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·~ A Publication of the American Academy of Osteopathy VOLUME 9 NUMBER 3 FALL 1999
Osteopathic Manipulative Treatment and Meniere's Syndrome ... see page 21
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September September AAO's AAO's A. American® Academy of Osteopathy 3500 DePauw Boulevard Suite 1080 Indianapolis, IN 46268-1136 (317) 879-1881 The mission of the American Academy of' Osteopathy is to teach, advocate, FAX (31 7) 879-0563 advance, explore, and research the science and art of osteopathic medicine, emphasizing osteopathic principles, philosophy, palpatory diagnosis and osteopathic manipulative treatment in total health care. 1999-2000 BOARD OF TRUSTEES Editorial Section President Mark S. Cantieri, DO, FAAO From the Editor ...... 5 by Raymond J. Hruby, DO, FAAO President Elect John M. Jones, DO, III Message from the President ...... 6 by Mark S. Cantieri, DO, FAAO Immediate Past President Melicien A. Tettambel, DO, FAAO Message from the Executive Director ...... 7 by Stephen J. Noone, CAE Secretary-Treasurer Anthony G. Chila, DO, FAAO Affiliated organization's CME Calendar ...... 8 Five tips for year-end giving ...... 9 Trustee Stephen D. Blood, DO, FAAO From the AOBSPOMM Files: Case study: Osteopathic Manipulative Treatment of an 8-year-old child born with anoxia ...... 10 Trustee Boyd R. Buser, DO by Mary Anne Morelli, DO Letter to A.T. Still ...... 13 Trustee Dennis J. Dowling, DO, FAAO by Raymond J. Hruby, DO, FAAO Letters to the Editor ...... 14 Trustee John C. Glover, DO David N. Grimshaw, DO; Robert Kidd, MD, CM; Richard C. MacDonald, DO; Dale E. A/sager, DO, PhD; John Ricke/man, Jr., MS-IV, KCOM Trustee Ann L. Habenicht, DO, FAAO Health services research: Evidenced-based medicine and the AAO five-year strategy ...... 16 Trustee Hollis H. King, DO, PhD, FAAO by Albert F. Kelso, PhD and Deborah M. Heath, DO From the Archives: Philosophy of Osteopathy, pages 260-262 ...... 17 Executive Director Stephen J. Noone, CAE Studenfs Corner: case study: Low back pain in pregnancy ...... 18 by Kevin M. Gallagher, MS-III
Editorial Staff Peer-Reviewed Section
Editor-in-Chief ..... Raymond J. Hruby, DO, FAAO Meniere's syndrome resulting from multiple traumatic brain injury: Two case studies ...... 21 Supervising Editor ...... Stephen J. Noone,CAE by Wesley C. Lockhart, DO Editorial Board ...... Barbara J. Briner, DO Perspectives: An overview of support for osteopathy in the cranial field ...... 25 Anthony G. Chila, DO, FAAO by Michael L. Kuchera, DO, FAAO James M. Norton, PhD Frank H. Willard, PhD A review of the principles of William G. Sutherland's general techniques ..... 32 by William J. Golden, DO Managing Editor ...... Diana L. Finley
The AAO Journal is the official quarterly publication of the Am~ri can Academy of Osteopathy, 3500 DePauw Blvd., Suite 1080, In dianapolis, Indiana, 46268-l l36. Phone: 3 l 7-879-1881; FAX: (317) 879-0563; e-mail [email protected]; AAO Website: http.// Advertising Rates for the AAO Journal Advertising Rates· SizLJJ.UJ2;. www.aao.medguide.net Full page S600 placed (1) time 7 1/2 x 9 112 An Official Publication S575 placed (2) times Tirird-cla.ss postage paid at Carmel, .IN. Postmaster: Send address The American Academy Osteopathy S550 placed (4) times changes to American Academy of Osteopathy 3500 DePauw Blvd., of of The AOA and AOA affiliate organizations 1/2 page S400 placed (]) time 7 l /2 x 4 3/4 Suite 1080, lndianapolis, lN., 46268-1136 S375 placed (2) times and members of the Academy are entitled S350 placed (4) times The AAO Journal is not itself responsible for statements made by to a 20% discount on advertising in this Journal. 1/3 page S300 placed (1) time 2 1/4 x 4 3/4 any contributor. Although all advertising is expected to conform to S275 placed (1) times ethical medical standards, acceptance does not imply endorsement $250 placed (4) times by this journal. Call: The American Academy of Osteopathy 1/4 page $200 placed (1) time 3 1/3 x 4 3/4 (317) 879-1881 for more information. $180 placed (2) times Opinions expressed in The AAO Journal are those of authors or speak $150 placed (4) limes ers and do not necessarily reflect viewpoint.s of the editors or official Professional Card: $60 3 tn x 2 policy of the American Academy of Osteopathy or lhe instirutions Subscriptions: $60.00 per year (USA) Classified: Sl .00 per word (not counting a, an, the) with which the authors arc affiliated, unless specified. $68.00 per year (foreign)
Fall 1999 AAO Journal/3 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 sci be submitted for review by the Editorial ence 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 I. 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" Orii:inal 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. the top of the photo. Use a photocopy to in Manuscript dicate the placement of arrows and other Case Reports 1. Type all text, references and tabular ma markers on the photos. If color is necessary, terial using upper and lower case, double Unusual clinical presentations, newly recog submit clearly labeled 35 rnm 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 Clinical Practice manuscripts. 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 Permissions Special Communications ures are cited in the text and in numerical Items related to the of practice, such as Obtain written permission from the publisher art order. poems, essays and stories. and author to use previously published illus trations and submit these letters with the 4. Include a letter that gives cover the manuscript. You also must obtain written per Letters to the Editor author's full name and address, telephone mission frorn patients to use their photos if Comments on articles published in The AAO number, institution from which work initi there is a possibility that they might be iden Journal or new information on clinical top ated and academic title or position. ics. Letters must be signed by the author(s). tified. In the case of children, permission must be obtained from a parent or guardian. No letters will be published anonymously, 5. Manuscripts must be published with the or under pseudonyms or pen names. correct name(s) of the author(s). No manu References scripts will be published anonymously, or 1. References are required for all material Professional News of promotions, awards, under pseudonyms or pen names. appointments and other similar professional derived from the work of others. Cite all ref erences in numerical order in the text. If there activities. 6. For human or animal experimental inves are references used as general source mate tigations, include proof that the project was rial, but from which no specific information Book Reviews approved by an appropriate institutional re was taken, list them in alphabetical order Reviews of publications related to osteo view board, or when no such board is in following the numbered journals. pathic manipulative medicine and to manipu place, that the manner in which informed lative medicine in general. consent was obtained from human subjects. 2. For journals, include the names of a11au thors, complete title of the article, name of Note 7. Describe the basic study design; define the journal, volume number, date and inclu Contributions are acceptedfrom members of all statistical methods used; list measurement sive page numbers. For books, include the the AOA, faculty members in osteopathic instruments, methods, and tools used for in name(s) of the editor(s), name and location medical colleges, osteopathic residents and dependent and dependent variables. of publisher and year of publication. Give interns and students of osteopathic colleges. page numbers for exact quotations. Contributions by others are accepted on an 8. In the "Materials and Methods" section, individual basis. identify all interventions that are used which do not comply with approved or standard Editorial Processing All accepted articles are subject to copy ed Submission usage. iting. Authors are responsible for all state Submit all papers to Raymond J. Hruby, DO, ments, including changes made by the manu FAAO, Editor-in-Chief, MSU-COM, Dept. Computer Disks script editor. No material may be reprinted of Osteopathic Manipulative Medicine, A- We encourage and welcome computer disks from The AAO Journal without the written 439 E. Fee Hall, East Lansing, MI 48824. containing the material submitted in hard permission of the editor and the author(s). copy form. Though we prefer Macintosh 3-
4/AAO Journal Fall 1999 From the Editor by Raymond J. Hruby, DO, FAAO
Osteopathic medicine without OMT: Is it possible?
There are a number of osteopathic realistic for them to think about prac modalities of OMT available, some web sites on the Internet. In fact, if ticing osteopathy without OMT. Ma would argue that there are safe and you have access to the Internet just nipulation is indeed the centerpiece effective techniques for any patient get into one of the search engines of their practice, and they would not condition. But I digress. sometime and try searching using be without it. How do we determine the clinical simple keywords such as "osteopa With respect to American-trained significance of a somatic dysfunc thy," "osteopathic," and other simi DOs however, my guess is we would tion? If a patient with congestive heart lar terms. You will be impressed with hear a number of opinions on this failure has segmentally related so the results you get just from this rela subject. While I have never had a con matic changes in the upper thoracic tively simple search. One of the sites versation with other DOs on this sub region, this would seem to be clini you will probably find is an osteopa ject, I can think of statements I have cally significant. But, what if that pa thy listserver that I, for one, find very heard colleagues make over the years tient only had altered mechanics of interesting. There are postings here that would seem relevant to this topic. the lower extremity? Is that signifi from people all over the world that For example, I have heard DOs say cant? Is it related to the patient's con are involved in osteopathy in one way that they always do OMT "when ap dition? Should it be treated? Some I or another. If you are interested in propriate." What does this mean? have spoken to have said no, others joining you can find the site at http:// Osteopathic theory states that there have thought that the altered lower www.rscom.com/osteo/forum/ is a somatic component to every dis extremity mechanics might constitute mailing.htm. There are some very ease or condition a patient might a large enough energy demand on that interesting conversations that go on have. There are some studies that patient's body to perhaps risk further over this listserver. would support this theory. If this is stress to an already compromised car An item that came up for discus the case, wouldn't every patient have diovascular system. sion recently was whether one could some kind of somatic dysfunction? What about the osteopathic physi practice osteopathic medicine with Shouldn't that somatic dysfunction be cian who does not utilize OMT per out using OMT. Oddly enough, there treated? Some would say that the an se, but has an OMM consultant treat were only a very few postings about swer is maybe yes, maybe no. It all of his or her patients? Is this DO what I thought would be an interest would be argued that if the somatic practicing osteopathic medicine? ing and, possibly, a controversial dysfunction is deemed to be related Again, some DOs would say no, topic. This seems to me to be a ques to the patient's condition and to have while others would say that between tion that we ought to wrestle with, and enough clinical significance, then it the two DOs all of the principles of I am surprised it has not come up be should be treated. One should also re osteopathic medicine are being con fore somewhere. member that OMT might not be ap sidered, and the patient is getting the I think there is a reason that not propriate if it is clearly contraindi full benefit of osteopathy. much was discussed on the listserver. cated in a given patient. Then again, I think most DOs would agree that I am only guessing, but I think the when is OMT contraindicated? While osteopathic medicine is much more majority of subscribers to the much has been written on this topic, than OMT, that it is a complete sys listserver are the DOs from overseas. I do not believe there is a clear con tem of medicine based on a unique Given their scope of practice in their sensus about contraindications to philosophy and set of principles. At respective countries, it would not be OMT. Indeed, with all the different continued on page 13
Fall 1999 AAO Journal/5
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by by Message Message Message from the Executive Director by Stephen J. Noone, GAE
What does certification in neuromusculoskeletal medicine and OMT really mean?
By this time, the reader should already be aware that cial attention to the neuromusculoskeletal system and the American Osteopathic Association's Board of Trust its interaction with other body systems. Neuromus ees adopted in July 1999 sweeping changes in the names culoskeletal medicine and osteopathic manipulative for both residency training and certification in the disci treatment encompasses increased knowledge and plines of family practice and osteopathic manipulative understanding of osteopathic principles and practice medicine. The new title given to FP residencies will be and heightened technical skills of osteopathic ma residency training in family practice and osteopathic ma nipulative medicine, and integrates each of these into nipulative treatment (OMT). AOA-certified FPs will now the management of pediatric, adolescent, and geriat receive a certificate in family practice and OMT. Simi ric patients. larly, the new title for OMM residencies will be neuro This specialty includes knowledge of anatomy, musculoskeletal medicine and OMT. DOs who pass the physiology, and pathology as they relate to all body new certification examination will receive certification in systems in health and disease, and focuses on knowl neuromusculoskeletal medicine and OMT. edge relevant but not limited to the disciplines of neurology, rheumatology, orthopedics, and physical What is neuromusculoskeletal medicine? In January medicine and rehabilitation. Neuromusculoskeletal 1999, tbe AOA approved the Basic Standards for Resi medicine and osteopathic manipulative treatment dency Training inNeuromusculoskeletal Medicine, which involves the development of skills in the use of vi included a mutually-acceptable definition of the new spe sual, palpatory, and biomechanical evaluation tech cialty approved by the AOA Council on Postdoctoral Train niques for improved physical assessment of body ing. In July 1999, the definition was amended to include disturbances expressed clinically in the neuromus "osteopathic manipulative treatment" as follows: culoskeletal system and in other fundamentally re lated systems. This specialty integrates the full field Neuromusculoskeletal medicine and osteopathic of medical and surgical practice with a high level of manipulative treatment is that component of medi proficiency in the area of neuromusculoskeletal di cine concerned with implementing systems in un agnosis and treatment. derstanding health and disease and managing pa This knowledge of structure and function and pal tients. The practice of neuromusculoskeletal medi patory skills are especially relevant in the manage cine and osteopathic manipulative treatment directs ment of medical and surgical patients with acute and special attention to the structural aspects of body chronic pain and disease in both inpatient and outpa function and their role in all disease processes, along tient settings. with those strategies prescribed and or administered As part of the curriculum outlined in these Basic to enhance homeostasis within the body unit. Practi Standards for Residency Training in Neuromuscu tioners of neuromusculoskeletal medicine and osteo loskeletal Medicine and Osteopathic Manipulative pathic manipulative treatment consider and/or incor Treatment, students learn the philosophy, principles porate all recognized treatment methods in the man and practice of osteopathic manipulative medicine, agement of patients. including osteopathic manipulative treatment. A core The discipline of neuromusculoskeletal medicine exposure to and preparation in the various models and osteopathic manipulative treatment directs spe- ---+
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46268-1136 Five tips for year-end giving
If you are like most people, you do deduction for the full amount of the come gifts (gift annuities, pooled in your major giving toward the end of stock, just as you would if your gift come fund contributions, trust ar the year. This probably occurs for sev was made with cash. And what is rangements, etc.). Your professional eral reasons. The closing of the tax sea more, if you cannot use all of the in advisor(s) and planned giving offic son encourages itemizers to obtain in come tax charitable deduction result ers are busy beyond belief as the year come tax deductions; a barrage of ear ing from the gift, you can carry it for winds down. The sooner you can get nest appeals by nonprofits increases ward for up to an additional five your gift activity going, the better it awareness of financial need; and many years. Such gifts are deductible up to will be for everyone concerned. are simply pre-disposed to end the year 30 percent of your adjusted gross in 5. Talk to your advisor. Before by making a charitable gift. come. making any significant gift to the Here are five tips to help you make 3. Consider a life-income gift. The Academy, or to any other nonprofit the most of your year-end giving: Academy offers a variety of life-in for that matter, you should have your 1. Calculate your income. Try to come plans to fit your needs. You can CPA, attorney or other advisor help get a handle on your tax liability for make a gift now, obtain tax benefits you understand the impact of your gift the year. Did your unearned income and receive income for the rest of on your income tax return and estate. increase? Did you sell any appreci your life. Sound too good to be true? We at the Academy want your giving ated assets? Will you owe more taxes? A few minutes of your time will con to be prudent, as well as generous and This alone may motivate you to in vince you otherwise. Our planned joyful. crease your giving before December giving officer can provide personal For more information about the 31. In fact, you may even want to ized illustrations and printed material year-end giving opportunities at the move some of your giving forward to assist you and your advisor(s). Academy, contact Executive Direc from next year to create a larger in 4. Do your giving early. This is tor Steve Noone; or complete and come tax deduction for yourself this especially true if you want to make a mail the coupon below. We are here year. Non-itemizers may especially gift of noncash assets (stock, real es to help you in any way we can. find this "grouping of gifts" useful in tate, etc.). It also applies to life-in- order to take advantage of an item ized tax return every other year. r ------7 In any case, by the time you fill out (Please complete and return this reply form.) your income tax return, it will be too late to make charitable gifts for the pre Dear Friends at the American Academy of Osteopathy: vious year. Take the time to do some planning while you still have the op D Please send me information about year-end giving. portunity to make a year-end gift. D Please contact me about a personal visit or other assistance. 2. Review your stocks. Look at D I have provided for the Academy in my will or other estate-planning document. the stocks you have held for more D Please send me information about the Academy's planned giving programs. than a year. Which ones have appre ciated the most? It may be prudent Name: ______for you to make your year-end gift Address: ______using one or more of these stocks. City:______Here's why: If you sold the stock, you ______would incur capital gains tax on the State: _ __ Zip:______Phone:______appreciation. However, if you give the stock and allow the American Mail this form to: Academy of Osteopathy to sell it, no The American Academy of Osteopathy, one pays tax. And you get a charitable L _3500______DePauw Blvd., Suite 1080, Indianapolis, IN 46268-1136. J
