FORUM FOR OSTEOPATHIC THOUGHT

TRADITION SHAPES THE FUTURE VOLUME 14, NUMBER 1, MARCH 2004

2003 Northup Memorial Lecture “Academy Contributions: What have you done for us lately?” page 16… March 2004 The AAO Journal/1 Instructions to Authors

The American Academy of Osteopathy® Editorial Review 1/2" disks, MS-DOS formats using either 3- (AAO) Journal is a peer-reviewed publica- Papers submitted to The AAO Journal may 1/2" or 5-1/4" discs are equally acceptable. tion for disseminating information on the be submitted for review by the Editorial science and art of osteopathic manipulative Board. Notification of acceptance or rejection Abstract medicine. It is directed toward osteopathic usually is given within three months after re- Provide a 150-word abstract that summarizes physicians, students, interns and residents ceipt of the paper; publication follows as soon the main points of the paper and it’s and particularly toward those physicians with as possible thereafter, depending upon the conclusions. a special interest in osteopathic manipulative backlog of papers. Some papers may be re- treatment. jected because of duplication of subject mat- Illustrations ter or the need to establish priorities on the 1. Be sure that illustrations submitted are The AAO Journal welcomes contributions in use of limited space. clearly labeled. the following categories: Requirements 2. Photos should be submitted as 5" x 7" Original Contributions for manuscript submission: glossy black and white prints with high con- Clinical or applied research, or basic science trast. On the back of each, clearly indicate research related to clinical practice. Manuscript the top of the photo. Use a photocopy to in- dicate the placement of arrows and other 1. Type all text, references and tabular ma- Case Reports markers on the photos. If color is necessary, terial using upper and lower case, double- Unusual clinical presentations, newly recog- submit clearly labeled 35 mm slides with the spaced with one-inch margins. Number all nized situations or rarely reported features. tops marked on the frames. All illustrations pages consecutively. will be returned to the authors of published manuscripts. Clinical Practice 2. Submit original plus three copies. Retain Articles about practical applications for gen- one copy for your files. eral practitioners or specialists. 3. Include a caption for each figure. 3. Check that all references, tables and fig- Special Communications ures are cited in the text and in numerical Permissions Items related to the art of practice, such as order. Obtain written permission from the publisher poems, essays and stories. and author to use previously published illus- 4. Include a cover letter that gives the trations and submit these letters with the Letters to the Editor author’s full name and address, telephone manuscript. You also must obtain written Comments on articles published in The AAO number, institution from which work initi- permission from patients to use their photos Journal or new information on clinical top- ated and academic title or position. if there is a possibility that they might be ics. Letters must be signed by the author(s). identified. In the case of children, permis- No letters will be published anonymously, 5. Manuscripts must be published with the sion must be obtained from a parent or guard- or under pseudonyms or pen names. correct name(s) of the author(s). No manu- ian. scripts will be published anonymously, or Professional News of promotions, awards, under pseudonyms or pen names. References appointments and other similar professional 1. References are required for all material activities. 6. For human or animal experimental inves- derived from the work of others. Cite all ref- tigations, include proof that the project was erences in numerical order in the text. If there Book Reviews approved by an appropriate institutional re- are references used as general source mate- Reviews of publications related to osteo- view board, or when no such board is in rial, but from which no specific information pathic manipulative medicine and to manipu- place, that the manner in which informed was taken, list them in alphabetical order lative medicine in general. consent was obtained from human subjects. following the numbered journals.

Note 7. Describe the basic study design; define 2. For journals, include the names of all au- thors, complete title of the article, name of Contributions are accepted from members of all statistical methods used; list measurement the journal, volume number, date and inclu- the AOA, faculty members in osteopathic instruments, methods, and tools used for in- sive page numbers. For books, include the medical colleges, osteopathic residents and dependent and dependent variables. name(s) of the editor(s), name and location interns and students of osteopathic colleges. of publisher and year of publication. Give Contributions by others are accepted on an 8. In the “Materials and Methods” section, page numbers for exact quotations. individual basis. identify all interventions that are used which do not comply with approved or standard Submission usage. Editorial Processing All accepted articles are subject to copy ed- Submit all papers to Anthony G. Chila, DO, iting. Authors are responsible for all state- FAAO, Editor-in-Chief, Ohio University, Computer Disks ments, including changes made by the manu- College of Osteopathic Medicine (OUCOM), We encourage and welcome computer disks script editor. No material may be reprinted Grosvenor Hall, Athens, OH 45701. containing the material submitted in hard copy form. Though we prefer Macintosh 3- from The AAO Journal without the written permission of the editor and the author(s).

2/The AAO Journal March 2004 FORUM FOR OSTEOPATHIC THOUGHT ®

3500 DePauw Boulevard TRADITION SHAPES THE FUTURE • VOLUME 14, NUMBER 1, MARCH 2004 Suite 1080 Indianapolis, IN 46268 A PEER-REVIEWED JOURNAL (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, emphasiz- ing the integration of osteopathic principles, practices and manipulative treat- ment in patient care.

In this Issue: ® AMERICAN ACADEMY OF OSTEOPATHY AAO Calendar of Courses ...... 4 Dennis J. Dowling, DO, FAAO ...... President Stephen D. Blood, DO, FAAO ... President Elect View from the Pyramids – Foundations ...... 5 Stephen J. Noone, CAE ...... Executive Director Anthony G. Chila, DO, FAAO Contributors ...... 6 Component Societies’ CME Calendar...... 7 AAO PUBLICATIONS COMMITTEE Dig On – “They were Contemporaries” ...... 8 Raymond J. Hruby, DO, FAAO ...... Chairperson Denise K. Burns, DO Stephen M. Davidson, DO From the Archives: The Lymphatic System: Applied Anatomy ...... 9 Eileen L. DiGiovanna, DO, FAAO Chapter One, Applied Anatomy of the Lymphatics, F.P. Millard, DO Eric J. Dolgin, DO Stefan L.J. Hagopian, DO Hollis H. King, DO, PhD, FAAO 2003 Northup Memorial Lecture: John McPartland, DO “Academy Contributions: What have you done for us lately?” ...... 16 Paul R. Rennie, DO Boyd R. Buser, DO, FACOFP Mark E. Rosen, DO Cystic Fibrosis: A Case History ...... 20 Ex-officio Members: Heather D. Back, OMS-III in collaboration with Russell G. Gamber, DO, MPH Myron C. Beal, DO, FAAO ...... Yearbook Editor University of North Texas Health Science Center - Fort Worth Anthony G. Chila, DO, FAAO ...... Journal Editor Texas College of Osteopathic Medicine

A Case of Right First Rib Somatic Dysfunction Diagnosed and Treated...... 24 THE AAO JOURNAL Through cooperative care*: CDR James A. Lipton, MC, USN, Michele Neil, MSIV, Anthony G. Chila, DO, FAAO .... Editor-in-Chief Brendon Drew, MSIV and Claudia McCarty DO Stephen J. Noone, CAE ...... Supervising Editor Diana L. Finley, CMP ...... Managing Editor The Neuroendocrine-Immune Complex Illustrated in the Work of Dr. Frank Chapman ...... 33 The AAO Journal is the official quarterly publica- John D. Capobiano, DO, FAAO tion of the American Academy of Osteopathy®, 3500 DePauw Blvd., Suite 1080, Indianapolis, Indiana, 46268. Phone: 317-879-1881; FAX: (317) 879-0563; Book Review: A Fulford Trilogy ...... 41 e-mail [email protected]; AAO Reviewer: Anthony G. Chila, DO, FAAO Website: http.//www.academyofosteopathy.org Elsewhere in Print: Static Innominate Asymmetry and Leg Length Discrepancy Third-class postage paid at Carmel, IN. Postmas- in Asymptomatic Collegiate Athletes ...... 43 ter: Send address changes to American Academy of Osteopathy®, 3500 DePauw Blvd., Suite 1080, Indianapolis, IN., 46268. Advertising Rates for The AAO Journal Advertising Rates: Size of AD: The AAO Journal is not itself responsible for state- Full page $600 placed (1) time 7 1/2 x 9 1/2 An Official Publication $575 placed (2) times ments made by any contributor. Although all ad- ® of The American Academy of Osteopathy $550 placed (4) times vertising is expected to conform to ethical medical The AOA and AOA affiliate organizations 1/2 page $400 placed (1) time 7 1/2 x 4 3/4 standards, acceptance does not imply endorsement $375 placed (2) times and members of the Academy are entitled by this journal. $350 placed (4) times to a 20% discount on advertising in this Journal. 1/3 page $300 placed (1) time 2 1/4 x 4 3/4 $275 placed (1) times Opinions expressed in The AAO Journal are those ® $250 placed (4) times Call: The American Academy of Osteopathy of authors or speakers and do not necessarily re- 1/4 page $200 placed (1) time 3 1/3 x 4 3/4 (317) 879-1881 for more information. $180 placed (2) times flect viewpoints of the editors or official policy of $150 placed (4) times the American Academy of Osteopathy® or the in- Professional Card: $60 3 1/2 x 2 Subscriptions: $60.00 per year (USA) stitutions with which the authors are affiliated, un- Classified: $1.00 per word $78.00 per year (foreign) less specified.

March 2004 The AAO Journal/3 2004 Calendar of Events

APRIL SEPTEMBER 24-25 Dr. Fulford’s Advanced Percussion Technique 30 - Oct 2 Emotional Diagnosis and Release (Barral CCOM, Downers Grove, IL Approach; San Diego, CA

MAY OCTOBER 14-16 Prolotherapy: Above the Diaphragm 3- 5 Unlocking the Cranial Sutures (The Face) UNECOM, Biddeford, ME San Diego, CA

JUNE NOVEMBER 4-6 Clinical Jones Strain-Counterstrain I for the 6 Modifying Delivery of OMT in an Allopathic Spine and Rib Cage; Indianapolis, IN Environment; San Francisco, CA 7-11 AOA / AAO Convention; San Francisco, CA JULY 12-14 Prolotherapy: Below the Diaphragm 23-25 Still Technique (Applications of a Rediscovered UNECOM, Biddeford, ME Technique), WVSOM, Lewisburg, WV DECEMBER AUGUST 4-5 Facilitated Positional Release 19-22 14th Annual OMT Update; Buena Vista, FL NUSOM; Ft. Lauderdale, FL

TOURO UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE THE DEPARTMENT OF OSTEOPATHIC MANIPULATIVE MEDICINE OF TOURO UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE IS SEEKING A FULL-TIME CLINICIAN EDUCATOR. THIS POSITION WILL PROMOTE OMM THROUGHOUT THE CONTINUUM OF OSTEOPATHIC MEDICAL EDUCATION. THE POSITION REPORTS DIRECTLY TO THE CHAIR OF THE OSTEOPATHIC MANIPULATIVE MEDICINE DEPARTMENT.

THE TUCOM PROGRAM IS AN INTEGRATIVE OSTEOPATHIC CURRICULUM.

BOARD CERTIFICATION IN OSTEOPATHIC MANIPULATIVE MEDICINE OR NMM PREFERRED, BOARD ELIGIBILITY ACCEPTED. CALIFORNIA LICENSE REQUIRED. CLINICAL PRACTICE EXPERIENCE DESIRABLE. PREFERENCE GIVEN TO APPLICANTS WITH RESEARCH EXPERIENCE. THIS POSITION OPENS JULY 1, 2004

Please respond with CV to: Robert C. Clark, DO, MS, Chair, OMM Department Touro University College of Osteopathic Medicine 1310 Johnson Lane Vallejo, CA 94592 Fax: 707/638-5255 or E-mail: [email protected]

Touro University is an Equal Opportunity/Affirmative Action Employer

4/The AAO Journal March 2004 View from the Pyramids

Foundations

Since its appearance in 1997, Foundations for Osteo- DO; George T. Caleel, DO; F. Munro Purse, DO; and pathic Medicine has been the premier text for the exposi- Otterbein Dressler, DO. tion of osteopathic theory, methods and practice. Having seen two editions, a third is now being planned. With such Those who did not contribute chapters, but whose sug- success, this seems an appropriate time to reflect on this gestions and criticisms were acknowledged included: volume’s predecessor. David W. Boone, DO; Angus G. Cathie, DO; W. Fraser Strachan, DO; and W. Kenneth Riland. In 1969, Osteopathic Medicine was published by McGraw-Hill Book Company, Inc. This volume of 786 As indicated in the Preface, “It is the awareness of the pages, including index retailed for $24.50. J. Marshall need to bring the musculoskeletal system into proper fo- Hoag, DO was Editor; Wilbur V. Cole, DO, Associate Edi- cus in modern concepts of health and disease, together tor and Spencer G. Bradford, DO, Assistant Editor. with a considerable experience in evaluating and treating the clinical problems involved, that has prompted the com- Part One (Basic Precepts) consisted of 6 sections: Os- pilation of this book. The work should be useful to pre- teopathic Medicine; Biological Foundations; The Auto- and postdoctoral students, clinical teachers, and practic- nomic Nervous System; The Musculoskeletal System; The ing physicians, as both text and reference source. Biolo- Osteopathic Lesion; Treatment Of Osteopathic Lesions. gists will be interested in the discussions of the nature and mechanisms of disease. The book also will provide a Part Two (Clinical Procedures) consisted of 8 sections: ready source of information on what to look for in the The Art of Practice; The Body’s Response to Challenges; musculoskeletal system in relation to various syndromes, Disorders in Physiologic Regulatory and Integrative what results might be expected from musculoskeletal treat- Mechanisms; Selected Errors in Metabolism; Disorders ment, and the effect of those results on the pathophysi- of Body Structure; Disorders of the Organs of Special ologic course of the case in question.” Function; Disorders Involving Immune Mechanisms; Neoplastic Diseases. In 1969, the osteopathic profession had not yet survived its first century of existence. The effects of the amalgam- A total of 52 Chapters comprised the content of the 14 ation experience in the state of California had not been Sections of Parts One and Two. completely overcome. The total number of colleges, all free-standing, had dropped from six to five. The institu- Editors aside, the authors represented an assemblage tional expansion of the profession was yet to come. Thirty- of the leaders of the time: George W. Northup, DO; Wil- five years later, the profession has entered its second cen- liam F. Hewitt, DO; Paul H. Thomas, DO; Paul T. Lloyd, tury of existence with full legal and social recognition. DO; Byron E. Laycock, DO; David Heilig, DO; S.V. The continuing contribution of Foundations for Osteo- Robuck, DO; David A. Patriquin, DO; William Baldwin, pathic Medicine stands on the shoulders of those who suc- Jr., DO; Theodore Weinberg, DO; Ira C. Rumney, DO; ceeded in the achievement of Osteopathic Medicine un- Ward E. Perrin, DO; Robert W.H. Ho, DO; R. McFarlane der circumstances of duress and faith. Tilley, DO; Albert F. D’Alonzo, DO; Donald J. Evans, DO; William D. Miller, DO; Joseph E. Giletto, DO; D. Leonard Vigderman, DO; William B. Strong, DO; Will- iam F. Daiber, DO; H. Willard Sterrett, Jr., DO; Elizabeth A. Burrows, DO; Carl B. Umanzio, DO; Elias E. Zirul,

March 2004 The AAO Journal/5 Contributors

Buser, BR. Academy Contributions: What have you Anatomy of the Lymphatics (1922), the introductory pages done for us lately? In this 2003 Thomas L. Northup Me- of FP Millard’s work are presented. Of particular note morial Lecture, the author reviews the activities of the should be the Summary offered as conclusion to the sec- American Academy of Osteopathy® through its strate- tion on lymphatic examination. The text was dedicated to gic plans. Dr. Buser addresses Education, Research, In- Carl P. McConnell, DO, who would, in 1937, become ternational Affairs, Coding and Reimbursement. His Chairman of the Osteopathic Manipulative Therapeutic address places in proper perspective the innovative programs and Clinical Research Association, the forerunner of of the AAO and complementary involvement with programs today’s American Academy of Osteopathy®. (p. 9 ) of the American Osteopathic Association. (p. 16) Book Review. Between 1996 and 2003, 3 volumes ad- Back, HD; Gamber, RG. Cystic Fibrosis: A Case dressing aspects of the teaching of the late Robert C. History. The authors offer an osteopathic approach in the Fulford, DO, FCA have appeared. While each can stand management of an adult patient afflicted with Cystic Fi- alone, the reader who draws from the trilogy will have brosis for one year. Their presentation is pertinent to the rich sampling of the beloved teacher’s personal, interpre- fact that this entity is the most common inherited fatal dis- tive and archival aspects. (p. 41) ease among Caucasians. The primary author is a Year III Osteopathic Medical Student at UNTHSC-TCOM. Dr. Elsewhere in Print. Postural assessment has long been Gamber was the recipient of the 2003 George W. Northup a characteristic of osteopathic teaching and practice. Leg Award from the American Osteopathic Association. (p. 20) length discrepancy has been given its fair share of consid- Lipton, JA; McCarty, C; Drew, B; Neil, ML. A Case eration. In an original contribution, Static innominate Study of Right First Rib Somatic Dysfunction Diag- asymmetry and leg length discrepancy in asymptomatic nosed and Treated Through Cooperative Care. The collegiate athletes (Krawiec, et al.) offers a fresh perspec- authors demonstrate that exhaustive clinical evaluation and tive. Key osteopathic authors are cited. (p. 43) conservative treatment of first rib dysfunction should be considered, where appropriate, prior to vascular surgical intervention. This case study is placed in the context of OPPORTUNITY KNOCKS extensive literature appreciation of Thoracic Outlet Syn- drome. (p. 24) I am looking for an associate, preferrably C-NMM/OMM Board Eligible or Board Certified. Please send your resume, a picture, and a letter which Capobianco, JD. The Neuroendocrine-Immune expresses your thoughts on Osteopathy. Complex Illustrated in the Work of Dr. Frank Chapman. A classic method of osteopathic clinical prac- Harold Magoun, Jr., DO, FAAO, FCA, DO, Ed(Hon) tice is presented in the light of contemporary understand- 8200 E. Belleview, Suite 408 C ing of the Neuroendocrine-Immune Complex. Submitted Greenwood Village, CO 80111-2803 in partial fulfillment of requirements for Fellowship in the American Academy of Osteopathy®. Dr. Capobianco was conferred status as Fellow in 2002. (p. 33) OSTEOPATHIC PHYSICIAN NEEDED Successful chiropractic clinic continuing to expand and Regular Features grow, searching for a motivated osteopathic physician Dig On. The motivations of two osteopathic pioneers, desiring to meet the future challenges of patient treatment Frank Chapman, DO and FP Millard, DO are put in the and care. We are offering an associate position with context of their contemporaneous education. As early stu- opportunities to advance in the Panama City, Florida dents of Andrew Taylor Still (1897), both expressed sig- area. nificant interest in the lymphatic system of the human Please contact Dr. Hal C. Cowen for further information. body, and each one left a different perspective still useful Telephone: 850-872-8880 in osteopathic practice today. (p. 8 ) 127 West 23rd Street, From the Archives. From the seminal text Applied Panama City, FL 32405

6/The AAO Journal March 2004 Component Societies’ CME Calendar and other Osteopathic Affiliated Organizations

March 31 May 23-26 August 21-22 Closing Date for submission of Abstracts Biodynamics Phase VII Ligamentous Articular Strain Technique for International Conference on The Health - Alone Dallas Osteopathic Study Group Advances in Osteopathic Research Farmington, ME Dallas, TX Lake Erie College of Osteopathic Med. Hours: 18.5 Hours: 16 Category 1A anticipated British College of Osteopathic Med. Contact: James Jealous, DO Contact: Conrad Speece, DO Contact: E-mail: [email protected] 214/321-2673 or authors can find instructions and an June 19-23 abstract template at Basic Course in Osteopathy www.bcom.ac.uk/research/ICAOR5.asp in the Cranial Field Doubletree Columbia River Complex Three Books on (1) CD April 21-25 Portland, OR Triology of Osteopathic Archives 82nd Annual Convention Hours: 40 Category 1A anticipated Wyndham Buttes Resort The Cranial Academy Osteopathic Mechanics Tempe, AZ Contact: The Cranial Academy by Edythe F. Ashmore, DO Hours: 38 Category 1A anticipated 317/594-0411 Arizona Osteopathic Medical Assn Contact: AOMA Applied Anatomy June 20-23 602/266-6699 of the Lymphatics Experiencing Osteopathy: An by F. P. Millard, DO April 22-25 Introduction to Continnuum Movement 49th Annual Conference Doubletree Columbia River Complex Intra-Pelvic Technique Florida Academy of Osteopathy ® Portland, OR by Percy H. Woodwall, MD, DO Grosvenor Resort at WDW Hours: 24 Category 1A anticipated Lake Buena Vista, FL The Cranial Academy CME: 22 Category 1A (anticipated) ONLY $19.95 Contact: The Cranial Academy Contact: Kenneth Webster, EdD 317/594-0411 (Item No. WPCD03) 727/581-9069 To order, contact: June 24-27 Kelli Bowersox, Assistant for Marketing, May 13-16 Annual Conference Sales, UAAO 107th Annual Convocation ® Doubletree Columbia River Complex American Academy of Osteopathy Indiana Osteopathic Association Phone: (317) 879-1881 Portland, OR Indianapolis, IN E-Mail: Hours: 21 Category 1A anticipated Hours: 30 hours category 1A [email protected] The Cranial Academy Contact: IOA Contact: The Cranial Academy 800/942-0501 or 317/594-0411 Endocrine Interpretation 317/926-3009 of Chapman’s Reflexes May 14-16 June 27-29 Crash Recovery the Long Road Home: Biodynamic Approach ONLY $15.00 to the Fluid Body Treating Victims of Motor Vehicle (Item No. WP0010) Accidents and Brain Injuries Doubletree Columbia River Complex PCOM, Philadelphia, PA Portland, OR To order, contact: Hours: 16 Category 1A anticipated Hours: 16 Category 1A anticipated Kelli Bowersox, Assistant for Marketing, The Cranial Academy The Cranial Academy Sales, UAAO ® Contact: The Cranial Academy Contact: The Cranial Academy American Academy of Osteopathy Phone: (317) 879-1881 317/594-0411 317/594-0411 E-Mail: [email protected] March 2004 The AAO Journal/7 Dig On Anthony G. Chila, DO, FAAO

