Treatment of Asthma using OMT 2005 Thomas L. Northup …€¦ · Treatment of Asthma using OMT …...

March�006 The AAO Journal/1

Treatment of Asthma using OMT… pages 24-26 and 28-31

2005 Thomas L. NorthupLecture: What if?Dennis J. Dowling, DO, FAAO

…page 11

ThomasL.Northup,DO

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tradItIon shapes the Future Volume 16 number 1 march 2006

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In thIs Issue:AAOCalendarofCourses...................................................................................4Contributors.........................................................................................................6ComponentSocieties’CMECalendar...............................................................��

edItorIal

ViewfromthePyramids:Anthony G. Chila, DO, FAAO ..............................5

regular Features DigOn............................................................................................................7 FromtheArchives..........................................................................................8 BookReviews......................................................................................... 37-38 ElsewhereinPrint.........................................................................................39

2005 thomas l. northup lecture Whatif?.........................................................................................................11

Dennis J. Dowling, DO, FAAO

clInIcal practIce Amyofascialtriggerpointontheskull:Treatmentimprovespeak flowvaluesinacuteasthmapatients.............................................................�3 Wm. Thomas Crow, DO, FAAO and David Kasper, MBA

scIentIFIc paper/thesIs (Faao) Intercostalribrelease....................................................................................�6 Claudia L. McCarty, DO, FAAO

the student physIcIan Multidisciplinaryapproachtotreatmentina38-yearoldfemale, restraineddriverfollowinginjuriessustainedinarear-endcollision...........33 James L. Rook, MPH, OMS-IV, Western University of Health Sciences and Ann Marie Auburn-Dean, DO

tradItIon shapes the Future • Volume 16 number 1 march 2006

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Forum for Osteopathic Thought

Tradition Shapes the Future • Volume 16 Number 1 March 2006

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Calendar of Events

2006

Mar 20-22 Visceral/Structural Integration inBirmingham,Alabama

Mar 22 AAOBoardsofGovernorsandTrustees inBirmingham

Mar 22-26 AAO ConvocationinBirmingham

May 5-7 Diagnosis and Treatment of Low Back Pain inDurham,NC

May 19-21 Prolotherapy: Above the Diaphragm atUNECOM

Jun 16-18 OMT for Common Organic and Clinical ProblemsatUMDNJ-SOM

Jul 1 AOBNMMapplicationdeadline

Jul 14-16 Visceral Manipulation: Urogenital inSanFrancisco

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ofIndianapolis

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Licensed Health Care ProviderinLasVegas

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Nov 3-5 Prolotherapy: Below the Diaphragm atUNECOM

Dec 1 AOBNMMapplicationdeadline

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View from the Pyramids

Anthony G. Chila

AndrewTaylorStill’scontributiontotheimprovementofthepracticeofmedicinehas,inrecentyears,shownapropen-sityforinternationalexpression.AlthoughstillrecognizedasbeingofAmericanorigin,thecommunityofpractitionersabroadhasshowndiverseexpressionformanyyears.

Thetrainingandscopeofpracticeintheosteopathic

worldhasdistinguishedthreetypesofpractitioners:US-trainedDOs(GraduatesofAmericanOsteopathicAssociation[AOA]-accreditedosteopathicmedicalschools);Nonphysi-cianosteopaths(Graduatesofschoolsofosteopathyinfor-eigncountries,trainedinosteopathicprinciplesandpractice,butnothavingunlimitedpracticerights);Foreignphysicianswithosteopathicspecialties(Graduatesofforeignmedicalschools,specializinginOsteopathicPrinciplesandPractice[OPP]).1

TheAmericanAcademyofOsteopathy(AAO)hostedits1stInternationalForumin1996.ThisforumprovidedanopportunityfordiscussionanddeliberationforNonphysi-cianosteopaths.SubsequentyearshaveseentheeffectsoftheInternationalForumsfacilitatetheemergenceoftwomajorforcesfortheexpressionofosteopathicpractice:anOsteopathicInternationalAlliance(OIA)establishedbytheAmericanOsteopathicAssociation(AOA);aWorldOsteo-pathicHealthOrganization(WOHO)establishedthroughtheeffortsofUStrainedDOsandinternationalosteopaths.AAOmembershavebeenactivelyinvolvedwithbothinmember-shipandgoverningboards.TheWorldHealthOrganization(WHO)hasbeeninstrumentalininitiatinganinternationalprojectaddressing“guidelinesonthesafetyandefficacyofosteopathy.”Again,theAAOhasbeenactivelyinvolved.

Thereisanearlierhistoryofactivitywhichcanbeviewedasinformalpreparationforthesepost-1996organizationalaccomplishments.Variousaspectsofactivityspoketoanappreciationofheritagewhileexpressingdifferentiationintraditions.Itisinthisearliererathatonecanseethesowingofseedswhich,slowlyatfirst,butwithgraduallyincreasingmomentum,preparedthescenewhichisbeingwitnessedtoday.ThepracticesofindividualUStrainedDOsincountriesabroadduringtheyearsfollowingWorldWarI,theinter-waryears,andthepost-WorldWarIIyearscanbecited.TheestablishmentoftheBritishSchoolofOsteopa-

thy(BSO)byJohnMartinLittlejohnwasthebeginningofaEuropeantraditionwhichfacedresistancetodevelopmentsimilartothatoftheUSexperience.Thisrepresentedacyclewhichbeganwhenthiseducator,apatientandstudentofStill,becameafacultymemberandDeanoftheAmericanSchoolofOsteopathy(ASO),laterfoundedtheAmericanCollegeofOsteopathicMedicineandSurgerywithhistwobrothers,thenreturnedtohisnativecountry.TheoppositionoftheGeneralMedicalCouncilofGreatBritaintotheeffortsofLittlejohnwascertainlycomparabletotheoppositionoftheAmericanMedicalAssociationtoosteopathicdevelopmentintheUnitedStatesduringthisperiodoftime.ThedecadefollowingWorldWarIIsawthebeginningofmorefrequentcommuni-cationandteachingbetweenUSandBritishDOsinLondon.FulllicensureofUSDOshadnotbeenachievedatthattime,andinterestwasbeingshowninosteopathicpracticebysomeEuropeanMDs.Duringthesecondpost-WWIIdecade(1964),aBasicCourseinOsteopathyintheCranialFieldwaspresentedinParis,conductedbyateachingteamoftheSutherlandCranialTeachingFoundation(SCTF).Invariousways,thenext30yearssawtheemergenceofnationalorga-nizationsandregistriesleadingtomoreformaldefinitionofeducationalrequirementsandpracticestatutes.Ahistoryofinternationalactivityfromtheearlyyearsofthe�0thCenturythrough,perhaps,1975wouldprovideawonderfulprologuefortheeventsofthepast10years.

OneyearaftertheAAO-sponsored1stInternationalForum,in1997,theAndrewTaylorStillMemorialAddresswasdeliveredbyW.DouglasWard,PhD.DoctorWardhadservedastheAOADirectorofEducation(1977-1993)andasAssociateExecutiveDirectorforEducationalAffairs(1993-1996).InhisaddresstotheAOAHouseofDelegatesAnnualMeetingatChicago,henotedthat:“OsteopathicmedicineisnowthoroughlyintegratedintotheorganizationalstructureoftheUnitedStates.Itisonlyamatteroftime—perhaps100years—forthisstructuretoextendthroughouttheworld.”�

Timehasmovedveryrapidly,andtheshadowofAndrewTaylorStillcontinuestolengthen.

1. The DO.April�005;10�. The DO.November�005;4�

The Wide World of Osteopathy


Contributors Regular Features

Dennis J. Dowling. What If? The33rdThomasL.NorthupLecture (�005) addresses a periodically recurring question.Inthisinstance,theauthordiscussesabonesetternamedJobSweet. This apprenticed practitioner was a descendent of afamilywhoseoriginscanbetracedto1637.Sweetwasbornin17�4,acenturybeforeAndrewTaylorStill.HewasadecadeslongpractitionerintheRhodeIslandregion.Typicalofbone-setterfamilytraditions,skillsandmethodswerepasseddownthroughgenerations.What If? pondersthequestionofSweet’sabilitytomodifytheevolutionofAmericanmedicineviatheimplementationofanewschoolofthought,Osteopathy. Thequestioncontinuesexploration throughrecommendationsforcurricularteaching.(p. 11).

Wm. Thomas Crow and David Kasper. A Myofascial Trigger Point On The Skull: Treatment Improves Peak flow Values In Acute Asthma Patients. Nine(9)patientswhowereexperiencingacuteasthmaticexacerbationsandwererefractorytostandardtreatmentwereseenbytheauthorsapproximately1-3hoursfollowingtreatment.Theauthorsidentifiedamyofascialtriggerpointattheleftparietaleminenceontheskull.Directpressureofthetriggerpointfor45seconds,afterwhicharepeatPeakFlowmeasurementwasobtained.Retrospectivestudyofthesepatients(ages16-55years)showeddramaticimprovement.Furtherstudyisindicated.(p. 23).

Claudia L. McCarty. Intercostal Rib Release. ThisScientific Paper/Thesis was submitted in partial fulfillmentof requirements for Fellowship in theAmericanAcademyofOsteopathy.TheauthorreceivedstatusasFellowin�000.Thepaperisextensive,offeringconsiderationsofEpidemiol-ogy,Physiology,Pathophysiology,Management.AReviewofResearchisalsoprovided.Forpublication,thesectiondealingwithaprotocolformanagementofacuteasthmaticexacerbationutilizingintercostalribreleasehasbeenchosen.Theauthormaybecontactedregardingothersectionsofthispaper.(p. 26).

JL Rook and AM Auburn. Multidisciplinary approach to treatment in a 38-year old female, restrained driver follow-ing injuries sustained in a rear-end collision. Complicatedsequelaefrommotorvehiclecollisionsareperplexingtomanypracticingphysicians.CurrentlyknownasCervicalWhiplashSyndrome (CWS) orWhiplashAssociated Disorder (WAD),multifactorial considerations are necessary. The authors de-scribesuccessfulmanagementofapatientseen14monthsaftersuchoccurrence,utilizingOsteopathicManipulativeTreatment(OMT)andTriggerPointInjections(TPI).(p. 33).

DIg ON. AndrewTaylorStilldidnot,inhiswriting,uni-formlyprovidereferencesfor“standardmedicalauthorities.”His Autobiography (1897) offers an example (pp. 44�-443,withillustration).ThroughcourtesyoftheFunkandWagnallsCompany,theillustrationofthemuscularsystemofthebodyaffordsStilltheopportunitytodiscuss“TheArmyofMuscles.”(p. 7)

fROM ThE ARChIVES. The Practice of Osteopathy (CarlPhilipMcConnellandCharlesClaytonTeall,1906)of-fersveryusefulconsiderationsfortreatmentofasthma.Reliefduringexacerbationisareadilyattainablegoal.Remedyoftheprocess isemphasizedduringthe intervalbetweenexacerba-tions.(p. 8).

BOOK REVIEW. The Science and Practice of Manual Therapy: Physiology, Neurology and Psychology (E.Lederman,�ndEd.,ChurchillLivingstone�005).ProfessorEyalLedermanrevisitsthequestionof“Whatishappeningunderthehandsofthemanual therapist?” twelveyears afterbeginning towritethefirsteditionofFundamentals of Manual Therapy. Thekeyelementsofpatient cognition, active involvementofpatient,effectivefeedback,repetitionandsimilaritytonormalizedmove-mentsareaddressed. (p. 37). Cranial Osteopathy: Principles and Practice (T.Liem,�ndEd.,Elsevier�004).TorstenLiem,DO(GB)hasprovidedacomprehensiveandhighlystructuredtextaddressingthemorphology,clinicalassociations,diagnosisandtreatmentofstructuresofthehumancranium.Thiseffortis theoutcomeof revisionofhisprevious text andprovidessignificantincorporationofcontemporaryresearchinthisarea.(p. 38).

ELSEWhERE IN PRINT. UrinaryTractInfection(UTI)isthemostcommonlydiagnosedbacterialinfectioninwomen.Whilemajormorbidityormortalityarerare,economicandqual-ityoflifefactorsareconsiderable(Johns Hopkins University Advanced Studies in Medicine: Volume6,Number1-January�006 ; �4.)Linearmouthopeningisbeingreplacedbytemporo-mandibularopeningindex(TOI)asameasureofmandibularopening.Thelatterisindependentofage,gender,ramuslengthandgonialangle. It isalsomoreuseful indiagnosticgroupcategorization (CRANIO, The Journal of Craniomandibular Practice; Volume�4,Number1-January�006;�5).(p. 39).

CME CREDIT. Inresponsetoreaderrequests,AAOJ willofferCMECredittoreaderscompletingtheenclosedquiz.Atthistime,1HourII-BCreditwillbeoffered,withrequestforupgradeasAAOJ qualificationsarereviewedbytheAmerican Osteopathic Association. (p. 30).


Dig On

The Army of Muscles“Autobiography of A. T. Still”, pages 442-443Published by the authorKirksville, MO1897© by A.T. Still

Muscular System of Man.1. Frontal. 2. Orbicularis palpebrarum. 3. Zygomaticus minor. 4. Zy-gomaticus major. 5. Temporal. 6. Levator labii superioris. 7. Levator labii superioris alaeque nasi. 8. Compressor narium. 9. Orbicularis oris. 10. Depressor labii inferioris. 11. Buccinator. 12. Platysma. 13. Sternoclidomastoid. 14. Sternohyoid. 15. Trachea. 16. Scaleni. 17. Tra-pezius. 18. Occipitalis. 19. Masseter. 20. Splenius capitis. 21. Splenius colli. 22. Levator anguli scapulae. 23. Supraspinatus. 24. Infraspinatus. 25. Rhomboideus. 26. Teres minor. 27. Teres major. 28. Deltoid. 29. Subclavius. 30. Intercostal. 31. Pectoralis major. 32. Pectoralis minor. 33. Serratus magnus. 34. Latissimus dorsi. 35. Biceps of the arm. 35’. Long head of same. 35”. Short head of same. 36. Coracobrachialis. 37. Triceps. 38. Pronator radii teres. 39. Flexor carpi radialis. 40. Palmaris longus. 41. Supinator longus. 42. Extensor carpi radialis longior. 43. Extensor ossis metacarpi pollicis. 44. Extensor tendonof the little finger. 45. Annular ligament of wrist. 46. Abductor pollicis. 47. Flexor brevis pollices. 48. Palmaris brevis. 49. Extensor tendon of middle finger. 50. Rectus abdominis. 50’. Sheath of same. 51. Navel. 52. External oblique of abdomen. 53. Internal oblique of abdomen. 54. Poupart’s ligament. 55. Inguinal canal. 56. Serratus posticus in-ferior. 57. Crest of the ilium. 58. Tensor fasciae latae. 5a9. Iliopsoas. 60. Pectineus. 61. Adductor longus. 62. Gracilis. 63. Vastus externus. 64. Vastus internus. 65. Rectus femoris. 66. Quadriceps extensor femoris. 66’. Tendon of same. 67. Sartorius. 68. Gluteus maximus. 69. Gluteus medius. 70. Gluteus minimus. 71. Pyriformis. 72. Obturator internus. 73. Obturator externus. 74. Tuberosity of the ischium. 75. Sacrosciatic ligament. 76. Biceps of the thigh. 77. Semitendinosus. 78. Semimembranosus. 79. Patella. 80. Tibia. 81. Peroneus longus. 82. Tibialis anticus. 83. Extensor longus digitorum. 84. Extensor longus pollicis. 85. Gastrocnemius. 86. Flexor longus digitorium. 87. Tendo Achillis. 88. Soleus. 89. Tibialis posticus. 90. Flexor longus pollicis. 91. Annular ligament of the ankle. 92. Extensor brevis digitorum. 93. Extensor tendon of the toes.

Chapter XXXII.The Muscles-Brain Headquarters-The Army of Muscles-

The Secret of God-How to Live Long and Loud-Time Coming for Big Dinners-Command to Eat-Off to the Country-Oste-opathy Cures Seasickness-Country Friends-Quiet and Shady-Explaining the Cause of Lumbago-Tired Nature Seeks Repose.

THROUGHthekindnessofFunk&WagnallsCompanyofNewYork,wearepermittedthiselaboratecut,whichshowsaboutone-fourthofthemusclesofthehumanbody,eachofwhichisausefulservantinperformingthelaborsoflife.Igiveplacetothosebeautifulpicturesofsomeofthepartsofthatgreatestofallknownmachines,whobearsthenameofman.Willthoseofyouwhohavenothadthechancetostudyanatomyinschoolsorotherwise,pleaselookforafewmin-utesandseetheshapesofafewmuscles;seehownicelytheyareformedandproperlyplacedtodothegreatdutiestheyhavetoperforminlife?Youseetheyhavegreatstrength,andallequaltothedutiestheyhavetodischarge.Ifyoulookalloverthebeingfromheadtofoot,youfindbracesatallpartsofthebody,andtheyarepowerfulinqualityandsize,justtosuittheplace,andarefixedtoholdallbonesinposition,withmuchpower,leftafterdoingtheworkofbracing,toliftmuchadditionalweight.

Eachmuscleissodistinctfromallothermusclesinformandoffice,infactwemightcalleachmuscleanofficerwhoserankisadivisioncommander.Hemustanswertothegrandroll-callhimself,whichisfromthecommandinggeneral,whoseheadquartersandnamearethebrain.Eachmusclemustreporttothecommandinggeneralandsalutehimwithbecomingdignity,andthishighofficermustsaluteandrespectallsubordinates,orthegreatbattleoflifewillbelost.Hemustkeepiscourierstoeachdivisioncommanderinmotion,allthetimebearingdespatchesoftheconditionofallcampsthatarebeingreportedatheadquarters.Eachdivisioncommandershallreceiveandreallalldespatchesinthefieldofaction-thequartermast,commissary,company,squads,andsections,notofonecampordivision,butallofthewholearmy.


From the Archives

Bronchial or spasmodic asthmaisachronicaffection,characterizedbyaparoxysmaldyspneaduetoaspasmodiccontractionofthemusclesofthebronchialtubesortoswell-ingoftheirmucousmembrane.

Osteopathic Etiology and Pathology.Themajorityoflesionscausingbronchialasthmaarefromthesecondtotheseventhdorsalregion,inclusive,eitherintheribsposteriorlyoranteriorly,orinthevertebrae.Theselesionsinvolvevasomotornervestothebronchioles,whichproducethenarrowingofthetubesandthuscausethedyspnea.Usuallythelesionisatthethird,fourthorfifthribontherightside,although,asstated,alesionmaybefoundaboveorbelowthispointattheanteriororposteriorendsoftheribsorinthevertebraecorrespondingtothesameregion.Probablylesionsarefoundmoreontherightside,becausemostpeoplearerighthanded;thesemusclesbeingbetterdevelopedwouldtend,whencontracted,todrawtheribsfromtheirarticulation.Thethird,fourthandfifthribsareusuallyfoundinvolvedbecauseitistheregionofgreatestvaso-motorinnervationtothebronchialtubes.

Inanumberofcasestherewillbefoundaposteriorcurvatureofthedorso-lumbarregion;andaccompanyingthisconditionwillbecatarrhanddilatationofthestomach,congestionoftheliver,and,perhaps,intestinalindigestionandconstipation.Carefulattentionshouldbegiventothedigestiveorgans.

Occasionallyalesionisfoundinvolvingthepneumogas-tricattheatlasandaxis.Suchalesionalsoirritatesfibresofthepneumogastrictothemusclesofthebronchiolesandthusproducesnarrowingofthetubesandconsequentlytheparox-ysms.Otherpointstonotearethecostalcartilagesandhyoidbone,andprobably,inafewinstances,lesionstothephrenic.

