Forum for Osteopathic Thought

Tradition Shapes the Future Volume 15 Number 2 June 2005

C1 Somatic Dysfunction see page 11 Instructions to Authors

The American Academy of ® of the paper; publication follows as soon as Abstract (AAO) Journal is a peer-reviewed publica- possible thereafter, depending upon the back- Provide a 150-word abstract that summarizes tion for disseminating information on the log of papers. Some papers may be rejected the main points of the paper and it’s science and art of osteopathic manipulative because of duplication of subject matter or conclusions. medicine. It is directed toward osteopathic the need to establish priorities on the use of physicians, students, interns and residents and limited space. Illustrations particularly toward those physicians with a 1. Be sure that illustrations submitted are special interest in osteopathic manipulative Requirements clearly labeled. treatment. for manuscript submission: 2. Photos should be submitted as 5” x 7” The AAO Journal welcomes contributions in Manuscript glossy black and white prints with high con- the following categories: 1. Type all text, references and tabular trast. On the back of each, clearly indicate material using upper and lower case, double- the top of the photo. Use a photocopy to Original Contributions spaced with one-inch margins. Number all indicate the placement of arrows and other Clinical or applied research, or basic science pages consecutively. markers on the photos. If color is necessary, research related to clinical practice. submit clearly labeled 35 mm slides with the 2. Submit original plus three copies. Retain tops marked on the frames. All illustrations Case Reports one copy for your files. will be returned to the authors of published Unusual clinical presentations, newly recog- manuscripts. nized situations or rarely reported features. 3. Check that all references, tables and figures are cited in the text and in numerical order. 3. Include a caption for each figure. Clinical Practice Articles about practical applications for gen- 4. Include a cover letter that gives the author’s Permissions eral practitioners or specialists. full name and address, telephone number, Obtain written permission from the publisher institution from which work initiated and and author to use previously published il- Special Communications academic title or position. lustrations and submit these letters with the Items related to the art of practice, such as manuscript. You also must obtain written poems, essays and stories. 5. Manuscripts must be published with the permission from patients to use their photos if correct name(s) of the author(s). No manu- there is a possibility that they might be identi- Letters to the Editor scripts will be published anonymously, or fied. In the case of children, permission must Comments on articles published in The AAO under pseudonyms or pen names. be obtained from a parent or guardian. Journal or new information on clinical top- ics. Letters must be signed by the author(s). 6. For human or animal experimental investi- References No letters will be published anonymously, or gations, include proof that the project was ap- 1. References are required for all material under pseudonyms or pen names. proved by an appropriate institutional review derived from the work of others. Cite all refer- board, or when no such board is in place, that ences in numerical order in the text. If there Book Reviews the manner in which informed consent was are references used as general source material, Reviews of publications related to osteopathic obtained from human subjects. but from which no specific information was manipulative medicine and to manipulative taken, list them in alphabetical order follow- medicine in general. 7. Describe the basic study design; define all ing the numbered journals. statistical methods used; list measurement Note instruments, methods, and tools used for 2. For journals, include the names of all Contributions are accepted from members independent and dependent variables. authors, complete title of the article, name of of the AOA, faculty members in osteopathic the journal, volume number, date and inclu- medical colleges, osteopathic residents and 8. In the “Materials and Methods” section, sive page numbers. For books, include the interns and students of osteopathic colleges. identify all interventions that are used which name(s) of the editor(s), name and location of Contributions by others are accepted on an do not comply with approved or standard publisher and year of publication. Give page individual basis. usage. numbers for exact quotations.

Submission Computer Disks Editorial Processing Submit all papers to Anthony G. Chila, DO, We encourage and welcome computer disks All accepted articles are subject to copy edit- FAAO, Editor-in-Chief, Ohio University, containing the material submitted in hard copy ing. Authors are responsible for all statements, College of Osteopathic Medicine (OUCOM), form. Though we prefer Macintosh 3-1/2” including changes made by the manuscript Grosvenor Hall, Athens, OH 45701. disks, MS-DOS formats using either 3-1/2” editor. No material may be reprinted from The or 5-1/4” discs are equally acceptable. AAO Journal without the written permission Editorial Review of the editor and the author(s). Papers submitted to The AAO Journal may be submitted for review by the Editorial Board. Notification of acceptance or rejection usu- ally is given within three months after receipt /The AAO Journal June 2005 Forum for Osteopathic Thought

Official Publication of the American Academy of Osteopathy® 3500 DePauw Boulevard Tradition Shapes the Future • Volume 15 Number 2 June 2005 Suite 1080 A Peer-Reviewed Journal Indianapolis, IN 46268

(317) 879-1881 ® FAX (317) 879-0563 The Mission of the American Academy of Osteopathy is to teach, advocate, and research the science, art and philosophy of osteopathic medicine, emphasizing the integration of osteopathic principles, practices and manipulative treatment in patient care. In this Issue: AAO Calendar of Courses...... 4 ® American Academy of Osteopathy Contributors...... 6 Stephen D. Blood, DO, FAAO...... President Karen M. Steele, DO, FAAO...... President Elect Component Societies’ CME Calendar...... 7 Stephen J. Noone, CAE...... Executive Director Editorial View from the Pyramids: Anthony G. Chila, DO, FAAO ...... 5 AAO Publications Committee Raymond J. Hruby, DO, FAAO...... Chairperson Regular Features Denise K. Burns, DO Dig On: ...... 8 Stephen M. Davidson, DO From the Archives: Diseases of the Head and ...... 9 Eileen L. DiGiovanna, DO, FAAO Eric J. Dolgin, DO Book Review...... 33 Stefan L.J. Hagopian, DO Elsewhere in Print...... 35 Hollis H. King, DO, PhD, FAAO John McPartland, DO Original Contribution Paul R. Rennie, DO C1 Somatic Dysfunction and Unilateral Retroorbital Cephalalgia Mark E. Rosen, DO David Coffey, DO, FAAO...... 11

Ex-officio Members: Clinical Practice Myron C. Beal, DO, FAAO...... Yearbook Editor Be Careful with this Kind of Case! Anthony G. Chila, DO, FAAO...... Journal Editor Richard C. MacDonald, DO...... 25

The AAO Journal Special Communication Anthony G. Chila, DO, FAAO...... Editor-in-Chief American Academy of Osteopathy® Concensus Statement Stephen J. Noone, CAE...... Supervising Editor for Osteopathic Manipulation of Somatic Dysfunction under Diana L. Finley, CMP...... Managing Editor Anesthesia and Conscious Sedation...... 26 The AAO Journal is the official publication of the American Academy of Osteopathy®. Issues are Review of the Intelligent Body published in March, June, September, and Decem- R. Paul Lee, DO, FAAO...... 29 ber each year.

Third-class postage paid at Carmel, IN. Postmaster: The Student Physician Send address changes to: American Academy of Abreactions in Ligamentous Articular Strain Osteopathy®, 3500 DePauw Blvd., Suite 1080, Laura McMurrey, OMS-III and Stuart F. Williams, DO...... 21 Indianapolis, IN., 46268. Phone: 317-879-1881; FAX: (317) 879-0563; e-mail snoone@academy ofosteopathy.org; AAO Website: http.//www.acad- emyofosteopathy.org

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/The AAO Journal June 2005 View from the Pyramids

Anthony G. Chila

Forty Years

On May 28, 1965, 103 new graduates of the Kansas City attend to recall the words of then-President Eugene P. Powers, College of Osteopathy and Surgery received the degree given in August 19661: Doctor of Osteopathy from that institution. At the time, the “Each of us, in one way or another, is a debtor. We are, osteopathic profession was not far removed from the damag- not in myth but in fact, debtors to a long line of ancestors ing effect of the MD-DO merger in the state of California who have given us religion, family, and civilization. In a very (1962). Five colleges of Osteopathy were in existence, all of specific way, every graduate of any college or university is a them free-standing institutions. The ability of the osteopathic debtor to that institution. profession to sustain itself was undergoing serious question. Reflect for one moment on your personal life as it exists The institution (KCCOS) celebrated its 50th Anniversary in now and as it was prior to attendance at and graduation from 1966, one year later. the Kansas City College of Osteopathy and Surgery. Is your financial picture better? Is your status position in community The graduates of 1965 uniformly entered a one-year period life better? Is your psychic income greater because you serve of Postdoctoral training described as a Rotating Internship. humanity as an Osteopathic Physician? These and many Following that year, entry into General Practice or Residency other questions could be asked and in the main your answer Training in various specialty programs provided the next step would, in all honesty, have to be an unqualified and emphatic in career development. With relatively few exceptions, these “yes”. If, however, only one of these many questions could be training programs were conducted in osteopathic institutions answered in the affirmative, you would qualify as a “debtor” under the purview of the American Osteopathic Association. to your Alma Mater, KCCOS. Subsequent years would show active and visible professional The honor of debtorship comes in the willing and prompt profiles for many of the class members. payment in full measure of those obligations which were The KCCOS Class of 1965 began celebrating reunions willingly accepted by the debtor. It is a personal and a private commencing with its 10th Anniversary in 1975. As is true of liability which must be resolved by each individual in the all institutional classes, reunions have provided the oppor- honor of his ethical self. One cannot in justice excuse his debt tunity to re-establish acquaintance, learn of interval occur- by blaming the past or rationalizing his own weakness into rences, and become aware of change at Alma Mater. In any the failures of others. It simply is true that you and you alone class, retirement has removed members from the active role are the measure of your indebtedness and of the progress you of osteopathic practice and death has diminished the number have made toward reparation of this deficit. of survivors attending each subsequent reunion. The Kansas City College of Osteopathy and Surgery is as June, 2005. Forty years later, the institution has undergone intimately you as if it were, in fact, your natural mother. Your various name changes: Kansas City College of Osteopathic education is as good as the education offered within her class- Medicine; The University of Health Sciences College of rooms. Her medicine is your medicine. Her image is your Osteopathic Medicine; Kansas City University of Medicine image. Destroy her image; hurt her progress; and you simply and Biosciences. The social history of osteopathic medicine hurt and destroy yourself. has shown remarkable change in numbers of institutions; We candidly ask you to appraise your indebtedness to your affiliation with universities; funding support; expanded Alma Mater and attempt to give her that fair share of financial training and practice opportunities. Various name changes and moral support which is just and reasonable. Preach the have occurred for osteopathic institutions during this period word to all that KCCOS is on the march toward excellence of time. It cannot be said that osteopathic institutions for con- and that each member of the Alumni should very naturally tinuing postdoctoral training are in existence, as they were in want to bear a little more than his fair share of the burdens 1965. Perhaps this is a price to be paid for satisfying society’s required for this progress. More important, however, is the expectation of adequate demonstration of philosophical dis- bold fact that we want each and every member of our Alumni tinction and differentiation of practice. to say with pride, KCCOS is my college, KCCOS is my Alma Mater.” The KCCOS Class of 1965 is scheduled to hold its 40th Anniversary Banquet on September 8, 2005 at Kansas City, 1. The HEARTBEAT: 50 Year Anniversary Issue; Kansas City College of Osteopathy and Surgery; August 1966 MO. In preparing to do so, it would be well for those who June 2005 The AAO Journal/ Contributors Regular Features

David Coffey. C1 Somatic Dysfunction And Unilat- manipulation. This consideration bears further observation eral Retroorbital Cephalalgia. As recently as one year and documentation. (p. 21) ago (2004), literature search revealed 3311 articles related to cervicogenic cephalgia. The author has addressed this in terms of attempting to provide anatomic and physiologic DIG ON. The process of osteopathic education often support for somatic dysfunction relevant to this problem. appears to contemporary students as a dichotomy: “This is Specifically considered is the observation of a painful and medicine; That is OMM”. Observations about this seemingly prominent transverse process of C1 associated with unilateral continuing struggle for synthesis move past today’s environ- retroorbital headache. In pursuing this original contribution ment to review a similar situation which occurred in 1969. to osteopathic literature, the author seeks to facilitate the (p. 8) elaboration of diagnostic considerations in the International Classification of Headache. Practicing clinicians are encour- FROM THE ARCHIVES. Periodic reminder that Prin- aged to use this finding to help avoid misdiagnosis of ocular ciples of Treatment must underlie the development of a ratio- migraine or cluster headache. Submitted in partial fulfillment nal plan for treatment is provided in this selection. Diseases of requirements for Fellowship in the American Academy of Of The Head And Neck (J. Deason, MS, DO; Journal Printing Osteopathy. Doctor Coffey was conferred status as Fellow in Company; Kirksville, Missouri, 1921) is such a reminder. The 2004. (p. 11) text is a representation of an early 20th Century osteopathic physician’s clinical and laboratory research. (p. 9) Richard C. MacDonald. Be Careful With This Kind Of Case! The author presents a forthright discussion of an BOOK REVIEW. In this issue comments are offered encounter with a complicated clinical presentation. The osteo- about the recent publication (2003 and 2004) of collected pathic assessment and utilization of manipulative intervention papers of Paul E Kimberly and David Heilig. Both of these are particularly relevant, given recent discussions of cervical prominent educators were strongly affiliated with the mission spine dysfunction. This is a highly instructive contribution. of the American Academy of Osteopathy®. Distinctive profes- Doctor MacDonald is a Past President of the American Acad- sional effort characterized each. Both were articulate expo- emy of Osteopathy (1978-1979). (p. 25) nents of osteopathic philosophy, principles and practice. The 20th Anniversary of the Osteopathic Center for Children American Academy Of Osteopathy® Consensus State- was the occasion for an International Research Conference ment For Osteopathic Manipulation Of Somatic Dysfunc- (2002), Proceedings of which are reviewed. (p. 33) tion Under Anesthesia And Conscious Sedation. Osteo- pathic physicians have made use of manipulation of somatic ELSEWHERE IN PRINT. Rheumatoid Arthritis and dysfunction under anesthesia for many years. Research Monosodium Urate Deposition Arthropathy are two clinical studies and publications regarding this approach have been conditions encountered by osteopathic physicians. Abstracts limited. This document represents a consensus statement, provided from two publications (Consultant and Advanced revised by the American Academy of Osteopathy Board of Studies in Medicine) offer contemporary views of diagnosis Governors, March 16, 2005. (p. 26) and management. The content of these abstracts suggests op- portunity for thoughtful application of osteopathic philosophy R. Paul Lee. Review Of The Intelligent Body. The author in management. (p. 35) shares his observations of the program of the Sutherland Cra- nial College (London, England; April 16-17, 2005). Speakers CME CREDIT. In response to reader requests, AAOJ will Stephen Levin, MD (Tensegrity) and James Oschman, PhD offer CME Credit to readers completing the enclosed quiz. At (The Living Matrix) provided challenge for integration of this time, 1 Hour II-B Credit will be offered, with request for these ideas through palpatory exercises. Doctor Lee’s descrip- upgrade as AAOJ qualifications are reviewed by the American tion of the seminar’s process of multilevel viewing of the Osteopathic Association. (p. 20) body (mechanically, spatially, energetically and spiritually) is exciting. (p. 29) Sage Sayings of Still Headaches Laura McMurrey and Stuart F. Williams. Abreac- “In all continued or periodic headaches I have found the tions In Ligamentous Articular Strain. The authors offer shutoff in the bones of the neck at their union with the head a thoughtful assessment of a clinical presentation associated and in the other joints as far down as the fourth dorsal and with abreaction (“the expression and emotional discharge even as far as the lumbar, sacrum and coccyx. I have found of unconscious material [as a repressed idea or emotion]”). abnormal positions of both bone and muscle resulting in Of particular value to practitioners is their interpretation of the production of such effects.” abreactions occurring in association with various forms of Research and Practice, p. 358

/The AAO Journal June 2005 Component Societies’ CME Calendar and other Osteopathic Affiliated Organizations

