Remission of Dowager's hump by manipulative correction of spinal alignment: a case report.

Dowager's hump is described as excessive kyphotic curvature in the thoracic spine with a Cobb angle of more than 40 degrees. This case report presents a 61 years old female office clerk who experienced headaches and neck pain for 3 years that extended into her right shoulder and upper chest. She consulted her primary care physician two months before seeing the chiropractor when the neck pain worsened. A diagnosis of cervicalgia related to osteoarthritis was made based on cervical and thoracic X-ray findings. The patient received non-steroid anti-inflammatory drugs (celecoxib and etoricoxib) and stretching exercises at home. At the onset of chiropractic care, radiographs showed loss of cervical lordosis, narrowing at the C4-5, C5-C6, and C6-7 intervertebral disc space with marginal osteophytes. Based on these findings, a working diagnosis of cervicogenic headache was established. After treatment for 9 months, the patient showed improvement in symptoms and function from cervical curve radiographic change and dextro-convexity of the thoracic spine. Avoiding forward head flexion and maintaining correct posture in daily activities will be key mechanisms to prevent the reoccurrence of Dowager's hump. The improvement of symptoms following chiropractic therapy has been shown to correlate with radiographic markers of spinal realignment.

Effects of corrective and breathing exercises on respiratory function of older adults with a history of COVID-19 infection: a randomized controlled trial.

BACKGROUND: Patients with a history of COVID-19 infection may suffer from different physical problems. This study aimed to investigate the effect of corrective and breathing exercises on improving respiratory function among patients with a history of COVID-19 infection. METHODS: In this clinical trial study, thirty elderlies with a history of COVID-19 disease were divided into two groups (mean age 63.60 ± 3.56 experimental, 59.87 ± 2.99 control groups) based on the study inclusion criteria. Exercise interventions included two sections- breathing exercises and corrective exercises in the cervical and thoracic spine. The spirometry test, craniovertebral angle, and thoracic kyphosis test were used. To evaluate differences between variables, paired-samples t-test and ANCOVA were used (p-value < 0.01). Also, Eta-squared was measured to assess the effect size. RESULTS: Results showed a significant difference between the two groups in craniovertebral angle (P = 0.001), thoracic kyphosis (P = 0.007), and respiratory capacity including Forced expiratory volume in one second (FEV1) (P = 0.002), FEV1/FVC (P = 0.003), Peripheral oxygen saturation (SPO2) (P = 0.001), while no significant differences were observed between two groups in terms of chest anthropometric indices (P > 0.01). The Eta-squared value of 0.51 for the Craniovertebral angle and the SPO2 indicates a large effect size. CONCLUSIONS: The results showed the combination of corrective and breathing exercises could improve pulmonary function and correct cervical and thoracic posture in patients with a history of COVID-19 infection. Therefore, corrective and breathing exercises can be helpful as a complementary treatment along with pharmaceutical therapy to reduce chronic pulmonary complications in patients infected with COVID-19. TRIAL REGISTRATION: This research was registered in the Iranian Registry of Clinical Trials (IRCT registration number: IRCT20160815029373N7, First trial registration: 23/08/2021, Registration date: 01/09/2021).

Correlation between thoracic kyphosis and dry needle length required to reach the pleural space needling the upper trapezius: A cadaveric fluoroscopic assessment.

BACKGROUND: It is unknown whether greater prone thoracic kyphosis increases pneumothorax risk during upper trapezius dry needling. OBJECTIVES: To fluoroscopically assess for a correlation between prone thoracic kyphosis and needle length required to reach the pleural space dry needling the upper trapezius in prone. DESIGN: Cadaveric study. METHODS: Prone thoracic kyphosis was assessed using dual bubble inclinometers. A 30 mm dry needle was inserted into the midsubstance of the upper trapezius perpendicular to the thoracic kyphosis. A single C-arm fluoroscopic image was obtained. This procedure was repeated with 40, 50, and 60 mm needles. Images were independently viewed by a radiologist to make a binary decision (yes vs. no) whether the needle had potentially broached the pleural space. RESULTS: Fifteen cadaveric specimens with a mean age of 74.9 ± 9.7 and mean kyphosis of 21.5° ±7.7 were used. A 30 mm needle never reached the pleural space. The pleural space was potentially broached on one, four and six occasions by the 40, 50, and 60 mm needle respectively. The correlation between needle depth penetration and kyphosis was not significant (r = 0.03, p = 0.93). Longer needles (50 and 60 mm) were significantly (p = 0.0049) more likely to reach the pleural space than shorter needles (30 and 40 mm). CONCLUSION: Thoracic kyphosis was not correlated with needle length required to reach the pleural space. Clinicians may consider selecting shorter needles (<40 mm) to mitigate potential risk while dry needling the upper trapezius in prone.