They were Contemporaries

It is fascinating to realize that the amination; Venous Stasis and Lymph (Chapman’s widow) and Dr. W.F. early classes of the American School Blockage. Chapter Two: Applied Link, secured the publication of the of Osteopathy often had more than Anatomy of the Lymphatics of the manuscript. Owens subsequently one student who would ultimately Head and Neck. Chapter Three: Ap- moved from interpretation of offer a significant contribution to the plied Anatomy of the Lymphatics of Chapman’s work to incorporation of elaboration of Andrew Taylor Still’s the Head and Neck in relation to Acute the reflexes into his own practice. teaching. Frank Chapman, DO and Poliomyelitis. Chapter Four: Lymphat- F. P. Millard, DO are two examples. ics of the Thorax. Chapter Five: Lym- It is interesting to read Chapman’s The year was 1897. Both men had phatics of the Abdominal and Pelvic comments in the Introduction: begun the study of osteopathy. In the Regions. Chapters 6-15 were each writ- years following their training and es- ten by a leading osteopathic specialist “The ideas here presented respect- tablishment of professional careers, of the time and provide extensive elabo- ing lymphatic reflexes have, to the each would offer a significant contri- ration of thought in response to best of my knowledge and belief, bution, still beneficial to the osteo- Millard’s impetus. The original publi- never been presented before. pathic profession today. cation of the text was under the aus- pices of the International Lymphatic “When I entered the American Millard’s Research Society. Among Millard’s School of Osteopathy in 1897 the pre- Applied Anatomy Credits: Author of Poliomyelitis; vailing thought in the school was Founder and President of The National there was no sickness without a bony of the Lymphatics League for the Prevention of Spinal lesion. Thirty years as an osteopathic (The Journal Printing Company; Curvature; Founder and President of practician in the field have, however, Kirksville, Missouri; 1922) was pre- the International Lymphatic Society, convinced me that bony lesions will ceded by a question during his stu- and Editor of a Quarterly Journal pub- account for only about twenty percent dent days. In 1897, he asked The Old lished by the Lymphatic Research So- of our ailments, the greater part of Doctor about the significance of the ciety; Anatomical Artist; Originator of which are due to dietetic errors and lymphatic system, and was told that Water-marked Spine in Stationery for poor hygiene that lower vitality and he (Still) was “still experimenting the Osteopathic Profession. make us susceptible to common colds along that line”. His curiosity stimu- and other infections, from which the lated, Millard pursued his own ques- (see page 7 to order Dr. Millard’s Book) return to health is often incomplete. tion and eventually published New Method Of Diagnosing Various Dis- An Endocrine “Years ago it seemed to me that the eases By Palpating Lymphatic Glands Interpretation of lymphatic system had a much more (Journal of the American Osteopathic profound influence on bodily func- Association; July 1920). In 1922, a Chapman’s Reflexes tions than it had been given credit for; full text became available. The text This was copyrighted in 1937 by that blocking, partial, or complete, of is organized such that the first five Charles Owens, DO. Frank Chapman, the lymph stream by common colds chapters were written by him: Chap- DO, died at about the time the origi- and other infections was responsible ter One: A New Method of Diagnos- nal manuscript was being prepared. for many phases of disease.” ing Various Diseases by Palpating Owens, working with his sister, Doc- Lymphatic Glands; A Lymphatic Ex- tor Ada Hinckley Chapman (see page 7 to order Dr. Chapman’s Book)

8/The AAO Journal March 2004 From the Archives The Lymphatic System Applied Anatomy Chapter One, Applied Anatomy of the Lymphatics, F.P. Millard, DO

General Outline in the body fluids in perverted func- portance of any perversion of the tis- Students of anatomy sometimes tion, such as the possibility of lymph sues that may alter the function of any fail to grasp the relative importance blockage through the malposition of part of the body. of collecting applied data as com- certain bones, and the resultant or- In the various regions discussed, pared to that of gaining a knowledge ganic disorders that follow a per- we hope to assist the student in clari- of the tissues, organs and general verted blood supply to the walls or fying the various influences that may framework of the human body as out- substance of an organ, and the lack have a bearing upon the structures lined in texts on that subject. of vasomotor control in some in- affected thereby producing tissue The physician in practice soon stances. As osteopathic physicians, changes to the extent of causing some feels the need of greater knowledge we are more or less familiar with this bodily disturbance. of the various vessels, nerves and or- follow through system, and we rea- The lesion theory as propounded gans along the line of applied con- son from cause to effect. We have fa- by Dr. A. T. Still, will be given first cept. As he advances in his work and miliarized ourselves with the general place in all our discussions, because studies his patients at the office and blood circulation both from an ana- we know that his reasonings were bedside, there comes a longing to tomical and physiological standpoint, correct and can be demonstrated in know just what relation exists be- and then the pathological. any instance where there remains suf- tween the various parts of the body Applied anatomies have been writ- ficient impulses to carry out this idea. and the disease that he is endeavor- ten both from a surgical and osteo- We realize there are certain dis- ing to diagnose. He wonders always, pathic standpoint that deal with many eases so far advanced that the reflexes or should, how great an involvement phases from a very practical view- are lost and the nerve impulses so dis- is present in certain disorders where point. From these books we have turbed or feeble that it is quite im- symptoms reveal specific pathologi- learned much although we are yet in possible to restore normal function- cal phases. In neuritis, for instance, our infancy, so to speak, as to the real ing, but these cases are extreme, and he asks what change has taken place significance of applied work. we will consider more particularly that has caused a normal nerve tone As mentioned in the preface no those cases that are amenable to ad- to be replaced by the symptoms so attempt as yet has been made to de- justment and restoration. strikingly impressed upon the patient. vote a book to the subject of the lym- In dealing with the lymphatic sys- He had been taught in college the phatics in all its various phases. tem, let us go about it in a manner that general outline of the nerve tracts, In dealing with the lymphatics will first of all be broad enough in out- their nerve root tracings and their re- first from an applied anatomy stand- line to realize that the body is a ma- lation to the groups of muscles. He point, we do not claim in any way to chine that is so correlated that if one also was taught the osseous frame- be adding any new anatomical fea- part suffers there will be a correspond- work and the relation of the nerves to tures, but we hope to enable the stu- ing reflex that will to some degree, at the various bones. But in some in- dent to get a mental picture of the vari- least, affect other parts or all parts. stances he had never worked out in ous structures so that he will more The tendency of the day is to spe- detail the applied part and felt that he readily grasp the significance of the cialize and narrow ourselves to the did not understand the various stages causation of disorders in the body when point of believing that any organic of muscle tension as related to nerve symptoms manifest themselves. disturbance is a localized one, and instability and irritability. The vari- We want to emphasize, in consid- that we must treat or deal with the ous causes of the chemical changes ering the lymphatic system, the, im- ➻ March 2004 The AAO Journal/9 affected part from a local standpoint. ics, but we could never draw any defi- which I found the inguinal glands. This must be overcome, and we must nite conclusions as to his reasonings. They serve as an index to the patho- fix in our minds the fact that the cir- One day, 23 years ago, I ventured to logical condition existing around the culation that bathes one part of the ask him regarding the significance of caecum and appendix. body one minute may be bathing a the lymphatic system, but he passed the As stated above, I almost hesitate remote part a little later; that the lym- subject, by simply stating that he was to announce this new method of di- phatic system is so arranged that the still experimenting along that line. agnosis and suggest that you will not drainage continues to the point of Recognizing that there was a field criticize too severely until you have emptying. The blockage at a point in only partially worked out, I set about gone through a period of personal the abdomen or pelvis will reflect it- to determine if I could discover any findings, and have satisfied yourself self upon the lymph flow possibly in hidden truth that might be of value to as to the merit of the method. I shall the feet. We can also see how enlarged the osteopathic profession. My first not try to cover in this article all of glands in the neck may cause any observations were rewarded, some 16 the diseases in which lymphatics number of disturbances in the organs years ago, by a revelation that gave are disturbed, but simply refer to of special sense in the head. me grounds for further research. The three or four disturbances, and Insufficient stress has been laid idea was so new I did not feel like an- leave it to you to think over and ex- upon the points of interference with nouncing it until I had satisfied myself periment for yourself. the flow of lymph, and in these chap- that there was sufficient merit in the Going back to appendicitis, let me ters on applied anatomy we hope to theory to warrant its publication. state that you will first have to famil- show, in some degree, the possibili- Three times during the past few iarize yourself with the various condi- ties of many diseases being existent years, I have ventured to throw out a tions found in the inguinal region. It is through a blockage of the lymph flow few suggestions. One reference to the well to always palpate carefully both either in the nodes or vessels. matter pertained to swellings found groins, first with the limbs extended, Finally, we want to assist the stu- in the breast and their relation to ax- and then flexed. When the limbs are dent by demonstrating that in any illary disturbances; a second was the extended, the glands, if present and pathological condition there is invari- inguinal disturbance found in the right enlarged, will present a different feel- ably a relative lymphatic disturbance, groin in cases of appendicitis; and the ing than when the knees are bent. and try to show how adjustment will third, published in the May number of The subject has so many phases assist the body in clearing up the re- this Journal, dealt with enlargement of that I find it difficult to describe in a tardation or obstruction. the lymphatic glands from outside in- brief article the thoughts that will fections and inoculations. bring out the most striking features. New method of Allow me to state that I believe that About the first thing that you will diagnosing various few, if any, physicians have made it a suggest is the question. How can you regular part in their diagnostic work, differentiate when there is a pelvic diseases by palpating year in and year out, to carefully ex- congestion, such as when a right lymphatic glands* amine the condition of the various ovary or tube is involved; also, how (Reprint of article by author from the Jour- lymphatic glands as a part of their can you distinguish if there exists an nal of the American Osteopathic Association, examination of patients, also the fol- infection of a venereal nature? To say July, 1920) lowing up of the state of these glands that it is easy would be foolishness, from time to time in cases where lym- but to state that skill will follow long Had Dr. A. T. Still lived a few years phatic enlargement was found. This research would be on a par with the longer, I sincerely believe he would calls for the development of a pecu- statement that months of practice are have given to the world a vast amount liar touch, as palpable glands vary so often necessary for the student to de- of information regarding the lymphatic much in different systemic conditions tect some hidden spinal lesions. system. I have always felt that he had that it is almost incredible the num- We are all quite familiar with the in his mind some information along the ber of phases these nodules assume. almost set type of glandular inguinal line of new physiology dealing with this For several years I have based, al- enlargement found in gonorrhea, for subject. He hinted at the reduction of most conclusively, my diagnosis as instance. The nodules are usually obesity by lymphatic control, and of- to the surgical or nonsurgical nature quite enlarged and often indurated. ten mentioned the lack of knowledge of the appendix upon the state in They ebb and flow, so to speak, as and research in relation to the lymphat-

*First publication of the technique of the newest thing in diagnosis - and it is OSTEOPATHIC, - Editor, Journal of the American Osteopathic Association. 10/The AAO Journal March 2004 the disease is acute and active, or sub- in one or both breasts. The signifi- Examining carefully the popliteal side with lack of congestion in the cance of these tumors depends upon regions, in all cases where a general sexual organs. the amount of lymphatic involvement examination is made, I have fre- I will admit that one difficult of a general nature. quently observed enlargement of diagnosis to make is when appendi- If you will carefully trace the chan- these glands when this space should citis is conjointly found with vene- nels back to the axilla in relation to the be comparatively clear. Upon remov- real infection. Should there be simple pectoral muscles, you can quite readily ing the stockings or the socks, as the ovaritis or salpingitis, with no vene- determine the amount of glandular in- case may be, I have found in a num- real infection, we usually find a dis- volvement. If the axillary region is ber of instances skin abrasions be- turbed lymphatic condition, accom- comparatively clear of nodules, and tween the toes. Through these cracks panied with certain reflexes. Ovarian there seems to be no particular block- or denuded slits perspiration, dust, or colic or cramps, or a hypersensitive ing of the connecting channels, it is dyes are constantly being absorbed, hypogastric plexus will enable the ex- usually safe to say that the lumps and the resultant effect is noted upon aminer to determine the presence of found in the breast are not of a ma- the nodules in the space behind the tubal congestion. lignant type, and may be reduced in- knee. After instructions, and the care- In a case of appendicitis, with ap- directly by corrective work. As a rule, ful healing of these tissues between parently no complications, if pus is malignancy of the breast follows axil- the toes, I have noticed the disappear- present and the caecal area is in- lary warning of some duration. Trau- ance of the nodular swellings. volved, the inguinal glands are found matic injuries of the breast should he This last reference does not per- slightly elevated and their nodular attended to at once, as the tendency is tain to the diagnosing of a hidden surfaces under the skin readily pal- toward circumscribed induration, with trouble, as in the instance of pelvic pable. This condition I have almost secondary lymphatic complications. and breast involvement, but carries out invariably found and verified by judg- Possibly the most patent instance my idea that infection of a part is in- ing as to the advisability of referring of lymphatic abnormality is found in variably manifested by nodular inter- the case to a surgeon on the strength the throat. ference at the nearest gland center. of the amount of nodulation. We are all familiar with the “ker- Some other time I may write on In a test covering a period of four nels”, “lumps”, and peculiar nodular other findings, especially the deter- years, some seven years ago, I treated enlargements found in children as mining of the degrees of tuberculosis 310 cases, with the result that three well as in adults accompanying vari- by lymphatic enlargement, according had to be operated upon after a trial ous epidemics and tonsillar infec- to the region of the body diseased, but to reduce congestion. That was a tions. In children we have a range of I have given you my ideas in part as small percentage. At one time I was swollen glands, from those found pre- to the possibility of diagnosing more treating eight cases that had been told ceding measles, chickenpox, etc., to accurately the degree of infection or to be operated upon within 24 or 48 those noted in scrofular and tubercu- accumulation of toxic products by hours. This strain was not small, as I lar diseases. Accompanying a simple lymphatic manifestations. appreciated the significance of the rhinitis we often note a marked dis- situation. Fortunately, I was rewarded turbance, while in tonsillitis, even in A lymphatic examination by bringing these eight cases out of the adult, there may be a most aggra- This is an innovation. We have danger, and I followed up the acute vated lymphatic disturbance. been accustomed to general and spe- attacks with corrective work. I relied One more instance and we will cial examinations, but to set out to entirely upon my diagnosis in rela- close this abbreviated article. make a lymphatic examination is a tion to the inguinal glands. The final reference is to septic in- new departure. In the March issue of The AOA fection of the lymphatics of the We have made a chart blank that Journal, 1916, there is a colored plate popliteal space by absorption of ma- outlines the points where the physi- showing the lymphatic glands of this terial, including perspiration, dirt, and cian is most likely to find lymphatic region. dyes from stockings, through soft variations and disturbances. The breast region is also a most corns and skin abrasions between the First of all, let us consider the lym- significant one, in that the axillary toes. We are all familiar with blood phatic system as a whole – a general region is so directly concerned. Sur- poison and lockjaw from plantar circulation, yet subsidiary to that of gical operations for removal are so punctures by rusty products, with dirt the vascular system. very common that one almost won- and cloth carried into the wound. The We find that there is a field for ders where it will end. It is not un- resulting symptoms may include applied anatomy of the lymphatics common to find lumps or swellings lockjaw. ➻ March 2004 The AAO Journal/11 just as of other tissues of the body. duct and right lymphatic duct, or we or hand. If there has been, note the pres- We find lymph blockage and nodular will find an over-burdened thoracic ence or absence of pus or even a blis- enlargements, hyperplasia and adeni- duct from too much tension or too ter. Also note the vasomotor tone in the tis, also in some instances a backing great an accumulation of lymph. The entire arm. Cold hands affect the lymph up and a reverse in the flow of lymph. system is constantly trying to clear stream. Should there be signs of a re- This has been described in connec- itself and the clearing house is partly cent vaccination or serum injection, tion with the gastric lymph vessels by made up of the lymphatic system. determine the amount of axillary ad- noted surgeons. Again we note a puffiness around enitis that existed at the time. There is an ebb and flow, so to the eyes. There is a cause for it. If we Next, palpate over the mammary speak, in the lymph stream. To illus- trace the lymph stream, we will soon region and note enlargement of nodes trate this point we will note that when discover that there is a blockage in and extent of induration if present. there is mesenteric blockage or pel- the cervical nodes, or possibly the Connect up the arm and pectoral re- vic lymph nodular adenitis, a corre- submaxillary, or nodes in the parotid gions, lymphatically speaking, and sponding disturbance is found in the region. There may be lesions caus- determine which area was first af- lymph areas of the popliteal space; ing tensed muscles that prevent a free fected and to what extent. also a slight edematous condition in drainage. In all of the lymph nodes Note carefully what quadrant of the. ankles, usually on the outer side and vessels in the throat and neck the breast is nodulated, and whether just in front of the external malleo- there is a possibility of blockage. they are deep seated nodes or super- lus. Again we note where there is a There is also a possibility of lymph ficial. Go over the thoracic vertebrae puffiness above the clavicles, on one obstruction through the enlargement and costal areas, and determine the side or both, a corresponding I block- of the salivary glands or a subluxation number and significance of lesions. age of the lymph stream exists either of the mandible or hyoid bone. The Adjustment of vertebral and costal at the emptying point of the thoracic puffiness of the eyes may be due to lesions may clarify the nodular en- over-burdened kidneys, and an en- largement if no abrasions or recent larged liver. Disorders of the spleen vaccine or serum injections have may also cause it when the system is taken place. We will go back to the loaded with toxic products and elimi- neck now and palpate for superficial nation is faulty. We may look then for and deep nodular enlargements (No. a lymph stream blockage and puffy 6). Note presence or absence of goi- areas in certain regions. Thus we see tre, and determine if there have been it is well to examine for areas of recent symptoms of laryngitis or lymph obstruction where there are pharyngitis. The presence of muscle evidences of edema. tension and venous stasis will be of Now that we have this viewpoint value in tracing the lymph blockage. in mind, let us proceed to make our Corresponding bony and muscular lymphatic examination. With the lesions may be found, and lymph blank before us, we will start always nodes enlarged to the extent of irri- at the emptying points of the lymph tating the nerve cords in the neck. If tubes or ducts. On both sides these there exists any congestion of tissues ducts empty into the subclavian veins. due to tonsillitis, abscessed teeth or If the drainage is perfect -there will sinus infection, note the effect on the be no puffiness above the clavicles. cervical lymph nodes. Determine, if If there is a blockage or over-load- possible, the amount of lymph sus- ing, we will observe edema. pended and retained in the vessels and Let us take the presents of edema nodes at all points above the hyoid on the left side and work out our ex- region (No. 7). After testing and pal- amination and diagnosis. The second pating the various nodes and edema- point we will note will be the axil- tous areas, including the tonsillar and lary region (No. 5). Note any nodu- faucial areas, try and determine the lar enlargement or adenitis, and if relation of this blockage to that found present trace out the cause. See if in the terminal area, back of and Plate I: Seven points of palpation in there has been a recent scratch or above the clavicles. making a lymphatic examination. abrasion of the skin on arm, forearm Again, we note the lack of drain- 12/The AAO Journal March 2004 age, if present, from the broncho- and thoracic duet. lymph and a reverse flow in spite mediastinal trunks. Following bron- In pelvic congestion the nodes are of the numerous valves. chitis or a pleuritic infection, there markedly enlarged, as you will deter- 8. Collateral lymph circulation may may be a difficult drainage that will mine by special local examinations, take place when indurated nodes reflect itself upon the tissues above vaginal and rectal. The inguinal or blocked lymph channels exist. the clavicles. How often in throat and glands (No. 3) will reflect not only 9. There is a direct and an indirect bronchial troubles we note not only pelvic congestion but appendicitis. vasomotor control of the lymph cervical nodular enlargement, but that The lymph blockage of the mesen- stream. peculiar puffiness above the clavicles teric glands and in the receptaculum 10. Enlarged nodes may irritate or which is so hard to reduce unless we chyli will reflect itself upon the in- over-stimulate nerve trunks. reason out just why this blockage guinal glands by a blockage of lymph. 11. Vaccines and serums are as direct exists, and drain the lymph vessels. Lastly, we will go briefly over the causes of nodular involvement as In this brief chapter we must nec- lower extremities. Palpate over the poisons taken into the system. essarily point out only a few of the popliteal space (No. 2) with patient 12. The lymph stream must always cardinal points. A thorough examina- on the back, and then with patient be drained first through the ter- tion including all applied anatomy standing. You will find a new view- minal areas. findings would fill a book. point when you make this double test. 13. Attempts to clear the lymph stream We will recall our anatomy teach- Look for varicose veins, even before clearing the edema in the ing regarding the collection of lymph small ones; also palpate the calf clavicular regions is to over-tax the on the two sides. This will explain the muscles deeply between thumb and general lymph stream and cause suggestion just made that more often fingers and determine presence or profound reactions. we find edema in the left supraclav- absence of stasis. Recently I noticed 14. Any permanent results in treating icular region. a lymph disturbance in inguinal re- the lymphatics must be accom- The epigastric region we will next gion due to a bruise on the thigh, also plished through the nerve centers discuss briefly (No. 4) The liver, from a popliteal lymph enlargement due to that control the vasomotor nerves a lymphatic standpoint, is more sig- a soft corn. Go over the ankles (No. of the blood vessels in the same nificant than the spleen. The tendency 1) and look for any swelling that region as the lymph blockage. of the liver to enlarge and become would indicate a lymph blockage 15. Never work over an enlarged or torpid and sluggish makes lymph higher up. Again, note vasomotor indurated lymph node, free the drainage uncertain. Part of the liver’s tone in blood vessels and observe the efferents and the lymph will drain. drainage is above, and eventually effect upon the lymph nodes in 16. General exercises will stimulate empties into the right lymphatic duct popliteal and inguinal regions. lymph flow, but if there is marked or indirectly into the thoracic duct in lymph blockage it is better to re- part. The principal lymph vessels Summary lieve the lymph tension before drain into the thoracic duct along with 1. For every congested tissue there exercises are given. This will the drainage of the stomach. is a corresponding lymph distur- save marked reactions. If the patient is thin, you will ob- bance. 17. In treating the extremities, see serve on palpation a peculiar enlarge- 2. Wherever pus is present there is that the axillary and inguinal re- ment of the receptaculum chyli when enlargement in the nearest nodes. gions are cleared first. the knees are flexed. Sometimes you 3. An abscessed tooth or even a 18. The only way to clear broncho- can palpate the larger nodes and you pimple or small boil will reflect mediastinal lymph blockage is can press the abdominal aorta so readily itself on the nodes. through cervical and thoracic ad- against the receptaculum chyli that you 4. The lymph stream ebbs and flows justment. Deep control can only can cause the pulse beat to fluctuate. I according to the amount of block- be reached in that manner. have palpated the receptaculum chyli age and nodular enlargement at 19. Indurated nodes may never re- when it could almost be picked up with certain points. duce. Establish drainage and col- the finger tips in a thin person when, 5. Edema is significant of lymph lateral flow will follow. there was a heavy mesenteric blockage. blockage. 20. Note from time to time the vari- Splanchnoptosis and venous stasis 6. Nodular enlargement is not al- ous accessible lymph areas in any combined with ovarian congestion or ways between the terminal lymph and every organic disturbance. appendicitis, will soon prove to you drainage and distant disturbance. 21. Learn to palpate nodes in every the great amount of blockage that 7. There may be a backing up of region where they are accessible. takes place in the receptaculum chyli ➻ March 2004 The AAO Journal/13 Venous stasis and lympha blockage