June 9-11, 2005 June 23-26, 2005 September 22-24, 2005 Getting a Grip on Low Back Pain 107th Annual Osteopathic Medical Osteopathic Pioneers: American Academy Convention & Scientific Seminar Honoring Paul Kimberly, DO, FAAO of Musuloskeletal Medicine Tennessee Osteopathic Medical Assn. KCOM Campus Thomas H. Ravin, MD Chattanooga, TN Kirksville, MO Denver, CO Contact: Sara Linton Contact: Rita Harlow, CME Director CME: 18 Category 1A (anticipated) [email protected] 660/626-2232 Contact: AAOM Further details, visit: http://www. 202/270-9191 tomanet.org October 6-9, 2005 SCTF Continuing Studies Course June 9-13, 2005 September 2-5, 2005 Teaching the Teachers Biodynamics Phase III: Chicago, IL SCTF 40-hour Basic Course The Long Tide and the Dura Contact: Judy Staser Osteopathy in the Cranial Field Topanga, CA NYCOM 817/926-7705 CME: 22.5 Category 1A (anticipated) Westbury, NY Contact: Stefan Hagopian, DO Director: Hugh Ettlinger, DO, FAAO 207/778-9847 October 8-9, 2005 Contact: Judy Staser Advanced NFR Course – 817/926-7705 Visceral Manipulation September 3-6, 2005 Arizona Academy of Osteopathy Biodynamics Phase II CME: 16 Category 1A (anticipated) June 18-22, 2005 Kona, HI June Basic Course Contact: Stephen Davidson, DO CME: 23 Category 1A (anticipated) The Cranial Academy 602/246-8977 (AZ) Contact: Thomas Shaver, DO Indian Lakes Resort 800/359-7772 (USA) 207/778-9847 Bloomingdale, IL website: www.healthabounds2.com CME: 40 Category 1A (anticipated) September 10-11, 2005 October 14-16, 2005 Contact: The Cranial Academy Neurofascial Release Conference West 317/594-0411 Using the Powers within the Patient’s Body Arizona Academy of Osteopathy A Still Sutherland Study Group CME: 24 Category 1A (anticipated) June 23-25, 2005 UNECOM Contact: Stephen Davidson, DO 3rd Annual Meeting Biddeford, ME 602/246-8977 (AZ) American Association of Colleges of CME: 14 Category 1A 800/359-7772 (USA) Osteopathic Medicine (AACOM) Contact: Andrew Goldman, DO website: www.healthabounds2.com Bethesda, MD 860/364-5990 Further details will be published on the November 13-16, 2005 Website as it becomes available: http:// Biodynamics Phase I: Biodynamics www.aacom.org.events/annualmtg September 11-14, 2005 Kona, Hawaii Biodynamics Phase II: The Fluid Body CME: 21.5 Category 1A (anticipated) June 23-26, 2005 Franconia, NH Contact: Thomas Shaver, DO Annual Conference: CME: 23 Category 1A (anticipated) 207/778-9847 The Osteopathic Mind Contact: James Jealous, DO The Cranial Academy 207/778-9847 Indian Lakes Resort Bloomingdale, IL Contact: The Cranial Academy 317/594-0411

June 2005 The AAO Journal/ Dig On Anthony G. Chila

The More Things Change…

The teaching of manipulative modalities in the osteopathic BS, DO. The topic of the workshop was Finding A Common medical curriculum has undergone significant change during the Denominator For The Variety Of Manipulative Techniques.1 The past forty years. Gradual movement away from a single mode panel participants were representative of Postdoctoral Intern approach to teaching has been accompanied by the appear- Training (Robertson); Recent years of practice (Stiles); Experi- ance of numerous modes. In the teaching and learning of these enced Clinician (Johnston). Doctor Johnston provided the sum- modes, emphasis is often placed on one or another aspect of mary of the workshop, and it is worth citing in its entirety: neurobiologic effect which seems appropriate to a given mode. All too often, adequate research-related support for explanation “In summary then, what we’ve been sampling in this work- is lacking. As a result, the osteopathic physician-to-be appears shop session is the use, first of all, of a particular kind of light to leave the academic arena without the ability to effectively palpation that rides or monitors a somatic area as it moves. Our synthesize the information presented. It would seem that the first project was using the motion of inspiration, and your objec- proximity of in-depth Basic Sciences and Clinical Sciences tive was to locate an area that resisted or expressed restriction to teaching in the several colleges of osteopathic medicine should this motion. Our second project was an extension in use of this at least facilitate evidence-based understanding of the neuro- same kind of palpation, for the purpose this time of fact-finding biologic mechanisms of manipulation. But is this really so? throughout the entire thoracic cage, anterior and posterior, to More often, it appears that the contemporary student body in pick out areas binding up restrictively during inspiration, and osteopathic medical colleges functions under the dichotomy of to qualify their size as to small (segmental), or large (larger “this is medicine and that is OMM”. Why is a (the) common than segmental). denominator missing? At this point we challenged you to examine each your own Foundations for Osteopathic Medicine (Second Edition, 2003) current use of clues from lesioned areas and especially your devotes three sections to osteopathic manipulative methods: application of these in treating large and small areas of somatic distortion, mostly so that you could knowingly appreciate your A. Overview: Evaluation and Management Chapters 30-44 own framewok for receiving a new kind of motion clue. B. Regional Examination and Treatment Chapters 45-53 C. Palpatory Diagnosis and Manipulative Treatment Chapters 54-73 This was examined in our third project, exploring the nature of movement into the anterior compartment, operator-induced. In Part C, approximately 17 technical approaches are pre- This fingertip clue, from an area which resisted going into the sented by various authors. The descriptors seem to represent anterior compartment, was then interpreted in relation to the consideration of practically all body components capable of changing position of hips-to-shoulders that became evident in being involved in a manipulative encounter. Additional discus- the testing. Our common denominator, of course, is this close, sion of application of treatment in the hospital setting and is- actually inseparable, relationship between body motion and sues of efficacy and complication complete this part of the text. changing position. In this workshop, we’ve developed but one Finding a common denominator for all of these presentations is aspect of this common denominator to show its relevance to the not necessarily easy to accomplish. successful use of a specific manipulative approach.”

The emphasis on Palpatory Diagnosis and Manipulative The more things change… the more they remain the same. Treatment described in the preceding paragraph was anticipated in a Workshop presented at the Spring Study Session, New 1. Finding A Common Denominator For The Variety Of Manipulative England Academy of Applied Osteopathy (May 2-3, 1969; Techniques: Academy of Applied Osteopathy; 1969 Year Book Of Lexington, Massachusetts). The Program Chairman was Foster Selected Osteopathic Papers, 5-15. Dryden Clark, DO. Panel members were William L. Johnston, DO, FAAO; J. Allan Robertson, Jr., BS, DO; Edward G. Stiles,

/The AAO Journal June 2005 From the Archives

Diseases of the Head and Neck J. Deason; Journal Printing Company, Kirksville MO, 1921, pgs. 41-43

Foreword This book is not intended to be complete in any sense, but only a monographic review of the author’s clinical and laboratory researches. It is written for the use of students and general practitioners and is intended to present the Osteopathic Concept as applied to cause and treatment of diseases of the head and neck, with special reference to certain diseases in which the profession has made unusual progress. Descriptions of surgical technic have been omitted, because they can be found in various other books. The book is supposed to be a revision of Bulletin No. 3 of the A. T. Still Research Institute written by the author and published in 1915, but it was found that a complete rewriting was necessary. With permission from the editor of the American Osteopathic Association Journal, some of the author’s material from various papers has been included. Also, with permission from the authors, a part of the material from McConnell and Teall’s Practice of Osteopathy has been used. The reader is expected to make frequent reference to his texts on anatomy for pictures and cuts illustrating the varous anatomical structures.

CHAPTER THREE “Adjust whatever slight irregularity accomplish this, Dr. Still advises adjust- you find in the cervical and upper dorsal ment of the upper ribs, clavicles and Principles of Treatment regions. Bring your clavicles well up and hyoid, and deep muscle relaxation. Rationalism in treatment requires logi- forward. Look carefully to your upper Since toxic absorption means systemic cal theory of cause. Empiricism in treat- four ribs and see that they are perfectly poisoning, elimination is to be accom- ment, while it frequently accomplishes adjusted on both sternum and spine. Free plished by lower dorsal and lumbar treat- results, cannot be the choice of the con- the hyoid bone from any contractured ment to maintain kidney and intestinal scientious, scientific physician, because muscle which could bind it. Treat your efficiency, while other methods, such as he wants his results to be constant and patient once or twice daily in severe colonic irrigation, sweating, etc., are to permanent. Such results can be obtained cases, and, when the case is a very obsti- be employed. only by following some definite, rational nate one, stick to it until you obtain good Surgery in Acute Disease is indicated plan. circulation. Then go to the lumbar region only in cases of abscess cavities, pyo- Acute Disease. It may be stated as and treat there to pen the excretories. See celes, etc., which are not readily drained an osteopathic theorem that body fluids that the lumbar vertebrae are in line and by other methods. In general, such contain the necessary chemic and biologic that the floating ribs are well up and in abscesses, when not drained otherwise, properties to combat ordinary infection their proper places. Do all your work in should receive surgical attention in from and, as a corollary, it may be added that the neck region from the outside.” 12 to 48 hours if the best results are to be certain body structures have the power to Second, the patient must be kept at obtained and normal function restored. produce specific, biologic substances for rest to conserve vital force for combat- Except, in these cases of occluded pus, protection against specific and virulent ing the disease and for repair. Third, the direct treatment is contraindicated in forms of infection. efficiency of local blood supply may be acute disease. After-treatment, for the Rational treatment, therefore, consists enhanced by aspiration or cupping of the purpose of restoring normal blood supply of those methods by means of which ar- part, by Bier’s hyperemic method, by hot and nerve control and for the reduction terial blood of good quality and quantity irrigation and by intermittent application of pathologic change to normally func­ is supplied to the parts involved. To ac- of heat. tional structure, is essential and should complish this: First, all structural lesions Dr. Still’s rule of the artery applies be continued until the desired ends have that may interfere with nerve control and equally to the venous and lymphatic been accomplished. direct arterial function must be removed. drainage, and this is just as important Similar osteopathic treatment is just (the author referred the reader to Dr. because the “sour” blood, the result of as essential following surgery, and here Still’s method): toxic absorption, must be removed. To ➻

June 2005 The AAO Journal/ is where the osteopathic concept of sur- The third stage or pathologic change, 3. The removal of any structure, not gery differs materially from the medical that which has resulted in definite struc- vitally essential, which endangers nor- concept of surgery. Osteopathically, tural change of tissue, can not be wholly malization and which structure itself can- surgery is only a means to an end, and is overcome because physiologic forces not be normalized. Again it is essential to never, in itself, a complete treatment. can only normalize. They cannot replace understand that surgery in itself is not to Chronic Disease. In the consideration structure except to a limited degree, but be considered the finality of treatment, of chronic disease it is necessary to these forces can normalize the function of but only a part of the necessary normal- understand that there has been an acute the unchanged tissue and they can prevent izing treatment.∆ stage, the results of which have not re- further pathologic change. ceived efficient after‑treatment, or there Principles of treatment in chronic dis- has been a slowly progressive impairment ease are, therefore, similar to those stated of function of long duration. in acute disease. Treatment intended to Pathologically, the first stages of per- normalize structural perversions, and thus Opportunity Knocks verted function, hyperemia, etc., have normalize physiologic forces, is efficient, I am looking for an associate, progressed into the secondary and more but the time of treatment necessary to preferably C-NMM/OMM Board developed stages of hypertrophy, hyper- cause restoration varies directly as the Eligible or Board Certified. Please plasia and marked deficiency of function time of causation, because natural forces send your resume, a picture, and and normal resistance. work slowly in cause as well as in cure. a letter which expresses your Theoretically, those anatomic perver- Surgery in Chronic Disease. In thoughts on Osteopathy. sions which have resulted in physiologic chronic disease, surgery is limited to and pathologic perversions will, when 1. The removal of structural perver- corrected, tend to permit restoration of sions which directly interfere with normal Harold Magoun, Jr., DO, FAAO, normal function through normal physi- function and which cannot be reduced by FCA, DO, Ed(Hon) ologic forces. It is interesting to note simpler methods. 5340 South Quebec Street, No. 220-S that clinical research proves quite con- 2. Drainage of pus cavities which Greenwood Village, CO 80111-1911 clusively the efficiency of this theorem directly or indirectly cause abnormal in practice. function or pathologic change.

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10/The AAO Journal June 2005 C1 Somatic Dysfunction and Unilateral Retroorbital Cephalalgia David Coffey

