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    Association between GDF5 single nucleotide polymorphism rs143383 and chronic lower back pain
    (2019-03-05) Phillips, Nicole R.; Aryal, Subhash; Licciardone, John C.; Tran, Apollo
    Introduction. Low back pain presents a unique and ongoing challenge for patients and physicians. Of those who experience an episode of low back pain, 10% go on to develop persistent chronic low back pain (CLBP). However, the cause of this progression is not understood and it is unclear why the clinical manifestation of CLBP differs across individuals. There is a large body of evidence demonstrating the role of genetics as a risk factor CLBP. Growth factor differentiation factor 5 (GDF5) is a protein involved in the growth and development of bone and cartilage. A variant of GDF5, single-nucleotide polymorphism (SNP) rs143383 has been implicated with increased susceptibility and severity of musculoskeletal disorders such as osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis. Considering that the cause of low back pain often involves musculoskeletal pathology, rs143383 may be implicated with symptomatology and the progression to persistent CLBP. Objective. This study seeks to determine whether the rs143383 SNP is associated with pain severity in CLBP. We hypothesize that subjects with the CC genotype experience higher levels of pain compared to the TT and CT genotypes. Methods. This project is an observational cohort study based on data retrieved from The Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION). Subjects were divided into three groups, TT, CT, and CC. Average pain levels based on the Numerical Rating Scale (NRS) for low back pain were compared among the groups. Results. Using a general linear model, we found that the rs143383 SNP was significantly associated with NRS scores (P = 0.001). We also found that the CC genotype had a statistical higher mean NRS score than the CT (P = 0.0370) and TT (P = 0.0004) genotypes. However, when the data was adjusted for race, ethnicity, gender and age, no significance was found between rs143383 and NRS scores. Conclusion. Our findings indicate that there is no association between the GDF5 rs143383 polymorphism after adjusting for race and ethnicity. We were unable to complete a stratified analysis due to the distribution of participants in each strata. Larger studies should consider a stratified analysis to determine whether there is an association between rs143383 and CLBP within different ethnicities and racial groups.
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    Effects of Practicing Osteopathic Manipulative Treatment (OMT) on Hand Function
    (2019-03-05) Chang, Mary OMS-III; Patterson, Rita PhD; Surve, Sajid DO; Barnum IV, Frederick DO
    Purpose: Practitioners who use osteopathic manipulative treatment (OMT) rely on their hands to diagnose and treat patients. While the general population’s hand functionality declines with age, OMT practitioners seem to maintain hand strength and function as they age. Although majority of studies involving OMT examine its effects on patients, there is scarce research on how its practice affects practitioners. The purpose of this cross-sectional study was to assess OMT practitioners’ hand functionality by measuring grip strength and comparing it to published gender- and age-matched normative data. We hypothesized that OMT practitioners’ grip strength is maintained/improved versus non-OMT-practitioners of the same gender and age despite increasing age. Methods: 264 OMT practitioners at the American Academy of Osteopathy (AAO) Convocation (90 subjects in 2017 & 164 in 2018) provided self-reported demographic data via Qualtrics, such as age, gender, height, weight, number of hours per week average OMT performed over career, and number of total years of OMT practice. Then, their intrinsic and extrinsic grip strength was measured with a pinch gauge and Jamar dynamometer, respectively. Finally, anthropometric data was collected, such as hand length using a tape measure and hand volume using a volumetric dunk tank. Results: OMT practitioners’ grip strength decline was calculated at -1.9 pounds over 5 years (lb/5y) for males and -1.0 lb/5y for females. Their decline rate was less than published normative data (males -4.2 lb/5y, females -2.4 lb/5y). Other collected data is currently undergoing analysis and significance has yet to be determined. In the next phase of data collection, we plan to investigate participants’ hand usage outside of OMT practice, what types of OMT they are utilizing, if practitioners have ever injured their hands while performing OMT, and if they have previously completed the study. Conclusion: The grip strength results suggest that osteopathic physicians who practice OMT slow the rate of decline of their hand function as they age rather than experience the more rapid decline seen in the general population. Data analysis supports that OMT physicians maintain hand strength, possibly due to the nature of using their hands more than the general population. The results from this study serve as the first database of grip strength normative data not just for OMT practitioners, but physicians overall.
