Combat-Related Post Traumatic Headache - Diagnosis, Mechanisms of Injury, And Challenges to...

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JAOA Vol 110 No 12 December 2010 737Letters

Combat-Related Posttraumatic

Headache: Diagnosis, Mechanismsof Injury, and Challenges toTreatment

To the Editor:

I am concerned that the original contri-bution by CPT Matthew Kozminski,DO,1 in the September 2010JAOA doesnot discuss effective treatment optionsfor soldiers with posttraumatic stressdisorder (PTSD) and postconcussionsyndrome (PCS). Dr Kozminski1 clearlydescribes the challenges of poor follow-up and overusage of headache-abortive

medications in soldiers with chronic

headache. However, the lack of any dis-cussion of effective ways to treat thesesoldiers is unfortunate.

Data from the Department ofDefense show that more than 1.6 mil-lion military personnel have beendeployed to the conflicts in Afghanistanand Iraq since late 2001.2 According to DrKozminski,1 more than 95% of soldiersface combat-related posttraumaticheadache attributed to PTSD and PCSand traumatic brain injury (TBI) may bethe underlying cause of both of theseconditions. If we are to improve the

quality of life of these soldiers, treatment

plans must be included and investigatedin our osteopathic medical literature.In cases of PCS, amitriptyline

hydrochloride is probably the most com-monly used medication. Studies haveshown that amitriptyline is effectiveagainst such nonspecific symptoms asdepression, dizziness, fatigue, insomnia,and irritability.3 Intravenous dihydroer-gotamine mesylate and metoclopramidehydrochloride may provide relief ofrefractory chronic posttraumatic

headache.4 Greater occipital neuralgiafrequently responds favorably to greateroccipital nerve block using a local anes-thetic, which can be combined with aninjectable corticosteroid.5 A trial com-paring either propranolol hydrochlorideor amitriptyline alone with both thesedrugs in combination revealed a highfavorable response rate in patients withposttraumatic migraine.6 Patients withposttraumatic paroxysmal hemicraniaand hemicrania continua have

responded favorably to treatment withindomethacin.7,8

Donepezil hydrochloride has pro-duced beneficial results in preliminarystudies of patients with severe TBI, butthis medication has not been studiedextensively in patients with PCS.9 Treat-ment with oxiracetam was described as

being helpful for patients with PCS.10

Patients with mild TBI who also met cri-teria for major depression and weretreated with sertraline hydrochloride for

8 weeks achieved substantial remissionin depressive symptoms, as well asimprovement in cognitive measures.11

An open-label study of 20 patients withdepression after TBI showed symp-tomatic improvements following treat-ment with citalopram hydrobromideand carbamazepine.12

For symptoms of PTSD, selectiveserotonin-reuptake inhibitors are first-line treatment.13 Tricyclic antidepres-sants and monoamine oxidase inhibitorshave been shown to decrease intrusivenightmares and flashbacks in patients

As the premier scholarly publication of the osteopathic medical profession,JAOAThe

Journal of the American Osteopathic Association encourages osteopathic physicians, fac-ulty members and students at colleges of osteopathic medicine, and others within thehealthcare professions to submit comments related to articles published in the JAOAand the mission of the osteopathic medical profession. TheJAOAs editors are partic-ularly interested in letters that discuss recently published original research.

Letters to the editor are considered for publication in theJAOA with the under-standing that they have not been published elsewhere and that they are not simulta-neously under consideration by any other publication.

All accepted letters to the editor are subject to editing and abridgement. Letterwriters may be asked to provideJAOA staff with photocopies of referenced materialso that the references themselves and statements cited may be verified.

Readers are encouraged to prepare letters electronically in Microsoft Word (.doc)or in plain (.txt) or rich text (.rtf) format. The JAOA prefers that readers e-mail lettersto [email protected]. Mailed letters should be addressed to Gilbert E. DAlonzo,Jr, DO, Editor in Chief, American Osteopathic Association, 142 E Ontario St, Chicago,IL 60611-2864.

Letter writers must include their full professional titles and affiliations, completepreferred mailing address, day and evening telephone numbers, fax numbers, and e-mail address. In addition, writers are responsible for disclosing financial associationsand other conflicts of interest.

Although theJAOA cannot acknowledge the receipt of letters, a JAOA staffmember will notify writers whose letters have been accepted for publication. Mailedsubmissions and supporting materials will not be returned unless letter writers provideself-addressed, stamped envelopes with their submissions.

All osteopathic physicians who have letters published in theJAOA receive con-tinuing medical education (CME) credit for their contributions. Writers of original let-ters receive 5 hours of AOA Category 1-B CME credit. Authors of published articles whorespond to letters about their research receive 3 hours of Category 1-B CME credit fortheir responses.

Although theJAOA welcomes letters to the editor, readers should be aware thatthese contributions have a lower publication priority than other submissions. As aconsequence, letters are published only when space allows.

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with PTSD.14 Adverse effects of thesemedications must be weighed againsttheir benefits.

A meta-analysis of seven random-ized, controlled clinical trials suggestedthat atypical antipsychotic medicationsreduce PTSD symptoms compared toplacebo.13 Anticonvulsant medicationsthat have demonstrated mood-stabi-lizing properties, including carba-mazepine, lamotrigine, and valproicacid, may be effective in managingimpulsive behavior, hyperarousal, andflashbacks in patients with PTSD.15 Pra-zosin hydrochloride decreased night-

mares of patients with PTSD in smallrandomized studies.16

In addition to pharmacotherapy,there needs to be discussion about psy-chotherapy, cognitive therapy, and stressmanagement for patients with PTSD andPCS. All of these treatments have shownpromise and, for completeness, should

be mentioned in any article aboutchronic headache in soldiers.

Our soldiers are put in extraordi-nary situations with extreme stress. As

osteopathic physicians, we must under-stand the causes of their symptoms, asDr Kozminski1 describes. However, tooptimally address this issue, we mustremember to include effective treatmentoptions as part of the discussion.

Eric S. Felber, DOMcLean, Virginia

References1. Kozminski M. Combat-related posttraumaticheadache: diagnosis, mechanisms of injury, andchallenges to treatment.J Am Osteopath Assoc.2010;110(9):514-519. http://www.jaoa.org/cgi/reprint/110/9/514. Accessed November 1, 2010.

2. VA fact sheet: impact of Iraq and Afghanistanwars. House Committee on Veterans Affairs Website. http://veterans.house.gov/Media/File/110/2-7-08/VA-DoDfactsheet.htm. Accessed November 3,2010.

3. Tyler GS, McNeely HE, Dick ML. Treatment ofpost-traumatic headache with amitriptyline.Headache. 1980;20(4):213-216.

4.Young WB, Hopkins MM, Janyszek B, PrimaveraJP. Repetitive intravenous DHE in the treatment ofrefractory posttraumatic headache. Headache.

