Thank you, Jeffrey. Once again, thank you very much for picking another wonderful venue. We always have such wonderful places for us to have our conferences. The first lecture will be by Dr. Polly Leonard. It will be Head, Shoulder, Elbow, Hand in Osteopathic Approach to Common Findings. Dr. Leonard is a clinical professor at UNICOM. She's board certified in both osteopathic family practice and neuromusculoskeletal medicine and is in private practice in Warwick, Rhode Island. It's a beautiful area over there. Dr. Leonard is the 1996 graduate of distinction from the University of New England College of Osteopathic Medicine in Biddeford, Maine, where she completed a one-year pre-doctoral teaching fellowship in osteopathic manipulative medicine and anatomy. She served her rotating internship at Memorial Hospital in Worcester, Massachusetts and completed her training at the New Hampshire Dartmouth Family Practice Residency in Lebanon, New Hampshire. She earned a master's in medical education leadership at University of New England in May of 2011. Dr. Leonard was the founding DME for the Kent Hospital Residencies in Warwick, Rhode Island and is on faculty. Dr. Leonard earned two fellow designations in the National Academy of Osteopathic Medical Educators, medical education leadership in 2012 and teaching and evaluation in 2014. She is chair of the publications committee for the American Academy of Osteopathy. She is recognized as a master teacher by the Training of Osteopathic Primary Care Educators Consortium. In 2015, she was inducted into the Gold Humanism Honor Society. Please welcome Dr. Leonard. Hello, and thank you for inviting me to speak today. I'm Polly Leonard Dio. I'm in Warwick, Rhode Island. This presentation is on head, shoulder, elbow, hand because I frequently see interrelations within these structures as I am treating patients. I'm double boarded in both osteopathic manipulative treatment and family medicine. And I frequently end up being the resort doctor, the doctor you resort to because nothing else has worked. I am not always successful and I'd be frightened if I could fix everyone. What we do as osteopathic physicians is oftentimes not cause and effect like removing a gallbladder, replacing a knee or prescribing blood pressure medication. A lot of what I treat does not show up on imaging or tests. It shows up in the patient history, in range of motion testing, in structural examination and palpatory diagnosis. Frequently, and I'm very disappointed to say this, I am the first person to touch the patient where it hurts or examine areas far removed from the area of pain. As we go through this presentation, please remember that I'm only talking about treating one region. When you are seeing patients, it is important to perform a complete structural examination in order to truly optimize the functioning of the structure. There are times I think I know what is going on just from the history, but I push that to the edge of my mind as a possibility until I perform a complete structural examination. I'm glad I do because oftentimes my knee jerk diagnosis is only a component of the total problem. At the end of this presentation, you should be able to identify common patient presentations that will benefit from osteopathic manipulative medicine. I can't be there and I'm sorry, but I'm hoping that you will be able to demonstrate the ability to treat common patient presentations with osteopathic manipulative medicine. I do think you will be able to identify the functional interrelationship between the upper extremity and the head and neck in pain and in dysfunction. In the references, I have cited an article by Dr. Price, which talks about workplace injury not being caused by any one thing. There is microtrauma, sympathetic input, emotional factors, repetitive injury, and other causes for chronic pain and dysfunction. Unfortunately, insurance companies are not all that interested in multiple contributing factors. Too bad for them. I put everything into my notes and into the forms, and that is a completely different presentation than just, gee, their arm hurts, gee, they have tendinitis. I try to convey to whomever is reading my notes that this is a person with a problem, not a problem with a person attached. It all comes down to looking at the person as a mind, a body, and a spirit. We need to make sure all are functioning as well as possible in order to achieve health. I don't plan on just reading you slides today. I will be having you look at things and make some commentaries. These next four slides are four tables from Bartolomeo's Eustachius' Anatomicae Summae Romanae Archetypae Tabula Anatomicae Novus Explicanibus, created sometime between 1550 and 1574. Just in case your Latin is rusty, the title translates to a new summary of Roman archetype anatomical explanations. And I wanna give a shout out to my eighth grade Latin teacher, Mrs. Dresner. Look at how the neck's muscles attach to the clavicle and the pectorals and the latissimus attach into the shoulder, providing opposing forces and distributing the force. The clavicle allows for much more rotation and movement of the upper extremity than a simple ball and socket joint. I'm going to have everybody put your hand near your angle of Louis. So your hand is on your proximal clavicle and then bring your