Somatic Dysfunction: a Principled Approach to Diagnosis and the Selection of OMT Modalities

Somatic Dysfunction: A Principled Approach to Diagnosis and the Selection of OMT Modalities

Raymond J. Hruby, DO, MS, FAAODist SPECIAL COMMUNICATION

Introduction From the Western University of Health Sciences College It is well established within the osteopathic medical profession of Osteopathic Medicine of the Pacific (WesternU/COMP) that our founder, Andrew Taylor Still, MD, DO, did not write in Pomona, California. technique manuals.1 He did not provide detailed descriptions for performing osteopathic structural examinations (OSE), nor did Financial disclosure: none reported. he provide step-by-step instructions for selecting and performing osteopathic manipulative techniques. Instead, he avoided such Correspondence address: approaches, admonishing his students to first be thoroughly knowl- Raymond J. Hruby, DO, MS, FAAODist edgeable about normal human anatomy and physiology, and thus Department of OMM be able to more easily recognize when abnormalities are present. In 309 E. Second St. short, knowledge of which body structures demonstrated “anatomi- Pomona, CA 91766-1854 cal obstructions” would lead to an understanding of the result- (909) 469-5289 ing “physiologic discord.” In turn, this would lead to the correct [email protected] diagnosis of the patient’s condition and the selection of treatment approaches most likely to be successful. Submitted for publication October 7, 2015; final revi- sion received January 28, 2016; accepted for publication In the case of structural diagnosis and manipulative treatment, March 3, 2016. Still was confident that this approach would allow the osteopathic physician to design rational treatments and apply the most appro- Board certified in family medicine and in neuromusculo- priate maneuvers and activating forces, resulting in the restoration skeletal medicine and osteopathic manipulative medicine of normal structural relationships and improvement in physiologic (NMM-OMM), Dr Hruby was the 1990-91 president of the function, facilitating the patient’s return to a state of health and Academy, and he is editor emeritus of The AAO Journal. In wellness. 2015, Dr Hruby was named a fellow of distinction of the AAO. With this in mind, this article proposes that osteopathic physicians (DOs) can use their knowledge of the anatomy, physiology, and Dr Hruby has been a professor of osteopathic manipula- biomechanics of specific musculoskeletal tissues and structures to tive medicine (OMM) and family medicine at WesternU/ rationally establish the presence of somatic dysfunction. Further- COMP for 16 years. He also has chaired the Department more, DOs can recognize which musculoskeletal elements (such of OMM there. as bone, joint capsule, muscles, ligaments, and so on) are most predominantly involved. Using their knowledge of functional anat- In addition to his DO degree, Dr Hruby holds a bachelor’s omy, physiology, and biomechanics, DOs can then more accurately degree in psychology and a master’s degree in computer judge what types of manual approaches and activating forces will science. be most successful in alleviating the patient’s somatic dysfunctions. DOs also use knowledge of osteopathic manipulative treatment (OMT) to judge which modalities would be most appropriate. The Tissues and Structures result will be a more accurate selection of OMT modalities that will Associated With Somatic Dysfunction prove to be more successful in re-establishing optimal structure- Somatic dysfunction is defined as “impaired or altered function function relationships for any given patient. of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vas-

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The AAO Journal • Vol. 26, No. 1 • March 2016 Page 7 (continued from page 7) Figure 1. Mesenchyme is the stem tissue of all the connective tissues of the body. cular, lymphatic, and neural elements.”2 Put another way, somatic dysfunction may be viewed as restricted motion of musculoskeletal Meninges structures, which in turn may compromise related arterial, venous, Mesenchyme lymphatic and neural structures, leading to abnormal physiologic Muscle functions. When DOs palpate for somatic dysfunction, they are palpating specific musculoskeletal tissues and structures: bone, joint capsule, cartilage, ligament, tendon, muscle, and fascia. DOs palpate for certain characteristics (Tissue texture abnormalities, Asym- metry, Restriction of motion, and Tenderness—commonly referred Cells Protein fibers to by the acronym TART) that indicate the presence of somatic Ground substance dysfunction.

