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The Osteopathic Approach to the Flu Pandemic

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Dr. Richard Chmielewski, DO, FACEP, NMM/OMM lectured on the flu pandemic and the osteopathic approach to treating influenza through various techniques focused on circulation and the lymphatic system.
More information is available at http://falconclinic.com.

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The Osteopathic Approach to the Flu Pandemic

  1. 1. Pandemic Flu: Lessons from the Past…. Thoughts for the Future Richard Chmielewski, DO, FACEP, NMM/ OMM Board Certified, Emergency Medicine Board Certified, Neuromuscular Medicine/ Osteopathic Manipulative Medicine Falcon Clinic for Health, Wellness and Recovery St. Elizabeth Medical Center Utica, New York
  2. 2. I had a little bird, Its name was Enza. I opened the window, And in-flu-enza.
  3. 3. INFLUENZA – definition  The name influenza comes from the Italian influenza, meaning "influence" ( Latin: influentia). The most common symptoms of the disease are chills, fever, sore throat, muscle pains, severe headache, coughing, weakness and general discomfort.[1] Fever and coughs are the most frequent symptoms. In more serious cases, influenza causes pneumonia, which can be fatal, particularly for the young and the elderly. http://en.wikipedia.org/wiki/Influenza
  4. 4. The Influenza virus http://upload.wikimedia.org/wikipedia/commons/3/3b/3D_Influenza_virus.png
  5. 5. Flu Facts  Each year almost 35,000 Americans die from the flu and its complications  Because it is caused by a virus, anyone can get it  Kids under 5, adults over 50 and people with chronic medical conditions, such as asthma, chronic bronchitis or heart disease, are at high risk for complications.  Being immunized by a flu shot or the inhaled FluMist ( FDA- approved only for healthy people ages 5 to 49) significantly reduces the risk of getting the flu.  Most folks who get the flu shot have no reaction. Up to 25% may have some redness and slight swelling at the site. A small percentage may experience a slight fever, chills and headache within 24 hours. These symptoms end within a few days.  The flu virus mutates from year to year, so a vaccination from last season is ineffective against this year’s strains. USA Weekend – Oct 5-7, 2007
  6. 6. Flu Fiction  Flu is just a bad cold – although it’s considered a respiratory infection, it affects the entire body, causing high fever ( up to 104 F) that’s accompanied by body aches, headaches, nausea and dehydration. Even after the infection is gone ( it can last up to 2 weeks) people can be weak for several more days.  You can get the flu from the flu shot – No, you can’t. The vaccine is not made from a live virus  You can get the flu from wet hair or cold weather – No, you get the flu by coming into contact with someone who is infected. In the cold of winter, when people cluster indoors, exposure to the flu virus is more likely, but cold weather itself doesn’t cause the flu.  The flu shot is only for high risk people – False. People at high risk definitely need the vaccinatjon, but those at low risk also should get the shot to help keep the flu from spreading.  If I haven’t had the flu by December, I’m in the clear – Flu season can extend through May. Although it’s never too late in the season to get the shot, the ideal period for immunization is from mid-October to mid-November. USA Weekend – Oct 5-7, 2007
  7. 7. Modes of Transmission  Typically, influenza is transmitted through the air by coughs or sneezes, creating aerosols containing the virus. Influenza can also be transmitted by bird droppings, saliva, nasal secretions, feces and blood. Infection can also occur through contact with these body fluids or through contact with contaminated surfaces. Airborne aerosols have been thought to cause most infections, although which means of transmission is most important is not absolutely clear. Influenza viruses can be inactivated by sunlight, disinfectants and detergents.[4][5] As the virus can be inactivated by soap, frequent hand washing reduces the risk of infection. http://en.wikipedia.org/wiki/Influenza
  8. 8. Announcement of H1N1 Pandemic for 2009  the novel H1N1 flu outbreak was first detected in mid-April 2009  On June 11, 2009, the World Health Organization (WHO) signaled that a global pandemic of novel influenza A (H1N1) was underway by raising the worldwide pandemic alert level to Phase 6 .  This action was a reflection of the spread of the new H1N1 virus, not the severity of illness caused by the virus.  At the time, more than 70 countries had reported cases of novel influenza A (H1N1) infection and there were ongoing community level outbreaks of novel H1N1 in multiple parts of the world.