arm to the midline and cross the midline. Feel how your clavicle moves anterior and then raise your arm over your head. Feel how much motion there is in that proximal joint. Extend your shoulder posteriorly and then bring it back. You have quite a lot of range of motion that is influenced by that clavicle and that helps to stabilize the shoulder joint and to move things much more effectively and it also increases the weight bearing load that the shoulder joint can accommodate. Some of the muscles have been removed in this image. Look at how much surface area of the thorax is taken up by the pectoral muscles and the serratus anterior. We tend not to think of long restrictors when we diagnose and treat shoulder and arm dysfunction. This is why we should. The deltoid is absent as well as the triceps. If this person were alive with an absent deltoid and triceps, I don't think they'd be holding their arm up. But here you can see on the cadaver's right side how the serratus anterior comes down and interdigitates along the rib line. That stabilizes the medial scapular border and also when the scapular border is fixed, allows the ribs to rise and fall by contraction. So it depends on which end you want to move. You either fix the ribs and pull against the shoulder or you affix the shoulder and pull against the ribs. Our brains are making these calculations constantly to provide us with fluid motion. Here you can see how the trapezius influences the head, the neck, and the shoulder. The latissimus connects the shoulder into the low back and the two are frequently found together in injuries. As an aside, physical therapists are frequently given orders just to treat shoulders and they can't look at how the hips and lumbar musculature are affecting the shoulder. Please remember that when you're ordering physical therapy. Just today, I saw a patient who had a car accident eight years ago. She was belted, she was the driver, and she's had neck pain ever since. No one has examined her hips and she had a left posteriorly rotated anominate which was affecting everything on her left side and doing some translation over to her right. When I fixed her left hip dysfunction, she immediately said, wow, my neck and shoulder feel better. And I didn't set her up because I was recording this lecture. She just actually said that. So when you're looking at people, make sure you're looking at those long restrictors and how they may end up affecting distant structures. Our proprioceptive receptors are usually quite adaptable. However, after an injury, communication from the strong proprioceptors of the small spinal muscles can get scrambled between the cerebellum and the target muscles. Many of my injured patients find it very difficult to do Tai Chi or other activities involving balance. I prescribe Tai Chi as a way to reeducate their circuits. I prescribe that more than yoga because in Tai Chi, you're constantly moving and in many forms of yoga, you are holding a static position. You will find that many injured people have trouble performing a standing flexion test. They may have chronic vertigo, which is likely cervicogenic or proprioceptively mediated. If you can make them even 10% better, you will change their lives. Never discount the contributions of the viscera as a referred pain. As osteopathic physicians, we have been educated in the Chapman reflexes and in viscerosomatic reflexes. Take these into account if you find a recurrent area of dysfunction or an area that just doesn't want to resolve. There was a lovely study done in Italy where they're doing a lot of osteopathic research called The Effect of Osteopathic Visceral Manipulation on Pain, Cervical Range of Motion, and Upper Trapezius Muscle Activity in Patients with Chronic Nonspecific Neck Pain and Functional Dyspepsia. The title was almost longer than the article, but it's still lovely. They demonstrated that treating the upper gastrointestinal viscera reduced or resolved neck and upper back pain. I would speculate this is due to autonomic feedback. If you aren't finding the answers that make sense, change your questions. On to how to treat patients. This is a balanced ligamentous tension technique, and yes, you can do this. You can treat people with whiplash, migraines, eye pain, sinusitis, and they will feel better. This is officially known as the sphenobasilar synchondrosis compression and release. One of my medical students dubbed this the claw in an homage to the Toy Story movie. Another student called it the three stooges technique because of the fingers in the eye sockets. You can call it what you want as long as you treat people. My model is rolled to the side so you can see the placement of my bottom hand. Your two middle fingers of one hand are in the superior orbital notches of the patient. Your middle finger is just off the foramen magnum, palpating the tentorium posteriorly. With the patient supine, you will bring your palms together so that your fingers spread apart like a clamshell or the claw. When you feel the tissues release, you can gently release your grasp. And then recheck motion and see how your patient is feeling. I recommend the article by McReynolds and Sheridan to you. It showed that osteopathic manipulative medicine in the emergency department was more effective at relieving pain than Ketorolac. Once