Fall 1999 AAO Joumal/9 From the AOBSPOMM Files
Case study: Osteopathic manipulative treatment of an 8-year-old child born with anoxia by Mary Anne Morelli, DO, CSPOMM, Osteopathic Center for Children, San Diego, CA
Patient Identification: included Lanoxin and Lasix. His walking, skipping was fair. When R.W. - an eight-year-old Cauca weight gain was slow. He nursed until creeping (crawling on hands and sian male 14 months. Immunizations were up to knees), there were 4 distinct sounds date. R.W. did have a low-grade fever indicating a lack of integration of the Chief Complaint: after several of the immunizations. He extremities. During creeping there Patient had difficulty with fine and had occasional colds, otitis media, and should be only 2 sounds as the right knee and left hand touch; then the left gross motor skills and had eye muscle a rare cough. imbalance. He did better with verbal knee and right hand touch the ground. than with written work and was very Past Surgical History: was disorganized and he used his arms more than legs. Pes planus was present smart, but a "watcher." At 9 days, a "switch" operation for transposition of the great vessels was with bilateral bowing of the Achilles tendon. The left ear and left shoulder History of Chief Complaint: done. At 10 months his left eye be were down, the left scapula was down Although R.W. was very social and gan to drift. He required 3 ocular sur and slightly winged. Head was held to did well in school, his mother felt that geries (Left eye -2, right eye -1). At the right with shoulders forward. For in some manner that she could not age 2 1/2 the pulmonic artery was sur ward flexion was 4" from the floor with quite put her finger on, he was not gically enlarged to prevent pulmonic midthoracic flattening. The left thorax functioning optimally. She believes stenosis. showed a slight hump. Balance was this may go back to his early events. difficult especially on the left foot. He also has occasional (hammerlike) Social History: Tympanic membranes were retracted headaches. R.W. lived with his 35-year-old mother and 36-year-old father. Both bilaterally. He had a high palate with .05 mm open bite. The centrals were Past Medical History: were in good health. There was a fam ily history of hypertension and obesity. separated and jaw deviated to the left. R.W. was born to a 27-year-old He had a flow heart murmur at the mother in good health. There was no Development. R.W. sat at 7 months, crept at 8 months but was not as skilled lower left sternal border. There was a history of medications, drugs, or alco thick midline scar. Lungs were clear to hol. Labor began two weeks early at 2 at creeping as his sister. He preferred cruising and did walk alone at 14 auscultation. Thoracic diaphragm was am and progressed rapidly. Membranes restricted with increased thoracic ten ruptured at 7 am and the baby was born months. He talked at age 2 1/2 years. At age 4, he fell off a play structure, sion. Abdominal fascia was tense. at 9 am. No medications were used. His There was no hepatosplenomegaly. head was markedly molded and his cutting his head in the occipital area. Although his vision was poor and he Right eye turned in more with an up color was blue, requiring oxygen. Nurs ward gaze. Left eye turned in more with ing was attempted and he was able to read with a contact, he was doing well academically in the 3rd grade. near- point focusing. Tracking was dif latch on well. He was taken to the spe ficult. Throat showed lymphoid stud cial care nursery later for observation ding. Anterior cervical lymphadenopa Allergies: due to episodes of cyanosis. An I. V was thy was present. Eyes had circles un No Known Medications: None started and oxygen given. A cardiology derneath. The nose deviated slightly left presently exam revealed transposition of the great and the nasal mucous was boggy with vessels. Prostin was given to keep the mouth breathing. The left leg showed ductus open. On day 9, a "switch" op Physical Examination: decreased internal and external rotation. eration was performed. He had a heart Weight 58.5 lbs; Height: 51 "; Temp. The straight leg raised left 75° and right attack after the surgery. R.W. was dis 98.2° F; Pulse 80; Respiratory Rate 20. 80°. The left thigh was 29.5 cm and charged to home at 3 1/2 weeks of age. His right foot externally rotated when right thigh 30.5 cm. Muscle spasms Medications for the first year of life 10/AAO Journal Fall 1999 were present in thigh and knee region. Course of Treatment: therapy. They often send a child for Babinski test: Left great toe downgoing Over a period of eight weeks of treatment prior to vision therapy to then up; right downgoing. weekly treatments, the whole body remove any structural component that The gastrocnemius were tight bi was addressed beginning with a can be addressed. laterally with lumbosacral compres venous sinus technique to begin de sion. The sacrum was very hard and compression of the cranial mecha Discussion: it pulled up on the left while rotating nism. Subsequent visits included: A young child will draw a picture on the anterior/posterior axis. The lumbosacral and sacroiliac decom of his body as it feels to him. R.W. right anterior superior iliac spine was pression and gluteal fascia! release to drew me a picture that showed his down. Grip strength was less on the decrease restrictions in pelvis and right side to be much larger than his left. Reflexes were 1 +4 bilaterally legs. According to Dr. Frymann, free left. In reality, his right side was much upper and lower. Head was com ing the gluteal fascia is very impor stronger. After I completed the physi pressed with superior vertical strain. tant in children with cerebral palsy cal exam, I saw the picture. I asked Metopic structure was very restricted. type symptoms. Occipito mastoid re him if one arm or leg was stronger, lease by V spread and sphenobasilar and he stated that his right arm and Initial Assessment: symphysis decompression and pari leg were much stronger so he drew Motor cerebral dysfunction; plagio etal lift were done to further free the them larger. The picture he drew af cephaly; eye muscle imbalance; so cranial mechanism. Intraoral tech ter a course of treatment showed a dif matic dysfunction of the head, cervi niques to address the high palate and ferent body per ception . R. W. 's cal, thoracic, lumbar, and sacral re overbite were done. Mediastinal fas mother reported an improvement in gions, and upper and lower extremities. cia release was done due to the ef his overall health and a decrease in fects of the scar which exacted a pull headaches. R.W. continues to receive Treatment Plan: into itself. Orbital techniques were intermittent treatment to decrease the Eight weekly treatments were rec done to improve eye function. In our damage to the motor tracks that can ommended. Vision therapy would be work with developmental optom be injured by spontaneous bleeds considered later. etrists, treating the cranial mechanism most often associated with premature improves visual function prior to their births, or in this case, by anoxia.D
Drawn on September 6, 1994
Drawn on November 18, 1994 after (8) Treatments
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Walter Walter Program Program continued from page 5 Letter to A.T. Still Message.from the Editor Dear Doctor Still, We have spoken before about a question that comes the same time there are those DOs who feel that OMT is into the mind of every osteopathic physician at one time the hallmark of osteopathic medicine and is precisely what or another: How often should a patient be treated? The makes us distinctive. obvious answer is that it depends on the nature of the Can we practice osteopathic medicine without OMT? patient's problem, and with experience, we all understand What do I think about this question? One thing seems clear: how that principle applies. There is no simple answer to osteopathic medicine as a profession would not be osteo this question. Very complex conditions sometimes respond pathic medicine without OMT. But, whether an individual to only a few treatments, and at other times require months DO can apply the principles of osteopathy to a given pa of effort. There is no rhyme or reason for this; and why is tient and not use OMT remains a topic that, in my experi that? I think it is because if we only look at diseases or ence, invites a wide range of opinions from DOs. I per conditions and try to come up with a "cookbook" answer sonally utilize OMT on virtually all my patients. I believe for the number of treatments it takes to resolve each one, that the decision to utilize or not to utilize OMT is based we will always be troubled for an answer. But, if we use on thoughtful consideration of the patient in light of the our osteopathic abilities to observe, listen, and palpate, unique principles of osteopathic medicine, and a way of we can know much more precisely whether or not the viewing the human body that is distinctively different from patient is responding to treatment, and when the patient is other approaches. These other osteopathic principles are well on the road to recovery. I am reminded of some words more cognitive in nature, and thus are not so observable in your Autobiography (p. 202), where you said: "To make as OMT. This is perhaps what brings about the wide range the sick well is not the duty of the operator, but to adjust a of answers to my question. I would love to see a sympo part or the whole of the system in order that the rivers of sium dedicated to just this topic. life may flow in and irrigate the famishing fields. We Can one practice osteopathic medicine without using
should stop and consider at the point of irrigation how OMT? What do you think?□ often the mains should be opened to supply the ditches and how long the sun of life should shine upon that crop,
doing its duty of nourishing and vitalizing it according to DIRECTOR □F" individual demands. I have said to heal the sick is a duty □ STE□ PATHICMEDICINE that belongs to another division of Operators, and not the hewers of timber nor to muscles of force, but to the rivers Our reputation for excellence and progressive thinking has placed Mount Clemens General Hospital at the forefront of of life only. To irrigate too much is as detrimental as too the most respected health care organizations in the Midwest. little or not at all. How much? Is the all-important ques We believe in success based on professional integrity and smart strategies and we're actively seeking a motivated, talented tion to solve. The kind and quantity of fluid or force must and experienced Director of Osteopathic Medicine to share in be supplied at the right time and place only." our continued successes. We cannot always have a direct answer to the question 1his high level position will be responsible for developing and implementing an effective Osteopathic Principles and Practice about how often to treat someone. However, if we plan program, reviewing and implementing policies in the Osteopathic our approach to patients based on sound osteopathic think medicine services, and performing teaching duties to various staff and students. Other duties include evaluating personnel ing, we can feel more confident that we will treat every performance and providing inpacient/oucpatient consultation5. patient sufficiently and properly. The successful candidate will be an Osteopathic physician Your ongoing student, with a fellowship and/ or residency training in Osteopathic Manipulative Medicine and have Board certification through Raymond J. Hruby, DO, FAAO the American Academy of Osteopathy. Must maintain an accive license to practice Osteopathic Medicine in the State of Michigan. Previous educational experience in Medical NEW ENGLAND Education is preferred. Interested in OMT, family medicine and woman's We offer an outslanding benefits package and salary commen surate with experience. Please send resume and salary history health? Be assured of being busy by joining this well to: Tom Stackpoole, One Sterling Town Center, 12900 established private practice closed to new patients. New Hall Road, Suite 400, Sterling Heights, MI 48313; Phone: (800) 680-2874 or (810) 741-4080; Fax: (810) 412-9472. office located next to well-equipped/staff hospital. Col An equal opportunity employer. lege city close to ski resorts and the coast. Contact Doug Page at Lawlor &Associates by phone (800) 238-7150; ~t~Mount Clemens fax (610) 431-4092; or email Lawlor [email protected]. ~ General Hospital
Fall 1999 AAO Joumal/13 Letters to the Editor
Dear Editor: perceptions of reality in the field dra reliability studies are not impossibil Iread your article in theAAO Jour matically, as Kuhn describes. ity in osteopathy. I suspect that the nal today, and wanted to communi There is a wonderful book for the more skilled the examiners, the more cate with you about it. Your thoughts educated layman about physics and likely the physical findings will were especially interesting to me as I these new ideas that was responsible change between examinations. If I too have been studying and contem for my change in understandings understand Dr. Masiello correctly, plating perception as the central as about physics. It is called, The Danc phenomenological principles might pect in understanding the phenom ing Wu Li Masters, by Gary Zukav. I explain this paradox. enon of healing. Also, I found the dis put the reference at the bottom of this I would be interested to know if cussion of metaphor with respect to letter. His newer book, The Seat of the other members of the Academy have The Tide to be very helpful. All in all, Soul, carries these concepts even fur come to similar conclusions. I thought it was a heuristic article. I'm ther. It is truly fascinating, and surely sure many persons will find benefit applies to the practice of Osteopathy, Robert Kidd, MD,CM, in reading it, as I did. as you discuss in your article.
AAO Coding PHYSICIAN Information Packet A full-time faculty position is iillillediately avail able for a board-certified/board-eligible Doctor of Osteopathy at the University of North Texas Health Science Center - Texas College of Os Contact: teopathic Medicine in Fort Worth. Teaching os American Academy of Osteopathy teopathic manipulative medicine is required. 3500 DePauw Blvd., Suite 1080 Clinical and research opportunities are available. Indianapolis, IN 46268-1136 Competitive salary and excellent benefits pack Phone: (317) 879-1881 or age. Letters of interest should be sent to: FAX: (317) 879-0563
Send: _ _ _ #of packets@ $15.00each to: Scott T. Stoll, DO, PhD, Name ______Interim Chairman/Assistant Professor c/o Elisa Bircher Street Address for UPS Shipment University of North Texas Health Science Center 3500 Camp Bowie Boulevard City, State, Zip ______Fort Worth, Texas 76107-2699 Daytime Phone ______817/735-2461 • Fax 817/735-2270 AAO Accepts MasterCard or Visa! Card Number ______An EEO/Affirmative Action Institution Expiration Date ______
Fall 1999 AAO Journal/15 Health services research: Evidenced-based medicine and the AAO five-year strategy by Albert F. Kelso, PhD and Deborah M. Heath, DO
The AOA agenda for the 21st Cen pathic care for illness. Support for os tabase and an infrastructure for de tury and theAAO five-year strategy is teopathic practice, as well as osteo veloping and maintaining health ser an opportunity for practicing DOs to pathic theory and philosophy, is ob vices research as a compliment to participate in providing evidence on tained by health services research. classical basic and clinical research total benefits of osteopathic health care Such data on optimum care requires on osteopathic medical concepts. for patients. The contribution of DOs reliable grass root data from the prac We need input on the planning and on research teams conducting clinical tices of DO family practitioners and implementation of health services studies and clinical trials is necessary specialists. research from the DOs who may par and increases contributions to specific We suggest that the AAO supply ticipate. Send your comments - res details of osteopathic health care. ervations, suggestions, and specific (Frymann, Mills). The contribution The contribution of DOs ideas to Louisa Burns Osteopathic from practicing DOs that we propose Research Committee, American provides evidence from practice that re on research teams Academy of Osteopathy, 3500 lates the procedures used in providing conducting clinical studies DePauw Boulevard, Suite 1080, In a patient's health care to the general and and clinical trials dianapolis, IN 46268-1136. These specific health benefits attained. This is necessary and increases comments will be included in plan is medical outcome research that we ning a health services research series will identify in future articles as Health contributions to spedfic details of articles on implementing an AAO Services Research. of osteopathic health care. data collection system. Adding a second clinical research In your comments consider the fol agenda, health services research, to the infrastructure and support for the lowing questions. Will health services existing research on osteopathic effort as part of the unified effort. The research provide evidence-based data health care will support any image AAO's support for previous data col on our image as health care providers? created by marketing efforts. Equally lection on post-doctoral education Do you see this data as needed for in important is that Health Services Re indicates that a similar commitment forming the public and governmental search gives evidence on the total for the first year or two will enable agencies? Is it important to include to benefits of osteopathic care obtained health services research to be devel tal health outcomes on the nature and by patients. This information is re oped. Practicing DO family clinicians effectiveness of osteopathic medical corded and published as aggregated and specialists will need education, services provided for patients? Is it fea data that protects the individual's pri training and guidance to justify their sible to expect practicing DOs and their vacy. Important information on the time and effort in providing the medi patients to participate in health services osteopathic profession's goal for re cal record data and reports for input research? Does including total health storing and maintaining a patient's to the proposed system . We can, outcomes as part of a patient's benefit health while addressing specific pa within the immediate future, supply from osteopathic health care improve tient health problems is gained. This background information, models for our image? Is change in physical, men concept of total health care as part of data collection, a central database for tal, or social health an important health osteopathic practice, poorly under reports, and creating a central clear benefit? Is this important information stood outside the profession, is docu ing station for questions. As this point to support osteopathic theory and mented from data on practice. Clas we have sufficient background and clarify the role of the somatic compo sical clinical research advances osteo- experience to establish a central da- nent in a patient's health and illness?□ 16/AAO Journal Fall 1999 From the Archives
