Hollis H. King

OSTEOPAThic Health outcomes In Chronic low back pain: The OSTEOPATHIC Trial

BackgroundOsteopathic manipulative treatment (OMT) and ultrasound physical therapy (UPT) are commonly used for chronic low back pain. Although there is evidence from a systematic review and meta-analysis that OMT generally reduces low back pain, there are no large clinical trials that specifically assess OMT efficacy in chronic low back pain. Similarly, there is a lack of evidence involving UPT for chronic low back pain.MethodsThe OSTEOPAThic Health outcomes In Chronic low back pain (OSTEOPATHIC) Trial is a Phase III randomized controlled trial that seeks to study 488 subjects between August 2006 and June 2010. It uses a 2 × 2 factorial design to independently assess the efficacy of OMT and UPT for chronic low back pain. The primary outcome is a visual analogue scale score for pain. Secondary outcomes include back-specific functioning, generic health, work disability, and satisfaction with back care.ConclusionThis randomized controlled trial will potentially be the largest involving OMT. It will provide long awaited data on the efficacy of OMT and UPT for chronic low back pain.Trial registrationhttp://www.clinicaltrials.gov, NCT00315120

Lymphatic Pump Treatment Mobilizes Leukocytes from the Gut Associated Lymphoid Tissue into Lymph

BACKGROUND Lymphatic pump techniques (LPT) are used clinically by osteopathic practitioners for the treatment of edema and infection; however, the mechanisms by which LPT enhances lymphatic circulation and provides protection during infection are not understood. Rhythmic compressions on the abdomen during LPT compress the abdominal area, including the gut-associated lymphoid tissues (GALT), which may facilitate the release of leukocytes from these tissues into the lymphatic circulation. This study is the first to document LPT-induced mobilization of leukocytes from the GALT into the lymphatic circulation. METHODS AND RESULTS Catheters were inserted into either the thoracic or mesenteric lymph ducts of dogs. To determine if LPT enhanced the release of leukocytes from the mesenteric lymph nodes (MLN) into lymph, the MLN were fluorescently labeled in situ. Lymph was collected during 4 min pre-LPT, 4 min LPT, and 10 min following cessation of LPT. LPT significantly increased lymph flow and leukocytes in both mesenteric and thoracic duct lymph. LPT had no preferential effect on any specific leukocyte population, since neutrophil, monocyte, CD4+ T cell, CD8+ T cell, IgG+B cell, and IgA+B cell numbers were similarly increased. In addition, LPT significantly increased the mobilization of leukocytes from the MLN into lymph. Lymph flow and leukocyte counts fell following LPT treatment, indicating that the effects of LPT are transient. CONCLUSIONS LPT mobilizes leukocytes from GALT, and these leukocytes are transported by the lymphatic circulation. This enhanced release of leukocytes from GALT may provide scientific rationale for the clinical use of LPT to improve immune function.

Lymph Flow in the Thoracic Duct of Conscious Dogs During Lymphatic Pump Treatment, Exercise, and Expansion of Extracellular Fluid Volume

BACKGROUND This investigation examined interactions between expansion of the extracellular fluid volume (ECE), osteopathic lymphatic pump treatment (LPT), and exercise on lymph flow in the thoracic duct of eight instrumented, conscious dogs. METHODS AND RESULTS After recovery from surgery, LPT was performed for 8 min before and after ECE with normal saline, i.v., 4.4+/-0.3% of body weight. Baseline lymph flow was 1.7+/-0.5 mL/min. LPT rapidly increased lymph flow to 5.0+/-1.1 mL/min at 1 min, and lymph flow remained above baseline for 4 min (p<0.05). LPT produced a net increase in lymph flow of 15.4+/-1.1 mL. Following ECE, baseline lymph flow was 4.8+/-0.6 mL/min (p<0.05). LPT increased lymph flow to 9.9+/-1.1 mL/min at 1 min (p<0.05), and lymph flow remained above baseline for 4 min (p<0.05); all flow values after ECE were greater than corresponding values before ECE. However, the net increase in lymph flow produced by 8 min of LPT (18.3+/-3.8 mL) was not significantly greater than that observed before ECE. Moderate treadmill exercise increased lymph flow for 4 min before ECE and for 6 min after ECE. All lymph flows during exercise were greater after ECE than before ECE. The net increase in lymph flow produced by 8 min of exercise was 24.9+/-5.5 mL before ECE and 39.6+/-5.1 mL after ECE (p<0.05). CONCLUSIONS Expansion of the extracellular fluid volume produced large increases in thoracic duct lymph flow, that were further augmented by lymphatic pump treatment and by moderate treadmill exercise.