  9. 9.  From April 15, 2009 to July 24, 2009, states reported a total of 43,771 confirmed and probable cases of novel influenza A (H1N1) infection. Of these cases reported, 5,011 people were hospitalized and 302 people died  On July 24, 2009, confirmed and probable case counts were discontinued. Aggregate national reports of hospitalizations .
  10. 10. Total U.S. Novel H1N1 Flu Hospitalizations and Deaths Posted August 14, 2009, 11:00 AM ET Data reported to CDC by August 13, 2009, 2:00 PM ET Reporting States and Territories Hospitalized Cases Deaths 51 7,511 477 http://www.cdc.gov/h1n1flu/surveillanceqa.htm
  11. 11.  A CDC model was developed to try to determine the true number of novel H1N1 flu cases in the United States. The model took the number of cases reported by states and adjusted the figure to account for known sources of underestimation (for example; not all people with novel H1N1 flu seek medical care, and not all people who seek medical care have specimens collected by their health care provider). Using this approach, it is estimated that more than one million people became ill with novel H1N1 flu between April and June 2009 in the United States http://www.cdc.gov/h1n1flu/surveillanceqa.htm
  12. 12. How have different age groups in the United States been impacted by novel H1N1 flu in terms of infection rates?  The information analyzed by CDC supports the conclusion that novel H1N1 flu has caused greater disease burden on people younger than 25 years of age than older people. http://www.cdc.gov/h1n1flu/surveillanceqa.htm
  13. 13. Novel H1N1 Confirmed and Probable Case Rate in the United States, By Age Group http://www.cdc.gov/h1n1flu/surveillanceqa.htm#grapha
  14. 14. Spread of H1N1 Novel Flu in Poland May, 2009 June, 2009 July, 2009
  15. 15. Poland H1N1 ( swine flu) Statistics  The first H1N1 (swine flu) case in Poland was confirmed on May 7th, 2009 • As of August 21st, 2009 there are 153 confirmed cases of H1N1 (swine flu) in Poland • As of August 21st, 2009 there have been 0 H1N1 (swine flu) deaths in Poland  • The number of H1N1 (swine flu) infections in Poland has risen by -129 cases or -45.7% in the seven days between August 14th and August 21st. http://h1n1.flu-virus.org/Cases-.php?in=Poland
  16. 16. Fear and the Flu The Influenza Pandemic of 1918  The influenza pandemic of 1918-1919 killed more people than the Great War, known today as World War I (WWI), at somewhere between 20 and 40 million people. It has been cited as the most devastating epidemic in recorded world history. More people died of influenza in a single year than in four-years of the Black Death Bubonic Plague from 1347 to 1351. Known as "Spanish Flu" or "La Grippe" the influenza of 1918-1919 was a global disaster. http://www.stanford.edu/group/virus/uda/index.html
  17. 17. Many influenza experts, policy makers, and knowledgeable observers believe that a novel influenza A (H1N1) strain directly caused most deaths during the 1918–19 pandemic, often from a hemorrhagic pneumonitis that rapidly progressed to acute respiratory distress syndrome and death http://www.cdc.gov/eid/content/14/8/pdfs/07-1313.pdf
  18. 18. An illustration of what influenza can be like: a copy of a letter by Professor N R Grist (Glasgow) published in the British Medical Journal of 22-29 December 1979:-  “It is salutary to remember that we do not really understand why the devastating pandemic of 1918-19 was so severe, and that we cannot therefore be confident that our modern medical measures would succeed against a similar future challenge.” http://web.uct.ac.za/depts/mmi/jmoodie/influen2.html
  19. 19. An illustration of what influenza can be like: a copy of a letter by Professor N R Grist (Glasgow) published in the British Medical Journal of 22-29 December 1979:-  These men start with what appears to be an ordinary attack of LaGrippe or Influenza, and when brought to the Hosp. they very rapidly develop the most viscous type of Pneumonia that has ever been seen. Two hours after admission they have the Mahogany spots over the cheek bones, and a few hours later you can begin to see the Cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the coloured men from the white. It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate. It is horrible. One can stand it to see one, two or twenty men die, but to see these poor devils dropping like flies sort of gets on your nerves. We have been averaging about 100 deaths per day, and still keeping it up. There is no doubt in my mind that there is a new mixed infection here, but what I dont know. My total time is taken up hunting Rales, rales dry or moist, sibilant or crepitant or any other of the hundred things that one may find in the chest, they all mean but one thing here -Pneumonia-and that means in about all cases death.