From Philosophy of Osteopathy pgs 260-262
Lymphatics and Fascia diseases, by washing out before fer AAO Coding mentation should set up in the lym I have thought for many years that Information Packet the lymphatics and cellular system of phatics, from being received and re the fascia, of the brain, the lungs, and tained the length of time, that destruc tive chemical changes would begin the heart throughout the whole sys Please mail or FAX this form its work of converting elements into tem of blood supply, do get filled up along with your order to: with impure and unhealthy fluids, gas and discharging them from the American Academy of Osteopathy long before any disease makes its system as unsuitable for nutriment. In 3500 DePauw Blvd., Suite 1080 appearance, and that the procedure of order to avoid this calamity we are Indianapolis, IN 46268-1136 changes known as fermentation, with met with two important thoughts, one Phone: (317) 879-1881 its electromagnetic disturbances, of the power of the nerves of the lym FAX: (317) 879-0563 were the cause of at least ninety per phatics to dilate and contract, also that of fascia and muscle, to dilate or con cent of the diseases that we labor to Send: _ _ # of packets@ $15.00 each to: relieve by some chemical preparation strict with great force when necessary Name ______called drugs. When I was fully satis to eject substances from gland, cell, fied that we were liable to do more muscle, and fascia. Thus we see a cell Street Address for UPS Shipment __ loaded to fullness by secretion which harm than good with such remedies, I City, State, Zip ______began to hunt for more reasonable it cannot do without; open-mouthed Daytime Phone ______methods to relieve the system of its vessels through which it receives this FAX _ _ poisonous gases and fluids, through the fluid. Then again the system of cel ______excretory system which we had hoped lular sphincters must dilate and con to renovate and purify the system. tract in order to retain the fluids in those cell-like parts of the body. Now Charge my: A Satisfactory Experiment we are at the point when ready for use in other parts of the system, those For twenty-five years I have tried or sphincters must temporarily give away, EE) == to balance myself, divert my mind that the gland may relax and dilate. from all previous methods and see if (circle one) Then the universal principle of constric I could not get more directly to the tion throughout the whole body can dis lymphatic system of nerves, and charge the contents of the lymphatics cause the millions of vessels known of all divisions of the body, which is Cardholder's Full Name to exist in the body to begin to un surely the normal condition. Let the load their contents and continue that lymphatics always receive and dis action until all impurities were dis Card Number charge naturally. If so we have no sub charged by way of the bowels, lungs, stance detained long enough to produce kidneys, and porous system. fermentation, fever, sickness, and Expiration Date death. Natural washing out I think this thought has been pre Authorized Signature At the conclusion of this philoso sented plainly enough to be fully un phy I will endeavor to explain just derstood and practiced by the reader, how nature has provided to ward off if an Osteopath.□
Fall 1999 AAO Journal/17 Student's Corner
Case study: Low back pain in pregnancy by Kevin M. Gallagher, MS-Ill, University of North Texas Health Science Center at Fort Worth /Texas College of Osteopathic Medicine
Introduction cine department with a complaint of left innominate and a chronic left flat foot. Recently, since December of Back pain during pregnancy has low back pain. She is gravida 1, para 1997, she has been demonstrating been known to exist since ancient 0 and is approximately 19 weeks somatic dysfunction, in addition to times. Cantin, in 1899, described pregnant with a 10-pound weight the previous dysfunction listed, of the symphysiolysis to be the most ne gain. The patient states that there ex lower thoracic and lumbar regions. glected problem during pregnancy.9 ists a sharp pain in her lower right The patient denies any other signifi In 1934, Abrahamson et al described back that intermittently radiates to the cant medical problems symphysiolysis to originate from all left lower back and down the right three pelvic joints.9 Farbrot, in 1952, leg. The patient rates the pain as usu described the widening of the pubic ally a 7 on a scale of 1-10, but it is Past surgical history symphysis and a correlation between only a 3 this morning. She states that None back pain and the inclination of the the pain is worse at the end of the day and began as soon as she became sacrum.9 Social history pregnant. The pain is usually aggra Back pain is very common in preg The patient denies any smoking, vated by walking, sitting for long pe nant women and often leads to a sig drinking or taking any illicit drugs. nificant amount of time the woman riods of time and exercise and seems is away from work and sometimes it to be lessened with stretching (which she preforms daily), sleep and tylenol. Allergies can be incapacitating. It is so com NKDA mon that most women expect to ex The patient also complains of long perience it. Unfortunately, many phy standing neck pain ( over 25 years sicians dismiss this pain as normal associated with a gymnastics neck Medications and may consider their patients ma and upper back injury) and intermit Prenatal vitamins and tylenol. lingering and usually disregard the tent headaches with the pregnancy. possibilities of any treatment or con The patient was also seen in the ma Review of systems cern. However, in most instances, nipulative medicine department at 9 The patient's review of systems simple, conservative, non-invasive weeks of pregnancy and stated that mainly applies to her chief complaint. modalities can be used to minimize the treatment was successful for a The patient also complains of inter the patients pain. 6 The osteopathic couple of weeks. mittent headaches since the beginning physician has the opportunity to nor of the pregnancy. malize the spinal complex and thus Past medical history influence the homeostasis of the col The patient has been coming to the Physical examination umn, which has been altered.7 As a manipulative department since April General result, the physician can reduce the of 1995 for the treatment of a gym This is a 33-year-old white female patients discomfort by simple proce nastics injury that occurred in her who is alert, oriented, and cooperative. dures and make the pregnancy more early teens. She demonstrates a his tory of recurrent lower cervical and enjoyable for the woman. HEENT upper thoracic somatic dysfunction Pupils are equally round and reac along with a left sacral shear and non History of chief complaint tive to light. Extraocular movements neutral mechanics ofL5. She also has This is a 33-year-old white female are intact who came to the manipulative medi- a history of anterior rotation of her
18/AAO Journal Fall 1999 Extremities Review of literature very difficult and even resulting in an Both upper and lower extremities The pelvis is the main foundation audible pop. 11 Although radicular show full range of motion without upon which the entire spinal column symptoms often accompany low back tenderness. is balanced.7 During pregnancy the pain during pregnancy, herniated enlarging uterus shifts the body's cen disks are generally not thought to be Neurologic ter of gravity forward, which in the cause. Lumbar disk disease has CN II-XII are grossly intact with creases the lumbar lordosis and weak been reported to be the result of preg out lateralization. Deep tendon re ens the abdominal muscles. This in nancy at an incidence of 1 in 1 4 flexes are 2/4 in both upper and lower creases the stress placed upon the 10,000. • It also has been reported extremities. No sensory or motor defi facet joints and posterior ligaments that 53 percent of pregnant women cits were present. of the lumbar spine and necessitates and 54 percent of nonpregnant excessive muscle strain to maintain women have disc abnormalities.10 Musculoskeletal proper balance.6 In addition, a hor Thus, disk disease does not appear to The patient exhibits a decrease in mone called relaxin, is produced dur be more prevalent in pregnant kyphosis and increased lordosis with ing pregnancy in order to prepare the women. It is possible that direct pres lateralization to the left. The patient sacroiliac joints to gradually stretch sure of the fetus on the lumbosacral exhibited a elevated left shoulder and so that the fetal head can fit through nerves is the cause of the radicular equal iliac crests and medial malleoli. the pelvic outlet. This relaxation of symptoms. The patient exhibited bilateral lower the ligaments can result in instability It is obvious that low back pain is cervical (C5-C7 region) and lumbar of the joints and a mechanically un very prevalent in women during preg (L2-L5 region) tenderpoints and tis stable pelvis.6 It has been found that nancy and the problem there lies in sue texture changes. The patient ex approximately 14 percent of pregnant relieving the pain to allow for a more hibited minimal restrictions in range women met diagnostic criteria for enjoyable pregnancy. The first tenet of motion in the cervical and lumbar sacroiliac subluxation.2 Therefore, it in medical management of the preg regions. The patient also exhibited a appears that the combination of the nant patient is to minimize the use of left sacral shear (severely decreased extra stress applied to the lumbar all medications. Drug therapy should left ILA) and a left innominate rotated spine along with the laxtivity of the always be considered as potentially anteriorly (left decreased ASIS and pelvic ligaments could result in the harmful to the mother, the fetus and increased PSIS). back pain experienced during preg the course of pregnancy. Nearly all nancy. However, this still remains medications reach the fetus to some 10 Assessment controversial. degree. Therefore, it is in the best interest of the pregnant mother and 1) Somatic dysfunction lumbar and It has generally been found that the fetus to use nonpharmacologic cervical region over 50 percent of pregnant women 10 therapies. Traditionally, low back 2) Left sacral shear suffer from low back pain and that pain during pregnancy has been ig 3) Left innominate rotated anteriorly 70.4 percent of women experience 5 nored by the physician and thought 4) 19 weeks pregnant back pain during labor. It has been demonstrated to be more common in of as something that is normal in preg nancy. It has been treated by limiting Plan women who experienced back pain in earlier pregnancies and less com the women's activities, such as avoid 1) Myofascial release lumbar and mon in well-fit women. The pain is ing stairs, extreme movements and cervical region usually located in the low back and overloading the pelvis, and by the use 2) Inhibition lumbar region gluteal areas and can be associated of Tylenol. In severe situations, low 3) Muscle energy - springing, with radicular symptoms. It is usu back pain has been treated by pelvic lateral recumbent, left sacral ally described as a dull ache in the belts, crutches or bed rest. There ex shear back and a stabbing pain in the glu ist many simple, conservative, non 4) Pubic decompression teal area. It is often described as in invasive modalities that can be used 5) Muscle energy right elevated termittent and aggravated by such to minimize the patients pain and first rib things as activity, bending forward make the pregnancy more enjoyable 6) Condylar decompression and overdoing things. 11 The pain for the female. Osteopathic manipu 7) Jones-strain counterstrain tends to limit the amount of time the lation has been used for years in or tenderpoints in cervical region women can participate in activities. der to relieve the symptoms of low 8) Pregnancy stretches The pelvis has also been described as back pain in pregnant females and 9) Follow up in 3 weeks locking up at times making walking --+ Fall 1999 AAO Joumal/19 recent investigations are beginning to There have been many recent in back pain in patients demonstrating statistically document its effective vestigations documenting the ease somatic dysfunction of the sacroiliac ness. However, many physicians still and effectiveness in treating low back joint.2 These investigations demon do not use the simple techniques of pain and sacroiliac disorders in the strate two techniques that can be per manipulation in the treatment of low pregnant female. The pain commonly formed on the obstetric patient.They back pain in pregnant females for sev described as low back pain is thought are effective in relieving low back eral reasons: to originate from somatic dysfunction pain that may be due to sacroiliac 1) Many medical practitioners are of three main joints: dysfunction. skeptical about manipulative therapy 1) Pubic symphysis, Patients that exhibit low back pain and associate it with only short term 2) Sacroiliac joints, and primarily due to somatic dysfunction relief. 3) Lumbar vertebral segments. of the lumbar region can be treated 2) The orthopedic literature tradi Treadwell and Magnus in 1996 re with lumbar counterpressure, also tionally taught that the sacroiliac ported that sacral shears are a com known as inhibition. Guthrie and joints do not move and therefore mon disorder in the pregnant female Martin in 1982 compared inhibition should not be considered as a source due to the laxtivity of the ligaments. 13 of the lumbar myalgia to the placebo of pain. In addition, they reported that a dys effect during labor.5 They applied 3) Low back pain 1ies outside most functional sacrum places undue stress counterpressure in the thoracic region obstetricians' area of expertise. on the surrounding musculature to stimulate the "hands on" or placebo 4) Most obstetric practitioners do which can lead to multiple complica effect. They illustrated that lumbar not have low tables to use for manipu tions, such as low back pain, pelvic inhibition relieved 81 percent of the lation, and pain and can restrict fluid drainage back pain and that 88 percent of the 5) Physicians feel the lack of time through the pelvic diaphragm result patients needed less medication. Fur available to treat the patient with ma ing in edema and venous insuffi thermore, lumbar inhibition reduced nipulation. 2 This is unfortunate since ciency. They described a technique of the use of major narcotics from 33.3 the skills of manipulation in the treat placing the patient in the lateral re percent to 23 percent The thoracic ment of low back pain during preg cumbent position for diagnosis and treatment group collectively received nancy can be learned relatively eas treatment. The patient is placed shear 16 doses of narcotic while the lum ily and require only simple equip side up with both legs flexed. The op bar-treatment group only received 3 ment. erator is positioned behind the patient doses. The pubes have also been ef The obstetric patient poses many and the caudal hand raises the fectively treated in the obstetric fe treatment difficulties to the physician. patient's leg from the table and stabi male by the use of pubic decompres The presence of the fetus eliminates lizes the leg with the operator's el sion and indirect techniques. It is also the ability to diagnose and treat the bow on the table. The cephalad hand now apparent that there is a signifi patient in the prone position and lim is placed on the sheared ILA. The pa cant need to continue manipulative its the use of many direct techniques, tient is asked to assist by compress therapy into the post-partum period especially techniques that involve ing the elevated leg down and, while as many patients still demonstrate low HVLA, in the lumbar and pelvic re the sacroiliac joint opens, the opera back pain six months after delivery.7 gion. HVLA techniques may induce tor springs through the inferior ILA. Even though there exist many ma injury/strain to ligaments in the body It is not uncommon for pregnant pa nipulative techniques that are effec that are already loose secondary to tients to have recurrent sacral shears. tive in relieving low back pain in the relaxin. 13 In addition, supine tech It has also been demonstrated that pregnant female, manipulative niques may also be complicated by sacral rocking is effective in releas therapy is contraindicated during pre the compression of the abdominal ing sacral restrictions.7 McIntyre and mature labor (it may enhance labor) vasculature by the large gravid Broadhurst in 1996 demonstrated that and in the presence of placenta pre uterus. 13 It is generally accepted that a rotational mobilization technique via, abruptio placenta, premature rup the Pneumatic hammer and the was significantly effective in reliev ture of the membranes and ectopic Aquamed should not be used in the ing low back pain in the pregnant fe pregnancies.7 obstetric patient. This is due to the po male. 8 Seventy-five percent of the There are many preventive mea tential complications to the fetus by the patients reported complete resolution sures that the patient can perform at vibratory motion and due to the poten after 3 treatments and the remaining home which can assist in limiting the tial of the release of oxytocin in the 25 percent reported 50-80 percent amount of back pain. The patient mother which can induce premature resolution. Daly et al in 1991 also re continued on page 36 labor. ported 91 percent resolution of low 20/AAO Journal Fall 1999 Meniere's syndrome resulting from multiple traumatic brain injury: Two case studies by Wesley C. Lockhart, DO, Department of Osteopathic Manipulative Medicine, Michigan State University College of Osteopathic Medicine
