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I I .. .. .AAmeriean Academy of Osteopathy

3500 DePauw Boulevard, Suite 1080 Indianapolis, IN 46268-1136 The mission of the American Academy of Osteopathy is to teach, (317) 879-1881 explore, advocate, and advance the study and application of the FAX (317) 879-0563 science and art of total health care management, emphasizing palpatory diagnosis and osteopathic manipulative treatment. 1994-1995 Board of Trustees From the Editor ...... 4 President Raymond J. Hruby, DO, FAAO Eileen L. DiGiovanna, DO, FAAO A.T. Still Medallion Deadline Nears ...... 4

President Elect Message from the Executive Director ...... 6 Boyd R. Buser, DO Stephen J. Noone, CAE

Immediate Past President Call for Papers ...... 7 Herbert A. Yates, DO, FAAO Letter to the Editor ...... 7 Secretary-Treasurer J.M. McPartland, DO, MS Anthony G. Chila, DO, FAAO Message from the President ...... 8 Eileen DiGiovanna, DO, FAAO Trustee Ann L. Habenicht, DO Request for Proposals ...... 8

Trustee A Hypothesis for the Facilitated Segment Based Upon Michael L. Kuchera, DO, FAAO Biological Principles Associated with Tumorigenesis ...... 9 G. Yonuschot, PhD, D.]. Mokler, PhD and B.]. Winterson, PhD Trustee Karen M. Steele, DO Review of the 1993 Journal of the New Zealand Register of Osteopaths .... 13 Robert C. Clark, DO Trustee John C. Glover, DO Letter to A.T. Still ...... 14 Raymond]. Hruby, DO, FAAO Trustee .. Judith A. O'Connell, DO Tiggerband Technique ...... 15 Stephen Typaldos, DO; Illustrations by Gina Belsito Trustee Software Review for the AAO Journal: IBIS ...... 19 Melicien A. Tetlambel, DO, FAAO reviewed by J.M. McPartland, DO, MS

Executive Director In Memoriam ...... 20 Stephen J. Noone, CAE From the Archives: "Who is to Blame?" Revisited ...... 21 Editorial Staff Philip E. Greenman, DO, FAAO From the AOBSPOMM Files: AAO Case History ...... 22 Editor-in-Chief Raymond J. Hruby, DO, FAAO Elaine M. Wallace, DO

Supervising Editor Stephen J. Noone, CAE AAO 1995 Annual Convocation ...... 24

Editorial Board Barbara J. Briner, DO Classifieds ...... 34 Anthony G. Chila, DO, FAAO Calendar of Events ...... 35 Frank H. Willard, PhD

Managing Editor Diana L. Finley Advertising Rates for the AAO Journal

ThcAAO Journal is the official quarterly publication of theAmeri• An Official Publication of The American Academy of Osteopathy can Academy of Osteopathy (3500 DePauw Blvd., Suite 1080, In­ The AOA and AOA affiliate organizations and members of the Acaderny dianapolis, Indiana, 46268-1136). Third-class pmtage paid at Cann cl, lN. Postmaster: Send address changes to American Ac.1demy o( Os­ are entitled to a 20% discount on advertising in this Journal.

teopathy 3500 DcPauw Blvd,, Sui1e 1080, Indianapolis, JN.1 46268- 1136 Call The AAO Journal is not iiself responsible for statements made by any contributor. Although all advettising is expecied to conform to The American Academy of Osteopathy ethical medical standards, acccplance docs not imply endorsement by lhis journal. (317) 879-1881 for Advertising d Opinions cxprc.~sed in TheAAO Journal are those o f au1hors or speak­ an Rate Car ers and do not necessarily reflect viewpoints of the editors or offidal policy of !he American Academy or Osteopa1hy or !he inslitutions wilh which 1bc authou are affiliated, unless specified. Subscriptions: $25.00 per year

Winter 1994 AAO Journal/3 From the Editor

The Uniqueness of Osteopathic Medicine: Do We Know What it is?

If you have been keeping up with him the "science" of osteopathy was Perhaps you would like to share your the literature over the past year or so, based on a thorough knowledge of thoughts with the rest of your col­ you know that there has been a great anatomy. The "art" of osteopathy leagues. If so, send us your ideas about deal written about how the osteopathic seemed to be embodied in his patient­ what makes osteopathic medicine dif­ profession should go about preserving centered approach. We all know that ferent. Maybe you will see them in its identity for the future. Everyone Dr. Still did not leave us with tech­ print right here in the Journal! seems to agree that in order to remain nique manuals on osteopathic ap­ a viable profession we need to dem­ proaches. He felt that each patient was 1 Korr, I. M. Osteopathic medicine: the profession's role in society. JAOA, Vol. 90, No . onstrate our unique aspects - those unique, and therefore felt that an over­ 9, Sept. 1990. things that justify our existence as a all philosophy of health care was more separate profession in the world of important than descriptions of tech­ 2 Gevitz, N. Parallel and distinctive: the philo­ medicine. I. M. Karr, one of the most niques. As he put it, "Then I will not sophic pathway to reform in osteopathic medical education. JAOA, Vol. 94, No. 4, Apr. 1994. prolific researchers and writers our have the worry of writing details of profession has had, feels that we need how to treat any organ of the human 3 Still, A. T. Osteopathy: Research and Prac­ to define our role as a profession with body, because he (i.e., the osteopath) tice. Kirksville, MO. By the author, 1910, p. 38. respect to the needs of society.1 An­ is qualified to the degree of knowing what has produced variations of all 4 Trowbridge C. Andrew Taylor Still: 1828- other astute writer, Norman Gevitz, 1917. Kirksville, MO. The Thomas Jefferson has studied the osteopathic profession kinds in form and motion. I want to University Press, 1991, p. 165. 0 for many years. He feels that we need establish in his mind the compass and to clearly define what is unique about searchlight by which to travel from the A.T. Still Medallion osteopathic medicine and establish effect to the cause of all abnormality Deadline Nears ourselves once and for all as a parallel of the body."3 and distinctive profession.2 Another distinctive aspect of osteo­ The deadline to submit the name One thing everyone seems to agree pathic medicine was Dr. Still's of a candidate for the 1996 A. T. Still on is that osteopathic manipulation is thoughts on where to look for the Medallion of Honor Award is April not the only unique aspect of our pro­ source of disease, and where to find 15, 1995. the cure. Carol Trowbridge, in her fession. The simple application of ma­ Deserving members of the Acad­ nipulative techniques to standard book, Andrew Taylor Still: 1828 - emy who shall have exhibited medical practice does not make us dif­ 1917, says, "The osteopaths and the among other accomplishments in ferent. The principles of body unity, MDs studied the same anatomy, the scientific or professional affairs an self-regulation and self-healing must same nervous system, muscles, liga­ exceptional understanding and ap­ all be integrated into the total care of ments, organs and lymphatic system; plication of osteopathic principles, the patient. How do we do this? And they faced the same diseases and con­ and of the concepts which are the how do we demonstrate this integra­ ditions. Whereas the regular physician outgrowth of those principles, may tion of principles so that people clearly looked outside the body for cures, the be awarded the Andrew Taylor Still see that osteopathic medicine is indeed osteopath looked within the body for Medallion of Honor. The Academy unique? cures, making Still's manipulative cherishes this award as its highest We often say the osteopathic medi­ therapy, rather than internal drugs, an honor, and all petitions are consid­ cine is both science and art. In times integral part of osteopathic practice."4 ered confidential. like this, when we want answers about What are your thoughts about the If you have any questions or need the nature of osteopathic medicine, I distinctiveness of osteopathic medi­ any additional information about this procedure, please contact the find that the best source of informa­ cine? Now more than ever it is impor­ Academy office or refer to page 125 tion is A. T. Still himself. If we exam­ tant that we have a clear description of your AAO 1994 Directory. ine Dr. Still 's writings, we see that for of what is unique about our profession.

4/AAO Journal Winter 1994 Instructions for Authors

TheAmericanAcademy 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, Uni­ contrast. On the back of each, clearly in­ ence and art of osteopathic manipulative versity of New England, 11 Hills Beach dicate the top of the photo. Use a photo­ medicine. It is directed toward osteopathic Road, Biddeford, ME 04005. 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 TheAAO 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 Articles about practical applications Manuscript from a parent or guardian. for general practitioners or specialists. l. 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 Comments on articles published in specific information was taken, list them The AAO Journal or new information on 3. Check that all references, tables and in alphabetical order following the num­ clinical topics. figures are cited in the text and in numeri­ bered journals. cal order. Professional News 2. For journals, include the names of all News of promotions, awards, ap­ 4. Include a cover letter that gives the authors, complete title of the article, name pointments and other similar professional author's full name and address, telephone of the journal, volume number, date and activities. number, institution from which work ini­ inclusive page numbers. For books, in­ tiated and academic title or position. clude the name(s) of the editor(s), name Book Reviews and location of publisher and year of pub­ Reviews of publications related to Computer Disks lication. Give page numbers for exact osteopathic manipulative medicine and to We encourage and welcome com­ quotations. manipulative medicine in general. puter disks containing the material sub­ mitted in hard copy form. Though we Editorial Processing Note: Contributions are accepted from prefer Macintosh 3-1/2" disks, MS-DOS All accepted articles are subject to members of the AOA, faculty members formats using either 3-1/2" or 5-1/4" discs copy editing. Authors are responsible for in osteopathic medical colleges, osteo­ are equally acceptable. all statements, including changes made by pathic residents and interns and students the manuscript editor. No material may of osteopathic colleges. Contributions by Illustrations be reprinted from TheAAO Journal with­ others are accepted on an individual basis. l. Be sure that illustrations submitted out the written permission of the editor are clearly labeled. and the author(s).

