An osteopathic approach for the concussed athlete · 2018-05-16 · an osteopathic approach for the concussed athlete albert j kozar, do, faoasm, r-msk board certified nmmomm, fp,

AN OSTEOPATHIC

APPROACH FOR

THE CONCUSSED

ATHLETE

ALBERT J KOZAR, DO, FAOASM, R-MSK

BOARD CERTIFIED NMMOMM, FP, CAQSM, RMSK

PROGRAM DIRECTOR / ASSOCIATE PROFESSOR

ONMM RESIDENCY & INTEGRATED SPORTS MED / ONMM RESIDENCY

EDWARD VIA COLLEGE OF OSTEOPATHIC MEDICINE

DISCLOSURES

My only disclosures are:

• I am a Fighting Irish Fanatic !!!

• I love Jazz !!!

• really can’t stand country music

OBJECTIVES ① Be able to discuss the Berlin Concussion Statement in relation to an

Osteopathic Manipulative Approach

② Be able to discuss the anatomical connectivity and mobility of the cranial & spinal dura

③ Be able to discuss the newly discovered Glymphatic drainage system of the CNS and recent high quality OMT research of the lymphatic system by Lisa Hodges, PhD

④ Be able to formulate a manipulative approach to the mechanical and whiplash affects of concussion ??

⑤ Be able to discuss the evidence in the literature

① Specific to OMT and concussions

② Specific to OMT and symptoms that occur in concussion

⑥ Be able to discuss the current active RTCs of OMT and concussion

⑦ Understand and be able to apply OMT techniques in the approach to treating concussion (Hands-On Lab)

⑧ Be able to discuss when to apply OMT in the treatment of concussions and the absolute / relative contra-indications (Hands-On Lab)

OSTEOPATHY

“Do you practice

decorticate or

decerebrate

Osteopathy ?”

Anthony Chila, DO, FAAO, FCA

OSTEOPATHY

“Even heads have

bodies attached to

them …”

Viola Frymann, DO, FAAO, FCA

CRANIAL CONCEPT

William Garner Sutherland proposed the cranial concept in

1929

“Cranial” osteopathy is a misnomer since it was originally described in the head but in reality is a whole-

body concept

Cranial is not a separate treatment modality but an extension of

osteopathy as originally described by A. T. Still

Sutherland

DEFINITION OF SRC

“Sport related concussion is a traumatic brain injury induced by

biomechanical forces. Several common features that may be utilized

in clinically defining the nature of a concussive head injury include: “

SRC may be caused either by a direct blow to the head, face,

neck or elsewhere on the body with an impulsive force

transmitted to the head

SRC may result in neuropathological changes, but the acute clinical

signs and symptoms largely reflect a functional disturbance

rather than a structural injury and, as such, no abnormality is

seen on standard structural neuroimaging studies

Berlin 2016 Consensus Statement on Concussion in Sport.

McCrory P, et al. Br J Sport Med 2017; 0; 1-10

SUSPECTED DX OF SRC CAN INCLUDE ONE OR MORE OF THE FOLLOWING …

Symptoms

• Somatic (HA, nausea, dizziness, fatigue, sensitivity to light & noise)

• Cognitive (feeling slowed down, feeling mentally “foggy”)

• Emotional (lability, sadness, nervousness, feeling more emotional)

Signs

• Physical (vomiting, LOC, amnesia, neuro deficits)

• Balance Impairment (gait unsteadiness)

• Behavioral Changes (irritability, personality changes)

• Cognitive Impairment (slowed reaction time)

• Sleep Disturbances (somnolence, drowsiness, change in sleep patterns, trouble falling asleep)

First organized this way with

Zurich 2012 Consensus Statement on Concussion in Sport.

Clin J Sport Med 2013; 23(2)



DIAGNOSIS OF PCS

A standard definition for persistent post-concussive symptoms is needed

to ensure consistency in clinical management and research outcomes

‘persistent symptoms’ …

“following SRC should reflect failure of normal clinical

recovery— that is, symptoms that persist beyond expected time

frames (ie, >10–14 days in adults and >4 weeks in children)”

“does not reflect a single pathophysiological entity, but describes a

constellation of non-specific post-traumatic symptoms that

may be linked to coexisting and/ or confounding factors, which

do not necessarily reflect ongoing physiological injury to the brain”



DIAGNOSIS OF PCS

A standard definition for persistent post-concussive symptoms is needed to ensure consistency in clinical management and research outcomes

‘persistent symptoms’ …

“detailed multimodal clinical assessment is required to identify specific primary and secondary pathologies that may be contributing to persisting post-traumatic symptoms”

“Treatment should be individualized and target-specific medical, physical and psychosocial factors identified on assessment”



SOMATIC

DYSFUNCTION

Impaired or altered function of related components of the somatic (body framework system) skeletal, arthrodial, and myofascial structures; and related vascular, lymphatic and neural elements

GOAL OMT

①Primary - direct change

in physiologic function

• Neurologic

• Vascular

• Lymphatic

• Optimization of body rhythms

• Optimization of movement of

musculoskeletal system – the

primary machinery of life

②Secondary - restoration

of structure

OMT FOR SRC & PCS

“detailed multimodal clinical assessment is required

to identify specific primary and secondary

pathologies that may be contributing to persisting post-

traumatic symptoms”

“treatment should be individualized and target-

specific medical, physical and psychosocial factors

identified on assessment”



OMT should be individualized and target

…specific areas of impaired or altered functional

STRUCTURE / FUNCTION

RECIPROCITY

Has moved beyond ‘simple’ muscle and bone to:

– BioTensegrity (Levin) & Mechanical-transduction

Macro - system integration Micro - Individual cellular structure Nuclear - Proteonomics

– Neuromuscular Balance

Systemic neuromotor integration of stability Engrams / Motor patterns

– Real Word Muscle Function (Brolinson & Gray)

Ecconcentric contraction Supination / Pronation Link (Spiral Power)

http://web1.tch.harvard.edu/research/ingber/images/image1_big.jpg

LETS REVIEW

SOME IMAGES &

FACTS ABOUT

THE DURA

The cranial dura mater: a review of its history, embryology, & anatomy.

Adeeb N, et al. Childs Nerv Syst (2012) 28:827–837







Primal Pictures 37

WHY MIGHT CNS VENOUS SYSTEM VULNERABLE TO SOMATIC DYSFUNCTION (STASIS) ?

1. Cranial venous sinuses are carried within the dura mater

2. Lack of muscular system to promote flow – flow is dependent on primary respiratory mechanism (PRM)

3. Anatomical mechanical restrictors:

1. # obtuse & right angles to flow against current

2. Rigidity, width, & trabeculae crossings



DURAL TENSION

“When the dural membrane of the cranium is subjected to tension in a certain direction over time, the fibers within the membrane seem to organize and align themselves with the direction of tension. Study of the fiber organization patterns may disclose the direction of principal tensions to which the membranes were subjected during life.”