whiplash patients have been medically cleared, soft tissue technique or a suboccipital tension release can be of great benefit. I could do a whole hour on just treating neck pain, but that's not what I was asked to do today. So I'll plant some seeds in your mind and keep going. The next time you have a patient with a migraine present to your place of business, think about performing this technique or a soft tissue tension release or a suboccipital tension release to see if you can get the patient feeling better. On to how to treat patients. This is a balanced ligamentous tension technique and yes, you can do this. It's called the sphenobasilar synchondrosis compression and release. With this, you can treat people with whiplash, migraines, eye pain, sinusitis, and most likely they are going to feel better. If you are treating somebody with sinusitis, they will feel their sinuses start to drain, they will start to cough, and a lot of mucus will discharge and they will feel better. With the migraine, their photophobia and some of their phonophobia will resolve as well as some of their pain. With the whiplash, you may be able to increase their range of motion and decrease some of their acute spasm and make them much more comfortable. So one of my medical students dubbed this treatment the claw in an homage to the Toy Story movie. Another student called it the three stooges technique because of the fingers in the supraorbital notches. You can call it what you like as long as you treat people. My model is rolled to the side so you can see my bottom hand. Usually the patient is supine and this is performed supine. So your two middle fingers of one hand are in the superior orbital notches of the patient. Try not to enucleate them. You just want the pads of your fingers on the supraorbital notches. This may be somewhat tender because of the supraorbital nerve, but you're also trying to release a lot of the fascia around that area. Your middle finger is just off the foramen magnum, palpating close to where the tutorial should be. You can take your finger and slide it down the midline of the occiput until you fall off at the foramen magnum. It will be somewhat uncomfortable for the patient and that tells you you're in the right place. You're going to then bring your palms together so that your fingers spread apart like a clamshell, like you're trying to open the patient's head. As you apply this strain, you're going to finally feel the tissues release and when that happens, you can then release your grip. Oftentimes, when the patient releases, they're going to start taking some very deep breaths in and you can feel their body relax. This can be very effective in so many patient presentations and there are some others that you can do as well. You can perform soft tissue technique or a suboccipital tension release, which also can be of great benefit. I would recommend the article by McReynolds and Sheridan in the references to you. It showed that osteopathic manipulative treatment in the emergency department was more effective at relieving pain than Ketorolac. Once Whiplash was done, it's perfectly okay to go ahead and treat them. I could do a whole hour just on treating neck and head pain, but that is not what I was asked to do. So I'm going to plant some seeds into your mind and keep going. The seated suboccipital muscle treatment. This is very effective in many patient presentations. This can be useful to help you start to loosen up a patient who comes in very stiff and you want to treat them, especially if you're treating in the thorax. This is also very helpful in people who have had Whiplash to very gently start to get everything working together again. Today I saw a patient and I finished, actually I saw several patients that I finished their treatment with this technique. Because they said, well, I just still feel a little stiff. So I stretched out just about all the fascia that runs posteriorly by doing this technique. What you do is you have the patient seated comfortably and have them cross their arms over their chest. You do this so they're not using their hands to push up against you because we are not treating their strength and we're not using their strength to push up against them. Their strength, we're treating the fascia around their spine. You will then flex the patient's head forward. You'll hold their head in place with one forearm and then along their back, you will stabilize their spine with the other forearm. You grasp your hands together or place your hands together over about T1. You will flex the head forward until you meet resistance. You just want to meet a very soft barrier there. You don't want to see how far they'll bend. You will then have the patient raise their head up against your resistance for a count of three and then have them relax. I always tell patients just enough to meet me because some people think it's a contest. So I just have them lift just enough to meet me but not to actually move me away. Hold that for a count of three and then relax. As they relax, you curl them forward. You're not going to bend them at the waist forward but you're trying to see how much flexion you can get into their head, neck, and upper back. They will inhale, exhale, and then they will resist against you again for at least three repetitions. Sometimes you