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Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
1
“More Than We Ever Imagined …”
Michael L. Kuchera, DO, FAAOProfessor, Department OMMMarian University College of Osteopathic Medicine
2013 AAO Convocation – SAAO Program
Curiosity almost killed the cat. Canine science kept it alive.
Students Appreciate Role of Osteopathic Research
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
2
Higher Tech - Higher TouchFocus on Lymphatics & Fluid Dynamics
Documenting: Palpatory Diagnosis, OMT, Post-OMT Change, Intra- & Inter- Examiner Reproducibility
Potential Impact: Perspective & Interpretation; Teaching; Learning; Research; Literature
Advancing Our Science & Art
Imagine DOcumentingPalpation & OMT
Several Important Objective Measures Useful in Teaching, Replicating & Documenting Procedures– Pressure / Force
– Duration & Frequency
– Direction
– Intra- & Inter- Examiner Reproducibility/Reliability
Useful in Conducting Studies of Inter-Examiner Reliabilitywww.FIMM-Online.com
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
3
Advantages of Adding High Tech
Only then can we begin to answer …
• Is it the type of “technique” itself?
• Is it presence or absence of SD?
• Is it the amount of pressure?
• Is it the duration of the OMT?
• Documents technique & assesses intra-examiner reliability
• Outside team can replicate the study parameters
• If pilot shows trend or other result, could design study for modifying “dosage” of pressure to see if modify outcomes
Example: Replicating Lymphatic Pump Parameters – Pedal Pump Equivalent
• Lymphatic Pump as commonly taught – 120-140 per min– “slosh” observed
• Compared hands-on to machine (accelerometer)
• Parameters measured – 130-138 / minute (95% CI)– 0.24 – 0.32 G-force (95%CI)
• Report for reproducibility; permit dose-response; etc
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
4
Alternative Line of Research on MOABiochemical Modulation?
Does lymphatic pump create shear forces/release eNOS?
“High-Tech” Enhancing “High Touch“
in Head/EENT/Cervical Research
AOA Research Convention
International Academy of MM Medicine
International Fascial Research CongressPart of 4 DO/MS Masters Theses
JAOA
Manuelle Medizin
J Bodywork & Movement Therapies
In conjunction with osteopathic students @
Philadelphia College of Osteopathic Medicine
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
5
Profession Needs Systematic Analysis of Structure – Function Inter-Relationships
eg: Parasympathetics (?)– CN X & the OM Suture– Proposed MOA’s ?– Goal(s) of OMT ?– Application(s) of OMT ?
• Need Document BOTHProcedures & Outcomes
• Build Upon Results: New Questions or ProtocolsKuchera. Osteopathic Considerations
in HEENT Disorders. Greyden; 2011
2 Occipitomastoid Suture TechniquesBroad Application Stim (?) Psym: “Slows Heart”
V-Spread to Remove SD? Treats Bradyarrhythmia
Broad contact version: Years of informal classroom observation in healthy subjects “slows” heart
AOA Fellowship2011-12 (J. Nelson)
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
6
Randomized, Controlled Pilot: CV Effect of OM Suture OMT
JNC 7 Pre- and Hypertensive Subjects (n=30) vs Normotensive Controls (n=30)
• Randomized 1 of 2 V-spread OMT techniques
• Rested / Supine Blinded BP, heart rate, pO2
• Wearing IsoTOUCH monitors, palpate for OM dysfunction (severity rated: 0-3) & deliver 5 minutes V-Spread (with documented pressures)
• Operator blinded to both CV & SD measures
• Blindly remeasure CV & SD parameters
• BP subject cross-over potential built in (min 4wk)
Right OM V Spread
-0.4-0.2
00.20.40.60.8
11.21.41.61.8
0 50 100 150 200 250
Time (half seconds)
Fo
rce
(lb
s)
Left Index
Left Middle
Left Thumb
Right Index
Right Middle
Right Thumb
Joint National Commission for ↑BP < 160/100; AOA/PCOM
Measuring a New Perspective:Role of CSF as “Lymphatic System” Equivalent for the Brain
• CNS Metabolites CSF Arachnoid Granulations Venous Sinuses Venous Sinus Drainage
• Gliovascular System
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
7
Enhancing Computer Software to Gather New Insights
• Simultaneous Physiological Input
• Physiological Maneuvers Changing Certain Values Relative to Other Values
• Enhanced Computer Analysis
• Mathematical Modeling
Eg: Moskalenko MethodCranial Compliance; CSF Flow
Cranial Compliance & CSF Mobility
(Evidence Based Measures)
Director, Center for Chronic Disorders of AgingDirector, Human Performance & Biomechanics Lab
Michael L. Kuchera, DO, FAAO
Philadelphia College of Osteopathic Medicine
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
8
Overview of This “New” Idea• High profile, high impact topic –
head trauma
• Important but controversial osteopathic approach – OCF
• Shift focus of prior research
• Employ state-of-art technology & methods
• Document impact on physiology
• Build on evolving evidence base
“High Profile – High Impact Topic”
Jan 11, 2012: Michelle Obama & Dr. Jill Biden announced JOINING FORCES @ Virginia Commonwealth University. AACOM joined AAMC leadership and member deans at the event.
