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Program Program CME CME AAmeriean Academy of Osteopathy 3500 DePauw Boulevard Suite 1080 The mission of the American Academy of Osteopathy is to teach, explore, Indianapolis, IN 46268-1136 advocate, and advance the study and application of the science and art of (317) 879-1881 total health care management, emphasizing osteopathic principles, FAX (317) 879-0563 palpatory diagnosis and osteopathic manipulative treatment.

1994-1995 From the Editor...... 4 BOARD OF TRUSTEES Raymond J. Hruby, DO, FAAO

President Message from the Executive Director ...... 6 Boyd R. Buser, DO Stephen J. Noone, CAE President Elect Michael L Kuchera, DO, FAAO Message from the President, "Facing the Challenges of Growing Up" ... 8 Immediate Past President Boyd R. Buser, DO Eileen L. DiGiovanna, DO, FAAO

Secretary-Treasurer AxopJasmic Transport ...... 9 Anthony G. Chila, DO, FAAO Gregory A. Dott, DO, FAAO Trustee Mark Cantieri, DO Continuum Technique ...... 15 Trustee Stephen Typaldos, DO John C. Glover, DO

Trustee From the Archives, "The Experimental Method of Learning" ...... 21 Ann L Habenicht, DO M. D. Young, DO Trustee Judith A. O'Connell, DO, FAAO Three-Dimensional Counterstrain Lifts (3-DCL) Trustee Theoretical Concept and Applications ...... 23 Karen M. Steele, DO, FAAO James A. Carlson, DO, J. Michael Carlson, DO and Daniel T. Earl, DO Trustee Melicien A. Tettambel, DO, FAAO To the Editor ...... 28 Executive Director Stephen J. Noone, CAE From the AOBSPOMM Files, "Severe Left Hip Pain" ...... 32 Sherri J. Tenpenny, DO Editorial Staff In Memoriam ...... 36 Editor-in-Chief Raymond J. Hruby, DO, FAAO Charles E. Still, Jr., DO Robert B. Thomas, DO SupervisingEditor Stephen1. Noone,CAE

Editorial Board Barbara 1. Briner, DO Classifieds ...... 38 Anthony G. Chila, DO, FAAO James Norton, PhD Frank H. Willard, PhD Calendar of Events ...... 39

Managing Editor Diana L. Finley Advertising Rates for the AAO Journal TboMOJo,..oal io tho officialquartcrlypublationoftho AmericonAcad­ An Official Publication of The American Academy of Osteopathy mny of~ (3500 Dol'uw Blvd., Suiu, 1080, lndianapaluo, mdi­ am.,46268-1136). Third-d-JlORISO paid al Cumcl, IN. PoatmulOr: Send The AOA and AOA affiliate organiuitions and members of the Academy adcheudJanso• to American Academy of O...opolhy 3.500 DoPsuw Blvd., are entitled to a 20% discount on advertising in this Journal. Suiu: 1080, hulianapolil, IN.,46268-1136

ThcMOJ°"'""' i,, not ibclCrcspaw'ble for llalmDcUII made by any con- 1n'butor. Altbou&h sll sd.crtising i,, expedmd to confmn toetlucal modical Call IWldarda, acceptance does oot imply ondonomem by tlul jounw. The American Academy of Osteopathy Opinion• •"l'..-d in Tho MO Jownal are thOIOor authors or 1pc,i1kl,n and. do not w,ceuarily reflect viewpointa of the cditon or official policy of (317) 879-1881 the American Academy of °"""J>athy or the imtitutions with which the for an Advertising Rate Card aulb.011 arc afliliak,d, unlo11 apcclfied.

Subscriptions: $25.00 per year

Summer 1995 AAO Joumal/3

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I'm I'm

From From by by Instructions for Authors

The American Academy of Osteopa­ Submission 2. Photos should be submitted as 5" x thy (AAO) Journal is intended as a forum Submit all papers to Raymond J. 7" glossy black and white prints with high for disseminating information on the sci­ Hruby, DO, FAAO, Editor-in-Chief, contrast. On the back of each, clearly in­ ence and art of osteopathic manipulative MSU-COM, Dept. of Biomechanics, A- dicate the top of the photo. Use a photo­ medicine. It is directed toward osteopathic 439 E. Fee Hall, East Lansing, MI 48824. copy to indicate the placement of arrows physicians, students, interns and residents and other markers on the photos. If color and particularly toward those physicians Editorial Review is necessary, submit clearly labeled 35 with a special interest in osteopathic ma­ Papers submitted to The AAO Jour­ mm slides with the tops marked on the nipulative treatment. nal may be submitted for review by the frames. All illustrations will be returned The AAO Journal welcomes contri­ Editorial Board. Notification of accep­ to the authors of published manuscripts. butions in the following categories: tance or rejection usually is given within three months after receipt of the paper; 3. Include a caption for each figure. Original Contributions publication follows as soon as possible Clinical or applied research, or basic thereafter, depending upon the backlog of Permissions science research related to clinical practice. papers. Some papers may be rejected be­ Obtain written permission from the cause of duplication of subject matter or publisher and author to use previously Case Reports the need to establish priorities on the use published illustrations and submit these Unusual clinical presentations, newly of limited space. letters with the manuscript. You also must recognized situations or rarely reported obtain written permission from patients features. Requirements to use their photos if there is a possibility for manuscript submission: that they might be identified. In the case Clinical Practice of children, permission must be obtained from a parent or guardian. Articles about practical applications Manuscript for general practitioners or specialists. 1. Type all text, references and tabular material using upper and lower case, References Special Communications double-spaced with one-inch margins. 1. References are required for all mate­ Items related to the art of practice, Number all pages consecutively. rial derived from the work of others. Cite such as poems, essays and stories. all references in numerical order in the 2. Submit original plus one copy. Please text If there are references used as gen­ Letters to the Editor retain one copy for your files. eral source material, but from which no specific information was taken, list them Comments on articles published in in alphabetical order following the num­ The AAO Journal or new information on 3. Check that all references, tables and bered journals. clinical topics. figures are cited in the text and in numeri­ cal order. 2. For journals, include the names of all Professional News authors, complete title of the article, name News of promotions, awards, ap­ 4. Include a cover letter that gives the author's full name and address, telephone of the journal, volume number, date and pointments and other similar professional inclusive page numbers. For books, in­ activities. number, institution from which work ini­ tiated and academic title or position. clude the name(s) of the editor(s), name and location of publisher and year of pub­ Book Reviews Computer Disks lication. Give page numbers for exact Reviews of publications related to quotations. osteopathic manipulative medicine and to We encourage and welcome com­ manipulative medicine in general. puter disks containing the material sub­ mitted in hard copy form. Though we Editorial Processing prefer Macintosh 3-1/2" disks, MS-DOS All accepted articles are subject to Note: Contributions are accepted from copy editing. Authors are responsible for members of the AOA, faculty members in formats using either 3-1/2" or 5-1/4" discs are equally acceptable. all statements, including changes made by osteopathic medical colleges, osteopathic the manuscript editor. No material may residents and interns and students of os­ Illustrations be reprinted from The AAO Journal with­ teopathic colleges. Contributions by oth­ out the written permission of the editor 1. Be sure that illustrations submitted ers are accepted on an individual basis. and the author(s). are clearly labeled.

Summer 1995 AAO Joumal/5 Message from the Executive Director by Stephen J. Noone, CAE

With the Academy's fiscal year This revenue distribution is an will not find significant dollars ending on July 31, AAO Treasurer excellent one according to the literature for debt reduction in recruitment Anthony Chila and I have been on not-for-profit organizations. The of new members. It will take 52 diligently engaged in the development norm is that associations must new members paying the full $175 of a proposed 1995-1996 budget for continually search for non-dues sources dues to increase revenues by one consideration by the AAO Board of of revenues. percent. Trustees at their July meeting. The budget development process includes Disbursements 2) There is potential additional input from all committee chairpersons revenue in the sale of AAO as they plan activities for the next 28% Staff payroll/benefits publications. For this reason, the fiscal year. 26% Educational programs Academy has stepped up its As Dr. Chila has reported frequently 14% Office operations marlceting efforts and expanded in the past, the Academy's leadership 9% Boards/Committees its overseas promotions. In established a strong policy of financial 9% Publications for sale addition to its annual yearbook management to move the organization 7% Outreach series, the Board also has away from recent deficit budgeting 5% Membership publications published one new text toward a goal for A balanced budget 2% UAAO (Functional Methods) and has by the 1997-1998 fiscal year. The another book currently under Academy is currently in its second The distribution of expenses negotiations. One caution is that year of living within this policy. The likewise is within the normal range for marketing and production still Board will face significant challenges not-for-profit associations. Since the require funding priorto generating sales. in the next three years as it fully Academy's mission is primarily an implements this goal without educational one, this accounts for the 3) Grants and donations are diminishing the services and programs significant allocations in educational another source of revenue. The for AAO members. programs and publications. Board reactivated the annual fund How does the Academy fund its - The Golden Ram Society - operations? I would like to share some Whataboutthefuture? AstheBoard which exceeded budgeted observations as reflected in the current of Trustees goes about the task of projections this year. The Board year's budget data: budget projections, they must face the also has challenged committee reality that the deficits must be reduced chairpersons to identify potential by 25 percent for each of the next three Revenues sources of grant funds to years in order to implement the goal of supplement the Academy's a balanced budget by 1997-1998. These 43% Educational programs operations. 25% Membership dues aresomeofthefactswhichtheTrustees must consider as they plan for the 16% Publications 4) The final source for increased future: 10% Grants/donations revenues are the Academy's 6% Interest and miscellaneous educational programs. Within this 1) While Academy membership category there are subsets of is steadily increasing, the Board revenue, i.e. tuition, program

6/AAO Journal Summer 1995 Coding Alerts! Please note this advisory and in­ form your staff members responsible for coding your professional services. The Health Care Financing Ad­ ministration (HCFA) has notified all Medicare intermediaries that it will NOT permit separate paymentforCPf code 97265 Goint mobilization) on the same day when CPT code 97250 (myofascial release) or CPI' codes grants to underwrite speakers and substantially increase revenues, 97260-97261 (manual manipulation) exhibitors for trade shows. why not just cut expenses? The have been reported for the same pa­ Tuition for the Academy's first place to cut could be staff. tient HCFA has deemed these ser­ vices as overlapping. Likewise, when educational programs is higher However, when I started my duties CPT codes 98925-98929 (osteopathic as CEO the Academy in April than courses sponsored by other of manipulative treatment) is billed to medical organizations. One reason 1992, there were six staff Medicare, Medicare carriers are di­ is that the cost of paying speakers members, the same number as rected to deny payment for 97265 and table trainers is borne currently employed. Since that Goint mobilization), 97250 (myofas­ primarily by tuition, not by grants time, the services to AAO cial release) and 972(,()-97261(manual from pharmaceutical companies members have increased manipulation). Osteopathic physicians and medical equipment substantially. Hence, cutting staff who fail to heed this advisory run the manufacturers as is the case with surely would result in a reduction risk, of a Medicare audit and may be most medical societies. Also, the in services to Academy members. penalized for fraudulent practice. Another substantial area of Academy's programs are CHAMPUS normally hands-on courses which expense is educational program­ July 15, 1995 is the expected date require table trainers to assist ming. However, if the Trustees for implementationof CHAMPUS' re­ participants, treatment tables for reduce the courses offered, they vised policy for payment of OMT in laboratory practice and more correspondingly cut out potential addition to E/M services. The Civilian square feet of meeting space to sources of revenue. Other expense Health and Medical Program of the accommodate the skill-building areas are likewise critical to the Uniformed Services had previously sessions. viability of the organization. notified the American Osteopathic As­ sociation that it had revised its Policy As the Academy has What is the answer to the dilemma? Manual to read as follows: A separate charge for an evalua­ ventured into holding an There will obviously be hard choices tion and management (E/M) (99201- exhibition at the annual for the Trustees in the next three years. 99205 or 99211-99215) may be al­ Convocation, industry supporters However, in my judgment, the lowed jointly with an osteopathic have not been beating down the Academy must aggressively work to manipulative treatment (0MT) door to attend. Pharmaceutical increase its revenues by ( 1) promoting (98925-98929)whentheOMTispro­ companies appropriate their increased attendance at its educational vided on the same day, if it can be marketing dollar more heavily for programs, (2) marketing its justified that the E/M is a significant, promotion ofrecently developed publications worldwide, (3) recruiting separately identifiable service. However, CHAMPUS has experi­ products, e.g. those for treatment more physicians as AAO members enced a delay in policy implementa­ of hypertension and infectious and (4) securing substantial donations tion. Prior to billing CHAMPUS for disease. Right or wrong, the from individuals and grantors to OMT and E/M services, AAO mem­ perception is that Academy supplement its operational expenses. bers are encouraged to contact their members are not an ideal target The AAO has·established itself as a CHAMPUS intermediary on July 15, market for the phannaceutical credible source of education in 1995 to confirm that this revised OMT industry. osteopathy and must now begin to policy has gone into effect. capitalize on that recognition as it seeks 5) If the Academy cannot to expand its sphere of influence.

