Osteopathic Medicine: Now Is the Time

Home , Andrew Taylor Still, Lymphatic pump, Muscle energy technique, Stephen Typaldos

HARVARD MEDICAL SCHOOL DEPARTMENT OF CONTINUING EDUCATION

and

The Mind/Body Medical Institute, Deaconess Hospital

Present

Spiritua _ Under the Direction of: Herbert Benson, MD

December 15 - 17, 1996 IN MEDICINE-II The Wes tin Hotel Copley Place Boston Boston, Massachusetts Healthcare professionals are invited March 15 - 17, 1997 to explore the relationship between The Wes tin Bonaventure Hotel and Suites spirituality and healing in medicine Los Angeles, California

at a continuing medical education For course brochure or course sponsored by Harvard additional information contact: Professional Meeting Planners Medical School. Spirituality and Tel: (800) 378-6857 (617) 279-9887 healing will be examined from the Fax: (617) 279-9875 E-mail: [email protected] perspective of major world religions.

The latest scientific evidence

supporting the effects of spirituality The courses are supported in part by an educational grant from the on healing will be discussed. JOHN TEMPLETON FOUNDATION AAmeriean THEAAO Academy of Osteopathy 3500 DePauw Boulevard Suite 1080 The mission ofJ the American "''""'·--~---·-~-- Academy Osteopathy is to teach, explore, of Indianapolis, IN 46268-1136 advocate, and advance the study and application of the science and art of (317) 879-1881 total health care management, emphasizing osteopathic principles, FAX (317) 879-0563 palpatory diagnosis and osteopathic manipulative treatment.

1996-1997 Feature: Page BOARD OF TRUSTEES From the Editor ...... 5

President by Raymond J. Hruby, DO, FAAO Michael L. Kuchera, DO, FAAO Message from the President ...... 6 President Elect Ann L.Habenicht, DO, FAAO by Michael L. Kuchera, DO, FAAO

Immediate Past President Message from the Executive Director ...... 8 Boyd R. Buser,-DO by Stephen J. Noone, CAE Secretary-Treasurer Anthony G. Chila, DO, FAAO Conflicting visions (Thomas L. Northup Memorial Lecture ...... 9

Trustee by Edward G. Stiles, DO, FAAO Mark S. Cantieri, DO Letter to A.T. Still ...... 14 Trustee John C. Glover, DO by Raymond J. Hruby, DO, FAAO

Trustee Ethan R. Allen, DO named 1996 Educator of the Year ...... 14 John M. Jones, DO, III A challenge to the concept of craniosacral interaction ...... 15 Trustee Judith A. O'Connell, DO, FAAO by James M. Norton, PhD

Trustee Calendar of Events ...... 16 Karen M. Steele, DO, FAAO In Memoriam: Wilbur V. Cole, DO, FAAO ...... 21 Trustee Melicien A. Tettambel, DO, FAAO From the archives ...... 22

Executive Director Pilot study to establish whether osteopathy reduces general practice Stephen J. Noone, CAE consultation rate of musculoskeletal problems based on patient perception of effectiveness of the osteopathic treatment - Part II ...... 23 Editorial Staff by Mary Banihasem, DO Editor-in-Chief ...... Raymond J. Hruby, DO, FAAO Planning research on ambulatory care ...... 35 Supervising Editor ...... Stephen J. Noone,CAE by Deborah M. Heath, DO and Albert F. Kelso, PhD Editorial Board ...... Barbara J. Briner, DO AAO Case History: Iatrogenic injury to the cranial mechanism ...... 37 Anthony G. Chila, DO, FAAO James M. Norton, PhD by Richard W. Skurla, DO, CSPOMM Frank H. Willard, PhD 1996 AAO Journal Index ...... 38 Managing Editor ...... Diana L. Finley

