevant to the topic of the submitted manuscript”).
Publication in the JAOA
Please include permission to forward the manuscript to The Journal of the American Osteopathic Association if the AAOJ’s editor-in-chief determines that the manuscript would likely benefit osteopathic medicine more if the JAOA agreed to publish it.
Page 4 The AAO Journal • Vol. 29, No. 4 • December 2019
In this issue of The AAO Journal we have a great selection of arti-cles, including “Impact of Predoctoral Teaching Fellows on Osteo-pathic Medical Students: A Near-Peer Teaching Program Evalua-tion” by Beatrice Akers, DO; Glenn Davis, MS; Jordan Keys, DO, MS; Stacey L. Pierce-Talsma, DO, MS MEdL, FNAOME; and Gregg Lund, DO, MS, FAAP. This article discusses the use of pre-doctoral teaching fellows in a peer-to-peer mentorship program. This article has me thinking about my mentors and how we as a profession plan to keep up with this challenge. Current statistics from the American Osteopathic Association include 37 colleges of osteopathic medicine in 58 locations with 1 in 4 medical students nationwide attending an osteopathic program.1 While these num-bers are astounding and a huge win for our profession, the task of finding mentorship for these students can be daunting.
With the total number of practicing osteopathic physicians being 114,425 and the newly graduated in 2018 being 6,500 of that number, it is easy to see that the balance of the profession is rapidly tipping towards the side of the young, mostly under the age of 40.2 While the medical profession has always used near-peer teach-ing, including senior residents teaching medical students, there is no replacement for the experienced mentor, who can provide the depth of knowledge and savoir-faire that is needed to relay the wonders of this great profession.
When I look to my own peer cohort for who is actively mentoring, there is a sad paucity of individuals who are stepping up. Reasons vary from being too busy with practice and physician burnout to no energy left for teaching and feeling unqualified to mentor.
A recent article pertaining to radiology addressed the importance of mentorship in that profession, but it can be equally applied to osteopathic medicine:
Mentorship plays a critical role in the success of academic radiologists. Faculty members with mentors have better career opportunities, publish more papers, receive more research grants, and have greater overall career satisfaction. However, with the increasing focus on clinical productiv-ity, pressure on turn-around times, and the difficult fund-ing climate, effective mentoring in academic radiology can
be challenging. The high prevalence of “burnout” among radiologists makes mentorship even more important.3
We can infer that, though we have no studies on the benefit of senior mentors in the osteopathic profession, mentorship matters for all the same reasons and more. If we wish to maintain the dis-tinctiveness of this profession, we need more seasoned mentors to step up. The question is how do we develop these mentors in a time where adding “one more thing” may be the tipping point for full-blown physician burnout.
I would argue that mentorship actually renews physician purpose through helping to create the next generation of physicians, regard-less of specialty. Mentorship reminds us of the reasons we chose this great profession and helps to refocus our passion.
In addition, we need to nurture a culture of giving back and devel-oping mentorship as a norm rather than an exception in our profes-sion. We need the seasoned physicians’ knowledge and understand-ing if we wish to keep our profession from becoming a statistic.
In his book Mentoring 101, John C. Maxwell addresses that many do not mentor due to feeling insecure in their own skill set, and that we need to adopt a “mentorship mindset.” Maxwell writes, “Mentorship is as much who you are as what you do.”4 My ques-tion to you is what legacy do you wish to leave behind?
The AAO provides a mentorship program through Convocation, and I encourage all to participate as we all have something special
View From the Pyramids: Where Have All the Mentors Gone?AAOJ Editor-in-Chief Janice Upton Blumer, DO, FAAO
EDITORIAL
“ Mentorship reminds us of the reasons we chose this great profession and helps to refocus our passion.
(continued on page 6)
The AAO Journal • Vol. 29, No. 4 • December 2019 Page 5
to offer. Do not let the feeling of being “unqualified” or “out of touch” stop you from offering the depth of knowledge you have to bring. Let’s make mentorship the norm so we develop the best pro-fession we can for generations to come.
In Gratitude,
Janice Blumer, DO, FAAO
References1. American Osteopathic Association. 2018-2019 annual report. https://
osteopathic.org/wp-content/uploads/AOA-Annual-Report-2018-19.pdf. Accessed November 21, 2019.
2. American Osteopathic Association. Osteopathic Medical Profes-sion Report 2018. Chicago, IL: American Osteopathic Association. https://osteopathic.org/wp-content/uploads/2018-OMP-Report.pdf. Accessed November 21, 2019.
3. Bredella MA, Fessel D, Thrall JH. Mentorship in academic radiol-ogy: why it matters. Insights Imaging. 2019;10(1):107. doi:10.1186/s13244-019-0799-2
4. Maxwell JC. Mentoring 101: What Every Leader Needs to Know. Nash-ville, TN: HarperCollins; 2008:11. n
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Page 6 The AAO Journal • Vol. 29, No. 4 • December 2019
AAO Calendar of EventsMark your calendar for these upcoming events and deadlines .
Dec. 11 Committee on Fellowship in the AAO’s teleconference—8 p.m. Eastern
Dec. 17 RAAO Executive Council’s web conference— 7 p.m. Eastern
Dec. 24-25 Christmas holiday—AAO office closed
Jan. 1. New Year’s Day—AAO office closed
Jan. 8 Committee on Fellowship in the AAO’s teleconference—8 p.m. Eastern
Jan. 9 AAO Publications Committee’s web conference—7 p.m. Eastern
Feb. 7-8 AAO Education Committee’s meeting—Indianapolis
Feb. 7-9 “Fascial Distortion Model: Treating the Shoulder, Ankle and Knee”—Todd A. Capistrant, DO, MHA, course director—Midwestern University Arizona College of Osteopathic Medicine in Glendale
March 8-10 Pre-Convocation course—“Brain Advanced: Releasing the Cranial Meninges Using a Biotensegrity Model”—Bruno J. Chikly, MD, DO (France)—The Broadmoor in Colorado Springs
March 8-10 Pre-Convocation course—“Cranial Nerve Course”—Kenneth J. Lossing, DO—The Broadmoor in Colorado Springs
March 8-10 Pre-Convocation course—“Pediatric Manual Medicine”—Lisa Ann DeStefano, DO, and Heather P. Ferrill, DO, MS MEdL—The Broadmoor in Colorado Springs
March 10 Committee on Fellowship in the AAO’s meeting and interviews—The Broadmoor in Colorado Springs—8 a.m. Mountain
March 10 AAO Education Committee’s meeting—The Broadmoor in Colorado Springs—6 p.m. Mountain
March 11 AAO Board of Trustees’ meeting—The Broadmoor in Colorado Springs—8 a.m. Mountain
March 11 AAO Board of Governors’ meeting—The Broadmoor in Colorado Springs—1 p.m. Mountain
March 11 AAO Investment Committee’s meeting—The Broadmoor in Colorado Springs—4 p.m. Mountain
March 11-15 2020 Convocation—“Embracing Integration: Creativity in Osteopathic Medicine”—J’Aimee Anne Lippert, DO, program chair—The Broadmoor in Colorado Springs
March 12 AAO annual business meeting and luncheon—The Broadmoor in Colorado Springs—11:45 a.m. Mountain
March 13 AAO Osteopathic Education Service Committee’s meeting—The Broadmoor in Colorado Springs—7 a.m. Mountain
March 13 RAAO annual business meeting and luncheon—The Broadmoor in Colorado Springs—12:30 p.m. Mountain
March 13 AAO Postdoctoral Training Committee’s meeting—The Broadmoor in Colorado Springs—2:30 p.m. Mountain
March 14 AAO International Affairs Advisory Council’s meeting—The Broadmoor in Colorado Springs—6:30 a.m. Mountain
March 14 AAO Board of Trustees’ meeting—The Broadmoor in Colorado Springs—11 a.m. Mountain
March 15 Post-Convocation course—“Residency Program Directors’ Workshop”—Darren Grunwaldt, DO, course director—The Broadmoor in Colorado Springs
April 17-18 “Motor Nerve Reflex Testing”—Steven Olmos, DDS, course director, and Mark S. Cantieri, DO, FAAO, course faculty—The Pyramids in Indianapolis
May 1-3 “Viscerosomatic Release: A Systemic Model for Neuromusculoskeletal Medicine”—John P. Tortu, DO, course director—Idaho College of Osteopathic Medicine in Meridian
June 4-7 “Introduction to Osteopathic Manipulative Medicine: Integrating OMM Into Clinical Practice and Teaching”—Lisa Ann DeStefano, DO, course director—The Pyramids in Indianapolis
2019-20
The AAO Journal • Vol. 29, No. 4 • December 2019 Page 7
Primary Care Physicianopportunity in Unity, MaineNorthern Light Inland Hospital in Waterville, Maine, is seeking a full-time board primary care physician to join their respected outpatient family practice for their Rural Health Center located in Unity, Maine. The right candidate would be joining an experienced clinical team in a diverse community. A team where you’ll enjoy the clinical autonomy and make a positive difference every day. We offer robust compensation/benefits and paid time off, student loan and relocation reimbursements, sign on bonus, free housing for first three months of hire. If you are seeking a more balanced lifestyle with beautiful country, yet with all the amenities and a variety of cultural and recreational options, Maine is the place to explore this great opportunity.
Northern Light Inland Hospital is a dynamic healthcare organization with a 48-bed community hospital and a 105-bed continuing care center on the hospital campus in downtown Waterville, Maine. Northern Light Inland Hospital is a member of Northern Light Health, an integrated statewide health delivery system that is raising the bar with no-nonsense solutions that are leading the way to a healthier future for our state. Enjoy the best of both worlds- practicing at a smaller community hospital in a comfortable, friendly environment while having the support of a large medical center.
For more information, please contact: MaryKate Friend, RMA, Provider Recruiter Northern Light Health - Provider Recruitment | [email protected] | 207.973.5358
Page 8 The AAO Journal • Vol. 29, No. 4 • December 2019
Impact of Predoctoral Teaching Fellows on Osteopathic Medical Students: A Near-Peer Teaching Program EvaluationBeatrice Akers, DO; Glenn Davis, MS; Jordan Keys, DO, MS; Stacey L. Pierce-Talsma, DO, MS MEdL, FNAOME;
ORIGINAL RESEARCH
and Gregg Lund, DO, MS, FAAP
Abstract
ContextThe Touro University California College of Osteopathic Medicine (TUCOM-CA) is one of many colleges of osteopathic medicine with osteopathic manipulative medicine (OMM) predoctoral teaching fellowship programs. OMM fellows serve as near-peer teachers for preclinical osteopathic medical students (OMS) at TUCOM-CA, with the objectives of increasing student satisfaction with and understanding of the OMM curriculum. Our aim was to assess whether the TUCOM-CA fellowship program has achieved these objectives.
MethodsAll osteopathic medical students at TUCOM-CA were sent an electronic survey. The survey items queried: frequency of and type of interaction; impact on satisfaction with and understanding of the OMM curriculum; impact on confidence in using osteopathic manipulative treatment (OMT); valuation of OMT and intention to use OMT in future clinical practice. Frequencies, means and standard deviations were calculated, omitting “no basis for evalu-ation” responses. Two-tailed Z-tests of proportions were utilized for analysis of statistical significance, with significance set at 95% (P<.05 ).
ResultsIn total, 156 of 538 (29.0%) responses were received, and 150 had sufficient data to analyze. Respondents reported varied rates and modes of interaction with OMM fellows (OMM lab table-training [97.3%] to early clinical experiences [30.9%]). Response means for items regarding satisfaction with and understanding of the OMM curriculum fell between “strongly agree” and “agree” for all activi-ties. Many respondents (82.5%-83.8%) reported that interaction with OMM fellows increased their confidence in using OMT. Additionally, respondents who were treated with OMT by OMM fellows reported significantly higher agreement with statements about clinical utility of OMT (Z=2.6, P<.05) and intention to use OMT in future practice (Z=2.3, P<.05).
ConclusionsThe majority of osteopathic medical students at TUCOM-CA reported significant agreement with the positive impact of interac-tion with OMM fellows on satisfaction with and understanding of the OMM curriculum. This supports the conclusion that the OMM predoctoral teaching fellowship program achieves its objec-tives to increase student satisfaction with and understanding of the OMM curriculum. The survey data also showed significantly stronger agreement with statements supporting valuation of OMT in clinical practice and intention to use OMT in the future, among respondents treated with OMT by OMM fellows.
IntroductionDifferent models of peer-assisted learning have been adopted in education at the university and graduate level with shown benefit to both the tutor and tutee.1 One way that the Touro University California College of Osteopathic Medicine (TUCOM-CA) has implemented this is by starting an osteopathic manipulative medicine (OMM) predoctoral teaching fellowship (OMM fel-
From the University of California, Davis, Neurology Residency (Akers); the Touro University College of Osteopathic Medicine–California (Davis, Keys, Pierce-Talsma); and the University of Utah School of Medicine (Lund).
Disclosures: none reported.
Correspondence address: Jordan Keys, DO, MS Department of Osteopathic Manipulative Medicine Touro University College of Osteopathic Medicine 1310 Club Drive Vallejo, CA 94592 [email protected]
Manuscript submitted for publication August 14, 2019; accepted for publication September 3, 2019.
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The AAO Journal • Vol. 29, No. 4 • December 2019 Page 9
lowship) in 2007. Each year, TUCOM-CA selects 2 second-year medical students as OMM fellows who complete an additional year of training. Fellows spend a third of each academic year in the department of OMM during their third, fourth, and fifth years of medical school. They deliver OMM lectures; table-train, lead, and provide technical support in OMM lab sessions; mentor and tutor preclinical students; work with supervising clinicians participating in clinical osteopathic manipulative treatment (OMT); develop and complete scholarly activity; and offer OMT demonstrations for student volunteers.
Peer-assisted learning has been defined as “people from similar social groupings who are not professional teachers helping each other to learn and learning themselves by teaching.”1 As a subset of this grouping, near-peer programming is described as a “phenom-enon whereby senior trainees teach more junior trainees.”2 Peer-assisted learning is not a new practice and has been evolving in its definition and ways of pedagogical practice. Initially, it was viewed as a linear model where knowledge is transmitted from teacher to tutor and then tutor to learner. However, it has now been recog-nized that peer–tutor interaction is actually quite different than teacher–student interaction and has differing advantages and disad-vantages. Increasingly it has been noted that not only does the tutee benefit from the interaction, but also the tutor.1
Multiple studies of peer-assisted learning in undergraduate medi-cal education have shown benefit for both near-peer teachers and learners, including development of professional attributes as well as knowledge and understanding.2-5 In one study, junior students were paired with senior medical students during a rotation in their medical training; surveys taken after the rotation showed that the junior medical students felt the senior medical students provided a nonthreatening learning environment as well as provided help-ful feedback and acted as role models. The senior medical students reported that they had been able to consolidate their knowledge and develop their teaching skills during this experience. In addi-tion, they expressed an interest in teaching in the future after this experience. This suggests that near-peer teaching may be beneficial to both the learner and teacher.5
Guidelines for implementing peer-assisted learning programs in undergraduate medical education include the development of objectives for learners and teachers, as well as process evaluation.6
The TUCOM-CA OMM fellowship provides a near-peer teaching program for osteopathic medical students (OMS) at TUCOM-CA, with objectives pertaining to both OMM fellows as near-peer teachers and the general population of OMS as near-peer learners.
The program’s objectives for the fellows are to develop osteopathic physicians who:
• Integrate osteopathic principles into clinical practice• Utilize enhanced skills in osteopathic diagnosis and treatment• Gain experience delivering academic curricular materials• Become leaders and educators in the profession
The objectives for the general student body are to increase TUCOM-CA student satisfaction with and understanding of the OMM curriculum through interaction with the fellows.
As per Samantha Tyler, OMS V, who has been collecting informa-tion on current predoctoral fellowships, TUCOM-CA is one of 27 osteopathic medical schools with OMM fellowships as of August 2019. The aim of this study was to evaluate the success of the TUCOM-CA OMM fellowship program in attaining its objectives of increasing student satisfaction with and understanding of the OMM curriculum.
Methods This study utilized a non-experimental design with online surveys (Appendix 1) sent to all TUCOM-CA OMS during the 2016-2017 academic year. The protocol was submitted to the TUCOM-CA Institutional Review Board which determined it to be exempt from formal review. The 43-item survey was delivered using Qual-trics software (Qualtrics, Provo, UT) and distributed via email in December 2016 using an anonymous link to the online survey. This was a general email sent to the class, and not specific to each individual student. A reminder email was sent 2 weeks after the ini-tial email, and the survey was closed 4 weeks after the initial email.
Survey items included Likert-scale and open-ended queries. The survey included items regarding the respondents’ interactions with the OMM fellows as well as the impact of these interactions on the respondents’ understanding of and satisfaction with the OMM cur-riculum. Participants were not required to respond to every survey item.
Survey responses were exported from Qualtrics into Excel (Micro-soft Corporation, Redmond, WA) for tabulation and analysis. Frequencies, means and standard deviations of responses were cal-culated for each survey item with a Likert scale, omitting “no basis for evaluation” responses. A histogram with confidence intervals was generated using Excel. Two-tailed Z-tests of proportions were utilized for analysis of statistical significance between groups for
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Page 10 The AAO Journal • Vol. 29, No. 4 • December 2019
weekly. The demographics of the survey respondents are presented in Table 1.