have somebody with a very tight fascia or a very tight posterior longitudinal ligament and it may take more than three episodes to get them to a place of relaxation or to get them to a place where they're actually moving well. You have to decide. Then you have them sit up, recheck, and see how they're doing. When patients have trouble turning their neck from side to side, one of the culprits is frequently the sternocleidomastoid. This is a good technique to do in patients with cervical spine dysfunction and an AC8 tender point, which is at the base of the sternocleidomastoid where it attaches to the clavicle. You have the patient supine. You will find the tender point and if you notice in this picture, I'm using my thumb to find the tender point. It's going to be along the superior medial aspect of the clavicle and it will not be subtle. It will hurt. You can check this on yourself. I know I have one today. You're going to gently flex the neck and then rotate the neck and head away from the tender point until relief is achieved. You want the patient to be at least 70% better or down to a three from a 10 and some people can't do one through 10. So I tell them what they're allowed to say is still hurts, better, relief and they can remember those and then I get some good feedback from them. I do have patients that will perseverate on giving me the right number and can't actually get any words out. You will hold this for 90 seconds and then gently release. You should have a significant improvement in neck motion. Most likely you will also have some improvement in clavicular motion and better movement in ribs one and two. You can do a similar technique for the scalenes as well. If you back up to the first and second rib and palpate the insertion of the scalenes onto the rib, you can side bend toward and rotate away to get some slack into the scalene muscles. Once that releases, oftentimes there will be much less cervical dysfunction because of the spasm in these small muscles. You can also hold that for 90 seconds and then release. And then always when you're treating the cervical spine, after you treat one side, go check the other. Frequently a dysfunction on one side will cause pain on the opposite side, but yet it won't present as the presenting complaint. Now this is the treatment of the biceps tendon within the bicepital tendon groove. Frequently when performing your structural examinations, you will find there is one shoulder superior to another or one shoulder held anterior compared to another. In my experience, the cervical spine is side bent toward the most dysfunctional shoulder. The biceps tendon attaches to the scapula at the superior aspect of the glenoid, and the scapula attaches to the neck and head by way of the trapezius and levator scapulae. Dysfunction in one tends to cause dysfunction in the other. Now, I'm not sure you can really see where my hand is, but with my first finger of my left hand, I'm palpating the biceps tendon. You can palpate this on yourself and find that tendon, and if you have been doing any sort of telehealth or any sort of computer work, most likely it's gonna hurt. Mine does. The patient can be seated or supine. I prefer supine because people relax more. You will palpate the tender point and use that as a marker so you're not actively pushing on it the entire time. Have the patient completely relax their arm and then flex the shoulder to 90 degrees with the elbow flexed. I'm not quite at 90 degrees here but the pain was relieved. Try 90 degrees. You will adduct the humerus across the midline until the pain is relieved. You may need to depress the shoulder as well and here with the palm of my hand I am depressing the shoulder as well as moving the elbow. Hold this in a position of ease for 90 seconds. Passively return the patient to neutral and recheck. Usually after I do this technique my patient will say but you're not pushing as hard and I have a policy that whenever I'm rechecking something I push just a little bit harder to make sure that that pain is gone and that that area is functioning well. I don't want to give an esoteric treatment and then have the patient go out and be dysfunctional. I want to actually do something that's going to help the patient and make them not need me. Now this is a balanced ligamentous tension technique and I can hear some of you now I can't do that sensitive stuff I could never palpate cranial motion in lab I don't have time to do this. Deep breath, happy place, I'll talk you through it. You can do this. It's going to make your patients better. If you can untwist your sock because it feels tight around your calf you can do this technique. You grasp the humerus at the middle of the shaft and gently try to pull the humeral head away from the acetabulum. Then try to externally rotate the humeral head within the rotator cuff. Then try internal rotation putting the strain the posterior aspect aspect of the rotator cuff. Ask yourself, self where does this humeral head feel balanced in relationship to the scapula? Find that place and hold the humerus there. Usually after about four deep breaths and exhalations the shoulder will relax and you will be able to feel it. Additionally you can get the patient to a point of relaxation and then with their ipsilateral arm with the arm that you're actually