Summer 1995 AAOJoumaV7 Message from the President by Boyd R. Buser, DO

Facing the Challenges of Growing Up

Editor's Note: The following is the ac­ within and outside our profession. Our 3. Our professional relation­ ceptance speech Dr. Buser gave dur­ growth in these areas has been suc­ ships with other healthcare pro­ ing the 1995 Convocation Presiden­ cessful in many ways, but not without viders must continue to evolve. tial Banquet this past March at the cost. I call this next phase of our ex­ Training and certification of MDs in OMM is an important step in this Opryland Hotel in Nashville, TN. istence, "Facing the Challenges of Growing Up". process. Clarification of our rela­ The challenges I see facing us, and tionship with DOs in other coun­ tries is also essential. These steps Once upon a I intend to address during my term as will help us develop educational time, there your president are as follows: policies relating to other allied was a group health professions. The world of 1. We must improve our abil­ of physicians manipulative treatment is ever­ ity to serve our members. Recog­ called the growing, and it is the Academy's American nition and appropriate reimburse­ responsibility to participate as lead­ Academy of ment for osteopathic manipulative ers in this process. Osteopathy. procedures is essential for our sur­ Nice people, vival. Therefore, we must continue All of these strategies must be ac­ they enjoyed to educate and assist our members complished in a fiscally responsible getting to­ in appropriate coding and documen­ manner. This is essential to our sur­ gether every year, like a family re­ tation procedures. We must become vival as an organization. The union. Gradually, they began to pay more active in research and partici­ Academy's leadership and staff are somewhat less attention to activities pate in the development of clinical committed to you, the membership. outside of their group, preferring their practice guidelines. You are the Academy. As the Acad­ own excellent company and camara­ emy serves you, so must you serve the derie. 2. We must continue to estab­ Academy. We depend upon you. Our Then, just a few years ago, some lish our leadership within the os­ momentum is great, but the future is stirrings began and suddenly the group teopathic profession. To accom­ far from certain. and the osteopathic medical students plish this we must continue to ex­ It is with great anticipation and en­ associated with them was impressive. pand our educational offerings. Our thusiasm thatlentermyterm asAAO It marked a turning point in the expertise and advice is sought by President. Despite the growth and Academy's existence. A new genera­ the AOA leadership, and we must change that has occurred, this is still tion of leaders became active. The continue to support them in their one great family, filled with love and Academy abandoned its inward-look­ drive to reestablish the distinctive­ support. You are my best friends, and ing existence. Our goals became lead­ ness of our profession. it is pure enjoyment working with you. ership in education and activism I can't wait! Thank you.

Please. .. to keep your mail coming and our records straight, be sure to let us know if you have a new name, home, office, FAX or telephone number! The American Academy of Osteopathy • 3500 DePauw Blvd., Suite 1080 • Indianapolis, IN 46268-1136 • Phone: (317) 879-1881 or FAX: (317) 879-0563 •

8/AAO Journal Summer 1995 Axoplasmic Transport Current mechanisms and their clinical implication regarding the use of Osteopathic Manipulative Medicine

by Gregory A. Dott, DO, FAAO

Editor's Note: Gregory A. Dott, DO, the dense cytomatrix. Alteration in the Still felt that the nerves took F AAO is a 1984 graduate of the Texas protein transport affects the end organ, elements or "chemical compounds" College of Osteopathic Medicine. He producing or enhancing pathologies out of the blood at the nerve's cell is certified both in family practice and such as diabetic neuropathy, Vitamin body, converted them for special osteopathic manipulative medicine. E deficient neurologic deficits and purposes and transportedthem along Dr. Dott is currently an assistant pro­ acetylcholine reduction of fast protein the axons to the end organs. fessor in the Department of Manipu­ transmission. Peripheral nerve injury Osteopathic belief holds that all parts lative Medicine at University of North can trigger central sprouting of of the human body require these Texas Health Science Center at Fort myelinated afferents. chemical compounds for survival and Worth/ Texas College of Osteopathic that they be supplied or manufactured Medicine. He became a fellow of the for local needs. Any changes which American Academy of Osteopathy at would disturb the delicate balance of the 1994 Convocation in Colorado "Microtubules the body's processes will result in the Springs. CO. within the axon detrimental function of the end organ and the body as a whole. The Scott first suggested in 1906 a play a central part osteopathic physician, therefore, is hypothesis that synaptic transmission trained to find such imbalances and I is dependent upon anterograde axonal in rapid transport, correct them. transportofmaterialfrom thecellbody. If " chemical compounds " are In the 1960s, Korr demonstrated the both antegrade and necessary for survival, then "we must ,, transfer of tagged proteins from the retrograd e . . . reason thatto withhold the supply from floor of the fourth ventricle to the a limb, to wither away would be I skeletal muscles of the tongue. With natural." Therefore, local supply of his work in the 70s he correlated his InA. T. Still'sbook, The Philosophy nutrients and removal of waste must models on the "lesioned segment" with of Osteopathy, he eluded to five be properly maintained and a balance their altered axonal transport or components of nerve function and of nerve and vessel is required for neuroproteins and the resulting effect delineated these in the categories of proper function of the end organ. In the on the end organ's function. sensation, motion, nutrition, voluntary prevention of disease, one requires Knowledge about the components of and involuntary actions. Of these, Still "unlimited freedom of the circulatory the axonal transport has increased considered the nerves of nutrition system of nerves, blood and cerebral 1 "d ,.I considerably during the past two essential to the health of the end organ. fl Ul . decades. The mechanism of transport, In this paper we will concentrate on Scott, in 1906, was suggesting the a long-standing mystery, is beginning the role of the axon in the delivery of importance of the passage of material to unfold. Microtubules within the axon neuroproteins and other "nourishing" from the cell body down the axon for play a central part in rapid transport, elements to the intercellularjunctions. the maintenance of stimulation- 3 both antegrade and retrograde, when For a more complete discussion on the induced synaptic transmission. He coupled with "motor proteins" (kinesin transferofthe "nourishing" substances actually fonnulated thoughts on both and dynein) and ATP or GTP. Slow across the intercellularjunctions as the axonal transport and chemical transport may be the result of dynamin final link in the nutritional support of neurotransmission. In 1910, Still noted, protein bridges attached to nerves to the end organ, please see "I think the law of the freedom of the 2 neurofilaments which "crawl" within Korr. nutrient nervous system is equal, ifnot ➔ Summer 1995 AAO Journal/9 superior in importance, to the law of exceptionally slow. Transport time of The faster component of the slow 4 the free circulation of the blood." He the same proteins in different axons axoplasmic flow is approximately also reasoned that we should cautiously appears to v~ with the axon's function twice as fast as the slower component's look at the atoms of the end organs, as and makeup. 0.2-2.5 mm per day. The faster their nature can be derived from the component protein composition is nervous system. Therefore, "we see Fast Anterograde Transport more complex and includes neomiosin that the two systems, nerve and blood Studies which observe the transport or miosin-like protein clathrin. Oathrin supply, must be kept fully nonnal or profiles of various labeled proteins fonnsahighlyorderedpolyhedralcoat we will fail to cure our patients. Let us along the nerve axon show that fast around vesicles and plays a critical remember that no atom of flesh in the (400 mm/day) anterograde transport role in the recycling of synaptic vesicle body is out of connection with the depends critically upon oxidative membranes. Calmodulin, a Ca2+ - three nerves, motor, nutrition and metabolism. The labeled proteins do bindingproteininthepresenceofCa2+, sensory, and that we should know that not appear to be affected by protein binds reversibly to many enzymes and all muscles and otherparts of the body synthesis. Also, they are independent other proteins thereby regulating their are fonned by and act through this function. Therefore, the enzymes of 4 of the cell body, as transport even nerve energy." occurs in nerves which have been intermediate metabolism that are In 1967, Korr initially suggested severed from the cell body located fonned on free ribosomes also move transynaptic transfer of radiolabeled within the ganglion. The fast in this faster form of slow axoplasmic proteins at the neuromuscular flow. 2 components utilize microtubules in the junction. Many researchers in the late neurons' cytoskeleton which provide 60s and early 70s actively pursued the an essentially stationary track for Fast Retrograde Transport mechanism of transport within the axon specific organelles to move within. Fast transport also occurs in a by placing radiolabeled material in the Alkaloids which disrupt microtubules retrograde direction from the cells' cell body to lateridentify in the nerve's and block mitosis, such as Colchicine nerve endings toward the cell body. In end organ. Prior to this time most and Vinblastine, also interfere with this manner, materials from the research was concentrated on the fast transport mechanisms. ATPases tenninals can be returned to the cell electrical conduction of nerves. such as Kinesin are believed to be body for either restoration and reuse or However, by the end of the 1970s, motor molecules for this anterograde degradation. The materials are microtubules and neurofilaments had movement and act as cross bridges (or transported via organelles that are part been identified as the cytoskeleton as feet) to help move the organelles of the lysosomal system. The • 6 within the axon and responsible in along the m1crotubules. retrograde transport is approximately some manner for the active transport 1/2 to 2/3 the speed of the anterograde of elements from the cell body to the Slow Axonal Transport transport. Retrograde transport also synaptic end plate. To date most As subcellular organelles move moves along microtubules. It appears researchers are busy fine tuning those down the axon via fast transport, the that dynein is the motor molecule for general models and observing what cytoskeletal elements and soluble retrograde transport as kinesin is the chemicals, disease processes or proteins transport via slow axoplasmic motor molecule for the anterograde physical entities might affect the 6 flow. Slow axonal transport is a transport. Through the study of potential or rate of axoplasmic complex mechanism having at least developmental neurobiology, it has transport. The trophic nature of nerves, two different components of become apparent that retrograde being to provide a nutritional basis application. A slower component transport informs the cell body about essential for the health of the end travels at a rate of0.2-2.5 mm per day events that are occurring in the distant organs, is no longer in question. and carries fibrillar protein elements ends of the axonal processes. Nerve of the cytoskeleton. These elements growth factor (NGF) is found in Mechanism of Transport contribute to the neurofilaments and to peripheral nerves. NGF, a peptide Axoplasmic flow has demonstrated the subunits of alpha and beta tubulin synthesized by the target cells, 6 several kinetic components ranging of the microtubule. The neurofila­ stimulates the growth of certain from a fast rate of 400 mm/day to a ments and microtubules are believed neurons and is utilized in regeneration slow rate of 0.2 mm/day. There do not to move in polymerized fonn as a of damaged axons. It is also well noted appear to be any stationary network and chemicals which clinically that various viruses and components, although there is a small depolymerize these proteins upset this toxins can be transported via cytosis minority that appear to be moving transport process. and retrograde method. 10/AAO Journal Summer 1995 Altered Axonal However, this decreased volume will easily and to a greater extent than the still have an altered function on the motor fibers. In experimental diabetic 3 Plasmic Transport end organ. Stretching produces a neuropathy, gangliosides facilitate The neurotransmitter acetylcholine beading-like appearance in which there structural and functional regeneration, (ACh) suppresses axoplasmic transport are corresponding areas of increased hence producing a preventive and reversibly in both antegrade and and decreased neurofilament levels. recovery stage. Gangliosides retrograde directions. Suppression This, too, demonstrates an altered accomplish this by restoring normal occurs through the activation of transport mechanism. Ligatures Na+, K+-ATPase transport, which muscarinic ACh receptors. The demonstrated some of the earliest stimulates an increased rate of axonal receptors inhibit adenylate cyclase, examples of altered function. It was maturation and reestablishes activate phospholipase and control the noted that axonal swelling would occur functionally and mo~hol_ogic~\\Y 1 ionic channels. Mediation of the proximal to the ligature while the distal normal neuromuscular Junctions. muscarinic ACh receptors occurs end of the axon would become Alcohol appears to have only a through islet-activating protein ~IAP)­ attenuated. A small degree of bulging transitory negative affect on fast axonal sensitive OTP-binding protein. occurs near the ligature on the distal organelle transport. After five months ATP is the primary source of energy end, which is attributed to the of exposure to alcohol there does not for fast axoplasmic transport and in retrograde transport mechanism. With appear to be any permanent impairment asphyxiation we see a rapid block of • 8 removal of the ligature redistribution of fast transport. The sensory endings this fast transport mechamsm. of axoplasm occurs and normal on muscle spindles did, however, show Neurotoxins usually adversely affect function usually returns. This, transitory increases in the organelle axoplasmic transport by decreasing however, depends on the degree of density. Retrograde transport speed glucose and producing a decrease in compression and its duration. appears to increase by 11 percent to 17 the amount of ATP available for the End organs constantly produce a percent and may be a partial active transport. In peridesheathed stream of NGF across the synaptic compensatory mechanism to help neurons, neurotoxins can increase or membrane which is transported restore normal terminal organelle • 16 decrease calcium ion content adversely retrograde along the axon. It appears density. affecting transport. Batrachotoxin that when this stimulus stops, the cell An accumulation of neurofibrillary (BTX) has been shown to hold open body becomes "aware" of the presence tangles (NFf) is associated withmajor sodium ion channels and affect the of an obstruction or axonal damage. decreases in the number of axonal sodium pump mechanism, thereby Schwann cells, when no longer under microtubules seen in Alzheimer blocking transport. Local anesthetics the influence of exogenous NGF, patients. A rise in NFT is also seen in at high concentrations will df fuse into produce their own NGF and assist in Down's Syndrome, post head trauma the axon and stop transport. the healing process. NGF helps (boxers dementia) and infectious In environments where the stimulate axonal cones in the conditions (post encephalitis - temperature is reduced, the fast developing embryo. Macrophages that Parkinson). This loss of microtubules axoplasmic transport rate is 10 respond to the site of injury to clean up producessignificantdysfunctionofthe decreased. In addition, it has been debris release Interleukin 1, a protein fast anterograde axoplasmic transport. shown that the concentration of which stimulates rapid and transient As a consequence of decreased magnesium ion, NGF, level of A TPase synthesisofNGFintheSchwanncells. microtubules, there is a disruption of and cAMP all help regulate axoplasmic In ligation and crush injuries, the retrograde axonal transport producing flow. presence of Scbwann cells to maintain an accumulation of degraded vesicular Mechanical effects such as ligature, m yelinated tracks, as well as to produce organelle, including mitochondria, stretching, compression and crush NGF, is essential to potential healing lysosomes and multivesicular bodies, 6 injuries all play a part in the rate of of the damaged nerve cell's axon. in the nerve ending. This contributes potential reversibility of abnonnal to the poor health of the end organ and 3.11.12 d" . h transport. In con 1t1ons w ere a the decreased effectiveness of Clinical Correlation 17 change in the axonal caliber occurs, an communication along the neive. alteration in the delivery of Abnormalities in axonal transport of proteins are thought to play an Acute and chronic compression of neurofilaments used in slow axon peripheral nerves may result in transport is noted. With the decreased important role in the pathogeneses of diabetic neuropathy. The peripheral disorders of sensory and motor neurofilaments a decreased volume function. Compression of a peripheral transport becomes apparent while the nerves involved in axonal transport of 13 rate appears to be largely unaffected. the sensory fibers are affected more ➔