  20. 20.  The effect of the influenza epidemic was so severe that the average life span in the US was depressed by 10 years.  The influenza virus had a profound virulence, with a mortality rate at 2.5% compared to the previous influenza epidemics, which were less than 0.1%.  The death rate for 15 to 34-year-olds of influenza and pneumonia were 20 times higher in 1918 than in previous years (Taubenberger). http://www.stanford.edu/group/virus/uda/index.html
  21. 21.  People were struck with illness on the street and died rapid deaths. One anectode shared of 1918 was of four women playing bridge together late into the night. Overnight, three of the women died from influenza (Hoagg). Others told stories of people on their way to work suddenly developing the flu and dying within hours (Henig).  One physician writes that patients with seemingly ordinary influenza would rapidly "develop the most viscous type of pneumonia that has ever been seen" and later when cyanosis appeared in the patients, "it is simply a struggle for air until they suffocate," (Grist, 1979).  Another physician recalls that the influenza patients "died struggling to clear their airways of a blood-tinged froth that sometimes gushed from their nose and mouth," (Starr, 1976).  The physicians of the time were helpless against this powerful agent of influenza http://www.stanford.edu/group/virus/uda/index.html
  22. 22.  The origins of the deadly flu disease were unknown but widely speculated upon.  Some of the allies thought of the epidemic as a biological warfare tool of the Germans.  Many thought it was a result of the trench warfare, the use of mustard gases and the generated "smoke and fumes" of the war http://www.stanford.edu/group/virus/uda/index.html
  23. 23.  Meanwhile the new sciences of the infectious agents and immunology were racing to come up with a vaccine or therapy to stop the epidemics
  24. 24.  Those who were lucky enough to avoid infection had to deal with the public health ordinances to restrain the spread of the disease. The public health departments distributed gauze masks to be worn in public. Stores could not hold sales, funerals were limited to 15 minutes. Some towns required a signed certificate to enter and railroads would not accept passengers without them. Those who ignored the flu ordinances had to pay steep fines enforced by extra officers (Deseret News). Bodies pilled up as the massive deaths of the epidemic ensued. Besides the lack of health care workers and medical supplies, there was a shortage of coffins, morticians and gravediggers (Knox). The conditions in 1918 were not so far removed from the Black Death in the era of the bubonic plague of the Middle Ages.