The above-mentioned musculoskeletal tissues and structures have at least 1 commonality among them: they all arise from the same embryologic tissue, namely mesenchyme (see Figure 1). Mesen- Matrix chyme is the stem tissue of all the connective tissues of the body. Connective tissues have cells and an extracellular matrix: In many types of connective tissue, the matrix-secreting cells are called fibroblasts. Frequently, an abundance of other cell types (eg, macro- phages, mast cells, lymphoid cells) may also be present. The extra- Connective tissue cellular matrix consists of ground substance and fibers. Ground substance consists largely of proteoglycans and hyaluronic acid, and there are 3 types of fiber secreted by connective tissue cells: collagen fibers, reticular fibers, and elastic fibers. The exact type of each- con nective tissue is determined by the ratio of cells to fibers within the extracellular matrix.3(p91),4(pp159-160) Proper Specialized

Connective tissue itself is divided into 2 types: connective tissue Figure 1. The embryologic origin of connective tissue. proper and specialized connective tissue (see Figure 1). Connective Figure 2. Connective tissue proper can be divided into loose and dense connective tissues. tissue proper can be further divided into loose and dense connective tissues (see Figure 2). The 3 types of loose connective tissue Connective tissue proper are: areolar, adipose, and reticular.5(pp36-42) Of particular interest to

DOs is loose areolar connective tissue, which is what is commonly referred to when dealing with OMT techniques that involve treat-

6(pp78-80) ing fascial or myofascial somatic dysfunctions. Dense Loose Dense connective tissue also has 3 types: regular, irregular, and elastic. Dense regular connective tissue is the basis for the formation of tendons, ligaments, and aponeuroses. Dense irregular connective tissue is found in tissues such as the dermis, fibrous capsules, peri- osteum, and perichondrium. Examples of dense elastic connective Areolar Adipose Reticular Regular Irregular Elastic tissue include that which is found in the bronchial tubes and the Figure 2. Types of connective tissue proper. 4(p161),5(p41) ligamentum flavum. nose and larynx. Elastic cartilage helps to form such structures as Specialized connective tissue also can be divided into 3 types: blood the external ear and epiglottis. Fibrocartilage is particularly notable and lymphoid tissue, bone, and cartilage (see Figure 3). The specific in structures such as the intervertebral disk or an articular labrum. forms of cartilage are hyaline, elastic, and fibrocartilage. Hyaline 3(pp129-133),4(pp199-205),5(pp84-86) cartilage is found as costal cartilage, as well as in such areas as the (continued on page 9)

Page 8 The AAO Journal • Vol. 26, No. 1 • March 2016

Figure 3. Specialized connective tissue can be divided into 3 types: blood and lymphoid tissue, bone, and cartilage. Sutherland Cranial Teaching Foundation

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These classifications of connective tissue give rise to some notable by hypertonic muscles would be better resolved using an isometric points: (muscle energy) approach.

• The musculoskeletal elements of somatic dysfunction include Diagnosing Somatic Dysfunction Using This Approach tissues and structures such as bone, joint capsule, cartilage, In addition to using the patient’s medical history and physical ligament, tendon, muscle, and fascia. examination, DOs perform an osteopathic structural examination • Any or all of them may be involved in the expression of (OSE) in the diagnostic process. The OSE is used to determine the somatic dysfunction in a given area. presence of somatic dysfunction related to the patient’s presenting • They may be seen as various forms of connective tissue. complaint(s). The examination7(pp22-40) is performed in 3 stages: • The properties of each of these elements depend upon the rela- tive amounts of cells and fibers within the element’s extracel- • the screening examination; lular matrix. • the regional (scanning) examination; • segmental definition (diagnosis) of somatic dysfunction. In fact, these connective tissue elements may be viewed as a continuum of tissues and structures, ranging from more fluid forms such The Screening Examination as blood and plasma, to firm, hard structures such as bone, at the In this portion of the OSE, the DO first takes in a general view of other end of the spectrum (see Figure 4). Alterations in the func- the whole patient, observing such things as posture, appearance, tions of these elements occur when they are involved in somatic nutritional status, gait, and any evidence of gross asymmetries. dysfunction. Skilled DOs can palpate these alterations, thus deter- The physician performs static and dynamic maneuvers. Abnormal mining which specific musculoskeletal elements need to be treated. findings indicate regions of the musculoskeletal system that require Based on this information, DOs can select the most appropriate further evaluation for TART changes and segmental motion restric- OMT modalities for the particular type of somatic dysfunction tions. present. For example, restricted motion and imbalance in lig amentous structures may respond better to a functional or balanced (continued on page 10) ligamentous technique, whereas somatic dysfunction manifested