In school we used to spend a few exists a puffiness back and above the the, lymph vessels have valves more days on the subject of lymphatics. clavicle on left side we must see that numerous than the veins, but they also Five years from now, or less, students the edema is reduced before we at- have a lesser caliber and the lymph will receive daily instruction on this tempt drainage at a point in the re- flow is constantly checked by the subject. It will be embodied in texts gion of the receptaculum chyli. This flow through the nodes. While some on applied anatomy, and each organ will necessitate correction of lesions nodes have vasomotor nerve fibers, and area will be considered from a from the cervical area down to the the blood vessels are much better sup- lymphatic standpoint. Under the dis- pelvis. It would be useless to correct plied with these fibers. This we have cussion of every diseased organ or cervical and thoracic lesions if a to contend in lymph blockage first, tissue a few paragraphs will be in- sacrum was tilted sufficiently to cause with a venous stasis that must be cluded referring to lymph drainage. an unbalanced spine. We must also cleared, then a lymph drainage that We have devoted much time in the work to restore normal impulse to the must include a reduction of the nodes past to a study of the vascular system mesenteric vessels in order that when enlarged, and a free lymph flow in all its details, but have neglected venous stasis will disappear. Normal at the terminals of the lymph ducts. to a great extent the tracing of lymph relations will come about only by The blood vessels that supply the flow and in accounting for edematous correction of all lesions causing pto- nodes may have vasomotor nerves, areas that indexed the amount of sis and misplacement. A sagged stom- but we must depend in freeing the venous stasis and lymph blockage ach dragging over the thoracic duct lymph stream upon indirect vasomo- that existed. We have paid so little and receptaculum chyli will interfere tor control through the nerves to the attention to the lymph stream that we with lymph drainage. vascular system. The vasomotors to have not gone beyond a few findings Venous stasis must be cleared up the nodes are not constant. Again, in in two or three regions, usually the by securing first of all a normal liver order to clear the lymph stream in the cervical, axillary and inguinal. condition. Any lesions affecting the mesenteric region, we must consider Let us spend a few minutes going various functions of the liver will the possibility of an unusual lymph over the principal findings that should check the clearing of the veins and flow from the pelvic region. If this be included in every examination, and lymph vessels. It is in this region that exists there will be found an addi- at every treatment. In the first place, we find the many tumors, benign and tional tax upon the receptaculum wherever there is venous stasis there malignant. The lymphatics are in- chyli from the lymph below, and this is bound to be lymphatic disturbance. volved, the nodes enlarged, and additional burden upon the thoracic We will take the mesenteric region lymph vessels obstructed. If you duct in eases of pelvic disturbance first. We recall the innervation and want, to see this object lesson make will make mesenteric drainage more vasomotor control of the vessels in a few post mortems in cancer of stom- difficult. this area. ach or associated parts and observe Normally, the receptaculum chyli With the osseous lesions that may the, lymph blockage. and afferent ducts are sufficiently cause an interference with peristaltic While venous stasis is relatively taxed, but abdominal and pelvic action, secretion and vasomotor con- important, yet we believe lymph venous stasis will overtax the lymph trol, we are familiar. If there is ptosis blockage the more significant in for- stream in every instance. This will and stasis we must naturally expect eign growths and in congestion. reflect itself upon the lymph drain- lymph blockage. The receptaculum While venous stasis, may precede age of the various organs in this re- chyli that drains this region is readily lymph blockage, yet, it is the lymph gion and only the insurance of a nor- blocked when the above conditions disturbance that spells disaster to the mal venous and lymph flow will clear exist. We cannot expect to correct tissues. In the final analysis the veins the area and remove the tax upon the these changes in blood and lymph are much less important, in relation lymphatics of the receptaculum chyli. streams unless we first of all correct to a pathological phase than are the The majority of ailments of the the ptosis. Organs that have sagged lymph vessels and nodes. It is easier human body have their beginning in cause pressure on vessels and lymph to re-establish venous drainage than the epigastric region. A sluggish, in- channels. Neither can we expect to lymph drainage. active liver may start a stasis and free lymph drainage unless there is a The nodes once enlarged and in- lymph blockage that will reflect itself normal thoracic duct passage. If there durated are not easily reduced. True, upon not only the immediate organs

14/The AAO Journal March 2004 14th Annual OMT Update “APPLICATION OF OSTEOPATHIC CONCEPTS IN CLINICAL MEDICINE” and tissues but, by blockage, prevent PLUS PREPARATION FOR CERTIFYING BOARDS pelvic drainage of the lymphatics. We will then note a little puffiness in the August 19-22, 2004 ankles, a similar condition back of the knees in the popliteal spaces, and unless we free the ducts and chyli Buena Vista, Florida nodes, the edema will persist. It is easy to block drainage below The program anticipates being approved for 22.5 hours of AOA Category 1-A CME the second lumbar segment. An ob- credit pending approval by the AOA CCME. structed alimentary tract will produce lymph blockage very nicely. A less- COURSE OBJECTIVES: LEVEL III ened vasomotor tone will also block This Academy program was designed to meet the needs of the physician desiring the the lymph vessels and nodes when following: venous stasis is present. There must be tone and there is • OMT Review - hands-on experience and troubleshooting only one way to get tone, and clear • Integration of OMT in treatment of clinical cases • Preparation for OMT practical portions of certifying boards the congestion, and that is by good • Preparation for AOBNMM (American Osteopathic Board of technique and specific corrective Neuromusculoskeletal Medicine) certifying/licensing boards work. • Information on CODING for manipulative procedures You will recall the peculiar vaso- • Good review with relaxation and family time motor control in the mesenteric re- gion. The second relay, so to speak, PREREQUISITES: Functional Anatomy; One Level II course to give extra impulse to the mesen- teric vessels. This will call for lesion findings, and corrections higher up PROGRAM TIME TABLE: than is usually found in other organic Thursday, August 19 ...... 5:00 pm - 10:00 pm disturbances. Friday, August 20 ...... 7:00 am – 1:30 pm It is well to re-read anatomies oc- Saturday, August 21 ...... 7:00 am – 1:30 pm casionally and keep in mind the nerve Sunday, August 22 ...... 7:00 am – 1:30 pm (Each day includes (2) 15 minute breaks) centers that control the vasomotors. It is through these nerves that we COURSE LOCATION: make headway in clearing stasis and Disney’s Contemporary Resort secondary lymph blockage. In this brief chapter we can discuss only one region, but we have tried to HOTEL INFORMATION: emphasize a fact that may be applied Disney’s Contemporary Resort 4600 World Wide Drive to any lymph area, namely, that a Lake Buena Vista, FL 32830 venous stasis will invariably cause a 1-407-824-3869 (Reservation line) lymph blockage. We have not in- Reservation Deadline: July 21, 2004 cluded in this chapter conditions Room Rate: $159.00 single/double where lymph obstruction may be pri- $25.00 per person each additional mary, such as direct poisoning of the (Identify yourself as attending American Academy of Osteopathy®’s Conference) system through introduction of vac- Contact: cines, serums, or ptomaine sub- ® stances. This phase of the subject American Academy of Osteopathy must be dealt with from a different Christine Harlan, Membership Services Coordinator/Meeting Planning Assistant ❒ 3500 DePauw Blvd., Suite 1080, Indianapolis, IN 46268 angle. Phone: 317/879-1881; Fax: 317/879-0563 E-mail: [email protected]

March 2004 The AAO Journal/15 2003 Northup Memorial Lecture Boyd R. Buser, DO, FACOFP “Academy Contributions: What have you done for us lately?”

Something important happened in AOA Convention program in the fall. pathic specialty college can approach the Academy in the early 1990s. The While there were occasionally other that level of student attendance; in AAO turned its focus to the world offerings (e.g., muscle energy tutori- fact, I dare say that we probably have outside the Academy. We imple- als), the new strategic plan called for more student attendance at Convoca- mented a new strategic plan and much more; educational programming tion than all the other specialty col- adopted a bold new mission state- that was not just for AAO members, leges’ programs, combined. In addition ment. We hired a new Executive Di- but for the osteopathic profession at to the UAAO, we now have an addi- rector and moved to the Pyramids in large, and even for allopathic physi- tional student organization, the Na- Indianapolis. We markedly increased cians interested in developing skills in tional Undergraduate Fellows Associa- our educational offerings in osteo- manual medicine. I will return to the tion (NUFA). There should be no doubt pathic manipulative medicine latter issue in a moment, but first let us that there is great student interest in (OMM) and osteopathic principles look at how our educational offerings OPP and OMT in our schools today, and practice (OPP). We utilized a sub- have developed over the past decade. and the Academy should be proud that stantial portion of our reserves in In the past 8 years, we have con- we foster and nurture that desire for these activities. While we have often ducted 127 CME programs, an aver- knowledge in the arena that most referred to ourselves as the “keepers age of 16 per year. Topics included a clearly distinguishes osteopathic from of the flame”, at that time the flame variety of manipulative approaches, allopathic medical education. was fanned and set ablaze. I was such as high velocity low amplitude, In the continuum of osteopathic edu- elected to the AAO Board of Trust- muscle energy, counterstrain, cation, I have addressed students and ees around that same time, and the myofascial release, percussion vibra- practicing physicians. What about resi- Board has been guided by our strate- tor technique, facilitated positional dency training and board certification? gic plan, which has been significantly release, and Still technique, as well Through most of the 1990s, our AOA revised on two occasions since that as exercise prescription and prolo- specialty board certification process time. In the day-to-day and year-to- therapy. We conducted programs fo- was conducted by the American Osteo- year operation, the leadership is of- cussed on clinical conditions as well, pathic Board of Special Proficiency in ten frustrated by the difficulties and such as management of lower back Osteopathic Manipulative Medicine challenges that we face in our interac- pain, and comprehensive OMT up- (AOBSPOMM). While this board tions both within and outside our pro- dates, particularly popular with DOs functioned very well, the name of the fession, and we do not always take time preparing for board certification ex- board was confusing to the profession to reflect on the bigger picture. I want ams. During those past 8 years, we at large. Most felt it implied that the to take this opportunity to take a step had an average of 826 paid physician certification conferred by the board back and give you my perspective on registrants in our programs. was like a Certificate of Added Quali- what we have accomplished in this past I would be remiss if I did not men- fication (CAQ); that a ‘’primary” cer- decade. The Academy is over 65 years tion student involvement in our an- tification by another AOA board was old (that qualifies it for Medicare), so nual Convocation. I remember attend- required in order to establish eligibil- let us ask, “What have you done for us ing Convocation as a student. In those ity for that board. While we knew it lately?” days, there were relatively few stu- was a primary certification, we also Education with the adoption of the dents attending, and no student-spe- recognized that the name was a prob- 1992 strategic plan, the Academy cific programming. However, there lem. We initiated a request to change made a commitment to be the lead- has been a complete transformation the name to the American Board of ing source of education in osteopathic in this regard. Over the past several Osteopathic Manipulative Medicine, manipulation. In the “pre-pyramid” years, we have averaged over 400 stu- through the Bureau of Osteopathic days, we traditionally conducted only dents in Convocation attendance, and Specialists, and this brought the situ- two educational programs each year; we have a complete parallel student ation to a head, resulting in the ap- the Convocation in the spring, and the program in place. No other osteo- pointment of an AOA task force to 16/The AAO Journal March 2004 study the issue. Had our board been teopathic principles, his purpose will concept of a national osteopathic re- relegated to a CAQ, it would have had have been served, and it would not search center, which as we know is a disastrous effect on our growing make any difference what you call it. now a reality. Incidentally, the AOA, residency programs; why would a Please don’t misunderstand me. I AACOM and the rest of the organi- graduate enter a residency program am in no way calling for amalgam- zations represented in OCCTIC plan- that did not lead to a primary board ation. We desperately still need our ning recognize the central role of the certification? We emerged from this own professional institutions, col- Academy in this area, and that is why crisis with a new certifying board, and leges, licensure examination, and we OCCTIC 4 was held in conjunction a new description of the discipline that will until we change all their minds, with the AAO Convocation earlier this I believe is more reflective of the prac- until they all think like us. And I do year, and why OCCTIC 5 will be held tice focus of the physicians who spe- not think we are in any danger of that in conjunction the 2004 Convocation cialize in this area. While many of our happening anytime soon. But again I in Colorado Springs. They know if they members felt that we had been “done say, the osteopathic profession must want these conferences to be well at- wrong”, we have seen an unprec- take a leadership role regarding edu- tended and successful, that they should edented growth in our residency pro- cation and practice standards in the hold them where the researchers are. grams. There are now 20 established world of manual medicine, and the There are many other research- residency programs with over 90 ap- Academy has pushed the envelope in related activities to which Academy proved positions in osteopathic this arena over the past decade. members have devoted significant neuromusculoskeletal medicine and time and effort, including develop- OMM. This includes 2-year NMM pro- Research: Speaking of protecting ment and validation of the osteopathic grams, “plus 1” programs, and com- the future of our profession, there are SOAP note, a standardized tool for bined 3-year integrated family practice/ few areas of more critical importance research data collection; conversion NMM programs. We have created the than research establishing the efficacy of the SOAP note into an electronic Postgraduate American Academy of and effectiveness of OMM. The lack format; development of a “single or- Osteopathy to serve the needs of our of a solid evidence base for this treat- gan system” musculoskeletal exam intern and resident members. ment approach affects everything form. They have worked to aid in the I want to return for a moment to from reimbursement to education to development of the National Osteo- the issue of non-osteopathic physi- licensure, and our strategic plan pathic Clinical Database, and pushed cians’ interest in manual medicine. makes research a priority for Acad- the agenda of inclusion of osteopathic There is clearly a growing interest emy activities. terminology into the Metathesaurus among our MD brethren in this ap- Academy members have naturally of the National Library of Medicine. proach, primarily in family practice been the leaders in the OMM research I know that the director of the national and preventive medicine & rehabili- agenda, and one fact that bears this out Osteopathic Research Center at the tation. They have no formal mecha- is that 75% of principal investigators University of North Texas (inciden- nism to recognize their skills, educa- and co-investigators of AOA-funded tally, a member of the AAO Board of tion and training in this area, and this clinical research studies are OMM spe- Governors) would tell you that the presents problems for those doctors, cialists who are Academy members. support of the Academy through the in reimbursement and privileging, The Academy should be proud of this. LBORC has been invaluable in the and in some cases, licensure issues I do not believe there is any AAO successful development of the Center. as well. The position of the Academy committee that has “done more with International Affairs: The AAO is that the osteopathic profession less” than the Louisa Burns Osteo- strategic plan adopted in 1992 de- should be the authority, and should pathic Research Committee manded that we become more in- take the leadership position in deter- (LBORC). These people have worked volved in the osteopathic profession mining what the educational and tirelessly, unselfishly investing un- outside the US; it identified us as practice standards should be for all counted time and working with lim- “...the world-wide source”. AAO fully-licensed physicians who utilize ited financial support, because they members had long had relationships manual medicine in their practice. If believe in the importance of their with osteopaths practicing in other we do not do it, who will? I think you goals. Their list of accomplishments countries, and there was interest can imagine who will. Make no mis- is long, but relatively unsung. within the Academy of establishing a take, this is a controversial position LBORC members were instrumental more formal relationship with these within our profession, but it is my in the planning and conduct of the folk. At that time, osteopathy was ei- belief that this position is consistent first Osteopathic Collaborative Clini- ther not recognized, poorly regulated, with A.T. Still’s vision of improving cal Trials Initiative Conference or in some cases illegal in most coun- the practice of medicine. When all (OCCTIC), from which grew not only tries outside the US, and where it was physicians practice according to os- OCCTIC 2, 3, 4 and 5, but the whole legal, practice rights were restricted. ➻ March 2004 The AAO Journal/17 That is, the American model of full, would have never happened without the Editorial Panel revised the introduc- unrestricted licensure did not exist. Academy! tory notes to the OMT codes, stating There was a lack of understanding of I also mentioned FIMM, the Inter- that E/M services could be reported the diverse nature of education, reg- national Federation of Manual Medi- in addition to OMT on the same date, istration and practice scope within the cine. The Academy is the official vot- by appending the -25 modifier to the Academy leadership at that time. In ing delegate to this Federation from the office visit code. This was intended order to help further our understand- USA, and the Academy is well repre- to clarify that both services could be ing and enable us to make more in- sented in the committee structure of the reported on the same day, but had the formed decisions about our own ex- organization, influencing the agenda of unfortunate side effect of reinforcing ternal relationships, the AAO orga- manual medicine world-wide. the notion that E/M services were in- nized the first International Forum, cluded in the OMT codes, and that held in Atlanta in March, 1996 in con- Coding and Reimbursement: therefore, the E/M could only be re- junction with the AAO Convocation. But now I need to turn our attention ported if a separate problem from the This forum was surprisingly well at- back to the USA. Perhaps nowhere problem for which the OMT service tended, and a tremendous exchange has the Academy had a quieter but was provided was reported. So we of knowledge occurred. The Forum more significant impact for our pro- went to the Feds for help. Some evolved into an annual event, and has fession than in the ongoing battle for people would compare that to getting served as a springboard to a new in- fair reimbursement for our profes- married for the third time; a triumph ternational organization. But before sional services. The AOA has consis- of hope over experience. Nonethe- I get to that, I think it is important to tently participated in the house of less, we were able to persuade HCFA talk about where the AOA was at the medicine’s activities in the payment to issue a memo to their local carri- time of the first International Forum. policy arena; activities organized by ers, stating a that a separate problem As part of the planning of that first the AMA and its specialty societies. or diagnosis was not required for the forum, an invitation was extended to The AOA garnered a permanent seat reporting of OMT and E/M on the same the AOA, and to the International on the RVS Update Committee, oth- date. Unfortunately, not all of HCFA’s Federation of Manual Medicine (a erwise known as the RUC, from its own Carrier Medical Directors mostly European, predominately MD inception. This body advises CMS on (CMDs) seemed to get the message. manual medicine organization). But RVUs for physician work, practice The AOA thus created a document for because there were these “limited expense, and PLI (the components of presentation at a meeting with high practice rights” participants there, the RBRVS). We have also had on- level HCFA staff in Baltimore, which both organizations, while sending going representation on the CPT Ad- resulted in a Medicare policy clarifi- representatives to Atlanta, refused to visory Committee. The CPT Edito- cation to all CMDs. Since that time, participate in the Forum itself. In fact, rial Panel determines the codes used our Medicare denial rate for OMT and the AOA was not at all interested in by all physicians to report their ser- E/M has been less than 5% nation- any sort of international activity; their vices to third party payors, public and ally. This was a significant success, main efforts in that regard involved private. Since the inception of the RUC and AAO leaders were instrumental directing individual American DOs to in 1992, either the RUC or CPT advi- in the development of the document foreign government authorities to sory committee members have been presented to HCFA, and had a lead help them seek licensure. As one chosen from Academy leadership. role in that important Baltimore meet- prominent AOA leader said to me at Prior to 1994, OMT services were ing. However, despite our success that time, “They do not call it the reported using HCPCS codes, and with Medicare, it was quite clear that American Osteopathic Association when it came time to establish “real” we still had a major problem with for nothing”! However, the Academy’s CPT codes, the AOA turned to the private payors, and that more needed initiatives in this arena could not be ig- Academy for advice and leadership. to be done. The HCFA document nored, and resulted directly in the es- The CPT proposal and testimony that evolved into the AOA’s Position Pa- tablishment of the AOA’s Council on resulted in the creation of our current per on OMT and E/M, a document International Osteopathic Medical Edu- OMT codes was presented with the that is still in use today, revised and cation and Affairs (CIOMEA). Now we help of Academy leadership, and that updated by AAO members with the have the World Osteopathic Health Or- proposal was adopted by the Edito- assistance of AOA staff. We returned ganization, which I alluded to earlier. rial Panel. Our OMT codes were thus to the CPT Editorial Panel, asking for And the AOA is increasing their in- first published in CPT 1994. Then a revision of the Introductory notes volvement, holding their own interna- began a long (and still ongoing) battle to the OMT codes, stating explicitly tional meeting this past June for the pur- to obtain reimbursement for an office that a separate problem or diagnosis pose of exploration of development of visit reported on the same day as was not necessary for OMT and E/M another international organization. This OMT services. At OUR request, the to be reported on the same date. The

