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TEACHING STRATEGIES: TEST ANXIETY: CAUSES AND REMEDIES
POSTURAL BALANCE AND GAIT IMPROVED WITH AN OSTEOPATHIC INTERVENTION IN A SPECIAL NEEDS POPULATION (SEE
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CASE REPORT OF OSTEOPATHIC TREATMENT OF INSOMNIA AND TRAUMATIC ANHIDROSIS (SEE ATTACHED)
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Rowan SOM University Commencement
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International Journal of Osteopathic Medicine (2016) xxx, xxxexxx
www.elsevier.com/ijos
CASE REPORT
Case report of osteopathic treatment of
insomnia and traumatic anhidrosis
Timothy Nobles a, Austin Bach b,*, David Boesler c
a
Nova Southeastern University College of Osteopathic Medicine, Davie, FL, USA
Nova Southeastern University College of Osteopathic Medicine, Larkin Community
Hospital, Beraja Medical Institute, Coral Gables, FL, USA
c
Department of Neuromusculoskeletal Medicine, Nova Southeastern University College
of Osteopathic Medicine, Davie, FL, USA
b
Received 14 July 2015; revised 10 November 2015; accepted 25 January 2016
KEYWORDS
Anhidrosis;
Insomnia;
Autonomic dysfunction;
Osteopathic manipulation
Abstract Insomnia and traumatic somatic dysfunctions are two very common
complaints that present in clinical practice. We present a case of a 28 year old
female complaining of chronic unilateral anhidrosis secondary to trauma and subacute insomnia. Somatic dysfunctions were noted and treated with a variety of
different osteopathic manipulations in one visit with maintenance osteopathic
manipulations at one week, one month, and six months after the initial visit. Both
symptoms resolved after the first visit and have yet to return. These results show
the efficacy of osteopathic manipulations in two of the more common complaints
seen in the office in both the subacute and chronic stages.
ª 2016 Elsevier Ltd. All rights reserved.
* Corresponding author. 7031 SW 62nd Ave, South Miami, FL 33143, USA. Tel.: þ1 (305) 284 7500.
E-mail address: DrAustinBach@gmail.com (A. Bach).
http://dx.doi.org/10.1016/j.ijosm.2016.01.006
1746-0689/ª 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Nobles T, et al., Case report of osteopathic treatment of insomnia and traumatic anhidrosis,
International Journal of Osteopathic Medicine (2016), http://dx.doi.org/10.1016/j.ijosm.2016.01.006
2
T. Nobles et al.
Implications for practice
This paper addresses one common medical
condition, insomnia, and anhidrosis, a more
uncommon condition, due to traumatic somatic dysfunction.
It shows the, nearly immediate, response of
the body to correction of proper anatomical
positioning in the correction of the autonomic
nervous system.
Introduction
The autonomic nervous system (ANS) is known to
control the vast majority of bodily functions. Understanding its parts, the sympathetic and parasympathetic nervous systems, and how they affect
the body enables us to understand why a patient
might be experiencing certain symptoms. We present a patient with two distinct autonomic dysfunctions, insomnia and anhidrosis, in the
subacute and chronic stages, respectively. She was
treated with a variety of osteopathic manipulations for each symptom which resulted in nearly
immediate resolution of these somatic dysfunctions to normalized physiologic function.
Case description
Patient history
A 28-year-old female occupational therapy student
presented complaining of insomnia for two
months. She stated that this started when she
separated from her husband. She also complained
of anhidrosis on the left side of her body for 5
years. This started after she was in a motor vehicle
accident. She was the driver, and the car was
struck on the driver side with her left arm hanging
out the window. The patient received no physical
harm to her arm as a direct result of the accident.
The patient has been doing Pilates-based exercise
since the accident to try to alleviate muscle pain/
tightness/spasms secondary to a herniated disc in
her cervical spine at the level of C6. She has not
been on any medications regularly except for
ibuprofen and acetaminophen, starting a few
months ago, for a prior podiatric surgery.