Lymphatic pump treatment increases thoracic duct lymph flow in conscious dogs with edema due to constriction of the inferior vena cava.

BACKGROUND Osteopathic lymphatic pump treatments (LPT) are used to treat edema, but their direct effects on lymph flow have not been studied. In the current study, we examined the effects of LPT on lymph flow in the thoracic duct of instrumented conscious dogs in the presence of edema produced by constriction of the inferior vena cava (IVC). METHODS AND RESULTS Six dogs were surgically instrumented with an ultrasonic flow transducer on the thoracic lymph duct and catheters in the descending thoracic aorta and in IVC. After postoperative recovery, lymph flow and hemodynamic variables were measured 1) pre-LPT, 2) during 4 min LPT, 3) post-LPT, in the absence and presence of edema produced by IVC constriction. This constriction increased abdominal girth from 60 +/-2.6 to 75 +/- 2.9 cm. Before IVC constriction, LPT increased lymph flow (P < 0.05) from 1.9 +/- 0.2 ml/min to a maximum of 4.7 +/-1.2 ml/min, whereas after IVC constriction, LPT increased lymph flow (P < 0.05) from 7.9 +/-2.2 to a maximum of 11.7 +/-2.2 ml/min. The incremental lymph flow mobilized by 4 min of LPT (ie, the flow that exceeded 4 min of baseline flow), was 10.6 ml after IVC constriction. This incremental flow was not significantly greater than that measured before IVC constriction. CONCLUSIONS Edema caused by IVC constriction markedly increased lymph flow in the thoracic duct. LPT increased thoracic duct lymph flow before and after IVC constriction. The lymph flow mobilized by 4 min of LPT in presence of edema was not significantly greater than that mobilized prior to edema.

Changes in alpha band activity associated with application of the compression of fourth ventricular (CV-4) osteopathic procedure: A qEEG pilot study

The compression of the fourth ventricle (CV-4) is one of the more well known procedures in the cranial manipulation curriculum and practice. Cranial manipulation has received criticism because of the subtle, difficult to learn techniques, controversy over whether or not cranial bone structures move, and what if any clinical effects have been shown. The aim of this study was to measure the effects of CV-4 in 10 healthy subjects through quantitative electroencephalography (qEEG), specifically in alpha band. Participants were randomly distributed in control, sham-CV4 and CV4 conditions using a cross-over design. qEEG activity was recorded for each of the 10 subjects in each of the 3 conditions. There was a significant increase in the alpha absolute power between pre and post in the CV-4 condition. There appears to be potential for understanding the effect of the CV-4 if these finding are replicated in further clinical trials.

Somatic dysfunction and use of osteopathic manual treatment techniques during ambulatory medical care visits: a CONCORD-PBRN study.

CONTEXT Osteopathic manual treatment (OMT) of somatic dysfunction is a unique approach to medical care that may be studied within a practice-based research network. OBJECTIVE To measure patient characteristics and osteopathic physician practice patterns within the Consortium for Collaborative Osteopathic Research Development-Practice-Based Research Network (CONCORD-PBRN). DESIGN Cross-sectional card study. SETTING Eleven member clinics within the CONCORD-PBRN coordinated by The Osteopathic Research Center. PATIENTS A total of 668 patients seen between January and March 2013. MAIN STUDY MEASURES Patient age and sex; primary diagnoses; somatic dysfunction as manifested by tenderness, asymmetry, restricted motion, or tissue texture changes; and use of 14 OMT techniques. Results were stratified by anatomical region and adjusted for clustering within member clinics. Clustering was measured by the intracluster correlation coefficient. RESULTS Patient ages ranged from 7 days to 87 years (adjusted mean age, 49.2 years; 95% confidence interval [CI], 43.3-55.1 years). There were 450 females (67.4%) and 508 patient visits (76.0%) involved a primary diagnosis of disease of the musculoskeletal system and connective tissue. Structural examination was performed during 657 patient visits (98.4%), and 649 visits (97.2%) involved OMT. Restricted motion and tenderness were the most and least common palpatory findings, respectively. Cranial (1070 [14.5%]), myofascial release (1009 [13.7%]), muscle energy (1001 [13.6%]), and counterstrain (980 [13.3%]) techniques were most commonly used, accounting for more than one-half of the OMT provided. Pediatric patients were more likely than adults to receive OMT within the head (adjusted odds ratio [OR], 9.53; 95% CI, 1.28-71.14). Geriatric patients were more likely than adults to receive a structural examination (adjusted OR, 1.83; 95% CI, 1.09-3.07) and OMT (adjusted OR, 1.62; 1.02-2.59) within the lower extremity. Females were more likely than males to receive a structural examination (adjusted OR, 2.44; 95% CI, 1.44-4.16) and OMT (adjusted OR, 2.11; 95% CI, 1.26-3.52) within the sacrum and OMT within the pelvis (adjusted OR, 1.79; 95% CI, 1.12-2.88). Intracluster correlation coefficients for the 4 most commonly used OMT techniques ranged from 0.34 to 0.72. CONCLUSION This study provides proof of concept of the feasibility of studying osteopathic medical practice on a national level by developing and growing the CONCORD-PBRN.