Winter 1994 AAO Journal/5

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AOA AOA Stephen Stephen The MBNA America® To The Editor Call for Papers Gold MasterCard®. It's the one more The AAO's Education Committee has doctors order. supported Chairperson Ann Habenicht's Dear Dr. Hruby, inclusion of a New Ideas Forum as part For physicians, the hours are long but of her 1995 program at the Opry land Ho­ time is always short. Remedy: This Gold I enjoyed Dr. Lipton's article on the tel in Nashville, Tennessee. The Commit­ MasterCard® from MBNA America®. Cranial Rhythmic Impulse. His grasp tee directed me to issue a "Call for Pa­ Designed specifically to keep pace with the of the literature is certainly compre­ pers" to be submitted to the Education demands of today's physician, it offers the Committee for consideration at their Feb­ hensive. But I'd like to debate one of advantages of individually established Dr. Lipton's suppositions - that wide­ ruary 1995 meeting. credit lines - up to $50,000 as well as the Presentations by leading clinicians and spread use of Sutherland's techniques convenience of the special priority privi­ researchers are planned for the has not caused any conceivable side main ses­ leges listed below - at no additional cost. sions as at the 1995 AAO Convocation. effects. Most cranial practitioners may Additional ideas are welcome in the form 8 .9% introductory Annual Percentage recall a patient or two who complained of posters and presentations. It is the Rate (APR) on Cash Advances and Bal­ of minor headaches or vertigo after policy of the Education Committee to in­ ance Transfers and ... treatment. These are side effects. In an vite additional contributions for possible NO annual fee! upcoming JAOA paper, Philip consideration at the 1995 Convocation Greenman and I report significant from all interested parties. Abstracts of ideas/papers should be directed to AAO 24-hour customer service iatrogenesis from Sutherland's tech­ Education Committee, 3500 DePauw While traveling, you're automatically niques, including emotional swings, Boulevard, Suite 1080, Indianapolis, In­ covered with up to $1 million psychiatric disturbances, nausea, vom­ diana 46268-1136. Phone (317) 879-1881. Common Carrier Travel Accident iting, diarrhea, cardiac palpitations, Deadline for receipt of abstracts is Insurance when you use Gold­ and opisthotonos. These occurred in a Passage® Travel Services and your January 13, 1995. population of patients with traumatic AAO Gold Card to purchase tickets brain injuries. on any common carrier worldwide. Furthermore, most cranial practitio­ Nearly everything you purchase is The Cranial protected up to 90 days against ners have faced the clinical challenge damage or theft of "undoing" a poor craniosacral treat­ Academy Immediate access to cash around the ment induced by others. "Others" in­ presents its world at more than 220,000 financial cludes osteopathic students, chiroprac­ institutions and over 160,000 ATMs tors, physical therapists, MDs, and lay Start each year with a record of your practitioners. I've collected several Basic Course previous year's charges. We'll send case histories. Untoward effects in­ in Osteopathy you your Year-end Summary of clude nystagmus, double vision, tro­ in the Cranial Field Charges to help you prepare for tax chlear nerve palsy, trigeminal neural­ June 17-21, 1995 season and track your spending habits. $5 charge gia, static labyrinthine reflex, convul­ and Emergency Cash and replacement sions, loss of consciousness, and hypo airline tickets, up to your credit limit pituitary syndrome. Some Sutherland Cranial Academy Emergency medical or legal network techniques seem particularly danger­ Annual Conference ous in the hands of ill-trained opera­ "Tour de Force" TheAAO has chosen to endorse the MBNA tors. I feel that a few illustrative cases June 23-25, 1995 GoldMasterCard® card because it reflects should be documented in the literature. the unsurpassed commitment to quality that I'm putting a paper together and wel­ has made MBNA one of the nation's lead­ come anecdotes or case histories. Arizona Biltmore ing credit card companies. Our decision Phoenix, Arizona was clear: the MBNA Gold MasterCard® card - there is no comparison! J. M. McPartland, DO, MS For more information, 53 Washington Street contact: To apply for your AAO Card Middlebury, VT 05753 The Cranial Academy (317) 879-0713 by calling 1-800-847-7378

Winter 1994 AAO Journal/7 Message from the President Request for Proposals

Now we need to establish the worth The Academy's Louisa of this certification. All who have be­ Burns Osteopathic Research come certified need to seek to have the government, insurance carriers and Committee (LBORC) an­ HM Os accept this as both primary care nounces a request for propos­ and specialty certification. als on clinical studies in osteo­ I recently received word that New pathic diagosis and treatment York Medicaid has recognized our in patient management. Pro­ certification as a specialty ranking. I posals must be submitted no was accepted onto one of the smaller later than January 1, 1995, to Eileen DiGiovanna, DO, FAAO HMOs as a specialist in manipulative the LBORC, c/o The American medicine. Each step we take is an im­ Academy of Osteopathy, 3500 The response from people wanting portant one. DePauw Boulevard, Suite to become certified in osteopathic ma­ We must continue to urge the AOA 1080, Indianapolis, IN 46268- nipulative medicine has been over­ to try to get OMM listed as one of the whelming, deluging the examiners al­ primary care areas. They need to en­ 1136. most beyond their capacity. They have sure that our certification will also be had to call for volunteers at the AOA recognized as a specialty field. Research Convention to assist with the exami­ Since there is strength in numbers, Committee nations. Over 119 people are already I urge all Academy members to seek certified. This is wonderful news. Os­ certification and urge your friends in Seeks Researchers teopathic physicians and, most impor­ all other specialty fields to seek OMM tantly, osteopathic medical students are certification as well. Keep the appli­ The Academy's Louisa Burns reaching back to the roots of the pro­ cations coming - we want you and we Osteopathic Research Committee fession. The number of Academy mem­ need you. (LBORC) is seeking physicians bers swells every year. This is great. Now is the time! interested in participating in de­ signing a protocol using osteo­ pathic diagnosis and treatment in Associate Wanted For outcomes research. Interested New Name? Osteopathic Practice physicians should write LBORC New Address? Chairperson Deborah Heath, DO, 100% OMT with emphasis New Phone? c/o The American Academy of on osteopathic cranial concepts. New Fax? Osteopathy, 3500 DePauw Bou­ levard, Suite 1080, Indianapolis, Wide variety of patients IN 46268-1136. with large pediatric population. Let us know, LBORC is also seeking physi­ Orientation to complementary fields; so we can cians interested in participating in nutrition, herbs, homeopathy, keep you informed! therapeutic exercise/movement a standard protocol for collecting very desirable. data from the use of osteopath di­ agnosis and treatment in their Please reply in writing - The American Academy of practices. Interested physicians No Phone Calls. Osteopathy • 3500 DePauw should write LBORC Chairper­ Blvd., Suite 1080 • Indianapolis, son Deborah Heath, DO, c/o The Bonnie R. Gintis, DO IN 46268-1136 American Academy of Osteopa­ • Phone: (317) 879-1881 or 18 Maverick Road thy, 3500 DePauw Boulevard, FAX: (317) 879-0563 • Woodstock, New York 12498 Suite 1080, Indiana pol is, IN 46268-1136.

8/ AAO Journal Winter 1994 --...,..----,A Hypothesis for the Facilitated Segment Based Upon Bialogical Pr.ineif)les Associated with Tumorigenesis

by G. Yonuschot, PhD, D. J. Mokler, PhD and B. J. Winterson, PhD University of New England, College of Osteopathic Medicine Biddeford, Maine

6 Introduction nociceptors. The hypothesis presented develop neoplasms and some not. The Osteopathic clinical practice in this paper expands the concept of the following is a formal statement of our recognizes the important role played facilitated segment beyond the hypothesis for the facilitated segment by the musculoskeletal system in health functional and cellular to the molecular that incorporates these concepts. and disease. More specifically, level. osteopathic manipulative diagnosis and Tremendous progress in cell and Hypothesis therapy focus on somatic dysfunction molecular biology over the last two A facilitated segment is the result of and its alleviation. In the 1940s, studies decades has provided new insights about facilitated cells that may act alone or in by Denslow and Denslow et al. provided cancer and tumorigenesis. It is our view concert to change the function of the · evidence that chronic hyperactivity of that these new biological concepts may spinal cord segment from normal to the spinal cord (segmental facilitation) be applicable when considering the abnormal. Facilitated cells may be was responsible for producing some of facilitated segment. Two concepts are neuronal or non-neuronal and both the features of the somatic dysfunction, particularly illuminating. types may arise from normal cells. i.e., restricted range of motion, tissue First, cancer is now conceptualized Facilitated cells are transformed (Table texture changes and changes in galvanic in terms of oncogenes, tumor 1) as a result of facilitated genes • 1,2,3,4,s Th h skm response. ese aut ors suppressor r,enes and growth factors (abnormally expressed genes). suggested that segmental facilitation ( cytokines) (Table 1). Oncogenes and Expression of facilitated genes may be was caused by sensitized neurons tumor suppressor genes are permanent or reversible reflecting restricted to a segment or section of the intracellular and can control cell growth whether the change in the gene is spinal cord controlling functionally and differentiation. However, many permanent or temporary. related parts of the body. More recent! y, growth factors are extracellular. Thus, Van Buskirk has postulated that other (noncan-cerous) cells contribute Rationale facilitation is induced by activation of to the initiation and maintenance of 8 The hypothesis developed from the neoplasms. Similarly, modifications idea that facilitation of a spinal cord in gene expression and growth factors segment is analogous to very early may contribute to the development stages of neoplasia. All cells, including l(eYWo.rd and maintenance of the facilitated those destined to develop into tumors, Facilitated S segment (Table 2). go through phases of cell division and Neon] . segment The second concept is that several differentiation (Table 1). This process r as1a mutations, not just one, are necessary is controlled by both the concentration Oncogenes for development of neoplasia. Both of extracellular growth factors and the Growth i:. somatic and germ cell mutations may G tactors 9 intrinsic ability of the cells to respond be involved (Table 1). Thus, some 10 enetic s to growth factors. A neoplasm occurs usceptib .1. individuals are predisposed to develop As trocytes I lty when the normal control mechanisms neoplasms, whereas others are not. Further, some regions of the soma may for cell division and differentiation go

Winter 1994 AAO Journal/9 promote tumorigenesis. These genes are thought to be responsible for the 13 Table 1. Concepts of N eoplasia initial stage of tumorigenesis. Oncogenes are derived by mutation I from proto-oncogenes. Proto- Differentiation: Acquiring a character or function different from that of the oncogenes are normal genes that are original type. Differentiation can be reversible. involved with normal cell division. Proto-oncogenes produce protein Growth factors: Mediators of intercellular communication that influence differentiation and proliferation. products that control normal cell division such as growth factors, growth Oncogene: A gene whose activation, by increased expression or by factor receptors, G-proteins, proteins alteration of protein product, contributes to the neoplastic state. involved with second messenger systems and nuclear regulatory proteins Proto-oncogene: A normal gene involved in normal control of cell differentiation (Figure 1). and proliferation. Oncogenes are mutated ("activated") forms of Oncogenes are derived from proto­ proto-oncogenes. onco genes by several types of mutations. One major category of The pathological process causing neoplasm. Neoplasia: mutations produces an abnormal Transformation: The conversion of one form of cell into another. protein that functions in the cellular response mechanism to extracellular Tumor suppressor: Genes that prevent abnormal cell proliferation. growth factors. In this case, the abnormal protein results in an abnormal cell division signal despite the fact that Table 1 no such signal is received at the cell membrane. A second major category of mutation results in the loss of the awry. Tumorigenesis is thought to Facilitated cells normal mechanisms controlling the result from a combination of mutations The cells that comprise a facilitated rate gene expression. causes and extracellular growth signals, i.e., segment are responsible for the of This the overproduction proteins it is the result of changes in the heightened activities. A single cell type of controlling cell division. For example, immediate environment of the cell, the (i.e. gamma motoneurons) may be the the c-fos oncogene protein product is cellular mechanisms for responding to sole contributor, but other cell types the environment, and/or other cellular (i.e. astrocytes) may also have altered known to be increased or mutated in many forms cancer. thought to mechanisms for controlling growth and function. However, one or more of It is "ff . . 11,12 function by helping to activate the d1 erenhation. facilitated cell types may not As with potential tumor cells, the necessarily produce a facilitated transcription of many genes involved cells responsible for the correct segment. Other factors might be in cell division. Segment cells have genes that functioning of a region of the spinal necessary for the facilitated segment may cord are controlled by their intrinsic to manifest as somatic dysfunction. modulate facilitation in a manner genetic expression and by extracellular We would like to distinguish facilitated similar to the way that proto-oncogenes factors modulating genetic expression. cells, which arise from normal cells, as modulate cell division and Under normal circumstances, almost all facilitation cells. Facilitation cells, due differentiation. For example, some cells function within normal to their genetic makeup, are capable of genes might regulate the behavior or physiological ranges. Occasionally, becoming facilitated. Also, facilitated number of membrane channels however, the function of cells is changed genes arise from normal genes called necessary for normal facilitation . due to mutations or to exposure to facilitation genes (Table 2). Changes in the expression of these extreme concentrations of extracellular Facilitated genes are genes that have genes would produce facilitated genes. factors so that the cells respond been changed so that either an abnormal It is extremely interesting that the abnormally. The abnormally responding gene product or an abnormal amount c-fos protein product, mentioned cells are much more likely to initiate and of gene product is produced (Table 2). above, is increased in the spinal cord . f 1 . 1· 14,15 maintain a facilitated segment. They are analogous to oncogenes, b y pam u sttmu 1. Thus, an tumor suppressor genes and genes oncogene might well be a facilitated controlling growth factors that help to gene.