Summer 1995 AAO Journal/11 nerve may impair intraneural uninjured nerve, when insulted a Summary microcirculation as well as produce second time. However, with change in Much has been added to our structural damage to myelin and the tubulin transport it appears that the knowledge of the mechanics involved axons. The rapid anterograde axonal nerve trunk becomes more susceptible in axoplasmic transport. The effects of transport may be reversibly blocked to a second (follow up) compressive various disease states on the rate of by as little pressure as 30 mm Hg, trauma. This increased susceptibility axoplasmic flow and nutrient volume when applied over two hours. may be the basis of the double crush to the end organ is being studied. The Microscopic observations demon­ syndrome. Patients with diabetic clinical application of therapeutic strated significant impairment of neuropathy appeared to be more approaches and preventive measures intraneural blood flow, at pressures susceptible, possibly due to the already in some neuropathies may soon be between 30-50 mm Hg. Compression present irritability and decreased available. Resurgence of research on at pressures between 200-400 mm Hg function of the axonal transport the mechanical effects seen in nerve produced complete ischemia and mechanism. deformation or compression on altered severe nerve fiber deformation. Neurotrophic viruses and toxins axoplasmic transport further support Endoneural edema is also observed may ascend via fast retrograde transport the principles and practice of following higher pressure applicatipns. from peripheral nerve terminal to cell osteopathy. As Korr stated, "any factor As expected, recovery time from fast bodies, thus not all materials 6 which for a protracted time alters the anterograde axonal transport block transported are beneficial. The polio metabolism and protein synthesis of varied depending on the degree and virus, herpes simplex, rabies, and the neuron or which impedes axonal . d 3 length of compression apphe . tetanus toxin have all been transport could block the neural 18 , 6,12 Dahlin describes the biochemical demonstrated to act in this manner. influence on the innervated structures changes and the effects on morphology There are some studies which have or cause it to become adverse and which occur in the neuron following demonstrated the retrograde transport detrimental, thereby contributing to compression injuries. The altered of lead, cadmium and mercury, with disease. Among the most probable axonal transport tubulin associated evidence of mercury found in the of 19,20 factors are the compressive forces and with nerve injury follows a slower brainstem of motoneurons. 21 mechanical stresses occurring in the time course while not proceeding Sucher evaluated the benefits of myofascial tissues and the channels ,,22 morphological changes. This is a Osteopathic Manipulative Treatment through which the nerves pass. In complete but reversible inhibition of (OMT) on carpal tunnel syndrome addition, the altered chemical axonal transport and is dependent on patients. An initial electrical nerve environment in these tissues with the the duration of inhibition and the conduction study was used to susceptibility of nonmyelinated nerve amount of pressure applied. In Dahlin' s demonstrate the presence of fibers could produce an even more nerve studies, compression with 50 conduction abnormalities in dramatic effects on altering axoplasmic mm Hg for two hours inhibits fast symptomatic patients who had failed transport. 18 transport for up to 24 hours. He noted conservative treatment. An osteopathic Dahlin demonstrated the effects that carpal tunnel patients may have structural exam of the wrist and related of relative low pressure compression pressure exceeding 100 mm Hg on the areas was performed. The patients were to nerve axons in the carpal tunnel. He median nerve. The ulnar and/or radial then started on treatment utilizing found that in the carpal tunnel the nerve frequently has pressure greater osteopathic myofascial release forces necessary to impair nerve than 200 mm Hg applied to them in manipulation and self stretching function could easily be produced 21 common physiologic entrapment techniques. Following symptomatic within the body. Sucher demonstrated conditions. Other studies with improvement the patients were in carpal tunnel syndrome the colchicine have noted similar reevaluated via electrical nerve beneficial effects of osteopathic temporary inhibitions of axonal conduction and MRI studies. In all of myofascial release manipulation and transport producing similar the cases presented electrical nerve simple home stretches. He documented morphological and biochemical conduction studies documented his findings with MRI and electrical changes in the neuron. electrical improvement corn;istent with 18 nerve conduction studies. Dahlin noted that neurons which clinical recovery. The cases further Scientists experimentally observes had W1dergone previous compression demonstrated improved antero­ one phenomenon at a time. This is to appeared to be more sensitive and posterior and transverse dimensions prevent more than one variable from demonstrated increased regenerative of the carpal canal. occurring and confusing the results of capacity, compared to the previously the experiment. In the human body, a

12/AAO Journal Summer 1995 multitude of factors may be in place axons. J Cell Biol, 117 (3) :607-16. 1992 nerve. Diabetes 1989 VOi 38 (Supp. 2) simultaneously. Exaggerated sympa­ May. 132A. thetic response initiated by a facilitated spinal segment causes a decreased 6. Kandel ER: Principles of Neuro­ 15. Figlioment B, Bacci B, Panozzo C, arteriole blood supply to an area and Science, 3rd Ed., New York: Elsevier Fogarolo F, Triban C, Fiori MG: subsequently alters the venous and Science Publishg, 1991:49-65, 258-269. Experimental diabetic neuropathy. Effect 23 of ganglioside treatment on axonal lymphatic drainage . This would transport of cytoskeletal proteins. Diabetes predictably produce multiple 7. Takenaka T, Kawakami T, Hikawa N, 1992Jul:41 (7) :866-71. interrelated changes such as a decrease Bandou Y, Gotoh H: Effect of in oxygen and glucose levels along neurotransmitters on axoplasmic transport acetylcholine effect on superior cervical 16. McLaneJA,AtkinsonMB,McNulty with altered ionic balance. These ganglion cells. Brain Res, 588(2) :212-6. J, Breuer AC: Direct measurement of fast conditions, when at appropriate levels, 1992 Aug 21. axonal organelle transport in chronic have already been identified as causes ethanol-fed rats. Alcohol Clin Exp Res. 16 for altered rates of axoplasmic 8. Ochs S, Hollingsworth D: Dependence (1) :30-7. Feb 1992. transport. Mild compressive forces of fast axoplasmic transport in nerve on from tissue edema, metabolic waste oxidative metabolism. Journal of 17. Brion JP: The pathology of the buildup, or myofascial tissue strain Neurochemistry, Pergamon Press 18: 107- neuronal cytoskeleton in Alzheimer's may accelerate changes in axoplasmic 114, 1970. disease. Biochim BiophysActa 1992Nov transport. It would be important to 10; 1160 (1) : 134-42. investigate the effects of altered 9. Ochs, S: The action of neurotoxins in axoplasmic transport on the functions relation to axoplasmic transport. Neuro 18. Dahlin LB, Archer DR, McLean and influences of sympathetic efferent Toxicology 8, 1987 (1) :155-166. WG: Axonal transport and morphological neurons. Further research documenting changes following nerve compression. An these hypotheses is needed . 10. Ochs S, Smith C: Effect of experimental study in the rabbit vagus temperature and rate of stimulation on fast nerve. J. Hand Surg [Br] 1993 Feb:18 (1) Acknowledgment axoplasmic transport in mammalian nerve :106-10. The author wishes to express his fibers. Dept. of Physiology, University of appreciation to thefollowingfor their Indiana Medical Center, Indianapolis, IN, 19. Arvidson B: Inorganic mercury in editorial contribution: Irvin M. Korr, Physiology, Federation Proceedings, transported from muscular nerve tenninals PhD and Claire McKay, DO. 30:2627, 1971. to spinal and brainstem motoneurons. Muscle & Nerve 15: 1089-1094 Oct. 1992. 11. Korr I: Neurochemical and neurotrophic consequences of nerve 20. Arvidson B: Retrograde axonal Bibliography deformation: Clinical implications in transport of metals. J Trace Elem Exp 1. Still, AT: Philosophy of Osteopathy. relation to spinal manipulation. JAOA 1989;2:343-347. Kirksville, MO: A. T. Still Publishing, 1975 75 (12) :409-14. 1899:40-1, 44. 21. Sucher B: Myofascial manipulative 12. Ochs S: Retrograde transport; Slow release of carpal tunnel syndrome: 2. Korr, I: The Collected Papers of Irvin transport models. Axoplasmic transport Documentation with magnetic resonance M . Korr . American Academy of and its relation to other nerve functions. imaging. JAOA 1993; 93 (12) :1273-8. Osteopathy, 1979; 91-118. John Wiley & Sons, 1982:51, 67,243. 22. Korr I: Andrew Taylor Still 3. Weiss, DG and Gorio, A: Axoplasmic 13. Hoffman PN, Thompson GW, memorial lecture: Research and practice­ Transport in Physiology and Pathology. Griffin JW, Price DI: Changes in acentury later(l974),The Collected Papers New York: Springer-Verlagl Publishing, neurofilament transport coincide of Irvin M. Korr. American Academy of 1982:16. temporally with alterations in the caliber Osteopathy. 1979; 190-95. of axons in regenerating motor fibers. 4. Still AT: Osteopathy Research and Journal of Cell Biology 101:1332-40, Oct 23. Korr I: Clinical significance of the Practice. 2nd Ed., Seattle, WA: Eastland 1985. facilitated state (1955), The Collected Press, 1992: 187-8. Papers of Irvin M. Korr. American 14. Bianchi T, Mennini P, Marini MG, Academy of Osteopathy. 1979; 152-157. 5. Lasek RJ, Paggi P, Katz MJ: Slow Fiori: Effect of Gangliosides on axonal axonal transport mechanisms move transport of Na♦•K•-ATPase in diabetic neurofilaments relentlessly in most optic Summer 1995 AAO Journal/13 Visceral Manipulation Course September 15-17, 1995 Indianapolis, Indiana

Program NeM.J COv<¥~ Advance Friday, September 15, 1995 11:00am Biliary System Practice 8:00am Registration Biliary system sequence Registration Deadline: 8:30am Introduction/ Announcements Liver/ Gallbladder induction August 15, 1995 8:45am Introduction to Course 12:00pm LUNCH What is visceral manipulation? 1:00pm Sphincter-like areas (SLA) SEMINAR FEE: Where does visceral manipulation come from? Meaning How does visceral manipulation fit Location Prior to August 15, 1995: into Osteopathy? Diagnosis AAOMember Purpose of the seminar Treatment $475 Intern/Resident $200 Basic Concepts: Different types of motion 1:30pm Practice treatment of SLA's AAO Non-Member $525 Basic Concepts: What are we doing? 2:15pm Duodenum 10:30am Small Group Discussion Anatomy & physiology 11 :OOarn Exercises Indications Sacral compliance Treatment techniques After August 15, 1995: Liver lift 2:45pm Small group discussion AAOMember $575 Intern/Resident 12:00pm LUNCH 3:00pm Duodenal practice $300 1:00pm Anatomy Duodenum via liver AAO Non-Member $625 Review of topography & general anatomy Direct treatment Attachments Induction / Conference Indications 4:15pm Jejunoileum Mobility and Motility testing Anatomy & physiology Registration Treatment techniques Indications 1:45pm Practice Mobility ad Motility testing Liver lifts revisited Treatment techniques Name for Badge (please print clearly) Liver via the ribs Use of upper extremities Sunday, September 17, 1995 Induction 8:00am Review and Questions Address 3:00pm Small group discussion 8:30am Jejunoileum Practice 3:30pm Stomach Loop-de-loop Anatomy Mobiliz.ation City State Zip Review of topography & general anatomy Root release Attachments Induction Indications 10:00am Cecum Daytime Phone Mobility and Motility testing Anatomy & Physiology Treatment techniques Indications Gastroesophageal junction Mobility and Motility testing AOANumber College/Yr Grad. Fundus Treatment techniques Pylorus 10:30am Cecum Practice Cecal attachments We Accept MasterCard and VISA Saturday, September 16, 1995 Ileocecal valve (circle one) Induction 8:00am Review and questions 11:30am Colon 8:30am Practice stomach diagnosis & treatment Anatomy Feeling stomach Card Number Indications Gastroesophageal junction techniques Techniques Expiration Date (direct & indirect) 12:15pm LUNCH Prolapse techniques 1:30pm Integration of the Viscera Signature General techniques intoOMT Induction 2:00pm Colon Practice 10:00am Biliary system Ascending colon Call for Reservations: Anatomy & physiology Flexures Holiday Inn Aiport Indications & cautions Sigmoid and mesocolon Treatment sequence Induction ( entire intestine) (317) 244-6861 10:30am Small Group Discussion 3:30pm Summary & Conclusion $79.00 14/AAO Journal Summer 1995 Continuum Technique by Stephen Typaldos, DO, Fort Worth, Texas The Manual Medical Center of Fort Worth