When assessing the statement “OMT is a useful part of osteopathic clinical medicine,” a majority (130 [87.3%]) of OMS strongly agreed or agreed, while only 5 respondents (3.3%) disagreed or strongly disagreed with the statement. A smaller majority (84 [56.4%]) of the OMS strongly agreed or agreed that they intend to use OMT in their own future clinical practice (Table 2). Of note, when comparing respondents who had never been treated with OMT by an OMM fellow, those who had been treated were sig-nificantly more likely to strongly agree with the statement “OMT is a useful part of osteopathic clinical medicine” (Z=2.6, P<.05). Additionally, those students who had been treated with OMT were significantly more likely to strongly agree or agree with the state-ment “I plan to use OMM/OMT in my clinical practice” (Z=2.3, P<.05) than those respondents who had never been treated by an OMM fellow (Table 2).
There are various activities in which OMM fellows interact with other OMS. All preclinical OMS attend required OMM labs, where fellows act as table trainers, so as expected, the most com-mon interaction was in this capacity (97.3%). However, a majority of OMS interacted with the OMM fellows in voluntary activities as well, though participation ranged from 30.8% to 90.5%. These included formalized activities OMM fellows are required to under-
some portion of the data (Ausvet, http://epitools.ausvet.com.au) with significance set at 95% (P<.05).
ResultsSurveys were sent to all 538 enrolled OMS in years I-IV, and 156 responses were received, a response rate of 29.0%. Six response sets were excluded for only answering anticipated graduation or no items at all, yielding a set of 150 responses used for final analysis. Participants were not required to respond to every survey item, thus percentages presented were calculated based on the number of responses submitted for that item.
The majority (109 [73.6%]) of the respondents were preclinical OMS I or OMS II students who typically would have had the opportunity for interaction with OMM fellows on campus at least
Table 1. Demographics of survey respondents.
Year of study Response No. (%)
OMS I 60 (40.5)
OMS II 49 (33.1)
OMS III 19 (12.8)
OMS IV 20 (13.5)
Response, Count (%)
TotalStrongly agree
(1) Agree (2) Neutral (3) Disagree (4)Strongly
disagree (5)
OMT is a useful part of osteopathic clinical medicine
All respondents 59 (39.6) 71 (47.7) 14 (9.4) 3 (2.0) 2 (1.3) 149
Received OMT from OMM fellowa
44 (47.8) 39 (42.4) 7 (7.6) 1 (1.1) 1 (1.1) 92
Never received OMT from OMM fellowa
14 (25.9) 30 (55.6) 7 (13.0) 2 (3.7) 1 (1.9) 54
I plan to use OMM/OMT in my clinical practice
All respondents 34 (22.8) 50 (33.6) 48 (32.2) 10 (6.7) 7 (4.7) 149
Received OMT from OMM fellowb
25 (27.2) 34 (37.0) 26 (28.3) 4 (4.4) 3 (3.3) 92
Never received OMT from OMM fellowb
8 (14.8) 16 (29.6) 20 (37.0) 6 (11.1) 4 (7.4) 54
aZ-test of proportional significance shows percent of “strongly agree” responses among those receiving OMT from fellows is significantly highter (P<.05) than among those not receiving.
bZ-test of proportional significance shows percent of “strongly agree” and “agree” responses among those receiving OMT from fellows is significantly higher (P<.05) than among those not receiving.
Table 2. OMS valuation of osteopathic manipulative treatment.
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The AAO Journal • Vol. 29, No. 4 • December 2019 Page 11
take, such as tutoring and review sessions for OMM examinations, as well activities fellows elect to pursue, including volunteering at early clinical experiences such as free clinics in which preceptors
oversee provision of OMT to patients from the community by OMS (Figure1).
Most students strongly agreed or agreed that table training assis-tance (135 [93.1%]), fellow-led review sessions (106 [77.4%]), and tutoring (58 [72.5%]) increased their satisfaction with the OMM curriculum (Table 3, Items 1-3). Additionally a high proportion of respondents strongly agreed or agreed that table training assistance (139 [95.9%]), fellow-led review sessions (121 [87.7%]), and tutoring by fellows (61 [80.0%]) helped them prepare for course exams, while fellow-led lectures (111 [78.7%]), OMT treatment (85 [85.9%]), and working with fellows in early clinical experiences (46 [79.3%]) increased their understanding of the OMM curricu-lum (Table 3, Items 4-9). Additionally, a large majority of respon-dents (117 [84.2%]) strongly agreed or agreed that labs taught by OMM fellows effectively improved their skills in the application of OMM (Table 3, Item 10). Response means were calculated for the same items (Figure 2). All of the means fell between 1 (strongly agree) and 2 (agree), and within the range of each respective confi-dence interval (Figure 2).
In addition to preparation for exams, working with the fellows can help improve OMS confidence in their OMT skill set and overall wellness. A high proportion (47 [82.5%]) of respondents strongly agreed or agreed that working with OMM fellows in early clinical experiences increased their confidence in using OMT. Similarly, most (83 [83.8%]) respondents strongly agreed or agreed that being treated with OMT by an OMM fellow increased their confi-dence in using OMT (Table 3, Items 11-12). Among those respon-dents who had received OMT from an OMM fellow, most (76
Figure 1. Frequency of interaction between OMS and OMM fellows.
Continuing Medical Education Quiz
The purpose of the continuing medical education quiz is to provide a convenient means of self-assessing your comprehension of the scientific content in the article “Impact of Predoctoral Teaching Fellows on Osteopathic Medical Students: A Near-Peer Teaching Program Evalu-ation” by Beatrice Akers, DO; Glenn Davis, MS; Jordan Keys, DO, MS; Stacey L. Pierce-Talsma, DO, MS MEdL, FNAOME; and Gregg Lund, DO, MS, FAAP.
To apply for 0.5 credits of AOA Category 2-B continuing medical education, fill out the form on page 17 and sub-mit it to the American Academy of Osteopathy. The AAO will note that you submitted the form and forward your results to the American Osteopathic Association’s Division of Continuing Medical Education for documentation.
Be sure to answer each question in the quiz. You must score a 75% or higher on the quiz to receive CME credit. The correct answers will be published in the next issue of the AAOJ.
(continued on page 14)
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Page 12 The AAO Journal • Vol. 29, No. 4 • December 2019
Survey item
Response, Count (%)
TotalStrongly agree (1) Agree (2) Neutral (3) Disagree (4)
Strongly disagree (5)
Satisfaction
1 Table training assistance from OMM Fellows during OMM labs increased my satisfaction with the OMM curriculum
77 (53.1) 58 (40.0) 9 (6.2) 1 (0.7) 0 (0) 145
2 Fellow-led review sessions increased my satisfaction with the OMM curriculum
52 (38.0) 54 (39.4) 25 (18.2) 4 (2.9) 2 (1.5) 137
3 Tutoring by OMM Fellows increased my satisfaction with the OMM curriculum
33 (41.3) 25 (31.3) 20 (25.0) 2 (2.5) 0 (0) 80
Understanding
4 Table training assistance from OMM Fellows during OMM labs helped me prepare for OMM exams
81 (55.9) 58 (40.0) 5 (3.4) 1 (0.7) 0 (0) 145
5 Fellow-led review sessions helped me prepare for OMM exams
58 (42.0) 63 (45.7) 15 (10.9) 1 (0.7) 1 (0.7) 138
6 The lectures taught by OMM Fellows effectively improved my understanding of OMM
46 (32.6) 65 (46.1) 27 (19.1) 3 (2.1) 0 (0) 141
7 Being treated by an OMM Fellow increased my understanding of OMM
42 (42.4) 43 (43.4) 13 (13.1) 1 (1.0) 0 (0) 99
8 Tutoring by OMM Fellows helped me prepare for OMM exams
34 (42.5) 27 (33.8) 17 (21.3) 2 (2.5) 0 (0) 80
9 Working with an OMM Fellow in my early clinical experience increased my understanding of OMM
28 (48.3) 18 (31.0) 12 (20.7) 0 (0) 0 (0) 58
10 The labs taught by OMM Fellows effectively improved my skills in the application of OMM
51 (36.7) 66 (47.5) 20 (14.4) 2 (1.4) 0 (0) 139
Confidence and wellness
11 Working with a Fellow in my early clinical experiences increased my confidence in utilizing OMM
30 (52.6) 17 (29.8) 10 (17.5) 0 (0) 0 (0) 57
12 Being treated by a Fellow increased my confidence in utilizing OMM
36 (36.4) 47 (47.5) 16 (16.2) 0 (0) 0 (0) 99
13 Being treated by a Fellow was an important part of my wellness during my pre-clinical years in medical school
43 (43.0) 33 (33.0) 20 (20.0) 4 (4.0) 0 (0) 100
Mentorship and accessibility
14 Advising from OMM Fellows effectively helped prepare me for my clinical rotations
13 (19.7) 32 (48.5) 20 (30.3) 1 (1.5) 0 (0) 66
15 Advising from OMM Fellows effectively helped me develop my study plan for standardized board exams
9 (15.0) 24 (40.0) 24 (40.0) 3 (5.0) 0 (0) 60
16 Working with a Fellow in my early clinical experiences motivated me to learn more about OMM
28 (48.3) 20 (34.5) 10 (17.2) 0 (0) 0 (0) 58
17 I felt more comfortable asking OMM Fellows for help in lab than I did asking faculty
35 (24.0) 49 (33.6) 47 (32.2) 13 (8.9) 2 (1.4) 146
18 I felt more comfortable seeking OMT treatment from a Fellow than from faculty
43 (42.2) 27 (26.5) 26 (25.5) 6 (5.9) 0 (0) 102
Table 3. Survey item response frequencies.
The AAO Journal • Vol. 29, No. 4 • December 2019 Page 13
[76.0%]) reported that it was an important part of their wellness during their preclinical years of training (Table 3, Item 13).
As discussed in the introduction, one aspect of peer-assisted learn-ing is mentorship and creating a comfortable learning environment. More than two-thirds (45 [68.2%]) of respondents strongly agreed or agreed that advising from OMM fellows effectively prepared them for clinical rotations, while more than half (33 [55.0%]) strongly agreed or agreed that advising from OMM fellows helped them develop a study plan for standardized board examinations (Table 3, Items 14-15). Approximately half of the respondents (84 [59.8%]) indicated that they were more comfortable asking OMM fellows than faculty members for table training assistance in labs, as well as more comfortable seeking OMT from fellows than faculty (70 [68.6%]) (with a response of “strongly agree” or “agree”) (Table 3, Items 17-18).
DiscussionSignificant results included an increased satisfaction with and understanding of the OMM curriculum, resulting from interaction with and near-peer learning opportunities provided by OMM fel-lows (Table 3, Items 1-3, 7, 9). Rates of exposure to different modes of interaction with fellows varied from 30.8% for early clinical
Figure 2. Response meansa and confidence intervals.b
a “No basis for evlauation” responses were excluded from analysis.b Whisker plots represent 95% confidence intervals for each mean.
experiences to 97.3% for table training, yet average agreement was strong and uniform that each mode of interaction increased satis-faction with or understanding of the OMM curriculum (Figures 1 and 2). These data support the conclusion that the OMM fellow-ship program is successfully meeting its objectives of increasing stu-dent satisfaction with and understanding of the OMM curriculum at TUCOM-CA.
The findings also suggest that as a near-peer teaching program, the OMM fellowship potentially has long-term effects on the OMS at TUCOM-CA. Previous studies have reported correlation between increased exposure to OMT and higher levels of agreement with osteopathic philosophy statements and intention to use OMT.7,8 It also has been proposed that clinical exposure to OMT during the didactic years is an effective way to encourage students to later use OMT clinically.7-9 This survey yielded similar findings, with a sig-nificantly higher proportion of respondents strongly agreeing with statements about clinical utility of OMT as well as intention to use OMT in future practice among students who had received OMT from OMM fellows (Table 2). Additionally, students reported increased confidence in using OMT after being treated with OMT by fellows and as a result of working with fellows in early clinical experiences. These data suggest that the OMM fellows may offer a novel means of increasing confidence levels among OMS, which
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Page 14 The AAO Journal • Vol. 29, No. 4 • December 2019
previously had been noted after completion of elective clinical rota-tions in OMM.9
In addition, students who received OMT from OMM fellows indicated that this was an important component of their wellness during their first 2 years of training. This finding may constitute preliminary evidence that receiving OMT during medical training promotes wellness among OMS.
Osteopathic medical schools are in the position of having long-standing near-peer teaching programs with potentially significant impact on medical student training. However a systematic litera-ture review of medical students as peer tutors identified a range of peer-assisted teaching programs that did not include those at osteopathic medical schools.3 To date, fellowship programs at osteo-pathic medical schools have not been evaluated in the literature, and thus have not entered into the broader conversation about peer-assisted learning programs in medical education. As the first published study framing OMM fellowships as a model for near-peer teaching, this study may benefit the community of medical educators by introducing the experience of osteopathic near-peer teaching programs.
Some limitations of the study include the sample that elected to respond to the survey. Those who responded might have done so because they felt strongly about OMT or the OMM fellowship program which may have biased the results. A more complete sam-ple of the student group would decrease this concern. The notice of the survey was delivered via email listserv instead of via individual email addresses which may have decreased the response rate.
In future studies measuring the benefits of OMM fellowship at TUCOM-CA, the survey could be repeated for subsequent classes to assess programmatic change over time and to validate the findings reported here. The reliability of future studies could be enhanced by improving sampling methods to increase the response rate. In addition, the performance on board exams, particularly the osteopathic principles and practices subdiscipline, could be com-pared to the time and type of interaction the student had with the OMM fellows.
Near-peer learning programs have been shown to impact near-peer teachers as well as learners2-5 and may also affect collaborating pro-fessional educators. Therefore, a new direction of future inquiry could be to evaluate the impact of the program on fellows them-selves, as well as on faculty and staff.
Finally, to identify best practices in OMM predoctoral fellowships, the survey could be administered at other colleges of osteopathic
medicine. Studying some of the 26 other fellowship programs of varied sizes and structures could enhance the understanding of the efficacy of different program designs, evaluation systems, and objec-tives.
ConclusionThis project demonstrates that OMS at TUCOM-CA report sig-nificant agreement with the positive impact of interaction with OMM fellows on satisfaction with and understanding of OMM curriculum. This supports the conclusion that the OMM predoc-toral teaching fellowship program achieves its objectives to increase student satisfaction with and understanding of the OMM cur-riculum. Additionally, the survey data show significantly stronger agreement with statements supporting valuation of OMT in clini-cal practice and intention to use OMT in the future among respon-dents treated with OMT by OMM fellows. Consistently strong agreement with statements about understanding and satisfaction was found among respondents for all interactions with fellows.
Acknowledgments The authors would like to thank the OMS at TUCOM-CA for their participation in this survey and David W. Crotty, DO, and R. Mitchell Hiserote, DO, for their support in undertaking this project.
References1. Topping KJ. The effectiveness of peer tutoring in further and higher
education: A typology and review of the literature. High Educ. 1996;32(3):321-345. http://www.jstor.org/stable/3448075. Accessed October 28, 2019.
2. Bulte C, Betts A, Garner K, Durning S. Student teaching: views of student near-peer teachers and learners. Med Teach. 2007;29(6):583-590.
3. Burgess A, McGregor D, Mellis C. Medical students as peer tutors: a systematic review. BMC Med Educ. 2014;14:115. doi:10.1186/1472-6920-14-115
4. Vaughn B, Macfarlane C. Perceived teaching quality between near-peer and academic tutors in osteopathic practical skills class. Int J Osteopath Med. 2015;18(3):219-229. doi:10.1016/j.ijosm.2015.04.013
5. Nelson AJ, Nelson SV, Linn AM, Raw LE, Kildea HB, Tonkin AL. Tomorrow’s educators … today? Implementing near-peer teaching for medical students. Med Teach. 2013;35(2):156-159. doi:10.3109/0142159X.2012.737961
6. Ross MT, Cameron HS. Peer assisted learning: a planning and implementation framework: AMEE Guide no. 30. Med Teach. 2007;29(6):527-545.
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7. Draper BB, Johnson JC, Fossum C, Chamberlain NR. Osteo-pathic medical students’ beliefs about osteopathic manipulative treatment at 4 colleges of osteopathic medicine. J Am Osteo-path Assoc. 2011;111(11):615-630. https://jaoa.org/article.aspx?articleid=2094073. Accessed October 28, 2019.
8. Volokitin M, Ganapathiraju P. Osteopathic philosophy and manipu-lation enhancement program: influence on osteopathic medical stu-dents’ interest in osteopathic manipulative medicine. J Am Osteopath Assoc. 2017;117(1):40-48. doi :10.7556/jaoa.2017.006
9. Shapiro LN, Defoe D, Jung MK, Li TS, Yao SC. Effects of clini-cal exposure to osteopathic manipulative medicine on confidence levels of medical students. J Am Osteopath Assoc. 2017;117(8):e1-5. doi:10.7556/jaoa.2017.105 n
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Page 16 The AAO Journal • Vol. 29, No. 4 • December 2019
CME Certification of Home Study
This is to certify that I, ____________________________,(type or print name)
read the following article for AOA CME credit.
Name of article: “Impact of Predoctoral Teaching Fellows on Osteopathic Medical Students: A Near-Peer Teaching Program Evaluation”
Authors: Beatrice Akers, DO; Glenn Davis, MS; Jordan Keys, DO, MS; Stacey L. Pierce-Talsma, DO, MS MEdL, FNAOME; and Gregg Lund, DO, MS, FAAP
Publication: The AAO Journal, Vol. 29, No. 4, December 2019, pages 9-16
Send this page to:American Academy of Osteopathy3500 DePauw Blvd, Suite 1100Indianapolis, IN [email protected] (317) 879-0563
AOA Category 2-B credit may be granted for this article.
00____________
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continuing MEdical Education
This CME Certification of Home Study is intended to document your review of the CME article in this issue of The AAO Journal under the criteria for AOA Category 2-B continuing medical education credit.
Complete the quiz to the right by circling the correct answers. Send your completed answer sheet to the American Academy of Osteopathy. The AAO will forward your results to the American Osteopathic Association. You must answer 75% of the quiz questions correctly to receive CME credit.