The efficacy of Theraband versus general active exercise in improving postural kyphosis.

BACKGROUND: Thoracic kyphotic posture is accompanying increased biomechanical load of the backbone which is possibly problematic. OBJECTIVE: The current study aimed to examine the effects of general active exercise versus Theraband exercise on female kyphotic posture. METHODS: An experimental study was conducted at the biomechanical lab. in Physical Therapy College, Cairo University. Fourteen female volunteers with kyphotic posture aged from 18 to 30 years were selected and equally distributed into two groups; 1st group received Theraband exercises (neck retraction exercise, scapular retraction exercise, and resistive shoulder blade squeeze) and 2nd group received general active exercises (Thoracic stretching exercise, thoracic extension exercises, and extension in lying with cervical retraction exercises). Each exercise was conducted properly for 60 min in 3 sessions per week for 4 weeks (total of 12 sessions per week). The Index of kyphosis (IK) was calculated before and after treatment. Moreover, the percentage of back disability index questionnaire (PBDI) and pain score were also detected. RESULTS: Multivariate analysis of covariance (MANCOVA) was used to compare the post-treatment's means between the first and second groups and control the pre-treatment variables. No significant differences were found post-treatment (P > 0.05). Moreover, IK measures showed a statistically significant difference post-treatment (P < 0.05). The paired sample t-test showed statistically significant differences (P < 0.05) in all variables within the first and second groups. CONCLUSION: The current study demonstrated the positive effect of both techniques in reducing the IK, percentage of back disability index, and pain score with a more positive effect of Theraband in reducing the IK measures post-treatment.

Effect of lumbar stabilization exercises and thoracic mobilization with strengthening exercises on pain level, thoracic kyphosis, and functional disability in chronic low back pain.

OBJECTIVES: The purpose of this study was to compare the effect of lumbar stabilization exercise and thoracic mobilization with strengthening exercise on pain level, thoracic kyphosis, and functional disability in patients with Chronic Low Back Pain (CLBP). METHODS: Thirty patients with CLBP were recruited based on inclusion and exclusion criteria. They were randomly allocated into two groups i. e., Group A (n = 15) and B (n = 15). Group A has received lumbar stabilization exercise and thoracic mobilization with strengthening exercises and Group B received only lumbar stabilization exercises, three sessions per week for 4 weeks both the groups. The conventional moist hot pack and interferential therapy was given to both the groups before the administration of exercise. Pre- and post-treatment pain level, Thoracic kyphosis, and functional disability were taken and statistical analysis was done. RESULTS: The result of this study showed significant improvement from pre-intervention to post-intervention on pain level, thoracic kyphosis, and functional disability for both the groups i. e., Group A and group B but Group A showed greater changes in Numerical pain rating scale (NPRS), Kyphotic index, and Oswestry disability index (ODI), than Group B. CONCLUSIONS: The 4 week of therapeutic intervention including lumbar stabilization exercise with thoracic mobilization and strengthening exercise showed significantly reduction of the thoracic kyphosis, pain level and functional disability in patients with Chronic Low Back Pain.

Transcutaneous neuromuscular electrical stimulation applied to optimal points on the lower abdomen and lumbar paraspinal region changes gait parameters in patients with lumbar degenerative kyphosis.