Tht AAO Journal is the official quarterly publication of the American Academy of Osteopathy (3500 DePauw Blvd .. Suite 1080, Indianapolis, Advertising Rates for the AAO Journal Indiana, 46268-1136). Third-class postage paid at Canmel, IN. Postmas ter: Send address changes to American Academy of Osteopathy 35CM) An Official Publication of The American Academy of Osteopathy DePauw Blvd., Suite 1080, Indianapolis, IN., 46268-1136 The AOA and AOA affiliate organizations and members of the Academy The A.AO Journal is not it,;clf responsible for statements made by any contributor, Although all advertising is expected to conform to ethical are entitled to a 20% discount on advertising in this Journal. medical standards, acceptance does not imply endorsement by this jour nal. Opinions expressed in The AAO lournnl are those of authors or speakers Call: The American Academy of Osteopathy and do not necessarily rcflccl viewpoints of the editors or otl:1cialpolicy of the American Academy of Osteopathy or the institutions with which Lhe (317) 879-1881 for an Advertising Rate Card authors arc affiliated, unless specified. Subscriptions: $50.00 per year

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(AAO) (AAO) Instructions Instructions From the Editor by Raymond J. Hruby, DO, FAAO Osteopathic medicine: Now is the time

When A. T. Still founded the has spent studying ways in which this what the osteopathic profession already profession of osteopathic medicine, self-healing power can be activated. He has. It is time for us to help them find inany of the ideas that formed the also talked about the body's need for what they are looking for and end their principles of his system of therapeutics proper nutrition, and for balance search. These other practitioners are were not new. It was not new to use a between mind, body and spirit. beginning to believe that the osteopathic hands-on approach to treat the patient. Likewise, Depak Chopra, MD, the approach is the foundation upon which Nor was it new to recognize that the modern proponent of Ayurvedic all physicians should practice, and they body had within it in the power to heal medicine, has made similar comments are asking us to teach them to be like itself, or that there was a nutritive quality regarding self-healing. In his book, us. It is time for us to take action. If this to the blood. It was also not new that air Quantum Healing, he states: "The is the healthcare of the future, then we was essential to life. frustrating reality, as far as medical should make ourselves known to the But it WAS new to have a system of researchers are concerned, is that we world as the "keepers of the flame." Let treatment that placed primary emphasis already know that the living body is the us take the lead in this effort. Now is on the inherent repair processes of the best pharmacy ever devised. It produces the time! D body which maintain health. It was new diuretics, painkillers, tranquilizers, to recognize that mechanical defects or sleeping pills, antibiotic and indeed derangements interfere with the normal everything manufactured by the drug ENCOURAGE functions of the body, and if persistent companies, but it makes them much, YOUR COLLEAGUES can cause disease. much better. The dosage is always right This system of therapeutics, and given on time; side effects are TO BECOME embraced by the osteopathic profession minimal or nonexistent; and the OMM CERTIFIED! for over a century, is now being directions for using the drug are included "discovered" by modern medicine. In in the drug itself, as part of its built-in DATES TO REMEMBER spite of the great advances made in intelligence." standard medical technology, other Didn't A. T. Still say this and much May 15, 1997 healthcare professions are finding that more? Did he not refer to the human Application Deadline there are limits to what they can offer body as "God's drug store"? Did he not the patient. A more complete approach say that osteopathy was "the law of July 15, 1997 is needed. In their own way, these mind, matter and motion"? He founded Case History Deadline practitioners are finding their answers a whole system of diagnosis and in the principles and philosopy we have treatment based ont the fundamental practice for so long. principles of body unity self-healing and November 15-16, 1997 For example, Andrew Weil, MD, the interrelationship between structure AOBSPOMM Examinations author of Spontaneous Healing, recently and function. And all before any of these gave a talk which I was privileged to other folks were around! AAmeriean attend. He is a strong supporter of The point of all this is that what was Aeademyof osteopathic medicine and of osteopathic rejected in Still's time is now felt to be Osteopathy manipulation, and much of what he said just what is needed for our healthcare reflected A. T. Still's principles. He system today and for the future. The 3500 DePauw Blvd., Suite 1080, spoke of the body's potential for self general public and the medical Indianapolis, IN 46268-1136 Phone: (317) 879-1881 or FAX: (3 I7) 879-0563 healing, and of the amount of time he profession-at-large is search for exactly

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education. education.

