A 32-year-old woman was admitted to an acute rehabilitation hospital at a large academic medical center after receiving a diagnosis of ileus and experiencing prolonged nausea and vomiting. The patient had a history of stiff person syndrome (glutamic acid decarboxylase [GAD]-65 antibody negative), an aminoacidopathy of mitochondrial origin diagnosed in 2008, and associated postural tachycardic syndrome and full body spasms. Before the current hospitalization, the patient had no history of

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... ntestinal symptoms nor singultus. The onset of singultus occurred early in her hospitalization, manifesting as recurrent bouts most frequently when the patient was in an upright position or when she forward-flexed either humerus. These episodes would last 20 minutes to 5 hours before spontaneous cessation. Various medications, including baclofen, ondansetron, metaclopramide, and carbemazepine, were unsuccessful in reducing the duration, frequency, or intensity of singultus. Three weeks after its onset, an episode of intractable singultus developed while the patient was on a tilt table during physical therapy. An osteopathic physician (B.S.) was consulted. The physician conducted an osteopathic structural examination and found tissue texture changes, asymmetry, and restriction of motion or tenderness in the neck, T1-T4, T10-T12, and sacrum and pelvic regions ( Table 1) . He then performed OMT using rib raising, diaphragmatic balanced ligamentous tension, and diaphragmatic doming of the left hemidiaphragm, 5 with instantaneous cessation of singultus. Singultus recurred the following day after a similar position change during therapy, and OMT was performed again with similar results. Four days later, during a period of singultus remission, we performed another osteopathic structural examination ( Table 2) , which showed persistence of the cervical, upper thoracic, thoracolumbar, and sacral dysfunction, with the addition of cranial and abdominal findings. Myofascial release and osteopathic cranial manipulative medicine were applied to the occiput, neck, S ingultus, or hiccups, is defined as "an involuntary, intermittent, spasmodic contraction of the diaphragm and intercostal muscles." 1 The current definitions divide singultus into 4 categories: acute, persistent, chronic, and intractable. Acute singultus is defined as hiccups lasting fewer than 48 hours; persistent, more than 48 hours; chronic, more than 7 days; and intractable, more than 1 month. 2,3 We describe a patient with recurrent bouts of presumed centrally caused singultus that responded to osteopathic manipulative treatment (OMT). Singultus, or hiccups, are involuntary spasms of the diaphragm that in most cases are harmless and self-limited. Treatments are reserved for those cases that persist, and current options include pharmacotherapeutics, complementary methods (such as acupuncture), and osteopathic manipulative treatment. A 32-yearold woman with stiff person syndrome and concurrent aminoacidopathy in the setting of acute inpatient rehabilitation was experiencing daily bouts of singultus, ranging from 20-minute to 5-hour durations. Osteopathic manipulative treatment at the onset of spasm resulted in immediate cessation of and further suppression of singultus for approximately 12 to 24 hours. Overall, there was a noted reduction in singultus frequency, duration, and intensity, as well as better tolerance of physical and occupational therapy. The authors theorize that OMT could be a useful adjunct to, or replacement of, pharmacologic interventions for singultus, especially when pharmacologic therapies have failed.