The AAO Journal • Vol. 26, No. 1 • March 2016 Page 9 (continued from page 9) tension in the tissues even though the quantitative range of motion The Regional (Scanning) Examination may be normal. These static and dynamic tests allow the examiner This part of the OSE is performed to answer 2 questions: to identify specific areas within body regions that may exhibit the presence of somatic dysfunction. Once these areas are identified, • What area within the body region shows signs or symptoms the examiner proceeds to segmental definition. In this part of the of somatic dysfunction? structural examination, individual vertebral segments or periph- • What tissues within this region are affected? eral joints are identified and given a specific somatic dysfunction diagnosis. In addition, the examiner identifies the specific motion The scanning examination is performed using a combination of restrictions that are present and the tissues that are most involved static and dynamic testing procedures. Static testing is done by in the dysfunctional segment. palpating the soft tissues (skin, subcutaneous tissues, muscles, ligaments, fascia) of the region in question, looking for tissue texture Segmental Definition abnormalities such as hypertonicity, ropiness, bogginess, increased The final part of the structural evaluation is the segmental examina- or decreased temperature, and increased or decreased moisture tion. This part of the structural evaluation determines the specific (see also TART above). The tissues within the region also may be somatic dysfunctions that are present. It is designed to answer the palpated for discrete trigger points or tender points. Asymmetry of following questions: tissues or joint structures within a region may be observed as well as palpated. • What specific segments are dysfunctional? In this context, a segment may be defined as a vertebra, a rib, the sacrum or one Motion testing for the scanning examination takes the form of of the innominate bones, or a specific upper or lower extremity active and passive range of motion testing within the body region joint. in question. Passive motion testing also will reveal any abnormali- • What are the specific motion restrictions present? ties in the quality of motion within the region. The examiner • What other tissues (such as muscle, ligaments, fascia) are should note whether the motion being tested is smooth and equal involved? in all possible directions or whether there is a feeling of excessive (continued on page 11)

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Page 10 The AAO Journal • Vol. 26, No. 1 • March 2016 (continued from page 10) significant.7(pp42-46) They are described as: • Are the somatic dysfunctions related to the patient’s presenting problems? • Thephysiologic barrier: the limit of active range of motion of the joint or tissues. The diagnosis of somatic dysfunction depends on determining • Theelastic barrier: the range of motion between the physio- motion loss at a given segment and the associated tissue charac- logic and anatomic barrier, where passive ligamentous stretch- teristics that accompany this motion loss. Having determined ing takes place. The space between the physiologic and ana- during the regional examination an area within a body region that tomic barriers has been described as the paraphysiologic space. may exhibit somatic dysfunction, the examiner’s goal now is to determine the specific segment that is dysfunctional, the specific These normal motion barriers are illustrated inFigure 5. motions that are restricted, and the associated tissues that may be causing or contributing to the motion restriction. If there are The following are abnormal motion barriers: several segments involved within a particular body region, the examiner attempts to find the most restricted segment, that is, the • Therestrictive barrier: an obstruction to motion within the segment that exhibits the greatest amount of motion restriction and anatomical range that results in an abnormal limitation to the associated tissue texture changes. physiologic range. • Thepathological barrier: a permanent obstruction of joint The Barrier Concept motion due to pathology within the tissues, such as contrac- Identifying somatic dysfunction during the osteopathic structural tures or osteophytes. examination requires the examiner to use any TART changes to identify clinically significant motion restriction in joints and tis- With a normal joint or tissue, there is a midline point from which sues. In the structural examination of joints and tissues, DOs can there is equal motion in either direction. When somatic dysfunc- identify both normal and abnormal barriers to joint and tissue tion is present, some motion is lost, producing a restrictive barrier motion. In any given motion plane, the total amount of motion (see Figure 6). This restrictive barrier reduces or prevents motion in from one extreme to the other is limited by what is called the the direction of the motion loss. Thus the amount of active motion anatomical barrier. This barrier is also the limit of passive range of present is limited in one direction by the normal physiologic bar- motion of the joint or tissues in question. Moving the affected joint rier and in the other direction by the restrictive barrier. The midline or tissues beyond the anatomical barrier may result in injury such point shifts from its normal position to the middle of the active as fracture, dislocation, or interruption of ligamentous structures. range of motion now available. The osteopathic physician uses the palpatory characteristics of the restrictive barrier to identify the Within this total range of motion defined by the anatomical barrier, there are several other normal motion barriers that are (continued on page 14)

Figure 6. When somatic dysfunction is present, some motion is lost, producing a restrictive barrier. Figure 5. An illustration of normal motion barriers.