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OMM-certified OMM-certified

What What

most most

certified certified

primary primary of of

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by by

osteopathic osteopathic

Message Message by by .,.--

Routes to certification in OMM seem much more ubiquitous than the one percent niche they American Osteopathic Association certification in OMM numerically occupy in the osteopathic family because statistics is available by passing oral, written and practical examinations show OMM-certified specialists are multiplying rapidly while administered by the American Osteopathic Board of Special contributing heavily in areas vital to leadership and Proficiency in Osteopathic Manipulat ive Medicine professional growth. (AOBSPOMM). Candidates must be OMM residency-trained Based on available educational, clinical and research data, DOs and MDs, graduates of family practice/OMM or internal "OMM"- certified appropriately designates the osteopathic medicine/OMM combined residency programs, and clinician who behaves as an "Obvious Model and Motivator." non.residency-trained AOA certified family practitioners with Please consider adding this appellation to your inner C.V. additional OMM training through the year 2005. Until the regardless of whether or not you earn the AOA certification. AOBSPOMM closes any grandfather clause, interested DOs D with special expertise in OPP and OMT can also -apply for certification. In 1980, the first OMM residency was opened. Originally it, like family practice, extended one year after an Those interested in an osteopathic residency in OMM AOA-approved internship. In 1991, the residency was can make contact at the following osteopathic medical expanded by an additional postdoctoral year focusing on con schools which offer these programs: tinuity of care in family practice, internal medicine, rheumatology, orthopedics, physical medicine/rehabilitative Chicago College of Osteopathic Medicine; medicine, OB-Gyn and pediatrics. In 1991, a "Residency Plus One" program allowed any Kirksville College of Osteopathic Medicine; AOA-approved residency trained physicians to add an Michigan State University College additional postdoctoral OMM year to create dual eligibility of Osteopathic Medicine; for certification in both OMM and their primary specialty. In 1996, a pilot three-year residency program was authorized NOVA Southeastern College for a combined integrated family practice/OMM program of Osteopathic Medicine; which will lead to dual certification. A pathway for MDs to New York College of Osteopathic Medicine; enter our OMM residencies was also created in 1996. This year the AOA additionally approved a "Plus One" program Ohio University College for nonresidency trained but AOA-certified family of Osteopathic Medicine; practitioners through 2005 after which time this option will be closed. Pennsylvania College of Osteopathic Medicine; Actively striving to meet the demand of clinical role University of North Texas Health Sciences/ models, the AAO's Postdoctoral Standards and Evaluation Texas College of Osteopathic Medicine; and Committee is meeting with other specialty colleges at their request to draft new integrative programs. At the time this University of New England College article is going to press, COPT is considering approval of a of Osteopathic Medicine. combined integrative program leading to dual eligibility as specialists in OMM and internal medicine. • •••• Allopathic physicians who are interested in fulfilling Summary pre-requisites for enrollment in an OMM residency OPP and OMT are taught to all osteopathic undergraduates. should contact Delann Jaynes at the Academy 's Furthermore, surveys show significant increasing interest and headquarters for more information; (317) 879-1881. participation in integration of OPP and OMT by primary care practitioners and specialists alike. Representing one-third of Those who are seeking an OMM specialist to teach the existing profession, undergraduate and postdoctoral or to practice should contact Executive Vice President students offer the greatest potential contribution to this Deborah DiStasio at OMM Recruiting, Inc. at (317) 337- increasing trend. Nonetheless, the role of teaching, researching 0786. and writing about OPP and OMT has benefited significantly from the expanding cadre of OMM-certified specialists. They Winter 1996 AAO Journal/7

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by by Message Message Thomas L. Northup Memorial Lecture Conflicting visions