Lymphatic Pump Treatment as an Adjunct to Antibiotics for Pneumonia in a Rat Model

BACKGROUND Lymphatic pump treatment (LPT) is a technique used by osteopathic physicians as an adjunct to antibiotics for patients with respiratory tract infections, and previous studies have demonstrated that LPT reduces bacterial load in the lungs of rats with pneumonia. Currently, it is unknown whether LPT affects drug effcacy. OBJECTIVE To determine whether the combination of antibiotics and LPT would reduce bacterial load in the lungs of rats with acute pneumonia. METHODS Rats were infected intranasally with 5×107 colony-forming units (CFU) of Streptococcus pneumoniae. At 24, 48, and 72 hours after infection, the rats received no therapy (control), 4 minutes of sham therapy, or 4 minutes of LPT, followed by subcutaneous injection of 40 mg/kg of levofoxacin or sterile phosphate-buffered saline. At 48, 72, and 96 hours after infection, the spleens and lungs were collected, and S pneumoniae CFU were enumerated. Blood was analyzed for a complete blood cell count and leukocyte differential count. RESULTS At 48 and 72 hours after infection, no statistically significant differences in pulmonary CFU were found between control, sham therapy, or LPT when phosphate-buffered saline was administered; however, the reduction in CFU was statistically significant in all rats given levofoxacin. The combination of sham therapy and levofoxacin decreased bacterial load at 72 and 96 hours after infection, and LPT and levofoxacin significantly reduced CFU compared with sham therapy and levofoxacin at both time points (P<.05). Colony-forming units were not detected in the spleens at any time. No statistically significant differences in hematologic findings between any treatment groups were found at any time point measured. CONCLUSION The results suggest that 3 applications of LPT induces an additional protective mechanism when combined with levofoxacin and support its use as an adjunctive therapy for the management of pneumonia; however, the mechanism responsible for this protection is unclear.

Assessment of calvarial structure motion by MRI

BackgroundPractitioners of manual medicine/manual therapy (MM/MT) who utilize techniques thought to have some impact upon and move the solid structures of the human head have been criticized for lack of evidence of cranial bone motion. The present study utilized magnetic resonance imagery (MRI) technology to address the question of whether or not inherent (non-operator initiated) calvarial structure motion can be assessed.MethodsSubjects: Twenty healthcare professionals, (physicians, nurses, medical students, pharmacists) between the ages of 24 and 52 were recruited. Seven females (ages 25-47, mean age 36.7) and 13 males (ages 25-53, mean age 31.2) volunteered. Technology: MRI scans were acquired at 450 ms per slice, in a 1.5 Tesla Signa Excite HD closed MRI system. The same scan prescription was repeated serially every 45 seconds to obtain eight serial slices for each subject. Image analysis was accomplished using ImageJ software (ImageJ 1.33 u National Institutes of Health, USA). Data from all eight images for each of the 20 subjects were analyzed to determine the two images with the largest differences in the parameters measured.ResultsDifference values for the measures of area, width, height, major axis, and feret were statistically different whereas the measures for perimeter and minor axis were not. However, only the difference values for area were both statistically different (p < 0.003) and exceeded the resolution threshold of 0.898 mm/pixel.DiscussionThe statistically significant difference value for area is suggestive of inherent motion in calvarial structures, and adds to the body of evidence supportive of biomechanically measurable calvarial structure motion in general. That the total intracranial area appeared to expand and recede was consistent with theory and prior studies suggestive of calvarial structure motion due to intracranial fluid volume changes.ConclusionThe use of MRI technology was able to demonstrate calvarial structure motion at a level exceeding the resolution threshold, and provides a means for further research on phenomena related to the cranial concept. It may be just a matter of time until increased resolution of MRI technology and image analysis provide the ability to examine more detailed areas of specific cranial bone motion.