Introduction head and neck rotation from constant tinuous or intermittent head noises ac Two patients were referred to the to episodes of 5 to 7 times in a two to companied by diminution of hearing, Department of Osteopathic Manipula three week period; in addition, the ver intermittent attacks of vertigo, dizzi tive Medicine at Michigan State Uni tigo was less intense during the epi ness, uncertain gait, staggering and versity College of Osteopathic Medi sodes. This same patient experienced falling accompanied by nausea, vom cine with a diagnosis of bilateral complete resolution of headache and iting and syncope. In 1938, Hallpike 5 26 Meniere's disease. Both patients had neck pain for three weeks after the frrst and Cairns and Yamakawa inde undergone extensive medical testing. treatment. Subsequently, when an epi pendently reported the finding of en Neither had responded to conventional sode of headache with neck pain did do.lym phatic hydrops in temporal treatments for their episodic vertigo, occur it was reported as less intense. bones from patients with Meniere's nausea, tinnitus, aural pressure and Both patients were referred for neuro syndrome. Hallpike and Cairns em hearing loss. We were consulted to de ophthalmologic evaluation. One patient phasized the apparent idiopathic na termine whether there was a structural was referred for acupuncture. Osteo ture of the hydrops. For many years, component contributing to the disease pathic manipulation to reduce the struc investigators described the essential process. Both patients were found to tural dysfunction improved some of the changes in the anatomy of the laby have extensive histories of closed-head symptoms and frequency but did not rinth thus making Meniere's a spe injuries. This resulted in the author entirely resolve the symptoms of cific disease. In many patients vesti making a subsequent diagnosis of Meniere's syndrome. bular or auditory symptoms can oc Meniere's syndrome secondary to mul cur months or years prior to develop tiple traumatic head injuries. Both pa Hypothesis: ment of other symptoms. Only one tients had additional neuromuscular Multiple mild traumatic head inju fourth of the patients in a study by dysfunctions that presented with sig ries can lead to the development of Paparella were found to have likely nificant biomechanical abnormalities. Meniere's syndrome. This paper dis causes for Meniere's syndrome. Primary treatment included manual cusses the development of Meniere's These were infections; (i.e. otitis me manipulation of structural dysfunctions syndrome as it relates to multiple trau dia, meningitis, viral inflammations), by the author aimed at improving the matic brain injuries and offers a struc trauma (especially physical trauma or symptoms and decreasing the fre tural explanation using two patients as explosive sound), otosclerosis and quency of attacks experienced by the case studies. syphilis. Paparella defined Meniere's patients. After three months of treat "disease" as referring to the classic ment with a mean number of eight treat Background finding of episodic vertigo, fluctuat ing and progressive hearing loss, au ments, both patients had reported a de information: crease in episodes of severe vertigo ral pressure and tinnitus, loudness in Prosper Meniere,28 in 1861, de with nausea and vomiting. One patient tolerance and diplacusis due presum- scribed a syndrome consisting of con- reported a reduction in vertigo with ➔ Fall 1999 AAO Joumal/21 -
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drops paper cent displayed scribed history. of radiographs. is widely endolymphatic the 22/AAO malabsorptive columnar the thelium
sorptive Case of the ferred Patient# pathic tural agnosed disease Michigan for tial and plained superior on the left. The right iliac one foot with arms down and eyes ported as normal from a neurologist crest and trochanteric heights were open revealed significant problems consulted by the patient's family phy superior on the right. There was a with balancing on the left. The patient sician for the low back pain with positive forward bending test on the would immediately fall to the right. some radiation down the right leg. left, which was less with the arms ex He could stand on the right foot for The patient's back was treated with tended over the head. (This represents more than five seconds with his arms myofascial release and muscle energy myofascial stress from above the dia down and eyes open without support. technique for sacral restrictio,n as phragm affecting the sacroiliac joint.} Myofascial stresses were found at well as thoracolumbar junction Positive Gillet (stork) test on the right. the occipitoatlantal junction and the myofascial restriction, which in There was decreased motion of the suboccipital muscles on the right with cluded release of a very restricted lumbar spine with side bending to the splenius capitus and cervicis tight and right hemi-diaphragm. Individual right. No scoliosis was noted. restricted. The deep anterior cervical segmental dysfunctions of the lum muscles on the right were inhibited and bar area were L5-ERS right with L4 Seated: Positive forward bending loose. The more superficial stemo following L5; the sacrum was still a test was found on the right with arms cleidomastoid, pectoralis minor and right-on-right sacral torsion. All of extended over the head. This was anterior scalene were tight and re these were treated with muscle en negative with arms resting between stricted. The latissimus dorsi were tight ergy. The overall cranial pattern was legs. Trunk rotation was mildly de bilaterally (with the right being more in extension with movement between creased to the left. restricted) which created an upper lum a right torsion, inferior strain and a bar lordosis and significant lumbar ex- left latera l strain with left Supine: A short medial malleolus tension. There was weakness of the side-bending patterns. was found on the left. Pubic symphy serratus anterior as well as the rectus sis was superior on the left. Pelvic abdominus bilaterally. Aright-on-right Second treatment muscle control for inferior pelvic tilt forward sacral torsion was accompa (two weeks after first treatment): was restricted as well as rotation of nied with tight piriformis muscle, sac Low back pain improved at least 50 the pelvis and lumbar spine to the left. rotuberous and sacrospinous ligaments percent by patient history. Vertigo con The patient's attempt to achieve this on the left. The hamstrings were tight tinues, especially with any head move position caused muscle spasm in the and restricted bilaterally, left greater ment. There is no improvement in the latissimus dorsi, quadratus lumborum than right, as well. cranial rhythmic pattern; it continued and erector spinae on the right. Cranial evaluation revealed an in to be an irregular, non-smooth move creased cranial rhythmic impulse rate ment, dependent on the breathing of the Prone: A short medial malleolus of 18 cycles per minute. The ampli patient. Treatment aimed at sacral and was found on the left. The left ilium tude and vitality were decreased. A thoracolumbar areas. was posteriorly rotated. The gluteus right sphenobasilar torsion, inferior maximus was weak bilaterally. A dys vertical strain, left lateral strain and Third treatment functional paraspinal muscle-firing left side-bending pattern were found. (three weeks after second treatment): pattern for left leg extension was The cranial pattern would easily Patient stated that the Meniere's noted. The patient's firing pattern change between the above patterns symptoms were not better. However, was: the hamstrings, erector spinae, and was deemed unstable, as it ap he had not had any episodes of severe contralateral quadratus lumborum, peared to be dependent on the respi vertigo with vomiting. Approximately then ipsilateral quadratus for left leg ratory (or secondary) rhythm. There one third of low back pain continues. extension rather than hamstrings, glu was little to no independent move Sacral restriction, thoracolumbar and teus maximus, contralateral erector ment of the sphenobasilar symphy diaphragmatic myofascial restrictions spinae and quadratus lumborum, then sis; this was highly suggestive of were again released with a direct ipsilateral erector spinae and quadra sphenobasilar compression. myofascial release technique. tus lumborum- which would be the preferred functional firing pattern Treatment: Fourth treatment which was present for extension of First treatment (three weeks after third treatment): the right leg. In addition, the patient (one week after initial exam): Consulted another osteopathic used latissimus dorsi and thoracic The patient was first treated by the manipulative medicine specialist for erector spinae to stabilize his back for author for low back pain and dysfunc acupuncture of the myofascial trig extension of either lower extremity. tion, which was the most acute prob ger points to aid ·in release of the Sensorimotor balance testing on lem. A lower extremity EMO was re- ➔ Fall 1999 AAO Joumal/23 myofascial restrictions of the upper This was the last visit by the pa cific head injury at that time. The pa thoracic and cervicothoracic junction tient as he was attempting to obtain tient also had an ice skating injury area which might have aided in release disability and would be referred to a where he fell back hitting his head on of the sphenobasilar compression. The Traumatic Brain Injury Rehabilitation the ice. He does not remember a spe patient received treatment for OA FRrS Program near his home. cific loss of consciousness. left with marked tissue tension abnor He continued to work at an assem mality, C2-3 rotated right, T 2,3,4 and Patient#2 bly line job that required him to turn 5 rotated left and sidebent right with A 50-year-old white male patient his neck from side to side often. This HVLA by the consulting physician. was referred to the Department of began to create severe dizziness and hnmediately following this treatment, Osteopathic Manipulative Medicine nausea in 1994. The patient relates a treatment of the sphenobasilar com for a 6 year history of dizziness, hear separate work related trauma approxi pression was attempted using direct and ing loss, buzzing in both ears, loss of mately 3 years before the initial ex indirect approaches to the barriers of balance and numbness in the right amination, when he injured his right motion, but was not released. arm and fingers. His diagnosis was arm while using a sledgehammer in bilateral Meniere's disease. The pa the overhead position. The right Fifth treatment tient could trace the beginning of the shoulder and arm became weak and (one week after fourth treatment): problem to when he was 28 years old. he complained of a tremor with any Patient felt his low back pain was At that time, he was hit in the head strenuous use or with the arm over improved. Cranial rhythmic impulse with a hammer at work. Soon after head. Only conservative treatment pattern established as low amplitude ward he was evaluated for hearing was given to the arm at the time of right torsion, left side bending. The loss and buzzing in his ears. There injury. However, he was diagnosed as patient continued to complain of inter was no treatment at that time due to having an ulnar nerve entrapment mittent low back pain, however he was lack of physical evidence for the with carpal tunnel syndrome of the working around the house and yard problem. In addition, he was able to right upper extremity in June of 1995. doing light to medium strenuous relate another five incidents of closed He was evaluated for the Meniere's chores. He had not had an episode of head and/or neck injuries as a child, disease and the right upper extremity severe dizziness and vomiting in three teenager and adult. Recall of his first dysfunction by his family physician months, which was a significant im head injury was at 5 years old when as well as referral to a neurologist, provement in frequency of attacks. he was hit in the head with a large who subsequently referred him for rock and required several stitches. He evaluation, by a neuro-otologist. A Sixth treatment does not remember a loss of conscious review of the findings follow: (one week after fifth treatment): ness, but does remember being dazed. Patient states his Meniere's symp At 11 years of age he was rendered 1. Mild right carpal tunnel syn toms of vertigo and tinnitus are no unconscious when someone dropped a drome due to ulnar entrapment better. The tinnitus is in fact a bit cannon shell casing approximately 12 at the elbow diagnosed with worse. Low back is 90 percent better feet from a tree, hitting him on the top EMG by neurologist June 1995. by patient's admission. No episodes of the head. As a teenager, he was 2. Vestibular function test by of severe nausea and vomiting. Cra swinging on a rope and hit a support neuro-otologist revealed a com nial rhythmic impulse remains re beam in a barn with full frontal body pensated lesion of the labyrinth duced in amplitude and irregular in a impact. He believes he was uncon or vestibular nerve. A very strict right torsion, left side-bending pat scious for several seconds. vestibulo-ocular and vestibu tern. Treatment by the consulting os The patient could relate at least lospinal tract reflex exercise pro teopathic manipulative medicine spe three additional injuries that resulted gram was recommended. He was cialist included dry needling of trig in head and/or neck trauma as an unable to tolerate the exercise ger points of the cervical, thoracic and adult. After the hammer strike to the program even with a mild vesti lumbar regions. Immediately after head, in September of 1990, he fell bular depressant (meclizine hy wards treatment by the author in out of a tree and landed on his back drochloride). cluded myofascial release to the injuring his head, neck, and elbows. 3. MRI revealed a left maxillary cervicothoracic junction, the thora In addition, there was a snowmobile polyp. There were no increased columbar junction and to the sacrum. accident where he had a neck injury nor decreased signal intensities Indirect craniosacral therapy to the in which he could not move his neck within the brain. Brain stem and sphenobasilar symphysis was per for several days. He did not have a cerebeIJum were normal. formed without release. fracture, nor does he remember a spe- continued on page 37 24/AAO Journal Fall 1999 Perspectives: An overview of support for osteopathy in the cranial field by Michael L. Kuchera, DO, FAAO, Vice President and Dean, Kirksville College of Osteopathic Medicine
The osteopathic profession makes nial field and other physician mod many of these structures has been no exaggerated claims regarding ei els, it is important to recognize that correlated in numerous texts to dys ther the use or the documentation of diagnosis and treatment of somatic function of related neural, vascular OMT in the head region. It balances structures of the head region requires and Lymphatic structures related to 4 5 6 7 its claims about its approach to "os a skilled physician. Only a physician the head region. • • · While osteopa teopathy in the cranial field" in its has the range of training and capa thy in the cranial field has much broader standard textbook, Foundations for bilities needed to differentiate func philosophical and clinical implications Osteopathic Medicine, by saying: tional symptoms from underlying as practiced by osteopathic physicians, pathology. Diagnostic and treatment it specifically includes a number of "Much research remains to regimens, which include appropriate manual techniques designed to modify demonstrate the exact mecha follow-up and concomitant care (with or remove somatic dysfunction in the nisms involved in craniosacral or without medication), will also be head region. dysfunction and recovery. How discussed only from the physician Somatic dysfunction in any region ever, more than 50 years of clini level model. This paper will not dis is based upon palpatory characteris cal experience has indicated that cuss so-called "craniosacral therapy" tics best summarized by the mne the use of osteopathy in the cra given by non-physician therapists monic, TART. 8 This mnemonic stands nial field has given relief to with inadequate training. for Tenderness, Asymmetry, Re many patients in whom no other stricted Motion, and Tissue Texture treatment was effective.''1 Somatic dysfunction Abnormality. Other than "tender of the head region ness," which some feel may rely too This short essay provides a quick heavily on the patient's subjective Somatic dysfunction is defined as overview of the diagnosis and treat report, each component element has impaired or altered function of the ment of somatic dysfunction in the been well documented by basic and somatic system -skeletal, arthrodial, head region, which is only one small clinical scientists as being objective and myofascial - and its related neu component of osteopathy in the cra and reliable physical findings exist ral, vascular and Lymphatic ele 9 10 11 nial field. ing in every area of the body. • • ments. 3 The International Classifica According to the Educational With respect to the head region, nu tion of Diseases (ICD-9-CM) further Council on Osteopathic Principles of merous researchers have documented subdivides somatic dysfunction into the American Association of Colleges both the existence of dysfunction (A, regions, one of which is "somatic of Osteopathic Medicine,2 all colleges R, and/or T) in the head region and dysfunction - head region." Skeletal, of osteopathic medicine offer an over its clinical relevance. In the complete arthrodial, and myofascial structures view of the principles and techniques history and physical examination, in this region include (but are not lim of osteopathy in the cranial field. anosteopathic structural examination ited to) the occipitoatlantal (OA) Mastery of physician-level treatment of the entire body, including the head joint, the temporomandibular joint skills typically is reserved for post region, is required by the American (TMJ), cranial sutural sites, and a graduate and/or continuing medical Osteopathic Association for every number of muscles attaching to the education. In osteopathy in the era- hospitalized patient. 12 cranium. Somatic dysfunction of