Osteopathic medical college deans attending: • Marc B. Hahn, DO – UNECOM• Don N. Peska, DO – UNTHSC/TCOM• Thomas A. Scandalis, DO – NYIT/NYCOM• Anthony J. Silvagni, DO – Nova/SECOM• Dixie Tooke-Rawlins, DO – EV/VCOM• Kenneth J. Veit, DO, MBA – PCOM
All 26 COMs (+4 branches) signed pledge
Major Press Coverage
Nationwide Attention
Important
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
9
Traumatic Brain Injury (TBI) – A “Joining Forces”
Key Topic(AAO Next Year)
Example: Indiana University School of Medicine• "The IU School of Medicine has a focus on the
neurosciences, which goes hand in hand with treatment for post-traumatic stress disorder and traumatic brain injury, two of the unique health care needs of veterans cited by the Joining Forces initiative.“ – Dean D. Craig Brater
Mild Traumatic Brain Injury - Concussion
Is there a role for OMT? Osteopathic focus on somatic dysfunction of head
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
10
Mechanism of Injury Pathophysiology
• Swelling• Metabolites• Bleeding
Body Attempts to Heal (Homeostatic Mechanisms)
• CSF-Venous Drainage • Cranial Compliance
Condition: MildSevere
FUNCTIONAL GOALS OF INTRA-CRANIAL FLUIDS
• Deliver nutrition to brain tissue• Transport nutrition in brain tissue• Maintain water balance in brain tissue• Optimize intra-cranial stroke energy for
brain nutritional supply• Distribute blood & CSF in brain under
stress situations• Evacuate wastes from brain tissue
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
11
Problem
Too Much Intra-Cranial Fluid
Symptoms: Headache, Dizziness, Nausea/Vomiting, LethargyFatigue, Sleep Disturbances, Concentration & Memory Loss, Irritability, Visual Changes
Clinical Examples
Homeostatic Mechanisms• Increase cranial
sutural compliance• Down-regulate CSF
production by the choroid plexus
• Up-regulate absorption/drainage mechanisms viao Lymphatics (spinal
nerves & CNI [cribriform plate])
o Arachnoid granulations Venous sinuses
Improved Symptoms
&Resolution
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
12
Measurements of Cranial Compliance & CSF Distribution of Intra-Cranial Stroke Volume
New Ideas: Switch Homeostatic Emphasis from the Container to the Fluid
Old Approach1. “Cranial bones move”
2. OMT corrects cranial SD (container)
3. We find “SD” & claim OMT removes it
4. They challenge 1-3 but if accept any, they say “no EBM that SD is clinically relevant”
New Idea/Approach 1. Head trauma is a “container –
fluid imbalance” problem
2. OMT/OCF has measurable effect on total fluid (CSF)
3. Evidence base now; underlying mechanism later
4. Oh & by the way … there is a measurable change in cranial compliance too
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
13
/
Treatment Options For Pathophysiology
Rx for ContainerSurgical / TrephinationVentricular ShuntOMT Rx for Fluid
Ventricular ShuntMedicationsOMT
Homeostasis Overwhelmedin an Infant (Chronic)
Eg: Hydrocephalus & Shortened Life Span
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
14
/
Homeostasis Overwhelmedin an Adult (Chronic)
Nausea/VomitingHeadache/Dizziness
Lethargy/FatigueCognitive/Memory Loss
Visual Changes
Death
Nausea/VomitingHeadache/Dizziness
Lethargy/FatigueCognitive/Memory Loss
Visual ChangesDEATH
Eg: Hydrocephalus & Shortened Life Span
Rx for ContainerSurgical/TrephinationVentricular ShuntOMT
Ventricular ShuntMedications / OMT
Rx for Fluid
Improved Symptoms
&Resolution
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
15
Not Just For Head Trauma / TBIPre- and Post- OMT in:• Healthy MOA• Headache• Hypertension• etc
Cranial Compliance & CSF Removal of Metabolites / Waste in:• Dementia• Neurodegenerative
Disorders• etc
At PCOM, I was Clinic Director for the Center for Chronic Disorders of Aging
Healthy Aging
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
16
Blood Flow Changes with Agebut not everyone develops dementia
CSF Mobility Changes with Age(Note After Age 50 …. Hmmmm)
• Changes with age of CSF mobility, calculated as the average of two indices — “SQ” and “T”.