holding on to have them try to reach for their opposite shoulder. That engages their shoulder muscles and then but as you're resisting them they start to function more as a unit instead of functioning in a disorganized fashion. Then after they reach for their shoulder you have them relax, you recheck motion and you release. This is a great way to loosen up a shoulder before more intensive treatment or motion testing and a great way to finish off a treatment where the patient is better but something is still kind of stuck. You do have the 45 seconds to do this technique and it may save you time down the road if you can get somebody's shoulder moving. Then they don't come back or you don't prescribe physical therapy or they feel release or they feel much happier and everything works out. The anterior pectoralis minor tender point is very similar to the bicipital tendon technique and uses the same concept of shortening of the painful muscle and fascia in order to reset to normal motions. The pec minor is the human version of the chicken tender. It braces the anterior aspect of the scapula when the shoulders are working posteriorly. It is located directly underneath the pectoralis major. It lifts the superior ribs the pump handle ribs when the shoulders are braced. You will see pec minor spasm frequently in respiratory disease. If somebody is feeling short of breath, frequently it is the pec minor that is mediating this. If the posterior shoulders or posterior neck are not releasing, look at this muscle on the front of the back. Frequently it will be a component of dysfunction that is readily solved. To do this technique you can be seated. The patient can be seated or supine. I prefer supine because they relax more. Find the tender point within the pectoralis minor. If you can find the coracoid process which is right underneath the clavicle on the lateral aspect and palpate, it's going to be uncomfortable. Mine surely is and yours probably is too. Find the tender point which is pretty much in the middle of the belly of the muscle but anywhere along that area is a clue that something is not functioning correctly. You're going to grasp the flex elbow on the painful side and move the humerus towards the contralateral hip until the tender point is at least 70% improved. You may need to elevate the patient's shoulder slightly off the table to cross the body and to get a good shortening of this muscle and a good relaxation. Hold the position for 90 seconds and then passively bring the patient back to neutral and recheck. So the most uncomfortable technique I have to offer today is slide lucky 13. This is the subscapularis release and it is very effective but it's also uncomfortable. Most of my patients where I've done this technique are not just grateful that it's over because it hurt but grateful because their shoulder is finally moving. This can release a lot of adhesions, a lot of poor motion that is occurring between the scapula and the thorax itself. This is also very effective in getting brachial plexus dysfunctions to release and to improve the amount of nervous conduction or potentially even arterial and venous flow to the upper arm because you're releasing this area. So you can have the patient seated comfortably or you can perform this supine. If the patient is seated, you have them gently lean over onto your thumb as you sweep your thumb up and down between their subscapularis and their ribs. You can have your, if they're seated, it's best to have the pad of your thumb towards their ribs. And if they're lying supine, you can do it either way. Here I've shown two different ways to place your hand. In a female patient, make sure that your fingers are above the breast. We women know we have breasts but it helps if the doctor says, I know my hand is here, are you comfortable with that? Because it takes the elephant out of the room and it prevents you from getting sued, especially in this day and age. So what you're going to do if your patient is supine is gently either milk this area or just keep inserting your thumb gently as you sweep superiorly and inferiorly and loosen up the tissue between the scapula and the ribs. You can use the arm to move the arm superiorly and inferiorly to try to move the scapula and get a better focus in this area. Once you, you will notice that there is much more softening of the area. There may be some reduction in any lymphedema or any sort of bogginess in this area. And then you recheck range of motion and see how comfortable the patient is. Sometimes, I always warn patients when we do this technique that they may have some bruising the next day because this is a very vascular area and this area is very easy to bruise. It doesn't mean that you are hostile or you are doing too much, it just occurs. This is a technique that I pretty much made up in order to get more treated more efficiently. It's a shotgun technique with muscle energy. The patient can either be seated or supine. If they're at the nurse's station and looking uncomfortable, of course you do it seated to the nurses and to the unit secretaries to make them happy. You will abduct the humerus to 90 degrees in internal rotation so their palm will be facing their feet. Hold their humerus and I, if you notice here, I'm looping their arm through mine so that I'm not just holding on