Attacksmaybeinducedreflexlybyvariousexcitants,asdust,diseasesoftheupperrespiratorytract,etc.,butthelesionstothevaso-motorandmotornervesarethepredispos-ingcauses.Laughlin1says:“Itisquestionablewhetherreflexcausesalonearesufficienttoproducegenuineasthmawithouttheexistenceofspecificlesionsaffectingthedirectnervecon-nectionsofthepartinvolved.”

Pathologically,trueasthmaisapureneurosis.Thereismoreorlesschronicinflammationofthebronchialtubes,shownbyinjectionandthickeningofthebronchialmucosainthemajorityofcases.Theremaybefoundthemorbidstatespeculiartochronicbronchitisandemphysema.Whetherthe

constrictionofthetubesisduetospasmsofthebronchialmusclesortoswellingofthemucosa,ortoboth,theprimary,predisposingandirritatinginfluencesarecommontoboth.Thesearevertebralandriblesionsaffectingthespinalnervesattheirexitandthesympatheticchainalongtheheadoftheribs;irritatinglesionstothevagi,constrictingpulmonaryvessels,andtothecervicalsympathetics,causingdisturbance

ofthesame,wouldbefactorsinthepathologicalchain.Reflexirritationsmaybefoundinvariousregions,buttheprincipalosseouslesions,accordingtoDr.Still,areontherightsidefromthesecondtothesixthdorsal.

Symptoms.Theattackmaycomeonatanytime,butusuallyitcomesoninthenightduringsleep.Theonsetmaybesuddenortheattackmaybeprecededbypremonitorysensations,suchastightnessinthechest,flatu-lence,sneezing,chillinessandacopi-

ousdischargeofpaleurine.Nervoussymptoms,headache,vertigo,neuralgia,andananxious,nervous,restlessfeelingmayprecedetheattack.Thereisasenseofoppressionandanxiety,followedbydyspnea.Soontherespiratoryeffortsbe-comeviolentandthepatientisobligedtosituporruntothewindowforair.Theshouldersareraised,thehandsareplaceduponsomethingfirmtokeeptheshouldersfixedsothattheaccessorymusclesofrespirationcanbe’broughtintoplay.Thecontractedtubesresisttheentranceofair.Expirationisprolongedandwheezy.

Inseverecasesthefacebecomespale,theskiniscoveredwithperspiration,theextremitiesarecold,thelips,finger-tipsandeyelidsarelivid,owingtodefectiveoxygenationoftheblood.Thepulseissmallandquickandthetemperatureisnor-malorsubnormal.Theattackmayterminatesuddenly,sometimeswithaspellofcoughing;thisisespeciallysoofseverecases,asthecoughisgenerallyabsentinbriefparoxysms.

Thecoughisatfirstverytightanddryandaccompaniedbyatough,scantyexpectorationwhichisexpelledwithgreatdifficulty.Thesputumcontainsroundedmassesofmatter,theso-called“perles”ofLaennec.Microscopically,theyarefoundtobeofaspiralstructure,containingcellsderivedfromthebronchialmucousmembraneandfattydegeneratedpuscells.Asecondformiscontainedintheinsideofthecoiledspiralofmucin,afilamentofgreatclearnessandtranslu-cency,thatismostprobablycomposedoftransformedmucin.Curschmann’sspiralsarefoundintheearlystagesoftheattackandforatimetheseweresupposed,bytheirirritation,

Bronchial asthmaThe Practice of Osteopathy.CarlPhilipMcConnellandCharlesClaytonTeall.Copyright1906.pgs.517-5�1


toexcitetheparoxysms.Theirspiralformisunexplained.Curschmannbelievesthatthesespiralsarefoundinthefinerbronchiolesandtobeaproductofbronchiolitis.

Physical Signs.Inspectionshowsenlargementofthechestwhichisfixedandbarrel-shaped.Thebreathingislaboredandthechestmovesbutslightly.Thediaphragmislowered.Per-cussionyieldshyper-resonance,especiallyincaseswhichhavehadrepeatedattacksorwhentheasthmaisassociatedwithemphysema.Auscultation.Withinspirationandexpirationareheardsonoroussibilantrales,whicharemoremarkedonexpi-ration.Asthesecretionincreases,whichislaterintheattack,theralebecomesmoist.Theattacklastsforavariableperiod,rarelylessthananhour.Insevereattackstheparoxysmsrecurforthreeorfournightsormorewithspontaneousremissionsduringtheday.Insomecasesthereliefseemstobeabsolute,butinthemajorityofcasesthereismoreorlessoppressionandcoughforadayortwo,sometimesformanydays.

Diagnosis.Thephysicalsigns,examinationofthesputumandthehistoryofthecasemakesthediagnosiseasy.

Prognosis.Itisnotafataldiseaseandonlydangerouswhencomplicationsarise.Underosteopathictreatmenttheprognosisisusuallyfavorable,unlessthereareseriouscom-plications,asthisisadiseasethatosteopathyhastreatedwithsignalsuccess.Inlongstandingcasesemphysemainvariablydevelops.

Treatment. Asthma,unlesscomplicatedwithbronchialandlungdiseases,isreadilyrelievedduringtheparoxysms..Casesofmanyyears’standinghavebeencuredinafewtreat-ments.Itshouldbeborneinmindthatasthmaisarespiratoryneurosis.

Torelieveanattacktheosteopathshouldlocatethele-sion,ifpossible,andcorrectit.Ifthemusclesaresoseverelycontractedthatitisimpossibletomakeoutthenatureofthelesion,thenstronginhibition,withanupward,outwardmovementovertheanglesoftheribsinvolved,willbequitesufficient.Theobjecttobegainedineverycaseistorelievepressureorirritationtothevaso-motorormotornerves,sothatthenarrowedtubesmayberelaxed.Stronginhibition,suchasplacingthekneeinthepatient’sback,atthesametimepullingontheshoulders,willhavetemporaryeffect,butitisalwaysbesttoreducethelesionifpossible.Inseverecasesdilatationoftherectummayrelievetheparoxysm,andinafewinstanc-esitwillbenecessarytotreattheuteruslocally.

Duringtheintervalbetweentheattacksisthetimetorem-edythedisease.Thenoneisabletolocateexactlythepositionofthedisturbedtissuesthatarecausingtheparoxysmsandapplytreatmentintheregionsgivenunderetiology.Many

casesofasthmaarecuredinfromonetothreemonths’treat-ment.Onetreatmentaweekissufficient,providedoneisableeachtimetoaccomplishsomethingtowardacorrectionofthelesinandthatthepatientdoesnotsufferduringthemeantime.Toofrequenttreatmentsmaysimplyactasanirritanttothenervouslesions.

Attentionshouldalwaysbegiventothedietandhygiene.Gastricdigestionshouldbecompletebeforeretiringoritmayinduceanattack.Complicationsaretreatedaccordingtothedisease..Examinetheupperrespiratorytract,thedigestivetract,andthepelvicorganswhenthereisreasontobelievetheparoxysmmaybeinducedreflexly.Laughlinsumsupthetreatmentasfollows:(1)Removalofspecificlesion;(�)removalofexcitingcauses;(3)removalofreflexcauses;and(4)treatmentofthepatienttoimprovetheconditionofthegeneralnervoussystem.

References1. Laughlin.Asthma.JAOA.Oct1904.


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March�006 The AAO Journal/11➝

Thomas L. Northup Lecture, 2005American Academy of Osteopathy®

What if?Dennis J. Dowling

Awarsuchasthecontinenthadneverpreviouslyseenhaddevastatedthecountry.Brotherhadbeenpitchedagainstbrotherandthetollhadcreatedalterationsinhowcommerce,politics,education,andmedicinehadbeenpracticed.

Itwasduringthistimethataloneitinerantdoctortraveledhundredsofmilesattherequestofafamilyinneedtodowhathe felt was his life’s work, healing the sick.The lone ridermade the trip to see to the needs of the young woman whowascrippledwithwhatwasdescribedasadislocatedhipbone.Hisreputationhadbeenwellestablishedwithinhisimmediateregionbecauseofallofthemiraculouscuresthatwereassoci-atedwithhishands.

Thepatient,thedaughterofaprominentsoldierandpoliti-cian,hadbeenunsuccessfullytreatedbyconventionalmedicalapproaches. In fact, the family physician and several otherlearneddoctorswantedtobepresentduringthetreatment.Afterhisarrival,atimeforthedemonstrationwassetfor10:00AMthenextmorning.Thespectatordoctorsleftfortheirhomesandthehostsoughttogethisguestsettled.Beingwearyandtired,butnotingthegreatpainthepatientwasexperiencing,thedoc-torexpressedhisdesiretosetabouttoworkimmediatelyandnotwaitforthenextday.The13-year-oldgirlwasalittletakenaback with the doctor’s disheveled and apparently eccentricappearance.However, thedoctorapproached thepatientandexplainedincomfortingtoneswhatitwasthathewasgoingtodototreather.Oncehehadsecuredhercooperation,heaskedforpermissionfromherfather,aswasproperforthetime,totouchherhipandleg.Likethedoctor,thepatient’sfatherwasnotsomuchinterestedindemonstrations,onlyinhisdaughter’scomfortandreadilyagreedforthetreatmenttobegin.Inafewminutes,manipulationoftheregionhadbeencompletedandthedoctorinstructedthepatienttowalkaroundtheroom.Muchtothesurpriseofthepatientandherfather,shewalkedaroundtheroomwithoutpain.Bythetimethephysiciansarrivedthenextmorning,thedoctorwasonhiswayhomeward.1Ifhehadbeenmoreofashowman,perhapshecouldhavechangedthewaymedicinewaspracticedontheAmericancontinentforever.

ForanyonewhohasreadstoriesaboutAndrewTaylorStill,thisscenariowouldnotsoundthatunusual.PerhapsitsoundslikesomethingfromHildreth’sThe Lengthening Shadow of Dr. Andrew Taylor Still.Intruth,itoccurredalittlelessthan80yearsbeforeA.T.Still“flunghighthebannerofosteopathy.”Thedoc-torofthestorywasnotAndrewTaylorStill,butwasabonesetternamedJobSweet,andtheyearwasmostlikely1795.

Duringtherevolutionarywar,Dr.Sweetwasoftencalled

toNewport,RhodeIslandtosetthebonesofFrenchsoldiers,somethingthattheirowndoctorscouldnotaccomplish.Hewasadoctorlikemanyoftheerawere:amanwhohealedthesick.LikeothersoftheSweetclan,whichcanbetracedasfarbackas1637whenJohnSweetcametothecolonies,Jobwassaidtohave“inherited”hisbonesettingtalent.

Hewasbornin17�4,practicedfordecadesintheRhodeIslandregion,andlikeothermembersofhisfamilyappearedtohaveanuncannyknowledgeofanatomydespitelackingaformaleducation.Once,whilebeingshownsomeexhibitsinasciencehallinBostonbyalearnedprofessorandphysician,heremarkedthatoneofthefootbonesofadisplayedskeletonwasinthewrongorientation.Thephysicianprotestedthatitwasexpertlyassembledbutuponlaterexamination,determinedthatJobSweetwascorrect.�

Itwasnotuntilthetwentiethcenturythatsomemembersofthefamilybecamemedicalschooltrainedphysicians.Dr.JobSweetmadethetripfromRhodeIslandtoNewYorktotreatTheodosiaBurr,thedaughterofColonelAaronBurr,thethirdvice-presidentof theUnitedStatesofAmerica. Itwasmanyyearsbeforetheunfortunateduel(July7th1804at7AM)3thathasbeenabigpartofBurr’slegendorhissubsequentattempttoestablishaseparateempireintheMidwestpartoftheconti-nent.JobSweetmayhavebeenthemostskilledbonesetterofa familyofpractitioners thathadfirstemigratedfromWalestotheAmericancontinentintheseventeenthcentury.Aswasthetraditionofthetimes,thesecretswerepassedfromgenera-tiontogenerationpriortoandafterDr.Sweet’streatmentofTheodosiaBurr.

Ashasbeenindicated,itoccurrednearly90yearspriortoDr.Still’sestablishmentofthefirstschoolofosteopathyaswellasnearly60yearspriortoWhartonHood’streatisesupportingbonesetting4.ItoccurredshortlyafterColonelBurrhadbecomea single parent. He was extremely devoted to his daughterTheodosiaandtohistwostep-sonsandinsisteduponathor-ougheducationforall.Theodosiacouldreadandwriteseveralmodern and classical languages and engage in conversationconcerningallmatteroftopics,includingpolitics.Shemeanttheworldtohimandheconsultedalltypesofphysiciansregardingherconditionwithoutmuchbenefit.Apparently,JobSweetac-complishedwhat“modernmedicine”couldnot.However,beingarelativelyshyman,hefinishedhistaskandretreatedtohishomewithoutfanfareorshowmanship.Whatifhehadwaiteduntil10:00AMthefollowingmorning?Couldthathavebeen

1�/The AAO Journal March�006

asimportantasthesametimeonJune��nd,1874?Whatifthedoctorshadbeenimpressedwithhisskillsanddesiredtolearnmore?Washereticenttobethecenterofattentionorwasitatacticalmovetoavoidexposureofthefamilysecretstocriticaleyes?WhatifbonesettinghadbeenincorporatedintocolonialAmericanmedicaltreatment?

ColonelBurrwasatonetimeaveryinfluentialmanandasapoliticianactuallycameveryclosetwicetobecomingpresi-dentoftheUnitedStates.Infact,hetiedThomasJeffersoninelectoralvotesandonlylosttobecomevice-presidentfollowing36ballotsbytheHouseof Representatives. Hewasalwaysinterestedinwielding power. Couldhe have exerted his in-fluence to incorporatebonesetting into theAmerican medical sys-tem?Intruth,therewasnoorganized systemofmedicine.Therewastheeducated physician orthe apprenticed physi-cian.Dr.Sweetqualifiedasthelatter.

The first medicalschoolattheCollegeofPhiladelphia was onlyestablished a few yearspriorin1765.Dr.Sweetwasalready41-years-oldbythistime.KingsCol-lege, which would be-come Columbia, wouldnot have a medicalschool until 1768. Har-vard,thethirdinstitutiontohostamedicalschool,would not establish itscollegeofmedicineuntilthe conclusion of theRevolutionary War in1781. Most medical-school-trainedphysiciansontheNorthAmericancontinentuptothatpointandevenforalongtimeafterwards,weretrainedattheUniversityofEdinburgh5.ThevictimsofbattleswagedduringtheRevolutionaryWarweretreatedbyphysicianshavingallsortsoftraining,butmostlikelybythecommonapprenticed-trainedvariety.Therewerealsobattlesbeingfought,politicallyandotherwisebythephysiciansofthelateeighteenthcentury.Shippen,Morgan,andRush,aswellasahostofothers,contestedto seewhowould control themedical professionof the era.CouldAaronBurrhaveintroducedDr.JobSweetandhissystemofcaretotheworldatlarge?CouldDr.Sweetteachwhathadonlybeenpasseddownfromparentstochildren?Woulditbe“osteopathy”asweknowit?Itwouldnothave,mostprobably,beentreatedasasystemofmedicinedifferentthanwhatwaspracticedandwouldmostlikelyhavebeenaddedtothethen

currentprocessesofphlebotomy,amputations,andpoisonousmedicinals.Itwouldhavebeenmerelyanadditionalmodality.Inaway,itwouldnotbeviewedanydifferentlythanhowsomeMDs see osteopathy today: manipulation as a possible formoftreatmenttobeaddedtotheothertoolsandnotasawholesystemofhealthcare.

ThebiggerquestiontoponderregardingthestoryofJobSweetis,“WhatifDr.SweethadhadthementalityofAndrewTaylorStill?”CouldhehaveinitiatedtheevolutionofAmeri-canmedicineawayfromitsallopathiccourse?Hewouldhave

needed to have had theintellectual curiosity ofAndrewTaylorStill,ac-companiedbytheeccen-tric ego that gave innerstrength and a sense ofrighteousness, as wellas the significanteventsthatwentintothefound-ing of osteopathy. Hewould have needed theconvictionthatheshouldteach the family secretstoothersforthegoodofmankind.Hewouldhaveneededtoplanttheseedsofthenewmedicineinaphilosophy that lookedatthepatientandnotthedisease;attheinteractionofthepartsofthewholeandnottheeffectofthesymptoms; at the inte-grative processes of theindividual in seeking orrestoringhisownhealthwiththeaidofthephysi-cianandnotthepassiverole when physicianstook extraordinary andoftentimes dangerousmeasures. The eventsof the founding of os-

teopathycameaboutatthemostpropitioustimeforitsbirth.Yet,Dr.Stillclaimedthatithadalwaysbeenpresent.Toquotetheolddoctor,“IdonotclaimtobetheauthorofthisscienceofOsteopathy.Nohumanhandhasframeditslaws;Iasknogreaterhonorthantohavediscoveredit.”6IthadbeenthereforDr.StilltofindanditwasthereforJobSweetorsomeotherhealertodiscover.Instead,itremainedhiddenasdosomanyofthe“secrets”thathavebeendescribedbygreatphysiciansformillennia.Glimpsesofgreatthingshavebeenobservedonlybrieflytothenbeburiedandforgotten.Whydidn’tJobSweetdiscoverosteopathy?Hewasnottherightperson.TherewouldandcouldhavebeennooneotherthanAndrewTaylorStilltoexposeosteopathytotheworld.

Thepracticeofwondering “What If?” is not somethingnew.Sciencefictionstorieshaveexploredtheconceptforhun-


➝

dredsofyearsandcomicbookshaveengagedintheprocessfordecades.Popularnovelsandmoviesarejustthejuxtapositionofimagination,creativity,andreality.Wealldoitinourmindswhetherwevoiceitornot.Wedoitprospectivelyandretro-

spectively.WhatifIdidn’tmake that turn? Maybe Iwouldn’thavegottenintothataccident.WhatifIhadpicked the right numbersin the lottery?What if Ihadn’tgonetoosteopathicmedical school? Wouldsomeonehavebeentheretohelpthepatientswhenthey needed it most?Weuse“whatifs”tolookbackat the roads not taken aswell as looking forwardduring decision-makingtimes to try to determinethealternatives.

Itisevenpracticedbyhistorians. The Military

HistoryQuarterlyhaspublishedtwopopularbookstitled“What If?”7,8,whicharecollectionsofarticlesthathaveappearedwithinitspages.Thetermthatisusedbytheeditorsis“counterfac-tualhistory”indicatingthatachangedkeyeventinhistoryisexploredforthepossibleconsequences.Ratherthanjustbeingfiction,thestoriesindicateagreatdealabouttheimpactoftheeventsastheyactuallydidoccur.WhatwouldhavehappenedhadAlexander the Great been killed when he attacked thePersiansnineyearspriortohiseventualdeath?Certainly,therewouldhavebeennocityofAlexandriainEgypt,nolibraryofgreatknowledge,noPtolemypharaohs,noCleopatra,andnoconquestoftheknownworld.Perhaps,therewouldhavebeenanearlierorlaterdevelopmentofaRomanEmpire9.

WouldtheAmericanRevolutionhavesucceededwithoutitsiconicleader,GeorgeWashington?BesideshismiraculousescapefromBrooklynwithallofhistroopsduringanalmostpreternaturalfog10,hecamewithinmomentsofbeingshotintheback.TheBritishmarksmanwhoinventedthebreechloadingmusketcouldhardlyhavemissed thestately6’3” redheadedcommanderwhomheeasilyrecognized.However,being themanthathewas,hecouldnotbringhimselftobehavedishon-orably by shooting the unsuspecting general11.We can alsowonderwhatwouldhavehappened ifhewasnot treatedbyphysiciansafteranupperrespiratoryinfection.ItwasnotavirusorbacteriumthatkilledPresidentWashingtonbuthisdoctorswhophlebotomizedhimuntil, inhisweakenedcondition,hesuccumbedtohisillness.