Examination and treatment
A full structural examination of the patient
revealed a number of somatic dysfunctions, most
notably in the cervical, thoracic, and lumbar
vertebrae. A somatic dysfunction is defined as an
“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.” Somatic dysfunctions include one or more
of the following classifications: tenderness, asymmetry, restriction of motion and tissue texture
abnormality. Osteopathic manipulative treatment
is used to correct any somatic dysfunction.1 The
lower cervical, full thoracic and lumbar spine
showed generalized muscle tightness with largely
asymmetric changes on the left. This is consistent
with a possible cause for chronic left sided anhidrosis from the car accident. The treatments provided were aimed at equalizing the muscle tone in
the cervical and thoracic areas. Multiple techniques were utilized including muscle energy,
facilitated positional release, and counterstrain.
Following normalization of muscle tone, bilateral
rib raising was performed to bring the upper
thoracic parasympathetics into a state of equilibrium. After relaxation of thoracic musculature, an
exhalation dysfunction of the fourth rib on the
left, which was causing pain with inhalation, was
fixed with a modified double arm thrust and all
lumbar, thoracic, and cervical vertebral dysfunctions were treated with direct techniques. Finally,
prone sacral rocking was performed for 3 min to
ensure that there were no other structural limitations to normal physiologic function and
occipito-atlantal decompression was performed
approximately 5e7 times for 3 min.
Follow-up
On her follow up, within the first week after
treatment, the patient stated that she was
sleeping better and was sweating equally on both
sides of her body. At this point, light muscle energy
and counterstrain treatments were performed for
approximately 20 min to the areas previously
treated with only minimal reversal of previously
relaxed musculature in the thoracic and cervical
spines noted on the structural exam. On her 1 and
6 month follow up appointments, her symptoms
were still abated and similar counterstrain and
muscle energy techniques were performed to the
thoracic and cervical spines for maintenance of
her previously chronic somatic dysfunctions. The
patient continues to do her Pilates-based exercises
and the practitioner explained the necessity of
working both sides of the body equally to prevent
re-exacerbating her somatic dysfunctions.
Please cite this article in press as: Nobles T, et al., Case report of osteopathic treatment of insomnia and traumatic anhidrosis,
International Journal of Osteopathic Medicine (2016), http://dx.doi.org/10.1016/j.ijosm.2016.01.006
Case report of osteopathic treatment
Discussion
This report describes a woman experiencing
insomnia, and unilateral anhidrosis. Insomnia is
classified as a sleepewake disorder according to
the DSM-5, where the person cannot initiate or
obtain quality sleep despite more than ample time
or opportunity. Insomnia affects approximately
one-third of all Americans, most vulnerable being
the middle-aged and elderly. Insomnia is brought
upon for many reasons including, psychiatric,
sleep apnea and other various disorders.2 In one
recent study, breathing problems were seen to be
more influential in developing insomnia when
compared to stress; a promising hypothesis to a
cause of insomnia due to difficulty breathing with
causing a drop in oxygen saturation to below
normal levels.3 Osteopathic manipulative treatment (OMT) has been shown to be an effective tool
at normalizing sympathetic and parasympathetic
activity by normalizing the tone in the thoracolumbar region.4 Seated rib raising is an OMT
used to normalize the tone in the thoracolumbar
region, which can then help normalize the airway
for more efficient breathing. In one study involving
a conventional care only group, light-touch treatment group, and an OMT group, the effects of OMT
on elderly patients with pneumonia showed a
decrease in the incidence of respiratory failure
and death relative to the conventional care only
(CCO) (standard care) group.5 CCO received direct
treatment by the attending physician that prescribed conventional pneumonia treatment with
antibiotics without any OMT. Furthermore, in
another study seated rib raising for greater than
90 s was proven to decrease the sympathetic nervous system activity.6
Insomnia finds itself as the most common
sleepewake disorder, with a higher prevalence in
women, up to 30%.7 Chronic insomnia and anhidrosis can be due to a variety of factors such as