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occurring occurring quently quently head region is an objective, codable turbances, disturbances of mastica ologic model, from an outcomes palpatory finding considered valuable tion, sinus symptomatology, and perspective, treatment could be to a number of clinical models and headache. Integrating objective find considered effective and the model patient conditions. ings of asymmetry, restricted motion considered to be operational if re Tissue texture changes in the and tissue texture change and inter moval of somatic dysfunction re head region are commonly recorded preting them with different patho sults in the predicted modification as alteration of sweat gland activity, physiologic models has resulted in a or elimination of clinical signs and an autonomic function, or as muscle number of clinical-approaches. By symptoms. For example, the osteo spasm or flaccidity. Often sites of ten definition, osteopathic physicians pathic and myofascial triggerpoint derness are palpated for evidence of welcome Travell's-approach as a sub models share a number of similari swelling, edema, warmth, spasm, or set of their understanding of somatic ties as to diagnostic and treatment other descriptors of a tissue texture dysfunction of the head region and as relevance but often differ in their pos change. These findings have been an additional set of treatment modali tulated mechanisms. Each prescribes correlated with traumatic, infectious, ties to remove somatic dysfunction specific diagnostic and treatment ac or malignant conditions or at least from the region.31 The key is to record tions and while many of these actions provide valuable information in the objective physical findings and inte share common characteristics, many differential diagnosis of problems af grate these findings into a clinical others are unique to the model upon fecting the head. Janet Travell, MD model which permits us to better un which they are based. Each treatment and David Simons, MD dedicate a derstand pain and dysfunction in our claims a reduction in somatic dysfunc dozen chapters in their book, Myo patients. Osteopathic physicians us tion using the original diagnostic ac fascial Pain and Dysfunction: The ing "osteopathy in the cranial field" tions which, in tum, parallels reduction Trigger Point Manual (vol l), 30 to as their operative model, look for vi of patient signs and symptoms. muscular (somatic) dysfunction asso sual and palpatory clues to somatic Travell's triggerpoint model docu ciated with the head region. They dysfunction (ART). This permits ments myofascial somatic dysfunc describe in detail the palpatory tests them to responsibly include primary tion as an important component of the and tissue texture characteristics de and secondary "somatic dysfunction differential diagnosis of head pain and fining latent and active myofascial of the head region" in the differential disorders of the HEENT and it fur triggerpoints used in this model of diagnosis related to each presenting ther documents that removal of this diagnosis and treatment. In addition complaint. somatic dysfunction is an effective to a number of well-documented and important treatment approach. As headache pain patterns arising from Treatment previously mentioned, the osteo muscles of the head region, they of somatic dysfunction pathic model also recognizes the im document, from clinical observation, portance of myofascial somatic dys associated symptoms affecting the of the head region function of the head region. This as function of the eyes, ears, nose, and Barring certain well-described pect is discussed in Foundations of 40 41 throat and a number of cranial nerves. contraindications to specific tech Osteopathic Medicine • and in the They also document impaired or al niques, a number of manipulative and EENT chapter of Osteopathic Con tered Lymphatic, vascular and_auto physical modalities have been de siderations in Systemic Dysfunction,42 nomic function secondary to these scribed to treat somatic dysfunc both frequently used teaching texts. 32 33 34 35 36 myofascial (somatic) changes. Tissue tion. • • • • Most agree that the spe Nonetheless, over and above texture changes are also universally cific treatment technique is less im myofascial somatic dysfunction, os accepted objective physical findings portant than the goal of reducing so teopathy in the cranial field also rec best experienced through palpation. matic dysfunction or otherwise restor- ognizes the skeletal and arthrodial In summary, a number of experts ing somatic functions. A number of components of somatic dysfunction in a wide range of clinical and dental mechanisms have been advanced to of the head region. In this regard, it disciplines recognize that somatic describe how these manipulative or may be important to note that some dysfunction of head region structures physical maneuvers work, often pos treatment to remove somatic dysfunc plays a role in the diagnosis and/or tulating pathways whereby the treat tion in the head region using an os treatment of multiple clinical entities. ment technique alters and reeducates teopathic model may be indistin These entities present with a wide the central response to peripheral re guishable from techniques indepen 37 38 39 range of signs and symptoms includ ceptor activity. • • dently developed and described by ing facial pain, organ dysfunction, Regardless of the postulated treat Travell using the triggerpoint model. muscle spasm, dizziness, visual dis- ment mechanism or the pathophysi- ➔ Fall 1999 AAO Journal/27 This , even though the postula ted where dispelling dogma using experi ity). Furthermore, they demonstrated mechanisms-of-action may differ. For mental methods was important to the that in subjects with loss of cranial example, treatment techniques inde osteopathic community. Dispelling compliance (restricted cranial motion pendently described by Travell to al dogma is important to individuals on capability), there was a loss of the ter autonomic activity to the nasal si both sides of the issue. Nonetheless, ability to compensate for increases in nuses43 or for improving eustachian proponents on each side of the ques intracranial pressure. Dowling and tube function44a re nearly identical to tion of cranial bone mobility were Lewandowski at the New York Insti osteopathic cranial manipulation ready to argue dogmatically on the tute of Technology (NYIT) demon techniques postulated to affect the basis of "what was generally said or strated a 95 percent correlation be sphenopalatine ganglion.45 In this believed," rather than objectively tween physician observers palpating case, the first treatments are based on looking at the data. At the root of this the cranial rhythmic impulse (a pal the triggerpoint model while the other debate was the fact that Sutherland's pable component attributed to several technique is based on the osteopathy observations and teachings led a num elements of cranial motion) and a in the cranial field model. Between ber of osteopathic clinicians to diag computer-based kinematic system different models, other treatment tech nose and treat motion restrictions of making simultaneous measurements niques to affect somatic dysfunction in the cranial sutures. Opponents dis from reflective markers anchored by the head region, including triggerpoint missed this approach as quackery fine needles into the frontal and oc injections, pressure across sutural sites, because most textbooks considered cipital bones of human subjects . and muscle stretching with or without the cranium to be a rigid, relatively These more recent studies from vapocoolant spray, may share only par immovable container. If motion at the Michigan State University and NYIT tial similarity or may share none at all. cranial sutures was not possible, then build on earlier investigations of The important fact to recognize is that alternative postulated mechanisms for structure and function of the cranial effective treatments to remove somatic clinical success of certain cranial sutures,50,51,52,53,54 which sought to in dysfunction vary as greatly as do mod OMT Techniques would need to be vestigate the validity of Sutherland's els used to describe why they work. developed. observations and his hypotheses. To examine whether motion is pos The implications of all of these Specific research related sible at the sutures experimentally, the findings may require a paradigm shift in the diagnosis and treatment of a to osteopathy in the American Osteopathic Association, the American Academy of Osteopa number of conditions in which the cranial field: Motion at the thy, and the Cranial Academy have cranial sutures are considered immov cranial sutures all funded research. Additionally, a able. (As an aside, note that prior to Reasoning from structure to func number of clinicians have indepen 1960, the same dogmatic argument was tion, William G. Sutherland, DO was dently studied interexaminer reliabil ongoing on whether the sacroiliac joint struck by the articulations of a disar ity of the palpatory components of was capable of motion. At that time, ticulated skull mounted in Kirksville, somatic dysfunction of the head re the American edition of Gray 's Missouri. His description of cran gion and have recorded their clinical Anatomy said there was no motion pos iosacral movement was espoused in observations of components of the os sible. Thus, despite clinical evidence to 1939 after several years of careful teopathic model relative to the head the contrary, osteopathic diagnosis and observation, palpation, and experi region in various clinical and con treatment of the sacroiliac joint was mental work with disarticu lated trolled settings. argued as obviously ineffective because bones. About Sutherland's contribu Typical among these studies is the textbook knowledge said that motion tions of thought, the osteopathic pro work of S. R. Heisey, ScD and Tho didn't exist in the first place. Now, in fession records, "One of the most in mas Adams, PhD at Michigan State ternational multidisciplinary confer 47 48 49 novative ideas to be advanced by a University. Their work • • con ences discuss the structure and func member of the osteopathic profession cludes that many of the original stud tion of the sacroiliac jointin detail along was the concept of articular mobility ies leading to the belief that the cra with its clinical relevance to pain and of the cranial bones ... His observa nium is immovable were falsely in dysfunction.) In any case, experimen tions ... and discussions of diagnos fluenced by the experimental use of tal documentation should displace the tic tests and treatment procedures for an immobilizing frame. Modification dogmatic belief that the cranium is in various conditions were presented in of the method using strain gauges capable of motion or the claims that at the book, The Cranial Bowl."46 across the parietal suture in cats per tempts to remove somatic dysfunction Whether or not the cranial bones mitted documentation of motion mea of the head region are based on quack were capable of motion was an area sured as compliance (motion capabil- ery or dogma. 28/AAO Journal Fall 1999 Specific research Osteopathic Approach to Diagnosis tions can support complex studies, re quiring major investments of resources related to osteopathy in and Treatment, published in its sec ond edition by J. B Lippincott (1997) and manpower. the cranial field: Consensus also appears in numerous Furthermore, we can borrow data Clinical uses textbooks written by acknowledged from other professions to explain those observations and clinical successes of leaders in the specialty field of Os The osteopathic profession has the osteopathic medical profession. long been a service profession and teopathic Manipulative Medicine. However, one of the best ways to show admits that much clinical research Consensus in teaching the role of di the efficacy of osteopathic medicine is must be performed in this area. None agnosis and treatment of somatic dys to study the phenomena in its natural theless, a wealth of clinical experi function of the head region is also setting, the office practice. ence, a number of books, and increas actively sought by educational sub Viola M. Frymann, DO and her col ing numbers of case reports published committees of both the American leagues, Richard E. Carney, PhD, and in the Cranial Letter and MO Jour Academy of Osteopathy and the Peter Springall, PhD, did just that. ...these researchers present the results nal exist regarding the use of oste Educational Council on Osteo of a very energetic undertaking con opathy in cranial field as a clini pathic Principles of the American the ducted at the Osteopathic Center for Association Colleges Osteo cal model for diagnosis and treatment of of Children in La Jolla, California. They of somatic dysfunction of the head re pathic Medicine. As a consequence designed and carried out a prospec gion. Recently, these observations of ongoing research and dialogue, tive study60 examining the effects of and increased funding to the AOA predoctoral, postdoctoral and con osteopathic medical care on children Bureau of Research have made in tinuing medical education (CME) with neurologic developmental creased research a possibility. concerning osteopathy in the cranial problems. This study, conducted As an example, clinical observa field is continuously updated and of during a 3-year period, represents a tion empirically suggested a role for fered throughout the United States. massive, concerted effort to test the osteopathic medical profession's the use of osteopathic manipulative As a profession, we are aware of claims that it offers treatment and treatment in patients with otitis me our clinical strengths and of the need care for a broad range of human for a stronger research agenda. None dia.56 This led to the design of sev problems, not just back problems. eral pilot studies at the osteopathic theless, professional expert opinions, The researchers evaluated 186 chil colleges in Missouri (Kirksville), expert consensus and peer-reviewed dren, aged 18 months to 12 years, as Oklahoma, and West Virginia to ex texts are strong starting points for our they underwent osteopathic manipula amine the incidence and the relevance ever-increasing research agenda. In tive treatment (0:1\tlT) for neurologic, of somatic dysfunction of the head closing this perspective, the June medical, or structural disorders. The region in children with otitis me 1992 editorial by Michael M. data show that OMT had positive ef dia.57·58The relevance of somatic dys Patterson, PhD in the Journal of the fects on the levels of neurologic de velopment in children with neurologic function of the cranium to pediatric American Osteopathic Associations, deficits. These beneficial effects con patients with recurrent otitis media is relevant and worth repeating. tinued long after treatment stopped. documented in these pilot studies led Immense effort went into the de " ...The September 1991 issue of the to two-year outcomes multicenter sign, execution, analysis , and studies funded through the American JAOA ... featured an editorial calling pre-publication preparation of this for more theory building and for the Osteopathic Association's Bureau of study. It should be a landmark event testing of osteopathic medical tenets Research. One was just completed for the osteopathic medical profession with scientific investigations, both ba and is being tabulated; the second was because it shows that such studies are sic and clinical. feasible; they can be accomplished. Of approved in July 1998. Good, scientifically valid and course, the fact that OMT seems to The expert opinion of the profes well-designed studies are, perhaps, one have "worked," just as many of us in sion regarding the clinical importance of the most difficult things a practic the osteopathic medical profession of the diagnosis and treatment of so ing physician can undertake in the of would have predicted, makes this a fice setting .... This type of undertak matic dysfunction of the head region landmark study. A starting point that ing, however, is the ultimate testing in a variety of musculoskeletal and should not be taken lightly, this study systemic disorders is expressed in ground for the ideas and theories of the should pave the way for more studies several peer-reviewed texts. These profession. in the office setting. The basic scientist can present texts include, Foundations.for Osteo It is the office setting, after all, that mechanisms that may underlie the pathic Medicine, published as an will serve as the ultimate testing clinical phenomena observed in the ground for osteopathic medical phi- AOA-endorsed consensus text by office setting. Our educational institu- Williams & Wilkins (1997), and An ➔ Fall 1999 AAO Journal/29 losophies, thereby completing the Baltimore MD, Williams &Wilkins, 1997, craniosacral mechanism to symptomatol circle from clinical observation to fi pp. 1067-1075. ogy of the newborn: study of 1,250 infants. IO.Peterson B (Ed): The Collected Papers of JAOA 1966; 65:1059-1075. nal clinical test." Irvin M. Korr. Newark OH: American 28.Frymann VM: Learning difficulties of Academy of Osteopathy; 1997. children viewed in light of the osteopathic Osteopathy in the cranial field de 11. Beal MC, Goodridge JP, Johnston WL, et concept. JAOA 1976; 76:46-61. veloped from applying osteopathic al: Interexaminer agreement on patient 29.Frymann VM, Carney RE, Springall P: principles to the study of the func improvement after negotiated selection of Effect of osteopathic medical management tests. JAOA. 1979; 79:432-440. on neurologic development in children. tional anatomy the cranium. From of 12.American Osteopathic Association: The JAOA 1992; 92(6):729-744. empirical observations to multicenter Accreditation Requirements for Health 30. Travell IG, Simons DG: Myofascial Pain clinical research, osteopathic practi Care Facilities. Chicago IL: American and Dysfunction, The Trigger Point tioners have continuously sought to Osteopathic Association, 1998. Manual. Baltimore MD, Williams & better understand the local and sys 13. Lay EM: Chapter 64. Cranial field. In Wilkins, 1983, pp.165-32931. Kuchera Ward RC (Ed): Foundations for Osteo ML: Chapter 66. Travell and Simons' temic effects of somatic dysfunction pathic Medicine. Baltimore MD, Williams myofascial trigger points. In Ward RC of the head region and outcomes of & Wilkins, 1997, pp. 901-913. (Ed): Foundations for Osteopathic Medi correcting that dysfunction. Properly 14.Hunt, CE, Peczynski MS: Does supine cine. Baltimore MD, Williams & Wilkins, integrated into a physician's complete sleeping cause asymmetric heads?" Pedi 1997, pp. 919-933. atrics 1996; 98: 127-129. 32. Ward RC (Ed): Foundations for Osteo evaluation of the patient, this model 15.Magoun HI: Osteopathy in the Cranial pathic Medicine. Baltimore MD, Williams of osteopathic diagnosis and treat Field 3"' edition Kirksville MO: Journal & Wilkins, 1997. ment offers documented beneficial Printing Co; 1976, p. 268. 33. DiGiovannaEL, Schiowitz S: Osteopathic options for primary or adjunctive care 16.Kuchera ML, Kuchera WA: Osteopathic Approach to Diagnosis and Treatment (2nd in enhancing health or treating dis Considerations in Systemic Dysfunction edition). Philadelphia PA, JB Lippincott, (2•d edition revised). Columbus OH, 1997. ease and dysfunction. Greyden Press, 1994, pp. 48-49. 34.Magoun HI: Osteopathy in the Cranial 17 .Magoun HJ: Osteopathy in the Cranial Field 3' d ed. Kirksville MO: Journal Print Field 3, 30/AAO Journal Fall 1999 and Dysfunction, The Trigger Point Manual. Baltimo re MD, Williams & Wilkins, 1983, pp.249-259. AAO's Bookstore 45.Magoun HI: Osteopathy in the Cranial Field 3rd ed. Kirksville MO: The Journal Printing Co; 1976; p.183. adds (3) Books 46. Northup GW (Ed): Osteopathic Research: Growth and Development. Chicago IL: American Osteopathic Association; 1987, p. 40. Osteopathic Principles in Practice, 4 7. Heisey SR, Adams T: Role of cranial bone Revised Second Edition mobility in cranial compliance. Neurosur by William A. Kuchera, DO, FAAO and Michael A. Kuchera, DO, FAAO gery 33:869-877, 1993. 48.Adams T, Heisey SR, Smith MC, Briner BJ: Parietal bone mobility in the anesthe "Leaming to be an osteopathic physician is a cooperative venture between the student and tized cat. JAOA 92:599-622, 1992. the faculty. There is no way that thefaculty, through lecture and demonstration, can give the 49.Heisey SR, Adams T, Smith MC, Briner student all the information that will be needed as a physician. The student must have or B: The role of cranial suture compliance develop a driving desire to learn, to know, to read about and to practice the basic osteopathic in defining intracranial pressure. MOA philosophy, principles, techniques, and procedures presented during the training years. 93(9J951, 1993. This text is designed and presented with the expectation that each student will graduate as 50.St. Pierre NF, Stedman P, Glick P: The a sensitive, well-trained physician who puts their osteopathic principles into practice detection of relative movements of cranial bones. JAOA 1976; 76:289. * providing the latest indicated text, pharmaceutical and surgical aids, 51.Frymann VM: A study of the rhythmic * recognizing the fact that even though illness today may be caused by stress, disease, and motions of the living cranium. MOA 1971; accident, clues to dysfunction in the body will be found in the neuromusculoskeletal 70:928-945. system; 52.Michael DK, RetzlaffEW: A preliminary * designing treatment to maximize structure-function relationships and homeostatic study of cranial bone movements in the responses with the body unit. " squirrel monkey. JAOA 1975; 866-869. 