by Edward G. Stiles, DO, FAAO

Editor's Note: Edward G. Stiles, DO, FAAO, the practice of Perrin T. Wilson, DO. Dr. 2. Big or small government solutions graduated from Kirksville College of Osteo Wilson served as president of this 3. Tax incentives or government stimulation pathic Medicine in 1965. He interned at organization from 1938-46 and was a great ofjob markets Waterville Osteopathic Hospital. Dr. Stiles admirer of Thomas L. Northup. Dr. Wilson 4. a large or small military and various has been certified in OMM since 1975 when related many stories about the early days of weapons system he earned his Fellowship in the American this organization as well as the conviction Academy of Osteopathy. He has been an and dedication of "Dr. Tom" to osteopathic The individual's vision of the human and active member of the AAO and has served principles. Therefore, with this personal and its potential will determine on which side of on the Academy's Board of Governors as historic background of this Academy, I am the debate they will participate . This well as various committees. Dr. Stiles honored to have been selected to make this realization helps one to watch, with developed the five-level coding system for presentation. fascination, the current political campaigns manipulative therapy and reimbursement for Recently I read an interesting political and debates. Maine Medicare Intermediary. This since book entitled "conflict of visions" by Dr. After reflecting on this vision concept, I has become the nationally accepted system. Thomas Sowell. The premise of the book is came to realize how our vision, our mental He served on the ADA Liaison Committee that our basic visions frequently dictate our structure or frame work, can dictate and - PSRO for the development of osteopathic actions. For example, have you ever noticed often determine the outcome, or function, of criteria for hospital admissions during which that in political debates the same people are our clinical practice. This is yet another he authored Model Critical Screening for usually on opposite sides of any given issue? application for the osteopathic principle of Professional Standards Review Organi It matters little what the topic might be; the structure and function being inter-related. zation, published by the U.S. Department of people involved are usually on opposite My desire today is to briefly review the Health, Education, and Welfare. sides. The debate can involve; history of our academy and examine how its vision may have influenced our It is with a great sense of honor that I 1. Individual vs. Government responsibility development and role today. present this lecture today. In 1968, I assumed to prevent or solve problems

In the late thirties, many osteopathic In the original general objectives and of the osteopathic profession." physicians were unhappy with the purpose statement we read, "osteopathic Contemplate the vision and burden this direction being taken by the American manipulative or adjustive therapy, founder held. How did their vision effect Osteopathic Association. Several former properly and accurately applied, is the the decisions and activities of this new AOA presidents, including Drs. Northup most important single factor in the organization? and Wilson, literally stormed into an therapeutic world." Therefore, this Academy of Applied Osteopathy AOA Board of Trustees' meeting and group or organization, believe that a became the name of the organization in asked the trustees to alter the direction Renaissance of these tenets is not only 1944. At that time in the profession's in which the profession was being taken. imperative, but should be definitely and history, specialty colleges were It was determined that a new immediately undertaken. In article 2, we developing and the expanding organization should be established read about the "treatment and cure of pharmacopoeia was being integrated within the osteopathic profession. The disease by manipulative or adjustive into the college curriculums. Did the newly formed organization, Osteopathic therapy." This represented the clinical new name reflect these vision changes Therapeutic and Research Association model in which Wilson operated in his within the profession? was established in 1938 in Cincinnati, practice. Remember, few specific Now lets investigate the change in Ohio. pharmacological agents were available clinical vision, just during my 35-year I find the name fascinating in at that time. career, in relation to our developing relationship to vision. Does the name In the purpose section we read, "this physiological understanding of accurately reflect the vision of the organization is banding together those osteopathic management. founders? The definition of therapeutic who are primarily interested in I matriculated at the Kirksville is: that branch of medicine concerned manipulative therapy" and it goes on to College of Osteopathy and Surgery in with the remedial treatment of disease. state, "to carefully guard the reputation -+