1. Which of the following statements is true regarding peer-to-peer and near-peer learning?
a. There is little benefit to the tutor.b. It is a very similar interaction as the teacher-student
interaction.c. Tutors had less of an interest in teaching after their
experience.d. Tutees expressed that this model provided a non-
threatening learning environment.
2. Which of the following is one of TUCOM’s program objectives for the OMM fellowship?
a. Encourage fellows to practice OMM exclusively in their future practice
b. Become faculty at osteopathic medical schoolsc. Deliver the OPP curriculum to the preclinical studentsd. Utilize advanced skills in osteopathic diagnosis and
treatment
3. Which of the following was the aim of the study?
a. Increasing student satisfaction with OMM curriculumb. Increasing student rapport with fellowsc. Encouraging students to apply to be fellowsd. Developing lifelong learners
4. Which of the following is true regarding students who received OMT from OMM fellows?
a. They felt it was an important part of their wellness during their first two years.
b. They were more likely to practice on their classmates.c. They were more likely to apply to become an OMM
fellow.d. They did better on the OMM practical exams.
Below are the answers to The AAO Journal’s September 2019 quiz on the article titled “An Osteopathic Approach to Uterine-Induced Low Back Pain: A Case Report” David M. Kanze, DO, FAAO.
1. a. Increased thoracic lordosis is generally present in pregnant women.
2. b. Irritation of the uterus most likely contributed to the patient’s pain.
3. c. The uterosacral ligament transmits the nerves of the hypogastic (pelvic) plexus to the uterus.
4. a. T12 extended, rotate and side-bent right dysfunction would most likely be found with irritation of the uterus.
The AAO Journal • Vol. 29, No. 4 • December 2019 Page 17
ORDER NOW AT:www.academyofosteopathy.org/shopMembers Receive a 10% Discount
Manipulate your way into a good book.
“This text is unique in its approach. Not only do the clinical chapters give a concise clinical case with physical exam, but they provide a short background of anatomy, ‘red flag’ reminders and straightforward direct techniques. References for the topics are also included.”
– Ann L. Habenicht, DO, FAAO, FACOFP Past President of the American Academy of Osteopathy
(Excerpt from Foreword, Second Edition)
Basic Musculoskeletal Manipulation Skills; The 15 Minute Office Encounter, Second Edition, is a valuable, engaging, crucial tool for any doctor who wants to understand what an office encounter with a patient is all about. With more than 400 photographs, 70 illustrations, and 200 charts, this resource is irreplaceable.
The book is filled with mnemonic devices to help the reader remember what has been learned, arrows on photos that show exactly how a technique is applied and easy to follow charts that enable a doctor to visualize precisely what’s going on. This is more than a good book, it’s the foundation for a good practice.
American Academy of Osteopathy Publications
An Osteopathic Approach to Traumatically Induced Mechanical Dyspnea: A Case ReportDavid M. Kanze, DO, FAAO
CASE REPORT
AbstractMechanical dyspnea (breathing pattern disorders), such as hyper-ventilation or hypoventilation, can result in increased pain and have negative mechanical, psychological, emotion, and biochemical effects.1,2,3 Proper breathing helps to stabilize the spine, maintain posture, and decrease anxiety. Injuries to the abdominal and pel-vic diaphragms can disrupt proper breathing mechanics, leading to increased pain, anxiety, poor posture, and poor spinal and overall body mechanics. Osteopathic manipulative treatment can help restore proper diaphragmatic motion and proper breathing mechanics as the present case will demonstrate.
IntroductionDyspnea is an abnormal or uncomfortable breathing pattern that differs for each person.4 It is a common complaint presenting to physician offices and the emergency department. It has a broad differential diagnosis that can be divided into emergent and non-emergent and then further differentiated into pulmonary, cardiac, cardiopulmonary, or noncardiopulmonary.4 Mechanical dyspnea, (breathing pattern disorders) is a noncardiopulmonary cause of dyspnea that is commonly encountered by physicians and often dismissed despite the fact that it can have negative effects on spinal mechanics, posture, psychological and emotional well-being, and pain, as well as, decreased oxygenation of the tissues.1,2,3
Andrew Taylor Still, MD, DO, and William Garner Sutherland, DO, spoke of the diaphragm as a piston to keep all the machinery of the body in order.5,6 Despite their teachings, there is a paucity of literature in treating traumatically and mechanically induced dyspnea.
This case depicts an osteopathic approach to a traumatically induced mechanical dyspnea that greatly decreased the patient’s pain and helped to restore her ability to do her activities of daily living and leisure.
Case PresentationA 23-year-old, wheelchair-bound woman presented to the clinic accompanied by her mother. Her chief complaint was 1 month
of left-sided pelvic pain and difficulty breathing that began after a horse reared and landed on her. Immediately following the injury, she was transported to the hospital via ambulance and was sub-sequently diagnosed with a left acetabular fracture, as well as two pubic rami fractures bilaterally. Her pain began as a 10/10 and, at the time of the visit, was a sharp, relatively constant, 5/10 that shot down the left leg globally and made it difficult to sleep. It was worse with sitting and while nothing alleviated it completely, she obtained some relief with ibuprofen and Percocet. She had had previous injuries to the pelvis after falling off horses and with her equestrian jumping events.
The patient’s difficulty breathing began immediately after the injury and had been constant. It was described as not being able to take a deep breath as it greatly increased her pelvic and rib pain. Her breathing remained unchanged despite albuterol inhalations.
From the Arcana Center for Integrative Medicine in Wynnewood, Pennsylvania.
Disclosures: none reported.
Correspondence address:David Kanze, DO , FAAOArcana Center for Integrative Medicine300 Lancaster Ave., Suite 201BWynnewood, PA 19096(267) [email protected]
Submitted for publication February 12, 2019; manuscript accepted for publication July 23, 2019.
Dr. Kanze prepared this manuscript as one of the requirements to earn fellowship in the American Academy of Osteopathy. The Committee on Fellowship in the AAO provided peer reviewing for this article, and it was edited to conform to the AAOJ’s style guidelines.
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EvaluationUpon review of systems, the patient acknowledged having migraine headaches (2-3x/week without aura), nausea, constipation (since the injury), acid reflux, neck, shoulder, ribcage, back, hip, knee, and ankle pain, parethesias in the lateral toes of her left foot, and a scaly, erythematous rash of 3 weeks’ duration. She denied fever, chills, night sweats, vomiting, diarrhea, chest pain, urinary symp-toms, and weakness.
The patient’s medical history was significant for a sacralization of L5 on the left, seasonal allergies, mild, intermittent asthma, and migraines. She was G0P0. She had had multiple falls off horses. She was a full-term vaginal birth without instrumentation or com-plications.
The patient’s surgical history was significant for a laparoscopic appendectomy, tonsillectomy and adenoidectomy, myringotomy and tympanostomy tubes, and an open reduction and internal fixa-tion of the right ankle.
The patient denied smoking, alcohol, or illicit drug use. She worked as an equestrian and ranch hand while attending college. Her family history was noncontributory. She was allergic to Norco (hydrocodone/acetaminophen). She was taking the following medi-cations: ibuprofen, 600mg every 6 to 8 hours as needed for pain; Percocet (oxycodone/acetaminophen), 5/325mg every 6 hours as needed for pain; Singulair (montelukast), 10mg daily; Nuvaring monthly; Zofran, 8mg every 8 hours as needed for nausea; alb-uterol MDI, 2 puffs every 4 to 6 hours as needed for wheezing or shortness of breath.
A physical exam revealed a healthy wheelchair-bound woman in moderate pain. She was 70 inches tall and weighed 170 lbs. Her blood pressure was 114/82 mm Hg with a pulse of 88 and a respi-ratory rate of 16. Her neck was supple and had full active range of motion. Her cardiac exam revealed a regular rate and rhythm with-out murmurs, rubs, or thrills. Her respiratory exam revealed shal-low breathing with deep breathing eliciting pain. She was clear to auscultation bilaterally without rhonchi, rales, or wheezes, however. She had an erythematous, scaly lesion with central clearing and excoriations about T7 on the left scapula. Her gait was not assessed due to her status of being wheelchair-bound secondary to heal-ing pelvic fractures. She had decreased range of motion of the left shoulder especially in internal rotation with warmth about the left pectoral muscle. Neurologically, C5, C6, C7, L4 and S1 reflexes were 2/4 bilaterally; she was unable to perform strength testing sec-ondary to pain.
An osteopathic structural examination revealed a compression of the sphenobasilar synchondrosis (SBS); C3 flexed, rotated, side-bent left; tight and tender left pectoral musculature; restricted tho-racic inlets, right greater than left; T4 extended, rotated and side-bent left; T5-T8 neutral, side-bent left, rotated right; a compressed left glenohumeral joint; tenderness about the left lower sternum; inhaled ribs 5-8 on the right; inhaled ribs 2-4 on the left; a severely restricted abdominal diaphragm and an extremely tight linea alba; L3 flexed, rotated and side-bent left; global tenderness of the pelvis and sacrum; tight bilateral pelvic floor/diaphragm with tenderness to palpation at bilateral ischial tuberosities, left greater than right; and right pes anserine tenderness to palpation. She also had tender-ness to palpation about the gallbladder 23 acupuncture point on the left.
TreatmentAfter verbal consent was obtained, the patient was assisted out of her wheelchair and onto the treatment table. Due to the relative contraindication to performing osteopathic manipulative treatment (OMT) on areas of fracture, and moreover, due to her severe pain, OMT was not performed on the pelvis and sacrum at this visit.7 Instead, treatment was directed to improve her breathing1 and decrease her pain. This began with release of the linea alba, utilizing ligamentous articular strain (LAS)8 and continued with direct inhi-bition to the corresponding trauma points about the linea alba8,9,10 along with the gallbladder 23 acupuncture point.11 The SBS com-pression was then treated utilizing osteopathic cranial manipulative medicine (OCMM).12 LAS was utilized to treat the ribcage and its dysfunctions, the lumbar spine, the pes anserine, the shoulder, and the lumbar spine.
Treatment focused on 5 of the 8 diaphragms in the body to improve the patient’s breathing and overall well-being.8 Treatment was directed towards the abdominal diaphragm, thoracic inlet, suboccipital muscles, the tentorium cerebelli, and sella turcica. The patient was sent home with modified Fulford breathing exercises,13 specifically the exercise that has the left palm facing superiorly and the right palm facing inferiorly while taking deep breaths. The exer-cise was modified as this patient could not yet stand. She also was given Lamisil (terbinafine) cream for her ringworm and instruc-tions to return within 2 weeks.
At the conclusion of her first visit, the patient noted that her ability to take a deep breath was greatly improved. She also stated that her overall pain, including her pelvic pain, was “at least cut in half.”
At her second visit 4 weeks later, the patient had progressed out of her wheelchair to crutches to full unassisted weight-bearing with
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to, in some circles, internationally as breathing pattern disorder (BPD).1,17 BPD is defined as an inappropriate breathing pattern that causes pulmonary symptoms without an apparent organic cause.2
BPD will be referred to as mechanical dyspnea for the purpose of this paper. In addition to the mechanical dyspnea, a typical response to trauma is to take a sharp inhalation and to lock in the abdominal diaphragm with an emotional response to the injury.18,19 This, in turn, can cause inhibition of the transverse abdominus.18 With mechanical dyspnea and inhibited transverse abdominis mus-culature, postural stability would be decreased, as normal breathing mechanics have been shown to aid in posture and stabilization of the spine.16 The patient’s inability to properly breathe would—and did—decrease her ability to compensate for her pelvic injuries. Mechanical dyspnea also contributes to pain and decreased well-being.1,16,3
In an effort to decrease her work of breathing, decrease her pain, and improve her well-being, treatment at the first visit concentrated on the mechanical components of the dyspnea via treatment of 5 (abdominal diaphragm, thoracic inlet, suboccipital muscles, the tentorium cerebelli, and sella turcica) of the 8 diaphragms (sella turcica, tentorium cerebelli, suboccipital muscles, thoracic inlet, abdominal diaphragm, the pelvic floor, the popliteal fossa, and the plantar fascia).8 The pelvic floor was treated indirectly through its connections via the core musculature anteriorly, and posteriorly by means of the semitendinosus’ insertion at the pes anserine.8,20 The treatment of the semitendinosus’ insertion at the pes anserine allowed the muscle to relax at its origin, the ischial tuberosity and sacrotuberous ligament, thereby allowing decreased tension in the pelvic floor. These indirect treatments of the pelvic floor helped to return stability to her sacroiliac joints and core musculature.21
Treatment was also directed to decrease the shock in her system via the linea alba release, treatment of the trauma point in the abdomen and the gallbladder 23 acupuncture (GB 23) point.8,10,11 Robert Fulford, DO, noted that when shock or trauma occurs in the body, the diaphragm can become locked under the sternal body and that a “recess” will be present adjacent to the sternum on the left at the level of the sixth rib or about where the xiphoid approxi-mates the sternum.10 He noted that treatment of this recess and the “midline of the abdomen,” the linea alba, will “release the breath.”10 Restriction of the GB 23 point, located in the fifth intercostal space, mid-axillary line on the left, causes “binding of the chest and the decreased chest wall compliance.”11 Treatment of this point increases chest wall compliance and allows for a deeper breath.11
the help of physical therapy. She returned to the office reporting continued, constant, left hip and associated low back pain that had been steadily decreasing with physical therapy and since getting off of her crutches. The left hip pain was mostly with ambulation, had an associated grinding as well as left leg weakness. Furthermore, she also reported discomfort about her left coracoid process radiating into the scapular region. Of note, she only had 2 migraines in the time between treatments, and this was greatly decreased from her regular migraine pattern.
A physical exam revealed a gait that was slowed and antalgic to the left. She was able to breathe deeply. She had pain with bilateral hip flexion, negative bilateral FABER (flexion, abduction and external rotation) tests, and negative bilateral hip impingement signs.14 Her rash had completely resolved. Osteopathically, she had an increased lumbar lordosis with increased lumbar extension; an SBS compres-sion with a restricted left occipitomastoid suture; tight bilateral sca-lenes with C3 flexed, rotated and side-bent right; bilaterally tight rhomboid and paraspinal muscles with T4 flexed, rotated and side-bent right; inhaled ribs 6-10 on the right; a restricted abdominal diaphragm; a tight linea alba; L5 extended, rotated and side-bent right; a left-on-right sacral torsion; extremely tight bilateral psoas muscles; a right superior pubic shear; a compressed left acetabulum with a medial fascial twist; and tight bilateral hamstrings. OMT was directed to the above areas with LAS and OCMM. After treat-ment, the patient reported and was observed to have increased range of motion of her hips and back as well as an improvement in her gait and a resolution of her shoulder pain. She was instructed to continue physical therapy, to stretch her psoas muscles, and to return in 2 weeks.
Including the initial presentation, she was treated 3 times in 2 months for similar dysfunctions that gradually resolved with OMT. She reported that as her breathing improved, her pelvic pain improved. Moreover, she was ecstatic to be able to ride a horse again. After beginning horseback riding, she was seen for follow-up, and her pelvis and breathing remained stable.15
DiscussionThis patient presented to the office 1 month after a severe trauma in which a horse landed on her, fracturing her pelvis in multiple locations and causing muscle imbalances in her pelvic floor and subsequent dyspnea. The differential diagnosis for dyspnea is exten-sive and includes mechanical restrictions, asthma, restrictive lung disease, deconditioning, anxiety, splinting/pain, hyperventilation, and diaphragmatic paralysis.16,4 Organic causes of dyspnea, with the exception of her asthma, had been ruled out while she was in the hospital. Her injuries caused mechanical dyspnea, that is referred (continued on page 22)
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Overall, treatment of these areas allowed for an initial deep breath to be taken and to decrease the shock in her system.8,10,11
Increased diaphragmatic motion directly affects breathing, and indirectly, via muscular attachments and through the pumping motion of the abdominal diaphragm, it influences the pelvic floor, core muscles, and musculature of the lower back. As her breathing mechanics improved, the patient’s pain decreased.21 In addition to spinal stabilization, proper breathing mechanics and pelvic floor motion are essential for many bodily functions, including defeca-tion. The pelvic floor and abdominal diaphragmatic dysfunctions were most likely contributing to her constipation. The constipation resolved with the balancing of these areas.
At follow-up visits, treatment of the 8 diaphragms continued and included treatment of the pelvic floor. As the pelvic floor became more balanced, her back pain decreased further, most likely due to the pelvis’ influence on spinal mechanics and stabilization.21 The patient continued to breathe easier as her mechanical dyspnea decreased, her pain decreased, and her activity increased. Initially, this began with a decrease in her migraine headaches and an increased ability to ambulate, and it progressed to a resumption of horseback riding. As her equestrian activities increased, her pain continued to decrease and her breathing eased further as the emo-tional component of the injury lessened.8,14
ConclusionThis case demonstrates how a knowledge of the interconnected-ness of anatomic structures, especially the 8 diaphragms, and their physiologic functions are required for proper treatment of a patient, especially after traumatic events.19
The patient’s injury caused mechanical dyspnea by disrupting her pelvic floor with subsequent abdominal diaphragmatic dysfunction. This dysfunction was exacerbated by shock, her underlying asth-matic condition and pain. After treatment utilizing ideas from Still and Sutherland was applied to the 8 diaphragms, the patient had pain relief and was able to resume her normal activities. Still wrote, in regards to the abdominal diaphragm, “all parts of the body have a direct or indirect connection with this great separating muscle,” and “the diaphragm has much to do with keeping all the machinery and organs of life in a healthy condition.”5 Sutherland continued this thought by comparing the motion of the diaphragm to a “pis-ton in the cylinder of an internal combustion engine.”6 He contin-ued by explaining how the diaphragmatic attachments range from the anterior cervical fascia to the pelvic floor, and he wrote that treatment of the pelvic floor allowed treatment of the diaphragm.6
For this patient, direct and indirect treatment directed toward the 8 diaphragms led to physical, psychological, and emotional relief. This type of treatment can likely help other patients recover from traumatic injuries whether they be physical, psychological, or emo-tional. Future studies are needed to expand these concepts.