Scientists also engage in the same sort of “What If?”thinking.WhatifHeronofAlexandria,alsoknownasHeroor“Mchanikos,theMachineMan”,hadcombinedhisknowledgeofothermachineswithhisinventionofthesteamengine?Thiswasnearlyeighteenhundredyearspriortotheappearanceofthesteamboatandlocomotive.SomehistoriansthinkthatHerononlyconsideredhisinventionatoywhileothersthinkthattheeconomicsofthedayandavailabilityofslaveandcheaplabor

precludedtheuseofmechanicaldevices1�.SomanyofHeron’sinventions13 were lost: hydraulics that automatically openedtempledoorsandpoweredmachines,mechanicalbirdsthatsangandmoved,therepeatingcrossbowthatwasa“machinegun”thatcouldfireseveralpowerfulboltsperminute,clockswhosefunction remained a mystery for nearly two thousand years,andtheautomatedtheaterthatwasas“computerized”asanyDisneyanimatronicexhibition.HewasasprolificandingeniousasEdisonandwecandeviseallsortsofalternativefuturesex-tendingfromthispoint.Explorerswouldhavetraveledhoursordaysacrossseasandoceansthathadpreviouslythwartedtheirefforts.FlyingmachinessuchasenvisionedbyDaVinciwouldhavetraveledfromcitytocity.Empiressuchaswehaveneverpreviouslyimaginedwouldhaverisenandfallen.Theindustrialeracouldhaveoccurred17centuriesearlierthanitdid.

AndrewTaylorStillengagedinhisown“WhatIf?”mus-ings.OneoftheseconcernedhisCivilWarexperiences:

“Duringthehottestperiodofthefightamusket-ballpassedthroughthelapelsofmyvest,carryingawayapairofglovesIhadstuckinthebosomofit.Anotherminie-ballpassedthroughthebackofmycoatjustabovethebuttons,makinganentryandexitaboutsixinchesapart.HadtherebelsknownhowclosetheywereshootingatOsteopathy,perhapstheywouldnothavebeenquitesocareless.”14

Hemusthavealsowonderedwhatcouldhavebecomeofhimwhenheaccidentallycameuponagroupofpro-slaverspriortotheoutbreakofthewar.TheyweredrillinginafieldwhilehewasonhiswaytovisitMrs.Jones,whowasill.Hetookadefiantstance:

“Whatintheh--lareyoufellowsupto?”IwasansweredbytheCaptainincommand:“Whereintheh--lareyougoing?”Isawinamomentthat

myfirmnesshadproducedgoodeffect,andtherewasnofurtherdanger.Irodeupandstoppedinfrontofthecompany,shookhandswiththeCaptain,toldhimtogivethecommandtomeandIwoulddrillhismen,andshowhimhowJimLaneandJohnBrowndidit,concludingwith:

“Ifyoudon’thaveyourmenbettertrained,andJimLane


evermeetsyou,hewillshakeyouup.”TheCaptainturnedhismenovertome,andIdrewthem

upinline,putthemthroughallthecavalrymovements,tangledthemup,straightenedthemout,andtoldtheCaptainhemustdrillbetter,sotheycouldgetoutoftightplaceswhentheymet

us.Then I turned the company over to the original CaptainOwens,whosaid:

“Attention,company;thisisDr.Still,thed--destabolitionistoutofh--l,whoisnotafraidofh--lorhighwater.Whenyouaresick,goforhim;hesavedmywife’slifeincholera,andIknowhimtobesuccessfulanyplaceyouareamindtoputhim.Inpoliticsheisourenemy,insicknesshehasproventobeourfriend.”Andclosedbysaying:“Doc,gohometodinnerwithme,andIwillgowithyoutoseeMrs.Jones.”IwentwiththeCaptaintodinner,andhemadehiswordgoodbygoingwithme.Fromthat,timeuntilthecloseofthepro-slaveryquestionin1857Imet,passed,and repassedhismenwithout fearormolestation.15

Therearesomanyotherosteopathic“WhatIfs?”:WhatifDr.Still’sfirstwifeandchildrenhadnotdiedofdisease?Whatif hehadnot treatedhisownheadacheswith a rope swing?Whatifhehadnotbeensointerestedandknowledgeableaboutanatomy?Whatifhehadbeenamoresuccessfulallopathicphy-sician?Whatifhehadbeenalesssuccessfulosteopath?WhatifDr.StillhadhadtheAmericanSchoolofOsteopathy(ASO)grantanMDdegreeinsteadofaDiplomateandlateraDoctorinOsteopathydegree?16WhatifAbramStillhadbeenalawyerinstead?Wouldhehavebecome“A.T.Still,Esq.–LightningLawyer”instead?Thelistcangoonandonyetthefactsremainthathisactionsleadtothefoundingoftheosteopathicprofessionandmorethan55,000osteopathicphysicianstoday.

Muchconjecturecanbedirectedatothereventsinthehis-toryoftheprofession.TheStillNationalMuseumpublishedanarticleinanewsletteryearsagorelatingthatsomeofDr.Still’sadmirersgavehimamementofromtheCivilWar,whichhekeptonhisporchforyears.Hemusthavestruckhispipeagainstitmanytimesandmayhaveeventappeditwiththewalkingstickthathealwayscarried.Afterhisdeath,itwaslaterdiscovered

thatthecannonshellheldliveammo.TherealcounterfactualstorywouldbetoconsiderwhatwouldhavehappenedtotheprofessionhadDr.StilldiedbeforeDecember1�th,1917.WouldtherehavebeenapowerstrugglethatwouldhavetorntheASOandtheprofessionapartatatimewhenitwaslesscapableof

weatheringthestress?Evenimmediatelyafterhisdeath,therewerestrugglesamongtheboardmemberswhenanon-DOnon-familymember,Mrs.MaeDeWittHamiltonthenexthigheststockholderafterDr.A.T.Stillinthecorporation,wasselectedpresident.CharlesStill,DOhadsoldoffmanyofhissharesinthecorporationthatownedtheASOandhadnoclout.17Theloyalties of the members of the board and the faculty werevery much tested at that time.The school had survived theearlyschismswithElmerBarberandMarcusWard,aswellasconflictswiththeLittlejohns,WilliamSmithandseveralothersbutthoseeventsoccurredpriortoDr.Still’sdeath.Some,eventhoughtheyweredisruptiveatthetime,definitelyreinforcedtheprofession.Ifitwerenotfortheseconflicts,therewouldbenoChicagoCollegeofOsteopathicMedicineandprobablynoosteopathyinEurope.ThestrengthtomaintaintheprofessionshouldDr.Stillhaddiedin1900mayhavecomefromBlancheStill.Alongwithherhusband,GeorgeLaughlin,sheco-foundedtheA.T.StillCollegeofOsteopathyandSurgery in19��. ItmergedtwoyearslaterwiththeoriginalschooltobecometheKirksvilleOsteopathicCollege.18

Theprofessionhashadmanyothercrossroadsorkeyeventsthatcouldhaveresultedinotheroutcomes.Oneofthesecon-cernedtheSpanishinfluenzapandemicof1917-1918.19,�0,�1,��,�3Itisnotsomuchthattheprofessionchanged,butletusimaginewhatwouldhavehappenedhadtherebeennoosteopathicphysi-cians.Morethan500,000Americansdiedrelatedtothedisease.Taskerdidasurveyandpublishedtheresultsfrom1,350DOsand43,500casesoffluwithjust160deaths.�4KendrickSmith,anM.D./D.O.,collecteddatafrom�,445osteopathicphysicianswhocollectively treated110,1��caseswith0.�5%mortalityor�75deaths�5.Theprojectednumberforthiscohortgiventhegeneralmortalityrateshouldhavebeenatleast11,01�dead.That indicates that 10,737 people survived who would have


otherwisedied.Ifweextrapolateevenfurtherandconsiderthatagenerationoccursevery�0yearswitheachpersonhavingtwochildren, thenwecanestimate thatover170,000Americansalivetodayaredescendantsofthosefortunatepatients.Ifwetake thehalfmillionwhodiedandapplya0.�5%mortality,1�,500wouldhavediedinstead.Thatisrelativelynearwhatthenormalstatisticsareformostrecentvirulentfluepidemics.Itwouldhavethenplacedbehindthe1957-1958and1968-1969epidemicswith70,000and33,000Americansinrelateddeathsrespectively�6.ThedifferencewiththeSpanishflupandemicisthatitdidnotjustkilltheveryold,theveryyoung,ortheverysick;itkilledindiscriminately.Theremayhavebeen15,000,000moreAmericanstodayhadtherebeenlymphatictreatmentforall.Withmorethan�0milliondeadfromthepandemicworld-wide,manytimesthecombatantcasualtiesfromWorldWarI,thenumberwhocouldhavesurvivedifthefocushadbeenonfacilitatingthenaturalimmunologicaldefenseswouldbeincred-ible.Theneedtohavealternativestothetreatmentofinfluenzamaybeevenmorepressingtodaysincewehaveseenthelackofdiscovery,preparednessandefficacyinmanyofthecurrentinterventions.However,wecannotrestonthesuccessesofthepast.Whenosteopathicphysicianssavedallthosethousandsofpeople,theywerestillmakinghousecallsandsometimestreat-ingpatientstwoandthreetimesperday.We,asaprofession,shouldprepareforthefutureneedsofpatientsshouldanothersuchvirulentpandemicoccur.

Twodecadeslater,WatsonandPercival�7didathreeyearstudyofchildrenhospitalizedforpneumoniaintwometropolitanhospitals.Atonehospital, thechildrenreceivedOMTandatthenon-osteopathichospital,standardcare.WheretheTaskerandSmitharticleswere theresultsofaretrospectivesurvey,WatsonandPercivalproducedaprospectivestudythatmetorfarexceededthesophisticationofmanyoftheotherepidemio-logicalstudiesoftheera.Thechildrenwithbronchopneumoniahadnearlyone-thirdthemortalityoftheuntreatedgroup.Themortality for children with lobar pneumonia in both groupswasessentiallythesame.Onehundredandfiftychildrenwithbronchopneumoniaweretreatedattheosteopathichospitaland90%livedversusthe70%ofthe331childrenwholivedattheother hospital.This indicates that 44 children survived whootherwisewouldhavebeenexpectedtosuccumbandtherearepossibly700descendantsalivetodaybecausetheirancestorswerefortunateenoughtobepatientsofosteopathicphysicians.AlthoughWatsonandPercivalhadonlypercentagestoreportthedifferences,theirreviewofthedatawasdetailedandwellrecorded.A Chi test on the data would be very statisticallysignificant.Isthereapossibilitythatsomeoneinthisaudienceisadescendentofthetreatedchildren?

Wecanwonderiftherewasnolymphatictreatmentandnoosteopathicmedicine.Wecanwonderiftheremayhavebeenmoreinterestinsuchalternativetreatmenthadtherebeennodevelopmentofrelativelyeffectivemedications.Priortothelate1930s,therewereanti-seraandinoculationsbutnotmuchelse.Thesulfaantibioticswereonlyafewyearsoldandnotveryavailable.ThemouldhadsettledontoFleming’scultureplatesbutitwasyearsbeforeithadanyconsequenceinthewaragainstinfection.Otherthanosteopathictreatment,therereallywasahodge-podgeofapproachesforinfectiousdiseases.Theheroic

ageofmedicinehadnotyetrunitscourse.Extraordinarymeth-ods,themainstayofthe“allopathic”orthodoxapproachwerestillrampant.Sweatingfevers,dangeroushomeandprescrip-tionremedieswerestillinuse,andthetypicalphysiciancouldjustwatchandwait.Osteopathicmedicine,withitshands-onapproachmadeadifference.Frommorerecentstudies,weun-derstandtoagreaterdetailthemechanismofactionandthetrueeffectivenessofosteopathicmanipulationintreatinginfectiousdiseases.�8�930Wecanwonderifosteopathicmedicinewouldhavebecomemorepopularhadtherebeennodevelopmentofantibiotics.Wecanalsoconsiderthattheremaybegreaterinter-estinthecurrentagesincetherearegrowingconcernsregardingpharmaceuticalsaswellasantibioticresistencesonthepartofmanypathogens.

Thegrowthoftheosteopathicprofessiondidnotjustcon-cernthenumberofphysicians.Themembersoftheprofessionalsoaddedtotheknowledgeanddevelopment.Wherewouldwebewithouttheircontributions?Wecanonlyhopethattherewouldhavebeensomeone todiscoverCranialOsteopathy iftherewasnoWilliamGarnerSutherlandorMuscleEnergyiftherewasnoFredMitchell,Sr..WouldtherehavebeenCoun-terstrainifLawrenceJoneshadn’tconsideredwhattodowitha patient who was severely bent forward?What ifThomasNorthuphadnotexisted?Firstofall,theremaynothavebeenanAmericanAcademyofOsteopathy.ItwasThomasNorthupwhotooktheinitiativetogetstudygroupsorganized31.

Inthefirstthreedecadesofthetwentiethcentury,thereweresectionalsocietiesthatwouldmeetattheAOAconventionsinroomsthattheywouldsecureatthehotels.Dr.PerrinWilsonranthesacroiliacsection,whichwassometimescalledthe“So-cietyofSacroiliacTechnicians.”Dr.Northuphadhissightssetlowerandwasinchargeofagroupthatfocusedonthefoot.In1937,Dr.Northupwroteto135colleaguesintheAOAinvitingthemtoabreakfastmeetingonJuly6th.Sixtythreecameandthegenesisofasocietytodevelopthescienceandartofosteo-pathic manipulative treatment, arrange programs to improveosteopathicphysicians’skills,encouragethedevelopmentanddistributionofteachingofnewmethods,andpublishoriginalarticleswasestablished.TheSocietyofSacroiliacTechniciansevolvedtobecomeTheOsteopathicManipulativeTherapeuticandClinicalResearchAssociationbythenextyear’sconvention,whenitwasrecognizedasacomponentsociety.ThisbecameTheAcademyofAppliedOsteopathyin1944anditunderwentanothernamechangein1970toitscurrentstatus,TheAmericanAcademyofOsteopathy.3�

We have to also assume that if there was no ThomasNorthup,therewouldbenoGeorgeNorthup.TheyoungerDr.NorthupwasalsotheeditoroftheJournal of the American Os-teopathic Associationfor�6years,editoroftheAAO Yearbook and Osteopathic Research: Growth and Development, author of Osteopathic Medicine: An American Revolution,andwasapresidentoftheAmericanOsteopathicAssociationin1958to1959.33Betweenthem,thecontributionsofThomasandGeorgeNorthuptotheprofessionhavebeeninvaluable.

Withinthehistoryoftheprofession,therearefewseminaleventsthathavehadanimpactonitsgrowthordangertoitsexistence like theCaliforniasituation thatexplodedin196�.


Proposition�� eliminated the mechanism to license any ad-ditionalosteopathicphysicianswithinthestatewhilesimulta-neouslyallowingfortheexchangeofaDOforanMDdegree.TheprocesscouldnothavecomeaboutwithouttheconspiracyandcooperationofaselectgroupofleadersandmembersoftheCaliforniaOsteopathicAssociation.JohnCline,MD,195�presidentoftheAMA,surveyedosteopathiccollegesin1953-55andrecommendedthatMDscouldteachinosteopathiccollegesHealsoadvocatedthatthe“cult”labelberemovedfromDOsandthatstatemedicalsocietiescoulddeterminetheprofessionalrelationshipbetweenMDsandDOs.However,theAMAwouldmaintainthesamerequirementsthattheyhadforothernon-al-lopathicpractitionerswhomtheyotherwisefoundacceptableand assimilated; would remove philosophical and historicalreferences; and would adhere to only thoseAMA approvedscientific principles.The College of Osteopathic PhysiciansandSurgeonsaswellas theCaliforniaOsteopathicAssocia-tionacceptedtheseprovisionsandthelatteramalgamatedwiththeCaliforniaMedicalAssociationin1961.COPSbecametheCaliforniaCollegeofMedicine.Proposition��wassupposedtosealthedealbyeliminatingthefurtherlicensingofosteo-pathicphysicians.TwothousandbecameMDsintheconversionprocesseswhile400didnot.Ofthe400,manyactuallymain-tainedpracticesoutofstate.IftheactualnumberofDOswhomaintainedtheirlicensefellbelow40,thepropositionallowedforthetotaldissolutionoftheosteopathicboard.TheAOAlostnearlyone-seventhofitsmembersandthereappearedtobethepossibilityofacascade.Partoftheironyisthattheconvertedphysicians,the“littlem.d.s”stilldidnotattaintherecognitiontheysoughtfromthespecialtysocietiesacrossthecountry,bytheir“colleagues”withinCaliforniaandespeciallybyotherstatemedical licensingboards.Acoregroup inCaliforniabandedtogetherand1�yearslaterwontherightforfutureDOstobelicensed.Eventuallyanewschool,theCollegeofOsteopathicMedicineofthePacific,wasdeveloped.Ratherthanrolloveranddie,theprofessionarosetobestrongerandmoresecure.Thatisthehistory.34,35

Wecanentertainseveralcorridorsof“WhatIfs?”.WhatiftheCMAandtheAMAhadbidedtheirtimeandnegotiatedwithseveralstateosteopathicmedicalsocietiessimultaneously.IftherewereDOsinCaliforniawhowishedtobeMDs,thentherewerecertainlymanyotherswhohadthesamedesirefromotherpartsofthecountry.Eveninthepresenttherearemany‘wannabe MDs’.The conversion process could have causedsuchadominoeffectthatitmayhavemadeitimpossiblefortheosteopathicprofessiontoeverrecover.Perhaps,themilitaryinthemid1960swouldhaveonlyacceptedanosteopathicallyschooledphysician ifheor shehad receiveda license tobeanMD.Wecanalso lookat it from theperspective that theamalgamationattemptfailedandthat therewouldhavebeennoProposition��.Withouttheenticementtobecomeinstantlyrecognizable,the�,000whoconvertedwouldnothavebecomeMDs.Insteadofthegenerationofnewschoolsthatarosemorethanadecadelater,theprofessionmayhaveremainedwiththesamesixosteopathicschools.Perhaps,thateventhadmoretodowiththegrowthoftheosteopathicprofessionoverthelast30to40yearsthanwithasetback.

Whataboutthepresentandthefuture?Whatifosteopathic

educationwasosteopathic?Thatisnotanattemptatsarcasmorironybutanobservationoftheconditionofthingsastheyare.AstheliberaleconomistStuartChase(1888-1985),said,“De-mocracy,ashasbeensaidofChristianity,hasneverreallybeentried.”Thesamecanbesaidanygovernmentalphilosophicalapproachortheologyaswellasforosteopathicmedicine.Oste-opathyhasnottrulyhappened–notinourschools,residencies,andnotinourspecialtycolleges.Althoughwecouldanalyzeanyofthese,Iwouldliketospecificallyaddressoneofmygreatestinterests:osteopathicmedicalschooleducation.Itwouldbeasimpleextensiontoaddresstheotherinstitutions.TheschoolsofosteopathicmedicinehaverootsstretchingbacktotheoriginalinstitutioninKirksvilleandthedeansofalloftheschoolsmustbeosteopathicphysiciansandallmusthavedepartmentstoteachosteopathicmanipulativemedicine.Therehavebeenmany“ten-fingered”deansandfacultyattheseschoolsovertheyears.Ofcourse,therehavealsobeendeanswhohavehadconsiderablyfewerfingers,atleastfiguratively.ThetruthisthattheacademicprogramsareoftennotthatdifferentthanonewouldfindinanMDschoolwith the exceptionof the additionalOsteopathicManipulativeMedicine(OMM)course.If it is justseenasamanipulationcourse,justamodalitytopulloutatcertaintimeswhenconvenient,thenwehavefailed.