10/AAO Journal Winter 1994 ~ I L this second type of facilitation gene would allow the defect of the first Table 2. Terms used in the Hypothesis. facilitated gene to be manifested as a facilitated gene. Finally, growth factors are involved Facilitation Gene: Any gene that has the capacity to produce a product that influences facilitation. in some neoplasias. For example, the sis oncogene product is P latelet A prefacilitated gene that has been changed so that either Derived Growth Factor expressed at Facilitated Gene: 18 an abnormal gene product or an abnormal amount of gene an abnormally high level . In addition, product is produced. A facilitated gene is necessary but much data has shown a relationship may not be sufficient to produce a facilitated segment, between hormones and cancers of the endometrium, breast, ovary, prostate, • 19,20 . . Temporarily thyroid and bone. Smee 1t does not Facilitated Gene: A facilitated gene that has been abnormally activated or seem plausible that the tumors always inactivated but that, after a time, will return to a normal state. develop a need for growth factors only after a neoplasm has developed, it is Permanently assumed that the need is present during Facilitated Gene: A facilitated gene that is the result of mutation. the earliest stages of neoplasia. Finally, there is speculation and evidence that Facilitation Cell: Any cell that can influence facilitation. These cells growth hormones act as tumor JO contain facilitation genes and can be neuronal cells or promoters. Tumor promoters do not cells that have the capacity to influence excitation and directly cause mutations but do cause conduction. increases in cell division and other cellular changes that increase the Facilitation Factor: An extracellular factor that modulates facilitation by 21 interacting with neuronal or nonneuronal cells. probability of mutations. The genes that control growth factors may be Facilitated Cell: Any cell that contains a facilitated gene and thus may found in both the cell being transformed influence facilitation. Facilitated cells may be neuronal or into a tumor cell and in the other cells nonneuronal and are necessary, but may not be sufficient, in the environment supporting to produce a facilitated segment. More than one type of tumorigenesis (Table 1). facilitated cell may cooperate to produce a facilitated In a similar fashion, genes producing segment. growth factors may inf! uence facilitation. Current hypotheses Segment: Interacting set of neuronal and nonneuronal cells serving regarding facilitation suggest that the a region of the body restricted in a rostro-caudal direction. excitatory amino acids released in response to noxious stimuli may act to 22 Facilitated Segment: The abnormal facilitation of a segment. facilitate a segment of the spinal cord. Studies have shown that epidermal Table 2 growth factor enhances excitatory amino acid effects in the central Tumor suppressor genes are neoplastic until the tumor suppressor 23 recessive genes that regulate cell genes are deleted. It may be that nervous system. Thus, growth factors may also influence facilitation in the differentiation and division indepen- segmental cells have genes that protect 16 dent of extracellular factors. Before the segment against the abnormal spinal cord. A general term we suggest to cover extracellular factors that tumorigenesis, both alleles must be expression of other genes. Thus, some inactivated by mutations. For example, facilitation genes would be similar to influence facilitation is facilitation several types of tumor suppressor genes tumor suppressor genes. For example, factors (Table 2). The fact that a cell contains an are deleted during the development of even if a mutation occurred that 17 is a colon cancer. It appears that most produced an abnormal amount of a oncogene, or lacking tumor oncogenes cannot be expressed in the membrane channel, it might be that suppressor gene, or is exposed to abnormal concentrations presence of specific tumor suppressor facilitation would not develop because of one or several growth factors, is not normally genes. Thus, even though cells contain another gene product would protect oncogenes , they will not become against this defect. However, loss of

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However, However, sufficient sufficient Review of the 1993 Journal of the New Zealand Register of Osteopaths

by Robert C. Clark, DO

Earlier this year I received a copy soned to be beneficial and cites the few presents seeking relief, it is advisable of the 1993 Journal of the New clinical trials of osteopathic treatment to evaluate the patient for underlying Zealand Register of Osteopaths of patients with asthma. The trials etiology in the article, "Osteopathic (JNZRO) from our colleague Richard showed improvement in patient symp­ Management of the Degenerative Hip Carruthers, DO. Dr. Carruthers has toms from 55-70% from manipulative Joint". graciously provided copies of prior treatment. "A Pilot Study on the Value of Ap­ issues of this annual journal for review. In both the medical literature and plied Kinesiology in Helping Children The 1993 JNZRO is different in that the public press, one medical topic with Learning Disabilities", by Mark Dr. Carruthers is now the assistant edi­ seems to garner much attention. That 0. Matthews, Bsc, DO, et. al. was less tor having yielded the editor's chair is the disease of osteoporosis. Jenni­ than satisfying. The preliminary re­ to Tracy Livingston, DO. Be assured fer Steinmetz reviews the prevention sults presented are very interesting and that with a change in editors there is and current treatments of osteoporosis suggest a valuable means of helping a no change in the high quality of ar­ and concludes that the "best treatment disadvantaged portion of our popula­ ticles and papers published. is prevention". Although there are ex­ tion. But the article failed to give any The JNZRO continues its fine os­ cellent hormonal treatments for the real description of what the procedures teopathic tradition with a blend of disease, the simple prevention includes were that produced the results re­ major articles, original research, dis­ proper diet with calcium rich foods, ported. At the end of the article was cussion papers, case studies and re­ calcium supplements, regular exercise the address of the author from whom ports and book reviews. It is worth­ and avoidance of alcohol, smoking and the reader could purchase a more com­ while reading for all DOs whose in­ other calcium depleting substances. plete article with references and full terests lie in the traditional osteopathic These is the easiest and most cost ef­ treatment protocol. way of treating patients. Most articles fective treatment of preventing the ef­ In the United States the political de­ are brief so that a busy practitioner can fects of osteoporosis. bate is over health care or, more pre­ read as time allows. In fact in 50 pages "Biomechanics of Sporting Inju­ cisely, who is going to pay for what there are over 30 items listed in the ries" by Belinda Fellowes, DO, ana­ and who is going to be in control? It is table contents. Do not let brevity im­ lyzes the problems with each of the no surprise to find that similar politi­ ply incompleteness - far from it. In three component events of the cal debates occur elsewhere. Mark several of the articles brevity implies triathlon. Along with the analysis of Franken, DO, the president of the New precision of thought on the part of the injury potential in swimming, cycling Zealand Register of Osteopaths, re­ author. and running the author gives several ports that the changes in the New Since there are too many articles to pointers to the reader to aid in locat­ Zealand government's handling of review only a few will be presented to ing the source of the athlete's prob­ health services and the payments for whet the reader's appetite. The lead lems and addressing corrective efforts. same offer the DOs opportunity to ad­ article is "The Osteopathic Treatment Since many other sports involve run­ vance the role of Osteopathy in the of Asthma" by Richard Carruthers, ning, many of the author's insights can care of the people of New Zealand. In DO. This article reviews the literature be applied to other athletes. another article Richard Carruthers, regarding osteopathic manipulative M. C. McGrath, DO, reminds us DO, concludes that" ... Osteopathy is treatment of asthma. It shows the ar­ that when a patient with lumbar dys­ an extremely cost-effective form of eas of the body where treatment is rea- function, buttock pain and thigh pain ---), Winter 1994 AAO Journal/13 treatment for musculoskeletal com­ analyzes the effect upon the person. in getting a copy of the 1993 JNZRO plaints. .." He also gives suggestions for the ideal for their own benefit should contact The last article I wish to mention is posture to prevent stress to the sacro­ Richard Carruthers, DO, Nelson Osteo­ "Sitting", by John Cullen, DO, who iliac joints and other dysfunctions. pathic Clinic, 300 Hardy St., Nelson, observes that, "Sitting in chairs has be­ There are many other articles cov­ New Zealand. The cost in New Zealand come the most common non-sleeping ering topics from cranial treatment to currency is $18.00 plus overseas ship­ postural position of humans in the de­ yoga as a form of self-treatment to ping. It is worth the purchase for this veloped world." Dr. Cullen examines short leg and the common compensa­ unique osteopathic journal.□ different types of sitting postures and tory pattern. Those who are interested

Letter to A. T. Still

Dear Doctor Still,

I think most people would agree matter very elegantly in your book, that there have been only a very few Philosophy of Osteopathy (pp. 66-67), original thinkers in the history of the when you said, "As our investigations world. I'm referring, of course, to are without the assistance of ancient those people who were able to develop or modern writers, we will have to rea­ new, different and unique ideas that son that man is a machine of form and had a profound effect upon all the rest power, forming its own parts and gen­ of us. We could argue about who erating its own powers as it has use would be considered an original for them. At this time we begin to rea­ thinker, but names like Socrates, Rene son thus, that all powers are invisible Descartes, Charles Darwin and Tho­ and we see effect only. We know such mas Jefferson come to mind. forces to be abundant in nature, and You are certainly amongst those con­ life is sustained by them. To find the sidered to be original thinkers, as was substances in the body that cause them one of your more notable students, Wil­ to act and how to act, has been the liam G. Sutherland, DO. I never cease object of my journey as an explorer. If to be impressed by the fact that you they give us health when normal ac­ were able to develop the unique con­ tion prevails and disease only when cepts of osteopathic medicine, and that abnormal, then we are admonished to Doctor Sutherland was able to extend form a more intimate acquaintance these concepts into the cranial area. with the qualities, and with all the But there is an even more impres­ products, when formed in this great Sponsored by: A American sive point to think about here. You laboratory which compounds and Aeademyof were able to put aside all of your pre­ qualifies each substance to fill its mis­ Osteopathy vious training and experience in the sion of force, construction, purity and standard medical world and allow action." You spent a lifetime develop­ For a $15 enrollment fee yourself to completely rethink your ing a new and different approach to you and your family members approach to health and disease in the healing. We would all do well to con­ can receive human body. Most of us tend to be so template the depth and breadth of replacement contact lens affected by our previous experiences knowledge contained in the simple at up to 75%discount! and our knowledge of standard medi­ principles you discovered. Call the AAO cal models that we have a ve ry for an enrollment diffficult time allowing ourselves to Your ongoing student, form today! look at things from fresh viewpoints. Raymond J. Hruby, DO, FAAO (317) 879-1881 You expressed your thoughts on this 0 14/AAO Journal Winter 1994 Triggerband Technique Abstract Triggerband Technique is by Stephen Typaldos, DO, Fort Worth, Texas The Manual Medical Center of Fort Worth a soft tissue manipulative Illustrations by Gina Belsito, approach that is used in the University of North Texas Health Science Center at Fort Worth treatment of acute and chronic musculoskeletal pain and dysfunction. It is based on the premise that distorted or

r injured fascial bands are the I Key Words f ascial band cause of many types of frozen shoulder musculoskeletal discomfort triggerband and that correction of these triggerpoint distortions will result in a reduction elimination Fascial Band Distortions neurological, muscular or dermatome or of in Musculoskeletal Pain pathways. both the pain and the somatic There is an extensive network of Fascial band distortions can occur dysfunction. fascial bands in the human body. in different varieties. Some effect the Trigger-band Technique is fascial 'plane', others result in Except for the iliotibial tract, few a treatment for acute fascial bands have been named or 'triggerpoints', and still others are syndromes, such as lumbar described ~reviousl y. In 1990 Gerlach predominantly bandular. However, I and Lierse documented the existence shall limit my discussion here to those sprain, whiplash injuries, of fibrous fascial bands in the lower that are most important for the headaches of a nonorganic physician learning Triggerband extremity. See Figure 1. nature, 'pulled muscles' and From their drawings it can be seen Technique. The most common of other athletic and nonathletic that the fascial bands are these is a 'triggerband' which is interconnecting and interwoven. defined as a distorted fascia) band musculoskeletal problems. In Because of this, fascia) distortions that has become twisted, torn and addition, many chronic pain can travel long distances and have shortened. This occurs during injury syndromes such as failed back what seem to be bizarre patterns of when some or all of the fibers become surgery, frozen shoulders, pain that do not follow known altered. See Figure 2. 'arthritic-like' pain, 'pseudo­ sciatica' and fibromyalgia often respond to this therapy.