The purpose of this paper is to estab- trigeminothalamic tract, which is con- The ophthalmic, maxillary and mandibular lish somatic dysfunction at C1, which tinuous with the anterolateral system, and branches jointly emerge from this root and involves the entire occipitoatlantoaxial is the site of termination for nociceptors distally exit the skull through the superior joint complex, as a cause of unilateral and thermoreceptors.4 Neurons of this orbital fissure, foramen rotundum, and fo- retroorbital cephalalgia and to describe nucleus give off crossed and uncrossed ramen ovale respectively. The ophthalmic an osteopathic treatment when there is a axons, which ascend to the thalamus by nerve and occasionally the maxillary nerve laterally prominent transverse process of way of the trigeminothalamic tract.5 course through the wall of the cavernous C1 on the same side as the cephalalgia. The fifth cranial nerve, the trigeminal, sinus. The motor root travels with the has three major divisions: the ophthalmic mandibular division. Within the pons, Cervicogenic headaches originate in (V1), the maxillary (V2), and the man- many of the sensory axons bifurcate and the neck, are unilateral in character, and dibular (V3). It emerges on the mid lateral send a branch to the pontine trigeminal do not move from side to side.1 Major surface of the pons as a large sensory nucleus thought to be concerned with symptoms include pain and reduced root and a smaller motor root. The cell touch sensation from the face, and cau- range of motion, which may be induced bodies of the sensory root are located dally to the nucleus of the spinal tract. by mechanical pressure or awkward in the semilunar or trigeminal ganglion All three divisions of the trigeminal nerve head positioning, in the ipsilateral upper on the floor of the middle cranial fossa. have meningeal branches. ➻ posterior region of the cervical spine. The pain is always on one side, starts in the Figure V-7: General Sensory posterior portion of the head or neck and Component of Trigeminal moves to the ipsilateral eye and fronto- Nerve (Opthalmic V, Division) temporal area. Duration of attacks vary and are moderate to severe in intensity.2 The Headache Classification Committee of the “International Headache Society” in 1988 concluded that the concept of cer- vicogenic headache was not sufficiently validated due to a lack of substantial numbers of patients using diagnostic tests or valid diagnostic criteria.3 I would like to provide an observation from clinical practice, which supports the diagnostic criteria of cervicogenic headache. I would also like to explore the phenomenon of a painful, laterally prominent, palpable transverse process of C1 and its rela- tionship to an unrelenting, continuous, ipsilateral retroorbital headache. Orbital and retroorbital pain is medi- ated by the trigeminal system. Afferent axons descend in the spinal trigeminal tract and terminate in the pars caudalis of the spinal trigeminal nucleus. The pars caudalis is that part of the spinal trigeminal nucleus found in the caudal Reprinted with permission from Department of Medicine, Division of Biomedical medulla and the upper three segments Communications, University of Toronto. Cranial Nerves: Anatomy and Clinical Com- of the cervical cord. It relays with the ments, 2nd Edition, page 61. June 2005 The AAO Journal/11 The ophthalmic division (V1) in- division. The inferior surface of the sympathetic symptoms help distinguish nervates the anterior cranial fossa and is tentorium and the posterior cranial migraine and cluster cephalalgia from a formed by the nasociliary, frontal, and fossa is supplied by fibers that travel cervicogenic headache. lacrimal nerves at the posterior aspect with the recurrent branches of the first Causes of unilateral retroorbital cepha- of the superior orbital fissure. It includes three cervical spinal nerves and the lalgia may include ocular inflammation, a meningeal branch to the tentorium vagus nerve (CN 10). Sensory fibers migraine, herpes zoster, referred dural pain, cerebelli. The maxillary division (V2) is that supply the walls of the proximal sinusitis, and painful ophthalmoplegia syn- joined by small meningeal branches from large intracranial arteries, veins and dromes. Neoplasms of the orbit, superior the dura of the medial part of the middle venous sinuses travel with the sym- orbital fissure, cavernous sinus, and middle cranial fossa as it enters the trigeminal pathetics. These fibers all terminate fossa affect the ophthalmic (V1) sensory dis- ganglion. Sensation from the meninges in trigeminal sensory nuclei, and are tribution of the trigeminal nerve. Likewise, of the lateral part of the middle cranial thus best categorized as “displaced” cerebellopontine angle tumors, trigeminal fossa is carried by the meningeal branch trigeminal fibers.9 neurofibromas, and tentorial meningiomas of the mandibular nerve (V3), which Exploratory neurosurgery under also affect the ophthalmic division.12 The travels with the middle meningeal artery local anesthesia has shown that pain syndrome of painful ophthalmoplegia through the foramen spinosum. This nerve produced from the dural sinuses and combines ocular nerve palsies with pain in is called the nervous spinosus and joins from pressure on the tentorium is re- and about the eye. Lymphoma, metastatic the main trunk of the mandibular nerve ferred to a distant site. Stimulation of tumor, pseudotumor, cavernous sinus throm- prior to returning to the cranial cavity the lateral aspect of the superior sagit- bosis, intracavernous aneurysm, pituitary through the foramen ovale.6 tal sinus in its posterior third causes adenoma, meningiomas, cranial arteritis, Most eye pain is due to ocular disease. pain, which is usually referred behind and contiguous sinusitis are a sample of The ophthalmic nerve mediates pain, tem- the ipsilateral eye or to the forehead. disease states, which may cause retroorbital perature and touch from the cornea, iris, Likewise, ipsilateral retroorbital pain pain with ophthalmoplegia.13 Headache, upper lid, conjunctivae, lacrimal gland, is produced from the lateral wall of the nausea and vomiting and papilledema is and the bridge and tip of the nose. The straight sinus and the upper wall of the the clinical triad associated with increased non-ocular distribution of the ophthalmic transverse sinus. Lateral pressure on intracranial pressure caused by an enlarging division is of major clinical importance the free margin of the falx in its middle tumor mass. Local effects of a brain tumor since disturbances of intracranial struc- portion may refer pain behind the ip- on adjacent meningeal vascular or neural tures including dural venous sinuses, ce- silateral eye. Electrical stimulation on tissues may produce focal signs before the rebral arteries, and veins all typically refer the tentorium may also refer pain to the tumor enlarges to the degree necessary to pain to the eye, orbit or brow. However, frontal region or behind the ipsilateral increase intracranial pressure. Headache is referral of pain from dural stimulation is eye. Pain described by patients while present in about one-half of patients with not sufficiently specific to provide precise they were awake during these cases is metastatic brain tumor and seizures are clinical localization.7 described as sharp or pressing.10 seen in one-fourth.14 Tumors, which involve Both the dura of the anterior cranial Migraine or vascular headache is pain sensitive structures such as meninges, fossa and the anterior two-thirds of the a common recurrent headache syn- cause headache. Unless there is increased superior sagittal sinus contain perivascu- drome. The presence of neurological intracranial pressure, tumors, which do not lar nerves, which follow the middle men- dysfunction in classic migraine differ- involve pain sensitive structures, do not ingeal artery and the ethmoidal branches entiates this syndrome from common cause a headache.15 of the ophthalmic nerve. The meningeal migraine, or migraine without aura. The nerves distributed to the spinal dura branch of the ophthalmic nerve, the ner- Aphasia, blindness, visual disturbance, mater are the meningeal rami of spinal vus tentorii, supplies the superior portion hemiparesis, paresthesias and vertigo nerves. The nerves distributed to the dura of the tentorium cerebelli, the dura of can occur with classic migraine. Pain mater covering the floor of the posterior cra- the entire cerebri, the falx, and the si- is pulsing or throbbing and is fre- nial fossa are derived from the sympathetic nuses associated with them, namely, the quently accompanied by photophobia, trunk and from the upper three cervical superior sagittal sinus, inferior sagittal nausea and vomiting. It is unilateral spinal nerves. They enter the posterior cra- sinus, transverse sinuses, straight sinus, in two out of three cases and is three nial fossa by way of the foramen magnum, and superior petrosal sinus. All the dural times more prevalent in women than hypoglossal canal, and jugular foramen. The nerves in the anterior and middle cranial men. Cluster headache is an uncom- nerves to the dura mater, which enter the fossa can be traced to trigeminal divi- mon headache disorder, which is cranium by way of the foramen magnum, are sions.8 More recent research confirms the unilateral and periorbital. It spreads branches of the meningeal rami of the upper innervation of the dura by the trigeminal over the affected side and becomes three cervical nerves and supply the dura nerve. The superior surface of the ten- sharp and severe. It is six times more mater in the anterior part of the floor of the torium and the anterior cranial fossa is prevalent in men than women. As- posterior cranial fossa. As they travel, these supplied by the ophthalmic division, sociated symptoms include ipsilateral branches give off branches to the spinal while the floor of the middle cranial fossa facial flushing, conjunctival injection, dura mater and the ligaments surrounding is supplied medially by the maxillary lacrimation, Horner’s syndrome, and the atlantoaxial joint at a level correspond- division and laterally by the mandibular rhinorrhea.11 Neurological and para- ing to the rostral end of the odontoid.

12/The AAO Journal June 2005 Branches of these nerves enter the cellular semispinalis capitis, semispinalis cervi- nent transverse process and an ipsilateral dura mater covering the clivus and extend cis, multifidus, longissimus and splenius retroorbital headache. rostrally to the region of the posterior capitis muscles and the zygapophysial The (C1) is ring-like and consists clinoid processes. The nerves to the dura, joints between C2 and C3 and between of an anterior arch, a posterior arch and which enter the cranial cavity by way of C3 and C4. The sinuvertebral nerves from two lateral masses. The anterior arch the hypoglossal canal and jugular fora- C1 to C3 supply the medial atlantoaxial contains a convex anterior surface with men, are derived from the anterior rami joint, transverse and alar ligaments, and a tubercle for attachment of the longus of the first and second cervical nerves and the intervertebral disc between C2 and colli muscle and a concave posterior from the superior cervical ganglion. They C3. They also supply the dura mater of surface with a circular facet for articula- supply the dura mater, which covers the the spinal cord, foramen magnum, and tion with the odontoid process of the lateral and posterior wall of the posterior clivus.19 axis (C2). The anterior occipitoatlantal cranial fossa. They also accompany the Somatic Dysfunction is defined in the and anterior atlantoaxial ligaments arise vagus (CN X) and hypoglossal (CN XII) ‘Glossary of Osteopathic Terminology’ as from the upper and lower borders of the nerves which enter the posterior cranial “impaired or altered function of the so- anterior arch and attach to the occipital fossa through the jugular foramen and the matic (body framework) system: skeletal, bone above and the axis below. The hypoglossal canal respectively.16 arthrodial, and myofascial structures and posterior arch terminates in the posterior The gray matter of the brain stem related vascular, lymphatic, and neural tubercle, which gives origin to the rectus that constitutes the pars caudalis of the elements.” Asymmetry, tissue texture capitis posterior minor muscle. It pres- spinal nucleus of the trigeminal nerve is changes, tenderness and restricted range ents above and below a surface for the continuous with the apical gray matter of of motion are the criteria used to define posterior occipitoatlantal and posterior the dorsal horns of the spinal cord. The somatic dysfunction.20 An in depth view antlanto-axial ligaments, which attach trigeminocervical nucleus can be identi- of the osteology, ligamentous structure to the occiput and axis respectively. On fied within this continuous column by the and muscle attachments of the occipital the superior surface of the posterior arch, common distribution of primary afferent bone (C0), atlas (C1), and axis (C2) and there is a groove behind each lateral terminals of the trigeminal and cervical the complexity of the interwoven struc- mass for transmission of the vertebral nerves. The trigeminocervical nucleus ture and function in this occipitoatlanto- artery and the first cervical (suboccipi- is defined as those cells in the upper axial joint complex provide the basis for tal) nerve. The lateral masses are bulky three cervical regions that receive both a a causal relationship between somatic and present two articulating processes trigeminal and cervical peripheral input dysfunction at C1 with a laterally promi- ➻ and is the essential nociceptive nucleus of the upper neck and head.17 The neuroana- tomical basis for cervicogenic headache is convergence within the trigeminocer- vical nucleus. Nociceptive neurons have receptive fields with the fields of both the trigeminal and the first three cervi- cal nerves. Their central connections are poorly organized somatotopically, and information may be interpreted from anywhere within the trigeminocervi- cal receptive fields. Thus, the possible sources of cervicogenic headache are any structures innervated by the cervical nerves C1, C2, and C3.18 The ventral rami from C1 to C3 supply muscles of the cervical spine including the longus colli, rectus capitis anterior, rectus capitis lateralis, , and the sternocleidomastoid. The dorsal rami from C1 to C3 supply the atlantooccipital joint, the lateral atlantoaxial joint, the dura mater of the posterior cranial fossa, and the . They also in- nervate the which include the obliquus capitis superior, obliquus capitis inferior, rectus capitis posterior major and rectus capitis pos- Reprinted with permission from the Interactive Atlas of Human Anatomy, illustrated terior minor muscles and supply the by Frank H. Netter, M.D. All rights reserved. June 2005 The AAO Journal/13 above and two below. The two superior anterior and posterior spinal arteries. The anterior vertebral muscles along with the processes are directed superiorly, medi- occipital bone also contains the foramen longus capitis and longus colli, which ally and posteriorly and form a cup for for the hypoglossal nerve.24 assist in flexing the head.29 The rectus the corresponding occipital condyle, The axis (C2) contains the odontoid capitis anterior, rectus capitis lateralis, which adapts to nodding movements of process, which serves as a pivot about and longus capitis muscles help produce the head. They are sometimes subdivided which the atlas (C1) rotates and is the flexion, rotation, and lateral bending by a deep indentation encroaching each embryological body of the atlas. An at the occipitoatlantal joint. The rectus lateral border. The inferior articular anterior elongation overlaps the body capitis posterior major, obliquus capitis processes are circular, concave, and di- of C3 and provides attachment for the superior, and obliquus capitis inferior rected inferiorly and medially in order to anterior longitudinal ligament. The muscles are the posterior suboccipital articulate with the axis and permit rotary spinous process of the axis serves as muscles, which form the suboccipital movements. The transverse ligament of the tendinous origin of the rectus capitis triangle. Along with the rectus capitis the atlas arises from a tubercle on the posterior major muscle, which inserts posterior minor muscle they extend inner surface of each superior articular on the occipital bone and extends and the head and assist rotation and lateral surface. It stretches across the ring of rotates the head.25 The obliquus capitis bending at the occipitoatlantal and atlan- the atlas and provides a smaller anterior inferior muscle arises from the apex of toaxial joints. As a general rule, flexion separation for the odontoid process of the spinous process of the axis and passes and extension of the vertebral column the axis and a larger posterior separa- obliquely in a lateral and superior direc- is accomplished when a paired muscle tion for transmission of the spinal cord tion to the inferior and posterior portion on both sides contract together. Lateral and its membranes. Due to its size, lat- of the transverse process of the atlas.26 bending and rotation of the vertebral eral displacement of the atlas may occur A tectorial membrane arises inside the column is accomplished when a paired without compression of this structure. vertebral canal and extends as a cephaled muscle contracts unilaterally.30 Somatic The transverse processes of C1 project projection of the posterior longitudinal dysfunction of the regions including the in a lateral and inferior direction from ligament from the body of the axis to occipital bone, the atlas, and the axis in- the lateral masses and contain grooves the occipital bone. Two alar ligaments volves the sensory distribution of the first for the vertebral arteries.21 The rectus project from the sides of the odontoid three cervical spinal nerves and engages capitis anterior muscle arises from the process to the occipital condyles and an the trigeminal system through the trigem- anterior surface of the lateral mass and apical odontoid ligament joins the apex inocervical nucleus. Increased tonicity or from the root of the transverse process of the dens to the foramen magnum. The injury to these muscle groups can activate of C1. It moves obliquely in a superior transverse ligament of the atlas, which the same system that produces unilateral and medial direction and inserts on the supports the odontoid process, attaches retroorbital headaches. basilar process of the occipital bone. The with a superior band to the occipital bone It should be noted that the floor of posterior surface relates with the front of and with an inferior band to the body of the suboccipital triangle contains the the occipitoatlantal articulation. The rec- the axis and forms the cruciform ligament posterior arch of the atlas, the posterior tus capitis lateralis muscle arises from the of the atlas.27 occipitoatlantal ligament, the vertebral upper surface of the transverse process of Articulation between the and the posterior division of the C1 and inserts into the undersurface of bone (C0) and atlas (C1) allows the . The posterior occipi- the jugular process of the occipital bone. movement of flexion, extension, lat- toatlantal ligament connects superiorly It approximates by its anterior surface eral bending, and rotation. Panjabi, et to the posterior margin of the foramen the internal jugular vein, by its posterior al. speak of the region from C0 to C2 as magnum and inferiorly to the posterior surface the vertebral artery, by its lateral the occipitoatlantoaxial joint complex. arch of the atlas. It is intimately blended surface the occipital artery and by its me- Using whole cadaveric cervical spine with and adherent to the underlying dura dial surface the suboccipital nerve.22 The specimens, they described and measured mater of the spinal canal.31 Researchers obliquus capitis superior muscle arises range of motions of the occipitoatlantal at the University of Maryland Dental and from the tendinous fibers on the upper (C0-C1) and atlantoaxial (C1-C2) joints Medical Schools showed a connective surface of the transverse process of C1, in flexion, extension, lateral bending tissue bridge between the rectus capitis joins with the insertion of the obliquus and axial rotation. Range of motion was posterior minor muscle and the posterior capitis inferior muscle and then passes obtained as a sum of the neutral zone and spinal dura. They observed dense connec- obliquely in a superior and medial direc- elastic zone and was measured between tive tissue attaching the deep surface of tion to insert on the occipital bone.23 C0 and C1 as 3.5 degrees in flexion, 21 the rectus capitis posterior minor muscle The occipital bone (C0) forms the pos- degrees in extension, 5.5 degrees in lat- to the complex of the posterior occipitoat- terior, inferior and anterior walls of the eral bending, and 7.2 degrees in rotation. lantal ligament and the spinal dura at the posterior cranial fossa, supports the lower Between C1 and C2 there was measured atlantooccipital junction.32 portion of the pons, and provides an at- 11.5 degrees in flexion, 10.9 degrees in Anterior and medial to the rectus capi- tachment point for the posterior tentorium extension, 6.7 degrees in lateral bending, tis anterior muscle is the pharyngobasilar cerebelli. Centrally, the foramen magnum and 38.9 degrees in axial rotation.28 fascia and the pharyngeal raphe which allows passage of the spinal cord, acces- The rectus capitis anterior and the attaches at the pharyngeal tubercle of the sory nerves, vertebral arteries, and the rectus capitis lateralis are two of the four occipital bone and is a direct connection