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    Effect of Palpatory Neuromodulation of the Trigeminal Nerve for Tenderness in the Posterior Neck Musculature
    (2019-03-05) Vaghasia, Miral; Fulda, Kimberly; Hensel, Kendi; Hansen, Malinda
    Purpose: The trigeminal nerve coordinates several reflexes in the head, including a head-retraction reflex (HRR) when a stimulus comes close to the face. HRR utilizes the posterior neck musculature (PNM) to remove the face from potential danger. PNM has been identified as a possible source of discomfort in headaches, muscular tightness, and chronic neck pain. Neuromodulation is the mechanical, electrical or magnetic stimulation used to affect a change in the signaling circuitry of a nerve to affect how sensory inputs are processed via neurotransmitters. Our goal in using neuromodulation on the trigeminal nerve where it exits the face is to influence the circuitry of this reflex to decrease the tension and pain of the posterior neck musculature. Osteopathic manipulative treatment (OMT) has many modalities, one of which is using constant palpatory pressure, or inhibition, for relief of discomfort. Typically, inhibition has been used with muscular tender points and other somatic issues. We are using the OMT palpatory pressure on specific points of the face where the branches of the trigeminal nerve are known to reside. This study investigated change in tenderness of the PMN before and after using an OMT-based neuromodulation intervention as constant pressure on facial trigeminal points. We hypothesized a decrease in tenderness of the PNM after the intervention. Methods: Fifty-two out of 100 subjects have been recruited thus far, 9 of which were excluded for no discomfort on initial assessment. The PNM was assessed for tenderness bilaterally using a 0-10 pain scale. If tenderness was present, the V1 and V2 branches of the trigeminal nerve endings on the face were assessed with an average pressure of 1.5±.21 lbs (left hand) and 1.6±.25 lbs (right hand), then given the 30-second neuromodulation OMT intervention. Using the IsoTouch system, average pressure used for intervention was 1.92 ±.16 lbs (left) and 1.92 ±.34 lbs (right). Results: The average change in pain pre to post PNM right versus left side is R 1.50±1.54 and L 1.48±1.44. Conclusions: The variability seen in the 52 subjects in our pre to post-intervention suggests neck pain is a multifaceted issue. The range of how the tenderness changed could indicate a role for the HRR circuitry as a target for neuromodulation. Length of neuromodulation, the amount of pressure used, and indication for intervention are all possibilities for future research. Study funded by American Osteopathic Association #291PIT1811606
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    Proximal Hamstring Tendinopathy Secondary to Malalignment Syndrome and the Effects of Running on Cross-Sloped Surfaces: A Case Report
    (2019-03-05) Vicenzi, Scott
    Background Patients with proximal hamstring tendinopathy (PHT) will typically report deep buttock or thigh pain that increases with running speed which may also flare with prolonged sitting. Malalignment refers to a minimal displacement from the normal alignment of any of the bones that results in abnormal biomechanical stresses. The effects of running on cross-sloped surfaces (i.e. cambered) involve asymmetrical forces that can predispose to malalignment. This case report serves to remind the clinician to check for pelvic malalignment early in the treatment of PHT and other common running injuries, provides recommendations for effective screening and treatment measures, and demonstrates that running on cross-sloped surfaces is involved in the development of pelvic malalignment. History A 19 year old male D1 collegiate long-distance runner initially presented with left buttock pain of 3 months duration. Over the course of the subsequent 7 years he experienced increasing pain in his right shin and tibial tuberosity, increasing soreness in his right calf, right Achilles tendinopathy, plantar fasciitis, and a left lateral ankle sprain. Physical Exam Significant Findings: -Right anterior rotated innominate -Left innominate inflare -Right leg shortened when moving from supine to sitting -Reduced ROM and flexibility on left when performing seated IT band stretch MRI of left hip: -Partial-thickness tearing at the ischial attachment of the left semimembranosus tendon Treatment and Outcomes Ineffective: -Physical therapy (hamstring strengthening, massage, EMS, LED, US, ice, heat) and Aleve -Active Release Technique and Graston -Left ischial tuberosity bursal injection with Marcaine and Methylprednisolone -1/8 inch right heel lift Effective: -Running on opposite side of road to reverse angle of cross-slope -Daily Muscle Energy treatment of left innominate inflare and right anterior innominate Conclusions Distance runners should avoid running on cross-sloped surfaces; regular reversal of direction is necessary. The seated IT band stretch may be a more suitable measure than Ober’s test to use in the clinical setting, both as a diagnostic and therapeutic tool when assessing for IT band contraction and innominate inflare. The IT band contraction and inflare are directly associated with the PHT and a result of adaptation to cross-slope; they may be a common etiology and should be investigated further. Daily treatment is necessary or the patient will fall back out of alignment.