Project100 that isbeingpromotedby theUnitedStatesBoneandJointDecadeorganizationisseekingtointegratesomelevelsofmusculoskeletalmedicinein100%oftheMDschools.Eveniftheyincludetraininginmanipulation,itwillnotbethesame.Itwillbemissingthecorecomponenttodrivethesuccess-fulapplication:theosteopathicphilosophy.SincethedaysoftheFlexnerreport,therehasbeengreatattentiontowardsfulfillingtherequirementsthatanMDschoolmustfulfill.ItwasforthisreasonthattheCollegeofOsteopathicPhysiciansandSurgeonswasabletobesoeasilyconvertedtoanon-osteopathiccollegeofmedicinein196�.Withmorethan�0schools,thereareasmanydifferentwaystoorganizethecurriculum.Itisalmostliketheoldstatementthatifthereweretwoosteopathsinatown,therewouldneedtobethreehospitals.Thereisa“homerule”phenomenonthatresultsinalackofconsistency.Thereneedstobeaparadigmshift.Inordertobecomeosteopathic,theyneedtofollowosteopathicstructureandfunctionintheircurriculardesign. Many of the schools have instituted Problem-BasedLearning(PBL)orothercurricularvariations.Theseprogramsaretypically“diseaseoriented”andhavelittletodowiththeosteopathicapproach.Often,theosteopathiccomponentislim-itedtothequestion“WhatOMTwouldweuse”attheendofamedicaldiscussiononetiology,pathophysiology,andtreatment.Thatdoesnotmakeitosteopathic.Generally,wearelookingatanacademicframeworkatmostschoolsthathasmoretodowithseparatesystemsthanitdoeswithtrueintegration.Thereislittleorno“BodyUnity”.WehavePhDs,MDs,aswellasDOswhoteachinourschoolswhoneverbringtheconceptsofosteopathicprinciplesandpracticeintotheirteachinginthelabo-ratorycourses,didacticcoursesandtheclinicalrotations.Atleastthenon-osteopathicpersonnelhavesomelevelofexcuse;theDOsdonot.Theydonotactasosteopathicrolemodelsforourstudents.Ourosteopathicstudentsandphysiciansseelessandlessdistinctionbetweenthemselvesandtheirnon-osteopathiccolleagues.36,37,38,39,40,41TheobviouscauseisthattheDOshave


becomemoreassimilatedintothepracticeof“routine”medi-cine.Bythefailureofnotbeingreinforcedinthebasictenetsofosteopathy,theschools,residencies,andspecialtycollegeshaveallowedtheslippageofphysiciansawayfromthefold.Thelastpost-graduateopportunity,theosteopathicinternship,4�,43,44,45,46isitselffallingaway.Inordertocombatthis,wemustrestructureandstrengthenthefoundation.Thesolutionisnotintechnology,generalist-to-specialistratios,distancelearning,researchoranyothermechanismoftheday.47Allofthosehaveimportanceastoolsforthesupportofwhatshouldbedone.

Wehaveseentheemphasisonprimarycare.Osteopathicphysiciansaremorefrequentlyprimarycarephysicians,butthatisnottheirexclusivepurview.Osteopathicphysiciansapparentlycommunicatewiththeirpatientsdifferently48,butthisiseasilyremediatedforotherphysicianpractitioners.Wehaveheardthatweare“Doctorstreatingpatients,notsymptoms.”IfIwasanMD,Iwouldbeinsultedandwouldreplytothiswith“HeyItreatpatientsandnotsymptoms,too!”IhavebeenfortunatetohavebeentaughtbyandworkedwithseveralexcellentMDswhorep-resentedourphilosophybetterthanmanyofourDOcolleagues.Thefactthatsomeonehasthefourthandfifteenthlettersaftertheirnamedoesnotmakethemosteopathic.Thesolutionisinareturntoosteopathy.TheprofessionmustundergoaparadigmshifttoWWDSD-“WhatWouldDr.StillDo?”ThegreatestgiftsthatIhavebeengivenbymymentorsandotherteachershavenotbeenosteopathicmanipulativetechniques.Withoutadoubt,theyhavetaughtmeagreatdealaboutthose.Instead,ithasbeenthewayinwhichIcanthinkaboutapersoninhealthandevendisease.TherearemanythingsthatIcandoroutinelythatjustseemtowork.However,wheneverIgetconfused,disrupted,orstoppedbyaclinicalsituation,Ireconfiguremythinkingtoapplytheosteopathicprinciples.Itisthesethatweneedtoreinforcewiththosewhoseektojoinourprofession.Weneedtofollowthedirectionsfromourfounderwhenhesaid,“Myobjectistomaketheosteopathaphilosopher…Iwanttoestablishinhismind,thecompassandsearchlightbywhichtotravelfromtheeffecttothecauseoftheabnormalityofthebody.”49

FollowingDr.Still’sdirectionsthat“Basicprinciplesmustatalltimesprecedeeachphilosophicalconclusion.”50,Iwouldliketotaketheopportunityofthisprivilegetospeakbeforeyoutorecommendatemplatethatcouldbeappliedeasilytoanyofthecurriculaofthecollegesofosteopathicmedicineaswellastomanyothersituations:Allacademiceventsshouldbeorganizedaccordingtoosteopathicprinciplesandphilosophy.51,5�,53,54,55,56,57Isay“all”butfeelthatifwecanaimforthestarsandthenreachthemoon,wewillstillaccomplishagreatdeal.Wewouldbeginwiththebasicprinciplesthatarefamiliartoallhere:

1. StructureandFunctionareinterrelated A. Normal 1) StructuregovernsFunction �) FunctionmodifiesStructure B. Abnormal 1) AbnormalStructureresultsinAbnormalFunction �) AbnormalFunctionresultsinAbnormalStructure

�. ThePerson(Body)isaUnit A. Interactionofdifferentsystems 1) Neurological

�) Dermatological 3) Musculoskeletal 4) Hematological 5) Cardiovascular 6) Pulmonary 7) Gastrointestinal 8) Genitourinary 9) Endocrine 10) Immunological 11) Behavioral/Psychological B. Mind,Body,Spiritconnections 1) Psychosomatics3. Thebodyhasaninherentabilitytoperform: A. Regulation 1) Normal • Maintainsystems �) Abnormal • Alteredregulation B. Adaptation 1) Normal • Reacttosmallalterationsinenvironments • External • Internal �) Abnormal (a) Pooradaptation (b) Inappropriatereaction C. Compensation 1) Toinherentordevelopedinadequacies (a) Normal • Congenital malformations • Genetic • Functional inadequacies (b) Abnormal • Overcompensation • Under-compensation • Maintenanceofadaptationpastusefulness D. Repair 1) Normal • Tissuerepair �) Abnormal (a) Scarformations (b) Adhesions E. Defense 1) Normal (a) Internalderangements (b) Externalinvasions �) Abnormal (a) Inappropriatereactiontoirritants (b) Recognitionofhostelementsas“enemy”4. Dysfunctionofthebody A. Istheinteractionofthe: 1) Host(person) �) Activatingevent (a) Endogenous (b) Exogenous B. Diseaseoccurswhenthebodyis 1) Overwhelmed �) Under-prepared

5. Rationaltreatmentisbasedontheaboveprinciples A. Treatmentdecisionisbasedonproper: 1) History


�) Examination 3) Experience 4) Knowledge 5) Understanding B. Thefunctionofthephysicianisto: 1) Facilitatethebody’sinherentcapacities �) Minimizeeffectsofdisease (a) Endogenousalterations (b) Exogenousthreats C. Methods 1) Lifestyle (a) Environment (b) Diet (c) Exercise (d) Social/Familial (e) Habits �) OsteopathicMedicalInterventions 3) OsteopathicSurgicalInterventions 4) OsteopathicManipulativeTreatment

Theoverallcurriculumshouldfollowthisandeachindividualcoursewoulddolikewisebyhavingthecoursesgroupedtheoreti-cally:

ThePersonasawhole–theemphasisofosteopathicmedicineisonthehost

• Behavioralmedicine • OMM 1. StructureandFunctionareinterrelated–understanding

howthecomponentsarebuiltandwhattheydo;howthetwointeractandmodifyeachother

a. Structure • GrossAnatomy • Embryology • Histology • Neuroscience • Neurology • Cardiovascular • Pulmonary • Renal • Gastrointestinal b. Function • Biochemistry • Physiology • Endocrinology • ClinicalNutrition �. Thebodyhasaninherentabilityto: a. Defend,Heal,Compensate,Repair • Dermatology • Immunology/Allergy • Hematology 3. Diseaseoccurswhenthebodyis: a. Overwhelmed • Microbiology • Infectiousdisease • ClinicalToxicology b Underprepared • Genetics • Pathology 4. Rationaltreatmentfacilitatesalloftheaboveprocesses • OsteopathicManipulativeTreatment • Medicine • Cardiology • Pulmonary

• Gastroenterology • Nephrology • Neurology • Endocrinology • Pharmacology • FamilyPractice • Psychiatry • Surgery • General • Otorhinolaryngology • Orthopedics • Urology • Ophthalmology • Obstetrics/Gynecology • Pediatrics • Radiology

Therecouldberepetitionwithoutredundancy.Ateachlevel– Curricular,Year, Subject,Topic, and Lecture – the courseobjectivesandcomponentsshouldbeorganizedaccordingtotheosteopathicprinciples.Inotherwords,thestudentswouldbeexposedtotheseprinciplesoverandoveragainandnotjustintheOMMcourse.WhethertheprofessorsareaDO,anMD,oraPhD,theycouldbeorientedtostructuretheapproachofthelectureorthecoursetofollowtheframeworkofosteopathicprinciples.Oneofthegreatquestionsineducationis“Howdoyougetsomeonetothink?”Amongthemanysuggestionsarerepetitionandprovocationtoapplykeyconcepts.Insteadofbe-ingonlylecturesintheOMMcourse,thestudentswouldlearnanapproachthattheycouldutilizeeverydayoftheircareers.Dr. Still wrote that “Osteopathic physicians must be able togiveareasonforthetreatmenttheygive,notsomuchtothepatient,buttothemselves.”58Ratherthanseeingnodifferencebetweenthemselvesandothers,theosteopathicwaycouldbedemonstratedagainandagain.ThefollowingisanexamplethatisinnowayexhaustiveforaPulmonarycourse:

Pulmonaryconsiderations:

b. Thebodyisaunit: • Respirationdeliversoxygentothewholebody

throughdiffusionbythepumpingoftheheart • Theheartaswellasbloodvesselsare responsibleforthedelivery • Thelungsaffectbloodpressure(angiotensin) • TheprocessofbreathingiscontrolledbytheCNS • Theairpassagesbeginintheheadandneckand

extendtothechest • Respirationisanactionofthewholebody • ThePrimaryRespiratoryImpulseoftheCranial

mechanismaffectspulmonaryrespiratory function • Chemotacticaswellasothercentersexistinthe

braintoregulatebreathing c. Structureandfunctionareinter-related: • Thenasalpassagesandoralpharynxmoisturize

theair • Theringsofthetracheaprovidesupportand

protectionforastructurethatshouldremain


uncompressedbypositionornormalapplied pressures

• Themultiplebronchiolesandaveoliprovidea greatersurfaceareafordiffusionthanifasingle surfacewasadapted

• Theproximityofthecapillariesprovidesfor turnoverofCO

�andO

�

• Thefunctionofhemoglobininthereleaseof CO

�andabsorptionofO

�

• Thediaphragmactslikeabellowscreating negativepressurewithinthethoraciccavitythus drawinginair

• Theribsprovideaframeworkfortheactionof themusclesallowingforachangeindiameterof allplanesandtherebyincreasethevolume

• Thesecondarymusclesofrespirationassist inchangingthepositionoftheribsandalter

thevolume • Thecostalcartilageisflexibleandtwistsduring

inhalationanduntwistswhenthediaphragm relaxesandtheycontributetoexhalation

d. Thebodyhasaninherentabilitytodefend,heal, repair,andadapt:

• Thehairsinthenaresfilterparticulatematter • Someinfectingagentsandparticulatematter

iscapturedinmucousmixedwithsalivaand swallowedfordestructionintheacidofthe stomach

• Theciliaactasan“escalator”anddeliversome foreigncomponentsbacktotheorophayrnx

• Therearelargelymphnodesadjacenttoall bronchiwithmanyterminalandconducting lymphaticstructuresadjacenttoalllungtissue

• Thestructureschangebasedonaltitudewith expansionofchestcavityandadaptationto loweroxygenenvironments

• Thereisaphysiologicalswitchtoair componentswhentherehasbeendamage. NormalpeopleareCO

�dependentfortheir

drivetobreathewhilepatientswithemphysema areO

�dependent

e. Diseaseoccurswhenthebodyisoverwhelmed orunderprepared: • Weareexposedtomillionsifnotbillionsof

pathogenseachdayyetdon’tbecomeillunless ourimmunesystemsareatareducedcapacity

orunlessthepathogenisabletooverwhelmthe defenses

• Smokingimmobilizestheciliathatlinethe respiratorytract

• Tobaccoproductsincreasethelikelihoodof aberrantcellstoreplicate

• Allergicreactionsoccurbecauseofanover whelmingandoftentimesinappropriateimmune response

• Asthmaisacombinationandcascadeof reactionsincludingprecipitatingelements, bronchospasticreaction,andinflammatory response

f. Rationaltreatmentisbasedontheaboveprinciples (i.e.Asthma):

• Decreasetheworkandeffortofbreathing (i) provideoxygen (ii) relaxspasticmuscles (iii)removeribmotionrestrictions • Increasetheefficiencyofstructures (i) Beta-agonistmedications-increaseefficacy ofthemechanism (ii) Corticosteroids-facilitatereductionof inflammation (iii)Increaseexcursionofthediaphragm (iv)Stimulatesympatheticresponse (v) TreatC3,C4,&C5inthecervicalspine toremoverestrictionstothescalenesand thephrenicnerves (vi)Ribraising (vii)Treatthepelvicdiaphragmtoallowthe changesinabdominalcavitypressure changes • Encouragethedefensiveandadaptiveinherent mechanisms (i) Lymphatic - Thoracicpump - Hepaticpump - Splenicpump - Dalrymplepedalpump - Effleurage - Galbreathtechnique (i) Chestpercussion (ii) Vaccination -Influenza -Pneumoccocus • Provideinterventions (i) Removepossibleenvironmentaland otherirritants (ii) Usemastcellstabilizingmedications (iii)Preventlatephaseinflammatoryresponse withlowdoseinhaledandothersteroids (iv)Lifestylechanges - Exercise - Diet (v) Patienteducation Therearemanyresourcesthatcanbeused59.TheEduca-

tionalCouncilforOsteopathicPrinciples(ECOP)hasdevelopedaCoreCurriculumthatcontainsthebasicframework.ItwastheoriginaldocumentthatleadtothecreationoftheFoundations for Osteopathic Medicine textbookandmanyof thebrilliantmembersofourprofessionworkedonitscreation.ECOPhasalsocreatedtheCOILS,Clinically Osteopathically Integrated Learning Scenarios60asateachinginstrumentforpost-gradu-atetraining.AlthoughIconsiderittobeaflawedinstrument,theOsteopathicSOAPNoteisastepintherightdirectionofpresenting a framework for organized osteopathic thinking.Therearemanyotherresourceslocatedinarticles61andtext-books.6�,63,64Wecanrelyuponthegoodsenseandguidanceofourfounder,Dr.AndrewTaylorStill.45,46Someofthescience

�0/The AAO Journal March�006

ofoveronehundredyearshasreaffirmedhislegacytous.Theman-powerresourcescanbedrawnfromthemembersofECOP,themembersofthedepartmentsofOsteopathicManipulativeMedicine,theFAAOs,themembersoftheAAO,andultimately,anyosteopathicphysicianwhoholdsthephilosophyandprin-ciplescloseinmind,handandheart.Ifwecanaccomplishsomeprogressinthisregardwithintheschools,thenwecanextendtheconceptbeyondinawaythattrulydemonstratestheunique-nessofosteopathicmedicine.Quitepossibly,wemaynotneedtotransformourpost-graduateprogramssincethosetrainedintheabovedescribedmannercouldnaturallybringitabout.

Thefutureoftheprofessionisdependentonanumberof“WhatIfs?”Isittoomuchofaconceittohopethatwecanre-establishthebasicprinciplesintoallpartsofourprofession?WecancontinuetheevolutionofmedicinethatDr.Stillplannedbyfacilitatinganinstructionofosteopathyasitshouldbelearnedandpracticed.Perhapsitcouldmeetitsdestinybybecomingthepredominantsystemofmedicalcareinfivecenturies.

(ThesceneisfromStarTrekVoyagerandCaptainKath-rynJanewayislyingproneonatreatmenttableinherprivatequarterswhiletheEmergencyHolographicPhysicianistreatingher with manipulation for her headaches and other physicalcomplaints.)

HolographicDoctor:“Yourtrapeziusishardasarock.Youhaven’tbeenfollowingtherelaxationregimenIprescribedforyou.”

CaptainJaneway: “I’vebeentoobusy.”HolographicDoctor: “Theusualstory.Haveyoubeenget-

tingenoughsleep?”CaptainJaneway: “Moreorless.Mostlyless.”HolographicDoctor: “Andhaveyourheadachesbeenget-

tinganyworse?”CaptainJaneway: “No.They’renotgettinganybetter

either.They’relikehotneedlesdriv-ingintomyskull.”

HolographicDoctor: “Thesesymptomsarehardlysurpris-ing,Captain.Youworkabsurdlylonghours,underconstantstress,eatingontherun,withoutsufficientexerciseorrest.Yourbodyiscryingoutformercy.”

CaptainJaneway: “Itcertainlyisrightnow!Theremustbesomeeasierwaytodothis,Doctor.Ahypospraymaybe?”

HolographicDoctor: “Alwayslookingforthesimplefix.Sometimesthere’snosubstituteforintensiveosteopathicpressuretherapy…”65

IwouldliketothanktheBoardofTrusteesandthemembersoftheAmericanAcademyofOsteopathyfortheirselectionofmetogivethislecture.TherearesomanyotherindividualswhomIwouldalsoliketothank:myfamilyforthehelpandunderstand-inginallofmyactivities;mymentors,StanleySchiowitz,DO,FAAOandEileenDiGiovanna,DO,FAAOfortheirguidance;and the many professors, clinicians and students who havetaughtmealloftheseyears.,Ialsowouldliketospecifically

thankMichaelSeffinger,DOwhokindlysharedhisknowledgeandmaterialconcerningtheCaliforniaamalgamationaswellasdiscussingwithmetheconceptsofthislecture.Finally,Ioweagreatdealofappreciationtoallofthoseosteopathicphysi-cians,especiallyAndrewTaylorStill,whobytheireffortsandknowledgehavemadeitpossibleforustodoourlife’swork,thecareofpatients.Thankyouforyourkindattention.

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35. SeffingerMA.Personalcommunication.36. AguwaMIandLiechtyDK.Professionalidentificationand

affiliationofthe199�graduateclassofthecollegesofosteo-pathicmedicine.JAOA.Aug1999.99:408-4�0.

37. SpaethDGandPheleyAM.UseofosteopathicmanipulativetreatmentbyOhioosteopathicphysiciansinvariousspecialties. JAOA.Jan�003.103:16-�6.

38. FryLJ.Preliminaryfindingsontheuseofosteopathicmanipu-lativetreatmentbyosteopathicphysicians. JAOA.Jun1996.96:91-96.

39. DPRusso,STStoll,andJHShores.DevelopmentoftheAttitudesTowardOsteopathicPrinciplesandPracticeScale(ATOPPS):preliminaryresults. JAOA.Sep�003.103:4�9-434.