to their arm which will strain my shoulder, but they're trying to pull my body weight over which is a formidable task. You will then have them reach for their toes for a count of three and then have them relax as you take up the slack. If you notice my other hand is on the clavicle and scapula because I just want to move the glenohumeral joint. I don't want to be lifting their whole scapula cephalad. You can repeat this three times and then recheck and see their range of motion. This is a very effective technique and it will frequently release issues in the thorax as well so there's just much less to treat overall. Here we are continuing to march down the arm. Now we're to common extensor tendon tendonitis and common flexor tendon tendonitis. These have been so common during the pandemic. People come in with all kinds of forearm pain. If they are having wrist pain, frequently there will be a continuation of that pain into their elbows and into their shoulders because as a dysfunction limits motion in one area, the other joints tend to take up the slack. You can get micro tears in the tendons where it attaches at the elbow. You can also just get a chronic strain present in the musculature. Let me show you how to fix those. To treat a common flexor tendon counter strain, the patient can be either seated or lying supine. You can locate the tender point on the medial epicondyle of the elbow. You can do that yourself right now and it's probably going to be tender. You can then passively flex the patient's wrist and rotate the patient's forearm so it's rotating supine. Apply a compression through the forearm until the tender point pain is minimal. You hold this position for 90 seconds and then gently release and recheck this area. The common extensor tendon counter strain is taken care of in the same way. The physician locates the tender point over the radial head. Again, yours is probably tender right now especially if you've been doing a lot of typing. You will extend the patient's wrist and rotate the forearm into supination applying compression through the radius until the tender point pain is minimal. You will hold that position for about 90 seconds and then gently release and recheck. When you're doing this in the forearm with either the common extensor or the common flexor tender points, what you want to do is think about shortening up that muscle. You rotate and you flex and then you can compress to shorten up that muscle and take the load off of the tendon. The brain takes about 90 seconds to reset this circuit so that the proprioceptive receptors and the Golgi tendon organs start to talk to each other once again and the pain releases. The brain is telling these muscles to be in spasm because it thinks it's helping the body but alas it is not. This technique is very useful in getting people better much quicker. Again, if you can get somebody 10, 15, 20 percent better they will be able to do much more for themselves at home and maintain their independence. I've cut and pasted this slide from the JAOA which is now the Journal of Osteopathic Medicine because it is much better than anything I could create on my own. For those who are squeamish about articulation or if the wrist is very tender, you can always place your hands as in figure A and B with the thumbs against the radius and the ulna and your fingers grasping the thanar and the hypothanar eminences. You then flex the wrist while distracting your fingers so you're stretching the carpal tunnel and the palmar fascia. You can then add an articulatory component to this by moving quickly in this motion or you can continue to stretch and then relax and stretch and relax. Your patient should have much less wrist pain and dysfunction after this technique. You can always check the TINEL sign prior to doing this technique and then check it afterwards to see if you've made a difference. There is a wonderful study done by Benjamin Sucre and I hope I'm pronouncing his name right. Benjamin Sucre DO et al. The study shows that traction applied to cadaveric transcarpal ligaments increased the length of the ligaments even after the stretching stopped. When OMM was applied to the cadaveric wrists before the load was added, there was an increase in the lengthening of the ligament and a greater widening of the transverse carpal arch. There was more improvement in female wrists than male wrists. We don't know why but it's pretty interesting. So if this technique can make dead people better, imagine what it can do for your living patients. We have gone through a lot of patient presentations, all of them taking into account the person as a whole being with a body, mind, and spirit. It is our job to listen, perform a proper and thorough structural examination, and figure out how to optimize the functioning of the structure. So at the conclusion, which is where we are now, I think you can identify common patient presentations that will benefit from osteopathic manipulative medicine. Even if you're not sure how to do the technique because you're not sure you remember, I know that you know the anatomy and I know that you know the physiology. So if you're going to do a counter strain tender point, you're going to rotate, you're going to rotate toward and a side bend toward to try and get that area to shorten up. If that doesn't work, try