AcknowledgementsI would like to acknowledge Wm. Thomas Crow, DO, FAAO, for his assistance with the FAAO project and Kylie Ann Kanze, DO, for being my editor.
References1. Chaitow L. Breathing pattern disorders, motor control, and low back
pain. J Osteopath Med. 2004;7(1):33-40.2. Bradley H, Esformes JD. Breathing pattern disorders and functional
movement. Int J Sports Phys Ther. 2014;9(1):28-39.3. CliftonSmith T, Rowley J. Breathing pattern disorders and physio-
therapy: inspiration for our profession. Phys Ther Rev. 2011;16(1):75-86.
4. Morgan WC, Hodge HL. Diagnostic evaluation of dyspnea. Am Fam Physician. 1998;57(4):711-716.
5. Still AT. The Philosophy and Mechanical Principles of Osteopathy. Kan-sas City, MO: Hudson-Kimberly Publishing Company; 1902;138-140.
6. Sutherland WG. Teachings in the Science of Osteopathy. Ft. Worth, TX; Sutherland Cranial Teaching Foundation; 1990.
7. Nicholas AS, Nicholas EA. Atlas of Osteopathic Techniques.Philadel-phia, PA: Lippincott Williams & Wilkins; 2008:75.
8. Speece CA, Crow WT, Simmons SL. Ligamentous Articular Strain: Osteopathic Manipulative Techniques for the Body. Rev ed. Seattle, WA: Eastland Press; 2009:50,71-110,160-176.
9. Crow, WT and Vandy TC. The Philosophy and Technique of the Osteo-pathic Masters. Texas. Self-published; 2017; 281-282.
10. Fulford, RC. Are We On The Path? Indianapolis, IN: The Cranial Academy; 2003:8,154,159.
11. Deadman P, Mazin A, Baker K. A Manual of Acupuncture. East Sus-sex, UK: Journal of Chinese Medicine Publications; 1998:440-441.
12. Magoun HI. Osteopathy in the Cranial Field. Boise, ID; Sutherland Cranial Teaching Foundation; 1976:135-137.
13. Fulford RC, Stone G. Dr. Fulford’s Touch of Life: The Healing Power of the Natural Life Force. New York, NY: Simon and Schuster; 1997:175-176.
14. Fam AG, Lawry GV, Kreder HJ. Musculoskeletal Examination and Joint Injection Techniques. Philadelphia, PA: Mosby; 2010:5,45-63.
15. Tettambel MA. Using integrative therapies to treat women with chronic pelvic pain. J Am Osteopath Assoc. 2007;107(Supplement 6):ES17.
16. Wahls SA. Causes and evaluation of chronic dyspnea. Am Fam Physi-cian. 2012;86(2):173-182.
17. Barral JP, Mercier P. The Thorax. Seattle, WA: Eastland Press; 2005:70-77.
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18. Wallden, M. The primal nature of core function: in rehabilitation & performance conditioning. J Bodyw Mov Ther. 2013;17(2):239-248.
19. Willard FH. Mechanics of respiration. In: Chila AG, exec ed. Foun-dations of Osteopathic Medicine. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:3,206-218.
20. Myers TW. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. 2nd ed. Edinburgh, Scotland; Churchill Living-stone; 2009:98-113.
21. Chaitow L. Chronic pelvic pain: pelvic floor problems, sacro-iliac dysfunction and the trigger point connection. J Bodyw Mov Ther. 2007;11(4):327-339. n
Traumatically Induced Mechanical Dyspnea (continued from page 22)
The AAO Journal • Vol. 29, No. 4 • December 2019 Page 23
Shut Up and Listen! Why Doctors Don’t Listen and How They Can be Part of the Cure
Stephen I. Goldman, DO, FAAO, FAOASM
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Stephen I. Goldman, DO, FAAO, FAOASM, was a graduate of Michigan State University and the Des Moines University College of Osteopathic Medicine in Iowa. He completed his internship and family practice residency at Botsford Hospital in Farmington Hills, Michigan. He was a member of the teaching faculty at Beaumont Farmington Hills, and he was an assistant clinical professor in the Department of Osteopathic Manipulative Medicine at the Michigan State University College of Osteopathic Medicine. Dr. Goldman also served as the program director for the ONMM2/Plus One Residency Program at Beaumont Farmington Hills. In addition, he served as a member of the Research and Education Committee of Sports Science and Medicine for United States Figure Skating, and he worked with figure skaters at the local, national, international and Olympic level for more than 20 years.
Applying Osteopathic Manipulative Treatment to Postconcussion Syndrome: A Case ReportSheldon C. Yao, DO, FAAO
CASE REPORT
Abstract Concussions are a form of mild traumatic brain injury, which are caused by trauma to the head or body. Symptoms of concussion can include headaches, dizziness, imbalance, and difficulty with concentration, which can persist for weeks, months, or even years after the event. This case report details the treatment of a 17-year-old girl suffering from postconcussion symptoms, which prevented her from full participation in school for 2 months after the injury. The patient’s symptoms greatly improved with the application of osteopathic manipulative treatment (OMT).
Treatment focused on balancing and restoring proper propriocep-tive input, addressing musculoskeletal restrictions, and improving circulatory and lymphatic flow. Posttreatment, the patient was able to return to full activities at school. This case demonstrates the positive effect of integrating OMT into a case of postconcussion syndrome.
Case report
History of Present IllnessA 17-year-old girl presented with complaints of persistent head-aches that occurred postconcussion that occurred 2 months prior to her initial office visit. She collided heads with another player during a soccer game, hitting the right posterolateral aspect of her head. She then fell, hitting the back of her head on the ground. She stated that her head whipped backwards when she hit the ground. She did not lose consciousness. She was taken to the emergency room immediately. X-rays were performed of the cervical spine and lower skull, and they were negative for fracture.
The next day, the patient attempted to return to school but felt sluggish and dizzy and was unable to complete the school day. She was then sent to a neurologist for further evaluation and was diag-nosed with postconcussion syndrome. She subsequently underwent an electroencephalogram and magnetic resonance imaging, which were both negative. She admitted to suffering from a concus-sion while playing soccer 2 years prior where she reported to have blacked out momentarily but was fine within the week.
The patient was referred for osteopathic manipulative medicine and was seen 2 months after her initial injury. On the day of the initial visit, she reported having headaches, neck pain, difficulty concen-trating, photosensitivity, and easy fatigability. Prior to the incident, she did not suffer from headaches. She stated that the headaches were right-sided and started in the posterior aspect of her head and extended to above her right eye. The headaches were constant and waxed and waned in severity. She rated the pain as a 5/10. Dizzi-ness was present initially, but she reported that she no longer had dizziness. There had not been any difficulty falling asleep, but she admitted to increased fatigue. Recently, she fell asleep at 2 p.m. and then did not wake up until the following day. She admitted to increased stress at school. As a high school senior, she was taking 3 Advanced Placement classes and was in the middle of applying
From the New York Institute of Technology College of Osteopathic Medicine in Old Westbury.
Disclosures: none reported.
Correspondence address:Sheldon C. Yao, DO, FAAODepartment chair and associate professorDepartment of Osteopathic Manipulative MedicineNew York Institute of Technology College of
Osteopathic MedicineNorthern Boulevard, PO Box 8000Old Westbury, NY [email protected]
Submitted for publication March 7, 2019; final revision received October 9, 2019; manuscript accepted for approval October 15, 2019.
Dr. Yao prepared this manuscript as one of the requirements to earn fellowship in the American Academy of Osteopathy. The Committee on Fellowship in the AAO provided peer reviewing for this article, and it was edited to conform to the AAOJ’s style guidelines.
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The AAO Journal • Vol. 29, No. 4 • December 2019 Page 25
for college. Due to the concussion, she had not been able to study or take any test, and she had not been able to complete her college essays and applications.
HistoryThe patient was previously diagnosed with exercise-induced asthma, and she took albuterol (90 mcg aerosol) every 6 hours as needed and mometasone-formoterol (5-100 mcg aerosol) twice a day. History was negative for surgeries.
The patients’ parents and both sets of grandparents were alive with no significant medical conditions, and her 15-year-old sister had no diagnosed medical conditions. A first cousin was diagnosed with seizure disorder since puberty.
A senior in high school, the patient denied tobacco, alcohol, or any other recreational drug use. She denied any medical or environ-mental allergies.
Review of Systems The patient denied any fever, chills, or weight loss; positive for fatigue since the concussion; negative for chest pain, shortness of breath; negative for nausea or vomiting; positive for neck pain and headache.
Physical Examination Upon examination, the patient was awake, alert, and oriented to person, place, and time. She demonstrated sensitivity to bright light, but she had a pleasant affect. Her blood pressure was 88/56 mm Hg, heart rate was 70 beats per minutes, oxygen saturation was 98%, weight was 111.4 lbs, height was 63 inches, and body mass index was 19.73.
Physical examination revealed a 17-year-old girl without acute distress. She had pain sensitivity when directed to look to the left only. Pupils were 4 mm bilaterally and reactive to light and accom-modation. She had decreased range of motion rotating her neck to the left due to pain. She was poised and spoke clearly with fluent speech, but she stopped at times to think of a word or an idea. No cranial nerve abnormalities were noted. She had 5/5 motor strength, and sensory and reflex test were normal in her extremities. She had bilateral down-going plantar reflexes. She had no cerebel-lar signs with no evidence of dysmetria or dysdiadochokinesia. Her gait was normal based with good arm swing. Her heart, lung, and abdominal examination were negative for any additional findings.
An osteopathic structural examination revealed a left lateral cranial strain pattern; bilateral occipitomastoid (OM) suture compression; bilateral condylar compression (right greater than left); bilateral
suboccipital muscle spasms; occipitoatlantal flexed, sidebent left, rotated right; C2 flexed, sidebent and rotated right; C3 extended, sidebent and rotated right with tenderness to palpation; C6 flexed, sidebent and rotated left; thoracic outlet restriction; T1 flexed, side-bent and rotated right; left rib 1 inhalation dysfunction; bilateral trapezius spasms; left scalene spasm; T5 flexed, sidebent and rotated right; T12-L1 flexed, sidebent and rotated right; L5 extended, side-bent and rotated left; lumbosacral compression; left unilateral sacral flexion; left innominate superior shear; bilateral sacroiliac compres-sion; and paravertebral muscle spasms in bilateral erector spine and cervical regions.
AssessmentThe patient had postconcussive syndrome and significant somatic dysfunctions of the head, cervical, thoracic, ribs, and sacral regions.
TreatmentOsteopathic manipulative treatment was applied to address the noted somatic dysfunctions. Occipitoatlantal (OA) decompression, balanced membranous tension, cranial base spread, parietal lift, and venous sinus drainage were applied to the cranium.
Myofascial release (MFR); facilitated positional release (FPR); and high-velocity, low-amplitude (HVLA) techniques were applied to the cervical and thoracic spine. Still technique and thoracic outlet release were applied to treat the inhaled rib dysfunction.
Balanced ligamentous tension (BLT) was applied to the spinal junctions and the sacroiliac regions. Doming of the diaphragm was applied to facilitate abdominal diaphragm excursion. Muscle hyper-tonicity of the neck and upper thoracic cage were treated using MFR, FPR, and muscle energy technique (MET). Sacral and pelvic dysfunctions were treated with FPR, MET, and BLT.
Fulford’s dural release technique was applied at the end of the treat-ment.
Response to TreatmentAfter the significant somatic dysfunctions were treated with OMT, the patient’s headache was improved but still present, having improved from a 5/10 pain to a 2/10 pain. Fulford’s dural release technique, engaging the oculocervical reflex, was applied at the end of the treatment, and the patient reported that her headache symp-toms were completely alleviated. The patient was overwhelmed and cried since it was the first time that she actually felt headache-free since the injury.
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The patient was seen subsequently for 4 additional visits every 2 weeks. The headache did return a couple of days after the first visit but not as severely and was no longer constant. After the 4 sub-sequent OMM visits, her symptoms improved to the point that she was able to fully return to school and resume her normal daily activities.
DiscussionA concussion, or mild traumatic brain injury (ie, mTBI), is a com-plex pathophysiologic process caused by traumatic biomechanical forces to the head.1 Mild TBI can cause physical, cognitive, visual, emotional, and sleep-related disturbances. Signs and symptoms are diverse and include headache, dizziness, gait disturbance, nausea, vomiting, photophobia, trouble focusing, and fatigue. Postconcus-sion syndrome (PCS) occurs in approximately 15% of patients who suffered from mTBI and do not recover after three months.2 Based on a 2016 literature review, the prevalence of nonspecific chronic headache after head injury in children was 39%, and prevalence of chronic posttraumatic headache, as defined by the International Classification of Headache Disorders (2004), was 7.6% (95% CI: 5.9–9.7).3
There are different theories for the pathogenesis of PCS. Forces from stretching or shearing to nerves and axons may be associated or followed by metabolic cerebral disturbances and alteration in the normal hemodynamic and cerebral blood flow. Abnormal release of excitatory neurotransmitters and other neuroinflammatory peptides may cause and perpetuate chronic headaches.4 Imaging studies have shown that patients with mild head injury have more frequent and more extensive areas of abnormality as measured by functional imaging scans, confirming possible diffuse structural and/or physi-ologic derangement in mild TBI.5-8
Overall treatment options for PCS are limited. Amitriptyline has been used for posttraumatic tension-type headaches as well as for the nonspecific symptoms such as irritability, dizziness, depression, fatigue, and insomnia.9 Symptomatic treatment is usually sug-gested, which may include migraine medications, analgesics, psy-chological counseling, and/or psychotropic medications as dictated by patient complaints and disability.10 Published studies investi-gating the effects of osteopathic manipulative medicine (OMM) on PCS are limited. Two published case studies have shown con-cussion symptoms improved following OMM.11,12 A case series showed that CranioSacral Therapy (CST), visceral manipulation, and neural manipulation modalities for treating 11 patients with postconcussion syndrome resulted in statistically greater improve-ments in pain intensity, range of motion, memory, cognition, and sleep in concussed patients.13 A retrospective review of 26 charts of
postconcussion patients demonstrated that OMT was effective at immediately reducing overall symptoms related to concussion listed on the Standardized Concussion Assessment Tool (SCAT2) follow-ing treatment.14
Due to the diversity in concussion symptoms and presentation, there has been further classification of concussion subtypes to physiological, vestibulo-ocular, and cervicogenic postconcussion disorders.15 Utilizing these classifications, this paper will further investigate how osteopathic manipulation was applied and how treatment potentially affects these subsets of postconcussion symp-toms in this case presentation.
OMM and PCSPhysiological PCS is characterized by concussion symptoms from alterations in cerebral blood flow secondary to autonomic nervous system dysfunction. Recent findings have established a glymphatic system in the brain and its potential to contribute to neurodegener-ative disorders if impaired.16 One study has shown that cerebrospi-nal fluid–mediated removal of tau via glymphatic routes is crucial for limiting secondary neuronal damage following traumatic brain injury.17 Utilizing a circulatory-lymphatic approach in this case, somatic dysfunctions were addressed that could potentially limit circulatory and lymphatic drainage of the head and neck.18 This includes key spinal junctions and diaphragms such as the tentorium cerebelli, thoracic inlet, and abdominal and pelvic diaphragms. Treatment included thoracic outlet release, OA decompression, OM suture spread, balanced membranous tension, and cranial lifts. Venous sinus drainage techniques were also utilized to help pro-mote circulation and venous flow.19
Dysfunction in the autonomic system has been found to be a major factor in the symptomatology in TBI. The central autonomic ner-vous system is a complex network involving the cerebral cortex (the insular and medial prefrontal regions), amygdala, stria terminalis, hypothalamus, and brainstem centers (periaqueductal gray, para-brachial pons, nucleus of the tractus solitarius, and intermediate reticular zone of the medulla).20 Mild TBI can affect these auto-nomic centers through catecholamine release and inflammatory response after the injury.21 The presence of autonomic dysfunction is associated with increased morbidity and mortality in moderate and severe TBI.22
A noninvasive way to measure postconcussion dysautonomia is to measure heart rate variability (HRV). Studies have shown HRV to be altered postconcussion and even after return-to-play protocol has been approved.23,24 Rib-raising and treatment of the cranial base and upper cervical region was applied with the goals to balance
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autonomic function. Prior studies have demonstrated the positive effects of rib-raising and suboccipital release on autonomic markers such as salivary IgA and heart rate variability.25,26 Osteopathic treat-ments focusing on improving lymphatic and circulatory flow and balancing autonomic function are significant goals when addressing PCS.