--==----- ~ -

) i•,: I,' i :( ' i \) ;\ I.>

Figure 1 Figure 2

Winter 1994 AAO Journal/15 Normal Fasical Band

Figure 4 Acutely Injuried Fascial Band Both acute and chronic triggerbands are treated the same way, by manually untwisting the twist, Chronically straightening the band, reapproxi­ Injured mating the tear and smoothing out the Fascial distortion. The difference is that in Band chronic pain the adhesions also must be broken making it much more painful. Please refer to Figure 5. Figure 3

To be able to understand this concept better, it is beneficial to know the 'anatomy' of a triggerband. All triggerbands have certain components which include a 'tear', a 'twist'* and, Correct the twist by pushing in many cases, a 'wave'. In chronic until it is completely untwisted pain' adhesions' also occur. Examples of an 'acute pain' triggerband and a 'chronic pain' triggerband are shown Acutely in Figure 3. Injured Note that in acute pain, the twist Fascial can move up and down the entire Band band as shown in Figure 4 and at times seems to 'jump' from one area to another. This does not occur in chronic pain Chronically because the adhesions are holding the Injured twisted band firmly in place. In Fascial chronic pain the number of adhesions Band _,,. gradually increases. As this occurs the patient will feel "tightness" and experience a loss of flexibility. Corrected Fascial Band *or other triggerband subtype as shown in Figure 6. Figure 5

16/AAO Journal Winter 1994 1\vist Wave Knot Pea Grain of Side Salt View ~

Top View A crumble is a triggerband wedged between two muscle layers

Figure 6

Triggerbands fascia! bands. Herniated Triggerpoints important that the patient and the are most common in the abdomen and physician realize that Triggerband and Triggerpoints are corrected by forcing the underlying Technique is normally a painful To use Triggerband Technique, the material that has become ' trapped' in procedure and that general!y the more physician first must be able to palpate the distortion down below the fascia! subjective the patient's severity of a triggerband. When it is encountered, plane. Herniated Triggerpoints occur pain is, the more helpful the treatment a triggerband may feel like any of in two varieties and are described and may be. those shown in Figure 6. * compared in the fascia! distortion Another point to consider is that There are many other types of model paper. TriggerbandTechnique can be painful fascia! distortions, some of which are for the physician as well. The discussed in detail in the physician's thumbs may become tired accompanying paper Introducing the and sore. Therefore, it is the advisable FascialDistortionModel. Twoofthe Triggerband Technique and the Physician that the physician not attempt too most common are 'Banded Pseudo­ many treatments in the early stages Triggerband Technique is a Triggerpoints' and ' Herniated until the hand and thumb muscles Triggerpoints' which are illustrated potentially painful modality for the have had a chance to strengthen. in Figure 7. Banded Pseudo ­ patient. This is especially true in When using Triggerband Triggerpoints occur when two or more chronic pain. Fortunately, it is rare Technique no lotion or gel should be that patients refuse the treatment triggerbands overlap. Correcting them used on the patient's skin. Lotions or requires following first one of the because of this. Once the treatment gels decrease friction and allow the distortions and then the other. They begins almost all patients will sense fingers to glide over the skin. In are not actually triggerpbints per se intuitively that the treatment is both Triggerband Technique it is necessary appropriate and necessary . It is but are an overlap of two distorted to use that friction to move and correct the underlying structure. Banded Pseudo­ Herniated Some patients may complain of Triggerpoint Triggerpoint having their hair pulled during the treatments, and it may be necessary to shave the affected area to reduce their discomfort. This occurs normally in only particularly 'hairy' men, with the thighs and legs being the biggest problem. Figure 7

*For comparison of triggerband subtypes see Introducing the Fascial Distortion Model. (JAAO; Summer, 1994)

Winter 1994 AAO Journal/17 Contraindications to Triggerband Typical Steps in Indications and Technique are mostly relative, and a Treating a Chronic Patient Contraindications partial list is offered below. Each Once the physician has determined The indications for Triggerband physician should, of course, use his/ that Triggerband Technique is to be Technique are multiple and include her best judgment before employing employed on a patient, he or she may most types of chronic and acute pain, this or any other treatment modality. need to go through specific steps to back pain, neck pain, headaches, Fortunately, I have never seen any insure that proper attention is paid to frozen shoulders, 'arthritis-like ' complications of the treatment itself, certain details so that mistakes in syndromes, abdominal pain of a but each physician should be aware diagnosis and treatment are avoided. somatic origin and a host of other that they can occur and could For most chronic pain syndromes musculoskeletal dysfunctions of a potentially be anything from stroke to several days should be allowed in nonorganicnature. As with all patients phlebitis. Again, each physician between treatments and four to six that are treated, the proper diagnosis should decide what he or she feels sessions may be needed. Progress is paramount. Metastatic cancer and comfortable treating with each should occur at each visit. multiple myeloma are two of the individual patient. conditions that I have seen more than once on so-called nonorganic chronic Partial List of Contraindications pain patients. The fact that they may have seen many other doctors does Edema Cancer not mean that the correct diagnosis Cellulitis Previous Strokes was made. In particular, any patient Osteom yeli tis Open Wounds who shows no response to Vascular Diseases Aneurysms Triggerband Technique should be Arteriosclerosis Hematomas carefully reexamined for an organic Skin Wounds Bone Fractures cause. Collagen Vascular Diseases A typical type of chronic pain that Bleeding Disorders may respond to Triggerband Poor Doctor-Patient Rapport Litigious Patient Profile Technique is illustrated in a patient Treatment of Abdomen or Infectious Arthritis that has some or all of the 'Rule of Pelvis During Pregnancy Phlebitis Fours'. Osteogenesis Imperfecta

Rule of Fours Side Effects • 4 or more years of pain Pain: This occurs close to 100 I) Rule out organic cause of pain. • 4 or more locations of pain percent of the time in nonathletes. 2) Review all previous records. • 4 or more physicians Athletes rarely have this complaint. In 3) Listen carefully to the patient's chronic pain there may be localized history. previously seen tenderness after the treatment for three 4) Mentally or graphically map out • 4 or more diagnostic or four days. In acute dysfunction pain patterns of pain. procedures previously done is generally only present during the 5) Physical examination. treatment. Note that any pain after the 6) Make the proper diagnosis of ~ • 4 or more therapeutic treatment is much less than the pain distorted fascia! syndrome. j modalities previously done during the treatment. 7) Ask the patient about possible contraindications. • 4 or more prescriptions Erythema of the Skin: This occurs 8) Discuss the treatment with the given in the past close to 100 percent of the time. patient, and state in no Brusing: This occurs in 5-10 uncertain terms that it will be percent of patients and is temporary. painful.

continued on page 28

18/AAO Journal Winter 1994 Software Review for The AAO Journal: IBIS (Interactive Bodymind Information System)

reviewed by J. M. McPartland, DO, MS Director, AMRITA (no relation)

IBIS is a huge database of lations" and therapies. Therapies Documentation accompanying the alternative medicine. Its core lists 282 include behavior modification, software is well-written and common "conditions" that bring process-oriented therapy, hypno­ comprehensive. Technical help is patients to our offices. Most of the therapy, affirmations, visualizations, available by telephone during working conditions are diseases, ranging from even medical astrology. hours, Pacific time. benign ones ( acne and such) to medical Of the eight modalities, emergencies (like myocardial Other Operations: Acupuncture, Botanical medicine, and infarction). Many nonpathological IBIS provides a Materia Medica, Chinese formulae seem the strongest. conditions are also covered (e.g., full of additional treatment The Psychospiritual section is daring menopause, contraception). information. It supplies dosages and - it comes with more cautions and toxicology, details manual techniques, contraindications than the other Features: and provides references for further secti.ons. The weakest section is Diagnostic criteria for each of the reading. Note Cards allows you to Physical Medicine, especially 282 conditions are provided, and customize IBIS by adding data on manipulation. This weakness is a linked with eight treatment modalities. therapeutics; the Research Module strength for osteopathic physicians. Physical Medicine is the first creates a patient database. Additional Indeed, IBIS seems tailor-made for treatment modality. It covers IBIS operations permit linking of DOs who don't need help with manipulation, exercises, hydro­ cards, analyzing databases, finding manipulative therapies. No indica­ therapy, and electrical/oscillating key words, indexing key words, and tions for manipulative treatment are therapies. Nutrition includes dietary printing information for patient listed for nearly a third of the 282 recommendations (foods to add or education handouts. conditions! Granted, OMT may not avoid), vitamin and micronutrient be indicated for hirsutism or scabies supplements, and a set of recipes. Strengths: (at least HCFA thinks not), but other Botanical Medicine concerns Western IBIS is designed for primary care conditions miss the boat (e.g., herbs and formulae; Chinese physicians. In the last month, I've metrorrhagia, intercostal neuralgia, Formulae does the same for Eastern encountered only one condition not post-surgical sequelae ). IBIS only lists herbs . Acupuncture suggests listed among IBIS's 282 varieties­ six conditions for craniosacral treatments for western diagnoses, trigeminal neuralgia. Nevertheless, treatment , and rarely mentions coupled with Chinese diagnoses. IBIS using "Find" and "Index" features, I visceral manipulation. IBIS uses the point numbering system in found treatments for trigeminal champions Chapman's reflexes, but Dan Bensky's Acupuncture: a neuralgia described in the Materia Muscle Energy , Counters train, Comprehensive Text. Homeopathy Medica. Functional, and Myofascial details a mini-repertory with rubrics IBIS contains a vast amount of techniques are unknown to the for each condition. Bach's flower information, which is well organized naturopaths who designed the remedies are listed in the next section, and easy to locate. Despite its program. Techniques they include Vibrational Therapies, which also ponderous size, IBIS searches are under manipulation are sometimes embraces color, sound, crystals, and performed quickly. Shortcuts are mysterious ("nasal specifics" for electromagnetic techniques. available using command keys and Downs), and sometimes not Psychospiritual Approaches has two floating palettes. Using the program manipulation (wiping with cotton sections, "metaphors and corre- is intuitive and easy to learn. instead of toilet paper for pruritus ani). ~ Winter 1994 AAO Journal/19 Weaknesses: up botanical remedies for prostatitis, a reference tool to investigate things your patients may be taking or doing. To click into a condition requires and you'll find saw palmetto buried IBIS version 1.2 is available for the practitioner to adopt IBIS's in a list of 18 different herbs. This Macintosh or IBM-compatible terminology. This can be lack of priority arises in all the idiosyncratic. For instance, gallstones modalities. The choices become computers. The Mac version requires are not listed (see cholecystitis), but overwhelming, and sometimes over 15 MB of disc space and 4 MB of 7. uses a kidney stones are. Some of the listed contradictory ( e.g., foods listed in both RAM on System IBIS conditions seem redundant, such as "add" and"avoid" columns). The IBIS HyperCard engine (version 2.1) with "intestinal parasites," "intestinal diagnosis section does not incorporate pull-down menus, pop-up text, and worms," "intestinal flora imbalance," osteopathic information. The mouse controls. It costs $895. Student and "intestinal dysbiosis." Since IBIS acupuncture section does not map discounts and interest-free payment was written by several authors, point locations ( except extra points), plans are available. Demo discs are treatments are not consistent. This is so you can't learn acupuncture from free. IBIS is produced by AMR 'TA especially evident in the nutrition IBIS. (Alchemical Medicine Research and section. For instance, ten nutritional Teaching Association), P.O. Box supplements are offered under Bottom Line: 14641, Portland, OR 97214, phone "tachycardia," but none are listed for IBIS is immensely useful for (800) 627-6851 or (503) 228-6851; "arrhythmia." physicians who wish to diversify their fax (503) 228-6904. D IBIS does not rank remedies. Look treatment modalities. It also serves as