Introduction objective findings. Transition zones swelling. Continuum Technique is Continuum technique is a soft tissue are found between different tissue designed to reverse this process by manipulative approach used in the types and are a CONTINUUM from 'shifting' the continuum back into its treatment of acute and chronic one of the tissue types to another. It is original configuration. Once this musculoskeletal pain and dysfunction. thought that during an injury the occurs, there is normally a dramatic It is based on the premise that injuries percentages of certain tissue and instantaneous improvement in can occur in tissues, 'transition zones', components of each 'subzone' both range of motion and pain. and correction of the distortion caused become 'shifted'. This results in pain, Continuum Technique is particularly by the injury will result in an tenderness, tightness, decreased useful in the emergency room setting improvement in both subjective and motion of the affected area and in which ankle and knee sprains and cervical and lumbar strains are treated ona daily basis. Drawings ofproposed 'shifting' continuum of a ligament­ bone transition zone are shown in Figures 1 and 2.

Clinical Applications of Continuum Theory A common example of 'shifting' continuum can be seen in ankle sprains. Inthetransitionzone between Figure 1 ligament and bone are four subzones. During the injury itself, bony components from the zone oflamellar bone are 'pulled' into the mineralized fibrocartilage zone. At the same time mineralized fibrocartilage compon­ ents are 'pulled' into the unminer­ alized fibrocartilage zone, and unmineralized fibrocartilage compon­ ents are 'pulled' into the ligamentous zone. The net effect of this is that the entire transitional zone has become 'shifted' into the direction of the ligament This results in a ligament that is now not only stiffer than it was prior to the injury but is also functionally shorter. Continuum ➔ Figure 2

Summer 1995 AAO Journal/15 Technique utilizes pressure in the reevaluation should be done. Failure the button hole'. The resolution OPPOSITE direction, which forces to respond suggests either the process can also be described by the continuum to 'shift' back into the diagnosis was incorrect (i.e., a fracture patients as a 'release'. The 'release' direction of its pre-injury state. was missed) or the technique itself of the distorted continuum occurs over The amount of force used in was improperly applied. The most a period of one to five seconds with Continuum Technique to 'shift' the common reason for improper two being the average. Once the continuum back into its pre-injury technique is hesitancy of the physician 'release' is complete, that distortion state is equal to the force that caused to use adequate force. With experience is considered 'corrected•, and the other the injury in the first place. The this is easily overcome. distortions are treated if they are difference is that the direction of the The actual physical act of present. When all the distortions have force applied is OPPOSITE and is Continuum Technique involves been corrected the treatment is much more SPECIFIC in that it is applying firm pressure with the completed. Follow-up is advised in a applied only to the resultant distortion physician's thumb to the area of day or two to recheck for any residual rather than to the injured area as a distorted continuum. The distortion distortions. whole. Although the patient may itself is located by palpation of the Continuum distortions should not complain of the entire ankle hurting, distortion and by the amount of pain beconfusedwithothertypesoffascial this is not anatomically correct. Only induced by the palpatoryprocess. Finn distortions . They are not certain specific distortions have pressure is applied into the direction 'triggerbands' which have a occurred and once they are corrected completely different etiology and the patient may then be pain-free, treatment, and are the subject of the regardless of how much pain or accompanying paper Triggerband swelling he or she had upon entering "Continuum Technique. In addition, they are not the emergency department. 'triggerpoints' which are compared The treatment itself is normally Technique with continuum distortions in Introducing the Fascial Distortion painful. This is because the forces works that caused the injury were significant Model. The differentiation of and thus the treatment forces used to on an continuum distortions from these correct it also need to be significant. other fascia! distortions is clinically But the pain induced by the treatment all-or-none relevant because the treatment is temporary and once the distortion modality selected should be based is corrected the severe pain and principle. " upon the anatomical findings tenderness are gone despite how much encountered. Failure to appreciate this force is then applied to the injured point will greatly decrease the results area. In most ankle sprains there are of any modalities used. The normally two to five continuum of maximum pain. The patient may presentation of other distortions in distortions that need to be corrected. describe the pain as being intolerable, the same patient at the same time Other acute injuries may involve only or more graphically "like a hot poker". occurs rather commonly. Trigger­ one. Ifonly a portion of the distortions The physician will feel it to be bands often occur in acute ankle, knee, are corrected there will be only a something like 'a bubble of gel in a cervical and lumbar sprains. They partial improvement, and although small button•. If the patient expresses should be treated, if they are present. this may still obtain a superior result that the pain is "not that bad", then the In chronic pain, triggerbands should compared to standard treatments, it is direction and force ofintensity should be treated first before Continuum not the dramatic and complete result be changed until the pain is maximized Technique is utilized. This is because that is normally anticipated and hoped again. The pressure should be constant adhesions have formed which are for with Continuum Technique. and gradually increased until holding the injury in its' shifted state•. Continuum Technique works on 'resolution'. When this occurs both Once the triggerband is corrected then an all-or-none principle. Either the physician and patient are immediately the continuum distortion can be continuum distortion resolved or it aware of it. The patient experiences successfully treated. did not. There is no in-between. If an an immediate and dramatic reduction Continuum distortions commonly objective and dramatic result does in pain and tightness, and the physician occur at the origin or insertion of not occur, then a complete feels as if the 'button has slipped into ligaments or tendons with bone.

16/AAO Journal Summer 1995 Because of this they can be found in the neck, back, ribs, elbows, knees or other locations that have tendons or ligaments. The treatment of all of them is essentially the same- that is, to guide the injured area into the direction of pain and to correct the distortion. The illustrations in Figures 3-6 show some of the most common sites of continuum distortions that are seen in the emergency room patient. Treatment of ankle sprains are then discussed in the following section. These are perhaps the most rewarding to treat since they often respond so dramatically. But just as each patient \ / is different so is each injury, and modifications are necessary for optimal results. As with any treatment modality the diagnosis is paramount, and contradictions should be reviewed Figure 4 before usage (see Triggerband Technique paper). Almost all patients will accept a painful treatment if it is effective, which fortunately when using Continuum Technique occurs most of the time.

'·- _l,N: Figure 5

\ ' Treatment of the ~ '- \\' Acutely Sprained Ankle ~ ' \·' Sprained ankles are perhaps one of ' X ·\, ,_, .

,-:-' 1,11 the most common extremity injuries seen in the emergency room setting. i I, The usual treatment of these consists II of rest, ice, elevation, splinting and 1 anti-inflammatory and analgesic i ,, medications. This treatment regimen typically results in gradual subjective improvement and takes days or weeks until most patients are able to walk Figure 3 Figure 6 ➔ Summer 1995 AAO Joumal/17 ! /; / ",.----1"/I--/ \

Figure 7a limp-free. Some patients continue to to correct all of those fascial 2) X-ray the ankle to rule out fracture. have residual pain even months later. distortions. Treating only the ankle In the fascial distortion model the will result in failure. Normally several 3) Have the patient point to the 'spot' sprained ankle is viewed as consisting treatments are needed for the of most intense pain of alterations of the bone-ligament chronically sprained ankle, and after transition zone. Once the distortion is the third or fourth visit thrusting 4) Explain to the patient that you are corrected then optimally there should manipulation of the joint is advised. going to examine the injury more be normal range of motion and no Acutely sprained ankles rarely need carefully and that he or she can expect pain. Fortunately, in the emergency high velocity manipulation, and often a temporary increase in discomfort. room setting this dramatic result is respond poorly to this treatment typical. Any result that is not dramatic modality. 5) Gently rotate the ankle into the should make the physician suspicious position in which it was injured, of an underlying fracture. Typical Steps normally done by inverting the foot. In the chronically injured ankle, in the Treatment of the Palpate the area indicated by the adhesions have formed and patient and feel for the continuum Triggerband Technique must be Acutely Sprained Ankle distortion. Gently apply pressure and employed before using Continuum gradually increase the force until Technique. These patients normally 1) Physical examination- record resolution. Please refer to Figures 7a complain of the pain radiating from passive and active range of motion and 7b. the ankle into the knee, foot or hip. To and check for ligamental instability successfully treat them it is necessary and vascular compromise.

Figure 7b

18/AAO Journal Summer 1995 Figure Sa

6)Afterthefirstdistortioniscorrected the patient is standing correct the recheck the range of motion and have distortion in the same manner as the patient palpate the area just previously described. Repeat this step corrected. This will demonstrate to until the patient can stand with little him or her that improvement has or no pain. occurred. 9) Next have the patient walk and 7) Again gently guide the ankle into a identify whatmovementinduces pain. position that elicits pain. Ask the Then hold the ankle in that position patient to point to the most painful and correct the distortion. spot, and feel for the distortion. Figures Sa and Sb show the most 10) Once the range of motion has common anterior ankle distortions. been restored and the patient has had Correct it in the same manner, recheck either a dramatic reduction in pain or is pain free, he or she can then be the range of motion and ask once Figure Sb more where it hurts. Repeat the discharged from the emergency room. Ice is encouraged and splints and sequence until the patient reports on1y medication are considered to be a diffuse sensation of generalized optional. Follow-up with their own Key Words tenderness or no pain. doctor is advised in 24-48 hours.□ continuum distortion 8) Ask the patient to stand and point ankle sprain to where the ankle still hurts. While transition zone

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The Experimental Method of Learning by M. D. Young, DO Seattle, Washington

e have all heard of how fingers and your common sense, so Dr. Still carried around a he must have reasoned, would tell W sack of bones of the you how to fix it. It seems that we human skeleton and that he would ask learn to find it long before we learn someone to pick out a bone out of that how to fix it. Perhaps, this is because sack and then he, blindfolded, would the human organism is so complex. describe the bone and its function. Our researchers are still trying to Pemaps not one of us has ever studied unravel those complexities. and mastered anatomy as he did. In the early days of osteopathic He studied every bone and then teaching the technic was often crude every other tissue of the body in its function to be performed in a normal and laborious. As the laws have given relation to the whole body efficiency manner, and according to nature's us unrestricted practice rights, many and economy. He philosophized upon intention. in our profession have found it easier that relationship and the function of When a carpenter picks up a saw to wield a hypodermic needle or write each part as related to the whole. If we he visualizes that saw in the role of a prescription- more is the pity! For are to be efficient followers ofhis, we the function it is going to perform. the greatest service to humanity, can never forget or discard the Sure, he sees to it that it has been manipulative osteopathy must be philosophic part any more than we properly made and properly sharpened preserved; which can only come about can the scientific part It all adds up to in its structure, but it is the function by more specific and easily efficiency in the practical. properly performed that he is most demonstrated technic. From those who knew Dr. Still interested in. So with every tool in his Now there are two phases in the personally and were privileged to sit tool chest. So with everything we use development of osteopathy which at his feet for instruction, we are told in our daily activities. The structure is should have run parallel. They have that he never left any written record, there in the form it is in for the purpose not always done so, but the ideal or even a verbal record of any specific of performing a perfect function. attainment is that they should receive technic. His only instructions were, Function is what we are striving for. parallel attention and development. I "Find it and fix it", and then for good Therefore, function may be defined refer, first, to the development of the measure, he added, "let it alone". as "a structure in action at a given most efficient technic possible to Those who watched him saw him time". attain. This has consumed the carefully examine the patient until he As often stated, technic has always attention, study and skill of the best located the trouble and he deftly been difficult to describe in words. minds in our profession for three "Fixed it". Perhaps that is one reason Dr. Still quarters of a century; not to overlook He studied the structure of the part, never left us a description in words, those of us lesser skilled who have or parts, but his mind must have been and again perhaps, he realized that plugged along as best as we could. centered upon the normal function to every patient is different, so he tried The amazing thing about all this is we be attained. Each bone orothertissue, to give the student the concept that that have done as well as we have and or part, had its function and he must every case is a project for research. come as far as we have. have visualized that function. He First, find it. continued on page 34 thought of structure in terms of a After you have found it, your