biological, environmental, neurological, psychiatric and so forth.7 Anhidrosis is found in good proportion to be of idiopathic nature, however it can
be induced directly or indirectly by an alteration in
nerve supply. Furthermore, a majority of insomnia
sufferers and patients with anhidrosis are likely to
have somatic dysfunctions, noted as having even
slight tissue texture change, such as musculoskeletal pain that may play a role in the etiology of the
respective condition.8 Patients that have a chronic
sleep disturbance have proven levels of increased
ANS activity, involving an increase in metabolism,9
body temperature,10 electrodermal activity11 and
heart rate.12,13 Moreover, chronic insomniacs
3
display an increase in sympathetic output, due to
raised cortisol levels and an activation of the
hypothalamic-pituitary-adrenal
(HPA)
axis,
involving cortisol releasing hormone.14 Targeting
the somatic dysfunctions and normalizing the
sympathetic tone can potentially help regulate
this increase in ANS activity, as well as the underlying somatic dysfunctions commonly seen with
insomnia that can both be treated by OMT.15 The
sympathetic model of OMT focuses on rib raising,
soft tissue OMT, thoracolumbar OMT, paraspinal
inhibition and collateral ganglion inhibition. OMT
and its correlation with treating the autonomics
was performed in a study using myofascial release
to induce heart rate variability. Results were significant for the use of OMT in influencing sympathovagal equilibrium.16
The autonomic nervous system drives the
involuntary responses the body experiences
throughout each day. Anhidrosis is the lack of
sweat in the presence of elevated body temperature. A correlation between acute musculoskeletal
tissue injury and the autonomic nervous system
was found in a study noting a change in the autonomic nervous system toward a sympathetic control, associated with chronic pain. Furthermore,
by activating the sympathetic nervous system the
skin’s sweat glands become more active.17 Tight
thoracic musculature and somatic dysfunction of
the vertebrae can inhibit sympathetic activity
which control sweating and relaxing it will increase
the parasympathetic activity inducing normalization of sweat production.
Conclusion
In summary, this case study shows the benefits of
OMT on autonomic nerve dysfunction. Our patient
had prolonged suffering of her various symptoms
until she was treated with OMT. After one session
of OMT, her symptoms of insomnia and anhidrosis
resolved. She stated that she did not change anything else in her daily routine in the time leading
up to or following her treatment. This leads to, a
likely, direct correlation of our patient’s alleviated
symptoms being resolved with OMT. Although she
did Pilates-based exercises, which is a form of
exercise that can help with the mind and body, this
is unlikely to have contributed to normalizing
autonomic activity as these exercises had been
performed by the patient for years and there was
no change in her routine near the time of alleviation of symptoms. Other studies have
demonstrated a direct cause and effect through
Please cite this article in press as: Nobles T, et al., Case report of osteopathic treatment of insomnia and traumatic anhidrosis,
International Journal of Osteopathic Medicine (2016), http://dx.doi.org/10.1016/j.ijosm.2016.01.006
4
T. Nobles et al.
OMT and the autonomic nervous system being
altered. An example is Budgell et al showing OMT’s
effects on heart rate variability adding to the
notion that physiologic changes in the autonomics
are achieved through OMT.18 More research needs
to be done to prove that OMT helps regulate the
ANS.
Conflict of interest
None declared.
Ethical approval
This article and treatment of the patient were
done under ethical guidelines for treatment and a
single patient case report.
References
1. Treffer K, Ehrenfeuchter W, Cymet T, editors. Glossary of
osteopathic terminology. Chevy Chase, MD: Educational
Council on Osteopathic Principles of the American Association of Colleges of Osteopathic Medicine; 2011. https://
www.aacom.org/docs/default-source/insideome/
got2011ed.pdf?sfvrsn¼2.
2. Edinger J, Carney C. Overcoming insomnia: a cognitivebehavioral therapy approach therapist guide. 2nd ed. New
York: Oxford University Press; 2008.
3. Hynninen MJ, Pallesen S, Hardie J, Eagan TM, Bjorvatn B,
Bakke P, et al. Insomnia symptoms, objectively measured
sleep, and disease severity in chronic obstructive pulmonary
disease outpatients. Sleep Med 2013;14:1328e33. http://
dx.doi.org/10.1016/j.sleep.2013.08.785.
4. Kuchera M, Kuchera W. Osteopathic considerations in systemic
dysfunction. 2nd ed. Columbus, OH: Greyden Press; 1994.