In Memoriam

Lecture in 1974 and the Scott Memo­ David M. Davidson, DO rial Lecture in 1982 He earned his Fellowship in the American Acad­ Dr. Davidson of Kettering, Ohio, emy of Osteopathy in 1978. passed away April 16, 1994. He was Dr. Siehl was certified in ortho­ a retired radiologist with 35 years of pedic surgery by the American Os­ service and remained active in teopathic Board of Surgery, later serv­ osteopathic medicine. Donald C. Siehl, DO ing as its secretary-treasurer and or­ Dr. Davidson graduated from thopedic representative. He also Kirksville College of Osteopathy and Dr. Donald Siehl passed away on served as president of the American Surgery in 1938. As well as being September 30. He graduated from College of Osteopathic Surgeons and certified in diagnostic roentgenology, the Kirksville College of Osteopathic American Osteopathic Academy of he was a fellow of the American Medicine in 1943 and served both an Orthopedics. He served as president Osteopathic College of Radiology. internship and orthopedic residency of the American Osteopathic Asso­ Memberships included The at Doctors Hospital in Columbus, ciation in 1978-1979. American Academy of Osteopathy and Ohio. He practiced as an orthopedic He is survived by his wife, Susan, life membership in the American surgeon in Dayton, Ohio until his and seven children. Four of his broth­ Osteopathic Association, among others. retirement. Dr. Siehl was one of only ers were also osteopathic physicians. Dr. Davidson was survived by his four DOs to serve in the U.S. Public Friends may write his family at 1500 wife, Lillian L, Davidson of Kettering, Health Service as a commissioned WestbrookRoad,Dayton, Ohio45415 two sons, David M. Davidson of medical officer during World War II. Memorial contributions may be made Boston, MA and Edwin S. Davidson A dedicated and loyal Academy to Grandview Hospital/Donald Siehl of Kettering. member since 1943, Dr. Siehl deliv­ Memorial Fund or to a charity of the The Academy sends its deepest ered the Academy's T.L. Northup donor's choice.□ condolences to his family.□

20/AAO Journal Winter 1994 From the Archives

11Who is to Blame?" Revisited

by Philip E. Greenman, DO, FAAO

Editor's Note: the following excerpts Yearbook. Forty-two years ago he system in our society are tremendous. are from Dr. Greenman's Thomas L. lamented what he saw as the decline We must find ways to harness the Northup, DO, Memorial Lecture of osteopathy within the profession. burgeoning and costly highly presented in conjunction with the How did the profession find itself sophisticated technological aspects of American Osteopathic Association's in such difficulty? It is quite easy for medicine control overall health costs annual convention, November 15, one to point a finger at one or more of provide access to quality health care 1989. the elements of the profession and say to all of our citizens and, assure a that they are to blame. personalized form ofhealth care which ... One is left with perception that our public seems to desire. The "Having practiced osteopathy for there is clearly enough blame to be osteopathic profession has many more than 40 years - having watched shared by all of us within the things to contribute to the solution of the growth of the profession through profession. In the words of the these problems, particularly in the the years in all of its unfolding and immortal bard, Pogo, "We have met area of primary care, holistic care and development, in its graduates, its the enemy, and they are us". Each of the role of the musculoskeletal system conventions and its publications - I in health and disease. We have an am free to confess that my us share in the blame for the condition we find ourselves in today, and each opportunity to influence the majority disappointment in our osteopathic development as an osteopathic ofus must contribute to the solution if school of medicine and health policy profession is indeed very great - we the profession is to survive into the makers at multiple levels about the have traded our birthright for a mess twenty-first century. valuable things of the osteopathic of pottage. It seems to me that each individual experience of the last century. Andrew We have progress, but not the osteopathic physician, each Taylor Still formed the osteopathic osteopathic progress that reasonably osteopathic hospital and each profession as a reform school of could have been expected of us. Our osteopathic organization can share medicine to meet the challenges of schools have grown, and the number the blame for our problems of today. his day. I would submit to you that of graduates has multiplied, but the It also seems to me that each individual there still is need for reform in our kind of graduate of today is very practitioner, each hospital and each health care delivery system, albeit disappointing - he does not rely on organization can contribute to the different from Still's day, but it is his knowledge of osteopathy to cure solutions to our problems ifwe apply certainly worth pursuing. If we, as his patients. He gives internal a basic osteopathic approach to the members of the osteopathic medicine to such an extent that many solutions. We all must function as profession, support the basic tenets of of his patients do not know that he is "osteopathic" practitioners so that our osteopathic philosophy and its an osteopathic graduate; he has such organizational structures will truly concepts, then we should strive an inferiority complex that he is reflect osteopathic health care and diligently to see that they are a part of ashamed to be known as an osteopathic public policy. I believe all health care. If you will, we should osteopathic physician and wants to be the osteopathic profession has the strive to make all physicians known as a physician and surgeon. Is inherent capacity for self-regulation "osteopathic" physicians. To do less this the kind of growth we have that has allowed it to meet the denies the heritage of Andrew Taylor expected of our graduates? Are we challenges of the past and to adapt to Still. Let us all become part of the satisfied with this kind of progress?" changes in the future, if we solution, rather than part of the These insightful, challenging and demonstrate the will to do so. As we problem, so that 40 years hence disturbing comments were made by approach the twenty-first century, the another lecturer does not need to

OrrenE. Smith,DO, in the 1947 AAO challenges to the health care delivery revisit "Who is to blame"?□

Winter 1994 AAO Joumal/21 From the AOBSPOMM Files

AAO Case History Immune System

by Elaine M. Wallace, DO

Introductory Statement: Grandmother (Paternal): .J.Heart attack Allergies: No known drug or food This case outlines the vital role Grandfather (Paternal): .J, Stroke allergies. Reports mild lactose that manipulative therapy has upon 2 Brothers: one older-Hyperthyroidism intolerance. one younger-healthy the immune system. This patient had 1 Sister: healthy HIV infection diagnosed in 1987 and Medications: 2 multiple vitamins/ has been consistently healthy through Social History: N.R. is a city day; 3000 mg. Vitamin C/day;2 B a combination of exercise and government employee whose job is Complex/day manipulative therapy. reading gas meters. He describes it as Review of Symptoms: Patient has low stress. He sets his own hours and no specific complaints or symptoms. Identification: N.R. is a 38 year old gets exercise (job related) daily. He black male He specifically denies hot flashes, has performed this job for six years. night sweats, diarrhea, easy N.R. does not smoke and drinks Chief Complaint: "I need to deal bruiseability, rashes, weight loss or alcohol rarely. He has a past drug rectal bleeding. with my positive mv test" history ( described as recreational) that includes; "poppers", cocaine Physical Examination: History of Present Illness: (snorting), marijuana and quaaludes. Patient found out a past lover was Blood Pressure 118/70 He describes this activity to have been HIV positive so had himself tested at Pulse 76 social and confirmed to his teens and a free health clinic two months ago. Height 6'1" early 20s. Incidence - weekly to 2 x He had the test redone and it was ( +) Weight 200 lbs a second time. He has heard I treat week - variable. He presently does no HIV patients and is seeking my care. drugs and has not for 4 years. This Body type: Mesomorph drug termination was self imposed. Skin: Cool and dry with no appreci­ Medical History: Negative - for N. R. describes himself as bisexual. able dermatologic lesions. cardiac, pulmonary, HEENT, GI, He presently is involved in a stable lymphatic, pulmonary, neurological, homosexual relationship ( 4 years Head/Neck: musculoskeletal systems -Specific duration) with a married (although Head: Normocedphalic negative answers to hepatitis and separated) male. They live in separate Neck: Supple with no apparent mononucleosis. domicles. masses. No cervical or clavicular Patient does report previous N.R. also reports an active (x 4 adenopathy appreciated. infections of nonspecific urethritis(" a years) in his mid-twenties when he Thyroid: Of normal size with no few"), GC - urethogential and was a male hooker. His partners were palpable masses. oropharyngeal and syphilis X 1. predominantly males - contacts made on the streets or in parks. None of the EET Examination: Demonstrates normal ocular examination. Tympanic Surgical History: negative activities at that time were performed membranes clear to visualization with with condoms. His present partner good light reflex. Dentation grossly Family History: has not been tested. They are intact with dental work appreciated in Father: Status unknown practicing safe sex. Mother: jHypertension, previous inferior posterior molars. There are no N.R. exercises daily (jogs 5 miles) breast carifaoma appreciable mucous membrane lesions Grandmother (maternal): I Heart attacks and teaches aerobic exercise 8 hours/ in the mouth. There are no bruits Grandfather (maternal): .J,Heart attacks week. auscultated in the caroltid region.