1994;34:297.

5. Hecht JS. Occipital nerve blocks in postconcus-

sive headaches: a retrospective review and reportof ten patients. J Head Trauma Rehabil.2004;19(1):58-71.

6. Weiss HD, Stern BJ, Goldberg J. Post-traumatic

migraine: chronic migraine precipitated by minorhead or neck trauma. Headache. 1991;31(7):451-456.

7. Lay CL, Newman LC. Posttraumatic hemicraniacontinua. Headache. 1999;39(4):275-279.

8.Matharu MJ, Goadsby PJ. Post-traumatic chronicparoxysmal hemicrania (CPH) with aura. Neu-rology. 2001;56(2):273-275.

9. Morey CE, Cilo M, Berry J, Cusick C. The effectof Aricept in persons with persistent memory dis-order following traumatic brain injury: a pilotstudy. Brain Inj. 2003;17(9):809-815.

10. Russello D, Randazzo G, Favetta A, et al. Oxirac-etam treatment of exogenous post-concussion

syndrome. Statistical evaluation of results [inItalian]. Minerva Chir. 1990;45(20):1309-1314.

11. Fann JR, Uomoto JM, Katon WJ. Cognitiveimprovement with treatment of depression fol-lowing mild traumatic brain injury.Psychosomatics.2001;42(1):48-54. http://psy.psychiatryonline.org/cgi/content/full/42/1/48. Accessed November 3,2010.

12. Perino C, Rago R, Cicolini A, Torta R, MonacoF. Mood and behavioural disorders following trau-matic brain injury: clinical evaluation and phar-macological management. Brain Inj. 2001;15(2):139-148.

13. Stein DJ, Ipser JC, Seedat S. Pharmacotherapyfor post traumatic stress disorder (PTSD). CochraneDatabase Syst Rev. January 25, 2006;(1):CD002795.

14.Frank JB, Kosten TR, Giller EL Jr, Dan E. A ran-domized clinical trial of phenelzine and imipraminefor posttraumatic stress disorder.Am J Psychiatry.1988;145(10):1289-1291.

15. Berlin HA. Antiepileptic drugs for the treat-ment of post-traumatic stress disorder. Curr Psy-chiatry Rep. 2007;9(4):291-300.

16. Miller LJ. Prazosin for the treatment of post-traumatic stress disorder sleep disturbances. Phar-macotherapy. 2008;28(5):656-666.

Dr Kozminski was shown this letter and

declined to comment.

Brief Report of a Clinical Trialon the Duration of Middle EarEffusion in Young ChildrenUsing a Standardized OsteopathicManipulative Medicine Protocol

To the Editor:

We read with great interest the prelim-inary analysis of the prospective, ran-

domized, blinded, controlled study onthe use of osteopathic manipulative treat-

ment (OMT) for children with middleear effusion (MEE) by Steele et al1 in theMay 2010 issue. The analysis included

the first 9 months of study data; theauthors plan to publish final results laterthis year.1 It is clear that many challengesexist when designing a study that seeksto objectively validate OMT techniqueswhen compared with standard treat-ment practices. These challenges arecompounded for studies that enrollinfants and young children. Further-more, it is best when the design of thestudy not only validates the OMT tech-niques, but also is directly applicable to

using OMT in a busy medical practice.Because MEE and acute otitis mediarank among the most common reasonsfor visits to pediatric practices, the impactof OMT in reducing morbidity andsurgery in patients with these conditionscan be substantial.

A core principle of osteopathicmedicine is that structure and functionare interrelated. As such, a detailedunderstanding of eustachian tube devel-opment enables one to comprehend the

tubes role in pathologic processes. Atbirth, the eustachian tube is 13 mm longand angled at 10 degrees to the base ofthe skull.2 An adults eustachian tube is33 mm long, with an angle of 45 degrees.By age 7 years, a childs eustachian tubereaches the adult length and angle as aresult of vertical elongation of the skulland widening of the skull bases angle.2

In addition, children have smaller sur-face areas of the tensor veli palatinimusclean anatomic feature that assists

in opening the tube to allow for equal-ization of pressures and drainage.3 Thisanatomic characteristic results indecreased drainage and increased refluxof secretions into the middle ear.2

Combined, the anatomic differencesin eustachian tube length and angle andtensor veli palatini surface area in chil-dren vs adults account for the frequencyof middle ear infections, as well as theadded complications of MEE, in chil-dren.4 Equally noteworthy is that thelymphatic drainage of the pharynx andnose joins that of the ear to create a


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plexus, which drains into the retropha-ryngeal nodes. Obstruction of this plexuscontributes to serous otitis media.5

A discussion about optimal designof studies to investigate the effects ofOMT on MEE is important for validationand application of the OMT techniquesused. We understand that problems ofpatient recruitment and retention exist inall facets of clinical research, especially instudies on acute otitis media. Evidenceof these problems is the huge discrep-ancy in recruitment and retention noted

between the two referral/treatment sitesevaluated by Steele et al.1 We can offer

no easy solution; suffice to say thatrecruitment and retention are best tai-lored to the patient population studiedand the location of that study group.Limiting the number of research sitesand practitioners may minimize vari-ability in outcome, though we acknowl-edge this would come at the expense ofreducing sample size.

Likewise, to minimize confoundingresults, we believe that a standardizedtreatment protocol should be used.

Many manipulation techniques wereperformed in the study by Steele et al,1

making interpretation of results diffi-cultespecially considering the possiblelow enrollment of study participants.

If one were to prioritize the OMTtechniques used in such a study, we

believe that direct techniques, such asGalbreath treatment and anterior cer-vical mobilization, may prove morepractical and better suited for MEE anal-ysis than the techniques used by Steele

et al.1 Galbreath treatment, developedby William Otis Galbreath, DO, pro-duces effects on several components ofthe middle ear. It facilitates lymphaticdrainage to the jugulodigastric nodesfrom the pharynx and ear, increases

blood flow, releases peripharyngealfascia, and changes pressure within themiddle ear and eustachian tube.5 Gal-

breath treatment has the added benefitsof being easy to perform on younginfants and to teach to parentsbenefitsthat may aid in decreasing rates of MEEas a result of more frequent treatments

(ie, typically 3 times a day). We do notunderstand why the treatment intervalof 1 week was chosen by Steele et al.1

Another direct maneuver that maybe beneficial in its applicationthoughit would be difficult to perform in pedi-atric patientsis the Muncie technique,which opens the eustachian tube byintraoral manipulation.6 Although bal-anced ligamentous tension, myofascialrelease, and osteopathy in the cranialfield were all used in the study by Steeleet al1 and can facilitate MEE drainage,these OMT techniques may also be lesspractical to perform in the office of a

busy pediatric practice. Cooperation ofa 2-year-old toddler who is the recipientof OMT lasting 15 to 30 minutes seemsunlikely. We predict that in the finalresults of the analysis by Steele et al,1

most patients enrolled in the study willbe less than 1 year of age.