This would indicate that distortion of the cranial vault creates resultant tension in the cranial dura mater



Dr. Alf Brieg

Biomechanic of the Nervous System (1960)

Precise & detailed movement in Rhesus monkeys

Telescoping

DURAL MOBILITY

SUMMARY

• The spinal Dura is suspended by the dentate ligaments, the brainstem by the cranial nerves

• The pons-cord tract changes length by 4.5-7.5cm during dorsal extension & ventral flexion

• 0.8-1.4 cm brainstem

• 1.8-2.8 cervical

• 0.9-1.3cm thoracic

• 1-2cm in lumbosacral cord

• The pons cord tract telescopes with dorsal extension

• The Pons cord tract is continuous with the spinal nerve roots and peripheral nerves

SPINAL DURAL

BRIDGES

1ST report of a myodural connection to the atlas (Hack, et al, Spine 1995)

• a “connective tissue bridge” between the posterior atlanto-occipital membrane and the rectus capitus posterior minor muscle

• observed that in all cases, extension of the head and neck produced an “infolding” of the dura mater

• protect the flow of cerebrospinal fluid during head extension

Dura mater is firmly attached to the 2nd and 3rd cervical vertebrae (Mitchell and Humphrey’s- JMPT 1998)

Dura mater is also attached, variably, to the posterior longitudinal ligament by fibrous slips denser toward the lumbar region

Most anatomy authorities tend to agree that the dura mater of the spinal cord attaches to the anterior surface of the sacral canal at the level of the 2nd sacral segment

Kourosh Kahkeshani And Peter J. Ward. Connection Between the Spinal Dura Mater and Suboccipital

Musculature: Evidence for the Myodural Bridge and a Route for Its Dissection—A Review

Clinical Anatomy 25:415–422 (2012)

TAKE HOME

PRINCIPLE

“Core Link” between the Cranium & Spine

Tensions that developed within the cranial dura mater may be

transmitted to the spine and pelvis (AND Visa Versa) through

① the connections specifically at C1, C2, C3, the sacrum & coccyx, &

② via dural sheath to epineural connective tissue at each segmental level in the spine

LETS REVIEW

SOME FACTS

ABOUT

LYMPHATICS

THE GLYMPHATIC

SYSTEM Virchow-Robin Space and Interstitial Flow

• production of CSF is not only derived from the choroid plexus but also from water flux dynamics occurring at the Virchow-Robin space (VRS)

• CSF interstitial flow directly drains into lymphatic channels at the base of the skull, suggesting a pathway that is equivalent to a drainage system for the clearance of waste molecules from the brain

• hydrodynamic process is bidirectional in terms of communication flux and is driven, in part, by respiratory and cardiac pressure pulsations

THE GLYMPHATIC

SYSTEM

OMT & GLYMPHATIC

SYSTEM

OMT applied to the glymphatic

system would have the same 4 goals

as OMT applied to the lymphatic

system:

① open myofascial transition areas

② maximize diaphragmatic

movement,

③ augment lymphatic flow, and

④ mobilize fluid in the lymphatic-

venous system

The Glymphatic-Lymphatic Continuum: Opportunities for OMM.

McCrory P, et al. JAOA March 2016 | Vol 116 | No. 3

WHAT DO WE

KNOW ABOUT

LYMPHATICS IN

OTHER PARTS OF

THE BODY ?

Lisa M. Hodge, Ph.D has develop a small animal model to study the

effect of LYMPHATIC PUMP TECHNIQUES (LPT) during disease

Discovered that LPT protects against pneumonia by reducing the

number of bacteria in the lungs of infected rats.

Huff, J.B., Schander, A., Downey, H.F. and Hodge, L.M. Lymphatic Pump Treatment

Enhances the Lymphatic Release of Lymphocytes. Lymphatic Research and Biology 2010;

2010; 8(4): 183-7.

Creasy C, Schander A, Orlowski A, Hodge LM. Thoracic and Abdominal Lymphatic Pump

Techniques Inhibit the Growth of S. pneumoniae Bacteria in the Lungs of Rats. Lymphat Res

Biol 2013;11(3):183-6.

Hodge LM, Creasy C, Carter K, Orlowski A, Schander A, King HH. Lymphatic pump

treatment as an adjunct to antibiotics for pneumonia in a rat model. J Am Osteopath Assoc.

2015 May 1;115(5):306-16.

OMT &

LYMPHATIC FLOW

OMT &

LYMPHATIC FLOW

Treadmill exercise and Lymphatic Pump Techniques (LPT)

enhanced lymphatic flow in instrumented dogs

Lymphatic Pump Techniques (LPT) significantly increased

the concentration of leukocytes in thoracic duct lymph in

conscious dogs

Lisa M. Hodge, H.H. King, A. G. Williams, Jr., S. Reder, T.J. Belavadi, J.

Simecka, S. Stoll, and H. F. Downey. Abdominal lymphatic pump

treatment increases leukocyte count and flux in thoracic duct lymph.

Lymphatic Research and Biology 2007; 5(2): 127-132.

LPT significantly increased lymph flow and the lymphatic concentration of leukocytes in both dogs and rats.

LPT did not preferentially mobilize any specific immune cell population

But LPT significantly increased both thoracic duct lymph flow and total leukocyte concentrations, resulting in a tenfold increase in the leukocyte flux

LPT also enhanced the lymphatic flux of inflammatory cytokines, chemokines and reactive oxygen and nitrogen species in both the thoracic and mesenteric lymph

The mesentery was a significant source of the lymph, immune cells and inflammatory mediators that were mobilized during LPT

Lisa M. Hodge, M.K. Bearden, A. Schander, J.B. Huff, A.Williams, Jr., H.H. King, H.F. Downey. Abdominal Lymphatic Pump Treatment Mobilizes Leukocytes from the Gastrointestinal Associated Lymphoid Tissue

into Lymph. Lymphatic Research and Biology 2010; 8(2): 103-10.

A. Schander, H.F. Downey and L.M. Hodge. Lymphatic Pump Manipulation Mobilizes Inflammatory Mediators into Lymphatic Circulation. Journal of Experimental Biology and Medicine 2012; 237(1):58- 63.

Schander A, Padro D, King HH, Downey HF, Hodge LM. Lymphatic pump treatment repeatedly enhances the lymphatic and immune systems. Lymphat Res Biol. 2013 Dec;11(4):219-26.

OMT &

LYMPHATIC FLOW

OMT & LYMPHATIC FLOW

PENDING STUDIES

The purpose of this proposal to identify lymphatic pump treatment

enhances efficacy of antibiotic for the treatment of pneumonia

AOA 13-11-687, Hodge (Primary Investigator), 09/01/13-02/29-16. Lymphatic pump treatment as an

adjunctive therapy for the treatment of pneumonia.