BACKGROUND: Lumbar degenerative kyphosis (LDK) is characterized by sagittal imbalance resulting from degenerative loss of lumbar lordosis. The ability of transcutaneous neuromuscular electrical stimulation (NMES) to activate deep lumbar stabilizing muscles has been demonstrated. OBJECTIVE: The aim of this study was to evaluate the effects of transcutaneous NMES applied to optimal points on the lower abdomen and lumbar paraspinal region on gait problems in patients with lumbar degenerative kyphosis (LDK). METHODS: Twenty-one patients with lumbar degenerative kyphosis underwent three walking sessions in the following order; walking for 5 minutes without NMES, walking with NMES on the lumbar multifidus (LM) only, and walking with NMES on both LM and transverse abdominis (TrA)/obliquus internus (OI). Differences in gait parameters at the commencement and completion of each of the three sessions were evaluated by gait analysis. RESULTS: During the 5-minute walk with NMES applied to the LM or to the LM and TrA/OI, participants showed lesser increases in spine forward tilt, pelvic anterior tilt, and external foot progression angle, and a lesser decrease in hip internal rotation than when walking without NMES (P< 0.05). In addition, with NMES, patients showed less decrement in gait velocity and stride length at walk completion than patients walking without NMES (P< 0.05). However, in the comparison between walks with NMES applied to the LM and walks with NMES applied to the LM and TrA/OI, we could not find any significant difference in changes of gait parameters (p> 0.05). CONCLUSIONS: Transcutaneous NMES applied at optimal points on the lower abdomen and back could provide a means of treating gait problems caused by a stooped trunk in LDK patients.

Training postural control and sitting in children with cerebral palsy: Kinesio taping vs. neuromuscular electrical stimulation.

OBJECTIVE: To elucidate the effects of Kinesio Taping (KT) in addition to neurodevelopmental therapy (NDT) on posture and sitting, and to compare the effects of KT and neuromuscular electrical stimulation (NMES). MATERIALS-METHODS: Seventy-five children were randomized into control, KT, and NMES groups. NDT was applied to all children 4 times a week for 4 weeks. In addition, KT and NMES were applied to KT and NMES groups, respectively. Sitting subset of Gross Motor Function Measure (GMFM) and kyphosis levels of the groups were analyzed by two way mixed ANOVA. RESULTS: GMFM and kyphosis values improved significantly in all groups (all p < 0.01), yet change levels were more prominent in the KT and NMES groups than the control group. Moreover, NMES group showed better improvement. CONCLUSION: KT or NMES application for four weeks in addition to NDT is effective on improving kyphosis and sitting. Besides, NMES is more effective than KT.

Comparison of manual therapy and exercise therapy for postural hyperkyphosis: A randomized clinical trial.

OBJECTIVE: To compare the efficacy of a manual therapy and an exercise therapy program in improving postural hyperkyphosis among young adults. METHODS: Forty-six women between the ages of 18 to 30 years with thoracic kyphosis diagnosed by flexicurve ruler were randomly assigned to either an exercise therapy or a manual therapy group. The exercise therapy program focused on stretching and strengthening exercises in 15 sessions over 5 weeks. The manual therapy group received 15 sessions of manual techniques including massage, mobilization, muscle energy and myofascial release. Kyphosis angle and back extensor muscle strength were measured with a motion analysis system and a dynamometer at the baseline and after treatment. The data were analyzed with paired and independent t-tests. RESULTS: After treatment, the angle of thoracic kyphosis was smaller and back extensor muscle strength was significantly greater in both the exercise and manual therapy groups (p < 0.001). We found no significant differences between groups in the changes in kyphosis angle or muscle strength after treatment (p > 0.05). CONCLUSION: Manual therapy was as effective as exercise therapy in reducing kyphosis angle and increasing back extensor muscle strength in young women with postural hyperkyphosis.

A decision analysis to identify the ideal treatment for adult spinal deformity: is surgery better than non-surgical treatment in improving health-related quality of life and decreasing the disease burden?