Cervicogenic PCS is characterized by muscle trauma and inflam-mation secondary to cervical spine somatosensory system. Patients with neck pain have demonstrated altered proprioception, balance disturbances, altered eye movement control, and altered postural activity of cervical muscles.27 These disturbances to postural control have been attributed to altered input from cervical afferents. There is an abundance of receptors in the cervical muscles, and there are multiple cervical and central reflex connections to the vestibular, visual, and postural control systems. In particular, the deep por-tions of the suboccipital muscles have the highest cervical receptor density and are known to have a specific role in these reflex and central connections.27 Utilizing the biomechanical model, treat-ment was directed to the cervical spine, upper thoracic spine and muscles, rib cage, and sacrum to address any somatic dysfunction that could contribute to the cervical muscle somatosensory sys-tem.18
Vestibulo-ocular PCS is characterized by symptoms secondary to dysfunction of the vestibular and oculomotor systems. In this case, the subject had significant improvement after application of the Fulford dural release technique. In this technique, the patient is asked to look to a direction (right or left) and the physician pas-sively brings the head in the same direction till the restrictive end-point of cervical/head rotation. Upon reaching the end range of motion, the patient then looks to the opposite direction and the head is passively turned to the same direction within the end-point of rotation. This is performed several times until fluid motion is accomplished in both directions. The patient is then instructed again to look in one direction. However, the head is now turned to the opposite direction. This is repeated again with the patient look-ing in the opposite direction to the passive head and neck rotation until there is improvement in fluid passive motion to both sides. (See Figure 1)
A proposed mechanism of action of the Fulford dural release tech-nique is that the patient’s eye gaze and cervical movement directly engages the cervico-ocular reflex (COR). The COR is a spontane-ous eye response that is elicited during neck rotation. The purpose of this reflex, along with the vestibulo-ocular reflex and the optoki-netic reflex, is to stabilize visual images during body movement.28 The stimulus is recognized via the proprioceptors of the cervical muscles and facet joints.29 Published studies indicate that the COR
is enhanced in people with neck pain due to the increased and modified afferent signals received by cervical muscles.30 Application of the Fulford dural release technique can potentially reset cervical muscle proprioception and decrease any somatic dysfunction in the cervical region. Movements of the eyes engage the smaller suboc-cipital muscles that can contribute to PCS. As was previously men-tioned, the suboccipital muscles carry significant afferent signals and proprioception.
The Fulford dural technique can potentially target these muscles more specifically with the engagement of the eye gaze. This treat-ment also can potentially treat cranial dural tension as Fulford proposed via the myodural bridge which extends from the anterior fascia of the rectus capitis posterior major and minor and obliquus capitis inferior muscles attaching on the cervical dura mater. The myodural bridge communicates with the posterior aspect of the cervical dura mater between the C1 and C2 vertebrae.31 Lastly, the extraocular muscles attach to the annulus of Zinn of the sphe-noid.32 Alternating pull of the extraocular muscles on the sphenoid could biomechanically affect the sphenoid and the cranial base and any potential strain patterns affecting the region.
Figure 1. Fulford dural release. Step 1 (a): Head movement in the same direction as the eye gaze. Step 2 (b): Head movement in the opposite direction as the eye gaze.
a.
b.
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ConclusionThe effect of osteopathic manipulative treatment on PCS can be profound as illustrated in this case. The patient was able to return to school and complete her coursework, and she was accepted into her college of choice. Further studies and research need to be con-ducted to more fully examine the mechanism and effects of OMM in the management and treatment of PCS. Fulford’s techniques have not typically been included in osteopathic medical school cur-ricula, but they can be safe and effective treatment techniques when applied appropriately. Further studies can determine the efficacy of the technique for PCS and other head and neck conditions.
References:1. McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement
on concussion in sport—the 5th international conference on con-cussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838-847.
2. Alexander MP. Mild traumatic brain injury: pathophysiology, natural history, and clinical management. Neurology. 1995;45(7):1253-1260.
3. Shaw L, Morozova M, Abu-Arafeh I. Chronic post-traumatic head-ache in children and adolescents: systematic review of prevalence and headache features. Pain Manag. 2018;8(1):57-64.
4. Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cer-vicogenic post-concussion disorders: an evidence-based classification system with directions for treatment. Brain Inj. 2015;29(2):238-248.
5. Kant R, Smith-Seemiller L, Isaac G, Duffy J. Tc-HMPAO SPECT in persistent post-concussion syndrome after mild head injury: compari-son with MRI/CT. Brain Inj. 1997;11(2):115-124.
6. Chen SH, Kareken DA, Fastenau PS, Trexler LE, Hutchins GD. A study of persistent post-concussion symptoms in mild head trauma using positron emission tomography. J Neurol Neurosurg Psychiatry. 2003;74(3):326-332.
7. Metting Z, Rödiger LA, Stewart RE, Oudkerk M, De Keyser J, van der Naalt J. Perfusion computed tomography in the acute phase of mild head injury: regional dysfunction and prognostic value. Ann Neurol. 2009;66(6):809-816.
8. Zhou Y, Kierans A, Kenul D, et al. Mild traumatic brain injury: lon-gitudinal regional brain volume changes. Radiology. 2013;267(3):880-890.
9. Tyler GS, McNeely HE, Dick ML. Treatment of post-traumatic head-ache with amitriptyline. Headache. 1980;20(4):213-216.
10. Baandrup L, Jensen R. Chronic post-traumatic headache—a clinical analysis in relation to the International Headache Classification 2nd Edition. Cephalalgia. 2005;25(2):132-138.
11. Castillo I, Wolf K, Rakowsky A. Concussions and osteopathic manip-ulative treatment: an adolescent case presentation. J Am Osteopath Assoc. 2016;116(3):178-181. doi:10.7556/jaoa.2016.034
12. Guernsey DT 3rd, Leder A, Yao S. Resolution of concussion symp-toms after osteopathic manipulative treatment: a case report. J Am Osteopath Assoc. 2016;116(3):e13–e17. doi:10.7556/jaoa.2016.036
13. Wetzler G, Roland M, Fryer-Dietz S, Dettmann-Ahern D. Cranio-Sacral Therapy and visceral manipulation: a new treatment interven-tion for concussion recovery. Med Acupunct. 2017;29(4):239-248. doi:10.1089/acu.2017.1222
14. Chappell C, Dodge E, Dogbey GY. Assessing the immediate effect of osteopathic manipulation on sports related concussion symptoms. Osteopath Fam Physician. 2015;7(4):30-34.
15. Esterov D, Greenwald BD. Autonomic dysfunction after mild trau-matic brain injury. Brain Sci. 2017;7(8):100. doi:10.3390/brain-sci7080100
16. Hitscherich K, Smith K, Cuoco JA, et al. The glymphatic-lymphatic continuum: opportunities for osteopathic manipulative medicine. J Am Osteopath Assoc. 2016;116(3):170-177.
17. Jessen NA, Munk ASF, Lundgaard I, Nedergaard M. The glymphatic system—a beginner’s guide. Neurochem Res. 2015;40(12):2583-2599. doi:10.1007/s11064-015-1581-6
18. Kuchera ML. Lymphatics approach. In: Chila AG, executive ed. Foundations of Osteopathic Medicine. 3rd ed. Philadelphia, PA: Wolt-ers Kluwer Health/Lippincott Williams & Wilkins. 2011:796-797.
19. Nicholas AS, Nicholas EA. Atlas of Osteopathic Techniques. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2016:584.
20. McCorry LK. Physiology of the autonomic nervous system. Am J Pharm Educ. 2007;71(4):78.
21. Lim HB, Smith M. Systemic complications after head injury: a clini-cal review. Anaesthesia. 2007;62(5):474-482.
22. Baguley IJ, Slewa-Younan S, Heriseanu RE, Nott MT, Mudaliar Y, Nayyar V. The incidence of dysautonomia and its relationship with autonomic arousal following traumatic brain injury. Brain Inj. 2007;21(11):1175-1181.
23. Dobson JL, Yarbrough MB, Perez J, Evans K, Buckley T. Sport-related concussion induces transient cardiovascular auto-nomic dysfunction. Am J Physiol Regul Integr Comp Physiol. 2017;312(4):R575-R584.
24. Senthinathan A, Mainwaring LM, Hutchison M. Heart rate vari-ability of athletes across concussion recovery milestones: a preliminary study. Clin J Sport Med. 2017;27(3):288-295.
25. Yao S, Hassani J, Gagne M, George G, Gilliar W. Osteopathic manipulative treatment as a useful adjunctive tool for pneumonia. J Vis Exp. 2014;6(87). doi:10.3791/50687
26. Giles PD, Hensel KL, Pacchia CF, Smith ML. Suboccipital decom-pression enhances heart rate variability indices of cardiac control in healthy subjects. J Altern Complement Med. 2013;19(2):92-96. doi:10.1089/acm.2011.0031
27. Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervi-cal joint position sense: the effect of two exercise regimes. J Orthop Res. 2007;25(3):404-12.
28. Kelders WPA, Kleinrensink GJ, van der Geest JN, Feenstra L, de Zeeuw CI, Frens MA. Compensatory increase of the cervico-ocular reflex with age in healthy humans. J Physiol. 2003;553(Pt 1):311-317.
29. Kelders WP, Kleinrensink GJ, van der Geest JN, et al. The cervico-ocular reflex is increased in whiplash injury patients. J Neurotrauma. 2005;22(1):133-137.
30. de Vries J, Ischebeck BK, Voogt LP, et al. Cervico-ocular reflex is increased in people with nonspecific neck pain. Phys Ther. 2016;96(8):1190-1195. doi:10.2522/ptj.20150211
31. Enix DE, Scali F, Pontell ME. The cervical myodural bridge, a review of literature and clinical implications. J Can Chiropr Assoc. 2014;58(2):184-192.
32. Qi Y, Yu G, Wu Q, Cao WH, Fan YW. Accessory extraocular muscle-a case report and review [abstract only]. Zhonghua Yan Ke Za Zhi. 2011;47(12):1111-1116. n
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Page 30 The AAO Journal • Vol. 29, No. 4 • December 2019
The Cranial Rhythmic Impulse as a Measure in Patients With Bipolar Disorder: A Case ReportTeodor Huzij, DO, FACN
CASE REPORT
AbstractBipolar disorder is a severe psychiatric illness associated with pro-found impairment in social and occupational functioning. Several conditions, including psychiatric disorders, have been associated with a decreased cranial rhythmic impulse (CRI). In this case report, a 20-year-old man with a recent manic episode is found to have a normal cranial rhythmic impulse, which is found to be decreased following resolution of the manic episode. This case illus-trates the potential that a relative CRI increase in bipolar disorder may be a sign of an active manic state.
IntroductionThe prevalence of bipolar disorder in the United States is 0.6%, with a male-to-female ratio of 1:1.1 and a mean age of onset of 18 years old.1 Pharmacologic treatments and psychosocial interven-tions are the mainstay.2 There is a paucity of articles that discuss assessment and possible treatment options for psychiatric illnesses such as bipolar disorder with osteopathic manipulative treatment (OMT).3 The cranial rhythmic impulse (CRI) is reported to be decreased in acute psychiatric conditions compared to the normal CRI within the populace.3 The current case report describes a young man with bipolar disorder who is found to have a notable relative increase in his cranial rhythmic impulse during an acute manic state compared to his euthymic state.
Case ReportA 20-year-old man was hospitalized for acute euphoric mood that lasted 7 days, associated with impulsive spending, grandiosity, rac-ing thoughts, increased activities, decreased need for sleep, and increased talkativeness with paranoid delusions. He had met criteria for bipolar disorder 1, severe with psychotic features.1 Laboratory and diagnostic imaging studies completed during psychiatric hos-pitalization were unremarkable and included a urinalysis, complete metabolic panel, complete blood count, thyroid stimulating hor-mone level, rapid plasma reagin, folate level, Vitamin B12 level, drug screen and a CT of the head.
Upon discharge and initial evaluation in the clinic, the patient denied any other episodes of hypomania or mania and no signifi-
cant episodes of depressive symptoms. He had no notable medical or family history. Social history was significant for marijuana use; last use was 3 months prior to his manic episode, and no other tobacco, alcohol, or illicit substance use was reported. Medications at discharge included ziprasidone, 40 mg twice a day; divalproex ER, 500 mg twice a day; and benztropine, 1 mg twice a day.
Physical examinationOsteopathic structural examination findings included a CRI of 12 cycles per minute; C6 ERLSL; T6 FRRSR; L1-3 SRRL; positive left standing flexion test; and left posteriorly rotated innominate.
Mental status examination was notable for the patient being alert and oriented, no mannerisms or motor hyperactivity, mood reported as “rested,” a full affect range, speech non-pressured, no suicidal or homicidal ideation, no hallucinations or delusions, as well as fair insight and judgment.
From the Trinity Institute in Colorado Springs, Colorado, and the Rocky Vista University College of Osteopathic Medicine in Parker, Colorado.
Disclosures: none reported.
Correspondence address: Teodor Huzij, DO, FACN 14960 Woodcarver Rd., Suite 101 Colorado Springs, CO 80921 [email protected]
Manuscript submitted for publication January 22, 2019; final revision received August 26, 2019; accepted for publication August 26, 2019.
Keywords: psychiatry, osteopathic medicine, osteopathic manipulative treatment, manipulation, osteopathic, bipolar disorder
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TreatmentThe patient was continued on his current medication regimen, and OMT was used to address somatic dysfunction. At 1 week follow-up, the subject presented with continued mood stability, denying any manic symptoms, but he reported severe daytime somnolence from the medications. To address the reported side effect, ziprasi-done was reduced to 40 mg at bedtime.
Within 4 days the patient experienced a relapse manic episode and was psychiatrically hospitalized again. Ziprasidone was replaced with risperidone 2 mg twice a day while the divalproex and benz-tropine were continued. Upon follow-up, the patient divulged that, on further reflection, he’d concluded his mania was not controlled on his initial visit, nor at the time of his ziprasidone dose reduc-tion. His repeat osteopathic structural examination was notable for a CRI of 8 cycles per minute.
DiscussionThe normal CRI biphasic cycle of motion is reported to have a rate of 10 to 14 cycles per minute.4,5 Internal and external factors have been found to alter the CRI.3,4,5 Individuals receiving first genera-tion antipsychotic medications were noted to have no significant changes in CRI.6 However, anecdotally, many osteopathic physi-cians, including this author, have encountered a reduced CRI in patients who are taking psychopharmacologic medications, par-ticularly antidepressants, mood stabilizers, and antipsychotics. To date, to the best of this author’s knowledge, no one has reported a relative increase in CRI in association with a manic state in an indi-vidual with a psychiatric illness such as bipolar disorder.
An increase in the CRI has been associated with vigorous physical exercise, fevers, and cranial OMT. A decrease in the CRI has been reported with many disease states including physical and psycho-logical stress, chronic fatigue, infections, depression and other psy-chiatric conditions, and chronic poisoning.3,4,5 In addition, the rate and amplitude of the primary respiratory mechanism (PRM), as manifested by the CRI, is a diagnostic and prognostic indicator of body unit compromise and response to treatment. A decreased rate and low amplitude suggest a compromised body unit.5
The PRM is manifested palpably as the CRI and was first described by the clinical team of John Woods, DO, and Rachel Woods, DO.3 Neuroimaging findings in patients with bipolar disorder have included abnormalities of prefrontal-striatal-thalamic circuits, amygdala and midline cerebellum. Functional imaging findings include increased activity of the anterior cingulate gyrus, striatum, thalamus, and amygdala.7
First-line pharmacologic treatment for those with an acute manic episode includes mood stabilizers (such as lithium, valproic, acid or carbamazepine) or second-generation antipsychotics (such as olan-zapine, quetiapine, and ziprasidone) and often psychiatric hospi-talization. Medication doses can be rapidly titrated on an inpatient setting and polypharmacy commonly occurs.2 Despite medication compliance, it can be hard for those with bipolar disorder to recog-nize they are in a manic state.
The patient here has been dependent on family and friends for identification of manic states. During his initial visit, this safeguard was not successful as the patient reports in hindsight he was down-playing his mania. His physical exam at that time did not reveal a decreased CRI. Fewer factors are associated with an increased CRI.7 There have been no literature reports of any psychiatric condition being associated with a normal or increased CRI.
This case report found a normal CRI in a patient reporting and presumed recovered from an acute manic episode, later further exacerbated by lowering medication. An active manic episode can fully manifest once a medication dose is lowered. This relapse is at increased risk if the initial manic episode has not fully resolved.8
Osteopathic medicine approaches each patient through the osteo-pathic philosophy.9 Osteopathic palpatory skills may have a role in assessing psychiatric patients with bipolar disorder. Whether a nor-mal CRI found in a bipolar subject in acute recovery from a manic episode can help to discern and guide management decisions may need to be further explored.
ConclusionThis case illustrates the potential that a relative CRI increase in bipolar disorder may be a sign of an active manic state. Osteo-pathic palpation of the CRI may provide an additional measure to monitor and guide treatment in acute manic episodes. Additional research is needed to determine baseline CRI in specific psychiatric disorders, acute changes during subtherapeutic states and the use of CRI as a potential method of monitoring disease course.
Acknowledgements Sincere gratitude to Brian Peppers, DO, PhD; Dana Anglund, DO; and Adrienne Kania, DO, FAAO, for reviewing drafts of this manuscript and providing valuable feedback.
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References1. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Asso-ciation; 2013:123-131.
2. Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Soci-ety for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disorders. 2013;15(1):1-44. Published online December 12, 2012. doi:10.1111/bdi.12025
3. Woods JM, Woods RH. A physical finding relating to psychiatric disorders. J Amer Osteopath Assoc. 1961;60: 988-993.
4. Nelson KE, Sergueef N, Lipinski CM, Chapman AR, Glonek T. Cra-nial rhythmic impulse related to the Traube-Hering-Mayer oscillation: comparing laser-Doppler flowmetry and palpation. J Amer Osteopath Assoc. 2001;101(3):163-173.
5. King HH. Osteopathy in the cranial field. In: Chila AG, executive ed. Foundations of Osteopathic Medicine. 3rd ed. Baltimore, MD: Lippin-cott Williams & Wilkins; 2011:736,741.
6. King HH, ed. The Collected Papers of Viola M. Frymann, DO: Legacy of Osteopathy to Children. Indianapolis, IN: American Academy of Osteopathy; 1998:149.
7. Strakowski SM, DelBello MP, Adler CM. The functional neuro-anatomy of bipolar disorder: a review of neuroimaging findings. Mol Psychiatry. 2005;10:105-116.