The objective of this proposal is to determine if LPT provides

protection during inflammatory bowel disease.

American Academy of Osteopathy, Hodge (Primary Investigator), 04/01/14-06/30/15. Lymphatic pump

technique as a treatment modality for inflammatory bowel disease.

The purpose of this study is to ascertain if OMT improves low back

pain symptoms in patients with Type 2 Diabetes Mellitus

AOA 13-11-686, Licciardone (Primary Investigator), 09/01/13-08/31-15 . American Osteopathic

Association Osteopathic Manipulative Treatment of Somatic Dysfunction and Chronic Low Back Pain in

Patients with Type 2 Diabetes Mellitus

OSTEOPATHIC

PRINCIPLES

APPLIED TO

CONCUSSION

CONCUSSION:

OSTEOPATHIC PRINCIPLES

Acute head trauma can create temporary craniosacral SD

• Forces can be linear or rotational

SD in head trauma can occur in any part of the neurocranium, viscerocranium or sacrum

• Dural attachments: described in prior slides

Diagnosis is made by ART: Screen, Scan, Segmental Diagnosis

• Observation of Asymmetry • Palpation for position • Palpation for mobility of areas involved

Becker RE. Craniosacral Trauma in the Adult. Osteopathic Annals, 1976;5:213-25.

Magoun HI. Whiplash Injury: A Greater Lesion Complex. JAOA, Feb 1964;63:524-35.

CONCUSSION:

OSTEOPATHIC PRINCIPLES

“Most acute trauma is self-correcting because of the rhythmic forces inherent in each person”

“Any residual effect - longstanding trauma - can leave a lasting effect on the efficiency of inherent body rhythms possibly leading to acute symptom disappearance and slow functional degradation over time - days, weeks, months, years”

Becker RE. Craniosacral Trauma in the Adult. Osteopathic Annals, 1976;5:213-25.

Magoun HI. Whiplash Injury: A Greater Lesion Complex. JAOA, Feb 1964;63:524-35.

CRANIAL SOMATIC DYSFUNCTION

AFFECTS FUNCTION

Ophthalmologic • CN II, III, IV, VI

Gastrointestinal • CN IX, X, XII

Respiratory • CN X

Musculoskeletal • CN XI

Parasympathetics • CN III, VII, IX, X

CONCUSSION: WHERE DO I LOOK FOR

AREAS OF SOMATIC DYSFUNCTION

Somatic Injury: Think: Whiplash assoc dysfunctions: • Impaired cranio-cervical flexion (OA)

• Impaired lower cervical extension, mid to upper thoracic extension

• 1st/2nd rib elevations

• Lumbosacral compression

What is autonomic innervation head ? • Sympathetic: T-L outflow T1-4, Infer & Super Cerv ganglia

• Parasympathetic: 4 Ganglia: Ciliary, Pterygopalatine, Otic, & Submandibular

What is somatic innervation of head ? • Somatic motor fibers of cervical nerves innervate muscles derived from cervical somites including the

prevertebral (ventral rami) and postvertebral (dorsal rami) muscles, and the strap muscles (ansa cervicalis)

• The cervical spinal nerve plexus formed by the ventral rami of C2, 3 & 4, innervates the anterior and lateral skin of the neck and innervate the posterior scalp and neck

What is lymphatic drainage of head ? • Newly determined Glymphatic pathways

What is arterial / venous flow to head ? • Why might they be vulnerable to SD ?

What was direction/mechanism of impact ? • For direct cranial membranous, sutural, &/or intra-osseous restrictions

• Compression of SBS is common, esp in football

5 MODELS OF

CONCUSSION GENERAL OSTEOPATHIC

APPROACH

Structural

• Goal – optimize mobility and biomechanics

Respiratory/Circulatory

• Goal – increase respiration, increase oxygenation

Metabolic

• Goal – enhance homeostatic and self-healing mechanisms

Neurologic

• Goal – enhance autonomic balance and neuronal reflex activity

Behavioral

• Goal – improve psychological and social elements of well-being

OSTEOPATHIC APPROACH

TO CONCUSSION

Structural

• Goal –Cranium, Sacrum, C/T/L Spine,

Ribs Restore tensegrity, postural/muscle imbal

Respiratory/Circulatory

• Goal – optimize CNS perfusion &

oxygenation, optimize CSF flow, optimize

lymphatic drainage

Metabolic

• Goal – optimize CNS metabolism/self-

healing

Neurologic

• Goal – optimize CNS fxn, ANS fxn, ENS

function

Behavioral

• Goal – address psychosocial symptoms

Credit: Gregory Hon, DO

2015 AOASM Lecture

RESEARCH

RESEARCH

PRIOR

STUDIES

RESEARCH

Cerritelli et al, J Pain Research, 2017 (OMT & primary headache)

• RTC: Cerritelli et al. Complementary Therapies Med 2015 (migraine)

• RTC: Rolle et al, JAOA 2014;114 (9):678-685 (frequent episodic tension-type headache)

• RTC: Voigt et al, J Alter Comp Med, 2011 (migraine – 42 fem)

• RTC: Anderson & Seniscal. J Head Face, 2006 (tension headache)

• RTC: Hoyt et al, JAOA, 1979 (muscle headache)

Guillaud, Darbois, Monvoisin, & Pinsault, PLOS ONE, 2016 (Cranial OMT & …)

• Efficacy Studies: (n= 14 RTCs): Raith 2016, Castro-Sanchez 2016, Haller 2015, Bialoszewski 2014, Elden 2013, Arnadottir 2013,

Amrovabady 2013, Mataran-Penarrocha 2011, Sandhouse 2010, Nourbakhsh 2008, Melh-Madrona 2007, Hayden 2006, Hanten 1999

• Reliability Studies: (n= 9 RTCs): Halma 2008, Sommerfeld 2003, Moran 2001, Vivian 2000, Rogers 1998, Hanten 1998, Norton 1996,

Wirth-Pattullo 1994, Upledger 1977

Franke, Franke, & Fryer, IJOM 2015 (chronic nonspecific neck pain)

• RTC: Tempel et al. 2008; RTC: Schwerla, 2008; RTC: Mandara. 2010

Jakel, Hauenschild, & BA, JAOA 2011 (Cranial OMT and …)

• RTC: Wyatt et al, Arch Dis Child 2011 (general health, well-being, cerebral palsy)

• RTC: Sandhouse et al, JAOA. 2010 (visual function)

• RTC: Hayden & Mullinger, Complement Ther Clin Pract. 2006 (crying, irritability, sleep in infantile colic)

• RTC: Sergueef et al, Altern Ther Health Med. 2002 (Traube-Hering-Mayer oscillations)

• RTC: Hanten et al. J Man and Manip Ther. 1999 (CV4, tension headache)

• RTC crossover: Cutler et al, J Altern Comp Med 2005 (Sleep Latency & Sympathetic N activity)