BACKGROUND: Adult spinal deformity (ASD) is a major public health problem. There are pros and cons of the available treatment alternatives (surgical or non-surgical) and it had been difficult to identify the best treatment modality. AIM: To construct a statistical DA model to identify the optimum overall treatment in ASD. METHODS: From an international multicentre database of ASD patients (968 pts), 535 who had completed 1 year follow-up (371 non-surgical-NS, 164 surgical-S), constitute the population of this study. DA was structured in two main steps of: (1) baseline analysis (assessing the probabilities of outcomes, assessing the values of preference-utilities-, combining information on probability and utility and assigning the quality adjusted life expectancy (QALE) for each treatment) and (2) sensitivity analysis. RESULTS: Four hundred and thirty-two patients (309 NS, 123 S) had baseline and 1 year follow-up ODI measurements. Overall, 104 (24.1 %) were found to be improved (a decrease in ODI > 8 points), 225 (52.1 %) unchanged (-8 > ODI > 8) and 65 deteriorated. Surgery presented with a higher chance of improvement (54.2 %) versus NS (9.7 %). The overall QALE ranged from 56 to 69 (of 100 years) and demonstrated better final QALE in the NS group (60 vs. 65, P = 0.0038), this group having started with higher QALE as well (56 vs. 65 years, P < 0.0001). There were improvements in overall QALE in both groups but this was significant only in the surgical group (S from 56 to 60 years, P < 0.0001; NS from 65 to 65 years, P = 0.27). In addition, in the subgroup of patients with significant baseline disability (ODI > 25) surgery appeared to yield marginally better final QALE (58 vs. 56 years, P = 0.1) despite very a similar baseline (54 vs. 54 years, P = 0.93). DISCUSSION AND CONCLUSIONS: This study demonstrated that a single best treatment modality for ASD may not exist. Conservative treatment appears to yield higher (up to 6 %) QALE compared to surgery, most probably secondary to a higher baseline QALE. On the other hand, surgery provides a significantly higher increase in QALE. Especially in patients with significant disability at baseline, the final QALE tended higher in the S group (although not significant). Finally, chances of a relevant improvement at first year turned out to be significantly lower with NS treatment.

Técnica de dog en extensión bilateral aplicada en una dorsalgia aguda: a propósito de un caso / No disponible

Objetivo: Describir las principales características de aplicación de la técnica de dog en extensión bilateral (TDEB), la cual puede ser utilizada para la reducción de lesiones grupales de flexión bilateral, utilizada para el tratamiento de un paciente con dorsalgia aguda. Material y Métodos: Aplicamos un protocolo de evaluación osteopático en una paciente de 35 años, por un cuadro de dorsalgia aguda, valorada mediante pruebas ortopédicas, de inspección, palpación, movilización global y analítica. Aplicamos como tratamiento la TDEB sobre el segmento en lesión. Resultados: Los resultados obtenidos han sido favorables, dado que se ha restablecido la movilidad, tanto a nivel global como segmentario, y se ha atenuado el dolor percibido por la paciente tras la aplicación de la TDEB. Conclusiones: Una correcta restructuración de la movilidad de los segmentos hipomóviles devuelve la función a los mismos, y produce efectos clínicos favorables, mejorando el estado de salud del paciente (AU)

No disponible

Técnica de dog en extensión bilateral / Dog technique in bilateral extension

La técnica de Dog en Extensión Bilateral (TDEB) es un procedimiento de tratamiento osteopático estructural, donde se realiza una fuerza de empuje controlado (thrust) sobre el paciente, con el objetivo de restaurar la fisiología articular de los segmentos vertebrales con movilidad restringida, para influir sobre los reflejos nociceptivos, y reducir o eliminar el dolor y la facilitación medular asociada. Aunque es considerada una técnica osteopática estructural, tiene gran importancia en el área visceral, puesto que, a través de los ganglios ortosimpáticos laterovertebrales del sistema nervioso vegetativo, que se sitúan próximos a los cuerpos vertebrales, se inician procesos de estimulación a distancia sobre sus órganos diana. Por ello, la aplicación de este procedimiento de manipulación consigue, no sólo estimular mecánicamente los segmentos vertebrales mediante el deslizamiento de sus carillas articulares, sino también inducir un estímulo ortosimpático visceral. Esta técnica tiene riesgos asociados que deberían conocerse y evitarse, y su eficacia ha sido demostrada, por lo que se recomienda su aplicación en los casos que presenten indicaciones para ello (AU)

The Bilateral Extension Dog technique (BEDT) is a structural osteopathic treatment procedure, where a thrust force is exerted on the patient, with the objective of restoring the joint physiology of the vertebral segments with restricted mobility, to Influence nociceptive reflexes, and reduce or eliminate pain and associated spinal cord facilitation. Although it is considered a structural osteopathic technique, it has great importance in the visceral area, since, through the laterovertebral orthosympathetic ganglia of the vegetative nervous system, which are placed close to the vertebral bodies, processes of remote stimulation are initiated on the target organs. Therefore, the application of this manipulation procedure not only mechanically stimulates the vertebral segments by sliding the joint facets, but also induces a visceral orthosympathetic stimulus. This technique has associated risks that should be known and avoided, and its efficacy has been demonstrated, so it is recommended to apply in cases that have indications for it (AU)

Age-related hyperkyphosis: its causes, consequences, and management.