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
17
CSF Mobility & Cranial Compliance Change with Age
• Changes of indices reflecting CSF mobility and CC at different ages demonstrating right and left hemisphere asymmetry.
Dementia Stratification (78-84 y/o):Note: Cranial Compliance & CSF
• Changes of CBF, CSFm, CC at rest and during voluntary breath cessation for elderly persons 78–84 yrs old, divided into 4 groups with different cognitive capabilities (Prognosis-2) irrespective of age:
Group I: mentally healthy, Gr II: initial dementia, Gr. III: moderate dementia, Gr IV: pronounced dementia. Significance ∗ p > 0.1, ∗∗ p > 0.05.
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
18
Alzheimer Disease: Early Sign = Anosmia
Viral infection
That VooDO that You DO !?!New Opportunity to dispel
that opinion by …
• DOcumenting physiological changes made in vascular & CSF dynamics
• Calculating CSF mobility (CSFmo)
• Calculating Cranial Compliance (CC)
• DOcumenting the OMT techniques we use (site, pressure, duration, etc)
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
19
Transcranial Doppler/Rheoencephalography
Simultaneous recordings of transcranial dopplerography (TCD); rheoencephalography (REG) (fronto-mastoid electrode position), from left & right hemispheres &intracranial pressure (ICP) in cysternamagna in quiet, comfortably awake recumbent subject
Systems & Structures Responsible for Circulatory–Metabolic Supply of Brain Activity
Central ArterialPressure
HEART ACTIVITY Central Venous Pressure
Intracranial Pressure
Pulsations ofCentral Venous
Pressure
Pulsations ofCentral Arterial
Pressure
Brain Blood Flow & Nutrition Supply
CSF-VolumeBrain Volume
Quality of Cognitive Brain Activity
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
20
Equipment & Finding TCD “Window”
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
21
Transcranial Doppler (TCD) Finding the Windows
(Middle Cerebral Artery)
Adjust TCD power settings to identify exact site along the MCA bilaterally
Bilateral Middle Cerebral Arteries on Transcranial Doppler
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
22
Initial Spectrum- baseline reading of subject• Subject remains motionless with eyes closed for 1-2 minutes. • No outside stimulation
Repeated at end of treatment to see if changed or not
Rt TCD
Lt TCD
Rt REG
Lt REG
EXAMPLE: Stookey Test – Subject breathes normally while examinerapplies pressure (8 lbs.) to the abdomen – This increases venous returnand therefore increases both intra-cranial volume and pressure.
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
23
TCD/REG Measurement Protocol --Baseline Functions : OMT : Post-OMT FunctionsFunctional Tests to Physiologically Modulate Vascular Fluid Flow• Frequency Spectrum (1 minute)
• Respiratory cessation (30+ seconds)
• 7 seconds cessation after inhalation
• 7 seconds cessation after exhalation
• Hyperventilation (20 seconds)
• Stookey test (20 seconds)
• Frequency Spectrum (1 minute)
The significant waves in the spectrum analysis are shown here. The slow fluctuation and the primary cardiac wave are most important for the analysis. The respiratory wave will be used mainly for a reference point and the 2nd harmonic is not needed for the analysis.
Slow Fluctuation wave
Respiratory wave
Primary Cardiac wave
2nd Harmonic
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
24
Pre- CV4OMT
Doubled slow wave frequency≈ Increased blood flow to brain
Increase in Amplitude directly proportionate to increase in cranial compliance
2nd Harmonic arrival ≈ skull expansion; stems from energy increase of
the slow fluctuation
Post CV4 - Moskalenko Interpretation
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
25
• Moskalenko Method: Intracranial volume–pressure relations by analyzing TCD & REG changes during a cardiac cycle.
• (a) Equalize amplitudes.
• (b) Isolate TCD & REG changes on ascending and descending phases of the cardiac cycle.
• (c) Transform coordinate axis from “amplitude/time” to “TCD/REG”.
• (d) Change orientation of abscissa for descendant phase of cardiac cycle and its phase in the united graphic.
• (e) Calculate
Moskalenko Method in EvaluatingCRANIAL COMPLIANCE & CSF (Mobility)
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
26
Can measure right & left hemispheres
• Results of the calculations including cranial compliance on each hemisphere side and CSF flow for the cardiac cycle of a 26-year-old healthy man recorded at rest, in a comfortable horizontal position.
• Responses to holding breath & the Stookey test in a healthy young adult male. (Correspond to rest conditions in previous Figure.)