  25. 25.  Patients with the influenza disease of the epidemic were generally characterized by common complaints associated with the flu. They had body aches, muscle and joint pain, headache, a sore throat and a unproductive cough with occasionally harsh breathing (JAMA, 1/25/1919). The most common sign of infection was the fever, which ranged from 100 to 104 F and lasted for a few days. The onset of the epidemic influenza was peculiarly sudden, as people were struck down with dizziness, weakness and pain while on duty or in the street (BMJ, 7/13/1918). After the disease was established the mucous membranes became reddened with sneezing. In some cases there was a hemorrhage of the mucous membranes of the nose and bloody noses were commonly seen. Vomiting occurred on occasion, and also sometimes diarrhea but more commonly there was constipation (JAMA, 10/3/1918). A few physicians associated psychoses with influenza infection. One article says that "the frequency of mental disturbances accompanying the acute illness in the epidemic has been the subject of frequent comment," (JAMA, 1/25/1919) The danger of an influenza infection was its tendency to progress into the often fatal secondary bacterial infection of pneumonia. In the patients that did not rapidly recover after three or four days of fever, there is an "irregular pyrexia" due to bronchitis or broncopneumonia (BMJ, 7/13/1918). The pneumonia would often appear after a period of normal temperature with a sharp spike and expectorant of bright red blood. The lobes of the lung became speckled with "pneumonic consolidations." The fatal cases developed toxemia and vasomotor depression (JAMA, 10/3/1918). It was this tendency for secondary complications that made this influenza infection so deadly. http://www.stanford.edu/group/virus/uda/fluscimed.html
  26. 26. Medical Signs/ Tests monitored during the 1918-1919 Influenza Pandemic  Temperature  Pulse rate  Respiratory Rate  Occasional chest x-ray  The Wasserman Reaction – testing the blood for antibodies  White blood cell count  Urine albumin  Sputum , nasopharyngeal and blood cultures (Commonly found were pneumococcus, streptococcus, staphylococcus and Bacillus influenzae (JAMA, 4/12/1919)
  27. 27. Treatment during the 1918-1919 Influenza Pandemic  Aspirin  Sialicin  cinnamon in powder or oil form with milk to reduce temperature (BMJ, 10/19/1918 )  Epinephrine injections for secondary pneumonia  Oxygen either by mask or injected under the skin  Quinine  Rest, fluids and nourishment  The serum of convalescent patients was used to treat influenza patients  Digitalis  Isotonic Glucose, IV  Sodium Bicarbonate, IV http://www.stanford.edu/group/virus/uda/fluscimed.html
  28. 28. Nonpharmaceutical Interventions Associated with Lower Overall Mortality Rates Systematic analyses of mortality data from large US cities have shown that nonpharmaceutical interventions (e.g., isolation, quarantine, closing schools, banning public gatherings) were associated with lower influenza-related mortality rates during the autumn of 1918 (33). Given the rapidity of spread of the pandemic, reductions of mortality rate associated with nonpharmaceutical interventions are unlikely to have been primarily related to reductions of influenza transmission (particularly in large US cities during wartime). http://www.cdc.gov/eid/content/14/8/pdfs/07-1313.pdf
  29. 29. A call to focus on prevention more than just on treating the influenza  We suggest that preparations for the next influenza pandemic should focus on more than  preventing and treating influenza virus infections. A modified influenza pandemic plan might  include the following components: 1) Before a pandemic, expand indications for and decrease  barriers to receipt of vaccination against S. pneumoniae (36–38,40). 2) During a pandemic, in  communities not yet affected, universally vaccinate with a safe and effective strain- specific  influenza vaccine, if available. 3) During local epidemics, treat all serious clinical cases with an  antibacterial agent that is effective against S. pneumoniae, S. pyogenes, H. influenzae, and S.  aureus (including methicillin-resistant S. aureus); isolate patients with clinical cases from other  patients and as many others as possible (35,37–39). 4) Conduct pandemic-related surveillance  that tracks the incidence, nature (e.g., species, affected sites, antimicrobial drug sensitivities),  and outcomes of bacterial infections that complicate influenza cases.  Given highly variable colonization and drug-sensitivity patterns across http://www.cdc.gov/eid/content/14/8/pdfs/07-1313.pdf
  30. 30. Novel H1N1 Vaccination Recommendations  CDC’s Advisory Committee on Immunization Practices (ACIP), a panel made up of medical and public health experts, met July 29, 2009, to make recommendations on who should receive the new H1N1 vaccine when it becomes available