The AAO Journal • Vol. 26, No. 1 • March 2016 Page 11 (continued from page 11) In respect to osteopathic structural diagnosis and treatment, other type of somatic dysfunction present, that is, the tissues or structures authors have provided additional information on the use of end- most responsible for the motion restriction that is present. feel. For example, Ehrenfeuchter6(p435) writes:

Somatic dysfunction can be categorized by the tissue or structure The concept of end-feel is one in which the characteristics of most responsible for the motion restriction at that segment.6(p434-435) how the tissue feels at the end of range of motion testing for The following are types of somatic dysfunction: large joint motions, or for segmental motion testing, has significant implications for the osteopathic physician. The quality • Arthrodial restriction, resulting from restrictions between joint of the end-feel is used to determine the most likely etiology surfaces themselves. of the motion restriction (articular, muscular, fascial, edema). • Muscular restriction, generally due to hypertonicity of muscles, Once this is determined, it is used by the physician to guide but may also be associated with other pathological processes, in the selection of which osteopathic manipulative technique such as contracture. Such changes may alter the positional and would be most useful in addressing that particular region or motion characteristics of the involved joint structures. dysfunction. • Fascial and ligamentous restriction: These tissues can become shortened due to fibrosis resulting from trauma, inflammation, Eherenfeuchter further describes the end-feel characteristics of each congenital or developmental conditions, disuse, or injury. A of the above types of somatic dysfunction as follows: Edema exhib- further distinction should be mentioned here: Motion restric- its a mushy or fluid-filled sponge kind of end-feel; muscle hyperto- tion due to abnormal ligamentous tension is sometimes also nicity has a somewhat stretchy or rubbery end-feel; the end-feel in referred to as ligamentous articular strain; within the primary arthrodial dysfunctions is more solid, with an accompanying loss respiratory mechanism (PRM), analogous motion restrictions of the elasticity usually felt in muscular or edematous restrictions; may occur secondarily to abnormal tension in the meninges, chronic ligamentous and fascial restrictions exhibit a very hard, particularly the dura mater. This type of restricted motion abrupt end-feel with near total loss of tissue elasticity.6(p436) within the PRM is referred to as membranous articular strain.8 • Edematous restriction: Abnormal fluid accumulation within Bourdillon10 has similar observations, stating that there are differ- body tissues can result in motion restriction. This is thought to ent types of end-feels that occur at or near the restrictive barrier be due to pain resulting from the distention and stretching of and reflect different causative factors for the associated restriction. fascial tissues, as a result of the presence of the fluid itself. Bourdillon describes the following end-feels:

End-feel • boggy, associated with edematous states; The most important characteristic of the restrictive barrier for • elastic or spring-like, associated with myofascial shortening; determining the type of somatic dysfunction present (and subse- • an asymmetrical and reduced range of motion associated quently the most appropriate type of OMT for treating the somatic with an early, gradual increasing resistance with a residual dysfunction) is end-feel. End-feel is the quality of the resistance to spring-like sensation at the end of the remaining free range of movement that the examiner feels when coming to the end point motion, associated with hypertonic musculature; of a particular movement.9 This sensation is typically felt by the • a very rapid build-up in tension occurring close to the limiting clinician when overpressure (additional movement applied after barrier, but some elasticity that is slightly more firm than that resistance to motion is felt) is applied at the end of passive range of felt from hypertonic muscle, associated with fibrosis (chronic motion. myofascial shortening); • a hard, nonelastic end-feel with an abrupt stop short of the End-feel can be further described as physiologic or pathophysi- normal range, associated with bony changes, such as hyper ologic. Physiologic end-feel occurs as a result of limitations of trophy of bone at articulations or altered bony anatomy due to passive range of motion by normally functioning structures such disease or developmental conditions; as bone, capsular tissues, or ligaments. Pathophysiologic end-feel • an empty end-feel, which occurs when the patient expresses occurs when there are pathological limits to motion, such as cap- severe pain, but no resistance is palpable to the examiner; and sule or ligament contracture before full range of motion is reached, • hypermobility, manifested by very little resistance until close muscle spasm, loose bodies, or the patient’s unwillingness to allow to the anatomical or bony barrier, when the tension builds the completion of the motion. (continued on page 15)