Summer 1995 AAO Joumal/21 Letter to A. T. Still

Doctor Still, a number of items on this subject in drug is given. Otherwise, it becomes Osteopathic physicians today still the book A. T. Still in the Living, by a poison instead of a remedial agency have discussions, even debates, re­ Robert E. Truhlar, DO. For example, and that is a lifetime job for any man garding your thoughts on the use of you said: "Early in life I began to hate or woman." This statement seems to pharmaceutical agents. The question drugs." And again, "You do not need imply some room for the proper use always arises: What would be your drugs. The body has a hundred drugs of medications. feeling regarding the use of drugs if of it own of which the doctor knows And so the debate will go on, I'm you were here with us today? There nothing. But the body's drugs actu­ sure. Where does the use of drugs fit are those who feel that you always ally cure disease , where as the in with our osteopathic principles? As were against the use of drugs, and that doctor's drugs kill." The thoughts a first line treatment? After osteo­ you would continue to be opposed to would seem to indicate that you had pathic manipulative medicine is ap­ their use even today. There are oth­ no use for drugs. plied? Or together with manipulation, ers who say that, given the effective On the other hand, you also said. in some fashion? If so, how do we medications available to us today, you ''To be able to intelligently prescribe decide? If only we could always would not oppose the use of at least any and all drugs, one must first learn know exactly what to do in every some of these agents. the fundamental principles that gov­ clinical situation. Your writings on this subject pro­ ern their administration. Namely: vide many insights, but still somehow There must exist within the body the Your ongoing student, we cannot resolve the debate. I found physiological wrong for which the Raymond J. Hruby, DO, FAAO

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22/AAO Journal Summer 1995 Three-Dimensional Counterstrain Lifts (3-DCL) Theoretical Concept and Applications J by James A. Carlson, DO, FAOAS, J. Michael Carlson, DO and Daniel T. Earl, DO

James A. Carlson, DO, FAOAS is a method, the heel lift is placed under When using the forefoot lift, the graduate of the Kansas City College the determined short leg. This method anterior part of the foot is raised, of Osteopathic Medicine. He is a of lifting does not take into whereas the hindfootlift will raise the fellow of the American Osteopathic consideration, however, all the posterior foot (heel). College of Sports Medicine and is a articulo-fascial planes and the rotatory The anterior articulo-fascial planes fellow of the American College of components. Therefore, a method of (discussed later) begin at the dorsal Sclerotherapy. He is certified in lifting must be developed which part of the foot and run anteriorly, osteopathic manipulative medicine. accounts for all aniculo-fascial planes, continuing toward the cranium. The He is in private practice in non­ of which there are three: anterior, posterior articulo-fascial plane begins surgical orthopedics and sports anterio-medial and posterior and on the plantar surface of the foot and medicine in Knoxville, Tennessee. rotational components which make runs continually on the posterior part up normal biomechanics. of the body toward the cranium. The three-dimensional counter­ Combining the effects of the lifts J. Michael Carlson, DO is a graduate strain lifting technique (3-DCL) is a on the articulo-fascial planes, one of the West Virginia School of new concept in lifting. This technique produces a relief of stress ("slack") Osteopathic Medicine, and is a uses forefoot as well as hindfoot lifts on the anterior articulo-fascial planes resident in the family medicine to accomplish a homeostatic when using a forefoot lift. In a like residency program at East Tennessee equilibrium allowing the body to begin manner, reliefofstress on the posterior State University. He has panicular healing processes and achieving articulo-fascial plane is achieved by interest in osteopathic postgraduate nonnal biomechanics. These forefoot using the hindfoot lifts. education and sports medicine. and hindfoot lifts can be used alone or The goal of 3-DCL is to relieve the in combination depending on the stress (tension) on articulo-fascial Daniel T. Earl, DO is a graduate of patient needs. When applied properly, planes which are in strain. This the Chicago College of Osteopathic these lifts correct all three articulo­ reduction in stress using the forefoot Medicine, and is an associate fascial planes and will decrease and hindfoot lifts will produce professor and associate program rotational stresses which have been "equilibrium" in all planes and in director, Department of Family superimposed on the body. addition, will tend to effect correction Medicine, East Tennessee State To begin conceptualizing 3-DCL for any rotational components which University.Johnson City, Tennessee. using the lifts, it is necessary to have been superimposed upon the understand the effects of lifting at the body. The correct placement of the Introduction plantar surface of the foot and the lifts is achieved by using the body's The traditional concept in heel­ subsequent effect of this lifting on the own monitoring system, the cranio­ lifting has beenlimited to one articulo­ anterior and posterior articulo-fascial sacral system. In this way, a physician fascial plane, the posterior plane. This planes which run the entire length of works with a patient's body to correct method oflifting has historically been the body. Beginning with the plantar for any undue stresses instead of detennined by radiographs and the surface of the foot, one can think of it against the patient's body and allows subsequentmeasurement ofleg length as a "teeter-totter". This teeter-toner time for adaptation. and/or sacral base level. In this has a fulcrum which is the talus bone.

Summer 1995 AAO Joumal/23 Articulo-Fascial Planes There are three anatomic articulo­ fascial planes which help explain the mechanics of the 3-DCL. These articulo-fascial planes are: anterior, anterio-medial (with two components) and the posterior. The anterior articulo-fascial plane is superficial and can, for all practical purposes, be considered superficial fascia. This plane begins at the dorsum of the foot and continues ipsilaterally up to the frontalis muscle on the cranium Figure 1. The anterio-medial articulo­ fascial plane has two components (superficial and deep). These components are unique in that they 11\l\\\\\\\ begin ipsilaterally on one side and progress to the contralateral side. This \\\\\\1\\\\ is in contrast to the anterior and posterior planes which stay ipsilateral their entire course. Beginning with the superficial component (Figure 2a), this articulo-fascial plane begins on the dorsum of the foot and continues in an ipsilateral path in the following order: anterior tibialis, quadriceps and rectus abdominus. From the rectus abdominus, the plane crosses over to the contralateral side using the sternalis muscle which is continuous with the stemocleido­ mastoid muscle and finally inserting onto the temporal bone. The temporal bone, by way of the spheno-temporal ligament, attaches to the greater wing of the sphenoid bone. The deep component (Figure 2b) of the anteriomedial articulofascial plane begins at the medial arch of the foot, where it progresses on an ipsilateral side in the following order; posterior tibialis muscle, adductor muscle group, ilio-psoas. From the ilio-psoas, the plane uses the anterior sacroiliac joint as a fulcrum to cross Figure 2a Figure 1 contralaterally, attaching onto the Anterio-Medial Articulo Fascial Anterior -Articulo Fasical Plane thoracic diaphragm. The thoracic Plane (Superficial Component)

24/AAO Journal Summer 1995 diaphragm (which attaches onto the last six ribs) is in a continuum with the pectoralis major and minor muscles. 1bis deep plane eventually ends at the glenohumeral joint. The last articulo-fascial plane to consider is the posterior plane (Figure 3).1bisplane, like the anterior plane, can be considered superficial fascia on the posterior part of the body. 1bis plane is a continuation of the plantar fascia of the foot and runs on the ipsilateral side, ending on the occipital portion of the cranium.

Application of the Hindfootand Forefoot Lifts One of the most remarkable features of the 3-DCL is that the body has an intrinsic mechanism (monitor) to assist the physician in determining how the patient must be fitted with the lifts. 1bis mechanism is the cranio­ sacral system. Thecraniosacralsystem functions to monitor the variations in stresses on the fascia along its distribution, which runs the length of the body. In this mode of monitoring, the anterior fascial planes are assessed by monitoring the sphenoid bone, whereas the posterior fascial plane is monitored by assessing the occipital bone. When the patient is standing erect, the physician can relieve the unwanted stresses on the body by placing the appropriate lifts ( with the assistance of another person) under the feet. The "net force" of the three articulo-fascial planes which were alluded to is computed by the cranio­ sacral mechanism, which in tum guides the physician in the placement of the right combination of lifts by a simple monitoring of the sphenoid and occipital bones. Figure 2b Cranial motion testing is chosen as Anterio-Medial Articulo Fascial the method of application and Figure 3 Plane (Deep Component) Posterior-Articulo Fascia/ Plane ➔ Summer 1995 AAO Joumal/25 monitoring of lift therapy since it be placed by an assistant while the allows the body to account for subtle physician maintains monitoring of the abnormalities that are not always cranial motion (Figure 7). Within a visible to the human eye. Treatment few minutes after the forefoot lift is begins with the patient standing erect placed, the sphenoid wings should with toes placed on a line to prevent come into balance. When this has an uneven stance and with the patient occurred, attention may be given to looking straight ahead. The physician the occipital bone. stands to the patient's side, facing the The physician, while monitoring patient (Figure 4). Using one hand, the motion of the occipital bone, will the physician places the thumb and feel the distinct inferior motion of one third finger on both the right and left side of the occiput as it goes into greater wing of the sphenoid bone to flex.ion. While monitoring this motion, monitor its cranial motion. The other 1/8" to 1/2" lifts are placed under the hand is positioned on the occiput,just calcaneal bone on the same side as the inferior and lateral to the greater low-sided occiput (the posterior protuberance (not on the mastoid articulo-fascial plane is ipsilateral) process) in order to monitor cranial until a balancing of the occipital bone motion (Figure 5). is attained (Figure 8). Monitoring the motion of the Once a balance of the sphenoid sphenoid bone, the physiciantypically ... and occiput has been attained, the feels one of the greater wings of the lifts should be placed in the patient's Figure4 sphenoid, distinctively higher when shoes and this "lift pattern" should be Physician standing at patient's side compared to the other side. Beginning left in place for several days, until re­ with small increments (1/8" to 1/2" examination is performed. It must be inches), forefoot lifts (Figure 6) are understood that the body may have placed under the ball of the foot which undergone several traumatic events is "contralateral" to the side of the rs which have led to this dysfunction in high wing of the sphenoid. Placing the body, and gradual "unwinding" the lift on the opposite side to the high may occur, leading to adjustments in sphenoid wing is done due to the the lift pattern over time . This cross-over pattern of the anteromedial "unwinding" is due to relief of articulo-fascial plane. The lift should rotational forces as well as release of

Figure S Close up Hand Position Figure 6 - Heel Lifts

26/AAO Journal Swnmer 1995 F \H POI\ I ~ monitoringtheeffectonfascialplanes. Using the hindfoot and forefoot lifts enables a physician to account for articulo-fascial stresses and rotatory stresses due to pathology and gravity. This technique can be used as another modality in conjuction with or an adjunct to all other kinds of Osteopathic Manipulative Treatment. The goal of "equilibrium" in all other articulo-fascial planes leads to a biomechanically sound patient and numerous other beneficial effects. The physician is guided in lifting by the body's own monitoring system, the craniosacral system.

Special Thanks to John H. Harakal, DO, FAAO

Bibliography Figure7 stored energy in muscles and fascia Anterior Lifts (Placement of) as resolution occurs. The individual's 1. Magoun, Harold Ives: Osteopathy in the own body will determine the order of Cranial Field, Missouri, Journal Printing "unwinding" that may occur, and the Co., 1976. temptation to use radiographic 2. Korr, Irvin M.: The Collected Papers of guidance to override an ongoing Irvin M . Korr, Colorado, American process of "unwinding" should be Academy of Osteopathy, 1979; pp 77-87. resisted. Frequent evaluation and 3. Gehin, Alain: Atlas of Manipulative adjustment of the lift patterns will Techniques for the Cranium and Face, eventually establish a set pattern, and Washington, Eastland Press, Inc., 1985. normal balance and motion can be attained. This process of changing 4. Upledger, John E., et al: Craniosacral Therapy, Illinois, Eastland Press, 1983. patterns needs to be explained to the patient so that they may be 5. Summary Report: Postural Balance and comfortable with their changing Imbalance, Ohio, American Academy of needs. After a set pattern is Osteopathy, 1983. established, this pattern can be 6. Williams, Peter L., et al: Gray's considered permanent, and Anatomy 36th ed., Philadelphia, W.B. permanent shoe lifts are advisable. Saunders Co., 1980.