18/The AAO Journal March 2004 proposed language was written and This includes a substantial increase AAO has done in the past ten years. the Editorial Panel testimony deliv- in staff time for the OMT codes, and One notable area I did not mention at ered for the AOA by an Academy rep- a change in staff type, which will in- all is the remarkable evolution of AAO resentative. Not only was the proposal crease the staff expense calculation publications, including the birth and accepted, but the revised language was from $0.23/minute to $0.37/minute. development of The AAO Journal. And incorporated into the description of the When the Final Rule is published next since this is the Northup Memorial -25 modifier, which benefited a num- month, we anticipate a substantial Lecture, I am afraid if I did not at least ber of specialties, MD as well as DO. increase in the practice expense mention publications, I would probably Around the same time, the Ameri- RVU’s for our 5 codes. This is an- have both Tom and George Northup can Chiropractic Association (ACA) other important victory for reim- spinning in their graves. brought forward a proposal to create bursement, however what may be I am sure you probably noticed that chiropractic codes in CPT. The AOA even more significant is that our prac- I have not mentioned any names here endorsed this proposal, as we be- tice expense proposal clearly sepa- today, and just tried to focus on ac- lieved there was a distinction between rated E/M services from the OMT complishments. The Academy has OMT and chiropractic manipulation, service, and this will be more ammu- always been blessed with many dedi- and we wanted that distinction main- nition in the ongoing struggle. cated members who have been will- tained. This was not as easy as it Now you may say that all these ing to give freely of their time and sounds, because the Editorial Panel has were victories for the AOA, and just talents, as volunteer leaders, because a policy against “specialty specific” happened to involve Academy mem- of their love of the profession and codes. This means that if the same pro- bers. And while I agree that the Acad- their desire to keep it alive, and they cedure is performed by multiple spe- emy could not have done all this do not do it because of any need or cialties or professions, the CPT code alone, the AOA would have been far desire to be recognized for it. You for reporting these services is the same less likely to be successful without know who so many of them are. But for all providers. An example is psy- our leadership and contributions. And there are many who most of you have chotherapy, which is performed by both I would also say that it did not just probably never heard of; committee physicians and non-physicians provid- happen to involve Academy mem- members and others. And without the ers yet both psychiatrists and psycholo- bers, but that these people were se- rank and file dues-paying members gists often use the same CPT code to lected for their involvement because and Golden Ram Society contribu- report psychotherapy services. Once they were Academy leaders. tors, we would not have the financial again, testimony developed and deliv- Advocacy for our members extends resources to even exist as an organi- ered for the AOA by the Academy was within our profession as well. An AAO zation. The AAO staff, from top to instrumental in the Panel’s decision to position paper on cervical spine ma- bottom, are dedicated and committed. include CMT codes in CPT. nipulation was instrumental in obtain- One of the greatest things about this The OMT-E/M battle rages on to- ing a favorable PLI coverage decision profession and about this Academy day. The most recent front was the for DOs who use manipulation on a is that it inspires so much caring and RUC, and its Practice Expense Advi- substantial percentage of their patients, dedication by so many. sory Committee. When the practice and was submitted to the AOA House I would like to thank the Academy expense RVU’s were transitioned of Delegates for adoption as an official for the honor of being able to speak from the old charge-based system to AOA position. Speaking of the House, with you here today. I would like to a resource-based system, the AOA the Academy has had an increasing thank the Academy staff for all their recognized that this was an opportu- level of involvement there in the past assistance in gathering the back- nity to further clarify that E/M ser- ten years. During that time we have ground information and statistics I vices are not included in the RVUs submitted 15 resolutions to the house, used in preparing this presentation. for the OMT codes. A practice ex- and the number of Academy members Most of all, I would like to thank my pense survey instrument was devel- in attendance has been on the rise. In wife, Pam, for all her understanding oped, again with significant input fact, 64 physician delegates and alter- and support, without which I would from the Academy, and our members nate delegates were AAO members of not be here today. Thank you all for were, I would argue, the most signifi- the 2003 House. coming, and please enjoy the rest of cant contributors to the data that were our program.❒ presented to the PEAC. An AAO rep- Conclusion resentative presented our testimony, In closing today, I would like to note Address Correspondence to: and it was accepted by the PEAC and that I have only touched on a few key Boyd R. Buser, DO, FACOFP the RUC. The current Proposed Rule areas of Academy activity. It is beyond UNECOM from CMS indicates that they ac- the scope of today’s presentation to try 11 Hills Beach Road Biddeford, ME 04005 cepted the RUC’s recommendation. and cover all the important things the Fax: 207/294-5908 March 2004 The AAO Journal/19 Cystic Fibrosis: A Case History Heather D. Back, OMS-III in collaboration with Russell G. Gamber, DO, MPH University of North Texas Health Science Center - Fort Worth Texas College of Osteopathic Medicine

Introduction CPT treatments per day with Cystic fibrosis is the most common nebulizers. This is Christy’s first visit Assessment: inherited fatal disease among Cauca- to a DO and wishes to know how 1. Somatic dysfunction C, T, L sians.1 The clinical picture of CF is a manipulative therapy could help her 2. Cystic fibrosis result of mucus stasis and obstruction increase the length of time between in various organs of the body, most her hospital visits. Plan: critically the respiratory tract. Defec- 1. OMT to regions of somatic tive mucus and decreased Current medications: dysfunction mucociliary clearance create fertile Zithromax 500mg on MWF, 2. Continue current meds breeding grounds for bacteria such as Ultrase MT18-6 per meal, albuterol 3. Follow-up in two weeks Staphylococcus aureus and with saline nebulizer Pseudomonas aeruginosa leading Review of the Literature from chronic bronchitis to bron- PMHX: According to Eli H. Stark, DO, chiectasis and ultimately to respira- Diagnosed with cystic fibrosis at most studies of chronic obstructive tory insufficiency. The degree of pul- 3 years old (1980) at Dallas Childrens pulmonary disease in patients, who monary impairment is the major fac- Hospital. Since then, she has been have not received osteopathic ma- tor affecting the patient’s ultimate hospitalized 5 times for CF related prognosis.2 Because respiratory func- illness: 1988, 1997, 2000, 2001, and nipulative therapy, have emphasized tion is key to survival of the patient 2002. significant chronicity and poor re- with CF, modes of therapy are fo- sponse to therapy. However, 92% of cused on maintaining maximum lung FMHX: patients, who received osteopathic function and controlling pulmonary Mother, Father, brother-good health manipulation, claimed subjective infection. Osteopathic manipulation Maternal grandpa-died of MI improvement in their capacity to do 3 therapy should play an integral part Paternal grandpa prostate cancer physical work. In this paper, two ar- in the management of the patient with Mother’s cousin-died eas will be discussed: cystic fibrosis.3 of cystic fibrosis 1) the impact of the autonomies on the respiratory system in the CF pa- Case History Social/Employment Hx: tient; and Vital signs: Match support coordinator for Big 2) the lymphatic system and its relationship to CF. Wt: 109 Brothers/Big Sisters of North Texas; BP: 110/66 Denies tobacco and EtOH. HR: 85 Autonomics-The Sympathetic Resp: 18 Allergies: and Parasympathetic Chief Complaint: Increased cough Augmentin, PCN Nervous System The autonomic system has 2 parts: HPI: Physical Exam: sympathetic (SNS) and parasympa- Christy is a 26 -year-old white fe- Areas of Somatic Dysfunction thetic (PNS). SNS fibers originate male with the chief complaint of in- Cervical: OA SLRR from T1-L2 and PNS fibers from cra- creased cough upon waking for 1 wk. Thoracic: T3-7 SRRL nial nerves 3, 7, 9, 10 and S2-4. When Sputum produced is yellowish-green. Lumbar: L2-4 SLRR considering bronchial musculature, She denies fever or dyspnea. Christy’s Sacrum: nl ROM SNS fibers cause broncho-dilatation last hospital stay for her cystic fibro- Pelvis: nl ROM and PNS fibers cause broncho-con- sis was just over one year ago due to UE: nl ROM striction. For optimal pulmonary pneumonia. She is currently doing 2 LE: nl ROM function, a major goal for the CF pa-

20/The AAO Journal March 2004 tient, it is important to balance these Lymphatics function. In combination with qual- two systems. Lymphatic techniques are intended ity medical care, osteopathic manipu- The upper thoracic region, T1-T6, to remove restrictions and promote lative treatment can aide in reaching represent the site of origin of sympa- flow of the lymphatic system in order this goal by maintaining good respi- thetic innervation to the pulmonary to increase fluid resorption, improve ratory mechanics and lymphatic flow. tissue. For this reason, patients with respiration and circulation, decrease pulmonary disease frequently mani- interstitial proteins, and provide a more Conclusion fest somatic dysfunction in this re- beneficial pH balance.4 Thus, appro- Christy’s increased coughing in the 4 gion, particularly T3-T4 rotated left. priate lymphatic return is essential for morning is a significant issue consid- According to Edward Stiles, DO this the associated tissues to realize their ering her diagnosis of cystic fibrosis. somatic dysfunction may have a det- functional potential.5 In order to meet This is commonly the first indication rimental effect on the related sympa- these goals, treatments should be that she has an infection, either viral thetic ganglia, and secondarily, on the aimed at removing flow restrictions or bacterial. The fact that she is cur- arterial supply to the pulmonary tis- and increasing flow. Typical lym- rently taking Zithromax leads one to sues. This may also decrease the abil- phatic treatment includes inhibition/rib believe either her immune system is ity of the cardiovascular system to raising to T1-L2 to decrease sympa- being overwhelmed; she has a resis- deliver nutrients, oxygen, and medi- thetic tone to lymph vessels, address tant strain of bacteria; or she has a 5 cation to the affected tissue. thoracic inlet somatic dysfunction, virus. If the condition persists, a spu- The vgus nerve, or cranial nerve 10, which commonly obstructs lymphatic tum culture and further antibiotic use represents the parasympathetic inner- flow, redoming of the respiratory dia- would need to be considered. Mean- vation to the pulmonary tissues. The phragm, and augmentation of lymph while, the osteopathic physician can vagus exits the skull at the jugular fo- flow via some type of lymphatic pump.4 help her body heal itself by helping ramen; therefore somatic dysfunction her lungs and lymphatics work as ef- at the occipitoatlantal joint can cause Treatment modalities ficiently as possible to fight off the increased parasympathetic tone leading The first technique to be applied infection. Maybe then Christy could to broncho-constriction and decreased should be the release of the thoracic avoid another lengthy stay in the hos- sympathetic tone. Establishing muscu- inlet bilaterally since the lungs drain pital. loskeletal mobility in the upper dorsal to both the right lymphatic duct and area may help establish a more normal thoracic duct. This will effectively References sympathetic input with bronchial dila- “open the drain” where the ducts 1 Evans, Daniel A. Cystic Fibrosis and tation resulting. The same clinical re- empty into circulation at the junction Asthma. JAOA 98(10 suppl): S6-9, Octo- sult can take place when cervical so- ber 1998. of the subclavian and internal jugu- matic dysfunction is treated, since a 2 Palmer, Judy. Cystic Fibrosis in the Ado- lar veins. The thoracolumbar and pel- more normal parasympathetic input can lescent and Young Adult. Osteopathic vic diaphragms should be released, Annals 5(8): 378-389, August 1977. result in diminution or reversal of bron- since these work together as a pump 3 Stark, Eli H. Osteopathic Manipulative chial constriction.5 to return lymph to the venous system. Therapy for Cystic Fibrosis. Osteopathic Annals 5(8): 396-399, August 1977. Rib raising can be used to free the rib Treatment modalities 4 Simmons, Steven L. Osteopathic Manipu- cage and improve lymphatic flow. lative Medicine: Review for the Boards. HVLA would be an appropriate Lastly, the use of a lymphatic pump 2001. method to treat somatic dysfunctions technique such as thoracic or pedal 5 Stiles, Edward G. Manipulative Manage- in the thoracic and cervical areas of the ment of Chronic Lung Disease. Osteo- pump should be applied to improve pathic Annals 9(8): 300-304, August 1981 CF patient, provided the patient is will- lymphatic flow. Note: Bacterial infec- ing and without contraindications. tions with fevers >102 degrees should HVLA utilizes a high velocity, low be treated with antibiotics before Address correspondence to: amplitude activating force for specific employing a lymphatic pump tech- Heather D. Back, OMS-III joint mobilization to increase motion, nique to avoid risk of systemic spread UNTHSC at Fort Worth/TCOM improve function, decrease pain, and of infection.4 3500 Camp Bowie Blvd. modify somato-visceral reflexes.4 Fort Worth, Texas 76107 Muscle energy would be another Discussion treatment choice, provided the patient As previously stated, the main goal was not acutely ill and/or fatigued. of treatment in the patient with cys- tic fibrosis is optimization of lung

March 2004 The AAO Journal/21 Dr. Fulford’s Advanced Percussion Course Downers Grove, IL April 24-25, 2004

Pre-requisites: One basic Percussion Course

Robert C. Fulford, DO Rajiv L. Yadava, DO Program Chair Note: Below are excerpts from Andrew Weil, MD, in the introduction of Dr. Fulford’s Book, Touch of Life, published one year prior to his OTEL CCOMMODATIONS death in 1997. H A : (within 3 miles of campus) Marriott Suites: 630/852-1500 Comfort Inn: 630/515-1500 “In my recent book, Spontaneous Healing, I devoted a chapter to Doubletree Suites: 630/971-2000 Holiday Inn: 630/810-9500 Dr. Robert Fulford, one of my teachers, the first who made me truly aware of the prodigious healing power of nature, which is now the REGISTRATION FORM focus of my work. I met Bob Fulford in Tucson, Arizona, in the early 1970s, when he was in his late sixties, supposedly in retirement but Dr. Fulford’s Advanced Percussion Course actually running a busy osteopathic practice from a small office on April 24-25, 2004 Grant Road. I spend many hours in that office watching the old doctor fix people by putting his hands on them and manipulating their bodies Full Name ______to allow the natural healing power to do its work. I marveled at the Nickname for Badge ______simplicity and effectiveness of his treatments, a striking contrast to the expensive, invasive high-tech medicine that had become the norm for Street Address ______most doctors - MDs and DOs alike. ______. . . As a physician dedicated to radical reform of medicine, I find Dr. Fulford’s life and work a great inspiration for my work. His em- City ______State______Zip______phasis on vital energy and the healing power of nature concepts that Office phone # ______animated medical inquiry from the time of Hippocrates through the last century - is completely missing from medical education today. I Fax #: ______once helped make a documentary video about this man, entitled “Rob- By releasing your Fax number, you have given the AAO permission to send ert Fulford: An Osteopathic Alternative,” but the more I think about it, marketing information regarding courses via the fax. the more I feel that his views are the mainstream of the evolution of E-mail: ______medical thought and that it is twentieth-century technological medi- cine that has taken an alternative path, one that has led to an economic AOA # ______College/Yr Graduated ______dead end. If medicine is to come back into alignment with the great I require a vegetarian meal ❒ healing traditions and satisfy the needs and desires of those who are (AAO makes every attempt to provide snacks/meals that sick, it must rediscover the truths that Bob Fulford expresses . . .” will meet participant’s needs. However, we cannot guarantee to satisfy all requests.) LEARNING OBJECTIVES: At the end of this session, participants should: REGISTRATION RATES • Design a treatment plan using the basic concepts taught ON OR BEFORE 3/25/04 AFTER 3/25/04 in the course AAO Member $400 $500 • Utilize the percussion vibrator on any area of the body Intern/Resident/Student $300 $400 for any age patient AAO Non-Member $605 $705 • Apply the basic concepts taught to make treatments easier, more effective, and quicker. AAO accepts Visa or Mastercard COURSE LOCATION: Credit Card # ______Midwestern University, Chicago College of Osteopathic Medicine Cardholder’s Name ______555 31st St, Downers Grove, IL 60515 Date of Expiration ______The program anticipates being approved for 14 hours of AOA Category 1-A CME credit pending approval by the AOA CCME Signature ______22/The AAO Journal March 2004 Clinical Jones Strain-CounterStrain I for the Spine and Rib Cage June 4-6, 2004 Indianapolis, Indiana

COURSE LOCATION: Edward K. Goering, DO The Radisson Hotel City Centre Program Chair, Co-author of Jones Strain-CounterStrain HOTEL ACCOMMODATIONS: The program anticipates being approved for 20 hours of AOA The Radisson Hotel City Centre 31 West Ohio Street, Indianapolis, Indiana 46204 Category 1-A CME credit pending approval by the AOA CCME. Room Rate: $125 single/double Reservation Phone: 317/635-2000 COURSE DESCRIPTION: LEVEL II Cut off Date: May 4, 2004 Clinical Strain-CounterStrain I is an exciting presentation of a REGISTRATION FORM proven clinically effective experience modality for every practi- Clinical Jones Strain-CounterStrain I tioner. Dr. Goering brings clinical experience from years of prac- tice as well as over 7 years of direct instruction from Dr. Lawrence June 4-6, 2004 H. Jones. He has taught throughout the United States as well as Full Name ______international venues. His clinical understanding helps participants appreciate the clinical application of Strain-CounterStrain as taught Nickname for Badge ______by its discoverer, L. H. Jones, DO. During the 20-hour course, Street Address ______participants will discuss the theory of somatic dysfunction and ______manipulation. A very specific presentation of the classic Jones Strain-CounterStrain will be provided as it impacts common clini- City ______State ______Zip______cal problems. The applications of this technique will be demon- Office phone # ______strated in multiple clinical examples upon which the student can Fax #: ______build an evaluation and treatment. There will be a full presenta- By releasing your Fax number, you have given the AAO permission to send tion of cervical, thoracic, and lumbar spine, as well as the ribs and marketing information regarding courses via the fax. sacrum. There will also be hands on laboratory time for partici- E-mail: ______pants to practice their newly acquired knowledge as they develop skills with each other. A brief review of documentation and cod- AOA # ______College/Yr Graduated ______ing will be provided. I need AAFP credit ❒ I require a vegetarian meal ❒ (AAO makes every attempt to provide snacks/meals that PREREQUISITES: Functional Anatomy; One Level I will meet participant’s needs. However, we cannot course or equivalent guarantee to satisfy all requests.)

LEARNING OBJECTIVES: REGISTRATION RATE The participants will be able to clearly discuss the physiology of ON OR BEFORE 5/6/04 AFTER 5/6/04 somatic dysfunction and manipulation as it relates to Strain- AAO Member $550 $650 CounterStrain in a real-life clinical setting. They will be able to Intern/Resident $450 $550 assess a patient for somatic dysfunction utilizing Strain- AAO Non-Member $755 $855 CounterStrain and determine an appropriate treatment sequence and perform that treatment. Clinical application of this informa- tion can be made after the course. AAO accepts Visa or Mastercard

PROGRAM TIME TABLE: Credit Card # ______Friday, June 4...... 8:00 am – 5:30 pm Cardholder’s Name ______Saturday, June 5 ...... 8:00 am – 5:30 pm Sunday, June 6 ...... 8:00 am –12:30 noon Date of Expiration ______(Friday & Saturday include (2) 15 minute breaks and a (1) hour Signature ______lunch; Sunday includes a 30 minute break.)

March 2004 The AAO Journal/23 A Case of Right First Rib Somatic Dysfunction Diagnosed and Treated Through cooperative care*: CDR James A. Lipton, MC, USN,** Michele Neil, MSIV***, Brendon Drew, MSIV**** and Claudia McCarty DO****

* “The opinions expressed in this article are those of the authors and do not reflect the official policy or position of the Depart- ment of the Navy, Department of Defense or the United States Government.” “I am a military service member. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that Copyright protection under this title is not available for any work of the United States Government. Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.”