  31. 31. Groups to be initially vaccinated with the Novel H1N1 Flu Vaccine becomes available  Pregnant women  Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants less than 6 months old might help protect infants by “cocooning” them from the virus;  Healthcare and emergency medical services personnel All people from 6 months through 24 years of age  Children from 6 months through 18 years of age Young adults 19 through 24 years of age Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.  Seasonal flu and novel H1N1 vaccines may be administered on the same day. http://www.cdc.gov/h1n1flu/vaccination/acip.htm
  32. 32. How to prevent the spread of the virus  Take everyday actions to stay healthy  Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.  Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol- based hands cleaners are also effective.  Avoid touching your eyes, nose or mouth. Germs spread that way.  Stay home if you get sick. CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them. http://www.cdc.gov/h1n1flu/vaccination/public/vaccination_qa_pub.htm
  33. 33. Making a vaccine against the novel H1 N1 influenza virus  Isolates sequenced at WHO and CDC suggest that circulating novel 2009-H1N1 influenza viruses look similar to A/California/07/2009 (the reference virus selected by WHO as a potential candidate for the new H1N1 vaccine )
  34. 34. Vaccination  Given the current lack of information to the contrary,  it is prudent to assume that 2 doses of pandemic virus  vaccine might be necessary for individual protection.  The number of doses required will be adjusted as and  when more information becomes available. http://www.who.int/wer/2009/wer8430.pdf
  35. 35. The clinical spectrum of pandemic A (H1N1) 2009 virus infection is broad  mild upper respiratory tract illness with or without fever  and occasional gastrointestinal symptoms such as vomiting  or diarrhoea and exacerbation of underlying conditions,  to severe complications such as pneumonia resulting  in respiratory failure, acute respiratory distress syndrome  (ARDS), multi-organ failure and death. http://www.who.int/wer/2009/wer8430.pdf
  36. 36.  Gastrointestinal symptoms, including vomiting and diarrhoea,  have been reported in up to 50% of patients  with mild to moderate illness not requiring hospitalization.
  37. 37.  While the vast majority of cases have resulted in mild, self-limited ILI, the global death toll caused by pandemic A (H1N1) 2009 influenza virus infection was 460 (as of 9 July 2009) in only 3 months since its inception and will soon exceed the total mortality caused by highly pathogenic avian influenza A (H5N1) virus infection since 2003.
  38. 38.  The main reason for hospitalization remains lower respiratory illness due to primary viral pneumonia, often described as “viral pneumonitis,” reflecting direct viral invasion in lung tissues.  Preliminary pathological findings  including diffuse alveolar damage, haemorrhagic  interstitial pneumonitis with lymphocyte proliferation  and a relative paucity of neutrophils (suggestive of viral  pneumonitis) and ARDS. Secondary bacterial pneumonia  has been infrequently documented but has been  found in some autopsied cases (in Chicago (USA) and  Manitoba (Canada)).
  39. 39.  In the USA, >70% of hospitalized patients  and approximately 80% of fatal cases have had underlying  conditions considered high risk for complications  of seasonal infl uenza. Severe cases and deaths have  been reported in pregnant women from all sites, especially  in their third trimesters, with intrauterine fetal  demise or spontaneous abortion; in some cases, treating  physicians have performed emergency Caesarean section  to rescue mother and baby.  A high prevalence of obesity in very severe or fatal  cases was initially reported from clinicians in Mexico
  40. 40.  a  considerable proportion of severely ill patients have not  received infl uenza antivirals until very late in the course  of their illness. A frequently reported pattern is for clinicians  to start empirical antimicrobial therapy for  community-acquired pneumonia, while deferring antiviral  therapy until laboratory test results have confi  rmed H1N1 infection. Where pandemic A (H1N1) 2009  infl uenza virus activity has been detected in the community,  clinicians should not delay antiviral treatment,  especially for patients with pneumonia or progressive  lower respiratory tract symptoms. Empirical antiviral  treatment with a neuraminidase inhibitor (oseltamivir  or zanamivir) should be initiated as soon as possible  upon hospital admission for any suspected case of pandemic  infl uenza.
  41. 41. Tamiflu ( oseltamivir phosphate)  Tamiflu twice daily for 5 days for acute illness, start within the first 2 days  Tamiflu once daily for 10 days as prophylaxis, after exposure, or community outbreak of H1N1 influenza.
  42. 42. Tamiflu
  43. 43. Relenza (zanamivir)  Delivered by blister pack inhalation of powder using a special dispersal device.  Each blister pack has 5 mg. Dose is two of the 5 mg blisters, twice daily, about 12 hours apart for 5 days for people over 7 yr old.  Prophylaxis is one blister pack, 5 mg, once daily for 10 days.
  44. 44. Relenza
  45. 45. The Osteopathic Approach to the FluThe Osteopathic Approach to the Flu PandemicPandemic Why?Why?