Finally, it is understandable thatSteele et al1 used tympanogram andacoustic reflectometer readings to mea-sure MEE in an effort to remain objec-tive. We agree with this strategy, but we

believe that these techniques could bebacked up by provider visualization ofthe tympanic membrane coupled withinsufflation to visualize mobility.Although these visual techniques mayintroduce a degree of clinical bias, theyprovide a realistic measure of MEE res-olution that can confirm or refute tym-panometry findings, and they minimizetympanometry results that are not read-able. We realize that the addition ofthis component is controversial.

It is encouraging to see formalresearch being performed in a difficultpatient population, and we applaud theefforts of Dr Steele and her colleagues1

to validate OMT in the treatment of chil-dren with MEE. We look forward to pub-lication of the final results of the analysis

by Steele et al1 in the near future.

Lori Prakash, OMS IVWestern University of Health Sciences, Collegeof Osteopathic Medicine of the Pacific, Pomona,

CaliforniaDavid E. Michalik, DOAssistant Clinical Professor of Pediatrics,

University of California, Irvine School ofMedicine; Division of Pediatric InfectiousDiseases, Miller Childrens Hospital of LongBeach, Long Beach, California

References1. Steele KM, Viola J, Burns E, Carreiro JE. Briefreport of a clinical trial on the duration of middleear effusion in young children using a standardizedosteopathic manipulative medicine protocol.J AmOsteopath Assoc. 2010;110(5):278-284. http://www.jaoa.org/cgi/reprint/110/5/278. Accessed September28, 2010.

2. Bluestone CD, Doyle WJ. Anatomy and physi-ology of eustachian tube and middle ear relatedto otitis media [review].J Allergy Clin Immunol.1988;81(5 pt 2):997-1003.

3. Doyle WJ, Swarts JD. Eustachian tube-Tensorveli palatini muscle-cranial base relationships in

children and adults: an osteological study [pub-lished online ahead of print June 30, 2010]. Int JPediatr Otorhinolaryngol. 2010;74(9):986-990.

4. Shah N. Otitis media and its sequelae [review].J R Soc Med. 1991;84(10):581-586.

5. Galbreath WO. Chronic catarrhal otitis media. JAm Osteopath Assoc. 1928;27(8):639.

6. Ruddy TJ. Osteopathic manipulation in eye, ear,nose, and throat disease. In: Barnes MW, ed. 1962Year Book of Selected Osteopathic Papers. Carmel,CA: Academy of Applied Osteopathy; 1962:133-140.

Response

We thank Student Doctor Prakash andDr Michalik for their thoughtfulresponse to our brief report,1 whichdescribed our experiences with a clin-ical trial. Although the well-knowndetails of the anatomic structure of thepediatric eustachian tube and middleear lymphatic system are indeed impor-tant in constructing a clinical trial ofosteopathic manipulative medicine(OMM), we did not believe that thesedetails were appropriate to include in areport intended to describe our experi-ences in implementing such a trial.

Prakash and Michalik correctlyidentified what we thought to be themost important observationthe dif-ference in recruitment between the tworeferral/treatment sites. We attributedthis discrepancy to the presence of anonsite research assistant at site B and tothe loss of three of the five committedreferring providers at site A.1

Furthermore, we agree with the


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commentary by Prakash and Michalikon Galbreath treatment and anterior cer-vical mobilization when used with older

children. However, these techniqueswere not included in the previously pub-lished study upon which our researchwas based,2 a study that demonstratedstatistical significance in outcomes foryoung children treated with a similarOMM protocol. In our experience, Gal-

breath treatment has not been found tobe as helpful for treatment of very youngchildren with otitis media as it is forolder children. This lack of efficacy may

be the result of anatomic differences

between younger and older children inthe mandible, hyoid bone, tensor velipalatini muscle, and pterygoid pro-cesses3-7 and the subsequent effects ofthese differences on soft tissues.

In regard to the treatment protocol,Prakash and Michalik seem to be underthe impression that the OMM techniquesused in our study1 varied between sub-

jects. The OMM protocol that we usedwas the same for all subjects and wasdesigned with the following three goals

in mind:

1.To use techniques that have some evi-dence of clinical effectiveness and thatare commonly taught in colleges ofosteopathic medicine (COMs). Thetechniques and treatment intervalschosen had been used by one or moretreatment providers in a previousstudy2 and are known to be com-monly taught in COMs.

2. To address the key areas of somatic

dysfunction in children with otitismedia, based on a review of publishedliterature and of unpublished docu-mentation from previous otitis mediastudies.

3. To use techniques that take less than15 minutes to perform.

Our treatment protocol will be elab-orated upon in our final report.Although there are many OMM tech-niques and combinations of techniquesthat may be helpful to children withotitis media, the protocol tested in our

study1 was designed to meet the afore-mentioned criteria.

Prakash and Michalik suggest that

the use of otoscopic (ie, provider) visu-alization to confirm or refute tympa-nometry findings might decrease thenumber of unreadable tympanometryevaluations. This method could well bea useful addition to future studiesthoughas noted by Prakash andMichalikit would introduce a level ofclinical bias. Moreover, tympanometryand acoustic reflectometry are typicallyused as diagnostic techniques for chil-dren when otoscopic examination results

are ambiguousnot vice versa.8Although a comparison of otoscopicvisualization vs gold-standard tym-panometry and acoustic reflectometrymight be an interesting project, in ourexperience the amount of infant cryingand noncompliance is directly propor-tional to the probability of an unread-able tympanometry recording and anambiguous otoscopy finding.

Very few studies have been pub-lished evaluating the clinical efficacy of

OMM in children, and there is a strongneed for many more such studies. Weare grateful for the interest that StudentDoctor Prakash and Dr Michalik haveshown in our brief report,1 and we hopethey will join the ranks of those of uswho are interested in studying the use ofOMM in children.

Jane E. Carreiro, DOAssociate Professor and Section Head ofOsteopathic Practice and NeuromusculoskeletalMedicine, University of New England College of

Osteopathic Medicine, Biddeford, Maine

Karen M. Steele, DO, FAAOProfessor and Associate Dean for OsteopathicMedical Education, West Virginia School ofOsteopathic Medicine, Lewisburg

References1. Steele KM, Viola J, Burns E, Carreiro JE. Briefreport of a clinical trial on the duration of middleear effusion in young children using a standardizedosteopathic manipulative medicine protocol.J AmOsteopath Assoc. 2010;110(5):278-284. http://www.jaoa.org/cgi/reprint/110/5/278. Accessed October28, 2010.