Manual Craniosacral Therapy May Reduce Symptoms of Migraine Headache

Physical therapy researchers in Iceland studied the effect of craniosacral therapy (CST) on participants with migraine headache. Participants aged 18 to 50 years were recruited if they had a diagnosis of migraine and reported that they had had 2 or more migraine headaches in the month preceding the study. Participants were allowed to continue their usual activities of daily life and any medications they were taking but were not allowed to have any other form of alternative treatment. The outcome measure was the Short-Form Headache Impact Test (HIT-6), which covers quality of life aspects such as “pain, social participation, general activity, vitality, intellectual activity and biological suffering.” The HIT-6 has been standardized and validated with 4 levels of influence on the life of the participant: little or no influence, some influence, considerable influence, and highest influence (“very seriously affect life of the individual”). The 20 participants (18 women, 2 men) were randomly assigned to 1 of 2 groups, A or B. The HIT-6 was filled out 4 times every 4 weeks: first, at baseline; second, after group A received CST and group B waited; third, after group B received CST and group A waited; and fourth, 4 weeks later. Craniosacral therapy was applied by 1 of 4 therapists who were trained in CST, which is a technique similar to cranial osteopathic manipulative medicine. In this study, the therapists followed the sequence of the so-called 10-step CST, which are diaphragm, cranial bone, and facial bone “releases.” Results showed significant lowering of HIT-6 scores immediately after CST and then at 4 weeks after receipt of CST (P=.004). The study was limited by the small number of participants, the potential skill level differences between providers of CST, and the lack of a control group. This study was selected for review because it was a well-designed pilot, it adds to the evidence base for application of manual medicine in head pain, and it confirms my own experience in applying cranial osteopathic manipulative medicine to patients with migraine headache. (doi:10.7556/jaoa.2017.011)

Thermography Examination of Abdominal Area Skin Temperatures in Individuals With and Without Focal-Onset Epilepsy

&NA; Early osteopathic theory and practice, and the work of the medical intuitive Edgar Cayce suggested that the abdominal areas of individuals with epilepsy would manifest “cold spots.” The etiology for this phenomenon was thought to be abdominal adhesions caused by inflammation and viscero‐somatic reflexes caused by adhesions or injury to visceral or musculoskeletal system structures. Indeed, until that advent of electroencephalography in the 1930s, medical practice regarding epilepsy focused on abdominal neural and visceral structures. Following two hypotheses were formulated to evaluate any abdominal temperature phenomena: (1) an abdominal quadrant division analysis would find one or more quadrants “colder” in the focal‐onset epilepsy group (ICD9‐CM 345.4 and 345.5) compared to controls. (2) Total abdominal areas of individuals with focal‐onset epilepsy wound be colder than a control group. Methods: Overall, 50 patients with the diagnosis of focal‐onset epilepsy were recruited from the office of the Epilepsy Foundation of Florida and 50 control subjects with no history of epilepsy were recruited through advertising to the public. Under controlled room conditions all subjects had infrared thermographic images made and recorded by Med‐Hot Model MH‐731 FLIR equipment. Results: There were no significant demographic difference between experimental patients and control subjects, though the control group tended to be younger and more often male; however, these were controlled for in all analyses. In the quadrant analysis, there were significant differences in that more epileptic patients had colder left upper abdominal quadrant temperatures than the control group (66.8% versus 44.9%; P = .030). In the total abdominal analysis, however, there were no significant differences. Discussion: The results support the hypothesis that individuals with focal‐onset epilepsy have colder abdominal areas. If substantiated in further research, present study results will require further examination of the mechanisms of action for epilepsy, and suggest the need for re‐examination of older formulations of abdominal epilepsy, including the place of abdominal injury, inflammation, and adhesions in epileptic pathology. The concept of somato‐visceral and viscero‐somatic neurological interactions is one of the possible mechanisms underlying the “cold spot” findings and warrants further consideration.