  46. 46.  During the Spanish influenza pandemic, an  estimated 30% of the world’s population became ill and 50  million people died Johnson NP, Mueller J. Updating the accounts: global mortality of the 1918-1920 “Spanish” influenza pandemic. Bull Hist Med. 2002;76:105-15.
  47. 47.  Effective vaccines will be difficult to produce before a novel human pandemic strain emerges and will take substantial time to manufacture and distribute in quantity.  The world’s annual production capacity for influenza vaccine is 300 million doses - enough for 4.5% of the world’s population.  These facts have caused some governments to develop response plans to pandemic influenza that involve creating antiviral stockpiles and increasing the capacity to handle surges in the need for medical care.
  48. 48. A case series report of Vietnamese patients with H5N1 influenza suggested that:  “supportive care may be the only option available”. Even if more effective standard pharmaceutical treatments are produced, it is unlikely that sufficient quantities will be rapidly or widely available because of financial, logistical, and health care delivery limitations. Tran TH, Nguyen TL, Nguyen TD, Luong TS, Pham PM, Nguyen VC, et al. Avian influenza A (H5N1) in 10 patients in Vietnam. N Engl J Med. 2004; 350:1179-88
  49. 49.  It may very well be that, depending on the availability of resources including antiviral drugs, hospital beds, ICU beds, respirators, antibacterial antibiotics, personnel healthy enough to care for the sick, the treatment of a massive H5N1 “Avian Influenza” pandemic will include many different approaches.
  50. 50. WHAT ABOUT OSTEOPATHYOSTEOPATHY?
  51. 51.  The philosophy and methodology of Osteopathic Medicine was founded by Dr. Andrew Taylor Still in the 1870s.
  52. 52.  He served as a surgeon in the Union Army during the Civil War. By the early 1870's Still criticized the misuse by doctors of drugs common to the day. Still supported a different philosophy of medicine: He advocated the use of osteopathic manipulative treatment. Still's philosophy focused on the unity of all body parts. He identified the musculoskeletal system as a key element of health. He recognized the body's ability to heal itself and stressed preventive medicine, eating properly, and keeping fit.
  53. 53. Osteopathy is about Circulation The Rule of the Artery reigns Supreme…. Andrew Taylor Still, MD, DO
  54. 54. http://static.howstuffworks.com/gif/adam/images/en/lymphatic-system-picture-c.jpg
  55. 55. Fluids, macromolecules, and cells extravasated from blood capillaries enter lymphatic capillaries in peripheral tissues and are then transported via the larger collecting lymphatic vessels and the thoracic duct back to the blood vascular system for recirculation. http://www.nature.com/jid/journal/v126/n10/fig_tab/5700464f1.html
  56. 56. Cellular level Lymph node level http://www.precadet.com/english/health_issues/lymphaticsystem.html
  57. 57. Osteopathy is “Leveropathy” The philosophy and techniques of OSTEOPATHY are not about treating bone disorder or “popping joints” to make a noise. That doesn’t heal anything. The body’s FASCIA, which contains all of the elements of the nervous system and circulatory system, attach at some point to various bony structures in the body. By using the bones as LEVERS ( thus, “leveropathy”), an osteopathic physician can affect the various elements of the circulatory and nervous system. This assists in making the body more effective in the healing process of many disorders.
  58. 58. Andrew T. Still, M.D., D.O. “ I have successfully treated many cases of pneumonia, both lobar and pleurotic, by convecting the ribs at their spinal articulations… I carefully adjust misplaced ribs…”
  59. 59. Andrew T. Still, M.D., D.O. “The osteopathic prognosis for speedy relief of influenza is good when the osteopath has been called to the case within reasonable time.”
