Osteopathic manipulative treatment (OMT) for MDs: piloting a longitudinal curriculum

Context Under the Accreditation for Graduate Medical Education (ACGME) single accreditation system, there is likely to be increasing interest and opportunity for teaching osteopathic manipulative treatment (OMT) to allopathic residents and residency faculty. When learning OMT, allopathic physicians (MDs) have distinct needs compared with osteopathic medical students. For example, MDs already have a foundation in anatomy and medical vocabulary, but incorporating an osteopathic approach to patient care may require a paradigm shift. Thus, a unique approach to osteopathic education for MDs in residency programs with osteopathic recognition (OR) is needed. Objective To create a longitudinal OMT elective for allopathic residents and residency faculty and assess its impact on attitudes and confidence regarding osteopathic principles and treatment. Methods Drawing from standard texts used during preclinical osteopathic education, a blended online and in-person laboratory modular curriculum for the OMT elective course was developed by osteopathic residents and faculty within the Department of Family Medicine and Community Health at the University of Wisconsin in Madison. The modalities of muscle energy, counterstrain, myofascial release, and soft tissue were included; the curriculum also reviewed autonomic physiology, somatovisceral, and viscerosomatic reflexes. A quality improvement study of the course was conducted via pre- and postcourse surveys to assess its impact on perceptions and confidence regarding the theory and practice, referral, and use of OMT. A precourse survey was distributed before the first module to obtain background information and assess participants’ prior OMT exposure, among other things. Nine months after the course ended, a corresponding postcourse survey was distributed. Pre- and postcourse surveys were individually matched to improve statistical analysis, using unique identifiers. Also, following each laboratory, a postlaboratory survey was collected about the participant’s experience for that lecture and for laboratory-specific quality improvement purposes. Two years after course completion, graduates were reached via phone or email for informal interviews to assess the perceived long-term impact from the elective. Results Eleven MDs from a total potential pool of 26 residents and approximately 120 attending physicians enrolled in the course; eight (72.7%) completed all modules and pre- and postcourse evaluations. Participants reported statistically significant gains in attitudes and confidence regarding OMT (“knowledgeable regarding OMT principles”: precourse mean, 2.50 [0.76], vs. postcourse mean, 3.37 [0.52]; p=0.021; “know how to treat using OMT”: precourse mean, 2.25 [1.39], vs. postcourse mean, 3.12 [1.25]; p=0.041). Several participants (five; 62.5%) had completed prior OMT training. There was an increase, albeit nonsignificant, in the use of OMT, with more providers using OMT (precourse mean, five, vs. postcourse mean, six; p=0.171), and providers using OMT more often (precourse OMT use monthly or more often, three, vs. postcourse OMT use monthly or more often, six; p=0.131). Conclusion Implementing a longitudinal elective curriculum is a feasible way to improve attitudes and confidence in OMT for MDs involved in a family medicine residency. Whether our elective leads to competency in OMT for allopathic residents and faculty remains to be formally evaluated. Our pilot established the feasibility and led to a revision of our curriculum; the elective continues to occur yearly. Future analyses will focus on competency assessment.

Topical intranasal lidocaine is not a sphenopalatine ganglion block

There is renewed interest in the central role of the sphenopalatine ganglion (SPG) in cerebrovascular autonomic physiology and the pathophysiology of different primary and secondary headache disorders. There are diverse neural structures (parasympathetic, sympathetic and trigeminal sensory) that convene into the SPG which is located within the pterygopalatine fossa (PPF). This makes the PPF an attractive target to neuromodulatory interventions of these different neural structures. Some experts advocate for the nasal application of local anesthetics as an effective route for SPG block with the belief that the local anesthetic can freely access the PPF. It is time to challenge this historical concept from the early 1900s. In this daring discourse, I will review anatomical studies, CT and MRI reports to debunk this old myth. Will provide anatomical evidence to explain that all these assumptions are untrue and the local anesthetic has to magically ‘travel’ a distance of 4–12 mm of adipose and connective tissue to reach the SPG in sufficient concentration and volume to effectively induce SPG blockade. Future research should focus on assessing a clinical biomarker to confirm SPG blockade. It could be regional cerebral blood flow or lacrimal gland secretion.

The Bright Sides of Sadness in Late Life

Sadness is often thought of as unpleasant and dysfunctional. Yet, evolutionary-functionalist approaches and discrete emotional aging frameworks suggest that sadness is an emotion that helps us deal with loss and thus may become particularly salient and adaptive in late life. This talk presents findings from a multi-study, multi-method research program using age-diverse samples and experimental and longitudinal study designs. Findings show (1) intact or elevated levels of sadness responding in late life (i.e., higher sadness expressions in response to distressing film clips; higher coherence between sad facial expressions and autonomic physiology in response to film clips depicting loss; stability in sadness behaviors in marital conflict interactions). Moreover, (2) higher levels of sadness responding are linked to adaptive outcomes in late life (i.e., higher social connectedness, higher compensatory control strategies) with some effects generalizing across age groups (i.e., links between sadness coherence and well-being). Implications for future research are discussed.