• RTC crossover: Nelson et al, J Manip Physiol Ther 2006 (low-frequency oscillations in cutaneous blood flow velocity)

• Observational: Milnes & Moran, Int J Osteopath Med 2007 (CV4, autonomic nervous system function)

Systematic

Reviews

PRIOR RESEARCH

SUMMARY

• This review suggested clinically relevant

effects of OMT for reducing pain in

patients with chronic nonspecific neck

pain

• evidence is of moderate quality

• larger, high-quality randomized controlled

trials are required to confirm these

findings

OSTEOPATHIC

MANIPULATIVE

TREATMENT FOR

CHRONIC

NONSPECIFIC

NECK PAIN: A

SYSTEMATIC

REVIEW AND

META-ANALYSIS FRANKE, FRANKE, & FRYER,

2015 IJOM

Papa et al, J Bodywork Movt Ther 2017 (proprioceptive balance, dizzyness)

Alessandro et al, JAOA, 2014 (ADD/hyperactivity disorders)

Giles et al, J Altern Comp Med, 2013 (suboccipital decompression on heart rate

variability)

Schwerla et al, J Altern Comp Med, 2013 (whiplash, neck pain)

Wyatt et al, Arch Dis Child, 2011 (CST on general health CP patients – sleep, pain)

Lopez et al, JAOA 2011 (balance in elderly)

Shi et al, JAOA 2011 (cerebral tissue oxygenation)

Duncan et al, JAOA 2008 (CST on general health CP patients & spasticity)

Jull et al, Spine 2002 (cervicogenic headache)

RTCs

PRIOR RESEARCH

SUMMARY

Friax et al, JAOA 2013 (dizzyness)

Friax M. PM R, 2010 (vertigo)

Frymann et al, JAOA, 1992 (OMT neurological development children)

Chappell, Dodge, & Dogbey, Osteo Fam Phys 2015 (concussion & CRS)

Schabert & Crow, JAOA 2009 (cost, migraine)

Frymann V. JAOA. 1976 (learning difficulties in children)

Guernsey, Leder, & Yao, JAOA 2016 (concussion)

Castillo, Wolf, & Rakowsky, JAOA 2016 (concussion)

McCallister et al. JAOA 2016 (severe mTBI – in level 1 trauma ward – St Barnabus, NY)

Channell, Mueller, Hahn, JAOA 2009 (concussion)

Greenman & McPartland, JAOA 1995.

Frymann …..

Cohort Studies

Case Control Studies

Case Series

Case Reports

Ideas, Findings

PRIOR RESEARCH

SUMMARY

ASSESSING THE IMMEDIATE EFFECTS OF OMT

ON SPORTS RELATED CONCUSSION SYMPTOMS CRAIG CHAPPELL, DO, OUCOM

Journal Osteopathic Family Physician

Retrospective analysis of the effect of OMT on concussion symptoms in athletes with sport-related concussion

26 patient charts included

OMT improved each of 22 self-reported symptoms on SCAT 2

• Statistical significance in 10 symptoms – headache, pressure in head, blurred vision, sensitivity to light, feeling in a fog, don’t feel right, difficulty concentrating, fatigue/low energy, irritability, sadness

• Would likely have reached statistical significance other symptoms if given more numbers – nausea/vomiting, dizziness, confusion, drowsiness

There was no worsening of any symptom after OMT

ACTIVE RTCS

RESEARCH

① The safety and efficacy of osteopathic manipulation in the treatment of mTBI (mild

traumatic brain injury) in U.S. service members as validated by SPECT scan: a reports

of planned research. Natalie Nevins DO & Marcel Friax DO

② Cranial Osteopathic Manipulative Medicine as an adjunct Treatment for Concussion.

Rosanna C Sabini DO, Northwell Health (ClinicalTrials.gov)

③ Comparing the Effect of Osteopathic Manipulative Medicine (OMM) vs Counseling in

the Treatment of Concussion. Sheldon C Yao DO & Hallie Zwibel DO, New York

Institute of Technology (ClinicalTrials.gov)

④ Head impact biomechanics, the clinical diagnosis of sport related concussion and the

application of osteopathic structural diagnosis & treatment. Brolinson, Leslie, Rogers,

Kozar, Griesemer, VCOM

Objectives

• To assess the safety of OMT in participants experiencing chronic mTBI

• To measure response to OMT on SPECT and neurobehavioral testing

Subjects – US soldiers with a diagnosis of mTBI

Intervention – OMT (vs no OMT control)

• 3 OMT treatments

• Weeks 2, 3, 4

Rosanna C Sabini DO, Northwell Health

Study Design: Non-Randomized, Parallel Assignment, Single Group

Assessment, Single Masking (Care Provider), Feb 2010 – Jan 2013

COMPARING THE EFFECT OF OSTEOPATHIC MANIPULATIVE

MEDICINE (OMM) VERSUS COUNSELING IN THE

TREATMENT OF CONCUSSION SHELDON C YAO DO & HALLIE ZWIBEL DO, NEW YORK INSTITUTE OF TECHNOLOGY

Primary Outcome Measure

① Change in concussive symptoms on the Post Concussion Symptom Scale [ Time Frame: 2 months ]

Eligibility Data:

• Ages Eligible for Study: 14 Years and older (Child, Adult, Senior)

• Sexes Eligible for Study: All

Inclusion Criteria:

• Concussion occurred within 8 weeks

• Age greater or equal to 14 years

• Complains of post-concussive symptoms with a symptom score of >10 on PCSS




Experimental ARM: Osteopathic Manipulative Treatment

Cranial Osteopathic Manipulative Medicine. The hands will be

placed on the head using the "vault hold" (bilateral thumbs are off

the head, index fingers on the temporal bones, middle fingers on

the sphenoid bones, ring fingers on the mastoid and the 5th

fingers on the occipital bone). Diagnosis and treatment of

restrictions palpated on the scalp will be made using this hand

position

Sheldon C Yao DO & Hallie Zwibel DO, New York Institute of Technology

Study Design: Randomized, Parallel Assignment, Single Masking

(Outcomes Assessor), 40 patient goal, Nov 2015 – Dec 2019




Primary Outcome Measure

① SMART Balance Master balance scores pre and post

intervention arm

[ Time Frame: change from the pre-intervention score after the

intervention, measured at each visit through study completion,

an average of 1 week after the initial visit ]

OMT should show a statistically significant improvement in

balance as measured by SMART Balance Master balance

scores as measured by change pre and post procedure




Secondary Outcome Measures

① Post-concussion symptoms as measured by ImPACT [ Time Frame: measured on day 1, day 3, and day 7 post concussion ]

OMT should decrease concussion symptoms as measured by subject responses on this performance test as measured by change pre and post procedure

② Post-concussion symptoms as measured by King-Devick [ Time Frame: measured on day 1, day 3, and day 7 post concussion ]

OMT should decrease concussion symptoms as measured by subject responses on this performance test as measured by change pre and post procedure.