Presented is a case, which illus- and Rehabilitation with a chief com- EMG report to review. Remaining trates the importance of recognizing plaint of right shoulder pain for 10 medical history was negative for hy- that elevation of the first rib exists as months. According to the patient, his pertension, cancer, diabetes, tubercu- somatic dysfunction treatable without pain originated from where his right losis, thyroid or sickle cell disease. surgery. Osteopathic physicians are trapezius met his right shoulder and The patient described his worst pain taught that first rib somatic dysfunc- was felt to be coming from inside his with this complaint as 70 out of 100 tion can present both as a lone entity neck and making his right arm weak. with 0 being no pain and 100 being and at times can be part of a larger He complained of his right arm feel- enough to black out. The patient de- syndrome depending on severity and ing cooler than his left. There were nied tobacco or alcohol use or abuse. related conditions. Recognition and no complaints of loss of control of He had a motor vehicle accident in treatment of this somatic dysfunction bowel or bladder. He noted that he 1997 without sequellae. He was can be accomplished cooperatively. had injured his right shoulder in 1993 single and had no children. The pa- This case illustrates through exhaus- by dislocation and occasionally his tient noted he was in bed nightly at tive workup that the diagnosis of an left elbow would swell. There was no 2200, asleep by 0100 and up for the elevated first rib is clinically signifi- recurrence of dislocation and no sur- day at 0430. cant and palpable. Elevation of the gical repair either of his shoulder or Review of the record revealed the first rib can be considered along with any other part of his body. The pa- patient had been through extensive all other known disease processes, tient denied any history of fractures. evaluations provided by orthopedics, and with multilevel symptoms and Past medical history was significant rheumatology, neurology, dermatol- signs in presentation. for maxillary sinusitis (documented ogy, and vascular surgery. The fol- on MRI in September of 1999) and lowing differential diagnoses were History right hand and knee pain in May of considered in the record reviewed: A 23-year-old, right-handed, active 1998. MRI of the right hand and knee Carotid Artery Disease, Human Im- duty, black male Petty Officer Third was negative, as was electromyogra- munodeficiency Virus, Seronegative Class Hospital Corpsman presented phy performed by a physical thera- Spondyloarthritidites, Thyroid Dis- to the Division of Physical Medicine pist for median neuropathy with no ease, Carpal Tunnel Syndrome, Tran- sient Tenosynovitis, Raynauds Dis- ease, Systemic Lupus Erythematosis, ** Department of Orthopedics Rheumatoid Arthritis, Ulnar Neur- Division of Physical Medicine and Rehabilitation opathy, Subclavian Steal Syndrome, Naval Medical Center, Portsmouth, Virginia, 23708 *** Oklahoma College of Osteopathic Medicine Subcoracoid Bursitis, Recurrent Tulsa, Oklahoma, 74127 Shoulder Dislocation, Rotator Cuff **** Stanley Schiowitz Dept. of Osteopathic Principles and Practice Tear, Fibromyalgia, Dermatomyosi- New York College of Osteopathic Medicine tis, Keloid Formation, Reflex Sym- Old Westbury, New York, 11568 24/The AAO Journal March 2004 pathetic Dystrophy and Thoracic tion noted at cervical vertebrae three 100. A full thyroid was evaluated with Outlet Syndrome. All labs ordered (rotated right and sidebent right) and thyroid function tests and a thyroid proved negative and included: com- five (rotated left and sidebent left). scan, which were normal. The patient plete blood count, ESR, Denver Leg lengths were symmetrical as followed up on 15 January 2001 for Panel, C3, C4, C reactive protein, were the anterior superior iliac spines treatment number three and presented HIV, Chem 17, rheumatoid factor, and the sacral base was level. with an essentially negative MRI of antinuclear antibody, cryoglobulin, the head (7mm pineal cyst), and a thyroid stimulating hormone and uri- Impression negative triple phase bone scan. The nalysis. Diagnostic imaging proved Working diagnoses now included patient’s pre-treatment pain score was negative and included: Duplex Ultra- cervical and rib somatic dysfunctions, 30% (comfort level 70%). He had re- sound of the Carotids and right upper sleep deficit, reflex sympathetic dys- mained at this level since 18 Decem- extremity, radiographs of the cervical trophy as well as the need for further ber 2000 for 30 days after his second spine, shoulder, chest, and lumbar spine evaluation and treatment. OMM was treatment. Both extremities were as well as MRI of the cervical spine, prescribed and administered first to symmetrical in temperature, sensa- and shoulder. Sphygmomanometer the cervical and lower rib somatic tion strength and circulation. The readings in bilateral upper extremities dysfunctions with correction but no right first rib was manipulated using were normal and symmetrical. relief of the chief complaint. When high velocity low amplitude (HVLA) The patient had received a physi- OMM was administered to the first technique following muscle energy cal therapy evaluation and treatments, rib correcting the somatic dysfunction and HVLA to relieve some minor which included one month of range immediate pain relief resulted down cervical somatic dysfunction. The of motion exercises and electrical from 70 to 25 on a scale of 1 to 100 post-treatment pain score was 20 out stimulation for the right upper ex- (1 being the least amount of pain and of 100. The patient was directed to tremity and neck, without relief. The 100 being the greatest amount of return in 2 weeks to 1 month. The patient had been prescribed at vari- pain). Immediate warming of the patient was followed up on 20 Feb- ous intervals, piroxicam, indometha- right extremity occurred. To further ruary 2001 for a fourth treatment. His cin, cyclobenzoprine, naproxyn so- explore the working diagnosis, a re- pre-treatment pain score was 20 out dium, propoxyphene/acetaminophen, peat EMG was ordered (performed by of 100 and had been so for over 30 ibuprofen and neurontin all in doses the author). MRI of the head was or- days. His post-treatment pain score widely accepted for use in patients dered to explore the possibility of cra- following OMM for the first rib was with his working diagnoses. His nial nerve or parenchymal involve- zero, on a scale of 1 to 100. On 29 medications were generally ineffec- ment along with a triple phase bone March 2001 the patient received his tive though at times able to lessen his scan to assess for reflex sympathetic fifth and final treatment. He had been pain to as low as 45 out of 100. He dystrophy. Hydroxizine hydrochlo- 0 on a scale of 1 to 100 for 17 days had been placed on a limited duty ride was prescribed to assist with and 15/100 for the following 13 days. board for 8 months due to expire in sleep and anxiety. Use of the pool was He felt so good that he played bas- January 2001. The patient presented encouraged 3 to 5 times per week to ketball for the first time everyday for on 16 November 2000 in 70 out of mobilize the rib cage along with pos- a week then raising his pain score the 100 pain on his medication. His vas- tural exercises. Follow up in one day of his fifth treatment to 40/100. cular surgeon at the present time re- month was scheduled. The patient Following treatment number 5, he left ferred him to receive treatment with presented for his second treatment on the office with a pain level of 0 out osteopathic manipulative medicine 18 December 2000. The pre-treat- of 100. He was also given instructions (OMM). ment pain score was a 70 out of 100. to use the pool (instead of daily bas- He had remained at 25 out of 100 ketball games) to maintain proper Physical Exam from 16 November 2000 through 23 position of the first rib. Directed pertinent negatives on November 2000 for one week. From physical exam included a negative 24 November 2000 through his ap- Discussion Allen’s and Adson’s test. Directed pointment time on 18 December 2000 Traditionally, first rib problems pertinent positives included a right his pain level was a 70 out of 100 for have been considered by the medical greater than left cooler extremity, an 3 weeks. He was treated with OMM community in the context of thoracic elevated first rib on the right, re- correcting an elevated first rib and outlet syndrome (TOS). The definitions stricted ribs numbered three through EC3RRSR and RC5RLSL. His post- of thoracic outlet syndrome have been six and extension somatic dysfunc- treatment pain score was 30 out of reviewed including the suggestion that ➻ March 2004 The AAO Journal/25 TOS has been both underdiagnosed92 reduces the distance between the an- the anatomy of the brachial plexus as and overdiagnosed.132 TOS has been terior scalene and the clavicle. Venous well as vascular compression or oc- defined as: compression is universally present with clusion.26 Three-dimensional comput- a) A compression pattern affecting this maneuver. Arterial narrowing oc- erized scans can reveal dislocation of either the upper or lower roots of the curs less often and in a minor fashion. the first rib.64 A cervical rotation lat- brachial plexus.91 Minor changes in TOS dimensions may eral flexion test has been described b) The compression syndromes produce venous compression without to examine patients with TOS.63 In- called scalenus anticus, costoclavicu- movement.69 Shoulder pathology must travascular ultrasound can be used in lar, hyperabduction and Paget- be considered in patients with TOS.57 the evaluation of TOS.12 The use of Schroetter Syndromes.34 TOS can be described from a MRI has potential value in the diag- c) Paget-Schroetter Syndrome (ef- myofascial standpoint involving the nosis of TOS by revealing nervous or fort thrombosis) including venous scalene and smaller pectoral muscles. vascular distortion, radiographically compression or thrombosis at the tho- The use of thermography has been ex- invisible or clinically significant racic outlet.50,122 plored to assist with diagnosis in dem- bands or ribs.78 The axial rotation and According to Press82 and Parziale onstrating pathology in views of the simultaneous lateral flexion of the et al,79 William Harvey in 1627/1628 hand. Global changes involving the cervical spine can be used in the described a patient with signs and hand suggest autonomic or vascular evaluation of thoracic outlet function. symptoms compatible with TOS. involvement while dermatomal dis- The test can illicit pain from the first More recently, 3 main sites of com- tribution suggests neurologic involve- thoracic transverse process bumping pression have been described which ment.111 Over the years, patients pre- against a subluxated first rib.61 Cin- include: senting with cervical radiculopathy eradiography can also demon- 1) Costoclavicular space between without neurologic findings and strate hypomobile first ribs and this the clavicle and the first rib (costo- negative MRI have suffered from a can also be elicited by palpating the clavicular syndrome) variety of symptoms, neck pain, head- first rib just beneath the clavicles on 2) Triangle between the anterior aches, lightheadedness, pain and tin- an expiration and inspiration test.60 A scalene, middle scalene and the up- gling which may include the shoul- complex series of TOS abnormalities per border of the first rib (anterior der and hand and the following signs may be studied using digital subtrac- scalene syndrome) including muscle spasms, rigidity, de- tion angiography. Additionally, chest 3) Angle between the coracoid pro- creased ROM. These symptoms are radiograph can detect fractures of the cess and the pectoralis minor inser- sometimes referred to as Scalene En- first rib through indirect signs, includ- tions (hyperabduction syndrome or trapment Syndrome.94 ing extrapleural fluid collection, pleu- pectoralis minor syndrome). The dif- Diagnostic tests have been re- ral effusion, and soft tissue mass.44 ferential diagnosis of TOS must rule viewed for efficacy with regard to Analgesic cervical disk puncture may out damage to C8/T1 and involve TOS: Examination in abduction by assist in the diagnosis of TOS. In pa- consideration of other entities such as MRI in an open scanner can assist in tients whose puncture is positive, herniated cervical disks, spondylosis, diagnosis. Symptoms due to TOS symptoms remain unchanged after Pancoast’s tumor, labral, rotator cuff may only be present in abduction and surgery while patients with a nega- and other shoulder pathology, median is not amenable to study by conven- tive test had excellent postoperative and ulnar neuropathies and neurofi- tional MR scanners.108 Symptoms and results.47 Doppler ultrasonography broma.23,82,136 signs in TOS can be common to other can be a valuable tool in studying Familiarity with the anatomy of the diagnoses. One study of 315 patients TOS.81 In the evaluation of TOS with thoracic outlet reveals significant nar- with cervico-brachial symptoms arterial symptoms involving the sub- rowing of the costoclavicular space showed 207 had TOS and 108 did not. clavian artery, Doppler flow studies can occur with postural maneuvers as Ninety-four percent of TOS patients and arteriogram are useful; with demonstrated by a helical CT. had at least 3 of the 4 following signs: venous involvement of the subclavian Postero-anterior displacement of the 1) Exacerbation of symptoms with vein, venous flow studies and veno- subclavian vessels was the change the arm elevated gram are useful; with neurogenic symp- seen most.86 Fibrous muscular and 2) Ulnar paresthesias toms involving the lower trunk of the osseous structures with the potential 3) Brachial plexus tenderness brachial plexus electrodiagnostic tests to entrap the brachial plexus occur 4) A positive “hands-up test.” Of are useful; and in symptomatic pa- within the thoracic outlet of normal note, the Adson’s test was not con- tients in general, use of the history patients, which may or may not pro- sidered indicative of pathology.87 and provocative tests on physical duce TOS.85 Abduction significantly MRI with MRA can demonstrate exam are useful, including the91 26/The AAO Journal March 2004 hyperabduction external rotation test, tions (1.9%). Seventy-eight percent ries versus non-work-related auto which evaluates the three main sites of patients with symptoms of neuro- accidents for example showed 13- of compression in TOS. On physical logic TOS in the follow up group im- 15% better success rates in the latter exam, there are a number of tests proved, 21% had complete relief, and group.100 A strong determinant of suc- which have been described to evalu- 32% had good relief, 25% had fair cess after first rib transaxillary resec- ate scalene entrapment, including the relief, and 22% showed no improve- tion was the length of the residual rib scalene-cramp test, scalene-relief test ment.43 Surgical decompression was stump.71 One study advocated a radi- and finger-flexion test.94 more successful when TOS was trau- cal surgical approach combining Historically TOS and TOS with matic or subacute.117 A review of the scalenectomy and transaxillary first related conditions such as reflex sym- literature and a survey of vascular rib resection to minimize the recur- pathetic dystrophy have been associ- surgeons reveals that primary subcla- rence rate and improve results.14 Long ated with many precipitating causes. vian/axillary vein thrombosis occurs term follow-up of TOS decompres- These causes include: trauma, like mostly (approx 70%) following un- sion patients revealed that with motor vehicle accidents68,84 congeni- usual exercise or dominant arm posi- transaxillary rib resection patients tal anatomy such as supernumerary tioning in such patients, and most thought to have neurogenic TOS that subclavius posticus, as a causative have severe symptoms and anticoagu- 47% of patients with a history of factor for Paget-von Schrotter syn- lant therapy is not affective. These trauma returned to pre-illness activi- drome,2,29 masses such as costoclav- patients can be considered for cath- ties versus 78% without trauma in the icular, exuberant callous formation eter directed thrombolysis. Other con- history. Seventy two percent of the following clavicle fracture,25 desmoid siderations include percutaneous trauma patients were satisfied versus tumor,30 ipsilateral subclavian steal translum inal angioplasty or stents. 83% of the non-trauma patients.33 and TOS syndromes can exist (as con- Removal of the first rib may have lost One study refuted the need for com- firmed by arteriography and its popularity in the treatment of post bined supraclavicular and electrodiagnostic testing,127 venous thrombotic occlusion of subclavian transaxillary approaches finding the thrombosis,17,31 effort thrombosis,67,126 segments as a lone approach in the transaxillary approach alone was sat- venous stenosis,132,133 aneurysms of absence of objective proof of posi- isfactory.124 the subclavian artery34 and associa- tional collateral obstruction. With regard to deep vein throm- tion with cervical ribs and exertion34 During a 28-year period 637 pa- bosis of the axillary-subclavian veins schwannoma of the C7 nerve root,4 tients underwent 770 supraclavicular phlebography was helpful in sus- compression with double crush phe- first rib resections and scalenectomies pected arm DVT. Primary DVT is nomena, (sometimes producing bilat- for TOS (92% were neurologic and treated with anticoagulants.58 The eral TOS), combination with bilateral 8% were vascular). Of the 8% that technique of scalenotomy yielded radial tunnel syndrome83,134 or the were vascular, 6% were venous and 100% excellent results in one study more common CTS,134 pacemaker 2% were arterial. An excellent re- of 119 patients.28 First rib resection lead fracture,114 anomalies of the first sponse was achieved in 59%, good is considered the primary decompres- rib,37 athletic injury45 pseudoarthrosis6 result in 27%, fair in 13% and poor sive procedure. Good and satisfactory or associated with acute arterial ob- results in 1% (95 cases). Two percent results were obtained in up to 89.7% struction, thrombus formation, aneu- required reoperation for recurrent of patients studied.102,74 rysm or embolism42 and tumor of the TOS (12 patients).39 Excellent and Critiques of surgical treatments first rib.70 good results following different op- reveal the need for strict preoperative Therefore there are numerous erations for TOS are close to 80% or criteria in use of the preferred treatments, which have been tried 70% at five years. The results were transaxillary approach when symp- over the years.125,18 Studies of surgi- very close for anterior and middle toms are found to disappear in only cal treatments reveal that first rib re- scalenectomy transaxillary first rib 47% of patients studied.139 One study section with scalenectomy are cura- resection and combined supraclavicu- found TOS only rarely to be caused tive for most TOS patients whose lar scalenectomy and first rib resec- by osseous anomalies. The definition symptoms are caused by compression tion. Reoperation improved results of TOS as a soft tissue disease, where of the brachial plexus.89 A review of 15% for transaxillary rib resection the c-8 and t-1 roots or the proximal 409 patients showed transaxillary rib and 17% for anterior and middle inferior trunk of the brachial plexus resection in 380 patients (83%) and scalenectomy. When the initial sur- is compressed by fibromuscular supraclavicular thoracic outlet de- gery was combined rib resection and anomalies is felt to be a clinical diag- compression in 29 (7%). There were scalenectomy reoperation improved nosis. If surgery is recommended it 8 complications of surgical interven- results only 3%. Work related inju- ➻ March 2004 The AAO Journal/27 should be directed to these anomalies plexus neurolysis without first rib re- be used to treat TOS.111 TOS involves and not to the first rib. Transaxillary section for post-traumatic TOS has more than just neurovascular com- rib resection carries serious compli- been used as well with the sugges- pression. A variety of osteopathic so- cations, most frequently brachial tion that brachial plexus compression matic findings can be treated with a plexus injury.88 Removal of the first best describes the pathology.21 variety of OMM treatments.113 TOS rib is not recommended when thor- Treatment failures have been re- may be treated successfully with ough removal of the scalene muscu- viewed: 77 patients with 84 operated myofascial release and self-stretching lature and other myofascial anoma- limbs were followed at an average of exercises.112 lies via the supraclavicular approach six years, status post first rib resec- can be performed for patients with tion for TOS 50% were totally asymp- Conclusion neurogenic TOS requiring operative tomatic after surgery, and remained Certain conclusions have been 11,97 intervention. Of the 4 operations asymptomatic for 6 months. In long reached in the past study of TOS studied to address recurrence of TOS, term follow up, 11 limbs had the same (Dale 1975). Elevation of the first rib transaxillary rib resection, supraclav- symptoms as before the operation. is addressed in the training of every icular first rib resection with neuroly- Results suggest that monotonous osteopathic medical student. The sis, scalenectomy with neurolysis and deskwork is an important factor in sequellae of an elevated first rib can 62 brachial plexus neurolysis complica- recurrence 13 of 100 patients treated range from asymptomatic to discom- tions included temporary plexus in- for TOS with first rib resection de- fort to the cause of thoracic outlet jury (0.7%), temporary phrenic nerve veloped “snapping scapula syn- syndrome. This case study is an ex- 136 palsy (3.7%), and permanent phrenic drome.” Other complications of ample of a confirmed diagnosis of nerve palsy (1.4%). The combined first rib resection included winging first rib somatic dysfunction treated 135 primary success rate of all 4 opera- of the scapula. A review of 100 pa- and relieved without surgery through tions for recurrence was 84% in the tients with TOS treated with first rib osteopathic principles and practice. first 3 months, 59% at 1 to 2 years, resection, including many with Allopathic and osteopathic physicians 50% at 3-5 years, and 41 % at 10-15 double crush syndrome, revealed worked the patient up and by the evi- 53 years. There was no difference be- 90% good and excellent results. in- dence accumulated were able to lo- tween operations for recurrence and dications for reoperation include per- calize and verify the source of the better results were obtained when re- sistent pain, ulnar nerve conduction patients problem. Had osteopathic currence was due to trauma vice spon- velocity of 60m/sec or less with nor- manipulation not been an option, the taneous and without neck injury in- mal being 72 to 82 m/sec and failure patient was next to undergo removal 99 volved. Transection of the phrenic of appropriate physical therapy. of the right first rib by the allopathic nerve may occur during decompres- Reoperation involved neurolysis, dor- vascular surgeon who referred the 35 sion of the thoracic outlet. sal sympathectomy and decompres- patient for manipulation. The patient 121 Other treatment approaches have sion. In this author’s experience a instead returned to full duty without included stretching of muscles, mo- conduction velocity of 60m/sec the need for surgery. bilizing the first rib and clavicle and would not be a reliable indicator of 82 improving posture and muscle tone. significant pathology. Abnormal ki- Bibliography For vascular TOS, thrombolysis, an- nesiology contributes to the reoccur- ticoagulation, surgical decompres- rence of TOS even after resection of Anatomy 62 1. Adelman MA, Stone DH, Riles TS, sion, and endovascular procedures the first rib. 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Can syndrome due to monostotic fibrous dys- Velling TE, Brennan FJ, Hemp JR, Hall J Surg. 1998 Oct. 41(5):404-6. plasia of the first rib. J R Coll Surg Edinb. LD. Vascular thoracic outlet syndrome: 31. Glass BA. The relationship of axillary 1990 Apr. 35(2):111. No abstract avail- successful outcomes with multimodal venous thrombosis to the thoracic outlet able. therapy. Cardiovasc Surg. 2001 Feb. compression syndrome. Ann Thorac 47. Kofoed H. Thoracic outlet syndrome: di- 9(1):1115. [Record as supplied by pub- Surg. 1975 Jun. 19(6):613-21. agnostic evaluation by analgesic cervi- lisher] 32. Gloviczki P, Kazmier FJ, Hollier LH. cal disk puncture. Clin Orthop. 1981 16. Crawford FA Jr. Thoracic outlet syn- Axillary-subclavian venous occlusion: May. (156):145-8. drome. Surg Clin North Am. 1980 Aug. the morbidity of a nonlethal disease. J 48. Kranz J, Crystal DK, Wagner CL, Day 60(4):947-56. Review. Vasc Surg. 1986 Oct. 4(4):333-7. SW. Thoracic outlet compression syn- 17. Dale WA, Allen TR. Unusual problems 33. Green RM, McNamara J, Ouriel K. drome. The first rib. Northwest Med. of venous thrombosis. Surgery. 1975 Long-term follow-up after thoracic out- 1969 Ju1. 68(7):646-50. No abstract Dec. 78(6):707-22. let decompression: an analysis of factors available. 18. Dale WA, Lewis MR. Management of determining outcome. J Vasc Surg. 1991 49. Kremer RM, Ahlquist RE Jr. Thoracic thoracic outlet syndrome. Ann Surg. Dec. 14(6):739-45; discussion 745-6. outlet compression syndrome. Am J 1975 May. 181(5):57585. 34. Gruss JD, Bartels D, Vargas H, Ohta T, Surg. 1975 Nov. 130(5):612-6. 19. Dale WA. Thoracic outlet compression Tsafandakis E, Schlechtweg B, Haidar 50. Kunkel JM, Machleder Hl. Treatment of syndrome. Critique in 1982. Arch Surg. A. Shoulder girdle compression syn- ➻ March 2004 The AAO Journal/29 Paget-Schroetter syndrome. A staged, 66. Macchiarini P, Dartevelle P, Chapelier A, first rib resection. A multidisciplinary ap- multidisciplinary approach. Arch Surg. Lenot B, Cerrina J, Ladurie FL, Parquin proach to the thoracic outlet syndrome. 1989 Oct. 124(10):1153-7; discussion F. Technique for resecting primary and Am Surg. 1986 Sep. 52(9):485-8. 1157-8. metastatic nonbronchogenic tumors of the 81. Pisko-Dubienski ZA, Hollingsworth J. 51. Kutsal A, Gokce-Kutsal Y. Radial ray de- thoracic outlet. Ann Thorac Surg. 1993 Clinical application of Doppler ultra- fect with vascular and vertebral anoma- Mar. 55(3):611-8. sonography in the thoracic outlet syn- lies. Arch Orthop Trauma Surg. 1989. 67. Machleder Hl. Effort thrombosis of the drome. Can J Surg. 1978 Mar. 21(2):145- 108(5):333-5. axillosubclavian vein: a disabling vascu- 7, 150. 52. Lagerquist LG, Tyler FH. Thoracic outlet lar disorder. Compr Ther. 1991 May. 82. Press, JM and Young JL. Vague Upper Ex- syndrome with tetany of the hands. Am J 17(5):18-24. Review. tremity symptoms? Consider Thoracic Med. 1975 Aug. 59(2):281-4. 68. Mailis A, Papagapiou M, Vanderlinden Outlet Syndrome. The Physician and 53: Lai DT, Walsh J, Harris JP, May J. Pre- RG, Campbell V, Taylor A. Thoracic out- Sports Medicine. Vol 22. No 7. July 1994. dicting outcomes in thoracic outlet syn- let syndrome after motor vehicle accidents 83. Putters JL, Kaulesar Sukul DM, Johannes drome. Med J Aust. 1995 Apr 3. in a Canadian pain clinic population. Clin EJ. Bilateral thoracic outlet syndrome with 162(7):345-7. J Pain. 1995 Dec. 11 (4):316-24. bilateral radial tunnel syndrome: a double- 54. Larson, NJ Osteopathic Manipulation for 69. Matsumura JS, Rilling WS, Pearce WH, crush phenomenon. Case report. Arch syndromes of the brachial plexus. JAOA. Nemcek M Jr, Vogeizang RL, Yao JS. Orthop Trauma Surg. 1992; 111 (4):242- December 1972. Helical computed tomography of the nor- 3. 55. Lascelles RG, Mohr PD, Neary D, Bloor mal thoracic outlet. J Vasc Surg. 1997 Nov. 84. Razi DM, Wassel HD. Traffic accident K. The thoracic outlet syndrome. Brain. 26(5):776-83. induced thoracic outlet syndrome: decom- 1977 Sep. 100(3):601-12. 70. Melliere D, Ben Yahia NE, Etienne G, pression without rib resection, correction 56. Lee WA, Hill BB, Harris EJ Jr, Semba CP, Becquemin JP, de Labareyre H. Thoracic of associated recurrent thoracic aneurysm. Olcott C IV. Surgical intervention is not outlet syndrome caused by tumor of the Int Surg. 1993. Jan-Mar. 78(1):257. required for all patients with subclavian first rib. J Vasc Surg. 1991 Aug. 14(2):235- 85. Redenbach DM, Nelems B. A compara- vein thrombosis. J Vasc Surg. 2000 Ju1. 40. Review. tive study of structures comprising the tho- 32(1):57-67. 71. Mingoli A, Feldhaus RJ, Farina C, racic outlet in 250 human cadavers and 57. Levin LS, Dellon AL. Pathology of the Cavallari N, Sapienza P, di Marzo L, 72 surgical cases of thoracic outlet syn- shoulder as it relates to the differential Cavallaro A. Long-term outcome after drome. Eur J Cardiothorac Surg. 1998 diagnosis of thoracic outlet compression. transaxillary approach for thoracic outlet Apr. 13(4):353-60. J Reconstr Microsurg. 1992 Ju1. syndrome. Surgery. 1995 Nov. 86. Remy-Jardin M, Remy J, Masson P, 8(4):313-7. 118(5):840-4. Bonnel F, Debatselier P, Vinckier L, 58. Lindblad B, Tengborn L, Bergqvist D. 72. Molina JE. Combined posterior and Duhamel A.Helical CT angiography of Deep vein thrombosis of the axillary-sub- transaxillary approach for neurogenic tho- thoracic outlet syndrome: functional clavian veins: epidemiologic data, effects racic outlet syndrome. J Am Coll Surg anatomy. AJR Am J Roentgenol. 2000 Jun. of different types of treatment and late 1998 Ju1. 187(1) 3945 174(6):1667-74. sequelae. Eur J Vasc Surg. 1988 Jun. 73. McGough EC, Pearce MB, Byrne JP. 87. Ribbe, EB, Lindgren, SHS and Norgren 2(3):161-5. Management of thoracic outlet syndrome. LEH Clinical diagnosis of thoracic outlet 59. Lindgren KA, Leino E. Subluxation of the J Thorac Cardiovasc Surg. 1979 Feb. syndromeevaluation of patients with first rib: a possible thoracic outlet syn- 77(2):169-74. cervico-brachial symptoms. Manual drome mechanism. Arch Phys Med 74. Nasim A, Sayers RD, Healey PA, Bell PR, Medicine. 1986. 2:82-85. Rehabil. 1988 Sep. 69(9):692-5. Barrie WW. Surgical decompression of 88. Richter HP. Removal of the 1st rib in tho- 60. Lindgren KA, Leino E, Manninen H. Cin- thoracic outlet syndrome; is it a worth- racic outlet syndrome. ls it helpful? Is it eradiography of the hypomobile first rib while procedure? J R Coll Surg Edinb. safe? Nervenarzt. 1996 Dec. 67(12):1034- Arch Phys Med Rehabil. 1989 May. 1997 Oct. 42(5):319-23. 7. Review. German. PMID: 9082194, Ul: 70(5):408-9. 75. Nguyen T 4th, Baumgartner F, Nelems B. 97152704 61. Lindgren KA, Leino E, Hakola M, Bilateral rudimentary first ribs as a cause 89. Riddell DH, Smith BM. Thoracic and Hamberg J. Cervical spine rotation and of thoracic outlet syndrome. J Natl Med vascular aspects of thoracic outlet syn- lateral flexion combined motion in the ex- Assoc. 1997 Jan. 89(1):69-73.PMID: drome. 1986 update. Clin Orthop. 1986 amination of the thoracic outlet. Arch Phys 9002419; Ul: 97155764 Jun. (207):31-6. Med Rehabil. 1990 Apr. 71(5):343-4. 76. Nichols AW. The thoracic outlet syndrome 90. Rignault D, Metges P, Pagliano G, Pailler 62. Lindgren KA, Leino E, Lepantalo M, in athletes. J Am Board Fam Pract. 1996 JL, Bouquet JP. Abnormalities of the 1 st Paukku P. Recurrent thoracic outlet syn- Sep-Oct. 9(5):346-55. Review. rib and their vascular effects. Apropos of drome after first rib resection. Arch Phys 77. O’Leary MR, Smith MS, Druy EM. Di- 8 cases. J Chir(Paris). 1976. 112(5):315- Med Rehabil. 1991 Mar. 72(3):208-10. agnostic and therapeutic approach to ax- 28. French. 63. Lindgren KA, Leino E, Manninen H. Cer- illary-subclavian vein thrombosis. Ann 91. Roos DB. The place for scalenectomy and vical rotation lateral flexion test in bra- Emerg Med. 1987 Aug. 16(8):889-93. first-rib resection in thoracic outlet syn- chialgia. Arch Phys Med Rehabil. 1992 78. Panegyres PK, Moore N, Gibson R, drome. Surgery. 1982 Dec. 92 (6): 1077- Aug. 73(8):735-7. Rushworth G, Donaghy M. Thoracic 85. 64. Lindgren KA, Manninen H, Rytkonen H. outlet syndromes and magnetic reso- 92. Roos DB. Historical perspectives and ana- Thoracic outlet syndrome—a functional nance imaging. Brain. 1993 Aug. 116 (Pt tomic considerations. Thoracic outlet syn- disturbance of the thoracic upper aperture? 4):823-41. drome. Semin Thorac Cardiovasc Surg. Muscle Nerve. 1995 May. 18(5):526-30. 79. Parziale JR, Akelman E, Weiss C, Green 1996 Apr. 8(2):183-9. Review. 65. Lord JW Jr. Critical reappraisal of diag- A Thoracic Outlet Syndrome. The Ameri- 93. Roos DB. Thoracic Outlet Syndrome is nostic and therapeutic modalities for tho- can Journal of Orthopedics. 2000 May. 33 Underdiagnosed Muscle and nerve. 1999 racic outlet syndromes. Surg Gynecol 80. Perler BA, Mitchell SE. Percutaneous Jan 94: Royder, JO Scalene Entrapment Obstet. 1989 Apr. 168(4):337-40. transluminal angioplasty and transaxillary Syndrome. The MO Journal. Fall 1998.