14/The AAO Journal June 2005 of the superior pharyngeal constrictor The rectus capitis anterior and longus triangle share their own respective inser- muscle. The retropharyngeal lymph capitis muscles cause flexion between tion and origin at the transverse process nodes that connect to the deep lateral the occiput and the atlas and restrict of C1. cervical (internal jugular) lymph nodes range of motion in extension. Contrac- In the fall of 1991, three patients also lie anterior and lateral to the rectus tion of extensor muscles including the presented to my office over a five-week capitis anterior muscle. The C1 nerve root sternocleidomastoid, upper trapezius, period with severe unilateral retroorbital has direct communication with gray rami semispinalis capitis, longissimus capitis, pain and associated pain in the upper from the superior cervical ganglion and splenius capitis, obliquus capitis superior, cervical region on the same side. The with the vagus (CN X) nerve. It branches rectus capitis posterior major, and rectus pain was described as throbbing and directly to the rectus capitis lateralis, capitis posterior minor muscles cause constant, and its duration was greater longus capitis, and rectus capitis anterior extension between the occiput and atlas than twenty-four hours. Analgesics had muscles.33 The greater occipital nerve and restrict range of motion in flexion. minimal therapeutic affect on the head- (dorsal ramus of C2) emerges below the Lateral bending between the occiput ache. During the course of the history and inferior capitis oblique muscle and turns and the atlas is affected by the trapezius, physical examination, the patients denied upward to cross the suboccipital triangle sternocleidomastoid, splenius capitis, parasympathetic symptoms associated and reaches the scalp by piercing the rectus capitis anterior, rectus capitis with a migraine such as nausea, vertigo semispinalis capitis, splenius capitis and lateralis, rectus capitis posterior minor, or associated aura. There was marked trapezius muscles. The occipital artery and obliquus capitis superior muscles.37 tenderness, contraction and spasm of the crosses the insertion of the obliquus Altered range of motion or tissue texture suboccipital muscles on the same side capitis superior muscle as it courses me- changes affecting these muscles will as the headache, and the upper cervical dialward to join and distribute with the cause somatic dysfunction at the occipi- paraspinal musculature was extremely greater occipital nerve. The suboccipital toatlantal joint. tender with spasm and mild edema on nerve (C1) has no cutaneous distribu- At the atlantoaxial joint, somatic dys- that side. There were similar but lessened tion. The greater occipital nerve (C2) function occurs with altered function and symptoms on the opposite side. In each distributes cutaneously to the vertex of restricted range of motion primarily with of these cases, the pain was severe and the scalp medially and to the proximity rotation to the right and the left. With ex- palpation alone increased the pain of of the ear laterally.34 tension, the rectus capitis posterior major the ipsilateral headache. The patients The arterial blood supply to the spinal muscle rotates the cranium, with the atlas, were not able to endure range of motion cord consists of the anterior and posterior around the odontoid process of the axis testing, as even the smallest amount of spinal arteries, which originate from the and turns the head to the same side. With movement to the cranium or cervical two vertebral arteries. The posterior spi- extension, the obliquus capitis inferior spine would make the pain worse. Any nal arteries originate in the region of the muscle rotates the atlas and with it the attempts at treatment with soft tissue medulla oblongata and descend through cranium around the odontoid process manual medicine modalities including the foramen magnum and run posterior to the same side. The obliquus capitis gentle manual cervical traction caused the to the dorsal roots of the spinal nerves. superior muscle, acting on the cranium pain to increase. Attempts to find position The veins of the spinal cord communi- and the transverse process of C1, rotates of ease at the occipitoatlantal joint or the cate with the intervertebral veins and the head to the opposite side with exten- atlantoaxial joint in the planes of flexion, terminate in the inferior petrosal sinus. sion.38 Also acting on the atlantoaxial extension, rotation or lateral bending also They interconnect with multiple venous joint is the sternocleidomastoid muscle, failed due to marked spasm. Palpation of plexuses in the vertebral column and also which rotates the head to the opposite the transverse processes of C1 revealed act as channels from all parts of the body. side and the semispinalis capitis, longus a noticeably tender, painful and laterally They terminate in the vertebral veins and capitis, splenius capitis, and longissimus prominent transverse process on the same the condyloid emissary veins. There are capitis muscles, which rotate the head to side as the headache. This finding was also terminations in the Basilar plexus the same side.39 not subtle and was perceived through and the occipital sinus.35 Muscles, which attach and/or act palpation as a hard bony projection of Primary somatic dysfunction is char- directly at the transverse process of the lateral transverse process of C1 much acterized in early stages by vasodilation, C1 include the rectus capitis lateralis, closer to the surface on the side of the edema, tenderness, pain and muscle rectus capitis anterior, rectus capitis retroorbital headache and upper cervical contraction. The positional and motion posterior minor, obliquus capitis superior somatic dysfunction. aspects of somatic dysfunction of the and obliquus capitis inferior.40 Acting The transverse processes of C1 project spinal column may be described using indirectly on the transverse process of so far laterally that they can be easily three parameters: (1) the position of the C1 is the medial border of the suboc- palpated by pressing inward between vertebral element as determined by palpa- cipital triangle, namely the rectus capitis the mandibular angles and the mastoid tion; (2) the direction in which motion is posterior major muscle, whose origin at processes.41 A CT scan of C1 showed an freer; (3) the direction in which motion is C2 and insertion at C0 is shared by the equal distance of 3.5 cm from the skin restricted. Chronic somatic dysfunction obliquus capitis inferior and obliquus ca- surface to the lateral aspect of the trans- is characterized by tenderness, itching, pitis superior muscles respectively. These verse processes of the author. A random 36 fibrosis, paresthesias and contracture. two remaining borders of the suboccipital ➻ June 2005 The AAO Journal/15 sampling of ten adult CT scans showed a Thus, a left lateral “sideslip” of the oc- prominence of the transverse process. By range of 3 cm to 5 cm from skin surface ciput on the atlas produces a somatic convention, somatic dysfunction is de- to lateral transverse processes. With pal- dysfunction of right lateral bending and scribed by naming the superior segment in pation of this region, obvious care must left rotation at the occipitoatlantal joint. relation to the inferior segment. A proper be taken to avoid the styloid process of Kuchera and Kuchera describe this description of this somatic dysfunction the temporal superiorly and the hyoid somatic dysfunction and show that the would be left lateral translation between bone inferiorly. Palpation is easier with mastoid process on the left is more lateral the occiput (C0) and the atlas (C1) and the patient in the supine position and the to the left transverse process of C1 and right lateral translation between the atlas examiner seated at the head of the table. that the mastoid process on the right is (C1) and the axis (C2). The examiner should approach from an closer to the more prominent right trans- Bogduk states that pressure on the inferior and lateral direction and use the verse process of C1. They also observe dura itself may activate the trigeminal volar surfaces, not the tips, of the second that the right suboccipital triangle feels system intracranially with a mechanical distal phalanges. Palpation should be an- firmer and more tender to deep palpation strain capable of producing a headache.45 terior to the sternocleidomastoid muscle than on the left.43 Jones states that the Along with an overwhelming increase on a line midway between the mastoid occipitoatlantal joint may have evidence of neuronal activity involving the C1 processes and the angle of the mandible. of a lateral strain with tenderness at the nerve root, the trigeminocervical path- It is biomechanically possible that the tips of the transverse process and that “the way may also be activated by increased combined three-dimensional forces ap- atlas bone appears to slide away from the mechanical pressure caused by tension at plied to the transverse processes of C1 side of lateral convexity of the strain and the rectus capitis posterior minor muscle will produce a vector (magnitude plus the distance between the mastoid tip and and its bridge to the posterior spinal dura direction) which provides motion later- transverse process of the vertebrae will through the posterior occipitoatlantal ally along the transverse line formed by be different on the two sides.”44 ligament. This overload of the trigeminal the union of the coronal plane and the As this somatic dysfunction of right pathway at C1 is capable of producing a transverse plane intersecting through the lateral bending and left rotation at the oc- severe unilateral retroorbital headache. transverse processes of C1. The motion is cipitoatlantal joint becomes more severe, An increase of mechanical pressure may described as lateral translation and is side it will involve the entire occipitoatlanto- also be caused by the effect of the rectus to side. It is freer to the side of the retroor- axial joint complex as the strain in the capitis posterior major on the fibers of the bital headache and the laterally prominent suboccipital muscles on the right side rectus capitis posterior minor muscle. An transverse process. Conversely, motion increases in an attempt to rotate the cra- interesting observation is that the sum of is restricted to the opposite side and nium to a neutral position and to prevent the force vector of the obliquus capitis the less prominent transverse process. sidebending. This homeostatic mecha- superior which is directed from its inser- In these three cases, palpation of the nism also involves recruitment of the left tion at the occiput (C0) to its origin at the atlas was perceived as sagittally neutral sternocleidomastoid muscle and the right transverse process of C1 and the force with severe restriction in all planes of semispinalis capitis muscle. As stated, it is vector of the obliquus capitis inferior motion at the occipitoatlantal joint and biomechanically possible that the vector which is directed from its insertion at atlantoaxial joint with the exception of resolution of these increased forces acting the transverse process of C1 to its origin lateral translation toward the side of the at the right transverse process of C1 will at the spinous process of C2 is the same laterally prominent transverse process produce increased lateral translation and magnitude and direction as the force vec- of C1. Somatic dysfunction at this level in the occipitoatlantoaxial joint complex may be described as lateral translation due to pain, tenderness, and tissue tex- ture changes at the laterally prominent transverse process of C1. Greenman states that the C0-C3 com- plex functions as an integrated unit and recognizes the need to look at each level both individually and within its function in the overall complex. He also states that there are coupled sidebending and rotation movements to the opposite side which are quite small between the occiput (C0) and the atlas (C1), and that lateral bending between the occiput and the atlas occurs with the occipital condyles moving superior on one side of the atlas and inferior on the side of lateral bend- ing between the occiput and the atlas.42 Reprinted with permission from The Dynamic Spine.

16/The AAO Journal June 2005 tor of the rectus capitis posterior major toward neutral with supporting pres- Acknowledgments muscle which is directed from its inser- sure, waiting for the tissues to reset, and The author wishes to thank Pat Cough- tion at the occiput (C0) to its origin at the restarting the process until a maximum lin, PhD, John Jones, III, DO, and Mark spinous process of C2 and may indirectly therapeutic effect is obtained. Bailey, DO, PhD for their assistance in add mechanical force to the rectus capitis In Chapter 11 of Modern Neuromus- the research and editing of this paper. posterior minor muscle with its bridge to cular Techniques, Dennis J. Dowling, He would also like to dedicate this the posterior cranial fossa. DO, FAAO reviews neuromuscular paper in memory of Nicholas Nicholas, Hallgren, et al. proposed a link be- techniques and the osteopathic modality DO, FAAO and David Heilig, DO, FAAO tween idiopathic head and neck pain and of inhibition. The described osteopathic for their inspiration and dedication. a cervical myodural bridge, which was treatment utilizes the physiologic prin- named by James Lipton, DO, FAAO,46 ciples of inhibition and other osteopathic and postulated that increased tension in techniques described by Dr. Dowling Bibliography 1. Sjaastad O. Cervicogenic Headache: The the rectus capitis posterior minor muscle including functional, strain/, Controversial Headache. Clinical Neu- would increase tension in the pain sensi- , and facilitated posi- rology and Neurosurgery. 94 (Suppl.) 48 tive spinal dura by means of this connec- tion release. (1992) S147-S149. tive tissue joining of the musculoskeletal With a strain or sprain to muscle fas- 2. Sjaastad O., Fredrickson, TA, system and the dura mater.47 cia, impulses from Golgi tendon organs Pfaffenrath V. Cervicogenic Headache: Following discovery of the palpatory and muscle spindle proprioceptors affect Diagnostic Criteria. Headache. 30 abnormality of a painful and laterally gamma gain and attempt to hold a joint (1990) 725-726. prominent transverse processes of C1 and in a strain. With proper joint positioning, 3. Headache Classification Committee a unilateral retroorbital headache on the spindles can be shortened and relaxed in of the International Headache Society: Classification and Diagnostic Criteria for same side, it was observed that an indi- the agonist muscle and stretched in the Headache Disorders, Cranial neuralgia, rect osteopathic treatment directed at the antagonist. Resetting proprioceptors us- and Facial Pain. Cephalgia. 8. (suppl.) transverse processes of C1 was tolerated ing this principle was first developed by 7:61-62, 1988. by the patients and produced a therapeu- Larry Jones, DO, FAAO in his “Strain 4. Dubner R and Bennett GJ (1983) tic effect which stopped the headache and Counterstrain” technique.49 Muscle Spinal and Trigeminal Mechanisms of and allowed for further treatment of the is integrally related to its fascia and bio- Nociception. Annu. Rev. Neurosci. upper cervical and suboccipital region. electrical properties. Restoration of the 6:381-418. The treatment began by using palpatory tissues involved with lateral translational 5. Glaser JS. 1978. Neuro-Ophthalmology. contact to support the affected tissues and somatic dysfunction in the occipitoat- Harper and Row, Inc. 40-4 1. Hagerstown, MD. allowing lateral translational motion to lantoaxial joint complex uses bioelectric 6. Wilson-Pauwells L., Akesson EJ continue toward the skin surface of the fascial activation and release manipula- Steward PA. 1988. Cranial Nerves: laterally prominent transverse process tive approach introduced by the Founder Anatomy and Clinical Comments. B.C. along the transverse axis previously de- of Osteopathy, , MD, Decker, Inc., 50-69, Philadelphia, PA. scribed. The amount of pressure applied in the beginnings of osteopathy and more 7. Glaser JS. 1978. Neuro-Ophthalmology. to the transverse processes is similar to recently developed by Judith O’Connell, Harper and Row, Inc., 38-39. the pressure that one would apply to a DO, FAAO in Bioelectric Fascial Activa- Hagerstown, MD. marble, which was on a hard surface tion and Release.50 8. Penfield W and McNaughton F. 1938. beneath a moist sponge of approximately A research survey in August of 2003 Dural Headache and Innervation of the Dura Matter. From the Department of 1 and 1/2 inches. The pressure needed using the “Yahoo” web site showed 2360 Neurology and Neurosurgery of McGill would be the minimal pressure to make articles written on cervicogenic cephalgia University, and the Montreal Institute. contact with the marble and to allow it and the existence of a “Cervicogenic 48-58. Archives of Neurology and Psy- to move freely along the hard surface. Headache Society.” A survey in March chiatry. Following approximately one minute of of 2004 showed 3311 articles. This paper 9. Sumner D. 1975. “Disturbances of the treatment, the tissue texture changes at has attempted to provide an anatomic and Senses of Smell and Taste after Head the laterally prominent transverse pro- physiologic case for the clinical observa- Injuries”, N Vinken PJ, Bruyn GW. cess began to soften and the transverse tion of the relationship between a painful (Eds) Handbook of Clinical Neurology. processes of C1 were allowed to move and prominent transverse process of C1 Amsterdam, North-Holland, Volume 24, 1-25. partially toward a more neutral position. and a retroorbital headache to the same 10. Penfield W. A Contribution to the Treatment to this area can last up to ten side. Hopefully, somatic dysfunction Mechanism of the Intracranial Pain. A. minutes and consists of a gentle resetting involving the trigeminocervical pathway Research Nerve and Mental Disease, of the transverse processes to a normal from C0 to C3 will be added to the “In- Proc. (1934) 15:399-416, 1935. position in a stepwise manner. The treat- ternational Classification of Headache” 11. Stallworth JK, Ahmad, M, Longworth, ment has distinct intervals and can be de- and help clinicians look to somatic DL. 2002. The Cleveland Clinic In- scribed as applying pressure towards the dysfunction at C1 as a possible cause tensive Review of Internal Medicine. side of the laterally prominent transverse of unilateral retroorbital cephalgia and 3rd Edition, Lippincott, Williams and process, waiting for relaxation and tissue avoid a misdiagnosis of either an ocular Wilkins. 53-65. Philadelphia PA. 12. Glaser, JS. 1978. Neuro-Ophthalmology. texture changes, allowing movement migraine or a cluster headache. ➻ June 2005 The AAO Journal/17 Harper and Row, Inc., 42. Philadelphia, Anatomy. Running Press Book Publish- Dura Mater. Spine. Volume 20, #23, PA. ers. 36, 37. Philadelphia, PA. 2484-2486. 1995. 13. Ibid. 264. 22. Ibid. 332, 333. 33. Netter FH. 1997. Atlas of Human Anato- 14. Netter, FH. 1986. The Ciba Collection 23. Ibid. 348. my. 2nd Edition. Icon Learning Systems. of Medical Illustrations. Volume 1. Ner- 24. Orrison, Jr. WW. 1995. Atlas of Brain Plate 25, 27, 57. Tetterboro, NJ. vous System. Part 2. Neurological and Function. Thieme Medical Publishers, 34. Netter FH. 1987. The Ciba Collec- Neuromuscular Disorder. Ciba Pharma- Inc. 19. New York, NY. tion of Medical Illustrations. Volume ceutical Company. 116. West Caldwell, 25. Ibid. 5, 20, 24. 8. Musculoskeletal System. Part 1. NJ. 26. Gray H. 1999. The Unabridged Gray’s Anatomy, Physiology and Metabolic 15. Stallworth JK, Ahmad, M, Longworth, Anatomy. Running Press Book Publish- Disorders. Ciba-Geigy Corporation. 6. DL. 2002. The Cleveland Clinic In- ers. 348. Philadelphia, PA. West Caldwell, NJ. tensive Review of Internal Medicine. 27. Pansky B. 1978. Review of Gross 35. Pansky B. 1978. Review of Gross 3rd Edition. Lippincott, Williams and Anatomy. 4th Ed. McMillan Publishing Anatomy. 4th Edition. McMillan Pub- Wilkins. 144. Philadelphia, PA. Co., Inc. 164. New York, NY. lishing Company, Inc. 160, 162. New 16. Kimmel DL. Innervation of Spinal Dura 28. Panjabi M, Dvorak J, Duranceau J, York, NY. Mater and Dura Mater of the Posterior Yamamoto I, Gerber M, Rauschning W, 36. Glossary Committee. Educational Coun- Cranial Fossa. Read at the section on Bueff HU. Three Dimensional Move- sel on Osteopathic Principles. Glossary Neuroanatomical Sciences of the 13th ments of the Upper Cervical Spine. of Osteopathic Terminology. 1995. Annual Meeting of the American Acad- Spine. 13:726-730, 1988. 37. Pansky B. 1978. Review of Gross emy of Neurology, Detroit, April 27th, 29. Orrison, Jr. WW. 1995. Atlas of Brain Anatomy. 4th Ed. McMillan Publishing 1961. Neurology 10, 800-809. (1960). Function. Thieme Medical Publishers, Co., Inc. 164. New York, NY. 17. Bogduk N. The Anatomical Basis for Inc. 17. New York, NY. 38. Gray H. 1999. The Unabridged Gray’s Cervicogenic Headache. Journal of Ma- 30. Pansky B. 1978. Review of Gross Anatomy. Running Press Book Publish- nipulative and Physiological Therapeu- Anatomy. 4th Ed. McMillan Publishing ers. 349. Philadelphia, PA. tics. 67. Volume 15. Number 1. January, Co., Inc. 164, 176. New York, NY. 39. Pansky B. 1978. Review of Gross 1992. 31. Gray H. 1999. The Unabridged Gray’s Anatomy. 4th Ed. McMillan Publishing 18. Ibid. 67, 68. Anatomy. Running Press Book Publish- Co., Inc. 164, 176. New York, NY. 19. Ibid. 68. ers. 229, 348. Philadelphia, PA. 40. Ibid. 164, 176. 20. DiGiovanna EL. 2001. An Encyclopedia 32. Hack GD, Koritzer RT, Robinson 41. Netter FH. 1987. The Ciba Collection of of Osteopathy. American Academy of WL, Hallgren RC, and Greenman PE. Medical Illustrations. Volume 8. Mus- Osteopathy. 87. Indianapolis, IN. Anatomic Relation between the Rectus culoskeletal System. Part 1. Anatomy, 21. Gray H. 1999. The Unabridged Gray’s Capitis Posterior Minor Muscle and the Physiology and Metabolic Disorders.