2. Mills MV, Henley CE, Barnes LL, Carreiro JE,Degenhardt BF. The use of osteopathic manipu-lative treatment as adjuvant therapy in children

with recurrent acute otitis media. Arch PediatrAdolesc Med. 2003;157(9):861-866.

3. Bosma JF.Anatomy of the Infant Head. Balti-more, MD: Johns Hopkins University Press;

1986:423-443.4. Rood SR. The morphology of M. tensor velipalatini in the five-month human fetus. Am J

Anat. 1973;138(2):191-195.

5. Rood SR, Doyle WJ. Morphology of tensor velipalatini, tensor tympani, and dilatator tubae mus-cles.Ann Otol Rhinol Laryngol. 1978;87(2 pt 1):202-210.

6. Ishijima K, Sando I, Balaban C, Suzuki C, TakasakiK. Length of the eustachian tube and its post-natal development: computer-aided three-dimen-sional reconstruction and measurement study.

Ann Otol Rhinol Laryngol.2000;109(6):542-548.

7. Carreiro JE.An Osteopathic Approach to Chil-

dren. 2nd ed. Edinburgh, Scotland: Churchill Liv-ingston Publishers; 2009:67-70,185-192.

8. Klein JO. Management of otitis media: 2000and beyond. Pediatr Infect Dis J. 2000;19(4):383-387.

Is Something Wrong WithOsteopathic Graduate MedicalEducation?

To the Editor:

According to data released in February2010, 1896 graduates of colleges of osteo-pathic medicine (COMs)representingonly 48% of eligible COM graduatesparticipated in this years AmericanOsteopathic Association (AOA) Intern/Resident Registration Program (ie, theAOA Match), the residencies of whichstarted in July 2010.1 That participationrate compares with 51% of eligible COMgraduates who participated in the 2009AOA Match2 and 52% of eligible COM

graduates who participated in the 2005AOA Match.3 Clearly, this trend isheading in the wrong direction.

The 2010 AOA Match results alsodocument that although 2443 fundedAOA-approved internship or residencypositions were offered, only 1473 (60%)of these positions were filled, leaving970 positions (40%) open.4 These unfilledpositions are in the subspecialties as wellas in primary careand in all types andsizes of hospitals with AOA-approvedtraining programs. At the same time, inthe 2010 National Resident Matching


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Program (NRMP [ie, allopathic medi-cine]) Match, there were 2045 partici-pants who were COM graduates, among

whom 1444 (71%) were matched and601 (29%) were not matched.5

These data reveal that substantiallymore COM graduates participated inthe NRMP Match (20454) than in theAOA Match (18961) this yearanalarming trend. While acknowledgingthat many COM graduates will partici-pate in the post-Match scramble, I

believe that these data lead to severalimportant questions, including the fol-lowing:

Why are decreasing percentages of eli-gible COM graduates choosing to par-ticipate in the AOA Match?

Why are only 60% of AOA-approvedtraining positions filled through theAOA Match,4 considering that thereare enough COM graduates to fill alloffered positions?

With the increased number of COMsand COM graduates, shouldnt thenumber of unfilled AOA-approved

training positions be decreasing ratherthan increasing, as it has often donein recent years?2,3,6

Given 4 years of COM training andmentoring, why is it that 2045 COMgraduates in the 2009-2010 academicyearmore than half the total numberof COM graduates that year5,7applied directly to AccreditationCouncil for Graduate Medical Educa-tion (ACGME)-accredited residencyprograms through the NRMP Match?

What are the implications of this trendfor the osteopathic medical professionand for the growth of osteopathicgraduate medical education?

Can AOA-approved training pro-grams be made more competitive toattract more COM graduates to filltheir slots? Do AOA-approved train-ing programs need to be made morecompetitive? If so, whose job is it?

As a graduate of a COM who com-pleted strictly AOA-approved post-graduate training, I have predominantly

worked at allopathic medical institu-tions. All these institutions have acceptedmy AOA-approved training and certifi-

cation as equivalent to allopathic medicaltraining.I currently work as a medical

director for the third largest nonprofithealth system in the United StatestheNorth Shore-Long Island Jewish HealthSystem in New York State. This systemhas a $4 billion annual budget and 38,000employees. My job is located just a fewcity blocks from where I lived as a child,in Glen Oaks, Queens. I have neverregretted pursuing AOA-approved res-

idency training, nor have I ever felt heldback because of my training.Furthermore, there are hundreds of

other COM graduates who have beenequally successful as I have beenoreven more successfulafter completingAOA-approved residency training.Clearly, completing osteopathic grad-uate medical education is an establishedpathway to career success.

Considering this record of success,I cant help but wonder what is so wrong

with osteopathic graduate medical edu-cation that decreasing percentages ofCOM graduates are participating in theAOA Match, while COM graduates areinstead choosing, in increasing numbers,to participate in ACGME-accredited res-idency training programs.

Kenneth J. Steier, DO, MPH, MHA, MGHMedical Director, Pre-Surgical Testing, LongIsland Jewish Medical Center, North Shore-LongIsland Jewish Health System, Lake Success, NewYork

References1. Crosby JB. Osteopathic Match results released.Daily Report Blog; February 9, 2010. DO-OnlineWeb site. http://blogs.do-online.org/dailyre-port.php?itemid=39321. Accessed November 13,2010.

2. Crosby JB. Osteopathic Match results released.Daily Report Blog; February 10, 2009. DO-OnlineWeb site. http://blogs.do-online.org/dailyre-port.php?itemid=20731. Accessed November 13,2010.

3. Crosby JB. AOA Match program results. Daily

Report Blog; February 14, 2005. DO-Online Website. http://blogs.do-online.org/dailyreport.php?itemid=1943. Accessed November 13, 2010.

4. 2010 Match results. DO-Online Web site.http://www.do-online.org/index.cfm?au=D&PageId=aoa_profmain&SubPageId=sir_match10res.Accessed November 13, 2010.

5. National Resident Matching Program. Resultsand Data: 2010 Main Residency Match. Wash-ington, DC: National Resident Matching Program;April 2010: 9. http://www.nrmp.org/data/resultsanddata2010.pdf. Accessed November 13, 2010.

6. Crosby JB. Osteopathic Match results released.Daily Report Blog; February 12, 2008. DO-OnlineWeb site. http://blogs.do-online.org/dailyreport.php?itemid=3947. Accessed November 13, 2010.

7. Applications, first_year enrollment, total enroll-ment and graduates by osteopathic medical school.American Association of Colleges of OsteopathicMedicine Web site. http://www.aacom.org/data/Documents/Applicants/AppEnrollGradsbySchool-061710.pdf. Accessed November 13, 2010.