40. ShlapentokhV;O’DonnellN,andGreyMB.Osteopathicin-terns’attitudestowardtheireducationandtraining.JAOA.Aug1991.91:786.

41. JohnsonSMandBordinatD.Professionalidentity:keytothefutureoftheosteopathicmedicalprofessionintheUnitedStates [letter]. JAOA.Jun1998.98:3�5.

4�. RodosJJ.LoyaltytotheprofessionnottheAOA:evidencebasenecessaryformembersupportofassociationpolicies[letter].JAOA.September�005.105:(9):4�6.

43. O’ConnorJJ.Bridgingperspectives,butregrettingdemiseofinternship[letter].JAOA.�004.104:365-366.

44. SmithAB.Evaluatingtherationaleoftheosteopathicintern-ship.June�004.JAOA.104(6):�30-�31.

45. ClarkRC.Osteopathicmedicaltraining:developingtheseasonedosteopathicphysicianJAOA.November�004.104:(11):45�-455.

46. NooneSJ.Theerosionofosteopathicidentity,American Acad-emy of Osteopathy Newsletter.October�005.p�.

47. Ross-LeeB,KissLE,andWeisserMA.Anosteopathicpre-scriptionformedicaleducationreform:part�.Specialtymixandcommunityintegration.JAOA.Aug1997.97:463-468.

48. CareyTS,MotykaTM,GarrettJM,andKellerRB.Doosteo-pathicphysiciansdifferinpatientinteractionfromallopathicphysicians?Anempiricallyderivedapproach.JAOA. Jul�003.103:313–318.

49. TruhlarRE.Doctor A. T. Still in the Living.PrivatelyPublished.Cleveland,Ohio.1950.p117.

50. TruhlarRE.Doctor A. T. Still in the Living,PrivatelyPublished,Cleveland,Ohio.1950.p117.

51. StillAT.The Philosophy of Osteopathy.Kirksville,Missouri.1899.

5�. StillAT.The Philosophy and Mechanical Principles of Oste-opathy.Hudson-KimberlyPub.CO.KansasCity,Missouri.190�.

53. LittlejohnJM.Theprincipleofosteopathy.JAOA.7:(6):�37-�46reprintedinJAOA. Mar�000.100:191-�00.

54. PetersonB.AcompilationofthethoughtsofGeorgeW.Nor-thup,DO,onthephilosophyofosteopathicmedicine.JAOA.Jan1998.98:53-57

55. SeffingerMA,KingHH,WardRC,JonesJM,RogersFJ,andPattersonMM.OsteopathicphilosophyinWardRC(Ed.)Foundations for Osteopathic Medicine,(�ndEd),Lippincott,Williams&Wilkins.Philadelphia.�003,pp3-18.

56. HuletGD.A Text Book of the Principles of Osteopathy,5thEdi-tion.Pasadena,California.A.T.StillResearchInstitute.19��.

57. DowlingDJandMartinkeDJ.ThephilosophyofosteopathicmedicineinDiGiovannaE,SchiowitzS,andDowling,DJ.Eds.,An Osteopathic Approach to Diagnosis and Treatment, 3rdEdition.LippincottWilliams&Wilkins.Philadelphia.�004.10-15.

58. TruhlarRE.Doctor A. T. Still in the Living.PrivatelyPublished.Cleveland,Ohio.1950.p11�.

59. GloverJC.Wheredowegofromhere?The AAO JournalMarch�005.15(1):11-15

60. ECOP.Clinically Osteopathically Integrated Learning Sce-narios.TheAmericanAssociationofCollegesofOsteopathicMedicine.�001.

61. RogersFJ.Themusclehypothesis:amodelofchronicheartfailureappropriateforosteopathicmedicine.JAOA.Oct�001.101:576–583

6�. KucheraMLandKucheraWA.Osteopathic Considerations in Systemic Dysfunction–Revised�ndEdition.GreydenPress.Columbus,Ohio.1994.

63. WardRC.(Ed.)Foundations for Osteopathic Medicine (2nd Ed).Lippincott,Williams&Wilkins.Philadelphia.�003.

64. DiGiovannaE.SchiowitzS,andDowlingDJ,Eds.An Os-teopathic Approach to Diagnosis and Treatment,3rdEdition.Lippincott,Williams&Wilkins.Philadelphia.�004.

65. StarTrekVoyager.“ScientificMethod”.October�9th.1997.❒

Accepted for publication: October 2005

Address correspondence to:DennisJ.Dowling,DO,FAAOOMMAssociates,PC575UnderhillBlvd.,Suite1�6Syosset,NY11791E-Mail:[email protected]

��/The AAO Journal March�006

April 21-23, 2006NeuroFascial Release Course EastPhoenix,AZContact: SteveDavidson,DO 800/359-777�

May 4-7, 2006109th Annual ConventionIndianaOsteopathicAssociationCME:30+Category1A(anticipated)HyattRegencyIndianapolis,INContact: IOA 317/9�6-3009or 800/94�-0501

Component Societies’ CME Calendar and other Osteopathic Affiliated Organizations

May 4-7, 200651st Annual ConferenceFloridaAcademyofOsteopathyOrlando,FLCME:��Category1A(anticipated)Contact:KennethWebster,EdD phone:7�7/581-9069 fax:7�7/581-8537 E-mail:[email protected]

June 17-21, 2006Basic CourseTheCranialAcademyFoundersInnVirginiaBeach,VACME:40Category1A(anticipated)Contact: TheCranialAcademy 317/594-0411

OklahomaStateUniversityCenter forHealthSciences,CollegeofOsteopathicMedicineisseekingtofillafull-time,non-tenure(clinical)or tenure-trackfacultypositionin theDepartmentofOMM.ThispositionisactivelyinvolvedinpatientcareandteachingmedicalstudentsandresidentsatCollegeambulatoryclinics,aswellasthehospitalinpatientservice.AppropriateeffortandactivityinclinicalresearchandservicewillalsobenecessaryaswellasaclinicalrecordofsufficientdepthtoqualifyforfacultyappointmentattherankofAssistantorAssociateProfessor.RequiresaD.O.degree,eligibilityforlicensureinthestateofOklahoma,Boardeli-gibilityandadevotedinterestineducation.Preferresidencyand/orfellowshiptrainingandteachingexperience.Competi-tivesalarywithexcellentfringebenefits.Applicationswillbereviewedasreceived;openuntilfilled.Mustapplyonlineat:https://jobs.okstate.edu,searchHealthSciencescampus.OSUisanaffirmativeaction/equalopportunityemployer.

Assistant/Associate ProfessorDepartment of Osteopathic

Manipulative Medicine

June 22-24, 2006AACOM’s 2006 Annual MeetingChallenges and OpportunitiesRenaissanceHarborplaceHotelBaltimore,MDContact:AACOM 301/968-4143

June 22-25, 2006Annual Conference – “Bent Twigs: Pediatric Osteopathy and Beyond”TheCranialAcademyFoundersInnVirginiaBeach,VACME:40Category1A(anticipated)Contact: TheCranialAcademy 317/594-0411


➝

AbstractBackground

4.4to6.�percentoftheadultpopula-tionhasaphysicianconfirmeddiagnosisof asthma. Physicians use pulmonaryfunctionalteststoaccuratelyassessandreproducethepulmonaryfunctionalstateofanasthmaticornon-asthmaticpatient.Myofascialtriggerpointsinvariouspartsof the body have been documented tohavephysiologicaleffectsontheorgansofthebody.

ObjectiveA myofascial trigger point on the

skullwas identifiedandtreatedinninepatientswithanacuteasthmaticexacer-bationandwhowereatthetimerefrac-torytostandardrescuetreatments.

MethodsA Peak Flow Meter was used to

determine peak flow. These measure-mentswereobtainedafter theuseof arescueinhalerornebulizerbutbeforetheexperimental treatment.A trigger-pointwasfoundattheleftparietaleminenceontheskullinpatients.Thetrigger-pointwastreatedusingdirectpressure,andthescalp was folded around the point.Anadditional measurement was obtainedapproximately three minutes after thetreatmentwasapplied.

ResultsThe percent change in peak flow

for patients classified as mild variedfrom8�%to89%.For themoderatelyinvolved, thepercent changewas5�%to87%.Onlyonepatientwasclassifiedassevereandtheincreasewasapproxi-mately53%.Asignificantchangeinpeakflowwasseenwith thepatients treatedwiththeosteopathicmanipulativetreat-menttechniquedescribed(p<0.0003).

A myofascial trigger point on the skull: Treatment improves peak flow values in acute asthma patientsWm. Thomas Crow and David Kasper

ConclusionWhile the retrospective study

showed interest ing and dramat-ic results, further study is needed.

KeywordsAsthmaMyofascialtriggerpointsOsteopathicManipulation

Abbreviations(FEV1) forcedexpiratoryvolumein

onesecond(PEFR) peakexpiratoryflowrates

IntroductionInEuropeandtheUnitedStates4.4

to 6.� percent of the adult populationhave a physician confirmed diagnosisof asthma.1, �Asthma cost nearly $500milliondollarsinemergencydepartmentvisits in 1994, according to the mostrecentdataavailable.3

Physiciansusepulmonaryfunctionalteststoassessthepulmonaryfunctionalstate of an asthmatic or non-asthmaticpatient. Data from these pulmonaryfunction tests can quantify the diseaseseverity,assessandmonitorthediseaseprogression, and lastly determine thepatient’s appropriate future course oftreatment.4

Peak flow meters are increasinglybeing used to objectively measure theseverityofairflowobstruction.Currently,the“goldstandard”parameterinscreen-

ing patients for airflow obstruction isforcedexpiratoryvolumeinonesecond(FEV1).However,physiciansareusingpeak expiratory flow rates (PEFR) viapeakflowmetersasanacceptablealter-nativescreeningtoolinidentifyingandmanagingtheirasthmaticpatients.5PEFRis an easily reproducible measurementwithpredictednormalvaluescalculatedbasedonheight,age,andsexwithnodif-ferencesamongracialgroups.5,6Byusingpeakflowmeterstomonitorthediseasecourseandassessingtheresponsetomed-ications, early intervention can reducetheriskofhospitalization.7-10Overall,theincreasinguseinthepeakflowmeterisdue to itsportability, simplicity inuse,economicvalueandoverallpracticalityintestinglungfunction.5,6

PEFRisnowacceptedastheleastinvasive measurement in measuringairway obstruction.Three attempts arerecordedtakingthebestofthethreere-cordings.6,11-13Measurementscanbecor-relatedtoseverityofexacerbation(Table1).Regardingblowingintothepeakflowmeter, someauthors concludewith themagnitudeandorderoftheblowstherewasnosystematicrelationshipnortrendbetweenthosetwovariablessincesomepatientsimproved,whileothersdeterio-ratedduringtheirthreeattempts.11

Amyofascialtriggerpointhasbeendefinedasalocalized,hyperirritablespotinapalpabletautbandofskeletalmusclefiber.14 The clinical characteristics of

PEFCOMPARISONS

PEF Condition

<50%predictedvalueorpersonalbest SevereExacerbation

50%-80%ofpredictedorpersonalbest ModerateExacerbation

>80%predictedorpersonalbest MildExacerbation

Table 18


a myofascial trigger point include: (a)localized tenderness in a taut band ofmuscle; (b) a local twitch response tocross-fiberstimulationofthetautband;(c)paintodeeppalpationthatisrecog-nizedaspain;(d)andautonomicdysfunc-tion.Travell and Simons proposed anintegratedworkinghypothesistoexplaintheunderlyingpathophysiologyassoci-atedwithmyofascialtriggerpoints.15Inshort, the theory states that injury canleadtomotorendplateirritability,whichmaycausefrequentlocaldepolarizationsofthemusclefibers,resultinginanener-gycrisiswitharelativelossofsufficientquantitiesofhigh-energyphosphatestoallow the calcium-dependent lengthen-ing of the myofibril unit.This in turncanleadtodecreasedcapillaryflowintothe muscle secondary to the increasedmuscletension,loweringofthelocalpH,andreleaseofsensitizingsubstancesintothemuscle thatcancauseactivationofmusclenociceptorsandpain.16

Referredpainfrommyofascialtrig-gerpointscanmimicvisceralpainsyn-dromesandvisceralpainsyndromescaninducemyofascialtriggerpointdevelop-mentandmyofascialpainanddysfunc-tion.14,15AnexampleofthismyofascialtriggerpointmimickingvisceralpainwasreportedbyTravellandSimons. In theanteriorchestwallintherightpectoralisminor,a triggerpointcancausesupra-ventriculartachycardiaaswellasothercardiac pain.Triggerpoints have beenknowntocauseormimicchronicpelvicpain, interstitial cystitis, prostatodynia,andirritativevoidingsymptomsaswellaschronicabdominalpain.14,15,17-�3

MethodsThis retrospective study involved

thecollectionorstudyofexistingdata,documents, and charts recorded by

the investigator in such a manner thatsubjects cannot be identified, directlyorthroughidentifierslinkedtothesub-jectsandisexemptfromIRBapprovalunderFederalRegulation.[15C.F.R.§�7.101(b)(4)]

SubjectsAllninepatients(age16to55years)

had a prior history and diagnosis ofasthma.Theyhadexperiencedanacuteasthmaticexacerbationandhadusedthestandardinhalerornebulizer.Theyself-referredtoanofficewhentheyfelttheyhadlessthanthedesiredresultsfromthestandardrescuetreatment.Patientswereseenfromonetothreehoursaftertheirstandard treatment.The patients wereclassifiedastoseverityoftheasthmaticepisodefollowingthestandardtreatmentofinhalersand/ornebulizerbyuseofthepublishedguidelinesforpeakexpiratoryflow.8

MeasurementsAmodelHS710PeakFlowMeter

(Respironics HealthScanAsthma &Allergy Products, Cedar Grove, NewJersey)wasusedtodeterminethepeakflow.Thiswasaccomplishedbyhavingthepatientexhaleintoamouthpieceat-tachedtotheFlowMeter.Theexhalationwasrepeatedthreetimeswiththehigh-est value accepted as the score.Thesemeasurements were obtained after theuseofarescueinhalerornebulizerbutbeforetheexperimentaltreatment.Oneadditional measurement was obtainedapproximately three minutes after theexperimentaltreatment.

TreatmentA trigger-point was found at the

leftparietaleminenceontheskullinthepatients.

The trigger-point was treated us-ing direct pressure and folding thescalparoundthepoint.Whilesimilartocounterstrain,thetriggerpointwasheldforapproximately45secondsnot90to1�0secondssuggestedforcounterstraintechniques.

ResultsThe number of patients classified

as mild, moderate or severe is showninTable �.Additionally,Table � pro-videstherawdataforboththepre-andpost-experimentaltreatmentPeakFlowvaluesforeachofthenineindividuals.Theweightandageofthepatientswereremoved from the table due to HIPPArequirements.

The percent change in peak flowfor patients classified as mild variedfrom 8�% to89%.For themoderatelyinvolved, thepercent changewas5�%to 87%. In this report, there was onlyasinglepatientclassifiedassevereandthe increase was approximately 53%.Thus,overall,mostpatientsdidshowanimprovement.

Thepre-experimentaltreatmentandpost-experimentaltreatmentvaluesofthePeakFlowMeterforeachsubjectwereanalyzedusingamatch-pair t-test.APvalue of 0.05 or less was accepted assignificant.Infact,asignificantimprove-mentinpeakflowwasdeterminedwhenthedatawereanalyzed(p<0.0003).

DiscussionWhiletheretrospectivestudyshowed

interestinganddramaticresults,furtherstudyisneeded.Theneurologicalbasisforthechangecannotbedirectlyinferredfrom any of the data. One etiology ofasthmaisbelievedtobeanoverstimu-lation of the parasympathetic nervoussystem.Itisinterestingtospeculatethat

IDENTIFIER PrePEF(L/min) PostPEF(L/min) %ChangeofPre/Post SEVERITY %PrePEFtoNormal %PostPEFtoNormal

1 450 550 81.8�% Mild 83.06% 101.51%

� 550 6�0 88.71% Mild 96.09% 108.3�%

4 550 670 8�.09% Mild 96.09% 117.05%

9 �60 500 5�.00% Moderate 50.98% 98.04%

8 �75 350 78.57% Moderate 53.9�% 68.63%

6 3�5 375 86.67% Moderate 57.0�% 65.79%

7 300 450 66.67% Moderate 58.8�% 88.�4%

3 350 550 63.64% Moderate 61.15% 96.09%

5 ��5 4�5 5�.94% Severe 37.96% 71.69%

Table 2: Patient Data


this myofascial trigger point treatmentmayhaveimpactedtheparasympatheticnervoussystemandreducedtheactivitythus improving respiratory function asdemonstrated by the increase in peakflow.

ConclusionFurther study is needed in a pro-

spective, double-blinded study to seeif thesefindingsare supported in largescaletrial.

AcknowledgmentPeggyStewartforherhelpwiththe

statisticalanalysisandotherhelp.

References1. HahnDandBeasleyJ.Diagnosed

andpossibleundiagnosedasthma:aWisconsinResearchNetwork(WReN)study.Journal of Family Practice.1994:38:373-9.

�. HedmanJ,KaprioJ,PoussaT,andNieminenM.Prevalenceofasthma,aspirinintolerancenasalpolyposisandchronicobstructivepulmonarydiseaseinapopulationbasedstudy.International Journal of Epidemiology.1999:�8:717-55.

3. WeissK,SullivanS,andLyttleC.TrendsinthecostofillnessforasthmaintheUnitedStates1985-1994.Jour-nal of Allergy and Clinical Immunol-ogy. �000:106:493-9.

4. GoldW.Pulmonary Function Testing, 3rded.Philadelphia.WBSaunders.�000.

5. D’SouzaW,CraneJ,andBeasleyR.Self-management plans.�nded.Lon-don.WBSaunders.�001.

6. RamirezNandLockeyR.Manage-ment of acute asthma in the office set-ting.1sted.Philadelphia.ACP.�00�.

7. BannerA,ShahR,andAddingtonW.Rapidpredictionofneedforhospi-talizationinacuteasthma. JAMA.1976:�35:1337-38.

8. KimmelS.Useofthepeakflowmeterinofficepractice. Am Fam Physician. 1986:34:107-11.

9. PlymatKandBunnC.Monitoringasthmawithamini-Wrightpeakflow-meter.Nurse Pract.1985:10:�5-7,47.

10. WilliamsM.Expiratoryflowrates:theirroleinasthmatherapy.Hosp Pract.198�:17:95-110.

11. DahlqvistM,EisenE,WegmanD,andKriebelD.Reproducibilityofpeakexpiratoryflowmeasurements.Occup Med.1993:8:�95-30�.

1�. BrownLandSlyM.Comparison

ofmini-WrightandstandardWrightpeakflowmeters.Annals of Allergy.1980:45:7�-4.

13. OwnbyD,AbarzuaJ,andAndersonJ.Attemptingtopredicthospitaladmissioninacuteasthma.AJDC. 1984:138:106�-66.

14. TravellJandSimonsD. Myofascial Pain and Dysfunction: The Myofascial trigger point Manual.Baltimore.Wil-liamsandWilkins.1983:1.

15. TravellJGandSimonsDG.Myofascial Pain and Dysfunction: The Myofascial trigger point Manual.Baltimore.Wil-liamsandWilkins.199�:�.

16. AudetteJF,WangF,andSmithH.Bi-lateralactivationofmotorunitpoten-tialswithunilateralneedlestimulationofactivemyofascialmyofascialtriggerpoints.American Journal of Physical Medicine & Rehabilitation.83(5):368-74,389.�004.

17. SimonsDG.Cardiologyandmyofas-cialmyofascialtriggerpoints.JanetG.Travell’scontribution.Texas Heart Institute Journal.30(1):3-7.�003.