30/The AAO Journal March 2004 95. Rutherford RB. Primary subclavian-axil- superior thoracic aperture. Acta Biomed changing management over 50 years. Ann lary vein thrombosis: the relative roles of Ateneo Parmense. 1997. 68(5-6):107-13. Surg. 1998 Oct. 228(4):609-17. Review. thrombolysis, percutaneous angioplasty, Italian. 126. Vogel CM, Jensen JE. “Effort” thrombo- stents, and surgery. Semin Vasc Surg. 1998 110. Stallworth JM, Quinn GJ, Aiken AF. Is sis of the subclavian vein in a competi- Jun. 11 (2):91-5. Review. rib resection necessary for relief of tho- tive swimmer. Am J Sports Med. 1985 Jul- 96. Saadi MH. Unilateral cervical rib, with racic outlet syndrome? Ann Surg. 1977 Aug. 13(4):269-72. exostosis of the first rib and pseudoarthro- May. 185(5):581-92. 127. Walker OM, Treasure RL.Coexistent ipsi- sis. Br J Clin Pract. 1966 Feb. 20(2):93. 111. Sucher, BM, Thoracic Outlet Syndrome- lateral subclavian steal and thoracic outlet No abstract available. A myofacial variant: Part I. Pathology and compression syndromes. J Thorac 97. Sanders RJ, Pearce WH. The treatment of Diagnosis Cardiovasc Surg. 1-975 Jun. 69(6):874-5. thoracic outlet syndrome: a comparison 112. Sucher, BM Thoracic Outlet Syndrome – 128. Wenz W, Husfeldt KJ. Thoracic outlet of diflerent operations. J Vasc Surg. 1989 A myofacial variant: Part II. Treatment syndrome – an interdisciplinary topic. Ex- Dec. 10(6):626-34. 113. Sucher BM and Heath, DM. Thoracic perience with diagnosis and therapy in a 98. Sanders RJ, Haug C. Subclavian vein ob- Outlet syndrome, A myofascial variant: 15-year patient cohort (80 transaxillary re- struction and thoracic outlet syndrome: Part 3. Structural and postural consider- sections of the 1st rib in 67 patients) and a a review of etiology and management. ations. JAOA. Vol 93. No 3. March 1993. literature review. Z Orthop Ihre Grenzgeb. Ann Vasc Surg. 1990 Ju1. 4(4):397-410. 114. Suzuki Y, Fujimori S, Sakai M, Ohkawa 1997 Jan-Feb. 135(1):84-90. Review. Review. S, Ueda K. A case of pacemaker lead frac- German. 99. Sanders RJ, Haug CE, Pearce WH. R e - ture associated with thoracic outlet syn- 129. Wessely P, Deutsch M, Samec P. Parox- current thoracic outlet syndrome. J Vasc drome. Pacing Clin Electrophysiol. 1988 ysmal brain stem ischemia in a combina- Surg. 1990 Oct. 12(4):390-8; discussion Mar. 11(3):326-30. tion of thoracic outlet syndrome with con- 398-400. 115. Thomas Gl, Jones TW, Stavney LS, tralateral subclavian steal syndrome. Wien 100. Sanders RJ. Results of the surgical treat- Manhas DR. The middle scalene muscle Klin Wochenschr. 1984 Aug. ment for thoracic outlet syndrome. Semin and its contribution to the thoracic outlet 3;96(15):589-92. German. Thorac Cardiovasc Surg. 1996 Apr. syndrome. Am J Surg. 1983 May. 130. Wilbourn AJ. Thoracic outlet syndrome 8(2):221-8. Review. 145(5):589-92. surgery causing severe brachial 101. Sessions RT. Recurrent thoracic outlet 116. Thompson RW, Schneider PA, Nelken plexopathy. Muscle Nerve. 1988 Jan. 11 syndrome: causes and treatment. South NA, Skioldebrand CG, Stoney RJ. Cir- (1):66-74. Med J. 1982 Dec. 75(12):1453-61. cumferential venolysis and paraclavicular 131. Wilbourn AJ. Thoracic Outlet Syndrome 102. Shalimov M, Driuk NF, Polyshchuk YuE, thoracic outlet decompression for “effort is Overdiagnosed. Muscle Nerve. 1999 Oleynik Ll, Lisajchuk YuS. Pathophysi- thrombosis” of the subclavian vein. J Vasc Jan. ology and selection of method for surgi- Surg. 1992 Nov. 16(5):723-32. 132. Wilhelm A, Wilhelm F. Thoracic outlet cal management of thoracic outlet syn- 117. Toso C, Robert J, Berney T, Pugin F, syndrome and its significance for surgery drome. Int Angiol. 1985 Apr-Jun. Spiliopoulos A. Thoracic outlet syndrome: of the hand. Handchir Mikrochir Plast 4(2):14752. influence of personal history and surgical Chir. 1985 Ju1. 17(4):173-87. German. 103. Shibe JC, Weimann RB. Thoracic outlet technique on long-term results. Eur J 133. Wilhelm A. Stenosis of the subclavian syndrome: resectioning the first rib as a Cardiothorac Surg. 1999 Jul. 16(1):44-7. vein. An unknown cause of resistant re- last resort. Todays OR Nurse. 1989 Aug. 118. Tucker AM. Shoulder pain in a football flex sympathetic dystrophy. Hand Clin. 11(8):8-12. player. Med Sci Sports Exerc. 1994 Mar. 1997 Aug. 13(3):387-411. 104. Short DW. The subclavian artery in 16 26(3):281-4. 134. Wood VE, Biondi J. Double-crush nerve patients with complete cervical ribs. J 119. Tyson RR, Kaplan GF. Modern concepts compression in thoracic-outlet syn- Cardiovasc Surg (Torino). 1975 Mar-Apr. of diagnosis and treatment of the thoracic drome. J Bone Joint Surg Am. 1990 Jan. 16(2):135-41. outlet syndrome. Orthop Clin North Am. 72(1):85-7. 105. Shuttleworth RD, van der Merwe DM, 1975 Apr. 6(2):507-19. Review. 135. Wood VE, Frykman GK. Winging of the Mitchell WL. Subclavian vein stenosis 120. Urschel HC Jr, Razuk MA, Albers JE, scapula as a complication of first rib re- and axillary vein ‘effort thrombosis’. Age Wood RE, Paulson DL. Reoperation for section: a report of six cases. Clin Orthop. and the first rib bypass collateral, throm- recurrent thoracic outlet syndrome. Ann 1980 Jun. (149):160-3. bolytic therapy and first rib resection. S Thorac Surg. 1976 Jan. 21(1):19-25. 136. Wood VE, Twito R, Verska JM. Thoracic Afr Med J. 1987 May 2. 71 (9):564-6. 121. Urschel HC Jr, Razuk MA. The failed outlet syndrome. The results of first rib 106. Siderys H, Walker D, Pittman JN. Anoma- operation for thoracic outlet syndrome: the resection in 100 patients. Orthop Clin lous first rib as a cause of the thoracic difficulty of diagnosis and management. North Am. 1988 Jan. 19(1):131-46. outlet syndrome. JAMA. 1967 Jan 9. Ann Thorac Surg. 1986 Nov. 42(5):523-8 137. Wood VE, Verska JM. The snapping 199(2):133-4. No abstract available. 122. Urschel HC Jr, Razuk MA. 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March 2004 The AAO Journal/31 The Still Technique Applications of a Rediscovered Technique of Andrew Taylor Still, MD July 23-25, 2004 Lewisburg, West Virginia

TESTIMONIALS • For the family practice physician, these are techniques to make your life simple • Not the typical stuff that you learn Richard L. Van Buskirk, DO, PhD, FAAO • Quick and easy techniques for your practice Program Chair and author of The Still Technique Manual: Applications of a Rediscovered Technique of Andrew Taylor Still, MD REGISTRATION FORM The Still Technique The program anticipates being approved for 20 hours of AOA July 23-25, 2004 Category 1-A CME credit pending approval by the AOA CCME. Full Name ______Nickname for Badge ______COURSE DESCRIPTION: LEVEL II Innovative approach using combined (indirect-direct) techniques Street Address ______in the treatment of common clinical somatic dysfunction. ______City ______State ______Zip______PREREQUISITES: Functional Anatomy; One Level I course or equivalent Office phone # ______Fax #: ______LEARNING OBJECTIVES: By releasing your Fax number, you have given the AAO permission to send By the end of this course the attendee will know: marketing information regarding courses via the Fax. • the history of the Still technique, its loss and recovery; E-mail: ______• the underlying method; AOA # ______College/Yr Graduated ______• segmental diagnostic techniques that are shared by this technique with HVLA and muscle energy techniques as ❒ ❒ well as those unique to the Still technique, and I need AAFP credit I require a vegetarian meal • specific applications of the technique to the cervical, (AAO makes every attempt to provide snacks/meals that thoracic, and lumbar spine, ribs, pelvis, extremities, will meet participant’s needs. However, we cannot muscles, and tendons. guarantee to satisfy all requests.)

REGISTRATION RATE PROGRAM TIME TABLE: ON OR BEFORE 6/25/04 AFTER 6/25/04 Friday, July 23 ...... 8:00 am – 5:30 pm AAO Member $550 $650 Saturday, July 24 ...... 8:00 am – 5:30 pm Intern/Resident $450 $550 Sunday, July 25 ...... 8:00 am –12:30 noon AAO Non-Member $755 $855 (Friday & Saturday include (2) 15 minute breaks and a (1) hour lunch; Sunday includes a 30 minute break.) AAO accepts Visa or Mastercard COURSE LOCATION: West Virginia School of Osteopathic Medicine Credit Card # ______400 N. Lee Street, Lewisburg, WV 24901 Cardholder’s Name ______Date of Expiration ______HOTEL ACCOMMODATIONS: located near WVSOM General Lewis Inn: 304/645-2600 Brier Inn: 304/645-7722 Signature ______Days Inn: 304/645-2345 Super 8: 304/647-3188 Budget Host/Fort Savannah: 304/645-3055

32/The AAO Journal March 2004 The Neuroendocrine-Immune Complex Illustrated in the Work of Dr. Frank Chapman John D. Capobianco, DO, FAAO