③ Post-concussion symptoms as measured by SCAT-3 [ Time Frame: measured on day 1, day 3, and day 7 post concussion ]

OMT should decrease concussion symptoms as measured by subject responses on this survey as measured by change pre and post procedure.




Other Outcome Measures

① Return to play time [ Time Frame: Up to 90 days ]

Players will be tracked for eventual clearance to return to play and

OMT should decrease return to play time.

Eligibility Data

• Ages Eligible for Study: 18 Years to 50 Years (Adult)

• Sexes Eligible for Study: All




Experimental ARM: Osteopathic Manipulative Treatment

A board certified NMM/OMM or FP/OMM physician will perform an osteopathic structural exam and osteopathic treatment for a 30 minute session. The investigators will follow a generalized protocol for diagnosis and treatment of the head, neck, spine, rib cage, and pelvis. The following techniques will be included in the treatment protocol, OA (Occipitoatlantal) decompression, V-Spread, venous sinus drainage, balanced membranous tension (BMT), cranial lifts, CV4, and a mix of balanced ligamentous tension (BLT), muscle energy techniques, facilitated positional release, articulatory techniques (ART), high-velocity low-amplitude, and counterstrain to address any somatic dysfunctions.

Active Comparator: Counseling

For the control group, an investigator will complete a 30-minute counseling session with the subject. The focus of discussion will be from the CDC's "What to expect after a concussion" article. Other resources that will also be used come from the American Academy of Family Physicians (AAFP), FamilyDoctor.org, and the Brain Care Center. Each counseling session will follow the same protocol. The counseling session will provide subject with similar face-to-face time with the OMT arm.

HEAD IMPACT BIOMECHANICS, THE CLINICAL DIAGNOSIS

OF SPORT RELATED CONCUSSION AND THE APPLICATION

OF OSTEOPATHIC STRUCTURAL DIAGNOSIS & TREATMENT BROLINSON, LESLIE, ROGERS, KOZAR, GRIESEMER, VCOM

Prospective, Longitudinal, Observational Cohort

Design – AOA Research Grant

• 3 subject groups

• Cohort 1: Concussed athletes

• Cohort 2: “High Impact” (>98g) athletes

• Previous research has demonstrated that this is the linear head

acceleration threshold for increased risk of concussion

• Cohort 3: Non-concussed non-impact athletes

• Recruitment Goals:

• Men & women, multi-sport




Aim 1: To delineates the typical osteopathic findings in concussion

in both men and women

• Hypothesis:

① Concussed athletes will demonstrate a pattern of somatic

dysfunction that is different from high impact non-concussed

active controls as well as non-impact, non-concussed controls

② Concussed athletes will demonstrate a Neuro EEG pattern that is

different from high impact non-concussed active controls as well

as non-impact, non- concussed controls

③ OMT will influence the Neuro EEG pattern in concussed athletes

④ OMT will not influence the Neuro EEG pattern in high impact non-

concussed and non-impact non-concussed athletes




Aim 1: To delineates the typical osteopathic findings in

concussion in both men and women

• multi-dimensional assessment:

• standardized clinical measures

• Neuro EEG parameters

• performance-based testing

• psychological health

• osteopathic structural diagnosis




Methods

• Outcome measures

•




Aim 2: Correlate head and neck impact biomechanics with

osteopathic structural evaluation through instrumenting

collegiate football players with helmet-mounted

accelerometer arrays

• A regression model will be developed from controlled

laboratory impact tests to relate head acceleration

measurements on the field to neck loads and moments

experienced by athletes during play

• Comparisons will be performed within a contact athlete cohort

and between contact and non-contact cohorts

• Assessment method(s):

• Head Impact Telemetry (HIT) system sensors




Aim 2: Correlate head and neck impact biomechanics with osteopathic structural evaluation through instrumenting collegiate football players with helmet-mounted accelerometer arrays

• Hypothesis:

① Neck loads, while not directly measured from the accelerometer arrays, can be accurately computed from measured head accelerations

② Within football subjects, concussions occurring on days without OMT (practice days) will be associated with lower head accelerations and lower neck loads than on days with pre-game OMT (game days)

③ The non-concussed contact athletes will demonstrate that higher head accelerations and greater necks loads are associated with increased somatic dysfunction compared to non-impact non-concussed controls




Methods

• Head Impact Telemetry (HIT) system sensors

• Accelerometer array fits between the normal padding of football helmets

• 1 of 5 Impact locations are determined from the accelerometer readings and are categorized as front (F), side (L and R), back (B), and top (T)

• Minimum threshold: Any event resulting in a peak resultant linear head acceleration greater than 10g is recorded

HEAD IMPACT BIOMECHANICS, THE CLINICAL DIAGNOSIS OF

SPORT RELATED CONCUSSION AND THE APPLICATION OF

OSTEOPATHIC STRUCTURAL DIAGNOSIS & TREATMENT BROLINSON, LESLIE, ROGERS, KOZAR, GRIESEMER, VCOM

Methods

• Full OMT evaluation and treatment for each subject

• OMT (+) regions recorded

• OMT is specific to individual




Methods

• Neuro EEG performed before and after OMT evaluation and

treatment for each subject




DEMOGRAPHICS

Cohort

Frequenc

y Percent

Valid

Percent

Cumulative

Percent

Vali

d

Concussed 10 34.5 34.5 34.5

High impact

baseline

7 24.1 24.1 58.6

Baseline 12 41.4 41.4 100.0

Total

29 100.0 100.0

Sex

Frequency Percent Valid Percent

Cumulative

Percent

Valid Male 16 55.2 55.2 55.2

Female 13 44.8 44.8 100.0

Total 29 100.0 100.0

Sport

Frequeny Percent

Valid

Percent

Cumulative

Percent

Valid

Football 12 41.4 41.4 41.4

Soccer 5 17.2 17.2 58.6

Basketball 3 10.3 10.3 69.0

Lacrosse 3 10.3 10.3 79.3

Swimming 2 6.9 6.9 86.2

Softball 1 3.4 3.4 89.7

7 1 3.4 3.4 93.1

8 1 3.4 3.4 96.6

9 1 3.4 3.4 100.0

Total 29 100.0 100.0

CRANIAL SOMATIC

DYSFUNCTION KEY FINDINGS

Comparison between sports-related concussion injuries (cohort 1) compared to baseline subjects (Cohort 1 and 2):

• Decreased Cranial Rhythmic Impulse (CRI)

• Key Suture Restrictions in concussed subjects

• Sphenosquamous Pivot

• Nasofrontal

• Zygomaticotemporal

• Occipitomastoid

• Parietomastroid

• Petrojugular (correlates with temporal paradoxical motion)