  60. 60. Spanish influenza-what and why? E.E. Tasker, D.O. J.A.O.A. 1919 Volume 19 Insurance companies 13% deaths due to influenza and 87% due to pneumonia 1,350 D.O.s1,350 D.O.s 43,500 cases of flu43,500 cases of flu only 160 deaths160 deaths (apparent 0.375% mortality vs. 2.5%) at the allopathic rate, would have expected death toll of 2,1752,175 from cases treated by D.O.s
  61. 61. One hundred thousand cases of influenza with a death rate one-fortieth of that officially reported under conventional medical treatment R.K. Smith, M.D., D.O. J.A.O.A. 1920 Volume 19  2,445 D.O.s  sometimes 100-120 cases per physician  1/40th the mortality rate of patients treated by MDs
  62. 62. CRITIQUES  Not “statistical enough” – “it’s only a survey” • Statistics as we understand it now doesn't really come around until the middle of the 20th Century. Surveys were the best available.
  63. 63. CRITIQUES  D.O.s were concentrated in rural and mid-country regions that were not as hard hit as urban and coastal regions  True and False – Most of the osteopathic schools were in the middle of the United States but several were in urban areas and Philadelphia and Los Angeles both had schools.  D.O.s migrated all over the country  D.O.s comprised <5% of the physicians but were responsible for treating 10% of the population (M.D.s were inducted into the armed services and served in WWI as officers and D.O.s were not if they were above the typical draft age)
  64. 64. CRITIQUES  Osteopathy was a “drugless” approach and some of the benefits may have been because allopathic physicians may have used dangerous or lethal interventions
  65. 65. “In a non-controlled observational study that lacked today's rigorous scientific standards, Smith reports that patients that received [OMT] had a mortality rate of 0.25% as compared to the 5% for those that did not receive manipulative treatment.” One Hundred Thousand Cases of Influenza With a Death Rate of One-Fortieth of That Officially Reported Under Conventional Medical Treatment (LETTER) JAOA • Vol 108 • No 9 • September 2008 • 484-530 MarkAlain Déry, DO, MPH, Fellow, Infectious Diseases Tulane University School of Medicine Section of Adult Infectious Diseases New Orleans, La
  66. 66.  J.A.O.A. January 1919  62 cases  9 developed pneumonia  7 bronchopneumonia - 2 lobar pneumonia  1 case developed edema glottitis and required surgery  2 cases terminal  “When rib mobility is re-established in pneumonia, your case has progressed far towards recovery.”
  67. 67. C. Earl Miller, D.O.  Prolific writer and teacher on Lymphatic fluid techniques (1920’s)  So much so that thoracic pump technique has been referred to as the eponymous“Miller thoracic pump technique”
  68. 68.  J.A.O.A. January 1919  Description of physical and clinical signs associated with pneumonia  “Pneumonia may be defined from an osteopathic viewpoint, as a general infection with local manifestations in the lungs.”  “Osteopathic lesions present in all pneumonia cases.”  “We have it from many of our most reliable (osteopathic) physicians that they have treated 100, 200, or 300 cases of lobar pneumonia without a single fatality.”  Estimates less than 2% mortality vs. 10-25 %2% mortality vs. 10-25 % otherwiseotherwise
  69. 69.  M.A.Lane also author of rare but informative book on Dr. Still  Experiment with rabbits exposed to antigen treated with manipulation  Possible relationship of continued manipulation on rise in antibody levels
  70. 70.  J.A.O.A. February 1922  Canadian D.O. wrote on specific findings and treatment of Lymphatic tissues  Textbook devoted specifically to treatment of lymphatics  Brief treatments repeated several times per week
  71. 71. The effect of direct splenic stimulation on the cells and antibody content of the blood stream in acute infectious diseases Castillo - Ferris – Swift- 1934  Splenic stimulationSplenic stimulation  increase in leukocyte count in 80% cases  average increase 2,000 cellsaverage increase 2,000 cells  shift to the rightshift to the right (mature cells)  increase in opsonic index in >80%opsonic index in >80% cases with expulsion of formed antibodies into the general circulation  decrease in erythrocyte count in 75% cases  bacteriolytic power of serumbacteriolytic power of serum increased in 68%increased in 68%
