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, FAAO Professor, Department OMM Marian 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
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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
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
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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)
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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)
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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)
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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)
• 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)
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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)
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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)
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)
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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)
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• 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)
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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)
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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)
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)
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
Michael L. Kuchera, DO, FAAO SAAO: "More Than We Ever Imagined"
Exploration of the World of Lympathics Osteopathic Research (March 2013)
34
Interpret Research Correctly!
Excellent health statistics … smokers are less likely to die of age-related illnesses!