• Palatine

Cohort CRI Crosstabulation

CRI

Total Normal Decreasd

Cohor

t

1) Concussed

Count 0 10 10

% within

Cohort

0.0% 100.0% 100.0%

2) High impact

baseline

Count 6 1 7

% within

Cohort

85.7% 14.3% 100.0%

3) Baseline

Count 9 3 12

% within

Cohort

75.0% 25.0% 100.0%

Total

Count 15 14 29

% within

Cohort

51.7% 48.3% 100.0%

CRI COMPARISON

AMONGST

COHORTS

REGIONAL SOMATIC

DYSFUNCTION KEY FINDINGS

Comparison between sports-related concussion injuries

(Cohort 1) compared to baseline subjects (Cohort 1 and 2)

• 90% of Cohort 1 had a pelvic and sacral somatic

dysfunction

• Increased prevalence of C2 and C7 somatic dysfunction

• Increased prevalence of L2-L5

AIM: this study aims to assess brain cortex electrical activity (alpha band frequency) in individuals with nonspecific chronic low back pain submitted to CV4 technique

Hypothesis: patients with chronic low back pain submitted to CV4 would have the peak alpha frequency (PAF) modulated and, thus, would experience physical relaxation & decreased pain

Primary Outcome

• blinded mean change in peak alpha frequency (PAF) (EEG analysis)

Secondary Outcome

• blinded mean change in pain intensity

EEG before & after each protocol section

participants will be recruited from the outpatient rehabilitation

service of the University Hospital of Brasilia

from August 2015 to August 2017

EEG & CV4

Support: CV4 technique affects:

• both central and autonomous nervous system (Jakel & von Hausenchild 2011)

• assessed by change in the blood flow (Nelson et al, 2001)

• assessed by changes in the tissue oxygen saturation (Shi et al, 2011)

• brain cortex electrical activity by electroencephalography (EEG),

• is a validated method to support the results (Abazol 2005, Guosheng 2013, Huneke 2013, Tiffany 2010)

• 2 crossover studies with healthy participants: • Cutler et al 2005 showed a decrease in sleep latency

• Miana et al 2013 showed an increase in the absolute power of alpha frequency

The EEG exam is useful to detect changes in the central processing of pain (Jenson 2013)

Marjan et al 2013 showed increased power amplitude in alpha frequency bands and a shift towards lower frequencies of the dominant peak in chronic pain patients

SUMMARY

Larger study – prospective, specific to concussion populations

• Controlled trial – OMT vs non-OMT/conventional care

Multi-center

Further studies to evaluate specific OMT techniques

Further study to elucidate optimum time course for OMT intervention

Osteopathic Manipulative Medicine (and often specifically Osteopathic in the Cranial Field) is helpful in: CNS oxygenation, CNS perfusion, HA (Migraine, Tension, Cervicogenic, non-osteopathic study), Neck pain, Dizziness (Vertigo, Cervicogenic Dizziness, non-osteopathic study), Sleep Latency (disruption?), Fatigue, Depression

Based on the evidence, it is reasonable to think OMT would be effective in the treatment of sub-acute concussion

Based on the evidence, it is reasonable to think OMT would be effective in the treatment of chronic post-concussive syndrome

OMT is (likely) safe in the treatment of concussion/post-concussion syndrome

Somatic Dysfunction Treatment of Concussion

QUESTIONS ?

14. Hanten WP, Olson SL, Hodson JL, et al. The effectiveness of CV-4 and resting position techniques on subjects with tension-type headaches. J Man and Manip- ulative Ther. 1999;7(2):64-70

15. Hayden C, Mullinger B. A preliminary assessment of the impact of cranial osteopathy for the relief of infantile colic. Complement Ther Clin Pract. 2006;12(2):83-90.

16. Sandhouse ME, Shechtman D, Sorkin R, et al. Effect of osteopathy in the cranial field on visual function—a pilot study. J Am Osteopath Assoc. 2010;110(4):239-243.

17. Sergueef N, Nelson KE, Glonek T. The effect of cranial manipulation on the Traube-Hering-Mayer oscillation as measured by laser-Doppler flowmetry. Altern Ther Health Med. 2002;8(6):74-76.

18. Wyatt K, Edwards V, Franck L, et al. Cranial osteopathy for children with cerebral palsy: a randomised controlled trial [published online ahead of print February 24, 2011]. Arch Dis Child. 2011;96(6):505-512.

19. Cutler MJ, Holland BS, Stupski BA, Gamber RG, Smith ML. Cranial manipulation can alter sleep latency and sympathetic nerve activity in humans: a pilot study. J Altern Complement Med. 2005;11(1):103-108.

20. Nelson KE, Sergueef N, Glonek T. The effect of an alternative medical procedure upon low-frequency oscillations in cutaneous blood flow velocity. J Manipulative Physiol Ther. 2006;29(8):626-636.

21. Milnes K, Moran RW. Physiological effects of a CV4 cranial osteopathic technique on autonomic nervous system function: a preliminary investigation. Int J Osteopath Med. 2007;10:8-17.

THERAPEUTIC EFFECT OF CRANIAL OSTEOPATHIC

MANIPULATIVE MEDICINE: A SYSTEMATIC REVIEW

JAKEL & HAUENSCHILD, 2011

EFFICACY STUDIES -- RTCs

Hanten WP, Olson SL, Hodson JL, Imler VL, Knab VM, Magee JL. The Effectiveness of CV-4 and Rest- ing Position Techniques on Subjects with Tension-Type Headaches. J Man Manip Ther 1999; 7:64–70.

Hayden C, Mullinger B. A preliminary assessment of the impact of cranial osteopathy for the relief of infantile colic. Complement Ther Clin Pract 2006

Mehl-Madrona L, Kligler B, Silverman S, Lynton H, Merrell W. The impact of acupuncture and craniosacral therapy interventions on clinical outcomes in adults with asthma. Explore N Y N 2007; 3:28–36

Nourbakhsh MR, Fearon FJ. The Effect of Oscillating-energy Manual Therapy on Lateral Epicondylitis: A Randomized, Placebo-control, Double-blinded Study. J Hand Ther 2008; 21:4–14.

Sandhouse ME, Shechtman D, Sorkin R, Drowos JL, Caban-Martinez AJ, Patterson MM, et al. Effect of Osteopathy in the Cranial Field on Visual Function—A Pilot Study. J Am Osteopath Assoc 2010

Castro-Sanchez AM, Mataran-Penarrocha GA, Sa nchez-Labraca N, Quesada-Rubio JM, Granero- Molina J, Moreno-Lorenzo C. A randomized controlled trial investigating the effects of craniosacral therapy on pain and heart rate variability in fibromyalgia patients. Clin Rehabil. 2011; 25:25–35. doi: 10. 1177/0269215510375909 PMID: 20702514

Matara n-Penarrocha GA, Castro-Sa nchez AM, Garc ıa GC, Moreno-Lorenzo C, Carreno TP , Zafra MD. Influence of Craniosacral Therapy on Anxiety, Depression and Quality of Life in Patients with Fibromyal- gia. Evid-Based Complement Altern Med ECAM 2011; 2011:178769.