SYNOPSIS: Age-related hyperkyphosis is an exaggerated anterior curvature in the thoracic spine that occurs commonly with advanced age. This condition is associated with low bone mass, vertebral compression fractures, and degenerative disc disease, and contributes to difficulty performing activities of daily living and decline in physical performance. While there are effective treatments, currently there are no public health approaches to prevent hyperkyphosis among older adults. Our objective is to review the prevalence and natural history of hyperkyphosis, associated health implications, measurement tools, and treatments to prevent this debilitating condition. LEVEL OF EVIDENCE: Diagnosis/prognosis/therapy, level 5.J Orthop Sports Phys Ther 2010;40(6):352-360, Epub 15 April 2010. doi:10.2519/jospt.2010.3099.

Adult degenerative scoliosis treated by acupuncture.

OBJECTIVE: This report of one case illustrates the potential effect of acupuncture on low back pain and curvature progression in adult degenerative scoliosis. CLINICAL FEATURES: A 74-year-old woman experienced low back pain and kyphoscoliosis for 2 years. She received regular rehabilitation and medications for 2 years, but the curvature of the lumbar spine and backache still progressed. The Cobb angle was 31 degrees and surgical intervention was suggested to reduce the pain. INTERVENTION AND OUTCOME: Before surgery, the patient was treated with acupuncture three times per week starting on May 29, 2008. After 6 weeks of treatment, the patient's lower backache decreased and follow-up radiographs showed that the Cobb angle decreased by 10 degrees . She underwent surgery on October 3 to have a better quality of life. CONCLUSIONS: Acupuncture was associated with a reduction in the degree of curvature in this case, after 2 years of conventional medical treatment had failed to stop the backache and curvature progression. This suggests that acupuncture not only plays an important role in pain control, but can also improve curvature progression for certain patients with degenerative scoliosis.

Kyphoscoliosis improvement while treating a patient for adhesive capsulitis using the active therapeutic movement version 2.

OBJECTIVE: This article presents a case report illustrating an improvement in the curvature of idiopathic scoliosis as a secondary benefit from treatment of adhesive capsulitis with an active therapeutic movement (ATM) device. CLINICAL FEATURES: The patient was a 55-year-old school teacher who was referred to physical therapy for adhesive capsulitis. It was determined that part of the patient's limited shoulder range of motion was due to her significant kyphoscoliosis posture, which resulted in decreased mobility of her thoracic spine. INTERVENTION AND OUTCOME: The patient was treated with an ATM device as a means to help mobilize her thoracic spine. The patient completed several weeks of therapy, which consisted of using the ATM exclusively. The patient gained near-normal range of motion in both arms and had improvement in her kyphoscoliosis posture. CONCLUSION: A nonsurgical treatment was a useful intervention for some of the physical and psychosocial aspects that this patient with kyphoscoliosis encountered.

Postural taping decreases thoracic kyphosis but does not influence trunk muscle electromyographic activity or balance in women with osteoporosis.

BACKGROUND: Greater thoracic kyphosis is associated with increased biomechanical loading of the spine which is potentially problematic in individuals with osteoporotic vertebral fractures. Conservative interventions that reduce thoracic kyphosis warrant further investigation. This study aimed to investigate the effects of therapeutic postural taping on thoracic posture. Secondary aims explored the effects of taping on trunk muscle activity and balance. METHODS: Fifteen women with osteoporotic vertebral fractures participated in this within-participant design study. Three taping conditions were randomly applied: therapeutic taping, control taping and no taping. Angle of thoracic kyphosis was measured after each condition. Force plate-derived balance parameters and trunk muscle electromyographic activity (EMG) were recorded during three static standing tasks of 40s duration. RESULTS: There was a significant main effect of postural taping on thoracic kyphosis (p=0.026), with a greater reduction in thoracic kyphosis after taping compared with both control tape and no tape. There were no effects of taping on EMG or balance parameters. CONCLUSIONS: The results of this study demonstrate that the application of postural therapeutic tape in a population with osteoporotic vertebral fractures induced an immediate reduction in thoracic kyphosis. Further research is needed to investigate the underlying mechanisms associated with this decrease in kyphosis.