Abstract itary, which in turns stimulates the ceral” in nature. The most obvious, Chapman’s reflexes represent a release of cortisol from the adrenal outward manifestations of the above classic modality of treatment in os- cortex. Cortisol inhibits the release of are “gangliform contractions” which teopathic medicine. First developed ACTH from the anterior pituitary. can be considered neuro-lymphatic by its namesake, a comprehensive Another demonstration of the bi-di- myofascial expressions of (and op- work delineating the author’s work rectional nature of the NEIC is the portunities for treating) systemic dis- was furthered by his wife, Dr. Ada production of ACTH and CRF from orders. “Neuro” denotes the sympa- Hinckley Chapman, her brother, Dr. immunocytes, which both stimulate thetic arm of the autonomic nervous Charles Owens and Dr. W.F. Link as the adrenal gland and also down- system. “Lymphatic” relates to immu- 7 outlined in An Endocrine Interpreta- regulate the immune response. The nity and it’s submission to unbridled tion of Chapman’s Reflexes (AEICR) principles of the NEIC may support sympathetic impulses. “Myofascial” in 1937. Implicit in the title, this work the scientific basis of Chapman’s re- speaks to the palpable tissue texture includes the “pelvic-thyroid cycle”1, flexes. The work of Dr. Chapman uti- reactions situated mostly in the inter- which later evolved into the “pelvic- lizes the concept of homeostatic costal regions anteriorly and spinal thyroid-adrenal syndrome” (PTAS) mechanisms by uniting physiologic region posteriorly, but may extend and greatly influenced the work of reflexes with one of the most impor- onto the extremities. Recognition and Drs. Beryl Arbuckle2, William tant and accessible organs for the os- knowledge of the endocrine system Gardner Sutherland3, Harold Magoun teopathic physician, the musculosk- were essential to the totality of the Sr.4, Fred Mitchell, Sr. and Jr.5, and eletal system. involuntary mechanisms of the hu- Robert Fulford. Numerous references man body according to Chapman. In will be cited to the endocrine, lym- Key Words the Owens treatise, An Endocrine In- phatic, autonomic and musculoskel- Chapman’s Reflexes, Neuroendo- terpretation of Chapman’s Reflexes etal systems in Chapman’s work. The crine-Immune Complex (NEIC), Pel- (AEICR) there is a strong emphasis relationship of the tripartite theory of vic-Thyroid Cycle, Pelvic -Thyroid- on the importance of the endocrine the pelvic-thyroid-adrenal cycle and Adrenal Syndrome (PTAS), An En- system consisting of the “broad liga- the neuroendocrine immune complex docrine Interpretation of Chapman’s ment, uterus, gonads, thyroid and 8 (NEIC) will be discussed. The NEIC Refiexes, (AEICR). adrenals”. Further, Chapman empha- may be defined as a “bi-directional sizes the correction of “bony lesions”, communication and serves to tie the Background specifically the pelvis (and its accom- panying gonads, the ovaries and tes- neuroendocrine and immune systems Frank Chapman entered the tes) via the innominates. The co-authors into one, very complex, multifunc- American School of Osteopathy in of the Chapman manuscript advised tional network for defense of the ho- 1897. As a student of Andrew Taylor 6 the “fundamental importance of the meostatic processes” . An example of Still, his work was certainly influ- sacroiliac lesion as probably the most a bi-directional mechanism is the enced by the unrecognized potential potent predisposing factor in bodily stress of illness illustrated by the hy- of the lymphatic system. Dr. ills… {and}… cognizance of the pothalamic-pituitary-adrenal (HPA) Chapman expounded upon the work newer knowledge of the endocrine axis. Corticotropin releasing hormone of A.T. Still and developed a schema system…by means of Chapman’s re- (CRH) in the hypothalamus activates for diagnosis and treatment that, in flexes…”9. This tripartite system, adrenal corticotropin releasing hor- hindsight, can be considered more aptly called the “neuroendo- mone (ACTH) in the anterior pitu- “viscerosomatic” and “somatovis- ➻ March 2004 The AAO Journal/33 crine-immune” system, forms the inflammatory substances and increased 2. Treatment of innominate basis of Dr. Frank Chapman’s work. firing of nociceptors. Thirdly, is the dysfunction: To the astute observer, however, one myofascial element. It is through the • Patient in sidelying position would add the musculoskeletal sys- enveloping layers of fascia surround- on uninvolved side. tem as the organ that binds this mass ing the musculature that the nerves, • Operator behind patient. network of the multi-directional in- including autonomics, vessels, includ- • Operator places inferior arm teraction of molecular messengers ing the venules, arterioles and lymphat- between legs. involved in the neuroendocrine im- ics, and immunocytes traverse. • Operator places superior arm mune complex. According to Robert What follows is the treatment se- over PSIS portion of the G. Thorpe, DO, FAAO, “We can give quence for the pelvic-thyroid-adrenal innominate. lungs, blood vessels, heart, liver, in- syndrome (PTAS) that this author has • Derotate pelvis clockwise for testines, glands, and skin to a brain extracted from AEICR and the work a right posterior innominate. in a jar and it will give orders to them of Dr. Arbuckle. It begins with the • Derotate pelvis counterclock- all the result of which would be a diagnosis and treatment of the pelvis, wise for a right anterior jelly-like quivering. The organ the keystone or foundation of the innominate. needed to act and interact with the spine and basis for eventual correc- • The same principle of treat- environment is the musculoskeletal tion of the neuro-endocrine immune ment applies to the left organ, the organ of behavior. With- complex (NEIC). Chapman’s organ innominate. out it, our brain-mind is nothing. With reflexes are diagnosed anteriorly and • [Note the similarity in patient it, our brain-mind is a person”10. In then posteriorly. The anterior reflexes positioning with muscle energy summary, Dr. Frank Chapman had tend to be along or between the ribs, treatment.11] charted a therapeutic modality based following the intercostal sympathetic • Treatment of sacrum may also upon the interconnectedness and po- nerve fibers. The posterior reflex is involve osteopathy in the cra- tential of human physiology and less discrete than the “receptor organ” nial field.12 anatomy. noted anteriorly but more like the rub- bery feel of a classic viscerosomatic 3. The lateral thigh (the tensor Methods reflex, which is 1ocated between the fascia lata and the iliotibial Chapman’s reflexes are manifested spinous and transverse processes of band): by gangliform contractions, which may two vertebrae respectively. The gangli- • Reflects one somatosomatic and best be defined as hypercongestions form reflexes are treated anteriorly with three viscerosomatic reflexes within fascia due to lymph stasis sec- a rotatory or circular motion lasting • Sciatic nerve (“sciatica”). ondary to visceral dysfunction. This anywhere from 5 to 120 seconds. The This is a somatosomatic reflex. represents a viscerosomatic reflex. In therapeutic end point is a softening of • Broad ligament. An Endocrine Interpretation of the gangliform contraction. If a poste- • Prostate. Chapman’s Reflexes this somatic dys- rior reflex persists, further treatment is • Large intestine. function has been described as feel- warranted. It is of interest to note that ing like a nodule ranging in size from contrary to the original text, AEICR, Note: The lower gastrointestinal a “BB” pellet to a pea that is inner- the more recent teaching of Chapman’s and pelvic organs and the lower ex- vated and mediated by the sympa- reflexes rely almost exclusively on the tremities share the same sympathetic thetic nerve fibers. There are three anterior ribs and spinal region for di- innervation, derived from the cell components to a “receptor organ” or agnosis and treatment respectively. bodies of the twelfth thoracic to sec- Chapman’s gangliform contraction. What follows is a schematic for treat- ond lumbar spinal regions. The one The first is neurological represented ing the PTA axis: that is pertinent to Chapman’s pelvic- by a reflex mediated by sympathetic thyroid syndrome are the broad liga- fibers. The lymphatic capillary and 1. Diagnosis and treatment ment and uterine reflexes. valves are innervated by the of the pelvis: sympathetics. Sympatheticotonia • Patient supine, operator at side. • Anteriorly, the reflex for the may lead to constriction of the lym- • Operator places pads of fingers broad ligament can be found from phatic vessel. Second is lymphatic as on Poupart’s (inguinal) ligament. below the greater trochanter on demonstrated by congestion due to • The side that is more tense is the the lateral thigh to slightly above sympatheticotonia, which leads to tis- side of innominate dysfunction. the knee ioint. Posteriorly, the sue stasis and accumulation of pro- • The operator may compare reflex can be found along the ili- with standing flexion test. olumbar ligament. 34/The AAO Journal March 2004 4. The Uterus: terone function) and their influence the basic sciences and our patients. • Anteriorly, at the junction of the on the thyroid and adrenal glands. As pubic ramus and the ischium. far as this author can determine, it was Research Posteriorly, along the iliolum- Dr. Beryl Arbuckle who added the Chapman’s reflexes and their clini- bar ligament. word “adrenal” in the pelvic-thyroid- cal application to the NEIC have been adrenal syndrome. As was stated ear- used extensively by those in the os- 5. The Pelvic (ovary-testes) - lier, Chapman and certainly his inter- teopathic profession. Scientific re- Thyroid-Adrenal Syndrome: preters understood the importance of search in the field of Chapman’s re- Specific points the adrenal gland as both a humoral flexes has not been conducted as thor- • Thyroid: Anteriorly, at the sec- and immune modulator. In her article oughly. Although the actual receptor ond intercostal space. Posteri- entitled “Reflexes,” which appeared organ has not been demonstrated his- orly, between the spinous and in the Academy of Applied Osteopa- tologically, an important study of the transverse process of T2. thy Yearbook (1947), Dr. Beryl use of Chapman’s reflexes as they • Adrenal: Anteriorly, about 2.5" Arbuckle cites the anatomic proxim- relate to the neuroendocrine arm of above & 1" lateral to umbilicus. ity of the hypogastric and aortic the NEIC has been described by This is in the region of the su- plexus (not to mention the ganglion Mannino. This study is highlighted in perior mesenteric ganglion. impar, which terminates to the far the Drs. Kuchera textbook, Osteo- Posteriorly, between the spinous reaches of the coccyx) and thora- pathic Considerations in Systemic and transverse processes of T11 columbar sympathetic outflow tracts Dysfunction.19 In his study, Mannino and T12. to endocrine organs and further to the treated the posterior adrenal 16 • Ovary/Testes: Anteriorly, on the higher centers of the pituitary. This Chapman’s reflexes (between the upper to lower border of pubes. makes for a complex and not com- eleventh and twelfth thoracic verte- Posteriorly, between the spinous pletely understood interaction of the brae) in 45 males, 24-32 years of age, and transverse processes of T9 neuroendocrine-immune system. For for 2 minutes with rotatory stimula- and T10. example, thyrotropin and thyroxin tion. The results were a statistically stimulates natural killer cells and pro- significant decrease of serum aldos- 17 The PTAS: An duces T-cells respectively. Stress, terone within 36 hours.20 Interest- Introduction to or the musculoskeletal ready state, is ingly, Mannino notes that there was mediated by the sympathetic nervous Chapman’s Concept no osteopathic correction of the pel- system and promotes the release of vis, a necessity according to the of the NEIC cortisol from the adrenal glands, AEICR. The neurological component 18 The coauthors of AEICR state that which also modulate immunocytes. of this treatment addressed the “posi- Chapman presented his work on the Although a half a century older, the tive feedback” of catecholamine re- endocrine system as early as 1927.13 concept of the pelvic-thyroid-adrenal lease from the adrenal medulla, which Perhaps the earliest recognition of the system goes beyond newer, more cur- is anatomically indistinct to a sym- neuroendocrine-immune connection rent notions of the neuroendocrine- pathetic ganglion. The aspect that was modeled after his pelvic-thyroid immune system by addressing the addresses the endocrine system is the cycle. These systems, the endocrine great interface between man’s exter- lowering of serum aldosterone. A and the musculoskeletal, served as “a nal (i.e., stress and a subsequent al- component of the renin-angiotensin- positive entity not hitherto described tering of adrenal function) and inter- aldosterone axis, which is vital for in either medical or osteopathic lit- nal (i.e., metabolism or thyroid func- blood salt retention and vasoconstric- erature, so far as the writer is tion) environment. The musculoskel- tion, it is a marker of generalized vas- aware.”14 Indeed, Chapman recog- etal organs role is expressed by the cular tone for blood pressure. Al- nized a link of the endocrine and im- importance of treating the pelvic (the though this would seem to comprise mune functions early on when de- innominate and sacrum) region. Dr. only two-thirds of the NEIC, upon scribing the thyroid gland bearing an Chapman closely followed the prin- further examination, an immune re- “important relation to the immunity ciples taught by his teacher, Dr. A.T. sponse may be postulated because of the body to disease infections.”15 Still, because they bridged the gap aldosterone is a steroid messenger The pelvic-thyroid syndrome ad- between altered physiology and struc- molecule, like cortisol, that sup- dresses the interrelationships of the ture. It involves not only the latter presses T-cell colony formation in structure of the pelvis (which houses element, but also the union of this contrast to other agents such as brady- the testes and ovaries and the result- anatomy with related function that is kinin, glucagon and luteinizing hor- ant testosterone, estrogen and proges- one of osteopathy’s greatest gifts to ➻ March 2004 The AAO Journal/35 mone.21 The immune system not only nodes.27 The lymphatics are inner- With all this mention of the auto- is influenced but also effects aldos- vated by sympathetic fibers that serve nomic nervous system one may ask: terone as evidenced by its increase in to constrict lymphatic vessels. Ini- What about the parasympathetics? response to histamine that is secreted tially, the effect is to propel the lym- Drs. Kuchera state that there is no by basophils and mononuclear (mast) phatic fluid containing antigens meaningful parasympathetic innerva- cells.22 It should be noted that hista- proximally into the central circulation tions to the thyroid, adrenal or go- mine is a potent vasodilator, creating for eventual excretion. Excess sym- nads. Why? One might speculate that edema during the inflammatory re- pathetic stimulation, however, can the primitive endocrine substances not sponse. The hypothesis that using lead to lymphatic stasis and a gener- only behaved dually as intracellular Chapman’s reflex manipulative treat- alized decrease in the immune re- mediator molecules that controlled the ment to decrease serum aldosterone sponse. Furthermore, the effects of internal milieu, but also acted as a sym- in order to improve the immune func- the adrenergic nervous system perme- pathetic, protective mechanism from tion seems to be supported by scien- ates the cells of all the organs in the external stimuli. Thusly, “the endocrine tific research. Numerous references body. According to Dr. Still in his and vegetative nervous systems be- to enhanced immunity from osteo- autobiography: “To know all of a came supplementary to each other.”34 pathic treatment can be found in bone in its entirety would close both From Pottenger’s quote, one may hy- DiGiovanna and Schiowitz’s (Eds.) ends of eternity.”28 Sympathetic acti- pothesize that the survival of an An Osteopathic Approach to Diagno- vation of the bone increases prolif- amoeba may be dependent upon this sis and Treatment23 and various jour- eration of immunocytes.29 Dr. primitive sympathetic-endocrine sys- nal articles.24,25 It is the osteopathic Chapman saw the body’s largest im- tem. However, the added calming ef- physician’s role to complete the ba- mune organ, the spleen, as second fect of the parasympathetic system is sic scientific research-clinical out- only to the thyroid when it came to necessary for the Homo Sapiens to comes circuit and publish more sci- immunity. Sympathetic tone to the pause, conceptualize during that pause, entific and case studies on Chapman’s spleen encourages arteriolar constric- and evolve. reflexes. In the “Osteopathic Treat- tion and release of blood and ment of Nephrotic Syndrome,” use of immunocytes into the general circu- Endocrine: Chapman’s reflex points in the tho- lation.30 The thymus produces T-cells, For the purposes of this paper, we racolumbar region were part of an the cell mediated response. Activation have sufficiently covered the HPA overall manipulative protocol in a of sympathetic firing from the cervical axis. In the acute stage, it serves to young African American female with and upper thoracic regions may in- contain inflammation. During long- IgA nephropathy that was refractory crease thymocyte cell differentiation.31 term situations, such as chronic ill- to the standard pharmocological Thymosins can limit interleukins via a ness, it will maintain this “flight or agents. The outcome of this case feedback cycle to the HPA axis. Like- fight” response, perpetuating the study resulted in the patient having a wise, thymosin output is influenced by autonomia and resultant immunosup- substantial diuresis and decrease in a thyroid hormone.32 This would serve pression. It is time to focus on a few generalized edema, thusly avoiding to highlight one more aspect of the role other key endocrine organs that are the use of cytotoxic drugs.26 of the thyroid in immunity. The med- emphasized as important in the ullary portion of the adrenal should be AEICR. Firstly, the thyroid gland that The NEIC- noted for its capacity to secrete epi- serves to produce thyroxine, is a po- A Specific Analysis nephrine and norepinephrine inde- tent immuno-modulator that stimu- pendent of sympathetic stimulation. lates lymphocyte function and natu- of a Tripartite System Catecholamines affect every cell in ral killer cells, augments immunoglo- Neurological: the body. Sympathetic fibers, how- bulin synthesis, stimulates the thymus The sympathetic response to stress, ever, do not innervate all the cells of gland and plays an important role in perceived or real, stimulates the hy- the body. The messenger molecules nerve conduction.35 Thymosin from pothalamus, which activates the HPA that are produced by the adrenal me- the thymus gland facilitates the func- axis and may ultimately suppress the dulla last 5-10 times longer than the tion of the thyroid hormones.36 This function of immunocytes if the ini- autonomic activation of sympathetic extra-cranial master gland, itself un- tial response is allowed to continue. neurons.33 It is a testament to der control from the hypothalamus Cortisol, a circulating byproduct of Chapman that he not only recognized and pituitary via the hypothalamic- stress, not only will decrease the func- function of adrenal gland as part of pituitary-thyroid (HPT) axis, influ- tion of the body’s immune cells but the nervous system but also included ences other bodily humors, immune may also cause atrophy of lymphatic it in the overall treatment protocol. and nerve cells, which serve to sup- 36/The AAO Journal March 2004 port Chapman’s statement that the response that begins to complete the throat, aphonia, productive cough, thyroid was an immune gland. NEIC triad. discharge from the corners of the eyes The sex hormones, in particular for which she is “taking some drops,” estrogen and testosterone, are se- Musculoskeletal: and malaise. Her history was signifi- creted from the gonads and are not (Completing the Quadra) cant for a borderline high thyroid coincidently, housed in the bony pel- As stated earlier, messenger mol- stimulating hormone (TSH) at 5.0 vis. Testosterone is also secreted from ecules bouncing around in test tubes MCIU (normal = .4-4.0) She denied the zona reticularis of the adrenal are not the same as those interacting fever or chills or loss of appetite. She gland. Both the pelvis (and its steroid in the dynamic milieu of a patient. Dr. is G3P3, denied gynecological sur- contents) and the adrenals are impor- Chapman and his interpreters empha- gery and was taking no other medi- tant in the overall schema of sized the role of the pelvis, not only cations. Her vitals were: temperature Chapman’s pelvic (adrenal) thyroid as Arbuckle demonstrated via the at 98.1°F; blood pressure-110/72; res- cycle. For example, estrogen aug- ganglion impar’s connection to the pirations-12; pulse-82. The patient ments the function of immunocytes.37 higher centers of the brain and organs, appeared toxic and pale. Laboratory Estrogen receptors have been found but also realizing that the pelvis findings were significant for hemo- on the human thymus gland and es- houses the gonads, which produce globin of 11.6. Pulse oximeter on trogen can suppress glucocorticoids, active immune substances. Dr. Still room air was 98%. Rapid enzyme test all of which may serve to explain why saw the function of the pelvis not only for streptococcus was negative. Ex- females may have a higher prevalence in terms of endocrinology but also the amination revealed reddened anterior of autoimmune disorders.38 Testoster- connection of the coccyx to what is pharyngeal pillars, but no exudates in one affects the immune system by presumably the terminus of the sym- either the throat or eyes. No lymph checking the production of interleukin pathetic nervous system, the ganglion nodes or thyroid nodules were pal- 6 in monocytes and has been used to impar. He postulated the outcome if pated. The heart rate and rhythm were suppress excess B-cell activity in the someone fell onto his/her buttocks: regular without any murmurs. Lungs blood samples of patients with systemic “The wedge-formed sacrum between were clear to auscultation and percus- lupus erythematosus.39 the two innominate bones would be sion. The abdomen was soft, non-ten- driven downward toward the ischii der with bowel sounds noted in all Immune: one-fourth, one-half, or one whole quadrants. Rectal examination re- The cells of the immune system inch. What effect would it have on vealed hardened feces but was with- secrete neuroendocrine substances. the shape of the coccyx, the coccygeal out masses, fissures, or hemorrhoids. Lymphocytes produce thyrotropin ligaments being fastened to the in- Guaiac for occult blood was negative. (TSH),40 in addition to CRF and nominate? Would it not leave the coc- Osteopathic findings revealed a hy- ACTH. Interleukins behave as cyx bent in and upward? What effect oid shifted to the left. Gangliform growth factors for thymosin.41 The would it have on the sacral nerves? contractions were palpated on the sec- lymphatic structures that house the The whole glandular system?” ond intercostal space, the left being cells and substances of immunity are [author’s emphasis]44 A.T. Still’s more prominent and more lateral, themselves innervated by sympa- teachings serve as the intellectual extending to the upper border of the thetic nerve fibers. Dr. Still admon- basis for Dr. Chapman’s pelvic-thy- second rib. The soft tissue overlying ished that: “Finer nerves dwell with roid cycle; the NEIC interlocked to the transverse processes of the sec- the lymphatics than even with the the musculoskeletal organ. ond and third thoracic vertebrae were eye.”42 A study by Dowling43 showed noted to have a “rubbery” feel. A an increase in lymphocytes in the Case Study mildly tender gangliform contraction was noted in the left periumbilical blood of subjects treated with osteo- The purpose of the following case region, about two inches superiorly pathic manipulation within one hour study is to demonstrate the usefulness and laterally to the rectus abdominus as compared to controls. Whether by of Chapman’s reflexes in everyday muscle. The right innominate was ro- gross mechanical stimulation of the clinical practice in a patient who pre- tated anteriorly on the right with a cor- lymphatic vessels or reflex treatment sented with an acute illness, subclini- responding right sacroiliac joint restric- to turn down sympathetic facilitation cal hypothyroidism and somatic find- tion. The assessment follows: in order to increase flow capacity of ings consistant with an altered neu- the lymphatic fluids, it is this libera- roendocrine-immune complex. One: Upper respiratory tract infec- tion of the immune cells via lym- A 57-year-old white female pre- tion, with laryngitis probably second- phatic pump and Chapman’s reflexes, sented with a 4-day history of sore which normalizes the inflammatory ➻ March 2004 The AAO Journal/37 ary to a adenovirus. tential “neurologic lens,”45 not only a recognition of the role of the endo- Two: Acute anemia, probably sec- relay station, but a processor, amplifier, crine system as a companion to the ondary to viremia. and transmitter of neuronal dishar- neurological reflexes, lymphatics and Three: Cough, secondary to pos- mony, creating a lowered threshold for the musculoskeletal system. Although terior pharyugeal drip and upper res- synaptic firing. The goal of the treat- the term “pelvic-thyroid cycle” was piratory infection. ment was to decrease arteriolar, venous expanded to include the adrenal glands, Four: Somatic dysfunction of the and lymphatic endothelial constriction the principle of reflex treatment out- cranial (hyoid), rib, thoracic, abdo- in the affected organs, in this instance lined in AEICR has been part of the men, and pelvic regions. the thyroid, adrenal and oropharyn- osteopathic profession for the better geal organs, which as was discussed, part of our heritage. Viscerosomatic and The treatment plan included direct can enhance immunocytes if stimu- somatovisceral reflexes have been en- myofascial release to the hyoid, trachea lated (the thyroid) or immunosup- coded in the primate genome for mil- and anterior cervical fascia. Chapman’s press lymphocytes if chronically over lions of years. Hopefully, the work of reflexes were treated by a rotatory stimulated (the adrenal cortex). More, Dr. Frank Chapman will be more fully motion in the second intercostal space, the tonsils and adenoids produce B- understood through research and left second rib area and the left peri- cells and act as the first immune gland shared case studies. Chapman’s umbilical region. Scapular lift and a that foreign organisms encounter as model of the pelvic-thyroid cycle, rotatory motion were given to the up- they enter the mouth. The anterior which in name only has been changed per thoracic segmental dysfunctions. cervical fascia is key for lymphatic to the neuroendocrine-immune com- Muscle energy and sacroiliac joint gap- drainage from the oropharynx. The plex has benefited osteopathic patients ping were performed on the innomi- correction of the pelvis, which in- for nearly three quarters of a century. nate and sacrum. Followup occurred in cludes the innominates and sacrum, The purpose of this paper was to re- 48 hours at which time the patient’s cannot be overemphasized due to its introduce Chapman’s work and temperature had returned to her proximity to the ganglion impar and present relevant scientific informa- baseline of 96.7°F, and her hemoglo- the organs of reproduction which pro- tion so reflex treatment and the mus- bin had risen to 12.4. She did not ap- duce steroid sex hormones, them- culoskeletal neuroendocrine-immune pear to have her previous pallor. This selves immuno-modulators. In this in- model will continue to expand be- author’s experience is that patients who stance, the patient with a history of a yond the curricula to be applied to the are hypothyroid do not mount a detect- borderline endocrinopathy presented practice of osteopathy. able temperature spike in the begin- with an acute infectious process and nings of an illness and this may explain anemia. The treatment sought to References: why this patient did not have even a maximize the homeostatic mecha- 1. Owens, C. An Endocrine Interpretation low-grade temperature increase upon nisms of the neuroendocrine-immune of Chapman’s Reflexes, 2nd Ed. Chatta- presentation. A marked decrease in the system with osteopathic manipulative nooga, TN. Chattanooga Printing and pharyngeal erythema along with nor- treatment. The clinical outcome was Engraving Co. 1937:19. 2. Arbuckle, BE. Reflexes, The Selected mal and clear thoracic organ sounds favorable, rapid, cost effective, and Writings of Bervl E. Arbuckle, DO. were recorded. The patient reported without adverse side effects. FACOP. Revised Edition. Published by feeling better and regaining her speech American Academy of Osteopathy. In- the night of the treatment. The patient dianapolis, IN. 1994:25. Conclusion 3. Sutherland, WG. In Wales, AL, Ed. reported only minimal cough and no The concept of the neuroendo- Teachings in the Science of Osteopathy. sore throat, and some left upper back crine-immune complex interfacing The Sutherland Cranial Teaching Foun- pain, which was of a longstanding na- with the musculoskeletal system was dation. Rudra Press. 1990:136. 4. Magoun, HI. Practical Osteopathic Pro- ture. She returned to work the next day at the very least developed by Dr. and resumed her exercise program in cedures. The Journal Printing Co. Kirks- Frank Chapman over 70 years ago ville, MO. 1978:29. 48 hours. with the concept of the pelvic-thyroid 5. Owens, C. An Endocrine Interpretation The osteopathic approach to this cycle. His ideas followed closely to of Chapman’s Reflexes. Second Edition. patient included the pelvic-thyroid- those of osteopathy’s founder, Dr. Chattanooga, TN. Chattanooga Printing adrenal connection that was used by and Engraving Co. l937:Foreward. A.T. Still, who was quite specific re- 6. Willard, FH. In Willard, FH, Patterson, Chapman and those who were influ- garding the neurological and endo- MM, Eds., Nociception and the Neu- enced by him. The author sought to de- crine (“glandular”) connection to the roendocrine Immune Connection. 1992. facilitate the sympathetic input from the innominates and sacrum. The genius International Symposium. American Academy of Osteopathy. 1994. xvi. intercostal nerves back to the spine. of the work of Dr. Chapman is the Korr described the spinal cord as a po- 7. Willard, FH, Mokler, DJ, Morgane, PJ. 38/The AAO Journal March 2004