5. Noll DR, Degenhardt BF, Morley TF, Blais FX, Hortos KA,
Hensel K, et al. Efficacy of osteopathic manipulation as an
adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial. Osteopath Med Prim
Care 2010;4:2. http://dx.doi.org/10.1186/1750-4732-4-2.
6. Henderson AT, Fisher JF, Blair J, Shea C, Li TS, Bridges KG.
Effects of rib raising on the autonomic nervous system: a
pilot study using noninvasive biomarkers. J Am Osteopath
Assoc 2010;110:324e30.
7. Thorpy MJ. The clinical use of the multiple sleep latency
test. The standards of practice committee of the American
sleep disorders association. Sleep 1992;15:268e76. http://
www.ncbi.nlm.nih.gov/pubmed/1621030.
8. Ohnmeiss D. Sleep disturbances in back pain patients. In:
Proceedings of the 30th annual meeting of the international
society for the study of the lumbar spine. Vol Vancouver,
BC, Canada; 2003.
9. Bonnet MH, Arand DL. 24-Hour metabolic rate in insomniacs
and matched normal sleepers. Sleep 1995;18:581e8.
10. Lushington K, Dawson D, Lack L. Core body temperature is
elevated during constant wakefulness in elderly poor
sleepers. Sleep 2000;23:504e10. http://www.ncbi.nlm.
nih.gov/pubmed/10875557.
11. Broman J, Hetta J. Electrodermal activity in patients with
persistent insomnia. J Sleep Res 1994;3:165e70.
12. Freedman RR, Sattler HL. Physiological and psychological
factors in sleep-onset insomnia. J Abnorm Psychol 1982;91:
380e9. http://dx.doi.org/10.1037/0021-843X.91.5.380.
13. Monroe LJ. Psychological and physiological differences between good and poor sleepers. J Abnorm Psychol 1967;72:
255e64. http://dx.doi.org/10.1037/h0024563.
14. Vgontzas AN, Bixler EO, Lin HM, Prolo P, Mastorakos G, VelaBueno A, et al. Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal
axis: clinical implications. J Clin Endocrinol Metab 2001;
86:3787e94. http://dx.doi.org/10.1210/jc.86.8.3787.
15. Kuchera ML. Osteopathic manipulative medicine considerations in patients with chronic pain. J Am Osteopath Assoc
2005;105:S29e36.
16. Henley CE, Ivins D, Mills M, Wen FK, Benjamin BA. Osteopathic manipulative treatment and its relationship to
autonomic nervous system activity as demonstrated by
heart rate variability: a repeated measures study. Osteopath Med Prim Care 2008;2:7. http://dx.doi.org/10.1186/
1750-4732-2-7.
17. Grimm DR, Cunningham BM, Burke JR. Autonomic nervous
system function among individuals with acute musculoskeletal injury. J Manip Physiol Ther 2005;28:44e51.
http://dx.doi.org/10.1016/j.jmpt.2004.12.006.
18. Budgell B, Hirano F. Innocuous mechanical stimulation of
the neck and alterations in heart-rate variability in healthy
young adults. Auton Neurosci Basic Clin 2001;91:96e9.
http://dx.doi.org/10.1016/S1566-0702(01)00306-X.
Available online at www.sciencedirect.com
ScienceDirect
Please cite this article in press as: Nobles T, et al., Case report of osteopathic treatment of insomnia and traumatic anhidrosis,
International Journal of Osteopathic Medicine (2016), http://dx.doi.org/10.1016/j.ijosm.2016.01.006
Checklist to Facilitate Cultural Competence in
Community Engagement
Excerpt from Policy Brief 4- Engaging Communities to Realize the
Vision of One Hundred Percent Access and Zero Health Disparities:
A Culturally Competent Approach
Community Engagement: Policy Implications for Primary Health Care Organizations
Health care organizations should give careful consideration to the values and principles that
govern their participation in community engagement. This checklist is designed to guide them in
developing and administering policy that supports cultural and linguistic competence in
community engagement.
Does the health care organization have:
A mission that values communities as essential allies in achieving its overall goals?
A policy and structures that delineate community and consumer participation in planning,
implementing and evaluating the delivery of services and supports?
A policy that facilitates employment and the exchange of goods and services from local
communities?
A policy and structures that provide a mechanism for the provision of fiscal resources and inkind contributions to community partners, agencies or organizations?