7. Rasch, Philip J., et al: Kinesiology and Summary Applied Anatomy 2nd ed., Philadelphia, Application of the 3-dimensional Lea and Febiger, 1963. counterstrain lifting technique 8. Wells, Katherine F.: Kinesiology 4th requires a thorough knowledge of ed., Philadelphia, W.B. Saunders Co., osteopathic concepts in both the 1966. 0 skeletal and cranio-sacral systems. When applied correctly, the 3-DCL Figure 8 offers a dramatic, effective treatment Posterior Lifts (Placement of) of leg length discrepancies by

Summer 1995 AAO Joumal/27 To The Editor

Dear Editor: Dear Mr. Noone: About 18 years ago, a colleague I wish to make the following com­ Rolles telling me he would be return­ called me up and requested that I re­ ments on the Obituary of Dr. John ing to England in the near future, and view some manipulative techniques Rolles which appeared in the Spring soon after his arrival he called on me with him because he was planning on issue of the Journal. I knew him well again and agreed to join me in prac­ taking the GP Boards. I told him to for years and had kept up with him tise. This he did at the end of Novem­ come to my office and I reviewed the until his death last December. ber 1956, and we worked happily to­ maneuvers with him. I quote from the Obituary... "John gether for the next twelve years." During this session, while palpat­ Rolles returned to England in 1956 I felt I should write to you to record ing his upper thoracic area, I noticed and took up an osteopathic practise more exactly the facts which con­ some lesions on the upper left from with an American (Dr. Carl Cooke)." cerned my husband and the length of Tl through T4. I mentioned it to him Cooke is misspelled- there is no "E" his years of practice before Dr. Rolles with the comment that I usually as­ at the end. joined him. sociated lesions in the upper left tho­ My husband, Dr. Carl M. Cook, All best wishes, racic area as indicative of possible had been in England since 1927 and Yours sincerely, heart disease. He then told me that practised in London where he built Mrs. Rosemary A. B. Cook he had two myocardial infarctions up a world wide practise until 1954, previously. I had not known that. when he left London to practise in Since that time I have observed Guildford. He invited Dr. John Rolles what I call a "normal lesion pattern". The Uniqueness Namely, involvement on the right to work with him as is explained on of the Osteopathic Profession from the A-O articulation through page 206 of his autobiography, "You about TS or T6 on the right with a re­ Must Become A Doctor", which you I have just finished reading the ciprocal left-sided lesion at the A-O. have in the Academy's archives, and editorial in the American Academy of From TS or T6, the pattern is more on I quote from this: Osteopathy Journal, Winter, 1994. the left caudally to the sacroiliac junc­ "For several years now I had The title really caught my eye: "The tion at which point there is also a re­ wanted to find a colleague to Uniqueness of Osteopathic Medicine: ciprocal S 1 lesion on the right. This work with me, as my work load Do We Know What It ls?" The editor pattern in the otherwise physically had become increasingly heavy. of the J oumal and the author of this well patient has helped me predict or­ .. A year or two before I left Lon­ writing is Raymond J. Hruby, DO, ganic problems with some regularity don a Dr. John Rolles called on FAAO and he does an excellent job when the pattern is not present. For me who had recently graduated of explaining his view point of what instance, lesions from the T6 or T7 from the osteopathic college at that uniqueness really is. He quotes area on the right through T12 often Des Moines, Iowa. He had met I. M. Korr, PhD and mentions his pro­ direct me toward GI problems. On the several ofmy friends while there lific scientific writings on osteopathy. left side this area is less of a worry. who had urged him to call on me He quotes Norman Gevitz, PhD, who I have since refined these obser­ and give me their greetings when has made in-depth studies of the os­ vations to question whether this "nor­ he passed through London on his teopathic profession over the years mal pattern" is in fact a protective way back to India, where he had from the outside looking in and he mechanism. Does the body protect its worked as a missionary for many also quotes Carol Trowbridge who internal organs by channeling mus­ years. The moment I saw him I wrote the Biography of A. T. Still. culoskeletal dysfunction into a distri­ felt he would be the colleague I bution less likely to promote visceral The one thread that weaves would like to join me, and he disease? This normal pattern has been through the three authors and is promised to let me know when very constant, irrespective of hand­ stressed by Dr. Hruby in that osteo­ he returned to England in a few edness. I was wondering whether pathic manipulation is not the only other clinicians have observed this. years' time. unique characteristic of our profes­ Sincerely, sion. He challenges each of us to Roderick T. Beaman, DO About a year after moving to share our views about this issue of Warwick, Rhode Island Guildford, I had a letter from Dr.

28/ AAO Journal Summer 1995 uniqueness. Dr. Hruby asks what our dents come and go. Some are inter­ practicing preventive medicine and thoughts are about this uniqueness. ested in the osteopath philosophy and being a good listener and friend to our He invites responses from readers so some are not. I do know that our patients. that the AAO Journal might put some graduates are extremely well-trained I believe that those are the things of them into print. and well-prepared for any residency that make up the uniqueness of our I have been an osteopathic physi­ program. profession. We must never lose those cian for 35 years. I have known about Now that the profession has gained qualities that constitute that unique­ the profession since 1944 as I was greater recognition and equality with ness and distinctiveness. We must not exposed to it by my uncle, a DO. I'd the allopathic profession, we are lose sight of the fact that our colleges like to share some of my thoughts about to find out that in doing so, we train the most graduates who enter with you about the profession. are losing some ofthe uniqueness that primary care fields. Our leadership in I have seen the profession undergo brought us to this point. If we con­ this area must not diminish. I finnly a lot of changes in those 50 years. I tinue to stress the need to be totally believe that we must continue to pro­ have seen the profession struggle to equal, we will eventually lose that duce graduates who want to become be recognized as equal to the unique difference which has made the primary care physicians, especially in allopathic profession. I have seen profession special over the last 100 family practice. DOs limited to caring for their pa­ years. We will lose that which has Those DOs who receive their train­ tients in strictly osteopathic hospitals sustained us for so long. We are al­ ing in allopathic programs must bring because they could not get staff privi­ ready at the point in time whereby our the best of what they have learned to leges on larger allopathic ones. I have graduates do not know what it means both undergraduate as well as gradu­ seen DOs limited to caring for their to fight for our survival. Those battles ate osteopathic medical education and patients in strictly osteopathic hospi­ were fought by many of us who en­ training. They must help improve tals because they could not get staff tered the profession many years ago. those programs where needed with­ privileges on larger allopathic ones. Manipulation is a very large part out diluting or diminishing the I have seen DOs gain full acceptance of the uniqueness, but there are other osteopathicness of our programs. in the military. I have seen the loss of things as well. As a part of become a I believe that we need not fear the one of our colleges and the granting DO, we are taught to put our hands other profession destroying us from of the little md degree to many of our on a patient. In doing so, we develop the outside, but that our real threat is California DOs. I have seen the ex­ something special - a special sense that we will destroy ourselves from pansion of our schools from 5 to 16 of trust the body has within itself the within by complacency and too much with 2 or 3 more on the drawing inherent ability to heal itself if all or­ "me-too-ism." We must maintain the board. I have seen allopathic hospi­ gans and tissues are in as nonnal a rationale for separation as a distinc­ tals open their staff memberships to condition as possible. Therefore, we tive and unique medical profession many of our physicians. learn that prevention is a very import that has something special to add to I have seen the acceptance of our part of medicine. The interest we take the health care of the people of this graduates into allopathic residency in each of our patients and their fami­ nation. I firmly believe that the os­ programs with open arms, partially lies is another part of the uniqueness teopathic profession will survive and because the MDs discovered that our because we know that each patient's our colleges will survive because of undergraduate training is very good, physical and emotional environment that special uniqueness. but also partially because their pro­ plays such an important role in their I invite each of you to examine grams were not being filled by their overall health. your own philosophies about osteo­ own graduates. As a result of that ac­ Nonnan Gevitz's idea of a profes­ path uniqueness. If you wish, I would ceptance, some of our schools have a sion that is both parallel and distinct also invite you to write your response very high number of graduates enter­ is right on target in my opinion. Par­ and send it either to the Texas DO or ing MD programs. Therein lies a allel means that we teach everything to the American Academy of Osteopa­ problem. I have also observed a trend the allopathic programs teach; train thy Journal. developing that might decrease the the same specialists and generalists number of our graduates who enter that they train and, basically, practice T. Eugene Zachary, DO primary care fields and opt for other medicine the same way they do. Dis­ Fort Worth, Texas specialities. tinctive means the use of palpation in As an osteopathic educator for the finding structural diagnoses, treat­ [Reprinted from the Texas DO Journal, last 15 years. I have seen many stu- ment of those structural problems, February, 1995.J Summer 1995 AAO Joumal/29 FIFTHANNUALOMT UPDATE OMT-ADVANCED OSTEOPATHIC LIFE SUPPORT PLUS PREPARATION FOR OMM BOARDS

OCTOBER 19-22, 1995

BUENA VISTA p ALACE HOTEL, LAKE BUENA VISTA, FLORIDA

This Academy program was designed to meet the needs of the PROGRAM physician desiring the following: Ann L. Habenicht, DO, Program Chairperson • OMT Review - "hands on experience and troubleshooting" Certified AOBSPOMM, Certified ACOFP • Integration of OMT in treatment of various cases • Preparation for OMM practical portions of certifying boards • Preparation for AOBSPOMM (American Osteopathic Board THURSDAY, OCTOBER 19 of Special Proficiency in Osteopathic Manipulative Medicine) 5 :00 pm Opening Reception certifying boards 5:30- 5:45 Overview of the Course; "Applications of Information on CODING for manipulative procedures osteopathic concepts in clinical medicine... Good review with relaxation and family time What to use: When and Why" Ann L. Habenicht, DO DATES: 5:45- 6:15 Cranial Osteopathy" October 19-22, 1995 includes question/answer period Melicien Tettambel, DO, FAAO (Thursday PM - Sunday AM) 6:15- 6:45 Counterstrain" - Ann Habenicht, DO LOCATION: 6:45- 7:15 Myofascial Release" - Buena Vista Palace, Lake Buena Vista, Florida Judith A. O'Connell, DO, FAAO 7:15- 7:45 Visceral Manipulation" - CMEHoURs: John Glover, DO 4 days; 20 hours; AOA Category 1-A 7:45-8:15 Muscle Energy" - 21 hours; AAFP Approved Boyd R. Buser, DO (Intermediate level course offered by the AAO) 8:15- 8:45 High Velocity/Low Amplitude" - Ken Nelson, DO, FAAO FEES: (SEE REGISTRATION FORM) 8:45- 9:15 Exercise Prescription" - John G. Hohner, DO 9:15- 9:30 Closing Comments - REFUND POLICY Ann L. Habenicht, DO All cancellations must be received in writing by September 19, 1995. An administrative fee of 15 percent of the total registration fee will be charged for all cancellations made by this date. No-shows FRIDAY, OCTOBER 20 and cancellations received after September 19, 1995 will receive no refund. 7:00am Breakfast Lecture Coding Update - Getting Paid for What You Do" - Judith O'Connell, DO, FAAO LODGING: BUENAVISTA PALACE (AN OFFICIAL 8:00-10:30 Lecture: "Thoracic Trouble-shooting" (to HOTEL OF WALT DISNEY WORLD@) include various modalities approach - HVLA, Participants will receive a rate of $155 single/double occupancy. ME, Counterstrain, indirect-MFR & cranial) This is prime season in Orlando, so please call early and make your Skills Session: Thoracic - hotel reservations. September 19, 199S is the reservation cutoff John Glover, DO date and you cannot be guaranteed a room after that date or at that 10:30-11:00 Break price. Call 1 (800) 327-2990 for reservations and be sure and tell them you are with the American Academy of Osteopathy's group.

30/AA0 Journal Summer 1995 11 :00- 1:30 Lecture: "Cervical/Suboccipital Troubleshooting" Skills Session: Cervical/Suboccipital - CONFERENCE REGISTRATION FORM Melicien Tettambel, DO, F AAO Wrap-Up Session: (Summary) - Faculty OMT UPDATE REGISTRATION Friday PM Free time for Exploration OCTOBER 19-22, 1995 BUENA VISTA PALACE; LAKE BUENA VISTA, FLORIDA SATURDAY, OCTOBER 21 Name _ 7:00am Breakfast Lecture Coding Update -- Part II ______Judith O'Connell, DO, FAAO Address ______8:00-10:30 Lecture: "Upper Extremity Troubleshooting" City _ Skills Session: Upper Extremity - ______State Zip ___ _ John Hohner, DO Daytime Telephone ______10:30-11 :00 Break 11:00- 1:30 Lecture: "Lumbar/Pelvis Troubleshooting" AOA # ______College/Year Graduated ______Skills Session: Lumbar/Pelvis - Boyd Buser, DO Wrap-Up Session: (Summary) - Faculty Prior to September 19, 1995 Saturday PM Free Time AAO Members DO/MD $475 AAO Non-Members $525 SUNDAY, OCTOBER 22 Residents/Interns $250 7:00am Breakfast Lecture - Coding Update Part III Judith O'Connell, DO, FAAO After September 19, 1995 8:00-10:30 Lecture: "Lower Extremity Troubleshooting" AAO Members DO/MD $575 Skills Session: Lower Extremity - AAO Non-Members $625 Ken Nelson, DO, FAAO Residents/Interns $350 10:30-11:00 Break 11 :00- 1 :30 Preparation for Manipulative Boards - Amount of Check $__ Boyd R. Buser, DO John Glover, DO John Hohner, DO Make Check Payable to: Ken Nelson, DO, FAAO American Academy of Osteopathy Judith O'Connell, DO, FAAO 3500 DePauw Boulevard, Suite 1080 Indianapolis, Indiana 46268-1136 Case Study Preparation - "How to write them" Telephone: 317/879-1881 or Fax: 317/879-0563 Written Exam Prep - "What to expect" Oral Prep -- "What to expect & how to do it" We accept VISA/ MC (Circle One) Individual Troubleshooting