Amrovabady Z, Pishyareh E, Esteki M, Haghgoo HA. Effect of Craniosacral Therapy on students’ symptoms of attention deficit hyperactivity disorder. Iran Rehabil J 2013; 11:41–50.

Arnadottir TS, Sigurdardottir AK. Is craniosacral therapy effective for migraine? Tested with HIT-6 Questionnaire. Complement Ther Clin Pract 2013; 19:11–4. doi: 10.1016/j.ctcp.2012.09.003 PMID: 23337558

Elden H, O stgaard H-C, Glantz A, Marciniak P, Linne r -C, Olse n F . Effects of craniosacral therapy as adjunct to standard treatment for pelvic girdle pain in pregnant women: a multicenter, single blind, randomized controlled trial. Acta Obstet Gynecol Scand 2013; 92:775–82. doi: 10.1111/aogs.12096 PMID: 23369067

Białoszewski D, Bebelski M, Lewandowska M, Słupik A. Utility of Craniosacral Therapy in Treatment of Patients with Non-specific Low Back Pain. Preliminary Report. Ortop Traumatol Rehabil 2014; 16:605– 15. doi: 10.5604/15093492.1135120 PMID: 25694375

Haller H, Lauche R, Cramer H, Rampp T, Saha FJ, Ostermann T, et al. Craniosacral Therapy for the Treatment of Chronic Neck Pain: A Randomized Sham-controlled Trial. Clin J Pain 2015:1.

Castro-Sa nchez AM, Lara-Palomo IC, Matara n-Penarrocha GA, Saavedra-Herna ndez M, Pe rez-Fa r- mol JM, Aguilar-Ferra ndiz ME. Benefits of Craniosacral Therapy in Patients with Chronic Low Back Pain: A Randomized Controlled Trial. J Altern Complement Med. 2016.

Raith W, Marschik PB, Sommer C, Maurer-Fellbaum U, Amhofer C, Avian A et al. General Movements in preterm infants undergoing craniosacral therapy: a randomised controlled pilot-trial. BMC Complement Altern Med. 2016; 16(12)

RELIABILITY OF DIAGNOSIS AND CLINICAL EFFICACY OF

CRANIAL OSTEOPATHY: A SYSTEMATIC REVIEW GUILLAUD, DARBOIS, MONVOISIN, PINSAULT DEC 2016, PLOS ONE

3 RTCs

① Tempel R, Steffen S, Ruetz M, Schwerla F. Osteopathy as an effective treatment alternative to physical therapy

for patients suffering from chronic non specific neck pain. A randomized controlled trial. Paper presented at:

Seventh International Conference on Advances in Osteopathic Medicine. 2008. Florida, USA.

② Schwerla F, Bischoff A, Nurnberger A, Genter P, Guillaume JP, Resch KL. Osteopathic treatment of patients with

chronic non-specific neck pain: a randomised controlled trial of efficacy. Forsch Komplementmed 2008;

15:138e45.

③ Mandara A, Ceriani A, Guzzetti G, Gulisano V, Fusaro A, Bado F. Osteopathic manipulative treatment for chronic

neck pain: a randomized placebo controlled trial on the effect on pain and disability. Int J Osteopath Med

2010;13:105.

OSTEOPATHIC MANIPULATIVE TREATMENT FOR CHRONIC

NONSPECIFIC NECK PAIN: A SYSTEMATIC REVIEW AND

META-ANALYSIS FRANKE, FRANKE, & FRYER, 2015 IJOM

• RTC: Hanten et al. J Man and Manip Ther. 1999

• RTC: Hayden & Mullinger, Complement Ther Clin Pract. 2006

• RTC: Sandhouse et al, JAOA. 2010

• RTC: Sergueef et al, Altern Ther Health Med. 2002

• RTC: Wyatt et al, Arch Dis Child 2011

• RTC crossover: Cutler et al, J Altern Comp Med 2005 (Sleep Latency)






PRIOR STUDY REFERENCES RTCs

• Cerritelli F et al. Clinical effectiveness of osteopathic treatment in chronic migraine: 3-Armed randomized controlled trial. Complementary Therapies in Medicine (2015) 23, 149—156

• Rolle, G; Tremolizzo, L; Somalvico, F; Ferrarese, C; Bressan, LC: Trial of Osteopathic Manipulative Therapy for Patients With Frequent Episodic Tension-Type Headache, J Am Osteopath Assoc. 2014;114 (9):678-685

• Alessandro et al. Effect of Osteopathic Manipulative Therapy in the Attentive Performance of Children With Attention-Deficit/Hyperactivity Disorder. JAOA May 2014, Vol. 114, 374-381.

• Florian Schwerla, MSc, DO, Albrecht K. Kaiser, MSc, DO, Richard Gietz, DO, and Ralf Kastner, DO. Osteopathic Treatment of Patients with Long-Term Sequelae of Whiplash Injury: Effect on Neck Pain Disability and Quality of Life. J Altern Comp Med, 19(6) 543–549, 2013

• Karen Voigt, MPH et al. Efficacy of Osteopathic Manipulative Treatment of Female Patients with Migraine: Results of a Randomized Controlled Trial. The Journal of Alternative and Complementary Medicine 17(3), p 225–230, 2011

• K. Wyatt, V. Edwards, L. Franck, et al., Cranial osteopathy for children with cerebral palsy: a randomised controlled trial, Arch. Dis. Child. 96 (6) (2011) 505–512.

• Lopez D, King HH, Knebl J, Kosmopolous V, Collins D, Patterson RM. Effect of a comprehensive osteopathic manipulation treatment on balance in the elderly population. In press J Am Osteopath Assoc. 2011

• B. Duncan, S. McDonough-Means, K. Worden, et al., Effectiveness of osteopathy in the cranial field and myofascial release versus acupuncture as complementary treatment for children with spastic cerebral palsy: a pilot study, J. Am. Osteopath. Assoc. 108 (10) (2008) 559–570.

• Anderson & Seniscal. A Comparison of Selected Osteopathic Treatment and Relaxation for Tension-Type Headache. The Journal of Head and Face 46(8), p 1273–1280, September 2006

• Jull et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine. 27(17):1835-1843, September 1, 2002

PRIOR STUDY REFERENCES

Cohort Studies

• Frymann VM, Carney RE, Springall P. Effect of osteopathic medical

management on neurologic development in children. J Am

Osteopath Assoc. 1992;92:729-744.

Case Series

• Erik Schabert, DO; William Thomas Crow, DO, FAAO. Impact of

Osteopathic Manipulative Treatment on Cost of Care for Patients

With Migraine Headache: A Retrospective Review of Patient

Records. J Am Osteopath Assoc. 2009 Aug;109(8):403-7

• Frymann V. Learning difficulties of children viewed in the light of the

osteopathic concept. JAOA. 1976;76:712-20.