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These works will enhance quick and effective learning of this osteopathic neuromusculoskeletal treatment method. Educators will find the CD version especially helpful for presentations. A point and click tender point locator map provides immediate referrence to detailed information including the associated anatomical considerations, clinical correlation, treatment position, and exercise link. Ad- ditionally, these exercise routines can be printed for patient use. The hardcover version is a milderly updated version of the CD. This work includes full-color imaging 8 1/2 by 11 inch format. It contains 256 illustrations in 186 pages and contains a more detailed index.

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18/The AAO Journal June 2005 Ciba-Geigy Corp. 10. West Caldwell, NJ. 42. Greenman PE. 1989. Principles of Manual Medicine. Williams and Wilkins. 125-126. Baltimore, MD. 43. Kuchera WA and Kuchera ML. 1994. Osteopathic Principles and Practice. Revised 2nd Edition. Greyden Press. 578-579. Colum- CME QUIZ bus, OH. 44. Jones LH. 1995. Strain and Counter-strain. Jones Strain-Counter- strain Incorp. 48. Boise, ID. The purpose of the quiz found on the next page 45. Bogduk N. 1986. Cervical causes of Headache and Dizziness. is to provide a convenient means of self-assessment N:GPED. Modern of the Vertebral Column. for your reading of the scientific content in the Churchill Livingston. 289-302. Edinburgh, England. case study, C1 Somatic Dysfunction and Unilateral 46 . Lipton JA and Hack GD. “The Clinical Implications of a Suboc- Retroorbital Cephalalgia by David Coffey, DO, cipital Myodural Bridge. Proceedings of the American Academy FAAO. of Osteopathy Scientific Convention. 1995. Oct 29-31. Orlando For each of the questions, place a check mark in FL. the space provided next to your answer so that you 47. Hallgren RC, Hack GD, Lipton JA. Clinical Implications of a Cer- vical Myodural Bridge. The AAO Journal. Winter, 1997. 30-34. can easily verify your answers against the correct 48. Chitow L. 2003, Modern Neuromuscular Techniques. 2nd Edition. answers that will be published in the June 2005 Elsevier Science Limited. 225-232. London, England. issue of the AAOJ. 49. Kuchera WA and Kuchera ML. 1994. Osteopathic Principles in To apply for Category 2-B CME credit, transfer Practice. Revised 2nd Edition. Greydon Press. 578-579. Colum- your answers to the AAOJ CME Quiz Application bus, OH. Form answer sheet on the next page, then mail the 50. O’Connell JA. 1998. Bioelectric Fascial Activation and Release: bottom half of the form with your AOA number The Physician’s Guide to Hunting with Dr. Still. American Acad- ONLY to the AAO as indicated. The top half of the emy of Osteopathy. Indianapolis, IN.∆ form should be sent to the American Osteopathic Association in Chicago. The AAO will record the Accepted for publication, March 2004 fact that you submitted the form for Category 2-B CME credit and will forward your test results to the Address correspondence to: AOA Division of CME for documentation. David Coffey, DO, FAAO Montgomery Family Practice, PC 1758 Park Pl., Ste. 402 Montgomery, AL 36106 Fax: 334/265-9055 E-mail: [email protected]

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This CME Certification of Home Study Form is intended to document individual review of articles in the Journal of the American Academy of Osteopathy under the criteria described for Category 2-B CME credit. This form should NOT be submitted in the same envelope with a AAOJ CME Quiz Application Form (see below).

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Author: David Coffey, DO, FAAO FOR OFFICE USE ONLY

Publication: Journal of the American Academy of Category: 2-B Credits ______Osteopathy, Volume 15, No. 2, June 2005, pp 13-20 Date: ______Mail TOP HALF of this page to: AOA No. 00 ______American Osteopathic Association Physician’s Name ______Attn: Division of CME 142 E. Ontario St., Chicago, IL 60611-2864 Complete the quiz below and mail to the AAO. The AAO KEEP A DUPLICATE OF YORU COMPLETED will forward your completed test results to the AOA. You FORM FOR YOUR RECORDS must have a 70% accuracy in order to receive CME credits.

1. The meningeal branch of the ophthalmic 4. According to Panjabe, et al., which is an nerve, the nervus tentorii, supplies which accurate description of range of motion intracranial structure. in the occipitoatlantoaxial joint complex. a. The falx a. Occipitoatlantal rotation: 6.2 degrees. b. The dura of the entire cerebri b. Atlantoaxial flexion: 11.5 degrees. c. The transverse sinuses c. Occipitoatlanal lateral bending: CME QUIZ d. The superior portion of the tentorium 4.5 degrees. APPLICATION FORM cerebelli d. Atlantoaxial lateral bending: 7.6 degrees. e. All of the above. e. None of the above.

Fill in your AOA member number 2. The posterior cranial fossa is supplied 5. The floor of the suboccipital triangle below. Do not place your name on this by fibers that travel with the vagus nerve contains: AAOJ CME Quiz Application Form. and the recurrent branches of the first a. The posterior arch of the atlas. b. The posterior occipitoatlantal ligament. Credit is granted by member number three cervical nerves. a. True c. The vertebral artery. only to preserve member anonymity. d. The posterior division of the suboccipital b. False. Complete the answer sheet to the right nerve. e. All of the above. for Category 2-B CME credit. 3. The dura mater of the spinal cord, foramen magnum, and clivus is Mail ONLY BOTTOM half of this inervated by: page with your AOA number and a. The ventral rami from C1 to C3. quiz answers to: b. The dorsal rami from C1 to C3. c. The sinuvertebral nerves from C1 to C3. Answer sheet to March 2005 d. All of the above. AAOJ CME quiz American Academy of Osteopathy® June 2005 e. None of the above. answers: 3500 DePauw Blvd, Suite 1080 AAOJ CME 1. D Indianapolis, IN 46268 quiz will appear 2. B in the Septem- 3. D ber 2005 issue. 4. B AOA No. 00______5. D (see membership card)

20/The AAO Journal June 2005 Abreactions in Ligamentous Articular Strain Laura McMurrey and Stuart F. Williams