Credit Card Number **** Alternate Program ••••

I 1:00- 1:30 Sports Medicine Expiration Date Extremity Review Mark McKeigue, DO Ann Habenicht, DO Signature of card holder Melicien Tettambel, DO, FAAO

ADJOURN FACULTY: Boyd R. Buser, DO Ann Habenicht, DO Mark McKeigue, DO Judith O'Connell, DO, FAAO Certified AOBSPOMM Certified AOBSPOMM Certified ACOFP Certified AOBSPOMM Certified ACOFP Certified ACOFP Sports Medicine Proficiency Melicien Tettambel, DO, F AAO John Glover, DO John G. Hohner, DO Ken Nelson, DO, FAAO Certified AOBSPOMM Certified AOBSPOMM Certified AOBSPOMM Certified AOBSPOMM Certified AOBOGS Certified ACOFP Certified ACOFP Certified ACOFP; Certified AAFP

Summer 1995 AAO Journal/31 From the AOBSPOMM Files

AAO Case Study: Severe Left Hip Pain by Sherri J. Tenpenny, DO lndentification pain bothers him most at night and he appendectomy in 1952, hemonhoid­ J. B. is a 74-year-old, white male is awakened 2-3 times a night with ectomy, retinal reattachment, lateral retired executive. searing pain radiating from his hip to femoral cutaneous nerve resection for his ankle. He has discovered that an "entrapment", a TURP and a right ice pack to the iliac crest area femoral hernia repair. Chief Complaint decreases the duration of the pain and The patient's chief complaint is sometimes helps him get back to sleep. Medications severe left hip pain with excruciating He has been on multiple medications intermittent shaxp pain radiating down Medications include Chlorthali­ including non-steroidal anti­ done 25 mg 1/2 tablet b.i.d., Atenolol the lateral aspect of his leg to the inflammatories and non-narcotic ankle. He also has intermittent sharp 50 mg 1 tablet q am, Amitriptyline 25 analgesics without much success. He mgt.i.d., Ibuprofen400mg q.i.d. pm. pains in the anterior aspect of his left states the most relief he had obtained thigh and in his left lower lumbar to date was from a series of region. He states this pain has been acupuncture treatments he received Allergies present for 42 years. approximately 15 years ago. However, None that physician acupuncturist moved History of Present Illness out of the area and he was unable to Social History This patient reports in 1952 he had continue with these treatments. In Patient is a former smoker of 25 an appendectomy and awoke with a addition, he relates intermittent years duration. He stopped smoking painful ecchymotic area noted over chronic low-back pain that is well in 1970. He admits to consuming the anterolateral aspect of his left iliac localized to the area of LS-S 1 on the approximately 1-2 ounces of alcohol crest. He states he was told a clamp left. This is exacerbated by twisting in the evening daily and is on no had been placed there during the and/or lifting. He denies any history special diet. appendectomy which caused the of trauma to his back that precipitated bruising. Since that time he has the initial onset of pain. Physical Examination experienced intermittent, searing and Physical exam reveals an awake, painful episodes 6-8 times a day, alertextremelypleasantanddelightful lasting 5-20 minutes at a time. He Past Medical History gentleman who appears his stated age. states that the pain al ways starts in the Past medical history includes He is 5 feet 7 inches tall and weighs area where the original bruise had hypertension, benign prostatic 190 pounds. His skin is noted to have been located. Over the years, he has hypertrophy and an upper extremity multiple senile keratosis across his been evaluated by multiple different tremor of undetermined etiology. upper back and extremities. He neurologists at major centers. In 1984, ambulates well without any obvious a lateral femoral cutaneous nerve disturbance to his gait. ENT exam is release of"scartissue" was performed Past Surgical History within normal limits. Heart rate is by a neurosurgeon at a major center, regular, rhythmical and without without success. The patient states the Past surgical history includes an

32/AAO Journal Summer 1995 murmurs. Lungs are clear to syndrome, including myofascial states that after the initial visit, he auscultation bilaterally. There is no release, muscle stretching and slept 3 of 7 nights in a row without obvious rib pain or rib somatic spraying utilizing Fluori-Methane, being awakened at all. He is faithfully dysfunction noted. Abdomen is soft, and, if necessary, triggerpoint doing his exercises 6-10 times a day non-tender. There is no rebound or injections. and also when he begins experiencing guarding. There is no organomegaly a painful episode. and no obvious palpable masses. Course of Therapy Physical exam reveals moderate Structural exam reveals decreased On the first visit, the patient pain still remaining at the sight of the range of motion in the cervical spine received osteopathic manipulative gluteusminimusanteriortriggerpoint. compatible with his age. He has a treatment using indirect and high­ He was treated with spray and stretch mild increase of his mid-thoracic velocity/low-amplitude techniques to techniques to all of the gluteus kyphosis. However, he has no mobilize the somatic dysfunction in muscles, upper thigh muscles, appreciable somatic dysfunction in the area of his lumbar spine. In latissimus dorsi and quadratus or through his cervical or thoracic addition, Fluori-Methane spray was lumborum. The triggerpoint was, spine areas. Lumbar spine reveals a utilized to spray and stretch the again, injected, this time with a positive standing and sitting flexion following muscle groups on the left: solution of 1 % Ponticaine (2cc) and test on the left. There is no apparent gluteus minimus anterior, gluteus normal saline (2cc). A good local short leg. There is noted to be somatic minimus posterior, gluteus maximus, twitch response was again obtained; dysfunction in the lumbar spine area adductors, rectus femoris, vastus however, the associated pain pattern with the LS noted to be neutral, side lateralis, biceps femoris and was much less intense than his bent right and rotated left. Deep tendon hamstrings. Full active and passive previous injection. Hot packs were reflexes were noted to be +2/4 range of motion was then perfonned applied for 10-15 minutes and the bilaterally in both the upper and lower to the muscle groups of the hip and area was fully stretched and extremities without any obvious low-back. An injection of Decadron mobilized. High-velocity/low­ weakness, atrophy or fasciculations. Occ) and Sensorcaine (3cc) was given amplitude techniques were applied to He has an otherwise normal into the triggerpoint of the gluteus the patient's lumbar spine somatic neurological exam. He has a negative minimus anterior muscle with a very dysfunction with good mobilization. Lasegue's test and a negative good local twitch response which There was no appreciable somatic Fajersztagn' s test assessing for included reproducing the referred pain dysfunction in the cervical or thoracic lumbar disc disease. He is found to pattern to the ankle. In addition, dry areas. The patient's craniosacral have exquisitely tender, point needling techniques were used to mechanism was assessed and found localizing pain in the area of his break-up several satellite triggers that to have a rate of 8-10 cycles per gluteus minimus anterior muscle. were located close by. The patient minute with good amplitude. Sub­ Palpation of this triggerpoint then received hot pack therapy for occipital release and a CV IV was reproduces the referred pain pattern approximately 20 minutes and 3 full performed. The stretches for his low down the lateral aspect of his leg to sets of active range of motion to the back were reviewed and several new bis knee and ankle. hip muscles. The patient was long trunk and quadratus lumborum instructed extensively on stretches to stretches were added. On his follow­ Impressions be performed every 1 1(2 to 2 hours up visit 2 weeks later, J.B. reported having no pain in the area his 1. Myofascial pain syndrome while awake for the next week. In of involving the gluteus minimus addition, he was instructed to use intensely painful gluteus minimus anterior triggerpoint. has been anterior muscle warm heat in the area of his He triggerpoint pain if he was awakened sleeping the entire night for the last 2 weeks. He reported a new pain 2. Somatic dysfunction of the lumbar during the night instead of using ice. in the anterior aspect of his left thigh. This spine The patient returned the following week stating the frequency of his pain pain isless frequent and less intensely painful than the gluteus minimus Treatment Plan attacks had definitely decreased to 5 times a day from 10 times a day. In anterior t igger, however he describes It was recommended that the this pain as a deep ache that is patient receive osteopathic addition, he states these painful episodes are now only lasting 5-10 exacerbated by climbing stairs and manipulation in addition to a series of playing golf. He stated that his low- treatments for myofascial pain minutes as opposed to 20 minutes. He

Summer 1995 AAO Jouma]/33 back pain has completely resolved. continuedfrompage 21 Physical exam reveals a latent, non­ AAO Extends tender but very ropey triggerpoint noted he discovery and development in the area of his rectus femoris muscle. of cranial osteopathy "Thanks" This was injected with a mixture of 1% T demonstrated that we early to Ponticaine(lcc)andnormalsaline(lcc) practitioners had overlooked much with a very good local twitch response. that was right in our hands. The whole Convocation There was complete relief of the taut field of technic has had many facets band within the muscle. He was and many false starts. WE are still far Supporters instructed to continue his previous from perfection, but that is the reason exercises and an additional exercise for this effort today. We are striving was added to stretch out the fibers of to bring ourtechnic to the ultimate for The American Academy of his rectus f emoris muscle. results in ease of operation upon both Osteopathy would like to convey The patient returned to the office 2 operator and patient and scientific its appreciation to those weeks later stating that he had no pain perfection. We are trying to correlate companies which exhibited at whatsoever in the area of his gluteus all of the knowledge, skill and the 1995 Annual Convocation minimus trigger or his anterior thigh. experience of the past into a better in Nashville, Tennesee this past At that time, he was complaining of working future. March. They are: some minimal pain to the area of his While we are working out this lumbar spine. The physical exam better modus operandi we are also American Anatomical Corporation revealed a positive standing flexion trying to work out a better teaching ASI - Aqua Med test on the left, with the L4/L5 area practice. That has at times shown a Bankers Leasing Company noted to be neutral, sidebent right, great weakness in our professional Basic Physician Supply rotated left. This somatic dysfunction development. It will not be enough Cerenex/Glaxo was treated with indirect, high­ for only a few to attain skill. We must Chicago College of Osteopathic velocity/low amplitude mobilization, work out an efficient system of Medicine and counterstrain with complete relief instruction for our students so that Curatek Pharmaceuticals of his pain. The patient went on an their time will not be wasted in much DaPat Pharmaceuticals extensive vacation through the vain striving as many of us have done. Electro Medical, Inc. Western states and did not return to And that also is why we are here. Genesis Osteothermal Designs, If we can, here and now, bring the office for 6 weeks. On his follow­ Corp. up visit, he was found to have no about a correlation between a better Health Care Manufacturing. Inc. recurrence of his hip, thigh or low­ working and more efficient technic to Johnson City Medical Center back pain. The patient was instructed the student, we will have reached Kirksville College of Osteopathic to follow up on a pm-type basis and to another important milestone in the Medicine continue all stretches at least twice a development of osteopathy. day with increased frequency at any We hope here, today, by practical Med.X Corporation signs of return of the pain. demonstration, to kindle the fire of Mosby/Williams & Wilkins inspiration that will permeate the National Levitor Center Discussion whole profession, including our National Osteopathic Foundation This case demonstrates how long a college curricula. Osteopathic Health Systems of myofascial pain syndrome can persist Texas without the appropriate diagnosis and 1) A function is a structure in action Osteopathy's Promise to Children treatment. In addition, secondary at a given time. Philadelphia College ofOsteopathic latent triggerpoints can become active Medicine and cause pain after the primary 2) A new approach to technic is Saunders, W. B. triggers have been treated. The patient combined with teaching Standard Homeopathic Company had experienced 42 years of exquisite methods, not formerly used, to Stronglite, Inc. make the learning of lesion pain that was relieved by recognition Thera Cane Company correction easy. that the muscle itself can be a source UAS Laboratories of pain.□ Zeneca

34/AAO Journal Summer 1995 1995 AAO Convocation New Horizons in Pain Management Nashville, Tennessee

Tape #1 "Neuroanatomy of pain" Frank Willard, PhD Convocation 1995 "Trawna vectors" Video Tape Order Form Judith O'Connell. DO, FAAO

Tape #2 "Reflex sympathetic dystrophy & VHS video tapes of the 1995 AAO Convocation are now sympathetic dystonia" available for your personal library at a discount price of Robert Kappler, DO, FAAO $149.95 plus $10.00 shipping and handling for the full set of 10 tapes. Program chairperson Ann Habenicht "Psychiatric aspects of chronic pain" arranged the program around the theme "New Horizons Andrew Lovy, DO in Pain Management". The Academy hired a profes­ Tape #3 "Pharmacology in chronic pain" sional contractor to tape these lectures with a two-cam­ William Elliot, DO, PhD era setup with on-site editing. Please review the titles of these lectures and order your complete set. You may "Oh, no, fibromyalgia!" also order individual copies oftape(s) which pique your Mark Cantieri, DO interest.