Sympathetic and parasympathetic involvement in time constrained sequential foraging

Appraising sequential offers relative to an unknown future opportunity and a time cost requires an optimization policy that draws on a learned estimate of an environment’s richness. Converging evidence points to a learning asymmetry, whereby estimates of this richness update with a bias toward integrating positive information. We replicate this bias in a sequential foraging (prey selection) task and probe associated activation within two branches of the autonomic system, sympathetic and parasympathetic branches, using trial-by-trial measures of simultaneously recorded cardiac autonomic physiology. In general, lower value offers were accepted during periods of autonomic drive, both in the sympathetic (shorter pre-ejection period PEP) and parasympathetic (higher HF HRV) branches. In addition, we reveal a unique adaptive role for the sympathetic branch in learning. It was specifically associated with adaptation to a deteriorating environment: it correlated with both the rate of negative information integration in belief estimates and downward changes in moment-to-moment environmental richness, and was predictive of optimal performance on the task. The findings are consistent with a parallel processing framework whereby autonomic function serves both learning and executive demands of prey selection.Significance statementThe value of choices (accepting a job) depends on context (richness of the current job market). Learning contexts, therefore, is crucial for optimal decision-making. Humans demonstrate a bias when learning contexts; we learn faster about improvements vs deteriorations. New techniques allow us to cleanly measure fast acting stress responses that might fluctuate with trial-by-trial learning. Using these new methods, we observe here that increased stress – specifically sympathetic (heart contractility) – might help overcome the learning bias (making us faster at learning contextual deterioration) and thereafter guide us toward better context appropriate decisions. For the first time we show that specific building blocks of good decision-making might benefit from short bursts of specific inputs of the stress system.

Parasympathetic and Sympathetic Activity Are Associated with Individual Differences in Neural Indices of Selective Attention in Adults

Multiple theoretical frameworks posit that interactions between the autonomic nervous system and higher-order neural networks are crucial for cognitive regulation. However, few studies have directly examined the relationship between measures of autonomic physiology and brain activity during cognitive tasks, and fewer studies have examined both the parasympathetic and sympathetic autonomic branches when doing so. Here, 93 adults completed an event-related potential (ERP) auditory selective attention task concurrently with measures of parasympathetic activity (high-frequency heart rate variability; HF-HRV) and sympathetic activity (pre-ejection period; PEP). We replicate previous findings showing effects of selective attention on mean amplitude of the N1 ERP component (Hillyard et al., 1973; Coch et al., 2005), and extend this result to show that the effects of selective attention were associated with baseline values of HF-HRV and PEP. Individuals with higher resting HF-HRV and shorter resting PEP showed larger effects of selective attention on their ERPs. Follow-up regression models demonstrated that HF-HRV and PEP accounted for unique variance in selective attention effects on N1 mean amplitude. These results are consistent with the neurovisceral integration model, which posits that greater parasympathetic activity is a marker of increased cognitive capacity, as well as other theoretical models which emphasize the role of heightened sympathetic activity in more efficient attention-related processing. The present findings highlight the importance of autonomic physiology in the study of individual differences in neurocognitive function, and given the foundational role of selective attention across cognitive domains, suggest that both parasympathetic and sympathetic activity may be key to understanding variability in brain function across a variety of cognitive tasks.

Facial Expression Is Driven by Appraisal and Generates Appraisal Inference

Emotion researchers generally concur that most emotions in humans and animals are elicited by the appraisals of events that are highly relevant for the organism, generating action tendencies that are often accompanied by changes in expression, autonomic physiology, and feeling. Scherer’s component process model of emotion (CPM) postulates that individual appraisal checks drive the dynamics and configuration of the facial expression of emotion and that emotion recognition is based on appraisal inference with consequent emotion attribution. This chapter outlines the model and reviews the accrued empirical evidence that supports these claims, covering studies that experimentally induced specific appraisals or that used induction of emotions with typical appraisal configurations (measuring facial expression via electromyographic recording) or behavioral coding of facial action units. In addition, recent studies analyzing the mechanisms of emotion recognition are shown to support the theoretical assumptions.

Autonomic Physiology

Autonomic physiology encompasses diverse interactions between the nervous system and visceral effector organs, and their impairment in many neurological disorders can be measured noninvasively. Autonomic outflow is organized neuroanatomically and functionally. Sympathetic and parasympathetic nerves coordinate the cardiovascular, peripheral vascular, and sudomotor responses that regulate blood pressure, heart rate, thermal equilibrium, and other automatic bodily functions. Knowledge of autonomic physiology is key to the recognition and diagnosis of autonomic failure, orthostatic hypotension, autonomic neuropathies, localizable regional autonomic disorders, neurodegenerative and general medical disorders that affect autonomic function. An important example is neurogenic orthostatic hypotension, which can result from impaired sympathetic vasoconstriction of peripheral vascular beds, impaired carotid baroreflex responses, or impaired autonomic influence on cardiac output. Another example is thermoregulatory failure from ineffective cutaneous sudomotor or vasomotor responses. Accurate measurement and valid interpretation of autonomic responses in the clinical laboratory rest on an understanding of autonomic physiology.