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
27
CSF mobility in response to voluntary breath holding for 30-seconds (27 y/o)
VOLUNTARY BREATH HOLDING
Research Protocol & Materials for CV4 Gathering Data for Moskalenko Method
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
28
Reproducibility Built Around IsoTOUCH® Pressure Sensitive Monitoring System
50 100 150 200
IsoTOUCH® Pressure SensorPalpation Monitor System
Non-invasive, pressure deformation sensors on finger pads & thenar eminences
Bluetooth data to computer for realtime graphic display of measured forces used during manual diagnosis and treatment of somatic dysfunction.
Better understanding of tissue loading, end-feel test impulses and OMT activation forces to diagnose or treat somatic dysfunction.
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
29
Volunteers experienced in palpation & MM
“High Tech” -- Sensitive 4 grams to 10 poundsLimitations: Direction - Traction
How does our touch compare?
Is my touch
anywhere near close?
I just can’t believe I’m
touching“the” Dr. Frymann!
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
30
TCD/REG Measurement Protocol --Baseline Functions : OMT : Post-OMT Functions
Repeat Functional Tests to Physiologically Modulate Vascular Fluid Flow
OMT selected with potential to modulate physiology:
• CV4
• Venous Sinus Drainage
• OM Suture Release
• Occipital Decompression
• Sub-Occipital Release
• Sham
-0.5
0
0.5
1
1.5
2
2.5
3
3.5
4
0 200 400 600 800 1000 1200
Time (sec)
Fo
rce
(lb
s)
CV4 Hold
Forc
e (l
bs)
1min 2min 3min 4min 5min
Still Point
CV4 Pressure measured using IsoTOUCH® Pressure Monitoring Sensor System (Thenar Pads bilaterally).
Only one pad displayed above. Report specifics in methods section to enhance reproducibility.
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
31
Right OM V Spread
-0.4-0.2
00.20.40.60.8
11.21.41.61.8
0 50 100 150 200 250
Time (half seconds)
Fo
rce
(lb
s)
Left Index
Left Middle
Left Thumb
Right Index
Right Middle
Right Thumb
Fluid direction 20-30 grams: left index-middle, Extension pulse toward Rt OM
V-Spread Pressure 0.5-0.8 lbsLateral fluctuation (peak=valley)
Right HandInitial 1.5 lb
V-SpreadNo waves
“Release” notedPhase restored
Synchronybtwn hands
etc
Rate CRI8/minute
PCOM 2005
Palpation Monitors
Example:
Plan of Action: First Show in Normal Population
• Write full protocol & grant application
• Recruit and train clinical research teams in TCD/REG
• Train in standardized OMM protocol
• Conduct & publish study data / results
• Share findings – AAO– Cranial Academy– ECOP– JAOA– Mainline basic
science journal
• Apply for larger externally funded study
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
32
Then Collaborative Research
Cranial Compliance &
CSF Flow
• Transcranial Doppler & Rheoencephalography
• Moskalenko Method
• CC: Altered in Dementia? In Multiple Sclerosis? In Head Trauma? In ADHD?
• See if ΔPre-Post OMT
Collegial DiscussionResearch Thoughts
Looking forward to further discussionPlease feel free to poke holes in any weak aspects of our new
ideas to make them (and us) stronger
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
33
Journal of Integrative Neuroscience, Vol. 10, No. 2 (2011) 131–160Imperial College Press DOI: 10.1142/S021963521100266X (Useful Synopsis Article of Method)
CHANGES OF CIRCULATORY–METABOLIC INDICES AND SKULL BIOMECHANICS WITH BRAIN ACTIVITY DURING AGING
Y. E. MOSKALENKO, N. A. RYABCHIKOVA, G. B. WEINSTEIN, P. HALVORSON and T. C. VARDY
Sechenov Institute of Evolutionary Physiology and Biochemistry of the Russian Academy of Sciences (Thorez Prosp. 44, St. Petersburg 194223, Russian Federation)
Dept. of Higher Nervous Activity, Biology Faculty; Lomonosov Moscow State University, Vorobyevi Gory (Moscow 119899, Russian Federation)
[email protected] 22 September 2010; Accepted 25 April 2011
Thanks & Acknowledgements Grant &/or equipment support• American Osteopathic Association• Bodiflo (equipment)• Neuromuscular Engineering grants and equipment• Non-Invasive Monitoring Systems (equipment)• Sigma Corporation (equipment)• USA Department of DefenceStudents & research coordinators of the Human
Perfomance & Biomechanics Laboratory at PCOM Pre- AND Post- OMT to Base of Skull, Upper Cervical & Venous Sinus