Osteopathic Medicines HolisticApproach Is More ImportantThan Ever

To the Editor:

Who would have imagined just a fewyears ago that certain major corpora-tions would be out of business,

bankrupt, or just remnants of what they

once were? Yet, this is my concern for thefuture of osteopathic medicine. Althoughour profession has undergone unprece-dented growth, the growth alone willnot guarantee future success. The mainstrengths of osteopathic medicine areour philosophy and training, which pro-vide a more holistic and comprehensiveapproach to treating patients than doesallopathic medicine. However, we cur-rently seem to be swept up in a tide toemulate allopathic medicine, and we are

eroding the principles that it truly takesto be the most well-rounded and edu-cated physicians.

A tremendous amount of informa-tion is learned in medical school, but thevast amount of our clinical knowledgeand expertise is acquired after gradua-tion. Regardless of specialty or exper-tise, a physician needs to have a solidand well-rounded knowledge ofmedicine and surgery. The traditionalosteopathic rotating internship helps tofoster our philosophy and to promotethis solid foundation. Unfortunately, the


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deregulation of this traditional rotatinginternship by the American OsteopathicAssociation (AOA) to allow specialty-

tract internships1,2

is a grievous mistake.These specialty-tract internships will notprovide the comprehensive exposureand knowledge that a physician shouldpossess to provide the best possiblepatient care.

As an allergy specialist, I believethat nowmore than evera holisticphilosophy and approach as developedin the traditional osteopathic rotatinginternship is invaluable.

Many patients are referred to me

by primary care physicians or special-ists for allergy treatment. In some cases,I find that these patients have been mis-diagnosed as a result of failure by thereferring physicians to use a holisticapproach. For example, I commonly seepatients who have been diagnosed ashaving chronic allergic cough, but whoin reality have asymptomatic gastroe-sophageal reflux diseasea conditionthat can also be exacerbated by certainmedications. One of my patients had

been diagnosed by her cardiologist ashaving an exacerbation of asthma, butshe actually had congestive heart failure.

Only a small number of osteopathicphysicians use osteopathic manipula-tive treatment (OMT).3 Nevertheless, thevast majority of osteopathic physiciansshould at least incorporate basic palpa-tory skills to improve their diagnosticacumen. I frequently see patients whowere diagnosed as having sinusheadaches that I find, upon palpation,

resulted from musculoskeletal causes.One of my patients with chest discom-fort had been incorrectly diagnosed byher primary care physician as havingcostochondritis. After performing a com-plete physical examination of the patient,including palpation, I concluded that achest radiograph was warranted. Theradiograph revealed a pneumothorax.

I have a longtime friend who writesbusiness-oriented books and tours thecountry as a highly paid speaker and

business consultant. In his work, healways stresses the critical importance

of having ones own niche, so one doesnot need to compete with others. Thisadvice is especially important during

these increasingly difficult times. Theosteopathic medical profession alreadyhas its perfect niche carved outyet weare squandering our great potential bytrying to emulate our allopathic col-leagues. In fact, some members of theosteopathic medical profession are evenpromoting a change of our DO degree to

be more like the MD degree.4,5

High-quality evidence-basedstudies, as Felix J. Rogers, DO,6 has pro-moted, could help propel us to the pre-

ferred physician status in the UnitedStates. Such studies could be the center-piece of an effective public marketingcampaign, which has been sorelylacking, to introduce and promote thesuperiority of osteopathic medicine. Inaddition, Norman Gevitz, PhD,7 hasstressed that for the osteopathic med-ical profession to thrive, young osteo-pathic physicians need to practice dis-tinctive osteopathic medicine and todedicate themselves to conducting

research on osteopathic principles andpractice and fighting for professionalautonomy.

A number of published studieshave indicated benefits from osteopathicmedicine for a variety of conditions. Forexample, a study by Licciardone et al8 inthe January 2010 issue of theAmericanJournal of Obstetrics and Gynecology pre-sented evidence that OMT may ease late-pregnancy back pain, though the authorscalled for further investigations. In

another example, Guiney et al9 foundstatistically significant improvements inpeak expiratory flow rates in pediatricpatients with asthma after OMT.

At the AOAs Annual Conventionand Scientific Seminar in Las Vegas,Nevada, in October 2008, one presentedabstract10 described a small pilot studydesigned to assess whether OMT couldreduce the need for cesarean sections. If

beneficial results of OMT for such casesare demonstrated in larger, controlledstudies, OMT may not only helppatients, but it may also help reduce

medical and surgical costs. Furthermore,results of such studies would increasepatient demand for osteopathic medical

services.We currently find ourselves at whatmay be the dawning of monumentalchanges in the US healthcare system.With the ballooning deficits of the federalgovernment, healthcare dollars will mostlikely dwindle in the future. Residencypositions that are funded by the Medi-care program may also decrease, cre-ating keen competition for the remainingspots. Allopathic residency slots in manyfields are still plentiful, but in certain

fields, such as dermatology, competi-tion for these slots is already extremelycompetitive. Moreover, according toMichael E. Whitcomb, MD,11 the avail-ability of allopathic graduate medicaleducation programs will cease to existfor osteopathic medical students in theforeseeable future.

In addition, slots that remainunfilled in the AOA Intern/ResidentRegistration Program (ie, AOA Match)may disappear with decreased

funding,12 creating the perfect storm offewer slots and more competition. Res-idency program directors will have theirpick of the top medical students in thecountry. By surrendering our uniqueosteopathic medical training, we wouldforce residency program directors to con-sider other information about candi-dates, such as medical school attended,college grades, and Medical CollegeAdmission Test (MCAT) scores. Thisdevelopment would place us at a greater

disadvantage. According to 2009 statis-tics from the Association of AmericanMedical Colleges13 and the AmericanAssociation of Colleges of OsteopathicMedicine,14 allopathic matriculants havehigher grade point averages (GPAs) andhigher MCAT scores than do osteopathicmatriculants (allopathic GPA=3.66 andMCAT=30.8, osteopathic GPA=3.48 andMCAT=26.19).

Further denigrating our professionare those applicants who wish to becomephysicians and have no interest in osteo-pathic medicine, but whose grades and


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board scores were not competitiveenough for admission to allopathic med-ical schools. Upon graduation from

osteopathic medical schools, such stu-dents will simply skip the rotatinginternship and enter the allopathicMatch and then blend into the allo-pathic medical profession.

The second-rate image of osteo-pathic medicine was fostered by a NewYork Times article in February 201015

that discussed the keen competition foradmission into allopathic medicalschools. According to the article, an indi-vidual who was rejected from 28 of 30

medical schools was told by his pre-medadviser that, with his 3.3 GPA, he shouldapply only to osteopathic medicalschools.