Page 14 The AAO Journal • Vol. 26, No. 1 • March 2016 (continued from page 14) OMT modalities, can be achieved by the osteopathic physician’s rapidly to a sense of hardness and there is a detectable, overall use of: increase in range. • knowledge of anatomy, physiology, and biomechanics; Greenman7(p46) notes that restrictive barriers can originate within • the connective tissue origins of the tissues involved in the diag- any of the following tissues or structures: skin, fascia, muscle, liga- nosed somatic dysfunctions; ment, or joint capsule and surfaces. He also describes the following • the history and physical examination; end-feels: • the osteopathic structural examination; and • the end-feel characteristics of the tissues involved in the • boggy, associated with edematous states; somatic dysfunctions diagnosed. • rapidly ascending end-feel that is harder and more unyield- ing than that associated with edema, and typically present in Table 1 summarizes this information and shows examples of pos- fibrotic states (chronic myofascial shortening); sible OMT modalities that can be used to treat the types of somatic • a more “jerky” and tightening type of end-feel than that associ- dysfunction discussed in this paper. The reader should note that ated with edema, associated with altered muscle physiology while a variety of OMT modalities have been developed, the Edu- (hypertonicity, spasm, contracture); cational Council on Osteopathic Principles (ECOP)11 of the Amer- • an empty feel, associated with marked pain; and ican Association of College of Osteopathic Medicine has designated • hypermobility, associated with a sense of looseness for a greater 7 of these modalities as being most commonly used by clinicians amount of the range of motion than one would anticipate, fol- and consistently taught by all colleges of osteopathic medicine in lowed by a rapidly increasing hard end-feel when approaching the United States. These 7 modalities are: the elastic and anatomic barriers. • counterstrain; Choosing Appropriate OMT modalities • high-velocity, low-amplitude (HVLA) thrust; The approach proposed in this paper suggests that an accurate diag- • muscle energy technique (MET); nosis of somatic dysfunction and rational selection of appropriate (continued on page 16) Table. Summary of somatic dysfunction characteristics and suggested choice of OMT modality.

Somatic Tissue(s) Connective Associated Examples of possible dysfunction type involved tissue origin end-feel type End-feel type description OMT modalities Arthrodial Joint surfaces Specialized Abrupt, solid, Abrupt end-feel, earlier than the High-velocity, connective loss of elasticity expected range of motion (ROM), no low-amplitude tissue (bone) “give” or elasticity, often painful (HVLA); articulatory technique Muscular Muscles Mesenchyme Stretchy or Asymmetric ROM, gradually increasing Soft tissue technique; (various rubbery resistance, spring-like resistance at muscle energy mesodermal end of free motion technique (MET) layers) Fascial Fascial Loose areolar Elastic, springy Acute: shortened ROM but still elastic Myofascial release connective or spring-like (MFR) technique tissue Chronic: rapid tension build-up, slight elasticity but generally a more abrupt end-feel Ligamentous Ligaments, Dense regular Shortened ROM Acute: similar to acute fascial Balanced tendons, joint connective with gradual restrictions, but less elasticity and ligamentous tension capsule tissue resistance and springiness (BLT) some remaining Chronic: harder, more abrupt, with elasticity only slight elasticity or springiness Edematous Abnormal fluid Motion of Boggy Mushy, sponge-like Lymphatic tech- accumulation various tissues niques within body is affected by tissues abnormal and excessive fluid accumulation