Introduction her last treatment. Significant past medical the patient is reacting is most often of An abreaction is defined by Merri- history includes a head injury with con- a traumatic nature. The trauma may be am‑Webster as “the expression and emo- cussion, a whiplash injury, and problems physical, such as physical abuse, sexual tional discharge of unconscious material falling asleep and with staying asleep. abuse, or the trauma of a car accident; or (as a repressed idea or emotion).” In the She currently has problems with back it may be emotionally traumatic, as with 1940s, psychiatrists began to think that pain, leftsided numbness and tingling, the 43-year-old with recurrent nightmares such a release of pent‑up feelings and en- left sided weakness, anxiety, depression from the time he was 16 following the wit- 1 ergy may be essential to moving forward and chronic pain syndrome (CPS). She ness of his brother’s suicide. Often, these in one’s personal emotional evolution. It was diagnosed with CPS seven years ago, initial events fail to resolve themselves was found that intravenous injections of and her pain tends to involve primarily and can become chronic in nature. This sodium amytal helped patients into a state the left side. She is currently under the is often diagnosed as post‑traumatic stress in which they were less likely to “shut care of a neurologist, a psychotherapist, disorder by psychiatrists. War veterans off” emotions that they had a tendency to an acupuncturist, and a massage therapist are a favorite source for research on post- avoid in traditional psychotherapy and in for the management of her CPS, and ­traumatic stress disorder, as they have everyday interactions.1 However, patients she has occasionally sought osteopathic often been the victims of both physical do not require pharmacological substanc- treatments as well. She denies the use of and emotional trauma on the battlefield. es in order to experience a spontaneous alcohol or illegal drugs, and her current In practice, osteopathic physicians tend release of previously repressed feelings medications include Neurontin, Celexa, to focus on physical stressors as these are and the physical response that accompa- BuSpar, trazodone, and synthetic thyroid more easily remembered by the patient nies it. The phenomena of abreaction has hormone. Also of potential importance and patients tend to be more likely to been documented in intense sessions of is that her last menstrual period occurred discuss physical trauma. Physical causes traditional therapy, in massage therapy, four months ago. are also more easily explained and treated in the alternative medical fields of body Osteopathic findings were as follows: by the typical physician. When tissue has energy work and acupuncture, and it has iliolumbar ligament tension, muscular been altered and is no longer in balance been documented in craniosacral and spasms of the external rotators of the hip at a neutral position with respect to the osteopathic manipulative treatment of on the left, sacral torsion with the right surrounding tissue, this point becomes a 2 these patients with post‑traumatic stress ILA markedly inferior, fascial tension reaction point. similar chronic disease processes (fibro- deep within the upper thighs bilaterally Treatment involves three basic steps, myalgia, chronic pain syndrome, and and a tight inguinal ligament on the left. with the goal of bringing the tissue similar diagnoses). All areas were treated with ligamentous holding the reaction back to the neutral articular strain as they were found. During point, where it is able to function at peak the release of the left inguinal ligament, performance. We must first understand Case Report the patient expressed that she was in quite the background fundamental concepts C.S. is a 48‑year‑old white female a bit of discomfort and that she felt very on which ligamentous articular strain who presented to the office with acute uneasy. This was not an unexpected reac- was built. It is the belief of many physi- low back pain for the last two days. She tion, as treating patients with ligamentous cians currently using and studying these was originally referred to the clinic for articular strain includes applying a moder- methods of osteopathic treatment that osteopathic manipulative treatment by her ate to deep pressure to ligaments, tendons the cranial rhythmic impulse, more com- massage therapist for left buttock and low and muscles that have gone into spasm monly referred to as “the tide”, is present back pain with symptoms of sciatica that and are quite often tender. not just within the central nervous system were not constant. She was last seen at but throughout the body.3 We learned in this clinic one year ago for low back pain our basic anatomy and physiology classes and left hip pain, and told us that she had Discussion The concept of ligamentous articular that not every cell within the body is di- avoided returning to the clinic since that rectly in contact with a capillary or blood time because of her post‑treatment reac- strain involves the treatment of allocation in the body that has reacted to an outside vessel. In order for these tissues to receive tion. She told us that she had felt weakness nourishment and for their waste products on her entire left side on the day following stressor. The inciting event to which ➻ June 2005 The AAO Journal/21 to be carried away, we learned that the interstitial fluid carrying nutrients from the blood vessels must wash over these cells, and then retreat back to the vessels carrying the waste.2 Osteopathic physicians treating with LAS believe that this fluid movement is indeed related the tide of the cranial rhyth- mic impulse, in fact is governed by it.3 The first step in a ligamentous articu- lar release treatment is often referred to as disengagement. It involves loosening the point of the reaction from the tissues around it. The patient typically perceives these reaction points as areas that are more tender on palpation than surround- the tension exerted on the lesion by the explained to the patient that her reaction ing areas. These may be anywhere on contracted side.3 was due to a surge of sympathetic output, the body, and can occur in ligaments (as The third step involves maintaining which appeared most directly to be a re- the description implies) or in tendons, an equal tension in all directions as the sult of the treatment of the inguinal liga- muscle, fascia, and even in the bones tissues begin to relax and regain their ment. During this discussion, the patient themselves (although these are very dif- original tensions. The palpatory experi- revealed to us that she was a survivor of ficult to palpate).3 A common example ence of this readjustment of the tissues incest. We now had all of the ingredients of such a reaction point often treated by is quite similar to that of myofascial for an abreaction according to its defini- LAS is the piriformis tenderpoint (in fact release, except that the pressure applied tion: the inciting trauma (both physical each of the six external rotators of the and the tissues affected are generally and emotional), and the expression and hip between the greater trochanter and much deeper than the superficial fascia. emotional discharge of unconscious ma- the sacrum will often have these reac- These two techniques often overlap. The terial, coupled with a sympathetic surge tion tenderpoints). Disengagement of treatment is complete when the tide can that would be expected when experienc- the reaction point is done by applying a be felt at the reaction point, palpated as ing such intense feelings. fair amount of pressure to the point until the reaction point itself moving back and it begins to move somewhat on its own. forth between its suspensions, with equal Review of Literature Occasionally, traction (also referred to as amplitude in both directions, at a rate of Literature on the connection between distraction) is instead required to disen- 8 to 14 cycles per minute (the rate of the any form of osteopathic manipulation gage the reaction. The reaction point has cranial rhythmic impulse). and abreaction is minimal. There are, now been loosened from the tensions that however, several references to the inter- held it. Once the point is disengaged, the Case report (continued) connections between lesions of the mus- second step involves taking the reaction Following treatment of the patient’s culoskeletal system and the autonomic to a place of balanced tensions. This will tight left inguinal ligament, reaction nervous system, and to the importance typically involve an exaggeration of the points between the patient’s ribs were of fascia in mechanical pain syndromes lesion, but only to the point at which all treated both anteriorly and posteriorly. and more importantly in this case, in 2 tensions are equal. During this time, the patient began to persistent pain syndromes.4 Foundations The reason exaggeration is required tremor slightly. She seemed very con- for Osteopathic Medicine states that “a to reach a point of balanced tension can cerned about this, which was appropriate decreased threshold to stimuli is applied be confusing. The existence of a reaction as it was unexpected and was restricted to above or below the segment [of the osteo- point is defined as tissue that is not at primarily the left side. Within a couple of pathic lesion] and can result in increased its neutral resting point. It has deviated minutes, her tremor was so intense that efferent somatic (muscle contraction) and from neutral and it is being suspended she appeared to be shivering severely. autonomic activity.5 The neurobiologi- there by malfunction of the surrounding Her jaw was also quivering to the point cal theory in psychiatry maintains that fascial connections: on one side of the that she had to use her hands to steady physical symptoms whose cause cannot lesion is a weak element, which allows her jaw so that we could understand her. be determined by current standards of the reaction to move further away. On At this point, the physician recognized diagnosis (CT scan, MRI, etc.) result the other side of the lesion, the fascial her body’s reaction as an increased surge from dysfunction in the neuroendocrine connections responsible for suspending of sympathetic output, and began a CV4 systems responsible for processing pe- the reaction point have tensed up and are cranial technique with the purpose of ripheral sensory AND central emotional pulling the reaction point in that direction rebalancing the autonomic output. With information.6 (see figure). Exaggeration of this lesion the CV4 treatment, her tremor improved There are also references to the benefit is required to (a) bring tension into the significantly, and she requested a mo- of abreaction in psychiatric progression weakened connection, and to (b) decrease ment to sit up and recompose herself. We (i.e., the Spirit portion of the osteopathic 22/The AAO Journal June 2005 philosophy) and between emotions and phenomenon are discussed as a response 5. American Osteopathic Association. the autonomic nervous system. Within the to . Abreactions oc- Foundations for Osteopathic Medicine. realm of psychotherapy, it is commonly curring in response to other forms of Pennsylvania PA. Lippincott Williams & felt that painful, abusive experiences manipulation require closer investigation, Wilkins. 2002. 6. Chamberlain JR. “Approaches to need to be uncovered before treatment which cannot occur until reporting such Somatoform Disorders in Primary Care.” can progress and that uncovering such reactions becomes routine in the practice Psychiatry 3:8:2003:438‑447. 7 memories can often be helpful. It is of OMT. 7. Tucker‑Ladd CE. “Catharsis and Abre- also well documented that feelings and action.” Psychological Self‑Help. http:// perceptions influence the muscular and Accepted for Publications: October www.mentalhelp.net/psyhelp/chap15/ autonomic activity of the body, as well 2004 chap15r.htm. October 13, 2003.∆ as the ability of the body to respond to exogenous influence (e.g., OMT)5 References Accepted for publication, October 2003 1. Denson R. “Clinical Report: Treatment Summary of Nightmares by Abreaction,” Canadian Address correspondence to: It is clear that more research and Psychiatric Association, http ://www. Laura McMurrey, OMS-IV case discussions must be presented and cpaapc.org/Publications/Archives/Bul- UNTHSC/TCOM letin/2003/february/denson.asp. October reviewed before the connection between 13, 2003. Dept of OMM abreaction and osteopathic manipulative 2. Speece CA, Crow WT, and Simmons SL. 3500 Camp Bowie Blvd. treatment well known as a potential out- Ligamentous Articular Strain: Osteo- Fort Worth, TX 76107 come and before physicians are able to pathic Manipulative Techniques for the or recognize it for what it is. One osteopath- Body. Vista, CA: Eastland Press, 2001. Stuart F. Williams, DO ic physician in Florida who has limited 3. Kalich A. Physician, Osteopathic Ma- UNTHSC/TCOM his practice of medicine and manipula- nipulative Medicine. Personal Interview, Dept of OMM tion to only craniosacral manipulation October 7‑24, 2003. 3500 Camp Bowie Blvd. has coined the term “somatoemotional 4. Bilkey WJ. “Involvement of Fascia in Fort Worth, TX 76107 Mechanical Pain Syndromes.” Journal release.” However, his references to this of Manual Medicine 6:1992:157‑160.

2005 Unified Osteopathic Convention American Osteopathic Association Sunday, October 23 through Thursday, October 27, 2005 Orlando, Florida Theme: Osteopathic Medicine: A Profession United for Excellence in Healthcare

AAO program theme: “Osteopathy in The Specialties: A Hands-On Approach” program chairperson: Kenneth J. Lossing, DO

Need Additional CME? AAO sponsors a one-day OMT workshop (Rapid OMT: Increase your Reimbursement in an Ambulatory Setting)

LOG-ON to DO-online at the link below for housing and registration information. http://do-online.osteotech.org/virtual_convention.cfm?PageID=conv_main

June 2005 The AAO Journal/23 Osteopathic Manipulative Medicine Faculty Position Opening

Touro University-California College of Osteopathic Medicine

The Department of Osteopathic Manipulative Medicine (OMM) has a full time position available. The applicant should have interest and experience in clinical practice and teach- ing osteopathic manipulative medicine in a variety of settings.

Qualifications: • Board certified in OMM/NMM or eligible to sit for certification • Clinical practice experience • Licensed or ability to be licensed in the State of California • Unrestricted DEA licensure • Graduate of an AOA-approved osteopathic college • Residency training and teaching experience desirable

Responsibilities: • Participate in the delivery of the Department of Osteopathic Manipulative Medicine (OMM) educational programs • Work/teach with other university departments to integrate OMM throughout the curriculum • Participate in other departmental programs, including pre and post doctoral training, research, and other scholarly activities • Patient care in the Touro University Health Care Center

Rank, Salary, and Benefits: •­ Assistant or Associate Professor • Salary based on experience and credentials • Touro University faculty benefit package

Letters of interest and current curriculum vitae are being accepted at this time and will continue until a suitable candidate is hired. The position will begin July 1, 2005. Informa- tion and inquiries should be sent to:

John C. Glover, DO, FAAO Chairman, Department of Osteopathic Manipulative Medicine Touro University-California 1310 Johnson Lane Vallejo, CA 94592 (707) 638-5219, Fax (707) 638-5255, e-mail: [email protected]

Touro University is an Equal Opportunity/Affirmative Action Employer

24/The AAO Journal June 2005 Be Careful with this Kind of Case! Richard C. MacDonald

WF, 44yr, Married, No Children 6‑ T5‑7 forward bent in May 2001. She may still have an intimal The above patient has been seen by me She was seen again the next day by me; flap at the dissection site. on numerous occasions for cephalalgia neurological exam was normal and the She continues to fly to many areas and and low back pain. Except for a recurring somatic dysfunction was much improved. do her regular business with continued viral type lesion on the lip she was in good I saw her two days later and she was not improvement. She fly’s under 5000 ft. and health. She had a history of sexual abuse, much improved, but all somatic dysfunction no scuba diving. malignancies X 2, one abortion, colitis was much improved except C2, which was This case represents a non‑typical and concussions. When first seen for the mobilized with thrust bilateral in a flexion example of trigeminal neuralgia. I believe following c.c. she had recently had the posture. I felt the viral trigeminal neuralgia that all of her symptoms were caused flu. I had not seen her in our office since would subside over the next several days by over stimulation of the sympathetic November 2000. if the somatic dysfunction mobilization nerves at the carotid dissection site. The On December 28, 2000 the patient was related. She was told if she was not sympathetics interacted with the cranial walked into the narrow edge of a door improved to get another opinion. I saw her nuclei and/or ganglion of the 5th, 7th, 9th, during the‑night. She struck her left frontal only during symptoms 1 & 2. 10th, and perhaps the 11th and 12th cranial region. The force of the injury caused her Cat Scan of her head was done to rule nerves. This would probably represent a to fall on to her back on the floor. She did out a contrecoup subdural hematoma. No visceral‑visceral type facilitation. not strike her head nor was she unconscious abnormal cranial findings were present on I believe that this case represents an from the fall to the floor or from the initial the Cat Scan. She also had blood work and example of a vector force causing an energy head trauma. all was normal even the Sed Rate. She had cyst, the dissecting aneurysm, which came On the January 10, 2001, the patient no family doctor in our area. She went to an early and then was followed by the clot began to have notable symptoms which outpatient clinic and the doctor at the clinic formation over several days and causing the were: agreed with my diagnosis of viral trigemi- sympathetic neurological reaction. 1‑ Severe pain to her right face, throat, nal neuralgia. But, the patient continued There have been several studies by TMJ, and head. to have the same severe symptomatology. physical therapists regarding dissecting 2‑ She had lost her sense of taste and She could not get to see a neurologist here aneurysms of the vertebral artery due to later began to develop nausea and vomit- so she went to Atlanta and saw her fam- manipulation of the upper cervical region ing. ily doctor who sent her to a neurologist. by DCs and PTs. I have found that ma- 3‑ Later the vomiting stopped and she Both agreed with the trigeminal neuralgia nipulative forces (thrust) are not necessary had difficulty eating, swallowing, and in- diagnosis. He prescribed pain medications, in a high percent of the time and never ability to concentrate. which did not help. necessary in the infant, child and older 4‑ She developed a right eye soreness Her symptoms continued and she adult. If the high velocity force is needed and a drooping eye lid (Homers Syn- happened to speak with a visiting friend it should always be done with the patient’s drome), which still returns slightly when who is a physician from South Africa. head on the neck in a forward bent posture. she is stressed by the return of the above The physician encouraged her to have a Incidentally, dissecting aneurysms of the symptoms 1 and 2. cervical MRI with contrast. This procedure internal carotid artery are usually diagnosed On structural evaluation she had some of was performed and the basic cause of her at autopsy. her usual cervical muscle tension. She had trigeminal neuralgia (plus) was defined as a It is interesting that a forward bent bi- minimal vertebral or sacral dysfunction to dissecting aneurysm of the internal carotid lateral thrust to C2 did not cause a positive explain the severity of her symptoms. Her artery at the external portion of the foramen or negative reaction at treatment two. I will cranial and dural tube motion was easily lacerum on the right with a formed clot. not miss this diagnosis again.∆ mobilized. Cranial Somatic Dysfunction She was immediately placed on Coumadin was present: for a six month period. Her pain improved Accepted for publication, April 2004 1‑ Frontal compression and her taste slowly returned over a two 2‑ Sphenobasilar compression week period. Address correspondence to: 3‑ Right lateral strain She has had two mild flare ups since Richard C. MacDonald, DO 4‑ Right temporal externally rotated February, which have come under control 860 U.S. Highway One, Suite 211 5‑ C2 side bent left once on its own and the other time by OMM North Palm Beach, FL 33408 June 2005 The AAO Journal/25 American Academy of Osteopathy® Consensus Statement for Osteopathic Manipulation of Somatic Dysfunction under Anesthesia and Conscious Sedation Background It is further classified by body regions, * primary or metastatic carcinoma in the The purpose of Osteopathic manipula- including head, cervical, thoracic, lumbar, area to be treated tion with or without general anesthesia sacral, pelvic, lower extremity, upper * local bone or joint infection in the area is to restore the patient to optimal health extremity, ribs, and . to be treated potential. This is accomplished by the * acute fracture proper use of those procedures that will Indications * unstable spondylolisthesis restore normal motion to the specific Manipulation under anesthesia may * acute inflammatory arthritis joint(s) and the associated muscles and be appropriate in cases of restrictions and * uncontrolled diabetic neuropathy tissues found to be in a dysfunctional abnormalities of function. These include * evidence of spinal cord compression state. recurrent muscle spasm, range of motion by tumor or disc herniation Manipulation Under Anesthesia restrictions, persistent pain secondary to * evidence of aortic aneurysm (MUA) is an OMT procedure, performed injury and/or repetitive motion trauma. * contraindications to general anesthesia with the added benefit of conscious or Furthermore it is an alternative approach or IV sedation, and general sedation of the patient. It is used after failure* to significantly improve * any condition that would contraindi- to circumvent and overcome the con- with conservative treatment including but cate direct manipulative techniques scious and unconscious defense mecha- not limited to OMT, physical therapy and which would likely result in harm to nisms and natural resistance to treatment medication. In general, MUA is limited the patient. manifesting in some conditions. Research to patients who have somatic dysfunc- and publication on the utilization and ef- tion which: ficacy of this procedure is limited. Relative Contraindications 1. has failed to respond to conservative The physician may choose to proceed Definitions treatment in the office or hospital that with caution and with documentation of Osteopathic Manipulative Treatment has included the use of OMT, physical his/her considerations on the chart in the (OMT) is an osteopathic medical proce- therapy and medication, and/or presence of dure involving the therapeutic application * systemic infections of manually guided forces by an osteo- 2. is so severe that muscle relaxant medi- * previous MUA for the same problem pathic physician to improve physiologic cation, anti-inflammatory medication performed within the previous three function and/or support homeostasis. It or analgesic medications are of little weeks, and is a form of manual treatment used to benefit, and/or * radiographic evidence of advanced de- eliminate or alleviate somatic dysfunc- generative joint disease, osteoporosis or tion and related disorders. This treatment 3. results in biomechanical impairment other condition of a degree in which may be accomplished using a variety of which may be alleviated with the use MUA may result in harm to the patient. techniques including direct approaches of the procedure. such as muscle energy and high velocity- Dosage and Frequency low amplitude (HVLA) thrust or impulse * Failure may be defined as a lack of MUA is usually a single dose proce- procedures, or indirect approaches such significant response in 3-6 weeks in dure. As with other OMT procedures, as strain/counterstrain, cranial oste- the acute phase, 6-12 weeks in the patients occasionally report post-treat- opathy, and myofascial release (MFR) post-acute phase, and greater than ment reactions. The reaction may last procedures, among others. 12 weeks in the chronic phase. In the 24-48 hours, and includes muscle sore- Somatic Dysfunction as used by chronic pain patient, these criteria may ness usually relieved by rest, warm bath, osteopathic physicians and surgeons, is be met at the initial evaluation by an and mild anti-inflammatory or analgesic defined as “Impaired or altered function of osteopathic physician. medication. In some cases a follow-up related components of the somatic (body MUA may be indicated after a three week frame work) system; skeletal, arthrodial, Contraindications interval. If a follow-up MUA is indicated and myofascial structures; and related Manipulation under general anesthesia with less than a three week interval, a vascular, lymphatic, and neural elements.” is contraindicated in the presence of second opinion is recommended. After

26/The AAO Journal June 2005 a second or follow-up MUA, any ad- complished and charted prior to the Greenman, Philip E, Manipulation with ditional MUA considerations should be procedure. the patient under anesthesia, Journal of with the consensus of appropriate consul- 5. MUA may be performed as a same- the American Osteopathic Association tants. These may include a neurologist, day or in-patient procedure depending (JAOA), Vol 92, No 9, September 1992, orthopedic surgeon, physiatrist, and/or on the condition of the patient. pages 1159 ff. a specialist in osteopathic manipula- 6. Hospital or surgical center quality tive medicine or neuromusculoskeletal management procedures apply. Greenman, Philip E, Principles of Manual medicine and osteopathic manipulative 7. The physician performing the MUA Medicine, Second Edition. Lippincott medicine certified by the AOBNMM or may be the attending physician or a Williams and Wilkins, 1996, pages 50- AOBSPOMM. consulting specialist. 52.