18. TravellJandRinzlerSH.Reliefofcardiacpainbylocalblockofsomatictriggerareas.Proc Soc Exp Biol Med. 1946:63:480-�.

19. FitzGeraldMPandKotarinosR.Rehabilitationoftheshortpelvicfloor.I:Backgroundandpatientevaluation.International Urogynecology Journal.14(4):�61-8.�003.

�0. CimenA,CelikM,andErdineS.Myo-fascialpainsyndromeinthedifferen-tialdiagnosisofchronicabdominalpain.Agri Dergisi.16(3):45-7.�004.

�1 Doggweiler-WiygulRandWiygulJP.Interstitialcystitis,pelvicpain,andtherelationshiptomyofascialpainanddysfunction:areportonfourpatients.World Journal of Urology.�0(5):310-4.�00�.

��. WeissJM.Pelvicfloormyofascialmyofascialtriggerpoints:manualtherapyforinterstitialcystitisandtheurgency-frequencysyndrome.Journal of Urology.166(6):��6-31.�001.

�3. Doggweiler-WiygulR.Urologicmyo-fascialpainsyndromes. Current Pain & Headache Reports.8(6):445-51.�004.❒

Accepted for Publication: Dec. 2005

Address correspondence to:EastOrlandoOsteopathicNMM/FPResidency7975LakeUnderhillRoad,Ste�10Orlando,FL3�8��E-Mail:[email protected]

AAO Bookstore Offers Second Edition

Coding ResourceActing on a recommendation from the

Publications Committee, the Board of Trust-ees has approved the addition of a new publication to the Academy’s inventory of resources on osteopathic medicine. The AAO is now the exclusive distributor of this publication within the osteopathic medical profession.

Douglas J. Jorgensen, DO, CPC and his brother, Raymond T. Jorgensen, MS, CPC are certified professional coders and the au-thors of A Physician’s Guide to Billing and Coding Second Edition. In the foreword, the authors state: “The book provides a direct approach to utilize the best evaluation and management (E&M) recommendations to date, on a conservative basis, while staying within the federal guidelines…Optimizing reimbursement means better capture of the money you deserve, which translates into an excellent return on time invested with more bonuses and/or gain at the year-end.”

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Asthma Protocol – Acute Exacerbation – Intercostal Rib Technique

A.Standardpharmacologictherapyshouldbeinprogress.

B.Explaintothepatientthatyouaregoingtouseatechniquethatmayhelptherespiratorymusclesrelaxsothattheycanworkbetterandbreatheeasier.

C.Thepatientshouldbeseatedeitheratthefootoforonthesideofatreatmenttable(gurney).

D. Thephysicianstandsperpendicularto,andfacingtowardtheleftsideofthepatient.

l. Thephysicianplacesthefingerpadsofthefourdigitsofonehandovertheintercostalmusclesbetweenthefirstfourribsandaboveribfiveanteri-orlynearthesternalborder.

�. Posteriorly,thephysicianplacesthefingerpadsofthefourdigitsofthephysician’sotherhandoverthecorrespondingintercostalspaces(levels1to4)betweenthetransverseprocessesoftheverte-braeandtheangleoftheribs.

3. Physician’supperarmsareclosetothephysician’sribs.

Note: the physician’s posterior handshouldbehigherthantheanteriorhandbasedontheanatomicalstructureoftherib,posteriorribsarehigherthananteriorribsatthesameintercostallevel.

4. Thephysiciannextexertsamild/moderate compressive pressure(deeppalpation)with thefingerpads, to the intercostalmuscles,directed in an anterior/posteriordirectiondowntothelevelofthefascia. (Theamountofpressurewilldependonthedegreeofspas-ticityintheintercostalmuscles).

5. Treatmentisdonewithoutregardtoinhalation/exhalation

Intercostal rib releaseClaudia L. McCarty

phase.6. Whilecontinuingtoholdthe

compressivepressureontheintercostalmuscles,thephy-sician’sfingerpadsaredrawnlaterallytowardthephysician,justuntiltaut.

7. Thisposition(inwardandlateral)ishelduntilarelease(changeintissuetextureand/ortension)isfeltundertheexaminer’sfingers.Thetissuechangemaystartwithsomeellipticalmovement/sensationsunderthephysician’sfingerpadsandfinishwithrelaxationoftheintercostalmusclesandachangeinchestexcursion.

8. Thisprocedureshouldtakeap-proximatelyone-and-a-halftotwominutesatthislevel.

9. Thephysicianthenchangeshandplacementbyslowlyreleasingtheanterior/posteriorpressureandallowingthetissuetomovemediallyawayfromtheoriginaltautposition.

10. Thephysician’sfingerpadsarethenrelocatedtoalowerposi-tionandplacedontheintercos-talmusclesbetweenribs4-5,5-6,6-7,7-8,againnearthecostalmarginsanteriorlyandbetweenthetransverseprocessesandribanglesposteriorly.

Ifnecessary,placementandcorrespond-ingpositionmaybeevaluatedbyplacingonefingeronaribposteriorlyandmovingtheribanterior/posteriorly,checkingformotionatthesamelevelontheanteriorsurface.

11. Physician’supperarmsareclosetothephysician’sribs.

1�. Thephysiciannowexertsamild/moderatecompressivepressure(deeppalpation)totheintercostalmuscles,directedinananterior/posteriordirectiontothelevelofthefascia.The

amountofpressuredependsonthedegreeofspasticityintheintercostalmuscles.

13. Treatmentisdonewithoutregardtoinhalation/exhalationphase.

14. Whilecontinuingtoholdthecompressive(inward)pressureontheintercostalmuscles,thefingerpadsarethendrawnlater-allytowardthephysician,untiljusttaut.

15. Thispositionishelduntilarelease(changeintissuetextureand/ortension)isfeltbeneaththeexaminer’sfingers.Thismaystartwithsomeellipticalmovement/sensationsunderthephysician’sfingerpadsandendinrelaxationoftheintercostalmuscles.

Again, this procedure should take ap-proximatelyone-halftotwominutesatthislevel.

16. Thephysicianthenreleasesthehandplacementbyslowlyreleasingtheanterior/posteriorcompressivepressureandallow-ingthetissuetoslowlymovemediallyawayfromtheoriginaltautposition.

17. Movingtotheoppositesideofthepatient,thephysicianrepeatstheprocedure.

During an acute episode, it may benecessary to repeat the treatment witheachnebulizertreatment,dependingonthe severityof theexacerbation.Treat-mentmaybestoppedormodifiedatanytime.

Note:Duringanacuteexacerbation,theC

�dysfunction,whichisareflectionof

vagalstimulationshouldNOTbetreated.TreatmentofC

�duringanacuteattack

mayoverstimulatethevagusnerveandworsenbronchospasm.


Theintercostalribreleaseprocedureis performed in a similar manner forthe chronic asthmatic patient. In thechronicpatient,treatmentmaybedonein either the seated or supine position.Treatment position will be determinedbythepatient’sasthmastatusatthetimeoftreatment.Additionally,inthechronicpatient,thephysicianmustaddresstheC

�

dysfunction, any thoracic dysfunctionsT

1-6,releasethediaphragmT

11-L

�,and

addresstheextensiondysfunctionofthecranium.Lymphaticdrainageshouldalsobe encouraged.The chronic asthmaticpatientistreatedatweeklysessionsuntilmedicationuseandfrequencyofexacer-bationsarediminished.Itmaybeneces-sarytotreatthepatientmorefrequentlyduringenvironmentalasthmaperiods.

This technique incorporates proper-tiesoffascial-ligamentousrelease(FLR),balancedligamentoustension(BLT)andfacilitated positional release (FPR).Afulcrumisestablishedbetweenthephysi-cianandthepatientinthepositioningoftheforearmsandfingerpads,asin(FLR).A facilitating force or compression isapplied between the two hands (FPR).Drawingthe tissue laterally toward thephysician and awaiting the release in-corporatesBLT.Thetensionisbalancedwiththatofthedegreeofspasmwithinthetissuesbeingtreated.Deeppressurepalpationplaysarole in this techniqueaswell.

Chila remindsus that, “Inperform-ing manipulative procedures, the bodyresponds comprehensively to an exter-nally applied force. From the momentofcontactwiththeskin,avenuesfortheimplementationofvariationsofforceareprovidedbypalpatoryclues.Thebody’scovering,theskin,mayberegardedasamassadrenergicmediumthatisusefulinthefacilitationandamplificationofpro-prioceptiveinterchangebetweenuniquepersons, the patient and the physician.Thesustainedeffectiveresponsefollow-ingtreatmentiscontingentonselectiveandcontrolledvariationofforcefromanappropriatefulcrum.

Whentheseconditionsaremet,inher-entneuroregulatorymechanismsactingin accordance with the capacity of thepatient will facilitate the resolution ofthe dysfunction. Generally speaking,thebody’sconnectivetissuesareundersomedegreeofloadandextension.The

increase and subsequent reversal ofextension produces a degree of tissueresponselessthantherelativelyunloadedstate.Thisphenomenonisreferredtoashysteresis.1Hysteresisistheoccurrenceofsomeflowanddissipationofenergythroughouttheloadedtissue.Hysteresisoccurs less with successive cycles ofextension, indicating stabilization ofresponse.Connectivetissuesundersus-tainedloadwillextendinresponsetotheload.Thiscontinuedextensionisreferredtoas“creep.”Animposedconstantloadwillresultin“relaxation”astheextensionremainsconstant.”1

RationalePossibleexplanationsfortheefficacy

of this treatment includethefascialre-leaseofboththeinternalandexternalin-tercostalmuscles.Sincefasciaenvelopsandcovers themuscles,decreasing theoverlyingtensionwouldlikelyincreasechestexcursion.Themusclesthemselveswouldrespondtothefacilitatingpressureofinwardcompression,deeppalpationorinhibition.The internal intercostals aremusclesof exhalation,which arequietin normal breathing. During an acuteexacerbation of asthma, exhalation isrestricted secondary to bronchospasmandairwayinflammation.

Inasthma,airwayobstructionisdueto(1)profoundconstrictionofthesmallerairwaysbyallergy-inducedspasmofthesmoothmuscleinwallsoftheseairways;(�) plugging of the airways by excesssecretionsofaverythickmucusand(3)thickeningofthewallsoftheairwaysdueto inflammationandhistamine inducededema.�

Itispossiblethattheefficacyoftheproposedtreatmentmayoccurasaresultofdecreasingtheworkofbreathingbyimproving compliance and decreas-ing airway resistance.Compliance is ameasureofthemagnitudeofchangeinlung volume accomplished by a givenchangeinthetransmuralpressuregradi-ent.Changesinthoracicdimensionsarealways accompanied by correspondingchangesinlungdimension.

The primary determinant of airwayresistanceistheradiusoftheconductingairways.Airway resistance is affectedby sympathetic and parasympatheticstimulationofairwaycaliberinresponsetoventilationandperfusion.�

Chila1suggestedinFoundations,theinherent neuroregulatory mechanismsacting in accordance with the capacityof the patient facilitates the resolutionof the dysfunction. Kuchera mentionsthatincreasingtheexcursionofthechestby1cmwillincreasethevolumeofairexchangedby�00cc.3Airhungerandairtrappingcouldbesignificantlyreducedby intercostal muscle relaxation anddecreasedfascialtension.

As discussed earlier, the work ofbreathing during an exacerbation ofasthma, requires a significant increasein total body energy expenditure.� Re-ducing this workload should allow thepatient’s inherentability tore-establishhomeostasis.

Comparison of techniquesTheproposedtechniquesharessome

similaritieswithothertechniquesfoundinreviewingboththeosteopathiclitera-tureandosteopathictextbooks.

Hoag notes that manipulative tech-niquesdiffer for the acute and chronicattack, and that it might be necessaryto treatanacuteattackseatedorsemi-reclining. He proposed that manipula-tion should be directed to the thoracicspine.4

DiGiovanna5describeshowthework-loadofbreathingshouldbereducedandadditionallyrecommendstreatmentinthechronicpatientaswell.5

PaulandBuser6treatedtheacuteasth-matic in theEDusingaseatedposturefor rib raising and respiratory motionaugmentation.Treatment of the uppercervicalunitwasavoided.

Purse7 sometimes used a modifiedseatedtechniquewiththepatient’sbacktotheoperatorwithhandsspreadaroundthe thorax, pressure was then applieddownward&caudallywithexhalation.

Belcastro8etal,usedanintercostalre-lease,whichwasdescribedas“eachhandbeingplacedlaterallyonthemiddleandlowerthoraciccage.Arhythmiccaudadmotion contributes to the stretching ofintercostalmuscles.”

Wilsonin1946notedthat“I like toset my patient up at the end of thesemanipulationsandplacemyfingersoverthefirstribsandmythumbsbetweenthetransverseprocesses4thand5th thoracicvertebrae. In this position I use direct

➝


pressurethroughthethumbsandfingersforabouttwominutes.Thispressurealoneinanacuteepisodeisofteneffective.”9

Rowane and Rowane10 also use aseated posture, with the patient facingawayfromtheoperator.Treatmentwasdirected toT

l-T

6, especiallyon the left

fornormalizationofthesympatheticin-nervationofthelungs.

SimilaritiesarenotedwithSutherland,RowaneandRowane,10PaulandBuser6and Wilson techniques that have thepatientseated.BoththeBelcastroetal8and Rowane and Rowane10 techniquesmentiontheintercostals.Belcastroetal8

specificallyaddressesthefascialreleaseoftheintercostalsusingtheribs.

The review of the textbooks andliteraturehas shownnumerouswaysofaddressing the asthmatic patient withmanipulativetechnique.Mostosteopathicmanipulativetechniquespresentlybeingtaught in theosteopathic collegeshavethe patient in a supine position.Thosethat have the patient seated utilize athrusttechniquetotheribsortransverseprocesses.Thereismentionofrhythmiccaudadmotion.8Ribraisingistraditionallydonewiththepatientinthesupineposi-tion.Thephysician’sfingers areplacedonthetransverseprocessesandanterior(upward)pressure is exerted tobalancethe ligamentous tension and affect thesympatheticinnervation.Ribarticulationisdonebygraspingtheribsneartheheadandalongtheshaftanddistractingasthepatientrotatesawaytogapthejoint.11

Other techniquesIn functional release, palpation at

the dysfunctional segment (spinal orappendiculer) provides for continuousfeedbackinformationaboutthepatient’sphysiologicresponsetomotion.Relativedegrees of compliance or resistance ofcomponentpartsarecomparedbyopera-tor-inducedmotion.Itdoessoinoppos-ingdirections.Themotions introducedarethosethatleadtoanincreasedsenseof compliance (decreased resistance)ofcomponentparts.1�

In fascial-ligamentous release, thepatient during the correctiveprocedureprovides muscular or respiratory as-sistance.Afulcrumissoughtwithinthephysician’sbodytomatchorbalancethefulcrumwithin thepatient’sbody.Thisfulcrumfacilitatesacontinuumofreflex

release from within the patient’s body.Thepatient’sbodyrespondscomprehen-sivelytoanexternalforceappliedduringmanipulativeprocedures.1

The fascia-ligamentous release tech-niquefortheribcagefollows.Thepatientissupine.Thephysicianplacesonehandposteriorly, beneath the rib cage, withthe fingertips just beyond the spinousprocessesoftheassociatedthoracicverte-brae.Placetheotherhandontheanteriorheadsoftheribs.Anelbowonthekneeestablishes the fulcrum. Ifwe combinethis with the upper thorax fascial-liga-mentousrelease,thepatient’sheadrestsonapillow.Onehandandarmcontacttheupperthoracictransverseprocesses,withthephysician’sfingersspreadslightlytocontact the ribsoneach side.Place theoppositehandonthesternum.Theelbowonthetabletop,beneaththepatient’sheadestablishesthefulcrum.1

Belcastrodescribedintercostalfascialrelease, et al. The specific techniquewas described as follows: Each of thephysician’shands isplaced laterallyonthe middle and lower thoracic cage.Arhythmic caudadmotion is then added,which contributes to the stretching ofintercostalmuscles.8

Deep-touch palpation, the fingerscompress the skin surface, palpatingthrough skin and subcutaneous tissuesto the superficialmuscle layer.Furthercompressionleadstopalpationofdeepermuscles,fasciaandbone.Deeppalpationutilizesforcesofcompressionandshear.Compression is a forceappliedperpen-dicularly to the skin surface.Shear is aforceappliedparalleltotheskinsurface.In some instances,deeppalpationcom-binesbothcompressionandshearintheexplorationofdeeptissuetexture.14

Facilitatedpositionalreleaseinvolvesplacingthedysfunctionintofirstaneutralposition,addingacompressiveforceandthetakingthedysfunctionintoapositionofease.13

Polarityisanadditionalconsideration.Thistechniquedirectsspecificcombina-tionsofgender-specificpositioning.Itisanadditionalconsiderationintreatingtheasthmaticpatient.

Theproposedintercostalribtechniqueincorporatessomefeaturesofthesepre-viously published techniques but withenoughvariationtoofferadifference.

SummaryIn treating asthmatic patients both

acutelyandchronicallywithosteopathictechniques, mechanical considerationshaveadifferentpriority.Itisclearthatthepatient’stotalpictureinvolvesbetterex-changeofairnotonlyinagrosssensebutinacellularsenseaswell.Theproblemsthatpersistevenwiththebestmedicinaltreatmentaremechanical.

Theproblem,simplyput,isaninabilitytoexhale.Exhalationisprimarilyafunc-tionofcomplianceorchestwallelasticityand muscular function. One must alsoconsiderthepulmonarytissueelasticity.Intheasthmapatient,theparenchymaisnotaproblemsofarasstretchorresilienceisconcerned.Secretionsmayaffectsurfacetensionbutthisisasmallcomponent,rela-tivelyspeaking,intheoverallscheme.

Themainproblemisthatligamentousandmuscularcomponentshavebeen inashortenedandhypertonicconditionthemajorityofthetime.Thisisknownasaninhalationpositionoronx-ray,aflatteneddiaphragm.Thesignificanceofthissitua-tionisthatitnowrequiresworktoexhalewhichisnormallyapassiveprocess.

The cause of death in an asthmaticpatientwhodiesduringanadmissionforstatus asthmaticus is respiratory failureor rather respiratory muscular exhaus-tion.(Retractions,secondarymusclesofrespirationinexcessiveuse,paradoxicalrespirationsetc.)

Withosteopathic treatment, theme-chanical issues are addressed directly.The structural goals includedecreasingtheworkofbreathingby increasing thefunctionalrangeofmotionoftheribcageandthediaphragm.Asecondaryeffectofthisistopromotelymphaticdrainageofthepleural spacesand theparenchymaltissuesasaresultoftherestorationoflargeexpansileandcontractilemotionsinthetissues.Thisdrivesfluidsandsecretionsintotheterminallymphaticsatthebron-chioles, andat theparietal pleura.Thisosteopathically addresses the inflamma-torycomponentofasthma.

Ifthismanipulativeapproachiscom-binedwiththeadministrationofappropri-atemedication,thetotaldosageisoftenreducedsignificantlyandtheefficacyofthemedicineisextremelyenhanced.Thismayreducethenumberofhospitaladmis-sionsdramatically.Inthelongtermcareoftheasthmaticpatient,thesetechniques


oftenreducethefrequency,duration,andseverity of attacks. It also reduces theutilizationofhighdosemedicationsoverextendedperiodsoftime.

Theintercostalribtechniqueoffersanadditionaloptioninthetreatmentofboththeacuteandchronicasthmaticpatient.Seated,thepatientislessthreatenedandmore cooperative.There is no interfer-ence with pharmacological or medicalmanagement.

Theworkofbreathing isdecreased.Physician touch and presence reassurethepatient.

References1. ChilaAG.Fascial-Ligamentous

ReleaseinWardRC,ExecutiveEditor.Foundations for Osteopathic Medicine. Baltimore,MD.Williams&Wilkins.1997.pp819-830.