8. Grunze H, Vieta E, Goodwin GM, et al. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2009 on the treat-ment of acute mania. World J Biol Psychiatry. 2009;10(2):85-116. doi:10.1080/15622970902823202
9. Giusti R, executive ed. Glossary of Osteopathic Terminology. 3rd ed. Chevy Chase, MD: American Association of Colleges of Osteopathic Medicine; 2017:40. n
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The AAO Journal • Vol. 29, No. 4 • December 2019 Page 33
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Index by Author
Akers, Beatrice, DOImpact of predoctoral teaching fellows on osteopathic medical students: a near-peer teaching program evaluation. AAOJ. 2019;29(4):9-16.
Blumer, Janice Upton, DO, FAAOView from the Pyramids: osteopathic identity. AAOJ. 2019;29(1):5,8.
View from the Pyramids. AAOJ. 2019;29(2):5.
View from the Pyramids: kale for days. AAOJ. 2019;29(3):5.
View from the Pyramids: where have all the mentors gone? AAOJ. 2019;29(4):5-6.
Cabrera, Kelsie L., DOOsteopathic structural findings in women during menstruation. AAOJ. 2019;29(1):7-13.
Clegg, James M., OMS IVPatient education of osteopathic manipulative medicine as a gateway to treatment: a pilot study. AAOJ. 2019;29(3):7-11.
Cox, Joshua, DOOsteopathic structural findings in women during menstruation. AAOJ. 2019;29(1):7-13.
Darwish, Adrianna M., DOOsteopathic structural findings in women during menstruation. AAOJ. 2019;29(1):7-13.
Davis, Glenn, MSImpact of predoctoral teaching fellows on osteopathic medical students: a near-peer teaching program evaluation. AAOJ. 2019;29(4):9-16.
Fleming, Regina K., DOPersistent postoperative swelling following arthroscopic meniscectomy: a case report. AAOJ. 2019;29(2):24-26.
Osteopathic approach for lateral knee pain caused by iliotibial band friction syndrome: a case report. AAOJ. 2019;29(3):17-20.
Fong, Kristyna K., OMS IVRescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
Goering, Edward K., DOCounterstrain as a diagnostic and treatment tool for rectus femoris origin injuries: a case report. AAOJ. 2019;29(2):19-23.
Hoover, H. V., DOHow and why I apply the osteopathic principles in practice. AAOJ. 2019;29(1):19-23.
Huzij, Teodor, DO, FACNThe cranial rhythmic impulse as a measure in patients with bipolar disorder: a case report. AAOJ. 2019;29(4):31-33.
Kanze, David M., DO, FAAOThe combined shoulder technique: a novel approach in the treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
An osteopathic approach to uterine-induced low back pain: a case report. AAOJ. 2019;29(3):23-26.
An osteopathic approach to traumatically induced mechanical dyspnea: a case report. AAOJ. 2019;29(4):19-23.
Keys, Jordan, DO, MSImpact of predoctoral teaching fellows on osteopathic medical students: a near-peer teaching program evaluation. AAOJ. 2019;29(4):9-16.
Kostanjevec, Juilett, DOOsteopathic approach for lateral knee pain caused by iliotibial band
friction syndrome: a case report. AAOJ. 2019;29(3):17-20.
Lewis, Drew D., DO, FAAO, FNAOME, FAOCPMR, FAAPMRRestoring full squat range of motion by applying OMT to superior innominate shear: a case report. AAOJ. 2019;29(2):7-12.
Student perceived value of reading assignments during mandatory clerkship-years OMM course. AAOJ. 2019;29(3):13-16.
Lund, Gregg, DO, MS, FAAPImpact of predoctoral teaching fellows on osteopathic medical students: a near-peer teaching program evaluation. AAOJ. 2019;29(4):9-16.
Lurz, Kelly L., DOOsteopathic structural findings in women during menstruation. AAOJ. 2019;29(1):7-13.
Majetich, Michael W., DOPatient education of osteopathic manipulative medicine as a gateway to treatment: a pilot study. AAOJ. 2019;29(3):7-11.
Majetich, Simone A., DOPatient education of osteopathic manipulative medicine as a gateway to treatment: a pilot study. AAOJ. 2019;29(3):7-11.
McClain, Elizabeth, DOOsteopathic structural findings in women during menstruation. AAOJ. 2019;29(1):7-13.
McClain, Rance L., DOOsteopathic structural findings in women during menstruation. AAOJ. 2019;29(1):7-13.
The AAO Journal’s 2019 Index
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Noblitt, Tiffany R., OMS VPersistent postoperative swelling following arthroscopic meniscectomy: a case report. AAOJ. 2019;29(2):24-26.
Pickos, Jonathan, OMS VRestoring full squat range of motion by applying OMT to superior innominate shear: a case report. AAOJ. 2019;29(2):7-12.
Pickos, Jonathan James, DOStudent perceived value of reading assignments during mandatory clerkship-years OMM course. AAOJ. 2019;29(3):13-16.
Pierce-Talsma, Stacey L., DO, MS MEdL, FNAOMEImpact of predoctoral teaching fellows on osteopathic medical students: a near-peer teaching program evaluation. AAOJ. 2019;29(4):9-16.
Qiu, Lisa, OMS IICounterstrain as a diagnostic and treatment tool for rectus femoris origin injuries: a case report. AAOJ. 2019;29(2):19-23.
Ratay, Susan M., DOPatient education of osteopathic manipulative medicine as a gateway to treatment: a pilot study. AAOJ. 2019;29(3):7-11.
Rummel, Tobin D., DORescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
Segars, Larry, PharmDOsteopathic structural findings in women during menstruation. AAOJ. 2019;29(1):7-13.
Yao, Sheldon C., DO, FAAOIntegrating osteopathic evaluation and treatment in a case report of acute chest pain. AAOJ. 2019;29(2):27-30.
Applying osteopathic manipulative treatment to postconcussion syndrome: a case report. AAOJ. 2019;29(4):25-29.
Index by SubjectACGMEBlumer JU. View from the Pyramids: osteopathic identity. AAOJ. 2019;29(1):5,8.
acupunctureKanze DM. An osteopathic approach to uterine-induced low back pain: a case report. AAOJ. 2019;29(3):23-26.
arthroscopic meniscectomyNoblitt TR, Fleming RK. Persistent postoperative swelling following arthroscopic meniscectomy: a case report. AAOJ. 2019;29(2):24-26.
balanced ligamentous tensionFong KK, Rummel TD. Rescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
Yao SC. Integrating osteopathic evaluation and treatment in a case report of acute chest pain. AAOJ. 2019;29(2):27-30.
Yao SC. Applying osteopathic manipulative treatment to postconcussion syndrome: a case report. AAOJ. 2019;29(4):25-29.
baseball pitcherKanze DM. The combined shoulder technique: a novel approach in the
treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
bipolar disorderHuzij T. The cranial rhythmic impulse as a measure in patients with bipolar disorder: a case report. AAOJ. 2019;29(4):31-33.
case reportFong KK, Rummel TD. Rescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
Goering EK, Qiu L. Counterstrain as a diagnostic and treatment tool for rectus femoris origin injuries: a case report. AAOJ. 2019;29(2):19-23.
Huzij T. The cranial rhythmic impulse as a measure in patients with bipolar disorder: a case report. AAOJ. 2019;29(4):31-33.
Kanze DM. The combined shoulder technique: a novel approach in the treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
Kanze DM. An osteopathic approach to uterine-induced low back pain: a case report. AAOJ. 2019;29(3):23-26.
Kanze DM. An osteopathic approach to traumatically induced mechanical
dyspnea: a case report. AAOJ. 2019;29(4):19-23.
Kostanjevec J, Flemming RK. Osteopathic approach for lateral knee pain caused by iliotibial band friction syndrome: a case report. AAOJ. 2019;29(3):17-20.
Lewis DD, Pickos J. Restoring full squat range of motion by applying OMT to superior innominate shear: a case report. AAOJ. 2019;29(2):7-12.
Noblitt TR, Fleming RK. Persistent postoperative swelling following arthroscopic meniscectomy: a case report. AAOJ. 2019;29(2):24-26.
Yao SC. Integrating osteopathic evaluation and treatment in a case report of acute chest pain. AAOJ. 2019;29(2):27-30.
Yao SC. Applying osteopathic manipulative treatment to postconcussion syndrome: a case report. AAOJ. 2019;29(4):25-29.
Chapman’s pointsCabrera KL, Darwish AM, Lurz KL, McClain RL, McClain E, Cox J, Segars L. Osteopathic structural findings in women during menstruation. AAOJ. 2019;29(1):7-13.
(continued from page 35)
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Page 36 The AAO Journal • Vol. 29, No. 4 • December 2019
chest painYao SC. Integrating osteopathic evaluation and treatment in a case report of acute chest pain. AAOJ. 2019;29(2):27-30.
cluster headacheFong KK, Rummel TD. Rescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
combined shoulder techniqueKanze DM. The combined shoulder technique: a novel approach in the treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
counterstrainGoering EK, Qiu L. Counterstrain as a diagnostic and treatment tool for rectus femoris origin injuries: a case report. AAOJ. 2019;29(2):19-23.
Kostanjevec J, Flemming RK. Osteopathic approach for lateral knee pain caused by iliotibial band friction syndrome: a case report. AAOJ. 2019;29(3):17-20.
Lewis DD, Pickos J. Restoring full squat range of motion by applying OMT to superior innominate shear: a case report. AAOJ. 2019;29(2):7-12.
Yao SC. Integrating osteopathic evaluation and treatment in a case report of acute chest pain. AAOJ. 2019;29(2):27-30.
cranial rhythmic impulseHuzij T. The cranial rhythmic impulse as a measure in patients with bipolar disorder: a case report. AAOJ. 2019;29(4):31-33.
dentistryFong KK, Rummel TD. Rescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
dural releaseYao SC. Applying osteopathic manipulative treatment to postconcussion syndrome: a case report. AAOJ. 2019;29(4):25-29.
dysmenorrheaCabrera KL, Darwish AM, Lurz KL, McClain RL, McClain E, Cox J, Segars L. Osteopathic structural findings in women during menstruation. AAOJ. 2019;29(1):7-13.
editorialBlumer JU. View from the Pyramids: osteopathic identity. AAOJ. 2019;29(1):5,8.
Blumer JU. View from the Pyramids. AAOJ. 2019;29(2):5.
Blumer JU. View from the Pyramids: kale for days. AAOJ. 2019;29(3):5.
Blumer JU. View from the Pyramids: where have all the mentors gone? AAOJ. 2019;29(4):5-6.
facilitated positional releaseYao SC. Integrating osteopathic evaluation and treatment in a case report of acute chest pain. AAOJ. 2019;29(2):27-30.
Yao SC. Applying osteopathic manipulative treatment to postconcussion syndrome: a case report. AAOJ. 2019;29(4):25-29.
five models of osteopathic careYao SC. Integrating osteopathic evaluation and treatment in a case report of acute chest pain. AAOJ. 2019;29(2):27-30.
From the archivesHoover HV. How and why I apply the osteopathic principles in practice. AAOJ. 2019;29(1):19-23.
functional technicHoover HV. How and why I apply the osteopathic principles in practice. AAOJ. 2019;29(1):19-23.
hamstring strainLewis DD, Pickos J. Restoring full squat range of motion by applying OMT to superior innominate shear: a case report. AAOJ. 2019;29(2):7-12.
high-velocity, low-amplitudeYao SC. Applying osteopathic manipulative treatment to
postconcussion syndrome: a case report. AAOJ. 2019;29(4):25-29.
hip painGoering EK, Qiu L. Counterstrain as a diagnostic and treatment tool for rectus femoris origin injuries: a case report. AAOJ. 2019;29(2):19-23.
historical perspectiveHoover HV. How and why I apply the osteopathic principles in practice. AAOJ. 2019;29(1):19-23.
iliotibial band friction syndromeKostanjevec J, Flemming RK. Osteopathic approach for lateral knee pain caused by iliotibial band friction syndrome: a case report. AAOJ. 2019;29(3):17-20.
inferior alveolar nerve contractureFong KK, Rummel TD. Rescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
intrauterine deviceKanze DM. An osteopathic approach to uterine-induced low back pain: a case report. AAOJ. 2019;29(3):23-26.
kinetic chainKanze DM. The combined shoulder technique: a novel approach in the treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
lateral knee painKostanjevec J, Flemming RK. Osteopathic approach for lateral knee pain caused by iliotibial band friction syndrome: a case report. AAOJ. 2019;29(3):17-20.
ligamentous articular strainKanze DM. The combined shoulder technique: a novel approach in the treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
Kanze DM. An osteopathic approach to uterine-induced low back pain: a case report. AAOJ. 2019;29(3):23-26.
Kanze DM. An osteopathic approach to traumatically induced mechanical
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The AAO Journal • Vol. 29, No. 4 • December 2019 Page 37
dyspnea: a case report. AAOJ. 2019;29(4):19-23.
low back painKanze DM. An osteopathic approach to uterine-induced low back pain: a case report. AAOJ. 2019;29(3):23-26.
mechanical dyspneaKanze DM. An osteopathic approach to traumatically induced mechanical dyspnea: a case report. AAOJ. 2019;29(4):19-23.
menstruationCabrera KL, Darwish AM, Lurz KL, McClain RL, McClain E, Cox J, Segars L. Osteopathic structural findings in women during menstruation. AAOJ. 2019;29(1):7-13.
muscle energy techniqueKanze DM. The combined shoulder technique: a novel approach in the treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
Kanze DM. An osteopathic approach to uterine-induced low back pain: a case report. AAOJ. 2019;29(3):23-26.
Kostanjevec J, Flemming RK. Osteopathic approach for lateral knee pain caused by iliotibial band friction syndrome: a case report. AAOJ. 2019;29(3):17-20.
Noblitt TR, Fleming RK. Persistent postoperative swelling following arthroscopic meniscectomy: a case report. AAOJ. 2019;29(2):24-26.
Yao SC. Applying osteopathic manipulative treatment to postconcussion syndrome: a case report. AAOJ. 2019;29(4):25-29.
Yao SC. Integrating osteopathic evaluation and treatment in a case report of acute chest pain. AAOJ. 2019;29(2):27-30.
myofascial pain syndromeFong KK, Rummel TD. Rescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
myofascial releaseKanze DM. The combined shoulder technique: a novel approach in the treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
Kostanjevec J, Flemming RK. Osteopathic approach for lateral knee pain caused by iliotibial band friction syndrome: a case report. AAOJ. 2019;29(3):17-20.
Noblitt TR, Fleming RK. Persistent postoperative swelling following arthroscopic meniscectomy: a case report. AAOJ. 2019;29(2):24-26.
Yao SC. Integrating osteopathic evaluation and treatment in a case report of acute chest pain. AAOJ. 2019;29(2):27-30.
Yao SC. Applying osteopathic manipulative treatment to postconcussion syndrome: a case report. AAOJ. 2019;29(4):25-29.
NSAIDKostanjevec J, Flemming RK. Osteopathic approach for lateral knee pain caused by iliotibial band friction syndrome: a case report. AAOJ. 2019;29(3):17-20.
original researchAkers B, Davis G, Keys J, Pierce-Talsma SL, Lund G. Impact of predoctoral teaching fellows on osteopathic medical students: a near-peer teaching program evaluation. AAOJ. 2019;29(4):9-16.
Cabrera KL, Darwish AM, Lurz KL, McClain RL, McClain E, Cox J, Segars L. Osteopathic structural findings in women during menstruation. AAOJ. 2019;29(1):7-13.
Lewis DD, Pickos JJ. Student perceived value of reading assignments during mandatory clerkship-years OMM course. AAOJ. 2019;29(3):13-16.
Majetich SA, Majetich MW, Clegg JM, Ratay SM. Patient education of osteopathic manipulative medicine as a gateway to treatment: a pilot study. AAOJ. 2019;29(3):7-11.
osteopathic cranial manipulative medicineKanze DM. An osteopathic approach to traumatically induced mechanical dyspnea: a case report. AAOJ. 2019;29(4):19-23.
Fong KK, Rummel TD. Rescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
Kanze DM. The combined shoulder technique: a novel approach in the treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
Kanze DM. An osteopathic approach to uterine-induced low back pain: a case report. AAOJ. 2019;29(3):23-26.
Yao SC. Applying osteopathic manipulative treatment to postconcussion syndrome: a case report. AAOJ. 2019;29(4):25-29.
osteopathic manipulative medicineHoover HV. How and why I apply the osteopathic principles in practice. AAOJ. 2019;29(1):19-23.
Majetich SA, Majetich MW, Clegg JM, Ratay SM. Patient education of osteopathic manipulative medicine as a gateway to treatment: a pilot study. AAOJ. 2019;29(3):7-11.
Yao SC. Integrating osteopathic evaluation and treatment in a case report of acute chest pain. AAOJ. 2019;29(2):27-30.
osteopathic manipulative treatmentAkers B, Davis G, Keys J, Pierce-Talsma SL, Lund G. Impact of predoctoral teaching fellows on osteopathic medical students: a near-peer teaching program evaluation. AAOJ. 2019;29(4):9-16.
Blumer JU. View from the Pyramids: osteopathic identity. AAOJ. 2019;29(1):5,8.
Blumer JU. View from the Pyramids. AAOJ. 2019;29(2):5.
Fong KK, Rummel TD. Rescued root canal: a case report on OMT for jaw
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Page 38 The AAO Journal • Vol. 29, No. 4 • December 2019
pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
Goering EK, Qiu L. Counterstrain as a diagnostic and treatment tool for rectus femoris origin injuries: a case report. AAOJ. 2019;29(2):19-23.
Huzij T. The cranial rhythmic impulse as a measure in patients with bipolar disorder: a case report. AAOJ. 2019;29(4):31-33.