The AAO Journal • Vol. 26, No. 1 • March 2016 Page 15 (continued from page 15) associated with it incorrectly interpreted. In such a case, failure to • myofascial release (MFR); accurately engage the restrictive barrier or apply the most appro- • lymphatic technique; priate OMT modality may result in less than optimum treatment • osteopathic cranial manipulative medicine (OCMM); and results or even failure of the technique to work. • soft tissue. Summary Closely related to OCMM are balanced ligamentous tension and bal- An osteopathic structural examination to diagnose clinically rel- anced membranous tension. evant somatic dysfunction is an essential part of the complete evaluation of the patient. Using their knowledge of anatomy, physi- While other proposed modalities can easily be applied to this ology and biomechanics, osteopathic physicians locate restrictive approach, the examples of OMT modalities listed in Table 1 are barriers to physiologic motion and then determines which tissues from the ECOP list of 7 major modalities. or structures are responsible for these barriers. This is accomplished by noting the total range of motion present, the quality of the Clinically, it is possible for 1 or more tissue types to be involved motion, and the end-feel at the barrier. With this knowledge, the in a given somatic dysfunction, and thus, it is possible for 1 or osteopathic physician can choose, from multiple OMT modalities more kinds of end-feel to be exhibited. Each restrictive barrier will and activating forces available, the most appropriate manipulative respond to the appropriate OMT modality, based on its end-feel approaches for the goal of achieving maximum physiologic motion. characteristics. Each additional restrictive barrier is evaluated and treated with appropriate OMT until the osteopathic physician References determines that physiologic motion in this restricted region or seg- 1. Van Buskirk RL. The Still Technique Manual: Applications of a Redis- ment has been maximized. For example, an edematous restriction covered Technique of Andrew Taylor Still, M.D., 2nd ed. Indianapolis, IN: American Academy of Osteopathy; 2006:9-10. may be relieved through the use of lymphatic or myofascial release 2. Educational Council on Osteopathic Principles. Glossary of Osteo- techniques, only to reveal an arthrodial somatic dysfunction that pathic Terminology. Chevy Chase, MD: American Association of Col- requires treatment with an OMT modality directed to the joint leges of Osteopathic Medicine; 2011:53. surfaces themselves, such as articulatory technique or a high-veloc- 3. Junqueira LC, Carneiro J. Basic Histology: Text and Atlas. 11th ed. ity, low-amplitude thrust approach. New York, NY: The McGraw-Hill Companies, Inc.; 2011. 4. Ross MH, Pawlina W. Histology: A Text and Atlas. 6th ed. Baltimore: Lippincott Williams & Wilkins; 2011. One must remember that there also can be situations such as in the 5. Sandring S, ed. Gray’s Anatomy: The Anatomical Basis of Clinical Prac- case of an inexperienced clinician, where the restrictive barrier in a tice. 39th ed. Edinburgh, Scotland: Churchill Livingstone; 2005. given somatic dysfunction is not properly located and the end-feel 6. Chila AG, ed. Foundations of Osteopathic Medicine. 3rd ed. Philadel- phia, PA: Lippincott Williams & Wilkins; 2011. Continuing Medical Education Quiz 7. DeStefano LA. Greenman’s Principles of Manual Medicine. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011: 22-40. The purpose of the continuing medical education quiz— 8. Hruby RJ. Balanced Ligamentous Tension techniques. In: Chaitow found on page 25—is to provide a convenient means of self- L. Positional Release Techniques. 4th ed. Edinburgh, Scotland: Elsevier; assessing your comprehension of the scientific content in the 2015:180. 9. Magee DJ. Orthopedic Physical Assessment. St. Louis, MO: Saunders article “The Use of Osteopathic Manipulative Treatment for Elsevier; 2008:21. Acute Dental Pain: A Case Report” by Karen Teten Snider, 10. Issacs ER, Bookhout MR. Bourdillon’s Spinal Manipulation. 6th ed. DO, FAAO. Boston, MA: Butterworth-Heinemann; 2002:39. Be sure to answer each question in the quiz. The correct 11. Hensel K, ed. A Teaching Guide for Osteopathic Manipulative Medi- cine. Chevy Chase, MD: American Association of Colleges of Osteo- answers will be published in the next issue of the AAOJ. pathic Medicine; 2015:1. n To apply for 2 credits of AOA Category 2-B continuing medical education, fill out the form on page 25 and submit it to the American Academy of Osteopathy. The AAO will note that you submitted the form and forward your results to the American Osteopathic Association’s Division of Con- Follow the AAO online: tinuing Medical Education for documentation. You must score a 75% or higher on the quiz to receive CME

credit.

Page 16 The AAO Journal • Vol. 26, No. 1 • March 2016