53.Retzlaff EW, Michael DK, Roppel R, Mitchell F: T he structures of cranial bone Easy OMT: sutures. JAOA 1976; 75:607-608. An easy to use, step-by-step photo reference guide 54.Retzlaff EW, Mitchell FL, Upledger JE, BiggertT: Nerve fibers and endings in cra to manual medical care nial bone sutures.JAOA 1978; 77:474-475. by William H. Howard, DO 55.Frymann VM: Diagnosis and treatment of Retired Kirksville College of Osteopathic Medicine Professor William L. Kuchera, otitis media in children (1992). In King DO, FAAO writes in the foreword: (Ed): The Collected Papers Viola HH of "Easy OMT presents the basic HVLA, muscle energy, and indirect osteopathic manipu Frymann, DO: Legacy of Osteopathy to lative techniques following the outline of the Kimberly Manual of Manipulation as taught Children. Indianapolis IN: Ame rican in the osteopathic medical colleges in the United States. Academy of Osteopathy; 1998, pp. 110- "The presentations are concise and clear. The professional photos orchestrated by Dr. 111. Howard clearly illustrate the position of the patient, the position of the physician and intent 56.Block MA: Texas DOs learn to treat otitis of the technique. .. media with OMT. The DO July 1993, pp. "It is my recommendation that this new edition be in the reference library of every 44-46. osteopathic medical student and physician." 57.Degenhardt BF, Kuchera ML: The preva lence of cranial dysfunction in children with history of otitis media from kinder garten to 3rd grade. JAOA 1994; 94:754. Osteopathic Considerations in Systemic Dysfunction 58.DegenhardtBF, Kuchera ML: The efficacy by M. L. Kuchera, DO, FAAO and W. A. Kuchera, DO, FAAO of osteopathic evaluation and manipula This text encourages the reader to examine familiar medical facts, anatomic relation tive treatment in reducing the morbidity ships and physiologicfunctionsfrom the osteopathic perspective. This perspective can then of otitis m edia in children MOA 1994; be carried into the diagnostic and therapeutic decisions which will repeatedly be required 94:673 of the medical student and the osteopathic physician for the rest of their professional lives. 59.Patterson MM: Testing osteopathic medi This text does not propose to replace the many reference texts of medicine and does not cal concepts in a real-life setting. MOA include a complete differential diagnosis or a complete treatment plan.for the clinical situ 1992; 92:689. ations that are discussed. Its purpose is to explore selected structural and functional con 60.Frymann VM, Carney RE, Springall P: siderations which may produce symptoms or compromise homeostasis. It also demonstrates, Effect of osteopathic medical management by example, clinical application o.fthe osteopathic philosophy in selected situations. Lastly, on neurologic development in children. it attempts to show where osteopathic manipulative treatments can be prescribed as pri JAOA 1992; 92(6):729-744.0 mary or adjunctive modalities available to the physician as they assist patients in reaching their maximum health potential. Fall 1999 AAO Journal/31 A review of the principles of William G. Sutherland's general techniques by William J. Golden, DO, Department of Osteopathic Manipulative Medicine, Michigan State University College of Osteopathic Medicine The following paper is the result Historical background ligamentous release, or ligamentous of the author's opportunity to person H.A. Lippincott, DO was a de articular release. "The purpose of the ally interact with several osteopathic voted student of Sutherland's, study technique is to establish a state of clinicians that were students of Dr. ing his philosophy and describing his ligamentous balance by placing the 6 7 joint in the position which puts just William Sutherland. After observing techniques. • In 1949, he writes: "In a diversity of techniques amongst these days of rapid changes in medi enough tension on the weakened liga them, an endeavor to discover a com cine, older methods are constantly ments to balance the tone in the mon method of approach was pur being replaced by new, and there is a unstrained tissues. This position is sued. This paper is not only a reflec scoffing at the procedures that were commonly found in the direction into tion of those experiences but also of used in the days of our grandfathers."6 which the joint moves most freely. the writings of others (the majority Let us therefore neither scoff nor ig When it is found and it is established, being students of Sutherland's) in the nore these foundations but rather it is maintained by the hold of the 8 attempt to bring together and harmo learn from them by examining their operator. " nize the osteopathic principles taught underlying principles. In another ar Ligamentous articular strain ( or by Dr. Sutherland. ticle of Lippincott's he states: "It is balanced ligamentous tension) tech evident that Dr. Still treated his pa niques are used to treat dysfunction Introduction tients carefully, with due consider at lesioned segments. Historically Dr. Sutherland's approach to the ation for the delicacy and the welfare termed the osteopathic lesion, these treatment of areas other than the cra of the tissues beneath his fingers. It dysfunctions were described as 9 nium are referred to as "general tech is also evident that he imparted to the "strains of the tissue of the body." niques." These treatment modalities students who came under his super Strain, as defined in the Glossary of were early applications of an indirect vision this wholesome respect for the Osteopathic terminology, is a "distor method in manipulative management tissues, the structures, and their func tion with deformation of tissue" evi to establish what he expressed as a tioning.'7 One of those students of Dr. dent by the presence of " motion and/ state of "balance" in the function of Still's was William Gamer Sutherland or positional asymmetry associated tissues (bony and soft). In his gen who graduated from the American with elastic deformation of connec eral manipu lati ve procedures, School of Osteopathy at Kirksville, tive tissue (fascia, ligament, mem Sutherland's hand placements, patient Missouri in 1899. brane)."10This distortion can be in positioning, etc., have already been Dr. Sutherland referred to strains duced by physical trauma (either mi 1 2 cro or macro), reflexes (such as vis described. • Several approaches us that involve the bony cranium and its ing variations of these procedures dural membrane as membranous ar ceral), emotional trauma, and perhaps have also been reported.3,4,sTh is pa ticular strains, and to those that in by external forces in utero and dur 11 per instead will explore some of the volve joints outside the cranium sur ing the birth process. basic osteopathic principles and rounded by ligaments as ligamentous Thomas F. Schooley, DO has sum methods that involve a variety of con articular strains. The osteopathic tech marized Dr. Sutherland's approach to cepts underlying these procedures. nique of William G. Sutherland, DO general techniques as follows: " The is sometimes referred to as balanced principle of 'indirect action' tech- 32/AAO Journal Fall 1999 nique is to position the articulation in the involuntary mobility of the tures. It also contains concentrically such a manner that there is no ten sacrum between the ilia. placed tubes which allow for the pas sion on any of the periarticular tis Rollin E Becker, DO states: sage of central nervous system, the ver sues in any of the cardinal planes of "Health requires that the PRM have tebral column and related structures." 18 motion. This position has been the capacity to be (an) involuntary, "Fascia is very extensive. If all other called... 'balanced ligamentous ten rhythmic, automatic, shifting suspen tissues and organs were removed from sion.' It is this position, with all ten sion mechanism for the intricate, in the body, with the fascia kept intact, one sion removed, that will allow edema tegrated, dynamic interrelationships would still have a replica of human tous fluids to escape into the sur of its five elements. It is intimately anatomy. Fascia surrounds every rounding tissues and circulatory sys related to the rest of body through its muscle and compartmentalizes organs tem ... when the edema has been elimi fascia/ connections from the base of in the face, neck, and mediastinum. nated and muscles relaxed, the body's the skull through the cervical, tho Fascia forms sheaths around nerves and own healingforces will restore the pe racic, abdominal, pelvic, and appen vessels. It envelops the thoracic and riarticular tissues to their normal state dicular areas of the body physiology. abdomino-pelvic organs. Fascia con of health. This healing mechanism is Since all the involuntary and volun nects bone to bone, and forms tendi known as homeostasis."12 tary systems of the body, including nous bands and pulleys."19 the musculoskeletal system, are found Thus, these two key principles of Osteopathic principles infascial envelopes, they too, are sub osteopathic philosophy, the unity of the The Natural Healing Power ject to the 10 to 14 cycle-per-minute body and the natural healing force, (re rhythm of the craniosacral mechanism flected as the "inherent activity of the PRM,") are common to the methods The principle involved in "body's in addition to their own rhythms of in voluntary and voluntary activity." 15 of Dr. Sutherland. There are two other own healing forces" is critical to the important principles of osteopathic understanding of Dr. Sutherland's philosophy that get frequent reference: teachings and methods. Osteopathy is Body Unity structure and function are reciprocally an art and science based on an articu Fascia is a Latin word that means a interrelated; and rational therapy is lated philosophy; the inherent ability "band." It is a sheet of continuous fi based on body unity, self-regulation, of self-regulation, self-healing, and brous tissue that lies deep to the skin and the interrelationship of structure self-maintenance appears to be a cor and invests all the structures of the and function. nerstone in that foundation. Termed vis body. Another concept of Dr. medicatri.x naturae in Latin, or "Breath Sutherland's general technique, which of Life" by Dr. Sutherland, the " inher also incorporates the osteopathic phi Application of principles ent recuperative, restorative, and reha losophy, is the unity of the person. Thomas F. Schooley offers some bilitative power... (is evident when) we "Anatomically, all the body structures comments about the therapeutic pro recover from illnesses, fevers drop, are involved in connective tissue or fas cedures that Dr. Sutherland applied in blood clots and wounds heal, broken cia, making them continuous and me addressing these principles: "He taught bones unite, infections are overcome, chanically interdependent... when one his students to first determine the di skin eruptions clear up, and even can component is stressed or altered, other rection in which the somatic dysfunc cers are known to occasionally undergo components are affected and respond tion was produced. This is the direc 16 'spontaneous remission.' 13 accordingly." As the body is united tion of greater motion. He taught us to i. It is this "body's own healing anatomically, that which makes the move the articulation in this direction forces" that Edna Lay, DO comments body mechanically continuous, as a to the limit of available range of mo on as the "use ( of) the power or po unified system is the fascia. Fascia "sur tion and then to 'back off' or release tency of the inherent activity of the rounds each muscle, vein, nerve, and the motion very slightly to the point 17 primary respiratory mechanism all organs of the body." where there was no tension on the sup (PRM) within the patient to assist the "From a functional point of view, the porting ligaments in any of the three release of strains."14 The PRM is de body fascia may be regarded as a single cardinal planes of motion and then to scribed as having five anatomic and continuous laminated sheet of con hold the articulation at this point until physiologic components: 1) the inher nective tissue. This laminated sheet there appeared a softening or relaxation ent motility of the brain and spinal extends without interruption from the of the periarticular tissues ... the opera cord, 2) fluctuation of the cerebrospi top of the head to the tips of the toes. It tor actually moves the articulation in nal fluid, 3) mobility of intracranial contains pockets, which allow for the the direction in which the somatic dys 20 and intraspinal membranes, 4) articu presence of the viscera, the visceral function was produced. " The under- lar mobility of cranial bones, and 5) cavities, the muscle and skeletal struc- ---+ Fall 1999 AAO Journal/33 lying concept that many of the originally occurred, and only this po ence of Osteopathy. Sutherland Cranial Sutherland students seemed to agree sition. When the joint is returned to this Teaching Foundation 1990, p 191 -217. upon, was that maintaining this "posi position, the muscles promptly and 3. Miller Herbert, DO, FAAO; personal com munication. 24 tion of balanced tension" allows the in gratefully relax." 4. Becker Rollin; Diagnostic Touch Part III herent force, the self-healing vis Also, the positional terminology Academy of Applied Osteopathy Year medicatrix naturae to work. 21 Edna Lay, and concepts such as "retracing the book, 1964, p 161166. DO writes: "keep your sensing appara path of the lesion" are not a universal 5. Chila Anthony; Fascial-Ligamentous Re lease. Foundations for Osteopathic Medi tus alert so that it perceives the slow medium for describing the application cine. Williams and Wilkins, 1997, p movement of the PRM (primary respi of indirect methods. One needs to con 819-832. ratory mechanism). This movement sider the functional orientation for 6. Lippincott HA; The Osteopathic Tech feels like a longitudinal ebb and flow technic in its development by Drs. nique of Wm G. Sutherland, DO, Ameri or a subtle pumping effect up and down Hoover, Bowles, and Johnston begin can Academy of Osteopathy Yearbook, 1964, p 138. the spine... continue to maintain this po ning in the 1940s. "Functional" tech 7. Lippincott HA; Basic Principles of Osteo sitioning and to observe this rhythmic nique is also considered an indirect ma pathic Technic; AAO Yearbook, 1961, p motion; the inherent force is working nipulative method. Instead of retrac 45. through the tissues that are maintain ing the path of the lesion and reiterat 8. Wales Anne: Ligamentous Articular ing the somatic dysfunction. As they ing other positional concepts, their ori Strains and Membranous Articular Strains American Academy of Osteopathy Year accomplish their task for this articula entation embodied a concept "of a book, 1951, p 74. tion at this time, the amplitude of the mobile system and mobile segments 9. Lippincott HA; American Academy of Os inherent rhythm lessens and the pump that acted in concert with one an teopathy Yearbook, 1964, p 138. ing decreases, and the tissues beneath other."25 It is not a positional criteria 10. The Glossary Review Committee of the your palpating fingers seem to soften that is applied in functional; rather, it Educational Council on Osteopathic Prin ciples. Glossary Osteopathic Terminol 22 of or melt." is the palpable response to specific ogy, AOA, I 993. motion demands. There is a motor co 11. Lay Edna; An Outline of Osteopathy in Discussion ordination "necessary for each bone to the Cranial Field. Department of Osteo be in the right place at the right time pathic Theory and Methods, 1980, p 1. Presented in this paper are some ba 12.Schooley T; Osteopathic Principles and during these demands, implying a sic, common underlying principles that Practice, 1987, p 45. were utilized by several students of Dr. theoretic basis in neurophysiology for 13.Korr I; An Explanation of Osteopathic 26 William Sutherland. Continuing devel indirect methods." Principles. Foundations for Osteopathic opment of such principles as body unity, The osteopathic principles underly Medicine. Williams and Wilkins, 1997, p ing the methods and concepts of Dr. 10. the self healing capabilities of the body, 14.Lay E; Cranial Field. Ibid. p 911. and therapy based on these concepts Sutherland's general techniques, such 15.Becker Rollin; Craniosacral trauma in the were carried on by several of Dr. as body unity and the self-regulatory, adult. Osteopathic Annual, 1976, 4:43-59. Sutherland's students (Drs. R. Becker, self-healing, and self- maintenance of 16.Seffinger M; Osteopathic Philosophy. E Lay, T. Schooley, A. Wales, and the body, continued being reflected in Foundations for Osteopathic Medicine. the writings of his students. Using in Williams and Wilkins, 1997, p 4. Herbert Miller respectively). 17. Still AT; The Philosophy and Mechanical Key application was the use of indi direct methods in manipulative treat Principles, p 60. rect methods to treat somatic dysfunc ment for somatic dysfunction also con 18.Upledger J; Cra niosacral Therapy. tions. Procedures "that initiate direc tinued to be a frequent approach Eastland Press, 1983, p 237-238. amongst his students. However, the 19.Burns N; Fascia. An Osteopathic Ap tions of decreasing tissue resistance are proach to Diagnosis and Treatment. 23 concept of position or retracting the termed indirect." Application of the Lippincott-Raven, 1997, p 19 indirect method used by several "position in which the lesion occurred" 20. Schooley T; Osteopathic Principles and Sutherland students applied terminol may deserve reconsideration as a Practice. Privately published, 1987, p 44. ogy to express a concept of "retracing teaching tool for indirect method, in 21.Lay Edna; Cranial Field. Foundations for light of the diverse themes that have Osteopathic Medicine, p 912. the path of the lesion." 22. lbid. p 912. emerged. The indirect method of decreasing 23.Johnston Wm, Friedman H; Functional tissue tension is not isolated to Methods. American Academy of Osteopa Sutherland's general techniques. By Bibliography thy, Indianapolis, Indiana, 1994. 1964, Lawrence Jones, DO who intro 1. Lippincott HA; The Osteopathic Tech 24.Jones, L; Spontaneous release by position- ing. The DO, 1964, 4: 109- 116. nique of Wm G. Sutherland, DO Acad duced "Spontaneous Release by Posi 25.Foundations, p 800. tioning" writes: "even the severest le emy of Applied Osteopathy 1964 Year book, p 138-146. 26.Johnston, Wm, DO, FAAO; Personal sion will readily tolerate being returned 2. Sutherland Wm G.; Teachings in the Sci- communication.