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    Osteopathic Manipulation for Genital Pain - A Case Report
    (2019-03-05) Smith, Vincent; Liu, Howe; Mason, David; Li, Nick
    Abstract Background: For U.S. Osteopathic Manual Medicine (OMT) physicians, there is an over emphasis on medication, rather than the usage of manual diagnosis and therapy. We report a rare case of idiopathic penile pain that, after conventional means failed, was resolved by OMT treatment. Case Information: A 54-year-old male presented with acute genital pain that was accompanied by dysuria. The patient reported his pain to be a 9 out of 10. His symptoms would come intermittently, lasting about 10 minutes before slowly receding away. The patient was initially treated with acupuncture and pain medicine, yet his symptoms persisted. The patient was then referred to a physician who had previously studied OMT, who utilized his knowledge of anatomy and the palpation technique to differentially diagnose the source and cause of the symptoms. With the use of Ligamentous Articular Strain Technique (LAS) and the High Velocity-Low Amplitude (HVLA) technique, the patient reported relief after 1st session of treatment on the 1st day, .and a full recovery after two extra treatments in next two consecutive days. Conclusions: This was our first time treating this kind of medical problem with the OMT. It was treated following a comprehensive history-taking and physical exam. The differential diagnoses of this case suggest that an anatomical analysis, detailed physical exam, and specific palpation should be combined with exploratory therapy. This type of treatment approach should be used by practicing OMT physicians in order to improve patient care.
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    Association of ABCB1 (rs1045642) single nucleotide polymorphism and drug metabolism reserve index (DMRI) with pain intensity among adults with chronic low back pain
    (2019-03-05) Licciardone, John C.; Phillips, Nicole R.; Salman, Justin
    Purpose Low back pain is the leading cause of disability in the United States. It is often associated with long term opioid use, which may lead to opioid misuse and serious adverse events. Current clinical guidelines caution that opioids may provide only a small to moderate therapeutic effect, despite these potential risks. This study explores the use of pharmacogenetics in patients with chronic low back pain who are managed with opioids by investigating nucleotide variants in ABCB1,a gene implicated in drug bioavailability. Additionally, a three gene model using CYP2D6, CYP2C9, and CYP2C19, will be used to determine opioid drug metabolism on a quantitative scale. We aim to identify pharmacogenetics variants that may lead to safer and more effective treatment of chronic low back pain in patients being managed with opioids. Methods This study included 102 patients with low back pain within the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION). All patients in the study reported using opioids for their low back pain. DNA genotyping of biological samples from all patients was conducted on Illumnina iScan Global Screening Array. A common SNP locus (C3435T, rs1045642) in ABCB1was genotyped. Additionally, SNPs for CYP2D6, CYP2C9, and CYP2C19 were used to construct the drug metabolism reserve index (DMRI) for each patient, which was then stratified as Sub-functional (DMRI 6). Outcome measures included a numerical rating scale for low back pain intensity, the Roland-Morris Disability Questionnaire, and the PROMIS-SPADE cluster for quality of life. The Mann-Whitney test was used for statistical analysis in SPSS. Results Patients with the T allele at rs1045642, which inhibits ABCB1 protein function and increases drug bioavailability, reported significantly lower pain intensity within the functional DMRI group (p = 0.01). However, there was no significant difference in pain intensity with the sub-functional DMRI group (p = 0.186). Conclusion The results suggest that gene variants in ABCB1 may potentially affect pain relief in opioid users, and may be useful in guiding opioid prescribing for pain management. Longitudinal pharmacogenetic studies in larger cohorts are necessary to establish the utility of such gene variants in ABCB1 in guiding safer and more effective pain management in patients with low back pain.