What is our goal for excellence? Ifan individual is truly committed to

becoming an osteopathic physician, he orshe should be willing to commit to com-pleting a rotating internship and then

be free to pursue any residency. Oneadditional year of training over a life-time of practice is little sacrifice and will

result in an immense payoff in terms ofboth personal and professional satisfac-tion.

Another problem that we faceinvolves lack of the holistic approach incoordination of care between physiciansand patients. This deficiency is becominga major obstacle in delivering qualitymedical care. A letter in the July 2009issue ofJAOAThe Journal of the Amer-ican Osteopathic Associationby DavidStuart Tabby, DO,16 illustrated this

problem. Dr Tabbys father, a retiredosteopathic family physician, was hos-pitalized in the intensive care unit at aPhiladelphia hospital. Dr Tabbydescribed his frustration regarding thelack of communication between hisfamily and his fathers physicians. Theletter16 revealed that even in an inten-sive care setting where both the patientand his son are physicians, there is nocontinuity of care, and no one seems to

be in charge. Unfortunately, this situationappears to be a growing epidemic that isexacerbated when physicians know

nothing outside their realm of expertise,resulting in a medical Tower of Babel.

In summary, it is critical in these

changing times that the osteopathic med-ical profession not be embarrassed byour history and embrace what has

brought us as far as we have comeaholistic approach to patient care and acomprehensive osteopathic training pro-gram. We must also demonstratethrough evidence-based studies that wepractice thorough and sound medicine.If we continue along our new path offollowing allopathic colleagues, I fearthat our prognosis is guarded.

Paul M. Goldberg, DOAlexandria, Virginia

References1. Obradovic JL, Winslow-Falbo P. Osteopathicgraduate medical education.J Am Osteopath

Assoc. 2007;107(2):57-66. http://www.jaoa.org/cgi/reprint/107/2/57. Accessed November 5, 2010.

2. Freeman E, Lischka TA. Osteopathic graduatemedical education. J Am Osteopath Assoc.2009;109(3):135-145. http://www.jaoa.org/cgi/reprint/109/3/135. Accessed November 5, 2010.

3. Spaeth DG, Pheley AM. Use of osteopathic

manipulative treatment by Ohio osteopathic physi-cians in various specialties.J Am Osteopathic Assoc.2003;103(1):16-26. http://www.jaoa.org/cgi/reprint/103/1/16. Accessed November 5, 2010.

4. Greenwald B. A rose is still a rose ... or is it?Can a new degree lead to more respect, recogni-tion for DOs? The DO. 2008;49(2):30-34.

5. Bates BR, Mazer JP, Ledbetter AM, Norander S.The DO difference: an analysis of causal relation-ships affecting the degree-change debate.J AmOsteopath Assoc. 2009;109(7):359-369. http://www.jaoa.org/cgi/reprint/109/7/359. Accessed November5, 2010.

6. Rogers FJ. Defining osteopathic medicine: can

you put your finger on it [editorial]?J AmOsteopath Assoc. 2010;110(7):362-363. http://www.jaoa.org/cgi/reprint/110/7/362. Accessed November5, 2010.

7. Gevitz N. Center or periphery? The future ofosteopathic principles and practices [editorial].J

Am Osteopath Assoc. 2006;106(3):121-129. http: //www.jaoa.org/cgi/reprint/106/3/121. AccessedNovember 5, 2010.

8. Licciardone JC, Buchanan S, Hensel KL, KingHH, Fulda KG, Stoll ST. Osteopathic manipulativetreatment of back pain and related symptomsduring pregnancy: a randomized controlled trial[published online ahead of print September 20,2009].Am J Obstet Gynecol. 2010;202(1):43.e1-e8.

9. Guiney PA, Chou R, Vianna A, Lovenheim J.Effects of osteopathic manipulative treatment on

pediatric patients with asthma: a randomized con-trolled trial.J Am Osteopath Assoc. 2005;105(1):7-12. http://www.jaoa.org/cgi/reprint/105/1/7.Accessed November 5, 2010.

10. Keurentjes AE. Relationship of OsteopathicManipulative Treatment During Labor and Deliveryon Selected Maternal Morbidity Outcomes: A Ran-domized Control Trial[PhD dissertation]. Blacks-burg, VA: Virginia Polytechnic Institute and StateUniversity; 2009.

11.Whitcomb ME. Physician supply revisited.AcadMed. 2007;82(9):825-826.

12. Freeman E, Duffy T, Lischka TA. Osteopathicgraduate medical education 2010.J Am Osteopath

Assoc. 2010;110(3):150-159. http://www.jaoa.org/cgi/reprint/110/3/150. Accessed November 5, 2010.

13. Table 17: MCAT scores and GPAs for appli-cants and matriculants to U.S. medical schools

1998-2009. Association of American Medical Col-leges Web site. https://www.aamc.org/download/85994/data/table17fact2009mcatgpa9809web.pdf.Accessed November 5, 2010.

14.AACOMAS matriculant profile, 2009 enteringclass. American Association of Colleges of Osteo-pathic Medicine Web site. http://www.aacom.org/data/Documents/Matriculants/2009Matricu-lantSummary.pdf. Accessed November 5, 2010.

15. Hartocollis A. Expecting a surge in US med-ical schools. New York Times. February 15, 2010:A1.http://www.nytimes.com/2010/02/15/educa-tion/15medschools.html. Accessed November 5,2010.

16. Tabby DS. Where is the captain of the ship[letter]?J Am Osteopath Assoc. 2009;109(7):386-387. http://www.jaoa.org/cgi/reprint/109/7/386-a.Accessed November 5, 2010.

Osteopathic MedicalTerminologyRedux

To the Editor:

Fifty years ago, the American Osteo-pathic Association established a policythat the term osteopathic medicine should

replace of the term osteopathy.During the AOA House of Dele-

gates meeting in 1960, a principal argu-ment proffered for considering the policywas that the term osteopathy is consid-ered by many to be restrictive and sug-gests limited training and restrictive priv-ileges (as in foreign-trained osteopaths).As a result, a policy was adopted that theterms osteopath and osteopathy bereserved for historical, sentimental, andinformal discussions only.1

By the late 1970s, colleges ofosteopathy had changed their names to


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colleges of osteopathic medicine, and sev-eral years later, the colleges adjusted thedegree designation from doctor of

osteopathy to doctor of osteopathic medi-cine. Most osteopathic medical associa-tions adopted the change in terminology.

Today, only the AmericanAcademy of Osteopathy continues touse osteopathy in its name. In addition,the Glossary of Osteopathic Terminology2

makes an exception for the termosteopathy in the cranial field, whichdescribes the palpatory techniques andosteopathic manipulative treatment usedto assess cranial dysfunction and to treat

patients with such dysfunction.In 1993, I wrote the editorial1 that isreprinted on this page to outline inJAOAThe Journal of the AmericanOsteopathic Association the reasons thatAOA publications follow the AOAs 1960mandate in preferred terminology. How-ever, some osteopathic physicians con-tinue to use outdated terms. So it is not asurprise that patients still do not realizethat we are fully licensed physicians.