□ to the position in which the formation 34/AAO Journal Fall 1999 "An Introduction to OMT" CME Hours: 23 Category, lA Program f Thursday, January 20, 2000 Fall 1999 AAO Joumal/35 Student's Corner obstetric patient to experience so pathic manipulative treatment) for inhi continued from page 20 matic dysfunction in the thoracic and bition of lumbar myalgia during labor. JAOA, 82(4); 247251: 1982. cervical regions, most likely due to should be thoroughly educated about compensation from the pelvic insta 6. Heckman, J.D. Managing musculoskel these techniques. The patient should bility. The obstetric patient also ex etal problems in pregnant patients. J. be instructed on stretches and exer periences somatic dysfunction of the Musculo. Med., 1(7); 14-24: 1984. cises such as, pelvic tilts, knee pulls, coccygeal region, and will experience 7. Hitchcock, M.E. Osteopathic care in curl ups and straight-leg lifts, which frequent headaches and disruptions of pregnancy. Osteo. Ann., 19-29, 1976. can strengthen the abdominal and the basic cranial rhythm. lumbar muscles and minimize the Osteopathic physicians have been 8. McIntyre, I.N. and N .A. Broadhurst. Ef pain.10 The patient should also be in assisting pregnant females with their fective treatment of low back pain in pregnancy. Aust. Fam. Phys., 25(9), structed on the benefits on minimiz somatic dysfunctions for many years suppl.2; S65-S67: 1996. ing weight gain, which leads to extra by altering techniques or designing lumbar stress, and the benefits oflow new techniques, such as the lateral 9. Ostgaard, H.C. Assessment and treat level aquatic exercise.6 The patient recumbent springing technique illus ment of low back pain in working preg can also be informed about using a trated by Treadwell and Magnus in nant women. Sem. in Perinat., 20(1); 61- 69: 1996. wedge shaped pillow to support the 1996. However, there is a severe lack abdomen when lying on her side. of publications on these techniques 10. Rathmell. J.P., C.M. Visconi and M.A. and research a lack of on the effec Ashburn. Management ofNonobstetric tiveness of the treatments. It is im pain during pregnancy and lactation. Discussion Anesth Analg., 85; 10743- 1087: 1997. Low back pain is a very common portant for osteopathic physicians to complication of pregnancy. It occurs attempt to expose the medical com 11. Sturesson, B., G. Uden, B. Midwifery in over half of pregnant females. Gen munity to these techniques and their and A. Uden. Pain pattern in pregnancy and "catching" of the leg in pregnant erally, it has been accepted as a nor effectiveness. This exposure will en hance the abilities of physicians to women with posterior pelvic pain ., mal side-effect of pregnancy. Thus, Spine, 22(16); 18801884:1997. it is usually left untreated due to the assist obstetric women in the side ef lack of knowledge of simple, conser fects of pregnancy and to develop a 12. Tettambel, M. Structural and hormonal vative, non-invasive techniques that more enjoyable experience for the influences on pelvic mechanics in labor and delivery. AAO J, 1721: winter 1995. can be used to relieve back pain in pregnant female. the obstetric patient. As osteopathic 13. Treadwell, R.C. and W.W. Magnus. Sac physicians we are educated in these References ral shear: review and a new treatment techniques and have the capabilities 1. Ashkan, K., A.TH. Casey, M. Powell method for obstetrical patients. AAOJ, to treat these patients and create a and H.A. Crockard. Back pain during 16-18: spring 1996.□ pregnancy and after childbirth: an un better experience for them. However, ■■■■■■■■■■■■■■■■■■ usual cause not to miss. J. Royal Soc. even with these techniques, the ob Med., 91; 88-89; 1998. stetric patient offers a challenge to the physician in diagnosing and treatment 2. Daly, J.M., P.S. Frame and P.A. Rapoza. of the symptoms. This is because of Sacroiliac subluxation: A common, treat able cause of low-back pain in preg the limitation of the positions into nancy. Fam. Prac. Res. J., 11(2); 149- which the physician can place the 159: 1991. patient on the manipulation table. The obstetric patient is basically limited 3. Diakow, P.R .P., T.A. Gadsby, J.B . Gadsby, J.G. Gleddie, D.J. Leprich and to the lateral recumbent and seated A.M. Scales. Back pain during preg Visit tne positions , especially in the later nancy and labor. J Manip. Physio. Ther., weeks of pregnancy. Therefore the 14(2); 116-118: 1991. :American Academy physician must alternate these tech ■ niques and adapt to the limitations in 4. Garmel, S.H ., G.A. Guzelian, J.G . D' Alton and M.E. D' Alton. Lumbar disk : of Osteopathy's positions. This becomes especially disease in pregnancy. Ob. & G.~., 89(5); • Home on the Internet important because the obstetric pa 821-822: 1997. ■ ■http:/www.aao.medguide.net tient tends to have a greater amount ■ 5. Guthrie, R.A. and R.H. Martin. Effect ■ of somatic dysfunction than just low ■ back pain. It is also common for the of pressure applied to the upper thoracic ■■■■■■■■■■■■■■■■■■■ (placebo) versus lumbar areas ( osteo- 36/AAO Journal Fall 1999 continued from page 24 well as bilateral rotation was normal. rib-key rib) of the right upper rib cage Meniere's Syndrome Neck flexion was restricted for use was noted. The hamstrings and piri of deep flexors and there was substi formis were moderately tight and re 4.Magneticresonantangiography tution by the superficial flexors . stricted, right greater than left. There of the circle of Willis, carotid was a tight anterior hip capsular pat and vertebral vessels were all Prone position: No iliac shear or tern on the left as a result of tight, re normal. rotation was noted. Hip extension was stricted rectus femoris and iliopsoas. full and equal using the appropriate The patient's cervical myofascial Additional history includes de musculature without excessive pelvic restriction were released on the first pression with heavy alcohol use and rotation, nor was there an inordinate visit. This was accomplished with an panic attacks, which were treated with amount of use of the upper back mus a mild anxiolytic. The patient com indirect technique involving the culature for stabilization. Hip abduc muscles and fascia, as well as releas plained of "trailing" vision for sev tion was normal and equal bilaterally. ing the most superficial cranial pat eral years. His description of this was Sensorimotor examination in a tern of inferior vertical strain and left that when an object passed through standing position was fair. The patient side-bending. Generally our patients his visual field, it was followed by was able to balance on each foot with are not treated on the first visit, so a additional overlapping images of the arms down and eyes open for 30 sec right temporomastoid suture restric object as if 'trailing' behind the origi onds. However, there was significant tion remained as well as right sphe nal. Medications: sertraline hydro foot movement; left foot standing was nobasilar torsion. chloride 50 mg per day, clonazapam worse. He was unable to stand on ei .05 mg three times a day, alprazolam ther foot with his arms crossed over his Second treatment .25 three times a day as needed for chest and eyes open for five seconds. (eleven days after the initial consul anxiety Myofascial stress patterns revealed tation and first treatment): restriction of the occipitoatlantal Structural evaluation on initial exam: He reported a significant improve junction especially involving the sple ment in the neck pain, as well as the Standing: The acromion was supe nius capitus and cervicis on the left. tremor the right arm. Both these rior on the right. Iliac crest and tro of of This extended to the cervicothoracic had been present for several years chanteric heights were superior on the junction and included the middle and according to the patient. Treatment to right. The forward bending test was posterior scalene, as well as the supe the right shoulder girdle and latissi negative. Decreased range of motion rior trapezius and the levator scapule mus dorsi was accomplished with di for the thoracic spine during right on the left. On the right cervicai spine side-bending. A mild rotoscoliosis of rect myofascial release, augmented there was inhibition of the deep flex - with voluntary muscle firing by the the high thoracic spine with convex ors extending to the cervicothoracic patient. Cervical treatment with ity to the left. The flexion test became junction. Also involved were restric muscle energy and myofascial release positive on the right with arms ex tions of the sternocliedomastoid as well to the right deep extensors, particu tended over his head. An obvious as the anterior scalene, both being tight larly at the C4, C5, C6 and C7 levels, tremor of the right arm was noted and short. as well as anterior superficial flexors while in this position. The middle and lower trapezius including stemomastiod, anterior and rhomboids were tight and restricted scalene and pectoralis minor. Seated: The forward bending test on the right, as well as the middle and was negative and was not changed upper portions of the thoracic erector Third treatment with arms over his head. There was spinae group. The latissirnus dorsi was (eighteen days after first treatment): decreased trunk rotation range of tight and restricted on the left. The right The patient stopped drinking alco motion to the right. Decreased scapu scapulothoracic musculature was loose, hol and had only one panic attack, as lar abduction was noted on the left as weak and restricted. well as only one dizzy episode. His well as restricted scapular retraction Cranial rhythmic impulse evalua balance on one foot, alternately, re on the right. tion revealed a normal rate; however mained unsteady. Myofascial release the amplitude and vitality were sig and indirect functional releases were Supine position: The medial mal nificantly decreased. There was right performed at the sphenobasilar sym leoli were equal as were the pubic sphenobasilar torsion, as well as an physis, atlanto-occipital joint (FRrS symphysis. Control of pelvic muscu inferior vertical strain and left left}, as well as the right deep ex ten- lature for anterior and posterior tilt as side-bending pattern. An inhalation restriction (first ➔ Fall 1999 AAO Journal/37 - - _ _ 12 12 In In to to of of in in not not in by by the the age age 3 3 In _ _ sud- au 1999 1999 loud loud soon soon will will new new The The with with cuff cuff stud years years abso with with well right right Three Three " In In _ several several to to acous reports reports later. later. a a patients patients distant distant patients patients was was 1983. he he the the muscle muscle his his rhythm rhythm process. process. Fall Fall blows blows fracture. fracture. Eighteen Eighteen fractures. fractures. complex. complex. temporal temporal mean mean syndrome syndrome uncertain- be be Brain Brain unlike unlike (nineteen) (nineteen) discussed. discussed. 19 19 developed developed sudden sudden syndrome syndrome compared compared in in by by caused caused or or evidence evidence retire retire rotator rotator case case --""_,.__ --""_,.__ area area o o and and with with with with the the near near patients patients of37 of37 made made the the years years time time and and patients patients bone bone to to skull skull 7 7 followed followed evaluation. evaluation. submitted submitted and and trauma. trauma. chronic. chronic. - syndrome syndrome an an they they technique. technique. who who exposure exposure of of trauma trauma and and published, published, when when of of rate rate following following and and or or to to group, group, '__ this this of of had had these these trauma trauma symptom symptom trauma trauma physical physical judged judged of384 of384 was was center center syndrome. syndrome. after after 4 4 Meniere's Meniere's noise, noise, few few ~ the the that that initial initial group, group, At At Traumatic Traumatic of of Mancini Mancini clinical clinical released released 's 's Meniere's Meniere's could could as as laboratory laboratory this this Nineteen Nineteen Mancini Mancini remained remained to to decided decided a a experienced experienced temporal temporal _:_:_ males males , , . . and and move move because because on on patients patients history-taking history-taking studies studies described described loss, loss, sudden sudden in in very very which which of of classic classic to to _ _ Meniere's Meniere's which which and and all all paper paper were were and and observations. observations. myofascial myofascial from from percent percent syndrome syndrome case case month) month) significant significant and and physical physical in in clinic. clinic. trauma trauma h h the the are are of of _ certain certain a a seen seen the the complained complained 30 30 however however were were Meniere Meniere patient patient seven seven pattern pattern no no and and " " ed ed patients patients - either either were were :...=_ :...=_ several several developed exposure exposure of of the the suc scapuJothoracic scapuJothoracic pathology pathology v by by hearing hearing 52.2years discussion discussion were were rehabilitation rehabilitation interest interest head head cases cases had had absence absence In In (eighteen) (eighteen) ..:,_ 18 18 least least referred referred these these There There The The those those ties ties coincidental coincidental important important Iutely 19 19 the the fully fully Paparella Paparella den den _:_::_::_ (within (within developed developed acoustic acoustic Of Of the the recei was was They They later later tense tense of of of of noise noise At At tic tic ied ied trauma trauma Meniere's Meniere's One One the the Thirty bone bone Paparella Paparella documented documented diagnosed diagnosed Discussion: Discussion: post-traumatic post-traumatic home. home. disability disability be be to to from from thor, thor, torsion; torsion; jury jury cranial cranial improvements energy energy restrictions restrictions Right Right _ _ - - _ of of in in to to his his 10 10 ev- ef by by C4, C4, ob im re still still five five left. left. _ cor- pain pain the the right right eyes eyes The The taper taper were were initial initial move move of of an an thora active active 's 's latissi and and (FRSr) (FRSr) cervical cervical to to through through restric inferior inferior the the restric patient's patient's will will once once indirect indirect the the since since manifes- released released been been occipital occipital __ on on 9 9 posterior posterior vertebral vertebral neck neck complain complain in in - y y aterally. aterally. for for of of not not the the _ consulting consulting l Additional Additional Patient Patient that that episodes episodes T7 T7 on on resulted resulted Referral Referral 8, 8, on on the the seventy seventy to to treatment): treatment): mechanism mechanism planes. planes. not not as as l bi technique. technique. thoracolum passes passes ophthalmolo hand hand and and segments segments with with patient followed followed at at were were for for no no to to neurologic neurologic was was than than patient patient The The junctions junctions Milder Milder ribs ribs original original was was Trailing Trailing the the had had Atlanto including including posterior posterior painful painful the the field. field. the the --- well well significant significant three three fourth fourth he he persists. persists. objects objects found found t This This individual individual neuro- but but muscles muscles A A and and - restriction restriction with nausea nausea with slightly, slightly, shoulder shoulder treated treated with with relates relates and and as as to to trapezius trapezius energy energy continued continued severe severe that that of of patient's patient's medication. medication. approximate possible possible the the myofascial myofascial Headache Headache myofascial myofascial after after torsion torsion including including " " exhalation exhalation spinae. spinae. technique technique release. release. according according visual visual from from as as and and serratus serratus field. field. C7 C7 of of two two advised advised -- right right junction junction by by trailing trailing and and to to stop stop less less weeks weeks dysfunctions dysfunctions were were motion. motion. testing testing clonazepam. clonazepam. vertigo vertigo his his - (ERSr) (ERSr) Patient Patient with with occur occur visit. visit. Thoracic Thoracic clonazepam. clonazepam. patient patient the the extensor extensor treatment treatment ailing C6, C6, adducted adducted noted noted muscle muscle admission. admission. weeks weeks such such of of and and cranial cranial after after of of - revealed revealed two two dorsi, dorsi, cervicothoracic cervicothoracic visual visual erector erector found found , , T8 T8 to to junction junction Myofascial Myofascial "tr Visual Visual The The - two two scalene scalene C5 was was own own deep deep evaluation evaluation would would percent percent initial initial ery ery severe severe tation. tation. the the provement provement rect rect taking taking ( ject, ject, Sixth Sixth were were gist gist diagnosis diagnosis dose dose physician physician fect fect across across diagnosis diagnosis neuro-ophthalmologist neuro-ophthalmologist of of and and treated treated and and mus mus columbar columbar myofascial myofascial and and with with restricted restricted segment segment right right bar bar leased. leased. cervicothoracic cervicothoracic was was tions tions strength strength myofascial myofascial tion tion range range - - , , - - 4 4 - is is be be A A re by by the the the the had had l the the left left el arm arm re the the diz epi and and tiple tiple with with tem CV CV to to visit, visit, func n n (C2 l right right some some as as chest chest symp poste right right by by atissi shoul o for for rotator rotator release release muscle muscle and and nausea nausea no no l left left l l the the pain pain the the were were mu C7 C7 anterior, anterior, residency residency stretches stretches pain pain headache omohyoid omohyoid junction junction and and the the technique technique well well URI URI include include visit): visit): but but for for and and of of and and caused caused pectora superficial superficial The The the the muscles muscles initial initial tight tight d d as as and and treatment): treatment): of of technique. technique. neck neck using using n nt nt and and with with and and indirect indirect anterior anterior of of i home home stretch stretch director director shoulder shoulder bilatera continued continued the the for for involving involving hand hand described described Cervicothoracic Cervicothoracic through through muscle muscle restriction restriction at at as as 4-15 4-15 visit. visit. right right would would performed performed to to the the the the serratus serratus seco shoulder shoulder Myofascial Myofascial third third biceps biceps pain pain the the suture suture do do author author C4 C4 as as left left ng ng dizziness dizziness and and dizziness, dizziness, functional functional eft eft i after after as as for for still-po regions, regions, d d l and and was was There There well well to to Movement Movement by by after after trapezius trapezius sinks sinks tentoria) tentoria) initial initial after after be . . included included to to periscapular periscapular an (which (which the the neck neck bad bad myofascial myofascial residency residency additional additional , , release release as as complained complained nausea. nausea. ups ups had had with with 23 23 restriction restriction Journal Journal - restriction restriction restriction restriction the the lothoracic lothoracic to to hip hip compressions compressions deltoid, deltoid, in in Thoracolumbar Thoracolumbar as as severe severe . . u ches. ches. days days month month and and right), right), and and t treatment treatment l l indirect indirect release release and and patient patient with with with with of of treatment treatment on on weeks weeks n n weak weak mechanism. mechanism. bones bones torsion Exercises Exercises dorsi dorsi h h pain pain push released released not not scalene, scalene, particularly particularly vomiting. vomiting. used used stre scap patient patient Patient Patient the the One One us us 38/AAO 38/AAO was was but but toms toms been been (two (two director Fifth Fifth was was rior rior stricted stricted shoulder shoulder cuff cuff author author tional tional technique technique junction junction ziness ziness occipital occipital Upledger, technique eased eased intracranial intracranial right right and and temporomastoid temporomastoid poral poral sodes sodes crania neck neck tingling tingling the the (eleve Fourt stretch, stretch, der der periscapular periscapular m m diagonal diagonal bow bow and and for for right. right. sternal sternal was was treatment treatment l inferolateral inferolateral