Position descriptions and personnel performance measures that include areas of knowledge
and skill sets elated to community engagement?
A policy, structures and resources for in-service training, continuing education and
professional development that increase capacity for collaboration and partnerships within
culturally and linguistically diverse communities?
A policy that supports the use of diverse communication modalities and technologies for
sharing information with communities?
A policy and structures to periodically review current and emergent demographic trends to:
– Determine whether community partners are representative of the diverse population in
the geographic or service area?
– Identify new collaborators and potential opportunities for community engagement?
A policy, structures and resources to support community engagement in languages other
than English?
•National Center for Cultural Competence• 3307 M Street, NW, Suite 401, Washington, DC 20007-3935•
•Voice: 800.788.2066 or 202.687.5387• TTY: 202.687.5503• Fax: 202.687.8899•
•E-mail: cultural@georgetown.edu• URL: http://gucchd.Georgetown.edu/nccc•
THE SOMATIC CONNECTION
The authors cite limitations of no randomization
some 15. Major clinical features of PWS are short
and participant self-referral by the parents. The au-
stature, obesity, scoliosis, developmental delay,
thors also suggest a possible gut-brain axis mecha-
muscular hypotonia, reduced physical activity, and
nism of action in which worsening of behavior
gait and postural disorders. Study participants
symptoms may be a result of inflammatory gut reac-
were 10 patients with genetically confirmed PWS.
tions mediated by immunologic signals. As a source
Two control groups were used: one of 15 obese
for such speculation, the authors cited the osteo-
individuals and another of 20 normal-weight
pathic research of Hodge et al.1,2
healthy participants. Obese participants were re-
This article demonstrates a possible benefit of
cruited among other inpatients in rehabilitation,
osteopathic intervention in this special needs popu-
and healthy participants were recruited from the
lation and thus warrants additional investigation.
institute staff. Exclusion criteria included history
(doi:10.7556/jaoa.2016.064)
of cardiovascular and neurologic conditions or
musculoskeletal complaints, vision loss, vestibular
Hollis H. King, DO, PhD
impairments, symptoms related to intracranial hy-
University of California,
pertension or use of neuro-active drugs, pregnancy,
San Diego School of Medicine
and substance abuse.
References
1. Hodge LM, Downey HF. Lymphatic pump treatment
enhances the lymphatic and immune systems [review].
Exp Biol Med (Maywood). 2011;236(10):1109-1115.
doi:10.1258/ebm.2011.011057.
2. Hodge LM, Bearden MK, Schander A, et al. Lymphatic
pump treatment mobilizes leukocytes from the gut
associated lymphoid tissue into lymph. Lymphat Res Biol.
2010;8(2):103-110. doi:10.1089/lrb.2009.0011.
The outcome measures were 3-dimensional gait
analysis and static posturography. The PWS participants were assessed on admission and 24 hours after
OMTh. One-time assessments were made with the
control participants.
Participants in the PWS and obese groups re-
ceived conventional treatment, but the PWS participants additionally received OMTh, which was
delivered in a single 45-minute session. This was a
pragmatic OMTh session delivered before any other
Postural Balance and
Gait Improved With an
Osteopathic Intervention in
a Special Needs Population
intervention or rehabilitation by a registered osteopath. Somatic dysfunction was assessed, and the
major sites addressed by OMTh were the spine, legs,
dural system, and thoracic respiratory diaphragm.
Vismara L, Cimolin V, Galli M, Grugni G, Ancillao A,
Capodaglio P. Osteopathic manipulative treatment
improves gait pattern and posture in adult patients
with Prader-Willi syndrome [published online
September 12, 2015]. Int J Osteopath Med.
2016;19:35-43. doi:10.1016/j.ijosm.2015.09.001.
Procedures used included “thrust,” muscle energy,
strain-counterstrain, and myofascial release.