PRIOR STUDY REFERENCES

Conference Presentations of Evidence base for OMT

• Kurt Heinking, DO, FAAO. Evidence Based Osteopathic Manipulative Medicine. 2017 ACOFP.

• http://www.acofp.org/ACOFPIMIS/Acofporg/PDFs/ACOFP17/handouts/FRIDAY/Fri_pm_200_Heinking,%20Kurt_OMT%20Evidence%20Based%20Medicine.pdf

• Hollis H King, DO, PhD, FAAO. Research on Osteopathy in the cranial Field, What we know, What we don’t know. American Academy of Osteopathy Convocation. March 18, 2011.

• Available upon request

• Smartt & O’Brien. Summary of Research Findings for Osteopathic Treatment in the Cranial Field. March 2015.

• http://www.brisbaneosteopathic.com.au/sites/default/files/Cranialresearch.pdf

http://www.acofp.org/ACOFPIMIS/Acofporg/PDFs/ACOFP17/handouts/FRIDAY/Fri_pm_200_Heinking, Kurt_OMT Evidence Based Medicine.pdf




http://www.brisbaneosteopathic.com.au/sites/default/files/Cranialresearch.pdf



CONCUSSION:

TREATMENT PRINCIPLES

SPORT CONCUSSION ASSESSMENT TOOL — 5TH EDITION

Key points

• Any athlete with suspected concussion should be

REMOVED FROM PLAY, medically assessed and

monitored for deterioration. No athlete diagnosed with

concussion should be returned to play on the day of

injury.

• Concussion signs and symptoms evolve over time

and it is important to consider repeat evaluation in

the assessment of concussion.

CONCUSSION: TREATMENT PRINCIPLES

•Acute Txm Goals: • Serially evaluate with

SCAT2 and regular medical evaluation as usual

• I do NOT do cranial work at the game or during first 1-2 hours

• I may treat same same day IF • 1) symptoms are

improving

• 2) symptoms are mild-moderate

• 3) HA is really the only symptom

•Subacute Txm Goals: • Next day, Day 1-10

• Assess & Treat whole body

• Move Fluids: • Assistance of the involuntary cycle of rhythmic

fluctuation of the CSF

• Remove venous stasis in compressed head

• General patterns of membranous articular strain correction:

• Flexion / Extension

• Torsion

• Vertical

• Side-bending rotation

• Lateral

• Compression

• Specific patterns of membranous articular strain correction

CONTRA-INDICATIONS TO

OMT IN CONCUSSION

Suspected/confirmed

cerebral/intracranial

hemorrhage

Severe head trauma

Skull fracture

Suspected/confirmed

cervical fracture

• xxxxx

Reliability Studies RELIABILITY OF

DIAGNOSIS AND CLINICAL

EFFICACY OF CRANIAL

OSTEOPATHY: A

SYSTEMATIC REVIEW GUILLAUD, DARBOIS, MONVOISIN, PINSAULT

DEC 2016, PLOS ONE

• This

RELIABILITY OF

DIAGNOSIS AND CLINICAL

EFFICACY OF CRANIAL

OSTEOPATHY: A

SYSTEMATIC REVIEW GUILLAUD, DARBOIS, MONVOISIN, PINSAULT

DEC 2016, PLOS ONE

Efficacy Studies

Review – 8 studies met inclusion criteria

Conclusion: Studies are heterogeneous and insufficient to draw definitive conclusions

In general, cranial OMM showed positive outcomes




Cerritelli et al, J Pain Research, 2017 (OMT & primary headache)

• RTC: Cerritelli et al. Complementary Therapies Med 2015 (migraine)

• RTC: Rolle et al, JAOA 2014;114 (9):678-685 (frequent episodic tension-type headache)

• RTC: Voigt et al, J Alter Comp Med, 2011 (migraine – 42 fem)

• RTC: Anderson & Seniscal. J Head Face, 2006 (tension headache)

• RTC: Hoyt et al, JAOA, 1979 (muscle headache)

Guillaud, Darbois, Monvoisin, & Pinsault, PLOS ONE, 2016 (Cranial OMT & …)

• Efficacy Studies: (n= 14 RTCs): Raith 2016, Castro-Sanchez 2016, Haller 2015, Bialoszewski 2014, Elden 2013, Arnadottir 2013, Amrovabady 2013, Mataran-Penarrocha 2011, Sandhouse 2010, Nourbakhsh 2008, Melh-Madrona 2007, Hayden 2006, Hanten 1999

• Reliability Studies: (n= 9 RTCs): Halma 2008, Sommerfeld 2003, Moran 2001, Vivian 2000, Rogers 1998, Hanten 1998, Norton 1996, Wirth-Pattullo 1994, Upledger 1977

Franke, Franke, & Fryer, IJOM 2015 (chronic conspecific neck pain)

• RTC: Tempel et al. 2008; RTC: Schwerla, 2008; RTC: Mandara. 2010

Jakel, Hauenschild, & BA, JAOA 2011 (Cranial OMT and …)

• RTC: Wyatt et al, Arch Dis Child 2011 (general health, well-being, cerebral palsy)

• RTC: Sandhouse et al, JAOA. 2010 (visual function)

• RTC: Hayden & Mullinger, Complement Ther Clin Pract. 2006 (crying, irritability, sleep in infantile colic)

• RTC: Sergueef et al, Altern Ther Health Med. 2002 (Traube-Hering-Mayer oscillations)

• RTC: Hanten et al. J Man and Manip Ther. 1999 (CV4, tension headache)

• RTC crossover: Cutler et al, J Altern Comp Med 2005 (Sleep Latency & Sympathetic N activity)



Papa et al, J Bodywork Movt Ther 2017 (proprioceptive balance, dizzyness)

Alessandro et al, JAOA, 2014 (ADD/hyperactivity disorders)

Giles et al, J Altern Comp Med, 2013 (suboccipital decompression on heart rate variability)

Schwerla et al, J Altern Comp Med, 2013 (whiplash, neck pain)

Wyatt et al, Arch Dis Child, 2011 (CST on general health CP patients – sleep, pain)

Lopez et al, JAOA 2011 (balance in elderly)

Shi et al, JAOA 2011 (cerebral tissue oxygenation)

Duncan et al, JAOA 2008 (CST on general health CP patients & spasticity)

Jull et al, Spine 2002 (cervicogenic headache)

Systematic

Revews

RTCs

PRIOR RESEARCH

SUMMARY

WHAT OMT

TECHNIQUE

SHOULD I USE FOR

CONCUSSIONS ?

CONCUSSION

Documents

An osteopathic approach for the concussed athlete · 2018-05-16 · an osteopathic approach for the concussed athlete albert j kozar, do, faoasm, r-msk board certified nmmomm, fp,