�. SherwoodL.The Respiratory System in Human Physiology,3rdEdition.USA.WadsworthPublishingCom-pany.1997.pp418-465.

3. KucheraMLandKucheraWA.Osteo-pathicConsiderationsandActionsoftheThoraxinOsteopathic Principles in Practice,�ndPrinting,�ndEdition.Columbus,OHGreydenPress.1993.pp��4-��9.

4. HoagJM,ColeWV,andBradfordSG.OsteopathicManagementinDisor-dersInvolvingImmuneMechanismsinOsteopathic Medicine.NewYork.McGraw-HillBookCo,Inc.1969.pp693-397.

5. DiGiovannaEL.Thepulmonarypa-tient.InDiGiovannaEL,SchiowitzS.An Osteopathic Approach to Diagnosis and Treatment,�ndEdition.Philadel-phia,PA.Lippincott-RavenPublishers.1997.pp466-467.

6. PaulFAandBuser,BR.Osteopathicmanipulativetreatmentapplicationsfortheemergencydepartmentpatient.JAOA.1996.96:403-409.

7. PurseFM.Manipulativetherapyofup-perrespiratoryinfectionsinchildren.JAOA.1966.65:971-985.

8. BelcastroMR,BachesCR,andChilaAG.Bronchiolitis:apilotstudyofOMT,bronchodilatorsandothertherapy.JAOA.1984.83:9:67�-676.

9. WilsonPT.Theosteopathictreatmentofasthma.JAOA.1959.45:491-49�.

10. RowaneWAandRowane,MP.Anos-teopatahicapproachtoasthma.JAOA.1999.99:5:�59-�64.

11. LippoincottHA.TheosteopathictechniqueofWm.G.Sutherland,DO.1949.AAO Yearbook.pp6-9.

1�. JohnsonWLandFriedmanHD.IntroductioninFunctional Methods.Indianapolis,IN.AmericanAcademyofOsteopathy.1994.

13. SchiowitzS.FacilitatedPositionalRe-leaseinDiGeiovannaEL,SchiowitzS.An Osteopathic Approach to Diagnosis and Treatment,�ndEdition.Philadel-phia,PA.Lippincott-RavenPublishers.1997.p91.

14. BealMC.OsteopathicBasicsinThe Principles of Palpatory Diagnosis and Manipulative Treatment.Newark,OH.AmericanAcademyofOsteopathy.pp10�-103.❒

Accepted for publication: Dec. 2002

Address correspondence to:ClaudiaL.McCarty,DO,FAAOOMMAssociates,PC575UnderhillBlvd.,Suite1�6Syosset,NY11791E-mail:[email protected]

CME QUIZThepurposeofthequizfoundonthe

nextpageistoprovideaconvenientmeansofself-assessmentforyourreadingofthescientificcontentinthe“AMyofascialtrig-gerpointon theskull treatment improvespeakflowvaluesinacuteasthmapatients”byWm.ThomasCrowandDavidKasperANDinanFAAOthesispaper,“IntercostalRibRelease”byClaudiaL.McCarty.Foreachofthequestions,placeacheckmarkinthespaceprovidednexttoyouranswersothatyoucaneasilyverifyyouranswersagainstthecorrectanswersthatwillbepub-lishedintheJune�006issueoftheAAOJ.

ToapplyforCategory�-BCMEcredit,transfer your answers to theAAOJ CMEQuizApplication Form answer sheet onthenextpage.TheAAOwillrecordthefactthatyousubmitted the formforCategory�-BCMEcreditandwillforwardyourtestresults to theAOA Division of CME fordocumentation.

fACULTY POSITIONS

Kirksville College of Osteopathic Medicine, the founding college of os-teopathic medicine, seeks physicians to fill clinical faculty vacancies for the department of Osteopathic Manipulative Medicine. faculty respon-sibilities include course development, instruction, research, and stu-dent advisement. Qualified candidates will be board certified or board eligible, with teaching experience preferred. On the cutting edge of os-teopathic medical education, there is a wealth of opportunity for faculty to grow professionally while using the latest instructional technology. In addition, faculty members participate in a wide variety of clini-cal activities which may include hospital consultation and treatment, specialty, outpatient care, nursing home and senior care, and mentoring of residents and osteopathic medical students. This person will have a faculty appointment in the department of OMM for A.T. Still University of health Sciences at its Kirksville College of Osteopathic Medicine.

Academic rank and salary will be commensurate with credentials and experience. Application review continues until positions are filled. Please send letter of interest, curriculum vitae, and 3 references to:

ATSUhuman Resources800 West Jefferson

Kirksville, MO [email protected]

Equal Employment Opportunity Employer


AMERICAN OSTEOPAThIC ASSOCIATION CONTINUINg MEDICAL EDUCATION

ThisCMECertificationofHomeStudyFormisintendedtodocumentindividualreviewofarticlesintheJournal of the American Academy of OsteopathyunderthecriteriadescribedforCategory�-BCMEcredit.

CME QUIZ

CME CERTfICATION Of hOME STUDY fORMThisistocertifythatI,___________________________,pleaseprintfullname

READthefollowingarticlesforAOACMEcredits.Questions 1-3: Name of Article: A Myofascial Trigger Point on the Skull Treatment Improves Peak Flow Values in Acute Asthma PatientsAuthor: Wm. Thomas Crow, DO, FAAO and David Kasper, MBAPublication: Journal of the American Academy of Osteopathy,Volume16,No.1,March�006,pp17-�1

Questions 4-6: Name of Article: Intercostal Rib Release: Asthma ProtocolAuthor: Claudia L. McCarty, DO, FAAOPublication: Journal of the American Academy of Osteopathy,Volume16,No.1,March�006,pp�9-3�

Category 2-B credit may be granted for these article.

00___________ _______________________AOANo. College,YearofGraduation

Signature_____________________________________________

StreetAddress_________________________________________

City,State,Zip_________________________________________

fOR OffICE USE ONLY

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Complete the quiz to the right and mail to the AAO. The AAO will forward your completed test results to the AOA. You must have a 70% accuracy in order to receive CME credits.

Answer sheet to June 2006

AAOJ CME quiz will appear in the March 2006 issue.

Mail this page with your quiz answers to:American Academy of Osteopathy®

3500 DePauw Blvd, Suite 1080Indianapolis, IN 46268

December 2005 AAOJ CME

quiz answers:1. D 2. D3. A4. A5. B

Dr. Crow’s Article:1. Atriggerpointwasfoundfortreatmentofasthmaat A. Theleftparietaleminence B. Therightparietaleminence C. ThelevelofT4left D. TheleftofT5right E. TheedgeoftheleftSCM

�. Peakflowmeters A. Arethegoldstandardforinpatientmeasurementsofasthma B. Assesstidalvolumeofthelungs C. Haveracebaseddifferentvalues D. Useheight,ageandsex E. Useonlyoneattempt

3. Thetreatmentofascalptriggerpointshowedimprovementinpeakflowvaluesinacuteasthma.

TrueorFalse

Dr. McCarty’s article:4. Inwhichofthefollowingpositionsisthepatientusuallytreated

withIntercostalRibReleaseTechniqueduringanacuteasth-maticattack?

A. LateralRecumbent B. Prone C. Seated D. Standing E. Supine

5. Theanterior/posteriorpressureusedduringtheIntercostalRibReleaseTechniqueisapplieddowntowhichtissuelevel?

A. Bone B. Fascia C. Muscle D. Skin E. Tendon

6. KucheraandKucherahavereportedthatforeach1cmofincreaseinchestexcursion,thevolumeofairexchangewillincreasebyhowmuch?

A. �5cc B. 75cc C. 100cc D. �00cc E. 600cc

Forum for Osteopathic Thought

Tradition Shapes the Future • Volume 16 Number 1 March 2006


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Diagnosis and Treatment of Low Back Pain

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Diagnosis and Treatmentof Low Back Pain

May 5-7, 2006Hilton Hotel, Durham, NC

Course Description: Level IILow back pain continues to be one of the most common

presentationstothephysicians’office.Thiscoursewillpresentparticipants with practical approaches to the evaluation andtreatmentoflowbackpain. Emphasiswillbeontheoveralltreatmentapproachutilizingvarious typesofOMTbasedonthe clinical scenario. Specific techniques will include highvelocitylowamplitude(HVLA),muscleenergy,counterstrainandmyofascialrelease.Additionaltreatmentapproacheswhichcanbeintegratedintotheoverallcareoflowbackpainwillbereviewed,however,demonstrationsandpracticewillbelimitedtoosteopathicmanipulativetechniques.

Learning Objectives:Participantsshouldbeableto:1)Understandthefunctional

anatomyofthelowbackregion;�)Correlatesomaticdysfunc-tion to the pathophysiology of low back pain; 3) Efficientlydiagnosesomaticdysfunctioninthelumbar,pelvisandsacralregionsandcorrelatewithclinicalpresentationsof lowbackpain;4)Selectandperformappropriate typesofOMTbasedondiagnosticfindings;5)Understandhow to integrateothertreatmentapproaches,suchasexerciseprescriptionandinjectiontechniques,intothecareofthepatientwithlowbackpain;and6)Documentfindingsandselectcodesforreimbursement.

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Prolotherapy: Above the Diaphragm

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May 19-21, 2006UNECOM, Biddeford, ME

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➝

BackgroundIn19�8,orthopedicsurgeonCrowe

was thefirst individual touse the termwhiplashtodescribeneckinjuryrelatedtomotorvehicleaccident.1Withgreaterrelianceonmotorized transportation inthe �1st century, the rate of whiplashrelatedinjuriesinWesterncountrieshasincreasedsignificantly.Newterminologyhasarisentodescribethecomplexityofinjuryrelatedtoboththeacuteandchronicphaseofwhiplash.Nowtermedcervicalwhiplashsyndrome(CWS)�orwhiplashassociateddisorder(WAD)3,itembodiesanarrayofmuscular,skeletal,neurologi-calandpsychosocialimpairments.

Treatmentoptionsandoutcomesforindividuals suffering fromWAD/CWShavebeenextensiveandvaryinsuccess.Modalitiesincludepharmacologicalman-agementofpain,acupuncture,physicaltherapy,chiropractic,hypnosis,surgery,osteopathic manipulative techniques(OMT)andtriggerpointinjections(TPI).Thetreatmentplanmustbeindividual-izedforeachpatientandshouldincludeamultidisciplinaryrehabilitativeapproachinordertoprovidepainmanagementandrestorationoffunction.

Wepresentthisreportaswefeelthatthispatientrepresentsamorecomplicat-edcaseofWAD/CWSsufferingchroniceffects from her injury. Furthermore,hercasedemonstratestreatmentfailurein theearlyprocessofmanagementbyother clinicians. Moreover, we believethat the combined modalities of OMTandTMIutilizedatourclinichavebeeninstrumentalinthehealingprocessofthispatient.

Multidisciplinary approach to treatment in a 38-year-old female, restrained driver following injuries sustained in a rear-end collisionJ.L Rook and A.M. Auburn

Patient ReportThisreportdescribesa38-year-old

Caucasianfemalewhowastherestraineddriverofavehicle,whichwhilemakingarightturn,wasstruckfrombehind.Thepatientdescribestheimpactassendingherforward,backwardandtotheright.Immediately following the accident,thepatientwasabletoexitthevehicle,ambulate without difficulty and onlyreported stiffness. She did not experi-ence any loss of consciousness (LOC)anddidnotrequireemergencymedicalservices. However, two days follow-ing the accident, the patient began toexperiencevertigo, neck and lowbackpain, headache in the occipital region,nauseawithdryheavesandsubsequentdifficultywithforwardbending.Atthistime,shesoughtmedicalattentionatalo-calemergencydepartment.Evaluationbytheemergencyroomphysicianrevealednoevidenceoffractureorlifethreaten-inginjuryandthepatientwasdischargedwith an anticholinergic and a non-ste-roidalanti-inflammatory(NSAID).Shesubsequentlysoughtinterventionintheform of physical therapy, chiropracticandcranial-sacralwithminimalimprove-mentinfunctionandnegligibledeclineofsymptomatology.

Approximately14monthsfollowingheraccident,thepatientpresentedtoourclinic forevaluation.Shecomplainsofoccipital-neckpain(6outof10qualityinstaticpositioning,increasingto8-9of10withmovement),mid-uppershoulderpain(4of10quality,increasingvariablyto9of10),right-sidedlumbrosacralpain(3of10quality, increasingvariably to5-6of10),vertigoassociatedwithfor-

ward and rotational head movements,intermittent diplopia, decreased abil-itytoperformactivitiesofdailyliving,increasing fatigue, and increasing dif-ficulties coping with her impairments.Past medical and surgical history areremarkablefortwopreviousstrabismuscorrections,twodilatationandcurettage(D&C)procedures,andacesareansec-tion.Familyhistoryisnon-contributoryand the patient reports no medical orfoodallergies.Atthetimeofevaluation,thepatient’smedicationusageincludesMotrin,Wellbutrin,Zyprexa,Tramadolandamultivitamin.

Onphysicalexam,thepatientisanobese femalewithaBMIof37.1 (71”and�66lbs),whoisinobviousdiscom-fort and mild distress. She is afebrile,normotensive and non-tachycardic.Gaitanalysiswaswith-innormallimits(WNL), Romberg was negative, deeptendonreflexes(DTR)were�+/4bilater-allyinbothupperandlowerextremitiesandthepatientdemonstrated4/5musclestrengthbilaterallyinbothherupperandlowerextremities.

Osteopathic examination revealedthe following findings: C1 R(R), C�FRS(L), C5 FRS(R), C6 FRS(L), in-creasedCRIapproximately15/minwithrestricted movement and increased tis-sue texture abnormalities (TTA) in theposteriorandlateralcranium;Roccipitalcompression,Ltorsion,Llateralstrain,SR(R)strainwithrestrictedmovementoftheLoccipital-mastoidandLsphenoidal-squamous pivot sutures;TTA at the Roccipital-cervical junctionextending totheRlevator,rhomboids,scalenes,ster-


nocleidomastoid (SCM) and trapezius,collectively; stacked ERS(L) ofT5-T8with concomitant L posterior rib dys-function;increasedtextureabnormalityoftheLerectorspinae;+RstandingandRseatedflexiontestswithtendernesstopalpation (TTP) at the R lumbrosacral(LS) junction,L1-L3NRrSl,L4FRSr,L5FRSrandaR/Lsacraltorsion.Fur-thermore,orthopedictestingdoneprevi-ouslyyieldedthefollowingresults:(-)RSpalding, (+)L Spalding, (-) bilateralseatedstraightlegraise(SLR),(-)Soto-Hall,(-)Ely’s,(+)RYeoman’s,and(+)RPatrickFABERE.

Othersignificantphysicalexamfind-ingsincludedneuromuscularimbalancesecondarytobilateralhipflexortestingwith notedTTA and decreased length(R>L),TTP (R>L) in the ileo-lumbarandsacro-iliacligamentsindicatingliga-mentus laxityandfinally thefollowingmyofascialtriggerpoints:Roccipital,Ruppertrapezius,Rlevator,Rscalene,RSCM,Rrhomboidandalongthecervicalandlumbarerectorspinae.

Basedonourphysicalexamfindingscoupled with the patient’s history, weconclude that the patient has multiplesomatic dysfunctions (SD) as noted inphysicalexam,myalgia/myositis,occipi-talandLSligamentuslaxity,cephalgiaand chronic pain syndrome secondarytoaboveandahistoryofvertigoassoci-atedwithnausea.ThedecisiontobeginaregimenofOMTprecededbyTPIwithafrequencyevery1-3weeksastoleratedwas initiated immediately. In addition,the patient was referred for physicaltherapy using neuromuscular balancetraining(�-3timesperweek).

As of the date of this report, thepatient has undergone six treatmentsutilizing a combination of OMT withandwithoutprecedingTPI:1)TPI/OMT;�)OMT;

3)TPI/OMT;4)TPI/OMT;5)TPI/OMT; and, 6) OMT. TPI is preparedinourclinicusingthefollowing: 4ccmarcaine,�ccprocaine,0.5ccwydase(hyaluronidase), 1 cc serapin and � cctraumeel. For treatment 5, an additionof Kenalog (0.5 cc) was added to thestandardmixture.

In response to each treatment ses-sion, the patient reported immediateimprovementsthatwerefurtherverifiedwith re-evaluation demonstrating im-

proved range of motion, restoration ofmusculoskeletal formandfunctionanddecreasedTTP.

AtthecompletionofsixtreatmentsusingtheacombinationofTPIandOMTthe patient admitted to decreased epi-sodesofvertigoandnausea,animprovedlevelofenergyandgreaterabilitytoac-complishADL’s.

DiscussionInthispaper,wedescribeafemale

patientwithwhiplashassociateddisordermanifestingasaprogressivechronicpainsyndrome(CPS).Patientswhohavede-velopedCWS/WADsymptomsthatarestill present beyond three months usu-allydonotfullyrecover.4Infact,somepatients,likeours,progresstowardspsy-chologicalsymptomatologythatimpairoverall physical and cognitive ability5

furthercomplicatingthehealingprocess.Thispatientrespondedwelltoamulti-disciplinarytreatmentstrategyutilizingcombinedTPI/OMT complemented byphysicaltherapythatincorporatedneu-romuscularre-education.

Simons et al have best describedtrigger points as hyperirritable spots,bothfocalanddiscrete thatare locatedwithin a taut band of skeletal muscle.6Trigger points may be either active,7causingpainatrestorlatent,8leadingtomovementrestrictionsandmuscleweak-ness.Inaddition,theycaninducereferredpain,tenderness,motordysfunctionandautonomicphenomena.6

The decision to use manual tech-niquesorTPIforthetreatmentoftriggerpointassociatedsymptomsismultifac-toral.9TPI is an effective technique toproviderapidrelieffromthesymptomsassociatedwithtriggerpoints,10especial-lythosethathaveamorelatentnature.9

Unfortunately,fewcontrolledstudiesex-istthatexaminetheeffectivenessofTPIforthereliefofchronicpain.Moreover,we areunawareof any studies or casereports that have reviewed the use ofTPIfollowedbyOMT.However,ithasbeendemonstratedthatstretchingofthemusclegroupfollowingTPIincreasesitsefficacy11andthisisfurtheraccomplishedbyengaging themusclesbetweenboththeirfullyshortenedandfullylengthenedpositions.9The premise of OMT is torelievesomaticdysfunctionbyengagingtheanatomicand/physiologicbarrierin

amusculoskeletalunittorestorebalanceoffunctionandform.1�,13

Buildingupontheconceptofmusclestretching and activity to increase theeffectiveness ofTPI is the use of neu-romuscular re-education inourpatient.Aspreviouslymentioned,latenttriggerpoints are associated with restrictionsin motion and muscle weakness.Thisensuing neuro-muscular imbalance iscomplicated by a complex series ofpathophysiologicmechanisms.14,15There-fore,havingthepatientperformaseriesof repetitive contractions that train theneuromuscular system to memorize aseriesofmotorpatterns,anengram,isthebasis of neuromuscular re-education.16

The result is restoration of the normalarthrokineticsofagonistandantagonistmusclegroupswithequivalentbalanceintheinputandoutputchannelsofunderly-ingneurologicalunits.

Thereisasignificantabsenceinthemedical literature that discusses viabletreatmentoptionsforindividualssuffer-ing from CPS.As the leading form ofdisabilityinadults17andwithcurrentfig-uressuggestingthatapproximately10%oftheU.Spopulationislivingwiththedisablingaffectsofoneormorechronicmusculoskeletal disorders,18 physiciansmustbeabletoprovidetherapeuticop-tionswhichallowtheirpatientstomain-tainqualityoflife.Westronglybelievethatthiscasereportillustratesthesuccessthatcanbeachievedinpatientoutcomebyprescribingamultidisciplinarytreat-mentapproachthatencompassesrestora-tionoffunction,eliminationofpainandre-educationofform.