➻ Neuroendocrine-Immune System and Raven. Philadelphia, PA. 1997:260. September 1997. 40:9:1703-11. Homeostasis. In Ward, RC. Ed. Foun- 24. Rumney, IC. Osteopathic Manipulative 40. Willard, FH, Mokler, DJ, Morgane, PJ. dations for Osteopathic Medicine. Will- Treatment of Infectious Diseases. In Stark Neuroendocrine-Immune System and iams and Wilkins. Baltimore. 1997:123. EH, Ed. Clinical Review Series in Osteo- Homeostasis. In Ward, RC. Ed., Founda- 8. Owens, C. An Endocrine Interpretation pathic Medicine. Publishing Sciences tions for Osteopathic Medicine. Williams of Chapman’s Reflexes. Second Edition. Group, Inc., Acton, MA. 1975:165-170. and Wilkins. Baltimore, MD. 1997:124. Chattanooga, TN. Chattanooga Printing 25. Thorpe, RG. Osteopathic Manipulative 41. Ibid:112. and Engraving Co. 1937:Foreward. Therapy for Infections. Osteopathic An- 42. Still, AT. The Philosophy and Mechani- 9. Ibid:41. nals. Insight Publishing Co., Inc. cal Principles of Osteopathy. Kansas 10. Thorpe, RG. Psychodynamics of Stress 1980:30:253. City, 1902. Reprinted. Kirksville, MO. and Relationships with the Musculosk- 26. Rivera-Martinez, S, Capobianco, JD. Os- Osteopathic Enterprises. 1986:66. eletal System, Osteopathic Annals. In- teopathic Treatment of Nephrotic Syn- 43. Dowling, DJ. Evaluation of the Thorax. sight Publishing Co., Inc. 1973:5. drome. The American Academy of Oste- In DiGiovanna and Schiowitz, Eds., Os- 11. Mitchell, Jr. FL, Moran, PS, Pruzzo, NA. opathy Journal. Fall:2001:24-28. teopathic Approach to Diagnosis and An Evaluation and Treatment Manual of 27. Thorpe, RG. Osteopathic Manipulative Treatment. Second Edition. Lippincott- Osteopathic Muscle Energy Procedures. Therapy for Infections. Osteopathic An- Raven. Philadelphia, PA. 1997:260. Valley Park, MO. Mitchell, Moran and nals. Insight Publishing Co., Inc. 44. Still, AT. The Philosophy and Mechani- Pruzzo. 1979:371. 1980:30:253. cal Principles of Osteopathy. Kansas 12. Mitchell, Jr. FL. The Influence of 28. Still, AT. Autobiography of Andrew T. City, 1902. Reprinted, Kirksville, MO. Chapman’s Reflexes and the Immune Still. Kirksville, MO. 1908:179. Osteopathic Enterprises, 1986:123. Reactions. In Stark, EH, Ed. Clinical Re- 29. Willard, FH, Mokler, DJ, Morgane, PJ. 45. Kuchera, WA, Kuchera, ML. Osteo- view Series in Osteopathic Medicine. Neuroendocrine-Immune System and pathic Principles in Practice. Revised Publishing Sciences Group, Inc., Acton, Homeostasis. In Ward, RC. Ed., Foun- Second Edition. Greyden Press, Colum- MA. 1975:181. dations for Osteopathic Medicine. Will- bus, OH. 1994:34. 13. Owen, C. An Endocrine Interpretation iams and Wilkins. Baltimore, 1997:120. of Chapman’s Reflexes. Second Edition. 30. Dowling, DJ. The Lymphatic System. In Chattanooga, TN. Chattanooga Printing DiGiovanna and Schiowitz Eds., An Os- Acknowledgements and Engraving Co. 1937:10. teopathic Approach to Diagnosis and Dennis Dowling, DO, FAAO, Sonia 14. Ibid:4. Treatment, Second Edition. Lippincott- Rivera-Martinez, MSIV, & Fred 15. Ibid:14. Raven. Philadelphia, PA. 1997:258. Mitchell, Jr. DO, FAAO 16. Arbuckle, BE. Reflexes, The Selected 31. Willard, FH, Mokler, DJ, Morgane, PJ. Writings of Beryl E. Arbuckle. DO, Neuroendocrine-Immune System and FACOP. Revised Edition. Published by Homeostasis. In Ward, RC. Ed., Foun- Addendum: American Academy of Osteopathy. In- dations for Osteopathic Medicine. Will- A Teaching Model for a dianapolis, IN. 1994:25. iams and Wilkins. Baltimore, MD. 17. Willard, FH, Mokler, DJ, Morgane, PJ. 1997:119-120. Regional Approach to Neuroendocrine-Immune System and 32. Ibid:116. Chapman’s reflexes. Homeostasis. In Ward, RC. Ed., Foun- 33. Guyton, AC. Textbook of Medical Physi- dations for Osteopathic Medicine. Will- ology. Eighth Edition. WB Saunders Co. This section is based upon my per- iams and Wilkins. Baltimore, MD. Philadelphia, PA. 1991:673-674. sonal observations as an osteopathic l997:123. 34. Pottenger, FM. Symptoms of Visceral educator over the last ten years. 18. Ibid:122. Disease. Sixth Edition. CV Mosby Co. Call it a mixed blessing of sorts, 19. Kuchera, ML, Kuchera, WA. Osteo- St. Louis, MO. 1944:412. pathic Considerations in Systemic Dys- 35. Sherwood L. Human Physiology. Third but it is a reality that our osteopathic function. Revised Second Edition. Co- Edition. Belmont, CA. Wadsworth Pub- students are facing an ever increas- lumbus, OH. Greyden Press. 1994:65. lishing Co. 1998:658. ing explosion of technological data. 20. Mannino, JR. The Application of Neu- 36. Willard, FH, Mokler, DJ, Morgane, PJ. Further, they are also presented with rologic Reflexes to the Treatment of Neuroendocrine-Immune System and Hypertension. Journal of the American Homeostasis. In Ward, RC. Ed., Founda- many manipulative modalities that Osteopathic Association. December, tions for Osteopathic Medicine. Williams involve rote memorization of specific 1979. 79:228-150. and Wilkins. Baltimore, MD. 1997:116. “points” and positions for treatment. 21. Eckels, DD, Gershwin, ME. Pharmaco- 37. Reichlin, S. Neuroendrinology. In Wil- Our osteopathic forebearer’s taught logic and biochemical modulation of son, JD, Foster, DW. Eds., Williams Text- perhaps more principle than tech- humanT-lymphocyte colony formation: book of Endocrinology. WB Saunders hormonal influences. Immunopharma- Co. Philadelphia, PA. 1992:232. nique; students were expected to uti- cology. September, l981:3(3):259-74. 38. Willard, FH, In Willard, FH, Patterson, lize theory to formulate a plan of 22. Aikawa, T., Hirose, T., Matsumoto, I., MM, Ed., Nociception and the Neu- treatment. However, we expect from Suzuki, T. Direct stimulatory effect of roendocrine Immune Connection. 1992. our students a level of recall that may histamine onaldosterone secretion of the International Symposium, American perfused dog adrenal gland. Jpn J Academy of Osteopathy, 1994:303. not necessarily translate into future Physiol. 1981:31:4:457-63. 39. Kanda, N, Tsuchida, T, Tamaki, K. Tes- osteopathic expertise and may actu- 23. Dowling, DJ. Evaluation of the Thorax. tosterone suppresses anti-DNA antibody ally discourage many of our students In DiGiovanna and Schiowitz Eds. Os- production in peripheral blood mono- from the concept that osteopathy is a teopathic Approach to Diagnosis and nuclear cells from patients with systemic Treatment. Second Edition. Lippincott- lupuserythematosus. Arthritis Rheum. ➻ March 2004 The AAO Journal/39 philosophy of medicine. The purpose ditions will precede each system. It post-traumatic stress disorder: of this addendum is to provide a sim- is easier to recall a specific Chapman Anteriorly: For brain and fatigue, plified format for the nearly one hun- reflex point if the student is provided upper anterior chest along the pecto- dred Chapman’s reflex points’ It is with a clinical correlation for that ralis major muscle and upper 4 ribs based upon the fact that individual particular dysfunction. and the corocoid process. For neural- structures within each system share HEENT: Conjunctivitis, otitis, gia of the upper extremities, third and common sympathetic nervous inner- pharyngitis, laryngitis, tonsillitis, hay fourth ribs and intercostal spaces. For vation. For example, the facial si- fever and sinusitis: torticollis reflex points are found nuses are similar in histology and Anteriorly: Clavicle to second rib. along the superior-medial portion of sympathetic flow as the pharynx, Posteriorly: Suboccipital muscu- the humerus. In this instance, too, the mastoid air cells, nasopharynx, con- lature, intertransverse spaces of C1 shared sympathetic innervation of the junctiva and the like. The Chapman and C2. cervical and upper extremity regions points for these structures are located CHEST: Asthma, bronchitis, dictates the treatment points, theory from the clavicle to second rib ante- pneumonia, and the myocardium, leads the way to treatment. For sci- riorly and the upper cervical spine particularly myocarditis: atica or lumbosacral disk disease posteriorly, each specific gangliform Anteriorly: Second through fourth points are found on the lateral thigh. contraction being not more than cen- ribs and intercostal spaces. Posteriorly: For brain and fatigue, timeters from one another. The im- Posteriorly: Between the spinous intertransverse space of C1 and C2 plication being that treatment for any and transverse processes of T2-5. and subscapular region. For neural- given substructure within a system, UGI: Esophagitis, gastritis, py- gia of the upper extremities, along the in this instance the “HEENT” region, loric stenosis, inflammatory or transverse processes of T2. As per our can be more generalized by assess- imiable bowel disease, hepatitis, gall analysis of the upper extremities, ing a given area and thus easier to bladder and splenic disease and pan- lower limb neuralgia can be assessed learn due to the common origin of the creatitis/diabetes: and treated between the spinous and sympathetic cell bodies. The cell bod- Anteriorly: Second through eleventh transverse processes of T11-L2, the ies for the sympathetics of the head, ribs and intercostal spaces and sternum. origin of their sympathetic cell bod- ears, eyes, neck and throat system are Posteriorly: Between the spinous ies. For torticollis, along the trans- found in the T1-4 area but they trans- and transverse processes of T2-12. verse processes of the middle to lower mit fibers into the superior cervical LGI/GU: Appendicitis, diverticu- cervical spines. For sciatica or lum- ganglion (approximately C2—which litis, constipation, hemorrhoids, pros- bosacral disk disease points are found may be the reason for viscerosomatic tatitis, urethritis, renal disease and along the iliosacral joint. changes located in the upper cervical stones, cystitis, vaginismus, inflam- Summary: Diagnosis and treat- spine—a region traditionally reserved mation of the fallopian tube and semi- ment using Chapman’s reflex treat- for parasympathetic findings) and an- nal vesicles, and uterine fibroma: ment for disorders of the head and teriorly along the intercostal nerves. For Anteriorly: Periumbilical, pubes, neck, chest, upper or lower gas- any given HEENT problem, then, the ischium, and lateral thigh (from im- trointestinal, genitourinary or neuro- curricula should emphasize diagnosis mediately below the greater tro- logic system can be readily learned and treatment of the upper rib and cer- chanter to above the knee). by understanding the unchanging vical regions. The following represents Posteriorly: Between the spinous laws of human anatomy and physiol- a schematic for the following systems: and transverse processes of Tl2 to L2, ogy, specifically the sympathetic arm head, ears, eyes, neck and throat, including the paralumbar muscula- of the autonomic nervous system. (HEENT), heart and lungs, (Chest), ture and the iliolumbar ligament and Clinical correlations may facilitate the upper gastrointestinal (UGI), lower sacroiliac joints. remainder of the educational process.❒ gastrointestinal and genitourinary NEURO: Neuritis of the upper (LGI/GU) and neurological extremity (the more modern correlate (NEURO). A discussion of the endo- may include “carpal tunnel syn- Address correspondence to: crine reflex points can be found in the drome” or reflex sympathetic dystro- John D. Capobianco, DO, FAAO 6 Circle Way above thesis, “The Neuroendocrine phy), torticollis, sciatica, disorders of Sea Cliff, NY 11579 Immune Complex Illustrated in the the “cerebrum and cerebellum” (such Work of Dr. Frank Chapman”. As put as a stroke, memory loss or disequilib- forth in the text: An Endocrine Inter- rium) and “neuroasthenia” which is an pretation of Chapman’s Reflexes a antiquated term for what may be con- partial list of common clinical con- sidered “chronic fatigue syndrome” or 40/The AAO Journal March 2004 Book Review Reviewer: Anthony G. Chila, DO, FAAO

A FULFORD TRILOGY DR. FULFORD’S TOUCH of LIFE Robert C. Fulford, DO with Gene Stone Pocket Books, 1996; 193 pages; $20.00 (US), $27.00 (CAN)

ROBERT FULFORD, DO AND THE PHILOSOPHER PHYSICIAN Zachary Comeaux, DO, FAAO Eastland Press, Inc.; Seattle, WA, 2002; 204 pages, including Bibliography and Index; $24.95

ARE WE ON THE PATH? The Collected Works of Robert C. Fulford, DO, FCA The Cranial Academy, Inc.; Indianapolis, IN; 2003; 294 pages; $24.95

Doctor Fulford’s Touch of Life was a sensation when released in 1996. Dedicated to Fulford’s wife, Glenna, and written with Gene Stone, emphasis was given to the healing power of the natural life force. The introduction was written by Andrew Weil, MD, author of the landmark bestseller Spontaneous Healing. Among Weil’s comments about Fulford’s work:

“In this book readers will not only learn the personal history of a remarkable healer, they will also discover many practical secrets of health and vitality, from the importance of proper breathing to the value of simple stretching as a superior tonic for nerves and muscles. Now in his nineties, Bob Fulford embodies and exemplifies his own wisdom about health and healing. He has led a remarkably vigorous life and had a remarkably productive old age, with little need for medical interventions....His emphasis on vital energy and the healing power of nature-concepts that animated medical inquiry from the time of Hippocrates through the last century-is completely missing from medical education today....If medicine is to come back into alignment with the great healing traditions and satisfy the needs and desires of those who are sick, it must rediscover the truths that Bob Fulford expresses in these pages.”

Five years after Fulford’s passing in 1997, Robert Fulford, DO and the Philosopher Physician appeared. This volume offers the perspective of a colleague who cared for Fulford’s wife during the last years of her life. This led to an ongoing relationship with Doctor Fulford in which visits to the author’s office (Comeaux) were characterized by the asking of the question “Well, what are you thinking about this week?” The sharing of mutual treatments or collabora- tive work on Comeaux’s patients were also part of this experience. Comeaux’s purpose in writing indicates that: “In preparing this book, I have tried to strike a balance between presenting the material as it was taught by Dr. Fulford, and elaborating upon it, based on his source materials themselves.

This book includes practical applications of techniques, and attention to an expanded sense of palpatory awareness and its use in treatment. Fulford’s way of expressing all of this was not as abstract as mine. He was a very practical man; his thoughts were organized in a dissociated, eclectic, Zen-like manner. By contrast, I have tried to express the expansive worldview that he brought to the osteopathic treatment table in a more linear fashion. Some redundancy in the text will hopefully serve to reinforce the concentric nature of Fulford’s thought in practice, emphasizing different nuances at different times, just as the same notes in music serve as the basis for a variety of melodies.

Dr. Fulford fought for what he believed, but in a gentle way. What is more, he also fought with himself over issues of intellectual pride and self-promotion. However, it was always with a reverence for the pursuit of truth, including ➻ March 2004 The AAO Journal/41 scientific explanation, and for the broader role of participating in the divine creative process. He saw medicine as a practice of loving service, not one of control, wealth, or pride of accomplishment. He always saw himself as part of an evolving osteopathic community of understanding.

It is hoped that this book will fill a gap in the resources available to those of us who are trying to preserve, teach, and pass on the insights and methods of this wonderful man. None of us can ever truly speak for Dr. Fulford, or treat just as he would have with his own hands, heart, and mind. We can only learn from him to enrich our own paths.”

Are We on the Path?, The Collected Works of Robert C. Fulford, DO, FCA has been released by the Cranial Acad- emy, Inc. In his last will and testament, Dr. Fulford dedicated his speeches and papers to the Cranial Academy, for the benefit of the organization and its members. This volume was edited by Theresa A. Cisler, DO, recently installed as President of the Cranial Academy. An excellent biographical sketch was prepared by Harold D. Goodman, DO. The reader can quickly grasp the essential features of Dr. Fulford’s views by reading in his 1987 Thomas L. Northup Lecture, entitled Are We on the Path?:

“Osteopathy is a philosophy. Philosophy is a particular system of principles for the conduct of life. Philosophy is mind that creates all things. Mind centers all things. Mind is the invisible cause. Ideas are all in mind.

Osteopathy is an art. Art is the skill or power of performing certain action. Art is the Universal Energy of mind- desire, thinking mind-desire to create. Thinking mind is the only energy of the Universe.

Osteopathy is a science. Science is systematized knowledge of nature and the physical. It is matter which is the effect of cause and motion. It has no stability. It is the visible world which is observed by our senses. It is manifested in motion by the polarizing forces of motion.

Osteopathy is a science of medicine, which means a healing art. It is a system of therapeutics founded on all fundamental physical, chemical and biological sciences. It bases its treatment of all abnormal conditions of the body on natural law and vital principles governing life. The natural law is, ‘there shall be a balanced rhythmic interchange between opposite pairs, namely, the adjustment of all the vital forces of the body.’ The vital force is love. Love can have but one motion, to give out from itself in order to find unity. The greatest urge in nature is unity.

The osteopathic profession is like a seed. It first had to establish its roots in the soil-society. It then had to crack the soil open-recognition by governments. The stem of the seed is out of the soil. Now it is time to mature and exhibit the bloom of osteopathy as it stands preeminently above all else. Dr. Thomas L. Northup had the divine awareness of osteopathy. He, more than any other person, is responsible for the present position of the American Academy as a potent force in the destiny of the osteopathic profession. What is the destiny of osteopathy?

Osteopathy is the medicine of the twenty-first century. Its philosophy, art and science will be based on health promotion, prevention and a natural approach to patients. Patients will be regarded not as disease processes or problems, but as people needing assistance in balancing the physical, emotional, mental and spiritual dimensions. This is our responsibility. Are we ready to accept the challenge of the new age!”

With these three volumes as resources, the student of osteopathy can very satisfactorily mine the thought of this beloved practitioner and teacher. Doing so will challenge and reward the effort by continuing the walk along the path of unfolding horizons envisioned by Andrew Taylor Still. Doctor Fulford was one in the listing of stellar individuals who walked Still’s path. How many of the present generation of osteopathic practitioners are ready to accept his challenge?

42/The AAO Journal March 2004 Elsewhere in Print

Krawiec, CJ, Denegar, CR, Hertel, J, Salvaterra, GF, Buckley, WE Manual Therapy: Volume 8, Number 4, November 2003; 207-213 Static innominate asymmetry and leg length discrepancy in asymptomatic collegiate athletes

Summary. The objectives of the study were to assess: (1) static innominate asymmetry in the sagittal plane, (2) leg length discrepancy (LLD), and (3) the relationship between static innominate rotation and LLD in asymp- tomatic collegiate athletes. The study was an observational study by design which took place in a University athletic training research laboratory. The participants were twenty-four male and 20 female asymptomatic intercollegiate athletes who volunteered to take part in the study. Static innominate asymmetry was assessed with a caliper/inclinometer tool and LLD was measured with a tape measure using standard clinical methods. Results showed that forty-two subjects (95%) demonstrated some degree of static innominate asymmetry. In 32 subjects (73%), the right innominate was more anteriorly rotated than the left. Nearly all subjects were deter- mined to have unequal leg lengths with a majority, 30 subjects (68%), showing a slightly longer left leg. Weak correlations (r = 0.33 - 0.44) were identified between static innominate asymmetry and LLD. In conclusion static innominate asymmetry and LLD are common among asymptomatic college athletes. This information provides clinicians with normative data of common clinical measures in a physically active population. (c) 2003 Elsevier Science Ltd. All rights reserved.

The authors of this paper provide a contribution to measuring and quantifying pelvic asymmetries in an symptomatic population. From the Introduction, “Alignment and motion in the pelvic region is particularly complex making clinical assessment difficult. The bony pelvis is comprised of the right and left innominate bones, which are each composed of the fused segments of the ilium, ischium and pubis. The motion between the sacrum and the innominate bones exists such that motion ipsilaterally is dependent on and relative to motion and position contralaterally (Bemis & Daniel 1995). Clinical assessment of innominate position and motion is subsequently made by describing motion or position of one side in relation to the other (Beal 1982; Erhard & Bowling 1977; Cibulka et al. 1988; Crowell et al. 1994; Bemis & Daniel 1995). The literature contains very little documentation of the incidence of specific innominate asymmetries as determined under controlled investigation. This is in large part due to the difficulty in assessing pelvic asymmetry, arising from the low reliability of common clinical tests and the lack of a gold standard objective measure (Potter & Rothstein 1985; Cummings & Crowell 1988; Dreyfuss et al. 1994). The most common pelvic asymmetry that has been studied is that of innominate rotation in the sagittal plane (Beal 1982; Cibulka et al. 1988; Crowell et al. 1994; Bemis & Daniel 1995). However, research related to the symmetry between the innominates in healthy and symptomatic populations is lim- ited. Leg length discrepancy (LLD) has long been implicated as an etiological factor of pain and dysfunction throughout the lower quarter (Beal 1977; 1982; Woerman & Binder 1984; Gogia & Braatz 1986; Aspergren et al. 1987; Danbert 1988; Schuit et al. 1989; Beattie et al. 1990; Don Tigny 1990; Hoyle et al. 1991; Mannello 1992; Cummings et al. 1993; Gross et al. 1998). Pelvic asymmetry and LLD are interrelated because the innominates will typically adapt in either an anteriorly or posteriorly rotated position in order to lengthen or shorten the extremity relative to the contralateral side (Kuchera & Kuchera 1997). The extent of the relationship between LLD and pelvic asymmetry has been investigated and described in the literature (Pitkin & Pheasant 1936; Cumings et al. 1993), however, the natural occurrence of this relationship has not been previously documented in a healthy athletic population.”

March 2004 The AAO Journal/43 ® NON-PROFIT ORG. U.S. POSTAGE PAID PERMIT #14 3500 DePauw Boulevard, Suite 1080 CARMEL, INDIANA Indianapolis, IN 46268

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March 21-23, 2004 2004 SCTF Intermediate Course – the Face (immediately following the AAO Convocation) The Broadmoor Hotel, Colorado Springs, CO Course Director: Doug Vick, DO Faculty: SCTF Board Prerequisities: 2 Basic Cranial Course, one being SCTF and 3 years of Clinical Practice

October 8-10, 2004 Intermediate Course: Children and Learning Disabilities Course Director: Rachel Brooks, MD Faculty: Maxwell Fraval, DO (ANZ); Miriam Mills, MD, Pediatrician; Mary Anne Morelli, DO; Frank Willard, PhD

Spring 2005 Basic Course TBA

Contact: Judy Staser @ Phone: 817/926-7705 or Fax: 817/924-9990

These programs anticipate being approved for AOA Category 1-A CME credit pending approval by the AOA CCME Visit our website at: www.sctf.com

44/The AAO Journal March 2004