Recommended Kohlbeck FJ, Haldeman S., Medication- Physician Qualifications Disclaimer assisted spinal manipulation. Spine J. As a minimum, it is recommended It is the intent of the American Acad- 2002 Jul-Aug;2(4):288-302. that the physician performing the MUA emy of Osteopathy that this document procedure, should meet all of the follow- be used as a guideline in establishing Krumhansel, B and Nowacek, C. Ma- ing qualifications: privileges for osteopathic physicians nipulation Under Anesthesia. In G.P. 1. Be board certified (or board eligible) and surgeons for the use of Manipulation Grieve. (Ed.) Modern manual therapy under the jurisdiction of an AOA Under Anesthesia. of the vertebral column. Edinburgh: certifying board. (See Grandfathering This document is not to be construed Churchill Livingstone. 1986. Guideline below.) as an endorsement of efficacy or final 2. Have demonstrated skill in Osteo- criteria for implementation by a hospi- Mosey, Jr, Lloyd W, Osteopathic manipu- pathic diagnostic and manipulative tal/institution without appropriate review lation under general anesthesia, JAOA, treatment procedures. and implementation of the hospital or Vol 73, October 1973, pages 84-95. 3. Have documented training and experi- institution’s own guidelines for Manipu- ence in manipulation under anesthesia. lation Under Anesthesia. Palmieri NF, Smoyak S., Chronic low In reviewing this document, each hos- back pain: a study of the effects of manip- pital or institution must review, formulate ulation under anesthesia. J Manipulative Physiol Ther. 2002 Oct;25(8):E8-E17. Grandfathering Guideline: and institute its own rules regarding Those osteopathic physicians cur- qualifications, statistical monitoring and outcomes in establishing procedures, Siehl, Donald, Manipulation of the spine rently credentialed to perform MUA and under general anesthesia, Yearbook whose privileges are in good standing controls, and systems for Manipulation Under Anesthesia. Academy of Applied Osteopathy 1967: may be allowed to continue these privi- pages 145 ff. leges regardless of board certification by Revised March 16, 2005 AAO Board of Governors the AOBNMM or AOBSPOMM. Siehl, Donald, and Bradford, W.G., Ma- nipulation of the Low Back Under Gen- eral Anesthesia, JAOA, 52:239f, Dec 52. Facility Guidelines MUA is a hospital or surgical center Suggested Readings Davis, C.G. Chronic cervical pain treated Soden, G Haddon, Manipulation of procedure. As a minimum, the physi- Lower Back Under Surgical Anesthesia, cian administering the procedure should with manipulation under anesthesia. Journal of Neuromusculoskeletal Sys- Yearbook Academy of Applied Osteopa- comply with all appropriate hospital or thy, 1952, pages 159 ff. surgical center protocols. tems 1996; (4) pp. 102 1. A signed informed consent approved Dreyfeuss, P., Michaelson, M and Horne, Soden, G Haddon, Osteopathic Manipu- by the hospital or surgical center. The lative Surgery Under General Anesthesia, patient must be informed about their M. Manipulation under joint anesthesia/ analgesia: a treatment approach for re- Yearbook Academy of Applied Osteopa- diagnosis, the procedure, alternatives, thy, 1949, pages 188 ff. potential risks and possible complica- calcitrant low back pain of synovial joint tions. origin. Journal of Manipulative and Physi- ological Therapeutics; April 17, 1995 Van Stratten, Leon, The Manipulative 2. The anesthesiologist/anesthetist is Surgery of Sir Herbert Barker, Yearbook properly credentialed by the hospital Gordon RC. An evaluation of the ex- Academy of Applied Osteopathy, 1953, or surgical center. pages 169 ff. 3. History and physical must be done perimental and investigational status and prior to or upon admission. clinical validity of manipulation of pa- tients under anesthesia: a contemporary Williams, H.A. Manipulation Under 4. All necessary laboratory reports, Anesthesia, Part III, Discussion/critique. x-rays and other imaging studies, opinion. J Manipulative Physiol Ther. 2001 Nov-Dec;24(9):603-11. American Chiropractic Association Jour- consultants’ reports, etc. will be ac- nal of Chiropractic. Feb. 1998

June 2005 The AAO Journal/27 15th Annual OMT Update “Application of Osteopathic Concepts in Clinical Medicine” plus Preparation for Certifying Boards August 18-21, 2005 at Walt Disney World® Lake Buena Vista, Florida

Ann L. Habenicht, DO, FAAO Program Chair “LAST OMT UPDATE before Closing The program anticipates being approved for 22.5 hours of AOA Category 1-A CME credit pending approval by the AOA CCME. AOBNMM PRACTICE TRACK

Course Objectives: Level III Registration Form This Academy program was designed to meet the needs of the 15th Annual OMT Update physician desiring the following: August 18-21, 2005 • OMT Review - hands-on experience and troubleshooting Full Name ______• Integration of OMT in treatment of clinical cases Nickname for Badge ______• Preparation for OMT practical portions of certifying boards • Preparation for AOBNMM (American Osteopathic Board of Street Address ______Neuromusculoskeletal Medicine) certifying/licensing boards ______• Information on CODING for manipulative procedures • Good review with relaxation and family time City ______State ______Zip______Office phone # ______Prerequisites: The participant should have a basic Fax #: ______understanding of functional anatomy and (1) Level II course. E-mail: ______By releasing your Fax number/E-mail address, you have given the Program Time Table: AAO permission to send marketing information regarding courses Thursday, August 18...... 5:00 pm - 10:00 pm via the Fax/E-mail. Friday, August 19...... 7:00 am – 1:30 pm AOA # ______College/Yr Graduated ______Saturday, August 20...... 7:00 am – 1:30 pm I need AAFP credit ❒ Sunday, August 21...... 7:00 am – 1:30 pm (AAO makes every attempt to provide meals that will meet (Each day includes (2) 15 minute breaks) participant’s needs. However, we cannot guarantee to satisfy all requests.) Course Location: Registration Rate Disney’s Contemporary Resort On or Before 7/18/05 After 7/18/05 Hotel Information: AAO Member $630 $730 Disney’s Contemporary Resort Intern/Resident $530 $630 4600 World Wide Drive AAO Non-Member $845 $945 Lake Buena Vista, FL 32830 407/824-3869 (Reservation line) AAO accepts Visa or Mastercard Reservation Deadline: July 21, 2005 Credit Card # ______Room Rate: $165.00 single/double Cardholder’s Name ______$25.00 per person each additional (Identify yourself as attending Date of Expiration ______American Academy of Osteopathy®’s Conference) Signature ______

28/The AAO Journal June 2005 Review of the Intelligent Body R. Paul Lee

From across the Atlantic, osteopathy tone in the system operating fluid filled function right down to the genetic mate- in the United Kingdom seems idyllic, compartments in the body that end in rial in the nucleus. Vibratory information philosophically pure, and unadulterated joints. Joints, in general, are in tension, transmitted by this tissue tensegrity system by allopathic influence. First-hand, I was not compression. Changing the tension activates enzymes and DNA. The icosahe- not disappointed when I attended the across a joint is to make the joint move. dron naturally oscillates between left and Sutherland Cranial College’s seminar and The joint is a frictionless plane which as right-handed forms with a larger-volume, workshop, The Intelligent Body, April 16 Levin discovered cannot be compressed higher-energy, cubic octahedron as the & 17, 2005, in London, England. I was when synovial fluid is in place and liga- intermediary. A veritable pumping action not only pleased to learn about scientific ments are intact. This phenomenon does results as icosahedrons oscillate. Any information that supports traditional osteo- not follow Newtonian laws of physics. Due energy put into the system (mechanical, pathic philosophy, but also about advanc- to tensegrity, the shoulder floats in muscle. electrical, ionic flows) activates this oscil- ing ideas percolating through the minds There is very little connecting the shoulder lation of life. Thus, within the connective of this osteopathic community. The urge to the axial skeleton. The scapula can be tissues, functioning on both a metabolic to develop osteopathic philosophy is alive visualized as a sesamoid bone within the and structural level is inseparable. and surging in the U. K. On the first day, shoulder girdle. the seminar featured Stephen Levin, MD Icosahedrons exhibit the phenomenon of Virginia and James Oschman, PhD, of Close packing changes spherical com- of “stacking.” Symmetrical placement New Hampshire, who lectured respectively ponents in living systems to icosahedrons of one icosahedron on top of another in on tensegrity and the living matrix. Then, (20 equilateral triangles), the next best long series is the basis for the formation of on day two at the workshop, faculty of the shape to a sphere that maximizes volume to helices. Hydroxyapatite is a helix. DNA is Sutherland Cranial College of Osteopathy surface area. Beneath the icosahedron are a double helix. Collagen is a triple helix. challenged the osteopathic students to more basic octahedrons (eight triangular Systems of helices form non-Newtonian clinically integrate these ideas through surfaces) and tetrahedrons (four triangles) pumps in which squeezing it increases palpatory exercises. into which icosahedrons can devolve. the pressure. Examples of these are the Foam offers a plausible model for the shape heart, alveoli, bladder, bowel, uterus, and Dr. Levin punctuated his presentation of connective tissue. In foam, spherical kidney. with good humor to emphasize that the bubbles are compressed in standard ways: concepts of tensegrity apply to the human close packing produces 120 degree angles Dynamical diseases are non-linear, body. He said that intervertebral discs don’t where any two adjacent films meet; three such as asthma, anaphylaxis, IBS, hives, hold you apart, they hold you together. films meet to form an edge; four edges migraines. Ingber says they are related to Levin has independently studied tensegrity meet at a single point. Just such arrange- mechanotransduction. They don’t show for all of thirty years, inventing the field ments are seen not only in connective tissue pathology once healed. of bio-tensegrity. He has concluded that but more dramatically in the structure of the spine is not a stack of blocks bearing the honeycomb of the beehive and of the Dr. Oschman focused on the living up against gravity. Rather, each vertebra, eye of the fly. matrix (connective tissue matrix) in his including the sacrum is suspended by trian- exciting presentation. As a biophysicist and gulating fibers of connective tissue. Microscopically, tensegrity is seen biologist, he has made a study of healing in the cytoskeleton, where microtubules systems and the mechanisms by which they One could compare the sacrum to the serve as the discontinuous compression work. He published a groundbreaking book hub of a bicycle wheel with the ligaments elements and microfilaments and inter- in 2000: Energy Medicine: the Scientific acting like the spokes. The serves mediate filaments serve as the continuous Basis, and more recently: Energy Medicine as the outer rim of the wheel. There are tension elements. Mechanotransduction in Therapeutics and Human Performance. only straight-line tensioning forces that occurs across the cell membrane thanks In his books as in this set of lectures he angulate with each other to support the to integrins, proteins imbedded within the marries optimal health and healing with system. Compressive elements (bones) membrane that are connected to both the its underpinnings in science. are discontinuous (like the hub), while extracellular matrix and the cytoskeleton. Oschman took the ball from Levin to tensional elements (muscles, ligaments, This means that all the cells and extracellu- show how the connective tissue matrix fascia) are continuous. Muscles create a lar matrix exhibit a continuous mechanical serves as a sensitive receptor and generator

June 2005 The AAO Journal/29 of biological information. He indicated Dr. Oschman went so far as to say All fibroblasts connect physically with that many phenomena exist within the that the connective tissues exhibit pri- each other creating another meshwork matrix as organizing forces for the entire mary consciousness. Before the nervous of communication within the matrix. In organism. Water organizes itself using system was phylogenetically established, this way we could explain the reaction octahedrons of hydrogen bonds around the connective tissues controlled the times of baseball hitters and other quick the proteins of the matrix. This “structured function of multi-celled organisms. The and intuitive responses of the organism. water” vibrates and transmits various in- function of these integrating phenomena We could also theorize that we are limited fluences such as flows of ions. Electrons of the connective tissues is very rapid. by observing with our nervous systems. and protons are the actors for life on the The movement of electrons and protons Instantaneous events are elusive. Accord- surfaces of the matrix proteins. along the protein surfaces is nearly ing to Oschman, the unconscious exists in instantaneous. Whole regions of this the matrix; intuition exists in the matrix. Bioluminescence, low level emission fibrous meshwork share electrons. The Einstein was quoted as saying: “Intuition of photons as part of the metabolic pro- more electrons the healthier is the tissue. is a sacred gift and the rational mind is its cesses, communicates biological informa- Shininess of connective tissue is evidence faithful servant. We have however created tion from cell to cell, integrating functions for a plentiful supply of electrons. a society that worships the servant and across wide regions of the organism. The has forgotten the gift.” connective tissues participate in this pro- Compared to the living matrix, the cess emitting most of the light from the nervous system is slow. Nerve impulses The workshops on the second day heart, forehead, and palms of the hands. and synaptic transport of neurotransmit- were no less stimulating and ground- The frequency of the emitted light deter- ters like acetylcholine require more time breaking. Jeremy Gilbey, the director mines the effect, not the amplitude or the than common response times of the of the weekend program led the first force. Cell membranes are constructed in human body. For instance, neurology practical, “tensegrity diagnosis.” The such a way that they inherently vibrate at cannot explain a baseball batters ability students were led through a screening a very high frequency. When they vibrate to hit a pitched baseball traveling at 90+ test of structural functioning, something synchronously, they are said to create miles per hour. The matrix conscious- we all can do with our eyes closed, but “quantum coherence.” This communi- ness explains this intuitive ability. Ted this time it was as if we closed our eyes cates a tone of information that regulates Williams, one of the greats in baseball and used the matrix consciousness to the functions of the body, in general. hitting history said he studied the pitcher establish where the patient’s body was and then just guessed. This intuitive structurally imbalanced. We looked at the Mechanotransduction, a phenomenon guessing is similar to the phenomenon body with an eye for the preset tension of the fibrous part of the connective tissue of “second sight” in which a soldier who that tensegrity espouses. We examined it matrix, participates in a vibratory commu- lost his sight in battle in World War I was relative to the many fluid compartments nication from the matrix outside the cell still able to negotiate around objects. and their relationships to each other. We into the cytoskeleton via the integrins and Oschman declares that the living matrix considered organs and their capsules as down into the nuclear genetic material, is the ultimate transducer between our part of the overall structural picture. We itself. And the reverse also occurs. Dr. thoughts and our experiences. used our whole body to let the informa- Oschman declared that the DNA is the tion come to us in an allowing manner. body’s master tuning fork, establishing The nervous system is a higher order a tone for the optimal functioning of the of consciousness including consideration The second practical by Liz Hayden proteins. This is called “systemic coopera- and contemplation. It developed from emphasized the connective tissue matrix tion” in which all parts of the person oper- the hydra, one of the earlier multi-celled as the focus for palpation. We palpated ate together. The heart causes resonances organisms. The hydra has tiny tentacles the quality and viscosity of the connective throughout the entire organism. The heart or cilia which transmit information to the tissue matrix. We used the bottom of the is constructed out of a single muscle nervous system. It uses this information patient’s feet and made contact with our strand that forms a double helix. to migrate by attaching cilia to an object thumbs listening to the primary respira- and releasing its foot to stand on its head tory mechanism. Then switching from As one palpates the skin, one connects and then to replace its foot further along person to person we gained a good sense with this microscopic meshwork of the the way, subsequently releasing the cilia. for the variability of different people. living matrix, thus permitting the ability to This is definitely a slow process. All our While waiting, we observed the change feel at a distance and to influence healing special sense receptors: retina, cochlea, from a more gel state of the connective within the system. Oschman referred to etc. have some form of hydra-like cilia tissue matrix to a more sol state. We con- healing as systemic cooperation in which to pass on information. These receptors sidered the reasons for the varying quality the healer deeply connects with the patient connect to both the sensory and motor of the tissue viscosity: toxins, allergies, and all parts of the patient work together. divisions of the central nervous system. drugs, etc. We visualized the macroscopic “Entrainment” may also play a role. This to microscopic connectivity of the matrix phenomenon results from synchronous There is another set of receptors in under our thumbs. vibrations between the healer and the the retina, the Muller cells, which send patient. information to the connective tissues.