References1. CompanaBA.Softtissuespineinjuries

andbackpain.InP.Rosen&R.Barken(Eds.),Emergency medicine concepts and clinical practice,4thed.St.Louis:Mosby.1998:878-905.

�. ChildsSG.Cervicalwhiplashsyndrome:hyperextension-hyperflexioninjury.Orthopedic Nursing.�004:�3:106-110.

3. SpitzerWO,SkovronML,SalmiLR,CassidyJD,ZeissE.Scientificmono-graphoftheQuebectaskforceonwhip-lash-associateddisorders:redefining“Whiplash”anditsmanagement.Spine.1995:�0:S1-S73.

4. BarnsleyL,LordS,BogdukN.Whip-lashinjury.Pain.1994:58:�83-307.

5. KessellsRPC,AlemanA,VerhagonWM,VanLuijtelaarELJM.Cognitive


functioningafterwhiplashinjury:ameta-analysis.J Int Neuropsych Soc. �000:6:�71-�78.

6. SimonsDG,TravellJG,SimonsLS.Travell and Simons myofascial pain and dysfunction: the trigger point manual,�nded.Baltimore.Williams&Wilkins.1999:5.

7. HanSC,HarrisonP.Myofascialpainsyndromeandtriggerpointmanage-ment.Reg Anesth.1997:��:89-101.

8. LingFW,SlocumbJC.Useoftrig-gerpointinjectionsinchronicpelvicpain.Obstet Gynecol Clin North Am.1993:�0:809-815.

9. SimonsDG,TravellJG,SimonsLS.Travell and Simons myofascial pain and dysfunction: the trigger point manual,�nded.Baltimore.Williams&Wilkins.1999:94-173.

10.AlvarezDJ,RockwellPG.Triggerpoints:diagnosisandmanagement.Am Fam Phys.�00�:653-660.

11.ZohnDA,MennellJM.Musculoskeletal pain: diagnosis and physical treatment.Boston.Brown.1976:1�6-1�9,190-193.

1�.FryetteHH.Principles of osteopathic technique.Carmel,CA.AmericanAcad-emyofOsteopathy.1954.

13.MitchellFL,MoranPS,PruzzoNA.An evaluation and treatment manual of osteopathic muscle energy procedures. ValleyPark.MitchellMoran&PruzzoAssociates.1979.

14.GreenmanPE. Principles of Manual Medicine,�nded.Baltimore.Williams&Wilkins.1996:449-5�4.

15.JandaV.Evaluationofmuscleimbal-ance.In:LiebensonC,etal.,(Eds.)

Rehabilitation of the spine.Baltimore.Williams&Wilkins.1996.

16.KergerS.Exerciseprinciples.In:KarageanesSJ(Ed.)Principles of manual sports medicine.Baltimore.Wil-liams&Wilkins.�005:65-76.

17.ColeTM,EdgertonVR.Musculoskel-etaldisorders.In:ColeTM,EdgertonVR,eds.Report of the Task Force on Medical Rehabilitation Research.June�8-�9,1990.HuntValleyInn,HuntVal-ley,MD.Bethesda.NationalInstitutesofHealth.1990:61-70.

18.ImamuraST,FischerAA,Imamura,TeixeiraMJ,TchiaYengLin,KaziyamaHS,etal.Painmanagementusingmyo-fascialapproachwhenothertreatmentfailed.Phys Med Rehab ClinNorth Am.1997:8:179-196.❒

Accepted for publication: Nov. 2005

Address correspondence to:

JamesL.Rook,OMS-IVWesternUniversityofHealthSciencesCollegeofOsteopathicMedicineofthe

Pacific309E.�ndSt.Pomona,CA91766E-Mail:[email protected]

and

AnnMarieAuburn-Dean,DO37005�ndSt.SEGrandRapids,MI4951�Fax:616/656-3701

Kaplan clInIc

arlIngton, VaseeKs omm physIcIan

Kaplan Clinic, an indepen-dent integrative-medicine prac-ticeinArlington,VAwithateach-ing affiliationwithGeorgetownUniversity School ofMedicine,isseekingaphysicianwithstrongosteopathic manipulation skillsto fill a permanent, full-timeposition. Candidates should beboardeligible/certifiedinfamilyorinternalmedicine.

Founded �0 years ago, theClinic is the oldest integrative-medicine practice in theWash-ington, DC area. The Clinicspecializes in treating patientswith chronic pain and illness.Our �1-person team of physi-cians,psychotherapists,physicaltherapists, nurses and supportstaffworktogethertoprovideawiderangeofconventionalandalternative treatments, includ-ing acupuncture, homeopathicandherbalremedies,nutritionalcounseling, psychotherapy, andmind-bodyclasses.

The Clinic is a 10-minutedrive from the nation’s capital;the metropolitan area is rich incultural, recreational, educa-tional, and social opportunities.Ifyouareinterestedinbuildingafamily-medicineandpain-man-agementpracticewhileenjoyingaguaranteedincome,productiv-ity bonus, and excellent benefitpackage (including liability in-surance, license fees and CMEallowance).

Please,emailyourCVto:JulieThompson,RN,

[email protected]:703/�37-3105

phone:703/53�-489�

Classified AdsmIchIgan

Medicalofficebuildingforsale.BetweenLakeErieandI-75.�0minutesfromhospitalsinMonroe,MIandToledo,OH.Floorareaspace1,�74sq.ft.3examrooms,office,�restrooms,library/kitchen,largewaitingroomandlargestorageroom.Pavedcarportandamplefrontparking.Naturalgas,citywaterandcitysewer.ContactIsabelleChapelloafter�:00pm.Phone734/848-5565.Buildinglocation:10643ValleywoodDrive,LunaPier,MI.

IndIanapolIs

WestviewHospitaliscurrentlyacceptingapplicationsforits�-yearNMM/OMMresidencyprograminIndianapolis,Indiana.Interestedcandidatesshouldcall317-9�0-7338forfurtherinformation.


The Science and Practice of Manual Therapy: Physiology, Neurology and Psychology E. Lederman, second ed.. Churchill Livingstone, 2005. Paperback, 336 pp., 186 illus, ISBN 0 443 07432 1. Price: $67.95

Oneofthemanychallengesfacingosteopathyandmanualtherapyingeneralisunderstand-ingtheprocessesandmechanismsthatoccurinourpatientsinresponsetotherapeuticmanualtechniques.Thisunderstandingincludesthebiophysical,cognitive,affective,spiritualandsocialdomains.Anappreciationofhowthesedomainsfunctionandinteractisessentialtoenabletheosteopathtodynamicallyassessapatientandidentifythemosteffective‘entrypoint’fortheirtreat-ment. TwelveyearsafterbeginningtowritethefirsteditionofFundamentals of Manual Therapy.ProfessorEvalLedermanagainrevisitsthequestionof“Whatishappeningunderthehandsofthemanualtherapist?”Inthisversion,Ledermanhaswrittenatextaimedatallmanualtherapists,andhasreworkedhisideasandtheoriesinlightofresearchthathasemergedintheinterim.Thisprovidesavitalbridgebetweentreatmenttechniqueandscience-increasinglynecessaryinthecur-rentclimate.Asbefore,thetextisorganisedintothreemainsectionswhichexploretheresponsestomanualinterventioninthetissue,neurologicalandalsopsychophysiologicaldimensions. Atatissuelevel,manualtechniquesareexaminedinthecontextofrepair,adaptationandfluidmovement.Theselectionofsuitablemanualtechniquesdependinguponthephaseofinjuryare

discussedtogetherwithcontra-indicationsandhowthetherapistmayeffectivelyfacilitatetheoptimumenvironmentfortissuerepairandadaptation.Thisextendsintoactivelyengagingthepatientintheirhealingbyencouragingthemtoapplytheseprinciplesintheirdailyactivities.Acentralconceptinthetissuedimensionisunderstandingthemeansbywhichcellsignalling(especiallycellsinvolvedinrepair)mayhemodulatedbymanualintervention.Theconceptofmechanotransductioniswellcontextualisedandexploredwithinamanualtherapycontext,andposesmanyinterestingfollowonquestionsforthereader. Ledermanproposesthatitisintheneurologicaldimensionthattheosteopathandpatientinterfacewithmanualtechniquesastheir‘sharedlanguage’.Healingand‘re-abilitation’aremodulatedcentrallyinthepatienttotheperiphery,andthisprocessmaybefacilitatedbythepractitioner.Fivekeyelementsareidentifiedasbeingtherapeuticallyimportant:patientcognition,activeinvolvementofpatient,effectivefeedback,repetitionandsimilaritytonormalisedmovements.Vitaltothisistheunderstandingthatthetreatmentprocessistherapeuticrelationshipguidedbythepractitionerandfullyengagingthepatientatalllevels(tissues,peripheralandcentralnervoussystem,emotions,thoughts,etc.)tohealthemselves.Ledermanemphasisesthattreatmentisnotsimplysomethingthatisdonetothepatient’stissuesfromtheirperiphery. Thefinalsectionexaminestheinvolvementofpsychologicalandpsychophysiologicalfactorsinmanualtherapy.TheeffectsofmanualinterventiongobeyondthelocaltissuesbeingtouchedandLedermanreviewswhole-personeffectsandprocessesencounteredduringinjury,therapeuticinterventionandrecovery.Alterationsinbodyimageandself-esteemareimportanthereandoftenhealinginthebiophysicaldomainsisimpededbythefailuretoaddresstheramificationsofinjuryinthecognitiveandaffectivedomains.Thewellknownlinkbetweenemotionandpostureisexaminedanddiscussedintermsofaninteractingsomatopsychic-psychosomaticse-quenceandhowtheseresponsesaredeveloped.Thepsychophysiologyunderlyingmanualtherapyisexploredandhowtheseprocessesaredeeplyenmeshedwiththelimbic,neuroendocrineandautonomicnervoussystemsarereviewedtherapeutictouchandtechniquesarediscussedinthecontextofre-orderingandre-integratingthebody-self. ThisisasuperbrevisionandexpansionuponFundamentals of Manual Therapy.Itiswellwrittenandorganisedwithnumerouscleardiagramsthatillustratethetext.IhaveusedFundamentals of Manual Therapyasacoretextbookintheteachingofundergraduatelevelosteopathystudents,andthisupdatededitionismostwelcomeasitfurtherdevelopsandupdatesthesameconceptsinafreshandaccessibleway. AlthoughLedermanhastakengreatefforttowriteatextthatallmanualtherapyprofessionswillfindrelevant,Iwouldsuggestthattheechoofunderlyingosteopathicprinciplesisevidentthroughoutthetext,andassuchthebookwillproveparticularlypopularamongstbothpracticingosteopathsandstudents.

---------------------------------------ReprintedwithpermissionfromElsevierpublishing;theInternationalJournalofOsteopathicMedicine,Volume8,NO.3.Sept�005.

Book ReviewReviewer: David J. H. Baskeyfeld


Liem, Torsten: Cranial Osteopathy, Principles and Practice. Second Edition, Published in English. ©2004, Elsevier Limited; Paperback, 728 pp. including glossary and Index, 514 illus. Price: $105.00.

TorstenLiem,DO is a registrant of theGeneralOsteopathicCouncil (GB). He serves asPrincipalofOsteopathie Schule Deutschland (Germany)aswellasanMScprograminPediatricOsteopathy.HeisamemberoftheResearchCommitteeoftheAkademie der Osteopathie (AFO).HispublicationsincludePraktisches Lehrbuch der Kraniosakralen Osteopathie, Praxis der Kra-niosakralen OsteopathieandOsteopathie-Die sanfte Lösung von Blockaden. HehasservedasCo-EditoroftheLietfaden Osteopathie andCo-FounderandformerChiefEditorofthejournalOsteopathische Medezin.

ThepresenttextisasubstantialreworkingofPraxis der Kraniosakralen Osteopathie. Havingmovedwellbeyondtheoriginalintentionofbriefrevision,theresultisamajorcontributiontotheconceptsandpracticeofOsteopathy in the Cranial Field. WithparticularattentiontotheoriginalthoughtofSutherland,whoseconceptwasinfluencedbyStill,thecontributionofMagounandmanyofthestudentsofSutherlandareappropriatelyrecognized.Forewordstothetextarepro-videdbyJean-PierreBarral,FredL.Mitchell,Jr.andRichardA.Feely.Eachoneacknowledgesthecomprehensivenessofthiseffort.

Thetextconsistsof�0chapters.AsindicatedbytheauthorinhisPreface to the second edition (�005):

“Theresultsofnewresearchandunderstandingoftheanatomicalstructuresandtheirphysiologicalsignificanceaswellasadditionaldiag-nosticandtherapeuticproceduresarepresented.Osteopathicapproachestothetemporomandibularjointareincreasinglybeingusedinplaceoforthopedictreatmentsofthejaw.Inthelightofthisitbecomesessentialfortheosteopathtopossessasoundbodyofknowledge.Allotherchaptershavealsobeenupdatedtoreflectthepresentstateofknowledge.”

TheIntroduction (pp.1-�8),isanexcellentpresentationoftopicssuchaspalpation,frequencyofprimaryrespiration,methodsofmanualdiagnosis,principlesandmethodsoftreatment,stagesoftreatmentandthefulcrum,treatmentofelectrodynamicfields,andassessmentofthecourseoftreatment.Theinformationpresentedissupportedby87referencesindicativeofthebroad,inter-nationalandmultidisciplinaryactivitycontributingtothestudyofthisformofpractice.

Inanygivenchapterthroughoutthetext,excellenceofillustrationandphotographycontributessignificantlytoeaseofunder-standingforusebythepractitioner.Morphology,clinicalassociations,diagnosticandtreatmentapproachesprovidetheframe-workforeachchapter.Itisthisclarityandconsistencyoforganizationwhichwillprovevaluablefortheteacherandthestudent.Substantialnumbersofreferencesareprovidedforeachchapter.

Chapter11,The mandible and temporomandibular joint canberegardedasthetour de force ofthetext.145pagesinlength,thischapterisamasterfulexpositionoftheosteopathicprofession’straditionalviewofthisjointanditsinvolvementinwholebodyresponsestoitsdysfunction.Asanexample,thesectionaddressingThe temporomandibular joint and body posture (pp.3�8-343)providesaframeworkforassessmentwhichcanbeutilizedinanyformofclinicalpractice.

TheGlossary representsanefforttocontributetoclarificationoftermshavingahistoryofcommunicationdifficulty.ThefocusisderivedfromthepublicationsofWGSutherland,REBeckerandthe1951editionofHIMagoun’sOsteopathy in the Cranial Field. Descriptiveterminologyisgivenpreferenceoverepistemologicalconsiderations.

Thistextprovidesacomprehensive,consistentlystructuredanddetailedcoverage(referenced)ofthematerialpresented. Thelinedrawingsandphotographsemployedabundantlythroughoutenhanceandmakemoreapproachabletheintricaciesofpalpation,diagnosisandtreatmentparticulartotheunderstandingandutilizationofOsteopathy in the Cranial Field.

Book ReviewReviewer: Anthony G. Chila


Urinary Tract Infection in Women LindaFrench,MD

ABSTRACTPURPOSE:Toreviewtheepidemiology,diagnosis,andtreatmentofurinarytractinfection(UTI)inwomen.EPIDEMIOLOGY:UTIisthemostcommonlydiagnosedbacterialinfectioninwomen.Uncomplicatedcystitisrarelyleads

tomajormorbidityormortality,buteconomiccostsandimpactonqualityoflifeareconsiderable.Populationsatincreasedriskofcomplicationsincludeolderwomen,pregnantwomen,andwomenwhohavediabetes,areimmunocompromised,orhaveanatomicorfunctionaldisordersoftheurinarytract.

REVIEWSUMMARY:ApresumptivediagnosisofuncomplicatedUTIcanbemadebasedonhistoryalone,orwithlimiteddiagnostictestingsuchasdipstickurinalysis.Cultureshouldbeobtainedifthepatienthasriskfactorsforcomplicateddisease,presumedtreatmentfailure,orfrequentrecurrences.A3-daycourseoftrimethoprim-sulfamethoxazolehasbeenrecommendedasthepreferredinitialtreatmentforuncomplicatedUTIaslongasresistancetothedrugremainssufficientlylow.Otheroptionsforfirstlinetreatmentincludeofloxacin,nitrofurantoinmacrocrystals,andcephalexin.Womenwithfrequentrecurrencesmayusecontinuousprophylaxis,postcoitalprophylaxis,orself-treatmentofrecurrentepisodes.Cranberryjuiceorpillsreducerecur-rences.Inpostmenopausalwomenintravaginalestrogencanreducerecurrences.

TYPEOFAVAILABLEEVIDENCE:Meta-analyses,controlledtrials,cohortstudies,case-controlstudies,andnationallyrecognizedandforeigntreatmentguidelines.

GRADEOFAVAILABLEEVIDENCE:Fairtogood.CONCLUSION:DiagnosisofUTIbasedonsuggestivehistoryaloneissafebutleadstoovertreatment.Inregardtotreat-

ment,thereisconcernaboutemergingantibioticresistance.Futureresearchshouldincludehead-to-headtrialsofinexpensivegenericantibioticsforthetreatmentofUTIs.

Reprintedwithpermissionfrom: Adv Stud Med.�006:6(l):�4-�9.

Differences in Initial Symptom Scores Between Myogenous TMD Patients with high and Low Temporomandibular Opening IndexVictorJ.Miller,BSc,BChD;VesnaV.Karic,DDS,MSc;SandraL.Myers,DDS

ABSTRACTThetemporomandibularopeningindex(TOI)isamoreusefulmeasureofmandibularmovementthanlinearmouthopening,

sinceitisindependentofage,gender,ramuslength,andgonialangle.Itisalsousefulwhencategorizingtemporomandibulardisorder(TMD)patientsintodiagnosticgroups.Twosubgroupsofmyogenouspatientshavebeenidentified,onewithahighandonewithalowtemporomandibularopeningindex.Thisstudyexaminedinitialsymptomseverityinthesetwosubgroups.Thirty-three(33)patientswithamyogenoustemporomandibulardisorderwererecruited.Twenty-six(�6)werefemaleandsevenmale.Elevenwerefoundtobeinthehightemporomandibularopeningindexgroupandtheremaining��inthelowgroup.Symp-tomseverityscoresweredeterminedpriortothestartoftreatment.Pain,jointsounds,headache,andneckpainwereallratedbypatientsonafour-pointverbalresponsescale.ThesesymptomscoreswerecomparedbetweenthetwosubgroupsusingtheWilcoxontwosampletest.Thereappearedtobeasignificantdifferencebetweenthetwogroups(p=0.00�5).TMDpatientswithhightemporomandibularopeningindexappearedtohavemoreseveresignsandsymptomsofTMDthanpatientswithalowindex.

Reprintedwithpermissionfrom:CRANIO: The Journal of Craniomandibular Practice.�006:�4(1):�5.

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Excerpts from the book’s ForewordFor those of us who have observed the development of the osteopathic medi-cal profession from the perspective of teachers, practitioners, and researchers of traditional osteopathic principles and practice, the name Myron C. Beal, DO, FAAO is well known and evokes feelings of respect and admiration. His osteopathic career has spanned the second half of the 20th Century and his contributions have served to propel the profession to the brink of 21st Century healthcare leadership. Ever the propo-nent of solid research design, Dr. Beal appreciated the fullness of osteopathic philosophy in action by emphasiz-ing palpatory skill in the osteopathic examination as an interaction between the patient and examiner. He appreci-ated the difference between sensing and perception, recognizing the mind body integration ever present in osteopathic philosophy and actualized in osteopathic education.

Hollis H. King, DO, PhD, FAAO, Editor

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