sors, sors, flexors. flexors. rotated rotated . . Figure 1. Lateral view of menbranous labyrinth (right side). Clinically Oriented Anatomy, Moore, Figure 7-124, p 777. Anterior semicircular duct and membranous ampulla Cochlear duct Saccule Utricle Endolyrnphatic duct Figure 2. Temporal bone and bony labyrinth. Clinically Oriented Anatomy, Moore, Figure 7-121, p 772. -- - - ·· Squamous part of temporal bone Cochlea- ---,;--j!f~ ~ ------·- Petrosquamous fissure Semicircular [ . Anterior canals Lateral ----:-tH Posterior---1t ' ' ~ - ---· Petrous parJ Vestibule -· Of temporal Aqueduct of bone vestibule ------Mas1oid part However, using one case in which non-positionally incited attacks of resulted in displaced epithelia of the histopathological information was vertigo. However, in some patients, sensory organs and other cellular el available as an example, it was diffi especially those with vestibular ements, which mechanically or cult for them to exclude the impor Meniere's, positional vertigo was a chemically caused decreased en tant role of trauma while considering severe problem between typical dolymph absorption by blocking the chronological and sequential events. Meniere's vertigo attacks." endolymphatic duct resulting in en "Disabling or incapacitating attacks When considering the pathogen do lymphatic hydrops and thus, of vertigo were the chief complaint esis of trauma causing endolymphatic Meniere's syndrome. in virtually every patient. Positional hydrops associated with Meniere's Ikeda 9 has demonstrated that there vertigo was a prominent complaint syndrome, the authors postulated that were fewer and smaller blood vessels especially during episodes of a shock to the membranous labyrinth --+ Fall 1999 AAO Joumal/39 Figure 3. Cerebral arterial circle ( of in the endolymphatic sac (ES) of termined by the results of clinical Willis), Figure 7.25, Grants Atlas of bones from individu als with tests on the living patient. There were Anatomy, p 471. Meniere's Disease than in the ES's of fewer vessels in the bones with hy control bones. This is particularly true drops, as well as the larger vessels in the rugose and the cranial orifice being smaller in size. The differences portions of the sac. He describes the in vascularity was not related to ves meshwork of the loose perisaccular tibular aqueduct size in either of the connective tissue surrounding the ES study groups. as normally being richly vascular The condition of the perisaccular under light microscopic and ultra connective tissue seemed to be related structural studies. Diminution of the to the vascularity of the endolym Middle cerebral vascularity of perisaccular connective phatic sac; the fewer the vessels in tissue has been noted by the authors the ES the more dense was the con Posterior communicating after examination of surgical speci nective tissue. However, this was not mens of the endolymphatic saccule statistically significant. Still this led -~ Posteriorcersbral ~ from patients with Meniere's Disease. the authors to conclude that it would Superi.orce rebellar Labydnth1 . Basila, The investigators were able to dem be reasonable to believe that the onstrate differences between pathological condition of the vascu - ~ ~ -- Anterior111ferlor U size-matched temporal bones com lature could be important in the eti ~,.: .:::::~•:.,ior ology of Meniere's Disease. Many -~~~ · cerebellar paring those with a history of 1 5 10 17 20 27 ~. . Vertebral Meniere' s and those without any other investigators • • • - - have Anler/or sprnal clinical history of same. Neither pointed out that the perisaccular loose group bad any other types of CNS in connective tissue undergoes fibrotic volvement, eighth nerve tumor or change in the temporal bones of pa other cochleovestibular disease as de- tients with Meniere's disease.9 Figure 4. Base of brain: cerebral arterial circle (of Willis). Figure 7.24 Grants Atlas of Anatomy, p 470. -.;,-:,.- - - Anterior communicating artery ~~...- -- Anterior cerebral artery Middle cerebral artery Optic nerve ------~y-;L'- _ .,,,_./'----' '--=l~ Temporal lobe------,'--- y / lnterpeduncular Iossa Internal carotid artery __ ...... 1.._ _ ..±.__ --2,;~ __ .------+-- Posterior communicating artery Posterior cerebral artery - -\-c-~ - - ~~ =--=-- -- - ~~ - Oculomotor nerve Superior cerebellar artery ---f~------'~=., -=--k~r"~~-- Trigeminal nerve Basilar artery Abducent nerve -- ---?-, a==== ::;;;,,._;....- Labyrinthine artery Facial nerve 7 Vestibulocochlear nerv~- -~ Glossopharyngeal nerve] Vagusnerve 1---"li=-~ ~ r:"lr\ Accessory nerve _j _ ~~~#/;'./l'}r;'!f---- Vertebral artery Hypoglossal nerve - -- -- ~~~ ~ ~~~~¥--- Anterior spinal artery 40/AAO Journal Fall 1999 Figure 5. Posterior cranialfossa. Figure 7-156, Grants Atlas of Anatomy, p 547. labyrinthine artery branches off of the anterior inferior cerebellar artery (AICA) from the basilar-vertebral artery system. (See Figure 3) The labyrinthine artery travels with the facial and vestibulocochlear nerves to Dorsum enter through the internal acoustic sellae meatus. Figure 4 shows the complete Circle of Willis; however, this illus Clivus tration shows the labyrinthine artery and theACIAas separate branches off of the basilar artery. In the internal Grooves for: auditory canal very extensive vessel systems were traced by 6 7 Trigeminal Hansen. • Considering the nerve petrous part of the temporal Superior [ bone, vessels on the surface, petrosal sinus as well as into the deeper parts, were found to be per fused by the vertebral artery Internal acoustic meatus system. From the AICA sling usually one to three branches supply temporal bone struc tures via the internal auditory canal and/or the subarcuate Jugular foramen Pit for ganglion of fossa. However, the number of Jugular tubercle glossopharyngeal nerve branches vary considerably. The range Hypoglossal canal Petro-occipital fissure of small arterial branches detected from tor inferior petrosal theAICAsling were as many as eleven sinus and as few as three. Some branches traveled to nerve sheaths, some to the subarcuate fossa and some through the the proximal portion of the sac. These A related paper from Sweden stud internal auditory meatus. See Figure 5. ied a very minute structure within the investigators found that a very signifi The most proximal of these arteries inner ear.21 The paraves tibular canali cant portion of the temporal bones of was usually the largest, the labyrinthine culus (PVC) can regularly be found patients with Meniere's disease dem artery. After entering the internal audi onstrated dense, nonpneumatized at microdissection. It runs through the tory canal it followed the superior an petrous portion of the pyramid (of the bone around the VA rather than the terior side of the acoustic nerve, divid temporal bone} from the vestibular loose connective tissue. They con ing into several branches. This is where portion to the posterior cranial fossa cluded that the absence of connective the arteries and nerves that supply the tissue could correspond to the ab in close proximity to the vestibular structures of the inner ear pierce the aqueduct. houses mainly veins rep sence or malformation of PVC. It dura mater. See Figure 6. resenting the primary drainage sys It is reasonable to assume that the The dura is contiguous with the 16 18 tem from the vestibule. • Besides loss of connective tissue is due to the thinner neuro-opithelium after it pen blood vessels, the canaliculus is filled loss ofvasculature support for the ar etrates the openings in the inner table with loosely textured connective tis eas surrounding the aforementioned of the cranium. The neuro-opithelium sue similar to that typical of the ves structures. This poses the question of covers the nerves through their tibular aqueduct (VA). Numerous tiny mechanism for the loss of blood and courses. It is here that the area of re vascular channels connect the PVC other normal homeostatic mecha- striction of the artery is most likely. with the VA. Apart from its drainage nisms to an area that would result in If the dura were compromised in any function, it is postulated that the what appears to be fibrotic change of way such that there was restriction on canaliculus is of nutritional impor these same tiss ues. A review of tance for the endolymphatic duct and anatomy of the area reveals that the Fall l 999 AAO Journal/41 Figure 6. Cranial nerves, exposed posteriorly. Grants Atlas of Anatomy, Figure 7.33, p. 475. Facial nerve (CN VII) . \ ,---=-- '--" '-- ::;e..._--'---- Vestibulocochlear [ nerve (CN VIII) ,--- -- 'r'- --= '---- Glossopharyngeal nerve (CN IX) .,. :!!.---~ - --__;, ::...... !:....=.;;c____ Vagus nerve (CN X) '---- =.....=c----' '-----A ccessory nerve (CN XI) 11i.i!/,~ = ,---=- ~=--= - Crania'7 Roots -- Sprnal j - • .--,,--'C.-~- - Jugular process 1st cervical nerve. dorsal ramus _...... ;~ - Atlantoaxial joint - - ---!.!~:.,- -.::, W:.---- Vertebral artery 2nd cervical [ Ventral ramus nerve Dorsal ramus _ ___; Axi. s Spinal ganglion ___ of C2 the structures entering the foramen, from a chronic decreased blood flow impedes blood flow and leads to fi the blood vessels would be the most and alteration of normal homeosta brotic change. likely to be affected. As a result of sis. Furthermore, the association of injury the venous system would be the loss or malformation of the Conclusion: affected subacutely. The arterial sys paravestibular caniculus with dense The two patients presented here tem would be slower to be affected surrounding tissue in Meniere's pa have Meniere's syndrome. Etiology by a chronic restriction, as the venous tients could indicate loss of perfusion. of the syndrome can be related to system would eventually have alter It is a well-known clinical fact that trauma in both cases. The evidence native routes for flow, especially af decreased perfusion to an area leads for diagnosis of mild to moderate ter the edema had subsided. In addi to fibrotic change of connective tis Traumatic Brain Injury from multiple tion, those specimens with fewer sue. This is especially true of a closed-head injuries is compelling branches from the labyrinthine artery chronic restriction which is not cor considering the histories of these two would seem more likely to be affected rected by normal mechanisms before patients. The cause and effect mecha distally by a restriction in blood flow. fibrotic changes occur. nism is suggestive of chronic de Evidence of regional arterial flow Note that patient number one had creased perfusion of the innermost restriction secondary to trauma can an abnormal auditory brain stem structures of the petrosal portion of be seen by Single-Photon Emission evoked potential in 1995 suggesting the temporal bone and the loose con Computed Tomography (SPECT) a dysfunction between the inner ear nective tissues surrounding the examination in patients with docu and brain stem bilaterally. However, periaqueductal structures in the inner mented Traumatic Brain Injury (TBI). five years previously, auditory and ear. The loss of proper homeostatic SPECT has been reported as show visual evoked potential testing sug mechanism by blood flow restriction ing areas of decreased perfusion in the gested no evidence of dysfunction, may have led to fibrosis of the con regions of the brain that are linked to although the patient was symptom nective tissues of the endolymphatic TBI patient symptoms, i.e., hearing atic; but he was less so than when he structures with the result of endolym 8 loss or visual defects. Abnormalities was referred to the Department of Os phatic hydrops and thus the symp in cerebral hemodynamics have been teopathic Manipulative Medicine. toms of Meniere's syndrome. demonstrated in animals and humans This suggests a progressive nature of 4 after mild head injury. Change in the change such as that seen with Additional epithelium of the endolymphatic sac Meniere's disease or syndrome. Con from columnar to simple cells would cussive injury to the head or specifi considerations: indicate a loss of function and a more cally to the temporal bone could serve More specific to cranial anatomy simplified cellular structure resulting as the source of the restriction that is the possibility of stress on the 42/AAO Journal Fall 1999 dura mater where it attaches to the cent to the area responsible for sen tion) of Meniere's Disease and Its Symp petrous portion of the temporal sory nerve processing. A consultation toms (Mechanical and Chemical). Acta Otolaryngol (Stockh) 1985; 99: 445-451. by physicians trained in the diagno bone resulting in mechanical stress 13.Paparella M: Pathogenesis of Meniere's 23 on the blood vessels. Although sis and management of structural and Disease and Meniere's Syndrome: Acta patient number one's symptomatol functional sensory loss secondary to Otolaryngol (Stockh) 1984 in press. ogy was relatively improved in oc head injury can be helpful when 14.Paparella M, Mancini F: Trauma and currence and severity, the failure to evaluating any patient exhibiting neu Meniere's Syndrome. Laryn gosco pe 1983;93:1004-1012. completely resolve his symptoms rosensory and ear-related symptoms 15.Rauch S, Merchant S, Thedinger B: suggests that he has fibrosis of the after closed head trauma. Meniere's Sundrome and Endolymphatic dura mater. The inability of the au Hydrops, Double Blind Temporal Bone thor as well as a consulting physician Study. Ann Oto! Rhino! Laryngol 1989; Bibliography: 98:873-83. to restore the normal cranial rhyth l. Arenberg I, Morovitz W, Shambaugh G: 16.Rask-Andersen H: The Vascular Supply mic impulse and symmetry suggests The Role of the Endolymphatic Sac in the of the Endolymphatic Sac. Acta a system resistant to alteration follow Pathogenesis of Endolympbatic Hydrops Otolaryngol (Stockh) 1979; 88: 315-27. ing multiple occasional traumatic in Man. Acta Otolaryngol (Stockh) Suppl 17.Saito H, Kitahara M, Yazawa Y, 1970; 275: 1-49. head injuries over five decades. Sub Matsumoto M: Histopathologic findings 2. Arhnold-Sehneider M: Degree of Pneuma in surgical specimens of endolymphatic jective improvement associated with tization of the Temporal Bone and sac in Meniere's Disease. Acta osteopathic manipulative-treatment Meniere's Disease: Are They Related? Otolaryngol (Stockh) 1977;83: 465-9. included less low back pain due to sac Am. J. Otolaryngol. 1990; 11: 33-36. 18.Sando J, Egami T, Harada T: Course and 3. Canalis R,Gussen R, Abemayor E: En ral dysfunction and an apparent reduc Contents of the Paravestibular Canalicu dolymphatic Hydrops After Fenestration: lus: Ann Oto! Rhino! Laryngol 1980: 89; tion in the number of episodes of se A Temporal Bone Study With Implications 147-156. vere vertigo, nausea and vomiting. on the Function of the 19. Sando I, Ikeda M: The Vestibular Patient number two reported sig Utriculo-Endolymphatic Valve. Am J Aquaduct in Patients with Meniere's Dis nificant changes in headache and Otolaryngol. 1989; 10: 404-409 ease, a temporal bone histopathological in 4. Evans R, The Postconcussion Syndrome neck pain, as well as a subjective re vestigation. Acta Otolaryngol (Stockh) and the Sequelae of Mild Head Injury, 1984; 97: 558-70. duction in the frequency of episodes Neurologic Clinics. November 1992; p 20.Schindler R: The ultrastructure of the en of severe vertigo with nausea. There 815-48. dolymphatic sac in Meniere's Disease: was improvement in the use and func 5. Hallpike C, Cairns H: Observation on the Otorhinolaryngol 1979: 25; 127-33. Pathology of Meniere's Syndrome. J tion of the right and left arms, per 21. Stahle J, Wilbrand H: The Temporal Bone Laryngol Otol 1938;53: 625-55. in Patients with Meniere's Disease. Acta taining to tremor and weakness. The 6. Hansen C: Vascular Anatomy of the Hu Otolaryngol (Stockh) 1983; 95: 75-80. failure of the magnetic resonant an man Temporal Bone, a preliminary report: 22.Thomsen J, Schroder H, Klinken L, giography to demonstrate vascular Acta Otolaryngol. Suppl. (Stockh). 1973; Jorgensen M: Meniere's Disease: Periph changes and fibrosis is not surprising, 309: 1-92. eral or Central Origin, a neuro-anatorni 7. Hansen C: The Aetiology of Perceptive since every evaluation was normal cal study. Acta Ololaryngol (Stockh) Suppl Deafness. Acta O!olaryngol 1973; 309: 1984; 406:46-51. and the findings were subtle. The in pp90. 23. Upledger J, Vredevoogd J: Craniosacral ability to release the persistent right 8. Ichise M, Dae -Gyun C, Wa n g Therapy. Eastland Press, Seattle; 1983. sphenobasilar torsion would once P,Wortzma n G, Gray B, Franks W : 24. Wadin K: Radioanatomy of the High Jugu Teehnetium-99m-HMPAO SPECT, CT again suggest a system resistant to lar Fossa and the Labyrinthine Portion of and MRI in the Evaluation of Patients with the Facial Canal. change, possibly due to fibrosis. Chronic Traumatic Brain Injury: A Corre 25. Yamakawa K: Uber die pathologische lation with Neuropsychological Perfor Verandemng bei einem Meniere-Kranken. Aecom mendations: mance. JNuclMed 1994; 35: 217-226 J Otorhinolaryngol Soc(Jpn) 1938;44: 9. Ikeda M, Kando I: Vascularity of En 2310-2. This author strongly suggests an dolymphatic Sac in Meniere's Disease, a 26. Yazawa Y, K.itahara M: Bilateral Endolym aggressive approach to patients with histopathological study. Ann Otol Rhino! phatic Hydrops in Meniere's Disease: Re neurosensory loss, including balance Laryngol 1984; 93: 540-6 view of Temporal Bone Autopsies. Ann problems that can be attributed to 10. Ikeda M, Sando I: The Endolymphatic Sac Otol Rhino! Laryngol 1990; 99: 524-28. in Patients with Meniere's Disease. A tem traumatic head injury after magnetic 27 .Zechner G, Altmann F: Histological Stud poral Bone Histopathological Investiga ies on the Human Endolymphatic Duct and resonant imaging with angiography tion: Ann Oto! RhinolLaryngol 1984: 93; Sac. Pract OtoRhinoLaryngol 1969; 31: and Single-Photon Emission Com 540-6. 65-83. puterized Tomography have been uti 11. Kochanek P: Ischemic and Traumatic 28.Atkinson M: Meniere's original papers. lized. Particular attention should be Brain Injury: Pathobiology and Cellular Reprinted with an English translation to Mechanisms. Crit Care Med 1993; Sep 21 paid to the brain and connective tis gether with commentaries and biographi (9 Suppl). p S333-5.12 Paparella M: The cal sketch. Acta Otolaryngol [Supple! sues including the dura mater adja- Cause (Multifactorial Inheritance) and (Stockh) 1961 (suppl 162).0 Pathogenesis (Endo!ymphatic Malabsorp- Fall 1999 AAO Journal/43 .A. American NON-PROFIT ORG. Academy of U.S. POSTAGE PAID Osteopathy PERMIT#l4 3500 DePauw Boulevard, Suite 1080 CARMEL, INDIANA Indianapolis, IN 46268-1136 ADDRESS CORRECTION AND FORWARDING REQUESTED ~ DISNEY, OMT, AND You AT THE ••• NINTH ANNUAL OMTUPDATE (I NTERMEDIATE COURSE) "APPLICATION OF OSTEOPATHIC CONCEPTS IN CLINICAL MEDICINE" PLUS P REPARATION FOR CERTIFYING BOARDS SEPTEMBER 22-25, 1999 This Academy program was designed to meet the needs of the physician desiring the following: • OMT Review - "hands-on experience and troubleshooting" • Integration of OMT in treatment of various cases • Preparation for OMM practical portions of certifying boards • Preparation for AOBNM (American Osteopathic Board of Neuromusuloskeletal Medicine) certifying board • Information on CODING for manipulative procedures • Good review with relaxation and family time LOCATION: The Contemporary Hotel (Walt Disney World® Resorts) Lake Buena Vista, FL CME HouRs: 4 days; 22 hours; AOA Category 1-A CONTACT : AMERICAN ACADEMY OF OSTEOPATHY FOR MORE INFORMATION: 3500 DEPAUW BLVD., SUITE 1080, INDIANAPOLIS, IN 46268-1136 PHONE: (317) 879-1881; FAX: (317) 879-0563; OR E-MAIL:[email protected]