22/AAO Journal Winter 1994 Heart: Rhythm and rate are regular respiratory motion noted in the sacrum somatic dysfunction this patient without murmurs. Apical beat with the sacral base held posterior undergoes a complete treatment appreciated at intercostal space 5 on (sacral extension-biomechanical/ protocol of lymphatic techniques. The left. sacral flexion-cranial). Bilateral lumphatic treatment begins with anterior rotation of the ilium with thoracic pump techniques (repetitive Lungs: Clear to auscultation in all slight inflaring bilaterally. pump) followed by pectoral traction, fields. rib raising, doming of the diaphragm, Cranial: Cranial rhythm is abdominal pump, effleurage and Breast Exam: Appropriate for male appreciated and evaluated to be slow petrissage of all extremities. This is examination and negative for masses. (8 impulses per minute). The occiput followed by complete cervical and Axilla bilaterally demonstrates no is held in slight extension. cranial lymphatic treatment including anterior or posterior adenopathy. anterior and posterior cervical lymph X-Rays: not applicable. node stroking, occipital node stroking, Abdomen: Exam reveals firm pre and post auricular node stroking, musculature with no guarding or Laboratory: Galbraith's Technique (raking the face), tenderness to palpation. Normal '87 '89 '90 submandibularnode treatment, anterior Total T cells 65-95 77 85 76 cervical chain treatment, supra and infra Liver: margin is normal. Mature T cells 55-85 69 78 68 hyoidnode treatment, and repetition of Spleen: Small although palpable Helper T cells 32-55 31 29 32 the thoracic pump (both repetitive and Kidneys: normal - no organomegaly Suppressor T cells 14-38 32 44 43 Helper/ vacuum type). This patient also receives or masses appreciated Suppressor ratio 1.1-2.55 .97 .66 .74 pedal pump at the time ofrepeat thoracic pump. Special attention is also given to Extremities/BV: Both arms Diagnosis: first rib dysfunctions and release of the demonstrate slight valgus presentation l. Healthy black male positive HIV superior thoracic inlet. at elbows. Normal arterial blood supply laboratory test. As part of this patient's exercise and venous blood supply appreciated in 2. Somatic dysfunction of sacrum­ protocol, this patient continues to jog 5 upper and lower extremities. Good bilateral sacral extension. miles per night, lifts weights in a balance tendon reflexes appreciated in upper 3. Somatic dysfunction of ilium­ directed manner and continues to teach and lower extremities (+2/+4). bilateral iliac rotation in inflare. aerobics on a weekly basis. 4. Somatic dysfunction of thorax-T7 His dietary supplement continues to Gait: Patient has a normal gait & 8, FR(R) SB(R) include the above mentioned vitamins without antalgicsteps. Weight bearing 5. Slow-Normal cranial rhythm. as well as anti-oxidants. He takes no appears appropriate and mid-line. 6. Cranial base in extension medication other than the above Patient absorbs weight in heel and mentioned vitamins. transfer weight appropriately from Treatment Planned: It was lateral foot to hallux. recommended to this patient that proper Prognosis: Stable diet, exercise and manipulative Biomechanical: (Structural) threatment would be appropriate in his Discussion: This case demonstrates Spinal: Patient shows extremely well life planning-therapy for HIV infection. the efficacy of osteopathic developed musculature in all areas of manipulative treatment when used on body. There is a normal, although Course of Therapy: This patient a regular basis in the ancillary decreased cervical lordosis, a normal receives regular osteopathic treatment of HIV infection. This kyphosis and a decrease in lumbar manipulative threatments on a two week patient's exercise regime, as well as lordosis. All ranges of motion in gross basis. His manipulative threatment structured manipulative threatment evaluation of the cervical, thoracic and includes treatment of specific somatic regime insures maximal functioning lumbar areas are normal. There is no dysfunctions as evaluated at the time of of the lymphatic system. This patient gross structural asymmetry noted. visit. For the patient's initial evaluation, has been stable in his HIV infection Patient demonstrates mid-thoracic high velocity-low amplitude thrusting since his original diagnosis in 1987. muscular tension at the areas of the was performed at the thoracic region. rhomboids bilaterally. Soft tissue was performed at all Plan of Therapy: There is an accompanying T7 & 8 muscular tension sites. Muscular energy This patient will continue to be somatic dysfunction rotated (R) was performed on the sacrum and the seen by me on a regular basis for sidebent (R), held inflexion . ilium. Balancing membranous of manipulative threatment for the tension was performed in the cranium. remainder of his adult life.□ Pelvis: There is a decreased In addition to treatment of specific

Winter 1994 AAO Journal/23 ••• ••••••Program•••••••••••••• •

Wednesday, March 22, 1995

7:45 - 8:00 Welcome Ann Habenicht, DO, Program Chairperson Eileen DiGiovanna, DO, FAAO, AAO President

8:00 - 8:45 Neuroanatomy of Pain Frank Willard, PhD

8:45 - 9:30 Trauma Vectors lvt~CuyUSA Judith O'Connell, DO 9:30 -10:00 Break/Exhibits

10:00 -10:45 Physiatrist's Role in Chronic Pain James Lipton, DO, FAAO

10:45 -11:30 Reflex Sympathetic Dystrophy & Sympathetic Dystonia American Robert Kappler, DO, FAAO

11:30 -12:00 Psychiatric Aspects of Chronic Pain Academy Andrew Lovy, DO of Osteopathy 12:00 - 1:30 Lunch 1:30 - 3:00 Workshops A-Back to Basics OMT: HVLA for Chronic Pain Robert Kappler, DO, FAAO

B-Back to Basics OMT: Facilitated Positional Release Stanley Schiowitz, DO, FAAO

C-Back to Basics OMT: Ligamentous Articular Release 1995 M. Denise Speed, DO and Conrad Speece, DO

AVvYUMiUI D-Torquc Unwind (runs entire PM) Elaine Wallace, DO

C o-rw~LO-rv E-Fellows Forum FAAO and NUFA Harold Magoun, DO, FAAO

3:00 - 3:30 Break/Exhibits

3:30 - 5:00 Workshops F-Back to Basics OMT: HVLA for Chronic Pain March 22-25, 1995 Robert Kappler, DO, FAAO G-Back to Basics OMT: Facilitated Positional Release Stanley Schiowitz, DO, FAAO

H-Back to Basics OMT: Ligamentous Articular Release Opryland Hotel M. Denise Speed, DO and Conrad Speece, DO I-Education Committee Forum Nashville, Tennessee Boyd Buser, DO, and AAO Education Committee

24/AAO Journal Winter 1994 •• · ··· · ········•New Horizons in Pain Management·•••···· Thursday, March 23, 1995 Friday, March 24, 1995

7:45 - 8:00 Morning Convocation Update 7:45 - 8:00 Morning Convocation Update Ann Habenicht, DO Ann Habenicht, DO

8:00 - 8:45 Pharmacology in ChronicPain 8:00 - 8:45 Nutritional Needs in Chronic Pain William Elliott, MD, PhD Stephc(l Elsasser, DO

8:45 - 9:30 Oh, No, Fibromyalgia! 8:45 - 9:30 Reducing Gravitational Strain Pathophysiology Mark Cantieri, DO Michael Kuchera, DO, FAAO

9:30 -10:00 Break/Exhibits 9:30 -.10:00 Break/Exhibits

10:00 -10:45 Chronic Foot and Ankle Pain 10:00-10:45 Chronic Pelvic Pain Thomas Ravin, MD Melicien Tettambel, DO, FAAO

10:45 -11 :30 Discogenic vs. Non-Discogenic Pain 10:45-12:00 Exercises for Chronic Pain Manuel Pinto, MD interactive lecture with audience participation Karen Gadja, DO 11:30 -12:00 Acupuncture in Chronic Pain Kenneth Lubowich, OMD 12:00-12:30 New Ideas Forum (two 15-minute presentation time slots available; prospective presenters must 12:00 - 1:30 Lunch submit outlines to the EDCOM for selection)

1:30 - 3:00 Workshops Saturday, March 25, 1995 K-Back to Basics OMT: Muscle Energy Boyd Buser, DO 7:45 - 8:00 Morning Convocation Update Ann Habenicht, DO L-Back to Basics OMT: Countcrstrain John Glover, DO 8:00 • 8:45 Anesthesia's Role in Chronic Pain Management Larry Harker, DO M-Torque Unwind (runs entire PM) Elaine Wallace, DO 8:45 - 9:30 Migraine Ccphalgia Hal Pineless, DO N-Treatment of Chronic Foot & Ankle Pain Thomas Ravin, MD 9:30 -10:00 Break/Exhibits O-Faculty Development: The Physician as a 10:00 -10:45 Facial Pain: Bell's Palsy & Trigeminal Neuralgia Researcher, Documenting Outcomes Research William Wyatt, DO John Hohner, DO 10:45 -11 :30 Chronic Cervical Spine Pain 3:00 - 3:30 Break/Exhibits Karen Steele, DO 3:30 - 5:00 Workshops 1:00 • 5:00 Conclave of Fellows P-Back to Basics OMT: Muscle Energy Boyd Buser, DO

Q-Back to Basics OMT: Countcrstrain ,-:-··························~ John Glover, DO • • • Ann Habenicht, DO, • • • R-Treatment of Chronic Foot & Ankle Pain • Program Chairperson • Thomas Ravin, MD • • • • S-Faculty Development: How to Represent • CME Hours: : Osteopathy to Third-Party Payors • • Judith Lewis, DO & MO Medical Economics Cmte • 25 Hours Category 1-A • \...... 1

Winter 1994 AAO Journal/25 continued from page 12

••~••••"••~•~ii•t><_____ Growth factors Corollary #1: i Receptors ,:···········""", ------People are predisposed -- Second messengers to develop specific Transcriplion factors. both positive and n~yative facilitated segments.

Chromatin containing prolo-oncagenes and Some people inherit a tumor suppressor genes predisposition to cancer but most cancers require several somatic Proteins that affect the c..,..-----rate of cell division mutations; the exact number of mutations is not known. However, colon cancer contains between 4 to 7 mutations and the initial tumorigenesis requires at least one oncogene and the loss of both alleles Figure 1. Componets of a normal cell that are important in trans[orma­ 40,41 o f a tumor suppressor gene. tion, first, to a normal cell and then to a neoplasm. If facilitated genes contribute to producing a facilitated segment, some individuals would be genetically A-Nonneuronal Cell predisposed to develop facilitated segments. Consider two people .! Receptors exposed to the same environmental '(~;-,--·····-·····'""""•~--- i circumstances. One individual would Transcription factors~ both display the phenotype of somatic positive and negative dysfunction because of the existence

Chromatin containing one of a certain set of facilitated genes. or more facilitated genes The other individual would not develop symptoms because of a lack of a set of facilitated genes. Neuronal facilitation factors Furthermore, since most somatic or enzymes lh~t catalize the production of neuronal mutations would be expected to be facilitalion factors. limited to certain areas of the

8. Neuron-al Cell organism, only those areas of the organism containing facilitated genes would be predisposed to develop a facilitated segment. Thus, each individual would have a unique set of predisposed segments, and be predisposed to develop specific facilitated segments.

Corollary #2: Proteins that modulate signal propagation Somatic dysfunctions presenting in a similar manner may be due to different sets of physiological changes. Figure 2. Example showing the case where both nonneuronal and neuronal cells have at least one facilitated gene.