Words have meaning. Is it not time

for the entire osteopathic medical pro-fession to join together to erase the con-fusion that still exists because of the con-tinued use of confusing terminology?

Thomas Wesley Allen, DO, MPHAOA Editor in Chief Emeritus

References1. Allen TW. Osteopathic physician defines ouridentity.J Am Osteopath Assoc. 1993;93(9):884.

2.Educational Council on Osteopathic Principles ofthe American Association of Colleges of Osteo-

pathic Medicine. Glossary of Osteopathic Termi-nology. Rev ed. Chevy Chase, MD: American Asso-ciation of Colleges of Osteopathic Medicine; April2009. http://www.aacom.org/resources/Docu-ments/Downloads/GOT2009ed.pdf. AccessedNovember 29, 2010.

Editors note: Dr Allen was not involvedin the decision to publish this letter orthe reprinted editorial that follows.

This editorial was originally published in the JAOA in September 1993.

Osteopathic physician defines our identity

Behind every name or label lies an idea, or an understanding. A misnomer,then, creates a misunderstanding. Certainly, this logic played some part inthe resolution adopted by the House of Delegates of the American Osteo-pathic Association (AOA) on July 20, 1960:

Be it resolved, that the American Osteopathic Association institute a policy,both officially in our publications and individually on a conversationalbasis, to use the terms osteopathic medicine in place of the word osteopathy andosteopathic physician and surgeon in place of osteopath; the words osteopathy andosteopathbeing reserved for historical, sentimental, and informal discus-sions only.

The AOA publications have followed the mandate of the profession inthe use of the preferred terminology. Osteopathyand osteopathare considered

by many to be restrictive, because they are commonly equated with manip-ulative treatment only. Structural diagnosis and manipulative treatmentare a means of expressing some of the basic concepts of osteopathic medicine

but do not define it. Nonetheless, many individuals may think that theterm osteopathy suggests restricted privileges and limited training.

The misapprehension that DOs have limited training and should havetheir practice privileges restricted was a consideration of early osteopathicphysicians. In fact, as early as January 1902, theJAOA reported, Fromwhat has been said the conclusion is inevitable that we are, properly speaking,

medical practitioners and that we hold a coordinate rank with other schoolsof medicine.l

We osteopathic physicians are understandably irritated to read so oftenin the lay press and in professional publications, the terms,physicians andosteopaths and doctors and osteopaths. Whether used by detractors in a pejo-rative context, or as a contraction for osteopathic physician, the aforemen-tioned terms are confusing. The public may infer from the juxtaposition ofthese two terms that we are not physicians. We are, and have been from the

beginning, the osteopathic medical profession. We are osteopathic physicians.As George W. Northup, DO, wrote, More modern terminology relating

to our profession will gain acceptance if we, ourselves, make use of it. Atevery opportunity, osteopathic physicians should urge correct professional

identification, remembering that we cannot expect to be identified properlyso long as we fail to identify ourselves properly.2

The terms osteopath and osteopathy were honorably retired more than 30years ago and do not accurately reflect who we are today. As such, it is upto us to communicate who we are, not only by identifying ourselves prop-erly in the written and spoken word, but also by our work.

Thomas Wesley Allen, DODO Editor in Chief

References1. Booth ER: Relation of osteopathy to the medical profession and to the people.JAOA.1902;1:89-98.

2. Northup GW: Oh, call it by some better name.JAOA. 1968;68:113-114.


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It Means Just What I Choose It toMeanNeither More nor Less

To the Editor:The late Sen Daniel Patrick Moynihan(D, NY) was fond of saying, We are allentitled to our own opinions, but not toour own facts.1 I would add that weare not entitled to our own professionallanguage choices, either.

To be a profession, a group shouldshare a body of knowledge and skills.2

Although professionals are granted con-siderable autonomy in practice and theprivilege of self-regulation, certain

boundaries must be respected. It is myopinion that we need to maintain a con-sistent standard of language indescribing osteopathic medicine and thatthe Glossary of Osteopathic Terminology3

defines that standard.The American Osteopathic Associ-

ations Foundations for OsteopathicMedicine4 textbook includes the followingstatement related to osteopathic med-ical terminology:

The evolution, growth, and teachingof osteopathic philosophy have beencoordinated through the EducationalCouncil on Osteopathic Principles(ECOP) of the American Associationof Colleges of Osteopathic Medicine.This organization consists of thechairs of the departments of osteo-pathic manipulative medicine andosteopathic principles and practicefrom each osteopathic medicalschool. ... One of ECOPs charges is toobtain consensus on the usage of

terms within the profession.

The terminology preferences ofJAOA-The Journal of the American Osteo- pathic Association differ from the Glos-sary3 in certain cases, based on AOApolicy (Michael Fitzgerald, BA, personalcommunication, May 11, 2010).Although I am not arguing that eithertheJAOA or the Glossary of OsteopathicTerminology3 is right or wrong, I am

arguing that we need to use a commonlanguage to describe what we do asosteopathic physicians.

In the early days of the osteopathicmedical profession, each school ofosteopathy developed its own language

to describe the manual medicine taughtat the school. The resulting inconsisten-cies made developing state licensingexaminations, national board examina-tions, and objective standards difficult

by allowing for a bias that benefited indi-viduals based on the schools theyattended rather than on the merits ofthose being tested.

In 1969, ECOP was established tostandardize osteopathic medical termi-nology and osteopathic principles and

practice. Twelve years elapsed beforeECOP reached agreement and the firstedition of its Glossary was published intheJAOAs April 1981 issue.5

Currently, the criteria6 for includingterms in the glossary are as follows:

Words to be included must have spe-cial significance to the osteopathic[medical] profession.

Words must be a part of our languageor appear in the osteopathic [medical]

literature. Terms that [are] defined in medical

dictionaries [are] excluded, unless they[have] a special significance to osteo-pathic physicians.

Osteopathic physicians from dif-ferent specialties often speak differentprofessional languageseven if they alluse English as their vernacular language.Yet standardization of professional ter-minology facilitates discussions amongdifferent specialists.7 Furthermore, theincreasing importance of clear commu-nication within interdisciplinary health-care teams means that we must be con-sistent with our language.

The JAOA often determines theissues discussed within the osteopathicmedical profession, and the languageused in the JAOA will be repeated,quoted, and cited. If theJAOA decides touse its own languageseparate from

that taught in osteopathic medicalschoolsunnecessary confusion willcloud professional discussions.

Discussions, as well as scientificresearch, cannot be accurate or produc-tive without a standard vocabulary.