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    Complex Regional Pain Syndrome Presenting Similar to A Myocardial Infarction: A Case Study
    (2019-03-05) Lee, Yein; Crow, Thomas; Nguyen, Ryan
    Background: Complex Regional Pain Syndrome (CRPS) is a disease of chronic pain often times arising after an initial triggering event (i.e., surgery, trauma, stroke etc.) that is refractory to normal pain management. CRPS is classified into type I and type II. Type I is absent of a nerve injury, while type II has a nerve injury. Both can present with symptoms of abnormalities in skin blood flow, edema, spontaneous pain, and hyperalgesia. The current mechanism of action of this syndrome is poorly understood, however it is believed that the trigger alters the autonomic nervous system, chronically stimulating the affected region. We report a patient who has a history of a myocardial infarction that left him with chronic chest and left arm pain refractory to pain management. Case Presentation: A 50-year-old male with a history of coronary artery disease in native artery, hypertension, hyperlipidemia, obesity, diabetes, and one prior myocardial infarction presented with severe chest pain located in the middle to upper left chest region that radiated to the left arm. He states that the pain is a 10/10, sharp, and burning. The pain that radiates to his arm is debilitating. He reports similar pain in the past with marked swelling and decreased range of motion in his left upper extremity. He says he has been suffering this chronic pain associated with episodes of intense pain since his myocardial infarction. He has been to the emergency room numerous times in the past for similar symptoms, which were all negative for any acute coronary syndrome. Conclusion: CRPS Type I often arises after an inciting event without any underlying nerve damage and usually affects a patient’s extremities. Since a uniform treatment for CRPS does not currently exist, treatment is usually patient specific and varies from neuromodulation, medications, nerve blocks, physical therapy, and regional anesthesia. Treatments are aimed at reducing a patient’s pain back to their baseline. Sympathetic nerve blocks provided the best relief of symptoms for our patient. The distribution of our patient’s chronic pain closely resembles the pain pattern seen in a patient suffering from a myocardial infarction. This unique presentation can help remind physicians that we should have an open mind to all possible differentials, and that we should pay close attention to our patients’ stories and physical exam to help us provide appropriate, cost-effective care for our patients.
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    Osteopathic Manipulative Treatments to Improve Functionality of Parkinson’s Disease: Case Study
    (2019-03-05) Henke, Austin
    Background: Parkinson’s is a progressive neurodegenerative disease, second most common neurodegenerative disease. Standard of care is generally pharmacologic treatment with Levodopa, as it manages the bradykinesias, tremors and rigidity. The muscles become rigid with increased tone; symptoms can become exaggerated by pain, spasms and facial restrictions. Several methods of adjunct therapy are researched and attempted to improve the quality of life in patients with Parkinson’s disease. Applying OMT to the joints and key muscles of posture/walking, improve the severity rigidity, allowing for increase usage of muscles; resulting in improvement in QoL and ADLs. Case Information: The patient is an 80-year-old male presenting to OMM Clinic seeking to improve function with Parkinson’s disease. The patient initially presented with mild Parkinsonian symptoms- such as minimal shuffled gait, worsened balance, and restricted sits to stand. Pharmacological treatment was Carbidopa 25mg- levodopa 100mg QID. He ambulates, when pain and rigidity symptoms are worse with bilateral walking poles. The gait was described as minimal shuffle, minimal rigidity of elbows and worsened throughout presentation. OMT was performed by a board certified osteopathic physician, and was applied regularly to major joints. The patient reports after OMT, he has improved range of motion and gait. A witnessed participation that occurred between the patient and the researcher revealed that the patient walked in with rigidity and need for walking poles, but walked out with smooth gait no assistive devices. Conclusion: While Parkinson’s disease is a progressive neuromuscular disease, quality of life can continue to remain stable with adjunct therapies such as OMT and exercise. This case demonstrates that improved movement and postural stability can occur after addressing range of motion, leading to improved QoL. With rigidity, muscles can become restricted and exaggerated pain/spasms. While neurodegeneration is of central origin, the peripheral manifestations are pain and shortened muscle fibers from chronic tone with OMT to remain relaxed for greater lengths of time. OMT treatments target these muscle fibers by attempting to reset the muscle spindle reflex. With improved hamstrings, hip flexors, and decreased flexion bias of the torso, this patient was able to stand with better posture and improved fluidity.