26/AAO Journal Winter 1994 The hypothesis also predicts that It seems likely that what physicians We have derived a numbe r of individuals with a somatic dysfunction call a facilitated segment will turn clinically relevant corollaries from affecting the same region may have out to be many types of facilitated this hypothesis. It is now incumbent different sets of faci Ii tated genes. Most segments. Each of these facilitated upon our laboratory and others to specific types of cancers have been segments may, in turn, be facilitated develop evidence to either support or reject this hypothesis. In either case, shown to contain different sets of in a variety of ways and by a variety the knowledge will be oncogenes and tumor suppressor of cells. At present, the problem derived valuable for our further understanding genes. What is diagnosed as colon appears quite complex. However, as of the facilitated segment. cancer is actually a large set of colon complex as cancer appeared to be, it cancers as judged by the different sets is now better understood in terms of , I of oncogenes and tumor suppressor oncogenes, tumor suppressor genes, References I genes present in each individual. For and multiple growth factors. It may example, the ras oncogene is found in be that the eventual identification of 1. Denslow JS: An analysis of the 42 variability of spinal reflex thresholds. J. facilitated genes and cells will expand 40 to 50 percent of all colon cancers. Neurophysiol, 1944;7:207-15. This means that it is missing in 50 to our understanding of the facilitated 60 percent of all colon cancers. Several segment and direct us toward more 2. Denslow JS: An analysis of irritability tumor suppressor genes are absent in specific therapeutic interventions. of spinal reflex arcs. JAOA, 1945;4:357-62. many cases but not all cases of colono­ 3. Denslow JS, Korr IM, Krems AD: rectal cancer. The MCC (mutated in Corollary #4: Quantitative studies of chronic facilitation in colono-rectal cancer) gene on The alterations causing human motoneuron pools. Amer J Physiol, 1947;150:20-38. chromosome #5 is often absent. The a facilitated segment may DCC ( deleted in colon cancer) gene is be permanent and persist 4. Korr IM, Wright HM, Chace JA: absent 70 percent of the time on for the lifetime Cutaneous patterns of sympathetic activity in chromosome #18 and the p53 tumor clinical abnormalities of the musculoskeletal suppressor gene is absent 75 percent of the individual. system. Acta Neurovegetativa, of the time on chromosome #17. Only 1964;25(4):589-606. 40 percent of the colon carcinomas One of the most obvious implications of the hypothesis is that 5. Korr IM, Wright HM, Thomas PE: have mutations in 3 of the 4 genes just Effects of experimental myofascial insults on 8 the underlying conditions, i.e. genetic mentioned. By analogy, anatomically cutaneous patterns of sympathetic activity in similar facilitated segments in two changes, may be permanent. This man. Acta Neurovegetativa, 1962;23(3):329- individuals may be due to different does not bode well for the efficacy of 355. sets of facilitated genes with their own therapy. In fact, should support for this hypothesis be forthcoming, it 6. Van Buskirk, RL: Nociceptivereflexes unique pathology. and the somatic dysfunction: a model. JAOA, would alter the way we approach 1990;90;792-809. Corollary #3: somatic dysfunction. The possibility that lesions may become permanent 7. Richardson GE, Johnson BE: The Somatic dysfunction should lead osteopathic physicians Biology of Lung Cancer, Seminars in will not respond and researchers to focus more on Oncology 1993;20(2):105-127. to a single intervention. preventive measures than symptom 8. Story, MT: Polypeptide Modulators of related therapy. Prostatic Growth and Development. Cancer The cell biology of cancer and our Surveys 1991;11:123-146. hypothesis offers another corollary. Summary Historical! y, researchers and clinicians 9. Fearon ER, Jones PA: Progressing A hypothesis has been presented toward a molecular description of colorectal have looked for a magic bullet to cure that the physiological mechanisms cancer development. FASEB J, 1992;6:2783- a single process gone awry. Now involved in the formation of a 2790. cancer is understood in terms of facilitated segment may have features 10. McMahon SB, Monroe JG: Role of multiple genes and processes. The in common with the molecular oncogenes and the sequence of their primary response genes in generating cellular mechanisms responsible for the responses to growth factors. FASEB J appearance are not identical from one development of cancer. This synthesis 1992;6:2707-2715. type of cancer to the next. Also the­ has been developed as the result of an cellular environ ments supporting increased understanding of the 11. Coffey RJ, McCutchen CM, Graves- different types of cancer vary greatly. common mechanisms of cell function.

Winter 1994 AAO Joumal/27 Deal R, Polk WH Jr. J Cell Biochem, Suppl 23. Abe K, Xie F, Saito H: Epidermal development:Normal and Pathological. Dev 16G, 1992;111-118. growth factor enhances short-term potentiation Neurosci 1992;14:1-10. and facilitates induction of long-term 12. Aaronson SA, Tronick SR: Growth potentiation in rat hippocampal slices. Brain 35. Prados MD, Wilson CB: Neoplasms of factors, in Holland JF, Frei E Ill, Bast RC Jr. Res 1991;547:171-174. the central nervous system, in Holland JF, et al. (eds) Cancer Medicine, 3rd Ed, Frei E III, Bast RC Jr. ct a I (eds) Cancer Philadelphia, Pa, 1993;1:33-48. 24. Hennings H, Glick AB et al.: Critical Medicine, 3rd Ed, Phi ladelphia, Pa, aspects of initiation , promotion, and 1993;1:1080-1119. 13. Akbasak A, Sunar-Akbasak B: progression in multistage epidermal Oncogenes:cause or consequence in the carcinogenesis. Proc Soc Exp Biol Med 36. Reynolds BA, TetzlaffW, Weiss W: A development of glial tumors. J Neurol Sci 1993;202(1):1-8. multipotentEGFresponsivestriatalembryonic 1992;111:119-133. progenitor cell produces neurons and 25. Radeke HH and Resch K: The astrocytes. J Neurosci 1992;12(11):4565-74. 14. Hunt SP, Pini A, Evan G, Induction of inflammatory function of renal glomerular c-fos-likc protein in spinal chord neurons mesangial cells and their interaction with the 37. Pons S, Torres A: Basic fibroblast following sensory stimulation. Nature cellular immune system. Clin Investig growth factor modulates insulin-like growth 1987;328:632-634. 1992;70:825-842. factor-I, its receptor, and its binding proteins in hypothalamic cell cultures. Endocrinology 15. Menetrey D, Gannon A, Levine JD, 26. Wilkin GP, Marriott DR, Cholewinski 1992;131(5):2271-78. Basbaum Al: The expression of c-fos protein AJ et al. Receptor activation and its in presumed nociceptive interneurons and biochemical consequences in astrocytes. Ann 38. SmitsA,KatoM, WestermarkB,etal.: projection neurons of the rat spinal chord: NY Acad Sci 1991;633:475-88. Neurotrophic activity of platelet-derived Anatomical mapping of the central effects of growth factor (PDGF):Rat neuronal cells noxious somatic, articular and visceral 27. Evans T, McCarthy KD, Harden TK: possess functional PDGF beta-type receptors stimulation. J Comp Neural 1989;285:177- Regulation of cyclic AMP accumulation by and respond to PDGF. Proc Natl Acad Sci 195. peptide hormone receptors in USA 1991;88(18):8159-63. immunocytochemically defined astroglial 16. CarboneDP,MinnaJD:Antioncogenes cells. J Neurochem 1984;43:131-138. 39. Ota A, Shen-Orr Z, et al.: TP A-induced and Human Cancer. Annu Rev Med neurite formation in a neuroblastoma cell line 1993;44:451-64. 28. Kimura H, Okamoto K, Sakai Y: (SH-SY5Y) is associated with increased IGF- Modulatory effects of prostaglandin D2, E2 1 receptor mRNA and binding. Molecular 17. Cho KR, Vogelstein B: Genetic and F2a on the postsynaptic actions of Brain Research 1989;6:69-76 Alterations in the AdenomaCarcinoma inhibitory and excitatory amino acids in Sequence. Cancer 1992;70:1727-31. cerebellar purkinje cell dendrites in vitro. 40. Cho KR, Vogelstein B: Genetic Brain Res 1985;330:235-244. alterations in the adenomacarcinoma 18. Westermark B, Heldin C-H: Platelet­ sequence. Cancer Supplement , American derived growth factor in autocrine 29. Murphy S, Pearce Bet al.:Astrocytes Cancer Society, J.B. Lippincott, Philadelphia, transformation. Cancer Research as eicosanoid-producing cells. GLIA J992;70(6):1727-31. 1991;51:5087-92 1988;1:241-245. 41. Stein WDL Analysis of ca ncer 19. Henderson BE, Bernstein L, Ross RK: 30. Clemens MJ: Cytokines, in Read AP, incidence data on the basis of multistage and Hormones and the Etiology of Cancer, in Brown T, (eds): Medical Perspectives Series, clonal growth models, in Holland JF, Frei E Holland JF, Frei E III, Bast RC Jr. et al (eds) BIOS Scientific Publishers Ltd., Oxford UK, III, Bast RC Jr. etal. (eds) Cancer Medicine Cancer Medicine 3rd Ed, Philadelphia, Pa, 1991. 3rd Ed, Philadelphia, Pa, 1993; 1 :1080-1119. 1993; 1 :223-232. 31. Malipiero W, Frei K , Fontana A: 42. Klein G: Oncogenes, in Holland JF, Frei 20. Dickson RB and Lippman ME: Production ofhcmopoieticcolony-stimulating E III, Bast RCJr. et al. (eds) Cancer Medicine, Molecular Determinants of Growth, factors by astrocytes. J lmmunol 1990; 3rd Ed, Philadelphia, Pa, 1993;1:65-77.0 Angiogenesis, and Metastases in Breast 144(10):3816-3821. Cancer. Sem inars in Oncology, 1992;19(3):286-298. 32. Lieberman AP, Pitha Pet al.: Production of tumor necrosis factor and other cytokines 21. Weinstein IB: The Origins of Human by astrocytes stimulated with lipopoly­ Encourage Cancer:Molecular Mechanisms of saccharide or a neurotropic virus. Proc Natl Carcinogenesis and Their Implications for Acad Sci USA 1989;86:6348-52. Your Cancer Prevention and Treatment. Cancer Colleagues Research 1988;48:4135-4143. 33. Farrar WL, Kilian PL, et al.: V isua lization and characterization of to become 22. Moore RW, Mokler DJ, Winterson BJ: interleukin 1 receptors in brain. J Immunol Board Certified Intrathecal ly administeredN-methyl-D-aspartate 1987;139(2):459-63. increases persistent hindlimb Hexion in rat. inOMM Neuroscience Letters 1992; 146:223-226. 34. Merril JE: Tumor necrosis factor alpha, interleukin 1 and related cytokines in brain

28/AAO Journal Winter 1994 New! New! New! New! New! New! New! Muscle Energy Course April 28-30, 1995

A complete twenty-hour course in diagnosis and treatment of somatic dysfunction using muscle energy technique. The physician attending this course will receive instruction in the diagnosis and muscle energy treatments for somatic dysfunction of the hip, pelvis, sacrum, lumbar spine, thoracic spine, costal cage and cervical spine. Common patient presentations will be discussed as well as some of the rarer types of dysfunction.

Program Chairperson: Call: Location: Walter Enhrenfeuchter, DO, FAAO American Academy Radisson Plaza Hotel of Osteopathy Indianapolis, Indiana Faculty: Karen Arscott, DO for more information Guy DeFeo, DO, CSP-OMM on advance registration Class Limited John Glover, DO, CSP-OMM to 50 John Jones, DO, CSP-OMM (317) 879-1881 Evan Nicholas, DO

BML Osteopathic BASICPHYSICIANS Principles and Practice SUPPLY,INC. OD10430Highway 412 West • Paragould,AR 72450 Fu II Inventory on by Rubber or Crepe Thomas F. Schooley, DO, FAAO

HEEL 'This book, ... , is an attempt to put LIFTS these subjects in some semblance of FREE rational conformity as an introduction I SAMPLE KIT to Osteopathic philosophy, principles and techniques for us by the "YOUR BEST BUY SUPPLY" beginning student." • Foot Orthotics • Electrodes • Orthopedic Braces • Lotions, Gels • Electrotherapy Equipment • Tables Attn: Publications 39 YEARS OF SERVING 1-800-643-4 751 Available from The American Academy of Osteopathy Call For FREECatalog $20 plus shipping and handling ------_---- -_-_ -_-_ ---_ ~--_ -_ Winter 1994 AAO Joumal/29 continued from page 18 14) Record and evaluate progress affected area, and then recheck each in the chart by using both sub­ of these motions at the end of 9) Use Triggerband Technique. jective and objective criteria. treatment. This demonstrates to the Begin by going to the patient objective improvement, so he 'Crossband'* of the most or she can appreciate your work. painful triggerband. Clinical Examples of Failure to respond means either the 10) Treat other affected bands. Commonly Seen diagnosis was wrong, or the treatments 11) On the second or third treatment consider OMT or Triggerbands were not forceful enough. A complete other modalities. Two examples of commonly seen reevaluation should be done on any 12) Give home instructions of ice, Triggerbands are shown in Figures 8 atient that does not respond. no heat, and other appropriate and 9. Fascia] shoulder injuries and Triggerband Technique requires activities. In chronic pain four their treatments are then discussed in certain palpatory skills that take some days of rest are usually needed the final portion of this paper. Before time to develop. Be sure to allow the in between treatments. In treating any fascia] distortion first patient to guide your treatment. If you acute pain the patient can check and record abduction, internal usua11y be retreated in 24 to are unsure of where the triggerband 48 hours. and external rotation, flexion and is, ask, "Am I on it?" In a short time, 13) Answer any patient questions. extension or other motions of the with a little practice and experience,

'Star' Triggerband Pathway Pathway for Lower Back Pain for Upper Thoracic Pain with Posterior Thigh Tightness

•m:r

~ ig-ur-e~9 Figure 8 fo------F-

Cadaver Dissection

*Crossbands are the anatomical starting place of trigger bands. They are typically strong fasical fibers that are found in the same plane and at an angle to the triggerband. In figures 8, 9, 11 and 12, the crossbands are present where thearrows originate.