  72. 72. Revisiting Castlio and Ferris-Swift's Experiments on Direct Splenic Stimulation in Patients With Acute Infectious Disease Donald R. Noll, DO; Jane C. Johnson, MA; Joseph E. Brooks, DO  Results: Contemporary statistical analysis confirms a modest posttreatment increase in leukocytes, a decrease in erythrocytes, a decrease in the Arneth index, and an increase in reticulocytes after the application of direct splenic stimulation for patients diagnosed with acute infectious disease. Contemporary reanalysis also confirms statistically significant posttreatment changes in the immune function tests. Findings were less conclusive for the leukocyte differential cell counts and for the effect of varying the number of splenic compressions.  Conclusions: Analysis of Castlio and Ferris-Swift's 1934 data using contemporary statistical methods supports many of their original conclusions. However, faults in study design common to that era limit the article's applicability for modern researchers. Additional research on splenic pump techniques using contemporary study designs and statistical methods is recommended. JAOA • Vol 108 • No 2 • February 2008 • 71-79
  73. 73.  J.A.O.A. November 1939  Comparison Los Angeles County Osteopathic Hospital vs. N.Y.C. Municipal Hospital  Bronchopneumonia  10.66 vs. 29.6% mortality10.66 vs. 29.6% mortality  Lobar pneumonia  11.2% vs. 10.8%11.2% vs. 10.8%
  74. 74.  Osteopathic Annals 1982, Vol. 10 No. 3  Study published in J.A.O.A. 1982  all subjects inoculated with pneumovaxall subjects inoculated with pneumovax - polyvalent vaccine  study subjects treated twice daily for one weektreated twice daily for one week  study subjects showed a significant increase insignificant increase in antibody response to many of the sub-antibody response to many of the sub- serotypesserotypes when compared to matched control subjects
  75. 75. Comparison of thoracic manipulation with incentive spirometry in preventing postoperative atelectasis Sandra L. Sleszynski, D.O. and Albert F. Kelso, Ph.D.  J.A.O.A. August 1993  One year randomized researcher blinded trial  21 received thoracic lymphatic pump and 21 received incentive spirometry  Atelectasis occurred in 2/21 (5%) patients regardless of treatment (predicted value for postoperative patients is 15-20%)  Thoracic lymphatic pump treated patients had earlier recovery and quicker return toward preoperative values for FVC and FEV1 than treated by incentive spirometry
  76. 76. thoracic pumpthoracic pump incentiveincentive spirometryspirometry pre-op day 1 day 2 day 3 day 4 day 5 0.4 0.6 0.5 0.9 0.7 0.8 1.0Forcedvitalcapacity
  77. 77. Transient basophilia following the application of lymphatic pump techniques: A pilot study  7 study subjects  All received lymphatic pump technique  pectoral traction and splenic pump  blood samples collected at 15, 30, 60, 120, and 240 minutes after treatment  All subjects showed significant basophilia  5 Control subjects  None received lymphatic pump technique  No change in white blood cell count  Significance is that Basophils and Mast cells may play a more significant role in initial immune response
  78. 78. Effect of lymphatic and splenic pump techniques on antibody response to hepatitis B vaccine: A pilot study  Experimental (n=20) vs. control (n=19)  Vaccinated at 0, 5, and 25 weeks with recombinant hepatitis vaccine  Experimental group received OMT 3x/week for 2 weeks after each vaccination  50% of experimental group reached protective antibody levels on 13th week vs. 16% of controls
  79. 79. Increased Lymphatic Flow in the Thoracic Duct During Manipulative Intervention E. Marty Knott, OMS V; Johnathan D. Tune, PhD; Scott T. Stoll, DO, PhD; H. Fred Downey, PhD JAOA • Vol 105 • No 10 • October 2005 • 447-456
  80. 80. Abdominal OMT Thoracic OMT Exercise
  81. 81. WHAT SHOULD WE DO?WHAT SHOULD WE DO? OMTOMT Osteopathic Manipulative Treatment
  82. 82. Influenza Epidemic or Pandemic? Time to Roll Up Sleeves, Vaccinate Patients, and Hone Osteopathic Manipulative Skills Gilbert E. D'Alonzo, Jr, DO AOA Editor in Chief JAOA • Vol 104 • No 9 • September 2004 • 370-371
  83. 83. Thank you………

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