Tape #4 "Chronic foot and anlcle pain" Please send me one complete set of tapes Thomas Ravin, MD @ $149.95 plus $10 shipping. "Discogenic vs. non-discogenic pain" Manuel Pinto, MD Please send me one copy of tape(s) # _____ (specify tape number) "Acupuncture in chronic pain" @ $30.00 per tape plus $5.00 shipping. Kenneth Lubowich, OMD

Tape #5 "Nutritional needs in chronic pain" Stephen Elsasser, DO Printed Name

"Reducing gravitational strain pathophysiology" Michael Kuchera, DO, FAAO Telephone

Tape #6 "Chronic pelvic pain" Melicien Tettambel, DO, FAAO Street Address for UPS shipment "Exercises for chronic pain" Karen Gajda, DO City State Zip Tape #7 "Anesthesia's role in chronic pain management" Larry Harker, 00 You may charge this purchase of your VISA or MasterCard (Circle one) "Migraine cephalgia" Hal Pineless, DO CMd# ______

Tape #8 "Fascial pain: Bell's palsy and trigeminal neuralgia" Expiration Date _ William Wyatt, 00 ______

"Chronic cervical spine pain" Signature ______Karen M. Steele, DO, FAAO Return this form along with your payment Tape #9A Conclave of Fellows to cover both tapes and shipping to: "Finding the key somatic dysfunction" Edward Stiles, DO, FAAO American Academy of Osteopathy Tape #9B Conclave of Fellows 3500 DePauw Boulevard, Suite 1080 "Fixing the key: which technique to use" Indianapolis, IN 46268-1136 Herbert A. Yates, DO, FAAO Phone (317) 879-1991 /FAX (317) 879-0563

Summer 1995 AAO Journal/35 Support the AAmeriean Academy of Osteopathy In Memoriam

by registering as Charles E. Still, Jr., DO grandfather once said, 'The squirrel of an Academy osteopathy is still in the tree; we have only got him by the tail."' Dr. Charles Still, Jr., the youngest member He is survived by his wife of 58 grandson of Andrew Tay!or Still, MD, years, Dorris; 2 sons, Charles and founder of the osteopathic profession Gerry, both of Scottsdale and 4 and the Kirksville College of GMT­ grandchidlren Osteopath Medicine, passed away. Basic Osteopathic He had decided early in his life to Life Support follow in the footsteps of his father, Robert B. Thomas, DO The Academy's program will focus Charles E. Still, DO, and his famous towards workshop demonstration grandfather. Robert B. Thomas, DO, 89, of and application of osteopathic Dr. Still earned his Doctor of Huntington, West Virginia, passed manipulative medicine. Osteopathy degree from the Kirksville away February 19, 1995. College of Osteopathic Medicine in Dr. Thomas had retired in 1987 Topics to be covered: 1933. He practiced in Missouri, after 62 years of practice. He was a Counterstrain Module Hawaii, California and Texas prior to member the American Academy of This four-hour module will allow his opening a practice in Arizona in Osteopathy , the West Virginia for short introductory lectures followed 1961. Osteopathic Association, the by hands-on sessions. The four main After he retiring in 1980, Dr. Still American Osteopathic Association topics and demonstrations will be focused his energy on assisting elderly and the Eastern States Osteopathic cervical region, pelvis, thoracic region citizens in Arizona. Named the and upper extremities. Society. Arizona Senior Citizen of the Year in A recipient of the American Utilization of OMM 1972, he served on the Governor's Osteopathic Association Distin­ in the Hospital Setting Council on Aging for 11 years, was guished Service Award, Dr. Thomas the founding chairperson of the Senior was also honored by the Kirksville High Velocity Low Amplitude Adult Education Advisory Committee College of Osteopathic Medicine in Module at Scottsdale Community College and recognition of 50 years of service to Evaluation and treatment of the assisted with various programs for society. He was recognized as cervical, thoracic, lumbar and pelvis. the elderly at the local, county and Mountaineer of the Year. state levels for many years. He was preceded in death by his Muscle Energy Module In 1994, Dr. Still was inducted into Evaluation and treatment ofthe hips, first wife, Effie Mae Sadler Thomas. sacrum, cervical and lumbar regions. the Health Care Hall of Fame in Survivors include his wife, Joyce H. Chicago, Illinois. Thomas; two daughters, Carolyn T. Myofascial Release Module He was convinced that the best was Beyer Pearson, DO of Chesterton, Evaluation and treatment of the yet to come for the osteopathic Indiana and Mary Suzanne and her cervical, thoracic, rib and upper profession. "There is such tremendous family residing in Florida; a extremity. potential that has yet to be tapped," he granddaughter, Mary Carolyn Riecke said during a visit to Kirksville in 1986. of Fort Wayne, Indiana; a stepson, OMT Coding Update "Although the profession has enjoyed Michael A Barnett of Sanford, Florida a rich history of growth, I believe the and four great-grandchildren. Guy DeFeo, DO, CSPOMM future of osteopathic medicine is Program Chairperson destined to be even greater. As my

36/AAO Journal Summer 1995 January 13-20, 1996 20 CME Hours (Category 1-A) Aboard the Sun Princess (A Brand New Ship) Learn Basic Osteopathic Diagnosis and Treatment; "Joint Mobilization and Articulatory Technique''

Objective of Course Learn to diagnose and treat motion restriction in the musculosketetal system. We will go over basic anatomy and terminology.

Who May Attend Course Educational objectives for AAO are to provide programs aimed to improve understanding of philosophy and diagnostic and manipulative skills of osteopathic physicians and foreign DOs with a full license or a registration, medical, podiatric and dental professions within their licensed privileges of practice and for those in programs leading to such license. Itinerary

Day P.o.n Arrive .J&p_art Saturday Ft. Lauderdale (CME) 5:00pm Sunday Princess Cays 10:00am 5:00pm Monday AtSea(CME) Tuesday Montego Bay, Jamaica 8:00 am 5:00pm Wednesday Grand Cayman 8:00am 4:00pm Thursday Playa del Carmen/Cozumel 8:00am 6:30pm Friday AtSea(CME) Saturday FL Lauderdale 8:00am Watch your mail for the Princess Cruise Flyer. Register by August 31, 1995 and Save $100 per person

Summer 1995 AAO Journal/37 Classifieds

Kentucky California Osteopathic Burlington, Vermont Family practice and OB/GYN Principles & Practice Need osteopathic sports medicine openings in various locations of rural, Applications for a qualified physician (board certified in general/ not-for-profit healthcare corporation. osteopathic physician for position as family practice or osteopathic Small, mountain communities serving Assistant Professor. Duties include manipulative medicine) with strong total populations of up to 50,000 classroom teaching and patient care skills in OMM and orthopedic people. Hospitals of 50-200 beds. in the college clinics. Competitive medicine. Call for details (802) 878- Choose salary plus benefits or salary and full benefits including 1003. minimum income guarantee plus excellentretirementprogram. BC/BE, productivity incentive. We take the OMT undergraduate teaching fellow­ Louisville, Kentucky business worries, you see the patients. ship background preferred. The Opportunity for right DO to share Sites also available inthe VIRGINIAs. College actively seeks applications OMM practice. Partorfull time. Great Experience the satisfaction and from women and minorities for this area of town. Wonderful patients. No security of life in a small town plus position. Send Curriculum Vitae and Medicare, Medicaid or Hospitals. APPRECIATION FOR YOUR three letters of reference to: John J. Questions? Contact Susan or Mary WORK. Send CV to or call Greg Jones, III, DO, Chair, Osteopathic Ann at (502) 894-8200. Please send Davis, Appalachian Regional Manipulative Medicine Department, letter of inquiry and CV to: P.O. Box Healthcare, Inc., P. 0. Box 8086, College of Osteopathic Medicine of 6054, Louisville, Kentucky 40206- Lexington, KY 40533. (800) 888- the Pacific, 309 E. Second Street, 6054. 7045 or (606) 281-2537 collect. EOE College Plaza, Pomona, CA, 91766- M/F 1889. Affirmative Action/Equal Practice For Sale Opportunity Employer. Successful OMM practice in Shciago. Opportunity for Payment at time of service; no OMM Specialist Full Spectrum weekends. Contact Mark La Beau, at Genesys Regional Medical Center, Family Medicine DO, (312) 266-8620. Flint Osteopathic Campus beginning Seeks a BE/BC family physician June 1, 1995.Full-timepositionwhich committed to holistic medicine to join includes opportunities for in-hospital three other physicians with interest/ Classified Ad and outpatient consultation in OMM, skills in holistic family medicine and and developing and directing OMM obstetrics, acupuncture, homeopathy, DEADLINE curriculum for house staff. Potential nutrition and osteopathic manipulative clinical faculty appointment at Michi­ medicine. Pleasant building shared is 10th of the month gan State University COM. Must be with alternative health center, location certified or board eligible by in college community. Supported by preceding publication. AOBSPOMM and completed community hospital with competitive undergraduate fellowship or residency salary and benefits. Contact: Full Advertising Cost in OMM. For more infonnation call Spectrum Family Medicine, 2025 Dennis DeSimone, DO, Director of Abbott Road, Suite 100,EastLansing, for the Medical Education, (800) 233-2863 Michigan 48823; Phone (517) 333- or write to Genesys FOC, 3921 3550. classified section Beecher Road, Flint, MI 48532. is $1.00 per word.

38/ AAO Journal Summer 1995 Calendar of Events

June August 16-18 AOA/AAO Convention 26-27 AAO Program: OMT - Basic 17-21 Osteopathic Life Support Concept and Technique of the Basic Course in Osteopathy Guy Defeo, DO, Program Chairperson Levitor Orthotic Device in the Cranial Field Orlando, Florida Michael Kuchera, DO, FAAO The Cranial Academy For information on AAO program Program Chairperson Arizona Biltmore Contact: Diana Finley American Academy of Osteopathy Phoenix, Arizona Associate Executive Director 3500 DePauw Boulevard (317) 879-1881 Contact: The Cranial Academy Indianapolis, Indiana (317) 594-9299 CME Hours: 16 Category 1-A Contact: Diana Finley 19-22 23-25 Associate Executive Director Fifth Annual OMT Update - Cranial Academy Annual Conference; (317) 879-1881 Advanced Osteopathic Life Support "Tour de Force" plus Preparation for OMM Boards The Cranial Academy September Ann Habenicht, DO, Arizona Biltmore Program Chairperson Buena Vista Palace Phoenix, Arizona 15-17 Contact: The Cranial Academy Orlando, Florida Introductory Visceral Manipulation (317) 594-9299 CME Hours: 20 Category 1-A American Academy of Osteopathy Contact: Diana Finley Holiday Inn Airport Associate Executive Director July Indianapolis, Indiana (317) 879-1881 CME Hours: 25 Category 1-A 8-9 Contact: Diana Finley November Associate Executive Director Workshop in Dr. T. Yamamoto's Scalp (317) 879-1881 Acupuncture; sponsored by 11-12 Maryland Society of Medical Advanced Percussion Vibrator Course Acupuncture; Presented by his student, 18-22 Robert Fulford, DO, Speaker Richard Feely, DO, FAAO Basic Course of the Expanding Osteo­ Richard Koss, DO, Instructor and pathic Concept into the Cranial Field­ No previous acupuncture experience is Program Chairperson necessary! Yamamoto scalp OP&S of California American Academy of Osteopathy acupuncture is impressive for instant Shilo Inn Pomona Hilltop Suites Hotel 3500 DePauw Boulevard CME Hours: 40 Category 1-A pain relief and the treatment of Indianapolis, Indiana Contact: OP&S of California neurologic disorders such as stroke. CME Hours: 15 Category 1-A (916) 447-2004 Fee: $325 Contact: Diana Finley Bethesda Holiday Inn Associate Executive Director Bethesda, Maryland 28-0ctober 1 (317) 879-1881 Contact: Lillian Somner, DO Twenty Fourth.Annual Convention (301) 718-3696 New England Osteopathic Association The Hyatt Regency Hotel Cambridge, Massachusetts Contact: Nancy Dickey, Exec. Secy. ~ Attention (207) 474-2357 Component Societies: Having a meeting/course? Call us at (317) 879-1881

Summer 1995 AAO Journal/39 p,J\-0 $Js_0 Piqc~ . pi..~~;e,~t\o\\- Functional Methods: 1'!5;o/Jf;:.':;f""" ~o\J A Manual for Palpatory Skill Development ·00 s'-":J/-tJd in Osteopathic Examination and Manipulation of Motor Function by William J. Johnston, DO, FAAO and Harry D. Friedman, DO This manual is valuable for any osteopathic physician ORDER YOUR COPY TODAY! from which he/she could learn and use this functional Printed Name_ _ _ method in the practice of osteopathic medicine. ______The text would also be useful to teach fundamental Address methods in any osteopathic college, to osteopathic ------physicians in the field, unfamiliar with this type of indirect City State _ Zip treatment, or to any other physician who has the prerequisite ______knowledge to follow the instructions. Telephone ______"The text includes and explains many of the concepts VISNMasterCard ______of the osteopath profession and explains advantages of (circle one) card number manipulation in an honest, matter-of-fact, nonthreatening manner. It should make nonusers wonder why they are not Expiration Date cashing in on the advantages of providing manipulation ------for improved patient care. " Signature ------William L. Kuchera, DO, FAAO FAX No. (317) 879-0563 or mail to the Coauthor of Osteopathic Principles in Practice American Academy of Osteopathy at the above address.

NON-PROFIT ORG. /4~ American U.S. POSTAGE PAID Academy of PERMIT NO. 14 Osteopathy CARMEL, INDIANA 3500 DePauw Boulevard Suite 1080 Indianapolis, IN 46268-1136

ADDRESS CORRECTION AND FORWARDING REQUESTED