the opposite. To see if you can get the patient to a position of ease, hold it for 90 seconds and then recheck. To do a muscle energy technique, you take the patient to the barrier, have them contract against you, and then advance that barrier. You can do a whole lot with very little time and really help someone. I am really sorry I can't do this in person. I hate COVID. I do love running around from table to table, infecting you with what I really love to do, which is solving problems. If we can get people feeling better, able to move better, and more functional, it may make the difference between keeping them in their own homes versus a nursing home or assisted living or keeping them at their jobs so they are financially secure. So I'm sorry I can't see you demonstrate the ability to treat common patient presentations, but I have every faith that you can. All you have to do is try. The majority of people will appreciate that you tried and you will be surprised at the difference you can make. It's just anatomy and physiology in action. I think by now you can identify the functional interrelationship between the upper extremity and the head and the neck. We've talked a lot about how the body is interrelated. If one part isn't working, the other parts have to take up the slack. Please always do a full structural examination on your patients and then work to eliminate barriers to movement. These are my references. They are really interesting articles. I'm not just padding with fluff. These are really cool articles that talk about how to get patients better and interesting articles about how to think about treating patients. Thank you so much for inviting me to present today and a massive thank you to Rhonda and Jeff LeBouf who put so much of this together. I hope what I presented today will help you care better for your patients and offer some avenues to getting patients better and back to functioning. Enjoy the rest of your conference. If anyone has questions that come up over the next few weeks, I am on Doximity and you can contact me through there. Take care. All right, great. Anyway, thank you so much, Dr. Leonard. Any questions from the audience? I see none in the Zoom, Dr. Leonard. Oh, I do have a question from Dr. Berkowitz. I'll bring this fancy mic to him, okay? You betcha. Hey, Polly, it's Murray. Hi, Murray. I can't hear you just yet. Wait till the microphone gets there. Can you hear me now? Yeah, go ahead. Anyway, suggestion on the treatment where you were concerned about, you know, possibly, you know, having a little sexual harassment. My solution to that is I use the patient's own hand between my hand and where their breast is. This avoids that particular problem. The other thing that I found anecdotally is that many times when I'm doing that, when I'm using their hand as a buffer, their hand is also able to press harder than I might actually press because they can withstand more pain from themselves than they can from somebody external to them. Okay, I caught half of that. I heard what you said, you had the patient put their own hand over their breast and then treat through that. Some of the colleges, did I get that right? Jeff is going to have to nod. Okay. Yes. Thank you. I know this is being recorded and I usually don't manage to hold back much of my opinion because that's what people pay me for, but as a woman who has breasts, I kind of find that extraordinarily awkward. I've been treated by lots of different men, lots of different women, and I have had some men say, well, put your hands over your breasts while I'm treating you. And I say, no, I'm a doctor, you're a doctor, you are the doctor, you took an oath, you can behave yourself, there's not a problem, I am not afraid of this. But I find that with my patients, that if I just acknowledge or if I'm working in the groin on a male patient, always make sure your hand is, your palm is towards the thigh if you're in the groin. And I always say, I'm sorry, this is a rude spot, and I have debt to have anybody say, that's a problem and I feel uncomfortable, but when I say I'm in a sensitive area, my patient relaxes. I think as people who take oaths and as people who are physicians and mindful of taking care of patients, if we are appropriate with our touch and acknowledge that we are in a sensitive area or something to that effect, then as long as everybody understands what's going on, then we will avoid getting in trouble with misunderstood touch. We want to be clear in our touch. We want to be direct with our patients in what we're doing and why we're doing it. But you do whatever makes you comfortable. I just have a strong opinion about everything. Any other questions? And I want to thank everybody who is sending me all these lovely comments. I really sincerely appreciate it. It is so hard to record these things in a vacuum and not read the room while you're presenting so you can alter your presentation to fit the audience. So thank you. The room was spellbound and everybody did a lot of biblical feeling. It was great. It was a very warm and fuzzy environment here. So I'll spin up Dr. Decker's lecture and then Dr.

osteopathic medicine

dysfunction treatment

structural examination

palpatory diagnosis

chronic pain relief

holistic approach

balanced ligamentous tension

counterstrain technique