30/The AAO Journal June 2005 The third practical by Lis Davies and of matter. The space between the mate- With that we had come through an myself referred to the communication rial elements and within the atoms of the amazing process of looking at the body ability of the matrix. We reviewed the matter is far greater than the matter itself. mechanically, spatially, energetically, and frequency spectrum and methods for The energy residing there in the space is spiritually. We had developed awareness treatment in this context used by Robert beyond comprehension. We succeeded in for matrix consciousness as it applies to Fulford, DO, the “percussion hammer.” seeing the individual as a negative instead physiology and healing. This was an enor- Lis played her violin to demonstrate of a positive “photograph.” mous osteopathic journey led by explorers dissonance coming into harmony as she of far-seeing intent. I will enjoy revisiting The final practical by Peter Cockhill tuned the instrument. In the practical this reality.∆ emphasized the ever-present and unex- we observed the patient’s “base note.” plainable now. William Sutherland spoke We then looked for harmonies and dis- Accepted for Publication: May 2005 of this concept as he mentioned Intelli- sonances in the system. We looked for gence with a capital “I”. In the practical altered tensegrity as an influence on the Address Correspondence to: we felt the parts all working together in quality of vibration. We explored whether R. Paul Lee, DO, FAAO “quantum jazz.” All the parts are indepen- the whole system would come into har- Osteopathic Center dent but harmonize to create a voice of the mony with the base tone. of the Four Corners, P.C. whole. In the now, the mega-organizing 160 E. 12th St ., Ste. 2 The fourth practical by Nicholas Han- happens. We acknowledged the different Durango, CO 81301 doll emphasized the individual in relation time durations of different processes in Phone: 970/247-3717 to the environment. Ordinarily we think the body. We synchronized with the now Fax: 970/247-3806 of ourselves as space occupying, moving and let the question come: from where E-Mail: [email protected] through emptiness around us. Instead, we does potency originate, from within or looked at the individual as space instead from without?

Proceedings of the International Research Conference Celebrating the 20th Anniversary of the Osteopathic Center for Children Conference Director: Viola M. Frymann, DO, FAAO Editor: Hollis H. King, DO, PhD, FAAO

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June 2005 The AAO Journal/31 32/The AAO Journal June 2005 Book Review Reviewer: Anthony G. Chila

Selected Writings of Paul E. Kimberly, DO, FAAO, D.Ost.Ed(Hon.), FCA Myron C. Beal, DO, FAAO, Editor. pp. 158. American Academy of Osteopathy®, 2003. AAO Bookstore: Item No. WPCD04 @ $34.95 plus S/H

Doctor Kimberly may well be recalled by many of today’s practitioners as the teacher who advocated Formulating a Prescription for Osteopathic Manipulative Treatment. In this volume it becomes quickly apparent that he was influential in other expressions of Osteopathic Philosophy, Theory and Methods. Close enough in time to the influence of AT Still (Kimberly’s mother entered the Des Moines school in 1925), his writing provides strong, documented support for the founder’s theories. For those whose practice includes the concept of Osteopathy in the Cranial Field, Doctor Kimberly was also the individual who taught the anatomy of the cranial structures to support the early courses of William G. Sutherland, DO. As Chairman of the Neurology Department of the Des Moines College, Doctor Kimberly was the organizer of the series of two-weeks seminars which featured Doctor Sutherland. In his (Kimberly) view, the teachings of Doctor Sutherland were designed to improve understanding of osteopathic principles and application of those principles to all areas of the body. Doctor Kimberly noted that Sutherland had the ability to make students conscious of the delicate complexities of the human machine, and that he was able to describe and demonstrate methods of handling this complex mechanism under any conditions of patient health. Doctor Kimberly served as a member of AAO Teaching Teams (1968-1973), Stuenenburg Professor and Chairman, Department of Osteopathic Theory and Methods, Kirksville College of Osteo- pathic Medicine (1974-1980) and as Lecturer and Chair, multiple postgraduate tutorials, Michigan State University College of Osteopathic Medicine. In these capacities he faithfully served the mission of the American Academy of Osteopathy®.

Collected Works of David Heilig, DO, FAAO Charlotte H. Greene, PhD, Editor pp. 272. American Academy of Osteopathy®, 2004. AAO Bookstore: Item No. WP0145 @ $39.95 plus S/H

Doctor Heilig was a long-time member of the faculty of the Philadelphia College of Osteopathic Medi- cine. In this capacity, he authored many publications which reflected his observations on the osteopathic profession’s philosophy. In addition, a great number of concise teaching guides were directed toward technical facilitation, valuable to students and to practitioners. Why Specific Osteopathy? (1951) is one example for thoughtful review by today’s practitioners. In this essay, one is reminded that Osteopathy provides a picture of dynamic processes occurring in patients. The use of osteopathic methods must find an individual pattern. Treatment is determined by the requirements of the individual. Complete manage- ment of the patient should be planned as far as possible, and as carefully as the individual treatment. Using this reasoning, the effective osteopathic practitioner will practice in an objective and scientific manner. Osteopathways: Tips on Technique; Easy Hyperextension (1988) is an example of conciseness. General rib elevation and hyperextension in the thoracic area is illustrated. Potential for specificity can be increased by careful positioning. Reminders to keep the patient’s hands clasped low behind the neck while the physician’s are held close together minimize leverage on the shoulders. Synchronization of hyperextension with respiratory exhalation facilitate this technique. Doctor Heilig worked long and faithfully in supporting the mission of the American Academy of Os- teopathy®. He cautioned that Osteopathic Manipulative Medicine must be more than merely a method. Within this thought, he recognized that residency, fellowships and certification tend to create a specialty. He indicated that this should not be a concern because of the necessity to maintain leaders and teachers of osteopathic principles and methods. The students and practitioners who were privileged to encounter and learn from these exemplary teachers stand today in great debt to their fidelity to the osteopathic concept. Repayment can come from renewal through review of their writings as represented in these volumes.

June 2005 The AAO Journal/33 Proceedings of the International Research Conference Celebrating the 20th Anniversary of the Osteopathic Center for Children: February 6-10, 2002; San Diego, California Hollis H. King, DO, PhD, FAAO, Editor for the Academy. pp. 106. American Academy of Osteopathy®, 2005. AAO Bookstore: Item No. WP0150 @ $30.00 plus S/H

This four-days Conference was directed by Viola M. Frymann, DO, FAAO, FCA. International in presentation (United States, France, Latvia, Russia), the event achieved another landmark in the remarkable career of Doctor Frymann. The outline of each day and the material presented provide an indication of the depth of the material presented:

Day One: Chaired by Albert F. Kelso, PhD. Topics presented included:

Benefits of Osteopathic Health Care for Children (Kelso) A Modern Conceptualization of the Functioning of the Primary Respiratory Mechanism (Moskalenko, Frymann, Kravchenko, Weinstein) Influence of the Venous Sinus Technique on Cranial Hemodynamics (Huard)

Day Two: Chaired by Melicien A. Tettambel, DO, FAAO. Topics presented included:

Dr. Viola Frymann’s Journey in Osteopathic Practice (Tettambel) The Cranial Rhythmic Impulse and the Traube-Herring-Meyer Oscillation (Nelson, Sergueff, Glonek) Applications of the Osteopathic Approach to Schoolchildren with Delayed Psychic Development of Cerebral-Organic Origin (Lassovetskaia)

Day Three: Chaired by Raymond J. Hruby, DO, FAAO. Topics presented included:

Awakening Research in Osteopathic Practice: Overcoming the Tomato Effect (Hruby) Bone-Tissue Conductivity of High-Frequency Acoustic Oscillations in the Cranial Structures of Human Beings Under the Influence of Various Osteopathic Techniques as a Method of Objective Estimation of Osteopathic Procedures Efficiency (Vartanyan and Kuznetsova) Influence of the Osteopathic Cranial Treatment On the Human Gravitational Posture (Caporossi)

Day Four: Chaired by Michael M. Patterson, PhD. Topics presented included:

Toward a Philosophy of Osteopathic Research (Patterson) The Osteopathic Approach to the Child with a Seizure Disorder (Frymann) Response of the Myocardium to Osteopathic Manipulation in the Cardiac Area Monitored by Simultaneous EKG Recording (LeHougre and Jurak) Observations From Normal Newborn Osteopathic Evaluations (Allen)

The papers presented during this Conference bear critical reading from students and practitioners alike. The study proposals and analytic methodologies indicate the precision with which the investigators have approached their study of the osteopathic cranial concept. Rational, objective statement of observations and conclusions strengthens the contribution of this volume to research literature.

The appearance of this volume, three years after the event, parallels publication habits of several institutions and foundations. As noted by the Editor (King), the start of future research projects can be discerned, as some of the authors have already evidenced continuation of their work as published here.

This volume is a testament to the legacy of William Garner Sutherland, DO. From his self-assessment of “having only drawn aside a curtain” through the tireless effort and dedication of Viola M. Frymann, the osteopathic cranial concept has moved into interna- tional acceptance of efficacy of method and value for research. The demonstrations represented herein are certainly indicative of appreciation and utilization of the expanding osteopathic concept.

34/The AAO Journal June 2005 Elsewhere in Print

Rheumatoid Arthritis: Clues to Early Diagnosis Eugene Mochan, DO, PhD Philadelphia College of Osteopathic Medicine Reprinted with permission from Consultant: Volume 45. Number 5. April 15, 2005

ABSTRACT: With the advent of disease-modifying anti-rheumatic drugs (DMARDs), which can prevent the joint destruction that occurs in rheumatoid arthritis (RA), early diagnosis of this progressive systemic disease has become crucial. Signs that may predate the onset of joint symptoms in RA include fatigue, weakness, depression, and unexplained weight loss. The early stage of RA is characterized by subtle joint changes and the absence of laboratory and radiographic markers of the disease. In moderate RA, patients frequently have diffuse swelling and limited joint mobility without joint deformities; acute phase markers and rheu- matoid factor are present, as are radiographic findings that can include periarticular osteopenia and minor cartilage destruction. Advanced RA is marked by severe cartilage and bone destruction and joint deformity. A key feature of the disease is very early activation of joint-destroying mechanisms. Suspect RA if a patient presents with persistent swelling of 3 or more joints; meta- tarsophalangeal, metacarpophalangeal, and proximal interphalangeal involvement; and/or morning stiffness that lasts 30 minutes or more. Collaboration between the primary care physician and the rheumatologist is crucial for a favorable long-term outcome.

Monosodium Urate Deposition Arthropathy (Part II): Treatment and Long-term Management of Patients with Gout Robert L. Wortmann, MD; The University of Oklahoma College of Medicine; Tulsa, OK H. Ralph Schumacher, Jr., MD; University of Pennsylvania School of Medicine; Philadelphia, PA Johns Hopkins University School of Medicine Advanced Studies in Medicine Reprinted with permission from Adv. Stud. Med. 2005. Volume 5. Number 4. pp. 183-194.

ABSTRACT: Purpose: To review recent findings on the acute and chronic treatment of patients with gout.

Epidemiology: Gout is an established consequence of hyperuricemia and affects an estimated 5 million Americans. The incidence of gout increases as serum urate levels increase.

Review Summary: In Part I of this series, the prevalence of hyperuricemia, its diagnosis, and natural history of gout were reviewed. Part II of this series focuses on the acute and long-term management of patients with hyperuricemia and gout. The pharmacologic management of asymptomatic patients who are found to be hyperuricemic is controversial, although lifestyle changes and careful assessment of factors that may predispose patients to hyperuricemia and/or gout should be undertaken. Type Of Available Evidence: Randomized-control trials, unstructured review, textbook, retrospective cohort studies. Grade Of Available Evidence: Fair.

Conclusion: The management of hyperuricemia and gout includes treating the acute attack, preventing attack recurrence, reducing the total body urate pool, and addressing comorbid conditions. Acute attack treatment often involves adjunctive physical measures and pharmacologic management. The choice of pharmacologic agent is based upon numerous factors (eg, the number of joints involved, the duration of the attack, the patient’s comorbidities, and the administration options). Urate-lower- ing maintenance therapy is needed for those who experience recurrent gout attacks or who have tophi. Uricosurics or allopurinol should be used, targeting a serum urate of <6mg/dL. Several urate-lowering agents with traditional as well as novel mechanisms of action are in clinical trials and may offer the promise of improved management of this chronic and often disabling condition.

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American Academy of Osteopathy® 2006 Annual Convocation

March 22-26, 2006 in “Sweet” Birmingham Many years ago in the South, passenger trains were the main means of getting from one place to another. In Alabama, many folks would take a trip simply to enjoy the wonder of life in the big city. That city was Birmingham. And at railway platforms all across the state you could hear one friend calling to another, “Hey, neighbor, where are you going”? And the reply would come: “Going to sweet Birmingham.” Going to sweet Birmingham … a city that is – all at once – young, traditional, friendly, and complex. It is been said that Birmingham is the last major Southern city in America, that the growth and development there has left unaf- fected the true Southern character of the city. Birmingham is a cool and distinctive place to visit. While the city continues to grow more sophisticated, its people also treasure many of the distinguishing ways of the South. It is diversity that is Birmingham’s greatest strength and strongest appeal. They are a spectrum of attitudes and cultures, all a part of the charm that is the South. With wonderful restaurants, entertaining nightlife, the glorious outdoors, sports and recreation, and attractions, Birmingham brings visitors back time and time again. Blessed with a great climate, Birmingham is a terrific place to visit. You can golf practically year-round. Other attractions include Birmingham Civil Rights Institute ( a self-directed movement of the 1950s and ‘60s); McWane Center (Alabama’s state-of-the-art science center and IMAX Dome® theatre); Birmingham Museum of Art (the largest municipal art museum in the Southeast); Birmingham Zoo; Barber Vintage Motorsports Museum (The largest motorcycle museum in North America); International Motorsports Hall of Fame & Museum (six-building complex houses over 100 vehicles and memorabilia valued at over $20 million. Includes six different halls of fame and race car simulator); Birmingham Bo- tanical Gardens (The glory of nature in the heart of the city, the 67-acre gardens features rhododendron, camellias, wild- flowers, even a Japanese Garden, complete with a Japanese Teahouse; Alabama Theatre (Built in the 1920s, the theatre is one of the last working movie palaces, featuring first-run and revival films, concerts and special events). The “Showplace of the South” is among the most elegant and elaborate theatres in the Southeast; and many, many more attractions. Reprinted from Birmingham’s Visitors’ Guide Magazine