Kanze DM. The combined shoulder technique: a novel approach in the treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
Kanze DM. An osteopathic approach to uterine-induced low back pain: a case report. AAOJ. 2019;29(3):23-26.
Kanze DM. An osteopathic approach to traumatically induced mechanical dyspnea: a case report. AAOJ. 2019;29(4):19-23.
Kostanjevec J, Flemming RK. Osteopathic approach for lateral knee pain caused by iliotibial band friction syndrome: a case report. AAOJ. 2019;29(3):17-20.
Lewis DD, Pickos J. Restoring full squat range of motion by applying OMT to superior innominate shear: a case report. AAOJ. 2019;29(2):7-12.
Noblitt TR, Fleming RK. Persistent postoperative swelling following arthroscopic meniscectomy: a case report. AAOJ. 2019;29(2):24-26.
Yao SC. Integrating osteopathic evaluation and treatment in a case report of acute chest pain. AAOJ. 2019;29(2):27-30.
Yao SC. Applying osteopathic manipulative treatment to postconcussion syndrome: a case report. AAOJ. 2019;29(4):25-29.
osteopathic medical educationAkers B, Davis G, Keys J, Pierce-Talsma SL, Lund G. Impact of predoctoral teaching fellows on osteopathic medical students: a near-peer teaching program evaluation. AAOJ. 2019;29(4):9-16.
Blumer JU. View from the Pyramids: where have all the mentors gone? AAOJ. 2019;29(4):5-6.
Lewis DD, Pickos JJ. Student perceived value of reading assignments during mandatory clerkship-years OMM course. AAOJ. 2019;29(3):13-16.
osteopathic principles in practiceHoover HV. How and why I apply the osteopathic principles in practice. AAOJ. 2019;29(1):19-23.
osteopathic professionBlumer JU. View from the Pyramids: osteopathic identity. AAOJ. 2019;29(1):5,8.
Blumer JU. View from the Pyramids. AAOJ. 2019;29(2):5.
Blumer JU. View from the Pyramids: kale for days. AAOJ. 2019;29(3):5.
Blumer JU. View from the Pyramids: where have all the mentors gone? AAOJ. 2019;29(4):5-6.
Hoover HV. How and why I apply the osteopathic principles in practice. AAOJ. 2019;29(1):19-23.
osteopathic structural examCabrera KL, Darwish AM, Lurz KL, McClain RL, McClain E, Cox J, Segars L. Osteopathic structural findings in women during menstruation. AAOJ. 2019;29(1):7-13.
patient educationMajetich SA, Majetich MW, Clegg JM, Ratay SM. Patient education of osteopathic manipulative medicine as a gateway to treatment: a pilot study. AAOJ. 2019;29(3):7-11.
percussion hammerKostanjevec J, Flemming RK. Osteopathic approach for lateral knee pain caused by iliotibial band friction syndrome: a case report. AAOJ. 2019;29(3):17-20.
Noblitt TR, Fleming RK. Persistent postoperative swelling following arthroscopic meniscectomy: a case report. AAOJ. 2019;29(2):24-26.
pilot studyMajetich SA, Majetich MW, Clegg JM, Ratay SM. Patient education of osteopathic manipulative medicine as a gateway to treatment: a pilot study. AAOJ. 2019;29(3):7-11.
postconcussion syndromeYao SC. Applying osteopathic manipulative treatment to postconcussion syndrome: a case report. AAOJ. 2019;29(4):25-29.
psychiatryHuzij T. The cranial rhythmic impulse as a measure in patients with bipolar disorder: a case report. AAOJ. 2019;29(4):31-33.
quadratus lumborum strainLewis DD, Pickos J. Restoring full squat range of motion by applying OMT to superior innominate shear: a case report. AAOJ. 2019;29(2):7-12.
rectus femorisGoering EK, Qiu L. Counterstrain as a diagnostic and treatment tool for rectus femoris origin injuries: a case report. AAOJ. 2019;29(2):19-23.
root canalFong KK, Rummel TD. Rescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
sacral torsionLewis DD, Pickos J. Restoring full squat range of motion by applying OMT to superior innominate shear: a case report. AAOJ. 2019;29(2):7-12.
scapular wheelKanze DM. The combined shoulder technique: a novel approach in the treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
shoulder painKanze DM. The combined shoulder technique: a novel approach in the treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
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The AAO Journal • Vol. 29, No. 4 • December 2019 Page 39
SICK scapular syndromeKanze DM. The combined shoulder technique: a novel approach in the treatment of scapular dysfunction—a case report. AAOJ. 2019;29(2):13-17.
soft tissue techniquesLewis DD, Pickos J. Restoring full squat range of motion by applying OMT to superior innominate shear: a case report. AAOJ. 2019;29(2):7-12.
sphenobasilar synchondrosis compressionFong KK, Rummel TD. Rescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
Still techniqueLewis DD, Pickos J. Restoring full squat range of motion by applying OMT to superior innominate shear: a case report. AAOJ. 2019;29(2):7-12.
Yao SC. Applying osteopathic manipulative treatment to postconcussion syndrome: a case report. AAOJ. 2019;29(4):25-29.
suboccipital releaseYao SC. Integrating osteopathic evaluation and treatment in a case report of acute chest pain. AAOJ. 2019;29(2):27-30.
superior innominate shearLewis DD, Pickos J. Restoring full squat range of motion by applying OMT to superior innominate shear: a case report. AAOJ. 2019;29(2):7-12.
temporomandibular joint disorderFong KK, Rummel TD. Rescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
trigeminal neuralgiaFong KK, Rummel TD. Rescued root canal: a case report on OMT for jaw pain following repeat root canal procedure. AAOJ. 2019;29(1):15-17.
undergraduate fellowsAkers B, Davis G, Keys J, Pierce-Talsma SL, Lund G. Impact of predoctoral teaching fellows on osteopathic medical students: a near-peer teaching program evaluation. AAOJ. 2019;29(4):9-16.
Interested in submitting a manuscript to The AAO Journal?
Download the AAOJ’s Instructions for Contributors.
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Page 40 The AAO Journal • Vol. 29, No. 4 • December 2019
Feb. 7-9, 2020 • Midwestern University Arizona College of Osteopathic Medicine in Glendale
Course DescriptionSometimes referred to as Module 1, this introductory course is an excellent starting point on the journey of learning the fascial distortion model (FDM). FDM is an excellent modality to be used in the clinic, on the field, and in the emergency room for fast and effective results. While there are some specific FDM techniques, emphasis will be placed on thinking and working in the model while using all manipulative modalities. Attendees will be introduced to the theory of FDM while focusing on the shoulder, ankle and knee regions. Learn how FDM expands the toolbox you use to help more patients. This modality is valuable for any practitioner and no previous manipulation experience is required. All medical providers are invited to attend, whether you are a DO, MD, PT, OT, PA, NP, DPM, DDS, DMD, ATC, DC, ND or a certified structural integration specialist.Course TimesFriday from 5 to 9 p.m. Saturday and Sunday from 8 a.m. to 5 p.m. Continuing Medical Education20 credits of AOA Category 1-A CME anticipated. Meal InformationDinner will be provided on Friday. Morning coffee and tea will be provided in addition to lunch on Saturday and Sunday. Course LocationMidwestern University Arizona College of Osteopathic Medicine Agave Hall, OMT Lab 10119555 North 59th Ave., Glendale, AZ 85308 See campus map.Travel Arrangements See a list of nearby hotels. Contact Tina Callahan of Globally Yours Travel at (480) 816-3200.
Registration Fees On or before Dec. 26, 2019
Dec. 27, 2019–
Jan. 27, 2020
On or after Jan. 28, 2020
Academy member in practice* $750 $800 $1,000
Resident or intern member $550 $600 $800
Student member $350 $400 $600
Nonmember practicing DO or other health care professional $1,150 $1,200 $1,400
Nonmember resident or intern $950 $1,000 $1,200
Nonmember student $550 $600 $800
* The AAO’s associate members, international affiliates and supporter members are entitled to register at the same fees as full members.
By registering for this course, you agree to abide by the AAO’s code of conduct, photo and video release, and cancellation policy.
Register online at www.academyofosteopathy.org, or submit this registration form and your payment by email to [email protected]; by mail to the American Academy of Osteopathy,
3500 DePauw Blvd., Suite 1100, Indianapolis, IN 46268-1136; or by fax at (317) 879-0563.
Registration FormFascial Distortion Model: Treating the Shoulder, Ankle and Knee
Feb. 7-9, 2020
Name: AOA No.:
Nickname for badge:
Street address:
City: State: ZIP:
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Course DirectorTodd Capistrant, DO, MHA, has been a physician with Tanana Valley Clinic since 2006. He has held many positions with the clinic, but his practice focuses full-time on osteopathic manipulative medicine (OMM). Dr. Capistrant earned his osteopathic medical degree at the Des Moines University College of Osteopathic Medicine in Iowa, and he completed a family medicine residency at the University of Minnesota-Bethesda Family Practice. Dr. Capistrant also received a master’s degree in healthcare administration from DMU. He specializes in OMM and is board certified by the American Board of Family Medicine.
Dr. Capistrant’s medical interests include osteopathic manipulation, working with athletes to maximize performance, dance medicine, OMM for pregnant women, and FDM. He is one of six people certified to teach FDM in the U.S. He is a past president of the American Fascial Distortion Model Association, and he continues to serve on the board of that organization.
The AAO accepts check, Visa, MasterCard and Discover payments in U.S. dollars. The AAO does not accept American Express.
Credit card No.:
Cardholder’s name:
Expiration date: 3-digit CVV No.:
Billing address (if different):
I hereby authorize the American Academy of Osteopathy to charge the above credit card for the amount of the course registration.
Signature:
� I am a practicing health care professional.� I am a resident or intern. � I am an osteopathic or allopathic medical student.
Fascial Distortion Model:Treating the Shoulder, Ankle and Knee
A Pre-Convocation Course • March 8-10, 2020 • The Broadmoor in Colorado SpringsCourse DescriptionReleasing the intracranial meninges is an essential and very powerful application for conditions such as motor vehicle accidents, concussion, strokes, chronic meningitis, surgeries, chronic headaches as well as for cerebral palsy, ASD, etc. It can be a challenging endeavor to work on every fiber of the intracranial meninges in 3-D.
In this course, we will use a curved biotensegrity model with 23 labs to release the meninges of the cranium and spinal cord.
The change of tension inside the cranium will modify the tension in the thorax, pelvis and abdomen and, ultimately, the whole-body. This model has been effectively used for patients of all ages, from newborns to the elderly.
PrerequisiteRegistrants must have completed an approved 40-hour introductory cranial course or Dr. Chikly’s Brain 1 course.
Continuing Medical Education21 credits of NMM-specific AOA Category 1-A CME anticipated.
By registering for this course, you agree to abide by the AAO’s code of conduct, photo and video release, and cancellation policy.
Register online at www.academyofosteopathy.org, or submit this registration form and your payment by email to [email protected]; by mail to the American Academy of Osteopathy,
3500 DePauw Blvd., Suite 1100, Indianapolis, IN 46268-1136; or by fax at (317) 879-0563.
Registration FormBrain Advanced: Releasing the Cranial Meninges
Using a Biotensegrity ModelMarch 8-10, 2020
Name: AOA No.:
Nickname for badge:
Street address:
City: State: ZIP:
Phone: Fax:
Email:
Course DirectorBruno Chikly, MD, DO (France), is a graduate of the medical school at St. Antoine Hospital in Paris, where his internship in general medicine included training in endocrinology, surgery, neurology and psychiatry.
Dr. Chikly also has the French equivalent of a master’s degree in psychology. In 2009, he received a doctorate in osteopathy from CROMON (Holistic Research Center for Osteopathic and Natural Medicine) and AIROP (Italian Association for Postural Occlusion Re-education) in Italy, and he is on the French National Registry of Osteopathy.
Dr. Chikly is an internationally renowned educator, lecturer and writer. He is the author of the book Silent Waves: The Theory and Practice of Lymph Drainage Therapy, as well as the creator of a DVD titled Dissection of the Brain and Spinal Cord, and he is working on a book about osteopathic manipulation and the brain. He lives in Scottsdale, Arizona, with his wife and partner, Alaya.
The AAO accepts check, Visa, MasterCard and Discover payments in U.S. dollars. The AAO does not accept American Express.
Credit card No.:
Cardholder’s name:
Expiration date: 3-digit CVV No.:
Billing address (if different):
I hereby authorize the American Academy of Osteopathy to charge the above credit card for the amount of the course registration.
Signature:
� I will attend the AAO’s 2020 Convocation.� I will not attend the AAO’s 2020 Convocation.� I am a practicing health care professional.� I am a resident or intern.
Brain Advanced: Releasing the Cranial Meninges Using a Biotensegrity Model
Registration Fees On or before Jan. 8, 2020
Jan. 9 through Feb. 20, 20201
Save 10% when you also register for the AAO’s 2020 Convocation.
With Convo
Without Convo
With Convo
Without Convo
Academy member in practice2 $891 $990 $981 $1,090
Resident or intern member $711 $790 $801 $890
Nonmember practicing DO or other health care professional $1,251 $1,390 $1,341 $1,490
Nonmember resident or intern $981 $1,090 $1,071 $1,190
1 Registrations received after Feb. 20 will be processed on-site, incurring a $150 late fee. 2 The AAO’s associate members, international affiliates and supporter members are entitled to register at the same fees as full members. This course is not appropriate for students.
Course TimesSunday and Monday from 8:30 a.m. to 6 p.m. Tuesday from 8:30 a.m. to 4 p.m.Meal Information Breakfast and lunch are on your own. Coffee and tea will be provided.Course LocationThe Broadmoor 1 Lake Ave. Colorado Springs, CO 80906 Make your reservations online at book.passkey.com/go/AAO2020, or call 855-634-7711 and use booking code AAO2020.Travel Arrangements Contact Tina Callahan of Globally Yours Travel at (480) 816-3200.
A Pre-Convocation Course • March 8-10, 2020 • The Broadmoor in Colorado Springs
Course DescriptionThis course will cover the functional associations between the cranial nerves, the sutures, the dura, and the brain. By directly palpating the peripheral branches of cranial nerves, we can evaluate/palpate them for abnormal tension. The nerves are 50% to 90% connective tissue. For example, all three branches of the trigeminal nerve have palpable parts. The maxillary and mandibular branches are often irritated in teeth problems, such as cavities, infections, bite malocclusion, tooth sensitivity, and improper fillings. These branches also supply sensation to the anterior and middle cranial fossa dura. We find osteopathically that teeth problems can affect dural tension. Besides having electrical conduction, the nerves also have fluid flow and nutritive functions.
PrerequisiteA basic understanding of functional anatomy and one basic cranial course.
By registering for this course, you agree to abide by the AAO’s code of conduct, photo and video release, and cancellation policy.
Register online at www.academyofosteopathy.org, or submit this registration form and your payment by email to [email protected]; by mail to the American Academy of Osteopathy,
3500 DePauw Blvd., Suite 1100, Indianapolis, IN 46268-1136; or by fax at (317) 879-0563.
Registration FormCranial Nerve Course
March 8-10, 2020
Name: AOA No.:
Nickname for badge:
Street address:
City: State: ZIP:
Phone: Fax:
Email:
Course DirectorA 1994 graduate of what is now the A.T. Still University–Kirksville College of Osteopathic Medicine, Kenneth J. Lossing, DO, served an internship and combined residency in neuromusculoskeletal medicine and family practice through the Ohio University Heritage College of Osteopathic Medicine in Athens. He is board certified in both neuromusculoskeletal medicine and family medicine.
Dr. Lossing studied visceral manipulation with Jean-Pierre Barral, DO (France). An internationally recognized lecturer, Dr. Lossing contributed to the second through fourth editions of the American Osteopathic Association’s Foundations of Osteopathic Medicine textbook.
As the AAO’s 2014-15 president, Dr. Lossing was featured in a segment of “American Health Front!” that focused on osteopathic manipulative medicine.
Dr. Lossing and his wife, Margret Klein, OA, run a private practice in San Rafael, California.
The AAO accepts check, Visa, MasterCard and Discover payments in U.S. dollars. The AAO does not accept American Express.
Credit card No.:
Cardholder’s name:
Expiration date: 3-digit CVV No.:
Billing address (if different):
I hereby authorize the American Academy of Osteopathy to charge the above credit card for the amount of the course registration.
Signature:
� I will attend the AAO’s 2020 Convocation.� I will not attend the AAO’s 2020 Convocation.� I am a practicing health care professional.� I am a resident or intern. � I am a medical student.
Cranial Nerve Course
Registration Fees On or before Jan. 8, 2020
Jan. 9 through Feb. 20, 20201
Save 10% when you also register for the AAO’s 2020 Convocation.
With Convo
Without Convo
With Convo
Without Convo
Academy member in practice2 $751.50 $835 $841.50 $935
Resident or intern member $571.50 $635 $661.50 $735
Student member $391.50 $435 $481.50 $535
Nonmember practicing DO or other health care professional $1,111.50 $1,235 $1,201.50 $1,335
Nonmember resident or intern $841.50 $935 $931.50 $1,035
Nonmember student $571 $635 $661.50 $735
1 Registrations received after Feb. 20 will be processed on-site, incurring a $150 late fee. 2 The AAO’s associate members, international affiliates and supporter members are entitled to register at the same fees as full members.
Continuing Medical Education21 credits of NMM-specific AOA Category 1-A CME anticipated.
Course TimesSunday and Monday from 8:30 a.m. to 6 p.m. Tuesday from 8:30 a.m. to 4:30 p.m.
Meal Information Breakfast and lunch are on your own. Coffee and tea will be provided.
Course LocationThe Broadmoor 1 Lake Ave., Colorado Springs, CO 80906 Make your reservations online with the physician link or student link, or call 855-634-7711 and use booking code AAO2020.