Use of neurodevelopmental treatment techniques in a client with kyphosis: a case report.

This case report describes use of an intervention developed for patients with neurological diagnoses (neurodevelopmental treatment [NDT]) with a patient with musculoskeletal and pulmonary diagnoses. The patient was a 78-year-old woman referred to physical therapy for gait training, therapeutic exercises, and neuromuscular reeducation. Standing at her most upright, the patient initially had a 30 degrees kyphosis with extreme capital extension to bring her head to vertical. Shoulders were internally rotated, and the medial borders of the scapulae rested near the lateral border of the ribs and the scapular spines were at the level of C7. To address the postural impairments, I used NDT spinal and scapular mobilization techniques and strengthening in weight-bearing postures with modified bridging as preparation for gait training. At the end of the episode of care, the patient's upright posture had improved to 10 degrees kyphosis with head in neutral extension in both standing and walking.

Conservative treatment of a patient with previously unresponsive whiplash-associated disorders using clinical biomechanics of posture rehabilitation methods.

OBJECTIVE: To describe the treatment of a patient with chronic whiplash-associated disorders (WADs) previously unresponsive to multiple physical therapy and chiropractic treatments, which resolved following Clinical Biomechanics of Posture (CBP) rehabilitation methods. CLINICAL FEATURES: A 40-year-old man involved in a high-speed rear-impact collision developed chronic WADs including cervicothoracic, shoulder, and arm pain and headache. The patient was diagnosed with a confirmed chip fracture of the C5 vertebra and cervical and thoracic disk herniations. He was treated with traditional chiropractic and physical therapy modalities but experienced only temporary symptomatic reduction and was later given a whole body permanent impairment rating of 33% by an orthopedic surgeon. INTERVENTION AND OUTCOME: The patient was treated with CBP mirror-image cervical spine adjustments, exercise, and traction to reduce forward head posture and cervical kyphosis. A presentation of abnormal head protrusion resolved and cervical kyphosis returned to lordosis posttreatment. His initial neck disability index was 46% and 0% at the end of care. Verbal pain rating scales also improved for neck pain (from 5/10 to 0/10). CONCLUSION: A patient with chronic WADs and abnormal head protrusion, cervical kyphosis, and disk herniation experienced an improvement in symptoms and function after the use of CBP rehabilitation protocols when other traditional chiropractic and physical therapy procedures showed little or no lasting improvement.

Chiropractic management of Ehlers-Danlos syndrome: a report of two cases.

OBJECTIVE: To discuss 2 patients with Ehlers-Danlos syndrome seeking chiropractic evaluation and management of their disabling musculoskeletal pain and associated disorders. CLINICAL FEATURES: Two disabled patients diagnosed with Ehlers-Danlos syndrome had spinal pain, including neck and back pain, headache, and extremity pain. Commonalities among these 2 cases included abnormal spinal curvatures (kyphosis and scoliosis), joint hypermobility, and tissue fragility. One patient had postsurgical thoracolumbar spinal fusion (T11-sacrum) for scoliosis and osteoporosis. The other patient had moderate anterior head translation. INTERVENTION AND OUTCOME: Both patients were treated with mechanical force and manually assisted spinal adjustments delivered to various spinal segments and extremities utilizing an Activator II Adjusting Instrument and Activator Methods Chiropractic Technique. Patients were also given postural advice, stabilization exercises, and postural corrective exercises, as indicated in Chiropractic BioPhysics Technique protocols. Both patients were able to reduce pain and anti-inflammatory medication usage in association with chiropractic care. Significant improvement in self-reported pain and disability as measured by visual analog score, Oswestry Low-Back Disability Index, and Neck Pain Disability Index were reported, and objective improvements in physical examination and spinal alignment were also observed following chiropractic care. Despite these improvements, work disability status remained unchanged in both patients. CONCLUSION: Chiropractic care may be of benefit to some patients with connective tissue disorders, including Ehlers-Danlos syndrome. Low-force chiropractic adjusting techniques may be a preferred technique of choice in patients with tissue fragility, offering clinicians a viable alternative to traditional chiropractic care in attempting to minimize risks and/or side effects associated with spinal manipulation. Psychosocial issues, including patient desire to return to work, were important factors in work disability status and perceived outcome.