Before treatment, the PWS group had a sig-
nificantly slower walk, shorter stride length, reduced cadence, and reduced postural stability
Researchers at the Istituto Auxologico Italiano in
compared with both control groups. After treat-
Piancavallo, Italy, evaluated the effects of a single
ment, the PWS participants showed significant
application of osteopathic manipulative therapy
improvement in knee and ankle kinematics with
(OMTh; manipulative care provided by foreign-
greater ground push-off force. Postural stability
trained osteopaths) on patients with Prader-Willi
also improved significantly, with reduced antero-
syndrome (PWS). This condition is a relatively
posterior and mediolateral sway. The authors
rare genetic disorder affecting a part of chromo-
noted the small sample size as a limitation, and
The Journal of the American Osteopathic Association
May 2016 | Vol 116 | No. 5
Downloaded From: http://jaoa.org/ by a Rowan University College of Osteopathic Medicine User on 05/02/2016
325
THE SOMATIC CONNECTION
they suggested that if verified by further research,
either OMTh or exercise twice a week for 4 weeks,
OMTh would show benefit and reduced cost in a
and each session was 30 minutes.
comprehensive rehabilitation program.
Each OMTh intervention was performed
This study was selected for review as demon-
by 2 osteopathy students under the supervision
strating a possible benefit of OMTh in patients
of a qualified osteopath. Techniques were individ-
with a genetic disorder and to highlight the further
ualized and included soft-tissue and joint mobili-
use of gait analysis and posturography in osteo-
zation, myofascial release, muscle energy,
pathic research. (doi:10.7556/jaoa.2016.065)
craniosacral release, and rib raising; no highvelocity, low-amplitude thrust was used. The same
Hollis H. King, DO, PhD
exercise protocol was used for all patients in the
University of California,
exercise group and included stretching for low
San Diego School of Medicine
back and abdominal muscles, isometric strengthening for back and hip extensors, and back sta-
Significant Benefit Shown
After Lumbar Disk Surgery
Rehabilitation by Inclusion
of Osteopathic Intervention
bility exercises using a Pilates exercise apparatus.
Outcome measures were made at baseline
(2-3 weeks after surgery) and after the final rehabilitation session (7-8 weeks after surgery).
Results showed that both groups improved on pri-
Kim BJ, Ahn J, Cho H, Kim D, Kim T, Yoon B.
Rehabilitation with osteopathic manipulative
treatment after disc surgery: a randomized,
controlled pilot study. Int J Osteopath Med.
2015;18:181-188. doi:10.1016/j.ijosm.2014.11.003.
mary outcome measures; however, post­surgical
The use of osteopathic manipulative therapy
VAS was reduced 53% in the OMTh group and
(OMTh; manipulative care provided by foreign-
17% in the exercise group, and residual back pain
trained osteopaths) in postoperative rehabilitation
reduced 37% in the OMTh group and 10% in the
after lumbar microdiskectomy was compared with
exercise group. Patients in both groups required
a standard exercise program in a major metropol-
less frequent use of medications—reduced 87% in
itan hospital in Seoul, South Korea. A total of 33
the OMTh group and 73% in the exercise group.
patients aged 25 to 65 years were randomly as-
Both groups were highly satisfied by their rehabili-
signed to the OMTh group (n=16) or exercise
tation, and there were no adverse events reported
group (n=17).
for either group.
Inclusion criteria were low back pain with re-
physical disability was more improved in the
OMTh group (54% vs 26%, P<.05). Although not
statistically significant, residual leg pain on
This study is the first to my knowledge that
ferred leg pain caused by imagery-verified herni-
assessed the use of osteopathic manipulation after
ated intervertebral disk at spinal levels L3-4, L4-5,
lumbar surgical care. I believe postsurgical use of
and L5-S1. Eight patients had more than 1 herni-
osteopathic manipulative treatment would be
ated disk. There were no statistically significant
beneficial for patients, and I hope this study is
differences between the groups.
replicated in the United States soon. (doi:10.7556
/jaoa.2016.066)
Primary outcome measures were the Roland-
Morris Disability Questionnaire and visual analog
scale (VAS) for pain. Secondary outcome measures were lumbar range of motion, use of medications, and patient satisfaction. Patients received
326
Hollis H. King, DO, PhD
University of California,
San Diego School of Medicine
The Journal of the American Osteopathic Association
Downloaded From: http://jaoa.org/ by a Rowan University College of Osteopathic Medicine User on 05/02/2016
May 2016 | Vol 116 | No. 5