People can easily talk past each other oruse the same words to talk about verydifferent things. The work of theJAOAis too important for it to occur outside ofthe academic work of osteopathic med-ical schools.

A system is in place for consideringchanges to the Glossary of Osteopathic Ter-minologyincluding openness to inputand lively discussion (http://www.aacom.org/people/councils/Documents/Glossary_Guidelines.pdf). I

respectfully request that theJAOA workwith ECOP to maintain standardizationin the language used within the osteo-pathic medical profession.

Tyler C. Cymet, DOAssociate Vice President for Medical Education,American Association of Collegesof Osteopathic Medicine

References1. Mike McCurrys tribute to Daniel PatrickMoynihan. The American Academy of Politicaland Social Science Web site. June 18, 2010. http:

//www.aapss.org/news/2010/06/18/mike-mccurry-ldquo-we-should-always-find-a-place-to-honor-pat-moynihan-rsquo-s-kind-of-insight-and-service-rdquo. Accessed November 23, 2010.

2. Cruess SR, Johnston S, Cruess RL. Profession:a working definition for medical educators. TeachLearn Med. 2004;16(1):74-76.

3.Educational Council on Osteopathic Principles ofthe American Association of Colleges of Osteo-pathic Medicine. Glossary of Osteopathic Termi-nology. Rev ed. Chevy Chase, MD: American Asso-ciation of Colleges of Osteopathic Medicine; April2009. http://www.aacom.org/resources/Documents/Downloads/GOT2009ed.pdf. AccessedNovember 23, 2010.

4. Seffinger MA, King HH, Ward RC, Jones JM,Rogers FJ, Patterson MM. Osteopathic philosophy.In: Ward RC, ed. Foundations for OsteopathicMedicine. 2nd ed. Philadelphia, PA: LippincottWilliams & Wilkins; 2003:3-18.

5. The Project on Osteopathic Principles Educa-tion. Glossary of osteopathic terminology.J AmOsteopath Assoc. 1981;80(8):552-567.

6. Kuchera WA. Introduction. In: Ward RC, ed.Foundations for Osteopathic Medicine. Baltimore,MD: Williams & Wilkins; 1997:1126.

7. Coren JS, Filipetto FA, Weiss LB. Eliminatingbarriers for patients with limited English profi-ciency.J Am Osteopath Assoc. 2009;109(12):634-640. http://www.jaoa.org/cgi/reprint/109/12/634.Accessed November 23, 2010.

(continued)


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Editors note: Dr Cymet is affiliated withthe American Association of Collegesof Osteopathic Medicine, which holds

the rights to publication of the Glossaryof Osteopathic Terminology.

Dr Cymet is also a member of theJAOA Editorial Board. He was notinvolved in the decision to publish thisletter.

Response

In this months Letters section of

JAOAThe Journal of the American Osteo-pathic Association, both Tyler C. Cymet,DO, and Thomas Wesley Allen, DO,MPH, take us back in time to remind usof how important it is for osteopathicphysicians to adhere to a common lan-guage in describing the unique care theyprovide.

Dr Cymet reminds us that beforethe Glossary of Osteopathic Terminologywas first published 29 years ago,1 manyosteopathic medical colleges used dif-

ferent terms to describe the same con-ditions and treatments. Dr Allen, in turn,reminds us that 21 years before the Glos-sary premiered, the American Osteo-pathic Association (AOA) establishedits first policy to use the term osteopathicmedicine in place of osteopathy and theterm osteopathic physician and surgeon inplace of osteopath.

As the American Association of Col-leges of Osteopathic Medicines staffliaison to the Educational Council on

Osteopathic Principles (ECOP), DrCymet is appropriately exercising hisduty as ECOPs steward when he ques-tions why theJAOA would adopt ter-minology that differs from what ECOPapproved for the Glossarys most cur-rent version.2

Like ECOP, theJAOA has long sup-ported standardized terminology inosteopathic medicine. In fact, on nearlyevery major issue related to terminology,theJAOAs style guidelines and the Glos-sary agree. Where they disagree on majorissues are in the rare instances in which

policy set by the AOA House of Dele-gates conflicts with the Glossary. Cur-rently, that conflict centers on one term:

osteopathy in the cranial field.While the Glossary uses osteopathyin the cranial field, theJAOA prefers touse either osteopathic manipulative medicinein the cranial field or cranial osteopathicmanipulative medicine. TheJAOAs pref-erence is grounded in the AOAs 50-yeartradition that Dr. Allen described in hisletter. The AOA House of Delegatesreconfirmed that tradition in July whenit passed as policy House Resolution 301(A-2010), which is titled Osteopath and

OsteopathyUse of the Terms. Whilethat 2010 policy allows for a few excep-tions, it calls for the AOA to preferen-tially use osteopathic medicine in place ofthe word osteopathyand osteopathic physi-cian in place of osteopath.

Despite theJAOAs style preference,THEJOURNAL does allow authors to useosteopathy in the cranial field if they insiston using that term in their articles. But indeference to the AOAs policy, theJAOAincludes with those articles an editors

note such as the following one from theJAOAs April brief report titled Effect ofOsteopathy in the Cranial Field onVisual FunctionA Pilot Study.3

Editors Note: In this article, theauthors use the term osteopathy in thecranial field to describe the palpatorytechniques and osteopathic manip-ulative treatment used to assess cra-nial dysfunction and to treat patientsfor such dysfunction.

The authors use osteopathy in thecranial fieldbecause it is a more uni-versally used term than cranial osteo-pathic manipulative medicineandosteo-pathic [manipulative] medicine in thecranial field, which are the terms pre-ferred by the style guidelines ofJAOAThe Journal of the AmericanOsteopathic Association.

Still, Dr Cymet makes a valid pointin urging theJAOA to bring its style con-cerns to ECOP for its consideration. The

JAOA plans to do just that in the hopethat ECOP can offer a solution that the

JAOA can bring back to the AOA Houseof Delegates.

Michael Fitzgerald, BA

AOA Director of Publications and Publisher

References1. The Project on Osteopathic Principles Educa-tion. Glossary of osteopathic terminology.J AmOsteopath Assoc. 1981;80(8):552-567.

2.Educational Council on Osteopathic Principles ofthe American Association of Colleges of Osteo-pathic Medicine. Glossary of Osteopathic Termi-nology. Rev ed. Chevy Chase, MD: American Asso-ciation of Colleges of Osteopathic Medicine; April2009. http://www.aacom.org/resources/Documents/Downloads/GOT2009ed.pdf. Accessed December2, 2010.

3. Sandhouse ME, Shechtman D, Sorkin R, et al.Effect of osteopathy in the cranial field on visualfunctiona pilot study.J Am Osteopath Assoc.2010;110(4):239-243. http://www.jaoa.org/cgi/content/full/110/4/239. Accessed December 2, 2010.

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