30/AAO Journal Winter 1994 to Figure 11. First, find a tender area in the anterior proximal lateral forearm. Then feel for an irregularity in the surrounding fascia. Once this is found, forcefully push it superiorly toward the shoulder. This tender area will move up the forearm, then up the arm and into the bicipital tendon area. Here it will be the most painful. Once it passes the biceps area it will continue to move into the supraclavicular fossa or along the clavicle. Then it will pass up the neck along the margins of the sternocleidomastoid muscle up to the mastoid where it terminates.

Step ill: After the anterior shoulder pathway is completed, check internal rotation. Many times it is normalized. If not, ask the patient again where the Figure 10 pain is. If he/she specifies the pain is still in the biceps groove area, then Triggerband Technique can be easily pressure variant seems to change. repeat the above more forcefully. If done with a minimal amount of time Follow the maximum 'bogginess' and instead the pain is more superiorly on involved. hold it firmly. After 15 seconds to 3 the shoulder or more posteriorly, then minutes (with an average of 1.5 the posterior shoulder pathway needs minutes) the triggerpoint will begin to be done. See Figure 12. This Treatment to release. This release is dramatic triggerband begins more laterally and of the Injured Shoulder but gradual. It may take as long as is on the posterior surface of the Before and after each step check one-half minute for the complete proximal forearm. It is treated in the abduction, and internal and external release. Hold it with constant or same manner as the anterior shoulder rotation. increasing pressure, and 'milk' it until triggerband pathway except that it it has completed its entire release. passes along the lateral arm and into Step I: The supraclavicular The patient will have a strong the upper margins of the trapezius triggerpoints are shown in Figure 10 sensation of this release as well. The muscle to the base of the neck. Then • I • and should be treated in all shoulder lateral supraclavicular triggerpoint is 1t crosses over at T to the opposite pain patients. The medial is far more more difficult to treat and is less side and moves up the neck along the important than the lateral. Treat the important. For most beginners, capitus muscle until it terminates at medial first by palpating at the base of treatment of the lateral supraclavicular the mastoid. It often becomes buried the neck between the clavicle and triggerpoint should be skipped. under the occiput en route to the scapula. The amount of tension varies mastoid. Once this is corrected, check widely. Find the triggerpoint by Step II: Triggerband Technique is internal rotation again. If it is not feeling for an area that feels like a the next portion of the treatment. If normalized ask the patient where the 'boggy marble'. Use firm pressure the pain is anterior in the shoulder pain is. If it is still in the posterior and push the triggerpoint in a along the biceps groove, then shoulder area, repeat this triggerband downward and slightly medial triggerband technique is done by using with more force. direction. Gently 'milk' it as the the anterior shoulder pathway. Refer

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had had

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decreased decreased motion. motion.

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thumb thumb

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32/AAO 32/AAO

Figure Figure Figure Figure manipulated. Have the patient seated pin a chair and stand behind and reach around and grab his/her flexed elbow of the sore shoulder with both palms. As the patient drops the shoulder, manipulate with a quick thrust in the superior-posterior direction. Usually a loud 'crack' or 'pop' is felt or heard. Many times motion is dramatically improved.

Step VI: The patient is rechecked in several days. At times, the entire procedure may need to be repeated. Any shoulder that does not respond should be thoroughly reevaluated. Once corrected, exercises and physical therapy are considerations but are usually unnecessary. At home these patients should practice "dropping" the injured shoulder while watching in the mirror. Ice should be used to reduce the tenderness and any application of heat should be strongly discouraged. □ Figure 13a

Figure 13b Figure 13c

References

1 Gerlach, U. J., Lierse, W.: Functional construction of the superficial and deep fascia system of the lower limb in man. Acta Anat (Basel) 1990;139(1):11-25.

Winter 1994 AAO Journal/33 Classifieds

OMM/ Iowa OMM Physician Needed Physical Medicine Major osteopathic college is seeking DO with manual medicine skills Physician well credentialed, motivated and needed for progressive interdiscipline enthusiastic BC/BE osteopathic musculoskeletal clinic. Located on to join busy, well established practice physicians to join an expanding Maryland's eastern shore peninsula, in Colorado Springs, Colorado . department of osteopathic mani­ close to ocean and Chesapeake Bay. Partnership or solo option available. pulative medicine. Position includes Excellent benefits package, Call Vincent Conner at (719) 260- a good balance between patient care competitiv e salary depending on 8179. and didactic teaching. Excellent experience level. Call Dr. Sebastian benefits with salary negotiable (410) 742-3931 for details. New Orleans according to experience. Send letter Phyiatrist practicing orthopedic of interest with CV and three Jean-Pierre Barral, DO medicine ( osteopathic techniques, professional references to David prolotherapy) seeks DO to ultimately Boesler, DO, Chairman, Department Visceral take over practice. Large physical of OMM, University of Osteopathic Manipulation therapy department; new medical Medicine and Health Sciences, 3200 office building 15 minutes from Grand Avenue, Des Moines, Iowa, (Part 1) downtown New Orleans. Contact: 50312. The University is an equal Videotapes Edna Doyle MD, 4224 Houma opportunity employer. Boulevard, Suite 470, Metairie, Louisiana, 70006; (504) 456-5160. WVSOM, OMM Department Residency Plus-One offers a complete set The University of North Texas Health of Dr. Barra! Science Center at Fort Worth is on Visceral Manipulation Part 1. OMM Externship currently accepting applications for The only video cassettes Available positions in the Plus-One Residency of his Part 1 course available. LCDR. James Lipton, DO, FAAO is in Osteopathic Manipulative Each set contains soliciting applications from fourth Medicine. New this year, this one­ ( 4) two-hour cassettes year osteopathic medical school year residency qualifies the physician (Edited from 21 hours of workshop) students for an OMM externship at to be eligible for certification in OMM. Cost for complete set is $320 Portsmouth Naval Hospital in A completed residency in any other $160 Virginia Beach, Virginia. Interested specialty is prerequisite for this plus $5 shipping and handling. Contact: parties should contact Dr. Lipton at program. Please address letter of WVSOM, OMT Dept. (804) 398-7266. application and curriculum vitae to 400 N. Lee Street, David A. Vick, DO, Chairman, Lewisburg, WV 24901 Colorado Department of OMM, UNTHSC­ (304) 645-6270 Opportunity immediately available TCOM, 3500 Camp Bowie for an OMT to join a private practice Boulevard,FortWorth, Texas, 76107- 2699; (817) 735-2461. in Grand Junction, Colorado. Our Classified Ad medical practice is expanding and we are in the process of developing a Associate Needed Deadline health promotion center as well. Reply Needed Associate; OMT practice with 10th of the month to: Catherine Princell, Health Partners, Cranial in Santa Cruz, California. preceding publication. 1060 Orchard Avenue, SuiteE, Grand Contact: Marcus Lay, DO, (408) 688- Junction, Colorado, 81501. 3112.

34/AAO Journal Winter 1994 -

II II

JANUARY

28-29 18-19 22-25 Use of the Advance Percussion Use of the Advance Percussion AAO Annual Convocation Vibrator in Adults or Children Vibrator in Adults or Children Program: New Horizons (Advance Course) (Advance Course) in Pain Management Indiana Academy of Osteopathy Indiana Academy of Osteopathy Opryland Hotel Location: The Nutritional Center Location: The Nutritional Center Nashville, Tennessee 724 West Bristol Street, Suite A 724 West Bristol Street, Suite A Contact: Diana Finley, AAO Elkhart, IN Elkhart, IN Associate Executive Director Hours: 16 Category 1-A Hours: 16 Category 1-A (317) 879-1881 Contact: Max Hostetler, DO Contact: Max Hostetler, DO (219) 262-9612 (219) 262-9612 APRIL

FEBRUARY 25-26 22-23 Ski & CME Midwinter Conference Sutherland's Methods for Treating 3-5 Colorado Society of Osteopathic the Rest of the Body Visceral Manipulation (Basic Course) Medicine Hours: 16 Category 1-A Eastmoreland Hospital, Dept of OMM Keystone Lodge & Resort Contact: Conrad Speece, DO and Northwest Osteopathic Keystone, Colorado 10622 Garland Road Medical Foundation Contact: Patricia Ellis Dallas, TX 76218 Portland, Oregon (303) 322-1752 (214) 321-2673 Hours: 20 Category 1-A Fee: $350 (space limited) 28-30 Course Director: Daniel Benksy, DO MARCH AAO Muscle Energy Course Contact: Al Turner, DO Ramada Plaza Hotel Director, OMM Dept 1-5 Indianapolis, Indiana Eastmoreland Hospital 34thAnnual Convention & Scientific CME Hours: 20 Category 1-A (503) 230-2501 Exhibit Show of the Osteopathic Contact: Diana Finley, AAO Physicians and Surgeons of California Associate Executive Director 11-12 Anaheim Hilton and Towers (317) 879-1881 Winter OMT Update Anaheim, California ''Application of Osteopathic Concepts Hours: 46 Category 1-A in Clinical Medicine" and preparation Contact: Kimberley Bauer The Academy Invites for OMM Boards OPSC Adams Mark Hotel (916) 447-2004 its Component Indianapolis, Indiana CME: 18 Hours, Category 1-A 9-12 Societies Contact: Diana Finley, AAO 92ndAnnual Convention to send in their Associate Executive Director Florida Osteopathic Medical Assn (317) 879-1881 Doral Ocean Beach Resort course schedules to Miami Beach, Florida Hours: 30 Category 1-A be published Contact: FOMA (904) 878-7364 in the AAO Journals and theAAO Newsletters.

Winter 1994 AAO Journal/35 Coming,.Soon ! ! ! ■ A New AAO Publication - "Functional Methods: A Manual for Palpatory Skill Development in Osteopathic Examination and Manipulation of Motor Function by William J. Johnston, DO, FAAO and Harry D. Friedman, DO

This manual will be a valuable text for any osteopathic physician from which "The text includes and explains many of the concepts of he/she could learn and use this functional method in the practice of the osteopathic profession and explains advantages of osteopathic medicine. manipulation in an honest, matter-of-fac~ non-threatening manner. It should make non-users wonder why they aren't The text would also be useful to teach cashing in on the advantages of providing manipulation fundamental methods in any for improved patient care. " osteopathic college, to osteopathic physicians in the field, unfamiliar with this type of indirect treatment, or to any William L. Kuchera, DO, FAAO other physician who has the pre­ Co-author of Osteopathic Principles in Practice requisite knowledge to fo]]ow the instructions.

NON-PROFIT ORG. U.S. POSTAGE PAID PERMIT NO. 14 CARMEL, INDIANA