A Pre-Convocation Course • March 8-10, 2020 • The Broadmoor in Colorado Springs
Course DescriptionIn this course, we will approach infant development from the perspective of three integrated systems; visual, vestibular and somatosensory. We will touch on diagnoses such as developmental delay, motor impairments, musculoskeletal dysfunction, altered nervous system processing, somatic dysfunction, and sensory integration difficulties. In the process, we will treat plagiocephaly, torticollis, various shoulder and pelvic girdle dysfunctions as well as autonomic nervous system alterations.
Continuing Medical Education20 credits of NMM-specific AOA Category 1-A CME anticipated.
Course TimesSunday from 1 to 5 p.m. Monday and Tuesday from 8 a.m. to 5 p.m.
Meal Information Breakfast and lunch are on your own. Coffee and tea will be provided.
By registering for this course, you agree to abide by the AAO’s code of conduct, photo and video release, and cancellation policy.
Register online at www.academyofosteopathy.org, or submit this registration form and your payment by email to [email protected]; by mail to the American Academy of Osteopathy,
3500 DePauw Blvd., Suite 1100, Indianapolis, IN 46268-1136; or by fax at (317) 879-0563.
Registration FormPediatric Manual Medicine
March 8-10, 2020
Name: AOA No.:
Nickname for badge:
Street address:
City: State: ZIP:
Phone: Fax:
Email:
Course DirectorsLisa Ann DeStefano, DO, has chaired the Department of Osteopathic Manipulative Medicine at MSUCOM since 2004. A protégé of the late Philip E. Greenman, DO, FAAODist, Dr. DeStefano edited the fourth and fifth editions of the textbook Greenman’s Principles of Manual Medicine.
A 1993 graduate of MSUCOM, Dr. DeStefano is board certified in osteopathic manipulative medicine and neuromusculoskeletal medicine and in osteopathic family medicine. In 2003, she received the Osteopathic Faculty Award and Guiding Principles Award from MSUCOM. She has lectured widely in the U.S. and internationally.
Heather P. Ferrill, DO, MS MEdL, a 2000 graduate of the Michigan State University College of Osteopathic Medicine (MSUCOM), is the department chair and a professor of osteopathic principles and practices (OPP) at the Rocky Vista University College of Osteopathic Medicine. Board-certified in family practice and neuromusculoskeletal medicine/OMM, her practice emphasizes osteopathic manipulative treatment in the pediatric population. Dr. Ferrill serves on the AAO’s Board of Governors and the International Affairs Advisory Council.
The AAO accepts check, Visa, MasterCard and Discover payments in U.S. dollars. The AAO does not accept American Express.
Credit card No.:
Cardholder’s name:
Expiration date: 3-digit CVV No.:
Billing address (if different):
I hereby authorize the American Academy of Osteopathy to charge the above credit card for the amount of the course registration.
Signature:
� I will attend the AAO’s 2020 Convocation.� I will not attend the AAO’s 2020 Convocation.� I am a practicing health care professional.� I am a resident or intern. � I am a medical student.
Pediatric Manual Medicine
Registration Fees On or before Jan. 8, 2020
Jan. 9 through Feb. 20, 20201
Save 10% when you also register for the AAO’s 2020 Convocation.
With Convo
Without Convo
With Convo
Without Convo
Academy member in practice2 $828 $920 $918 $1,020
Resident or intern member $648 $720 $738 $820
Student member $468 $520 $558 $620
Nonmember practicing DO or other health care professional $1,188 $1,320 $1,278 $1,420
Nonmember resident or intern $918 $1,020 $1,008 $1,120
Nonmember student $648 $720 $738 $820
1 Registrations received after Feb. 20 will be processed on-site, incurring a $150 late fee. 2 The AAO’s associate members, international affiliates and supporter members are entitled to register at the same fees as full members.
Course LocationThe Broadmoor 1 Lake Ave., Colorado Springs, CO 80906 Make your reservations online with the physician link or student link, or call 855-634-7711 and use booking code AAO2020.
Travel Arrangements Contact Tina Callahan of Globally Yours Travel at (480) 816-320.
April 17-18, 2020 • The Pyramids • Indianapolis
Course DescriptionThe Motor Nerve Reflex Testing (MNRT) course is the only course currently available that will teach you how to identify the true cause of your patients’ symptoms. MNRT gives you the priority of injuries for each individual based on survival instincts. There are many ways to evaluate, but only MNRT gives you the order in which to treat. Proper Diagnosis is 95% of effective treatment and any medical professional looking to elevate their diagnostic skills should take this course. After this course you will be able to help more of your patients get the relief they are seeking. After discussing the the motor nerve reflex findings for a specific region, Dr. Cantieri will discuss various injuries and dysfunctions clinicians should evaluate for at the area and treatments that should be considered. Dr. Cantieri will address some of the pain issues that are found in the areas where a primary MNRT is found.
Course TimesFriday from 8 a.m. to 5 p.m. Saturday from 7:30 a.m. to 4:30 p.m.
Continuing Medical Education15 credits of AOA Category 1-A CME anticipated.
Meal InformationContinental breakfast and lunch will be provided each day.
Course LocationThe Pyramids, Building Three 3500 DePauw Blvd., Lower Level, Conference Rooms A and B Indianapolis, IN 46268
Registration Fees On or before Feb. 17, 2020
Feb. 18– April 8, 2020
On or after April 9, 2020
Academy member in practice* $1,225 $1,275 $1,425
Resident or intern member $1,025 $1,075 $1,225
Nonmember practicing DO or other health care professional $1,625 $1,675 $1,825
Nonmember resident or intern $1,425 $1,475 $1,625
* The AAO’s associate members, international affiliates and supporter members are entitled to register at the same fees as full members.
By registering for this course, you agree to abide by the AAO’s code of conduct, photo and video release, and cancellation policy.
Register online at www.academyofosteopathy.org, or submit this registration form and your payment by email to [email protected]; by mail to the American Academy of Osteopathy,
3500 DePauw Blvd., Suite 1100, Indianapolis, IN 46268-1136; or by fax at (317) 879-0563.
Registration FormMotor Nerve Reflex Testing
April 17-18, 2020
Name: AOA No.:
Nickname for badge:
Street address:
City: State: ZIP:
Phone: Fax:
Email:
Course FacultyCourse director Steven Olmos, DDS, an internationally recognized lecturer and researcher, has dedicated the past 30 years to the fields of craniofacial pain, temporomandibular disorder and sleep disordered breathing. He is board certified in craniofacial pain and sleep medicine. He founded the TMJ & Sleep Therapy Centres International and directs research in craniofacial pain and sleep medicine through data collection at 51 centers spanning seven countries.
Mark S. Cantieri, DO, FAAO, of Mishawaka, Indiana, is an AOA board-certified osteopathic manipulative medicine specialist and a fellow of the American Academy of Osteopathy (AAO). He is the chief executive officer of Corrective Care, PC, in Mishawaka. A clinical assistant professor at the Marian University College of Osteopathic Medicine in Indianapolis, Dr. Cantieri has served the osteopathic medical profession in many capacities, including as president of the AAO, as a member of the American Osteopathic Association’s Commission on Osteopathic College Accreditation and as a member of the AOA’s Strategic Planning Committee.
The AAO accepts check, Visa, MasterCard and Discover payments in U.S. dollars. The AAO does not accept American Express.
Credit card No.:
Cardholder’s name:
Expiration date: 3-digit CVV No.:
Billing address (if different):
I hereby authorize the American Academy of Osteopathy to charge the above credit card for the amount of the course registration.
Signature:
� I am a practicing health care professional.� I am a resident or intern.
Motor Nerve Reflex Testing
May 1-3, 2020 • Idaho College of Osteopathic Medicine
Course DescriptionThis course is designed to enhance attendees’ palpatory skills (tissue texture, asymmetry and restriction of motion of both somatic and visceral interconnected structures); enhance knowledge of related somatic/visceral anatomy with fascial continuity via traditional Chinese medicine energy channel mapping; and provide a framework for cross-organ symptomatology and somatic dysfunction, bridging gaps between internal medicine subspecialties and neuromusculoskeletal medicine.
PrerequisiteRegistrants should have completed a basic cranial course and have a grounding in ligamentous articular strain and visceral techniques.
Course TimesFriday and Saturday from 8 a.m. to 5:30 p.m. Sunday from 8 a.m. to 12:15 p.m.
Continuing Medical Education20 credits of AOA Category 1-A CME anticipated.
Meal InformationMorning coffee and tea will be provided. Lunch will be provided Friday and Saturday.
Course LocationIdaho College of Osteopathic Medicine 1401 E. Central Dr.Meridian, ID 83642See campus information.
Travel Arrangements See a list of nearby hotels. Contact Tina Callahan of Globally Yours Travel at (480) 816-3200.
Registration Fees On or before Feb. 24, 2020
Feb. 25– April 24, 2020
On or after April 25, 2020
Academy member in practice* $910 $960 $1,160
Resident or intern member $710 $760 $960
Student member $510 $560 $760
Nonmember practicing DO or other health care professional $1,310 $1,360 $1,560
Nonmember resident or intern $1,110 $1,160 $1,360
Nonmember student $910 $960 $1,160
* The AAO’s associate members, international affiliates and supporter members are entitled to register at the same fees as full members.
By registering for this course, you agree to abide by the AAO’s code of conduct, photo and video release, and cancellation policy.
Register online at www.academyofosteopathy.org, or submit this registration form and your payment by email to [email protected]; by mail to the American Academy of Osteopathy,
3500 DePauw Blvd., Suite 1100, Indianapolis, IN 46268-1136; or by fax at (317) 879-0563.
Registration FormViscerosomatic Release:
A Systemic Model for Neuromusculoskeletal MedicineMay 1-3, 2020
Name: AOA No.:
Nickname for badge:
Street address:
City: State: ZIP:
Phone: Fax:
Email:
Course DirectorJohn P. Tortu, DO, graduated from the Philadelphia College of Osteopathic Medicine in 2000. In early 2009 he discovered the VisceroSomatic Release (VSR) concept and presented the initial concept at the AAO’s 2014 Convocation in Colorado Springs. Since then, Dr. Tortu has presented the VSR concept to a number of osteopathic residency programs in Michigan and Texas. Over the past 10 years, the VSR concept has grown to become a comprehensive diagnostic and treatment method that is predictive of visceral dysfunction by somatic clues and somatic dysfunction by visceral clues. Effortless treatment is accomplished at both the local somatic dysfunction and the underlying visceral dysfunction, simultaneously affecting all structures that follow the associated traditional Chinese medicine energy channel.
The AAO accepts check, Visa, MasterCard and Discover payments in U.S. dollars. The AAO does not accept American Express.
Credit card No.:
Cardholder’s name:
Expiration date: 3-digit CVV No.:
Billing address (if different):
I hereby authorize the American Academy of Osteopathy to charge the above credit card for the amount of the course registration.
Signature:
� I am a practicing health care professional.� I am a resident or intern. � I am an osteopathic or allopathic medical student.
Viscerosomatic Release: A Systemic Model for Neuromusculoskeletal Medicine
� I confirm I meet the required prerequisite.
June 4-7, 2020 • The Pyramids • IndianapolisCourse DescriptionThis course will: • provide basic and refresher knowledge and skills for program
directors and core teaching faculty who supervise osteopathic manipulative treatment (OMT) in clinics.
• help MD students and graduates obtain the prerequisites for entering osteopathic-recognized residencies.
• be valuable for clinicians interested in adding OMT to their skill set.
Through a combination of lectures and hands-on workshops, attendees will learn the basics of osteopathic manipulative medicine, which encompasses osteopathic tenets, palpatory diagnosis and OMT. The curriculum includes lessons on muscle energy technique; thoracic spine technique; articulatory techniques; functional techniques; myofascial release; and high-velocity, low-amplitude thrust.Course registration includes one copy of Greenman’s Principles of Manual Medicine, 5th edition.
Course TimesThursday from 1 to 6 p.m. Friday and Saturday from 8 a.m. to 6 p.m. Sunday from 8 a.m. to 4 p.m.
Continuing Medical Education28 credits of AOA Category 1-A CME anticipated.
Meal InformationMorning coffee and tea will be provided Friday through Sunday, as will lunch.
Course LocationThe Pyramids, Building Three 3500 DePauw Blvd., Lower Level, Conference Rooms A and B Indianapolis, IN 46268
Registration Fees On or before April 30, 2020
May 1– May 31, 2020
On or after June 1, 2020
Academy member in practice* $784 $834 $984
Resident or intern member $584 $634 $784
Student member $384 $434 $584
Nonmember practicing DO or other health care professional $1,184 $1,234 $1,384
Nonmember resident or intern $784 $834 $984
Nonmember student $584 $634 $784
* The AAO’s associate members, international affiliates and supporter members are entitled to register at the same fees as full members.
Register online at www.academyofosteopathy.org, or submit this registration form and your payment by email to [email protected]; by mail to the American Academy of Osteopathy,
3500 DePauw Blvd., Suite 1100, Indianapolis, IN 46268-1136; or by fax at (317) 879-0563.
Registration FormIntroduction to Osteopathic Manipulative Medicine
June 4-7, 2020
Name: AOA No.:
Nickname for badge:
Street address:
City: State: ZIP:
Phone: Fax:
Email:
Course DirectorLisa Ann DeStefano, DO, has chaired the Department of Osteopathic Manipulative Medicine at the Michigan State University College of Osteopathic Medicine (MSUCOM) in East Lansing since 2004. A protégé of the late Philip E. Greenman, DO, FAAODist, Dr. DeStefano edited the fourth and fifth editions of the textbook Greenman’s Principles of Manual Medicine. A 1993 graduate of MSUCOM, Dr. DeStefano is board certified in osteopathic manipulative medicine and neuromusculoskeletal medicine and in osteopathic family medicine.
The AAO accepts check, Visa, MasterCard and Discover payments in U.S. dollars. The AAO does not accept American Express.
Credit card No.:
Cardholder’s name:
Expiration date: 3-digit CVV No.:
Billing address (if different):
I hereby authorize the American Academy of Osteopathy to charge the above credit card for the amount of the course registration.
Signature:
� I am a practicing health care professional.� I am a resident or intern. � I am an osteopathic or allopathic medical student.
Introduction to Osteopathic Manipulative Medicine:Integrating OMM Into Clinical Practice and Teaching
By registering for this course, you agree to abide by the AAO’s code of conduct, photo and video release, and cancellation policy.
“The teaching of the course itself was guided very wisely, carefully, with good examples. It helped me personally to draw a whole picture about integration of OMM in clinical practice.” –Sofio (MD)
Component Societies and Affiliated Organizations Calendar of Upcoming Events
Jan. 23-26, 2020 Osteopathy’s Promise to Children Fluid Flow and the Healing Process
Course director: Philippe Druelle, DO (F-Qc) Osteopathic Center San Diego
Learn more and register at the-promise.org/cme/.
Feb. 15-19, 2020 The Osteopathic Cranial Academy
Midwinter Introductory Course: Osteopathy in the Cranial Field Course director: Zinaida Pelkey, DO, FCA Associate director: Therese M. Scott, DO
Hilton Norfolk The Main in Virginia Learn more and register at www.cranialacademy.org.
Feb. 21-23, 2020
The Osteopathic Cranial Academy Orofacial Development: Merging OCF and Functional Dentistry
Course director: Eric Dolgin, DO, FCA Assistant director: Jose Camacho, DO
Hilton Norfolk The Main in Virginia Learn more and register at www.cranialacademy.org.
April 17-20, 2020
Osteopathy Underground The Many Facets of Visceral Treatment:
The Biomechanical, Biofunctional, and Biodynamic Approaches to Abdominal Viscera
Course director: Dana C. Anglund, DO Rocky Vista University College of Osteopathic Medicine
Parker, Colorado 28 credits of AOA Category 1-A CME anticipated
Learn more and register at osteopathyunderground.com.
April 18-20, 2020 Osteopathy’s Promise to Children
Rule of the Artery 1 Course director: R. Paul Lee, DO, FAAO, FCA
Hilton Garden Inn San Diego 23.5 credits of AOA Category 1-A CME anticipated Learn more and register at the-promise.org/cme/.
April 24-26, 2020 Osteopathy’s Promise to Children
Rule of the Artery 2 Course director: R. Paul Lee, DO, FAAO, FCA
Hilton Garden Inn San Diego 23.5 credits of AOA Category 1-A CME anticipated Learn more and register at the-promise.org/cme/.
April 30–May 2, 2020
Osteopathy’s Promise to Children Rule of the Artery 3
Course director: R. Paul Lee, DO, FAAO, FCA Hilton Garden Inn San Diego
23.5 credits of AOA Category 1-A CME anticipated Learn more and register at the-promise.org/cme/.
June 6-10, 2020
The Osteopathic Cranial Academy June Introductory Course: Osteopathy in the Cranial Field
Course director: Richard F. Smith, DO JW Marriott in Houston
Learn more and register at www.cranialacademy.org.
June 11-14, 2020 The Osteopathic Cranial Academy
Annual Conference: Viola Frymann – Continuing the Legacy: Research and Practice
Conference director: Hollis H. King, DO, PhD, FAAO, FCA Associate director: Deborah Heath, DO
JW Marriott in Houston Learn more and register at www.cranialacademy.org.
July 15-19, 2020
Osteopathy’s Promise to Children Foundations of Osteopathic Cranial Manipulative Medicine
Course directors: R. Mitchell Hiserote, DO; Raymond J. Hruby, DO, MS, FAAODist; and Rebecca E. Giusti, DO
Osteopathic Center San Diego 40 credits of AOA Category 1-A CME anticipated
Learn more and register at the-promise.org/cme/.
Visit www.academyofosteopathy.org/affiliate-cme for additional listings.