Winter 1996 AAO Journal/9

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problem problem Conflicting Conflicting Conflicting visions ... Edward G. Stiles, DO, FAAO range of motion. It was restricted, Academy, Larry Jones also started beyond the neurological model to opened or closed. He taught us teaching strain-counterstrain tutorials. include both vascular and lymphatic techniques utilizing patient generated Again, the outcome was an expansion functions in addition to the neural corrective forces as compared to of the understanding of the mechanisms elements. Another driving force for this operator thrusting forces that I had been and benefits of that unique osteopathic nomenclature change came from outside taught at Kirksville and by Dr. Wilson. application for patient management. the profession by the developing coding He explained how muscle energy Renewed interest in osteopathic system (the ICD system). Cooperation techniques functionally reversed the manipulation was generated as a result between the osteopathic profession and origin and insertion of the utilized of these new educational programs. I can the coding agency enabled the somatic muscles. Fred taught us a specific illustrate this reality from personal dysfunction terminology to develop. diagnostic system correlating skeletal experience. I attended my first Academy Therefore, our expanding clinical vision landmarks with motion testing. He then Conclave in 1970 at The Broadmoor in was also reflected in this nomenclature taught us specifically designed muscle Colorado Springs. Academy officials change which encouraged better energy techniques. He illustrated were delighted because 35 osteopathic understanding with other health treatment strategies with case reports. physicians attended that conference. I professions and related industries. He vigorously emphasized he did not believe the subsequent increase in I believe the educational, conceptual utilize manipulation to treat disease but attendance at Academy Conclaves can and clinical advances altered the only to treat the patient who had a be directly traced to our expanded academy's vision and resulted in another disease. I vividly remember Fred's educational vision and the impact it had name change for our organization in response to the inquiry as to whether he on Academy members, as well as, the 1970. Our newly selected name was the utilized the "lymphatic pump" undergraduate students. American Academy of Osteopathy. The technique. His response changed my At about the same time, the first new new name correlated better with the vision. He replied, "I usually do not use osteopathic school was established. For names of the various specialty colleges that technique." If, on the other hand, the first time, an osteopathic school within the osteopathic profession. Also, the operator assists the rib cage to affiliates with a major university. the earned fellowship program was properly function, then each breath of Michigan State University-College of being proposed as a certification the patient will provide a lymphatic Osteopathic Medicine instituted these program to the American Osteopathic pumping effect. On the other hand, the new educational concepts since they Association. The new name would benefits of the lymphatic pump provided a diagnostic and management encourage and strengthen this policy technique will cease once the operator model to which the University's modification. Neurophysiological discontinues that procedure on a scientific community could relate. research, conducted outside our dysfunctional rib cage. Thus my vision Interestingly, as the educational and profession, expanded our understanding of osteopathic management was technique models were changing, a of the function and role of the muscle changing. As the tutorial progressed, we nomenclature change also occurred. spindles, golgi tendon organs, pacinian observed amazing clinical changes This was the result of forces from both receptors, mechanoreceptors and during patient demonstrations. Fred within and outside the profession. The nocireceptors in the 1970's. This body further explained how these clinical term somatic dysfunction replaced the of knowledge gave our profession many outcomes were due to the fact that a older term of osteopathic lesion. I would explanatory tools and models. It helped muscle energy technique utilized several suggest that as our physiological, us to better understand and explain the seconds of corrective activity, both educational and clinical understanding possible mechanisms involved in both mechanically and neurophysiologically, matured, the v1s10n of the the development and maintenance of and, therefore, could generate musculoskeletal problem evolved and somatic dysfunctions, as well as, the tremendous work-related forces. My required the development of a new benefits realized with manipulative care. vision was, again, challenged and nomenclature. Within our own profession, Korr and expanded. Look at the definition of somatic his multi-departmental research team As a result of that first tutorial, Fred dysfunction: an impairment or alteration enabled Academy members to better became encouraged when he realized of function of related components of the understand the neurophysiological this small group of physicians was somatic (body framework) system. We concepts ofneurological facilitation and beginning to understand how to apply had by now progressed from a vision of neurotrophic axionic flow. This research this new clinical approach. disease, remedial care, out of place, etc. group also expanded our understanding With encouragement by the to one of altered function that went -+ Winter 1996 AAO Journal/11 Conflicting visions ... Edward G. Stiles, DO, FAAO concerning the uniqueness of the of metabolic demands, that system might pituitary and endocrine organs, and sympathetic nervous system. We came begin to fail. This expanded our therefore, the autonomic systems. Pain to appreciate the sympathetic system as understanding of the primacy of the the limbic system can alter modulation. the sole innervator of the musculoskeletal system in the economy Some feel the limbic system is also the musculoskeletal system, by its of the body. This conceptual model also region that stores abusive and traumatic innervation of the muscle spindles, in helps to better understand the beneficial memories. This region is the area where addition to its vasomotor controlling role of physical exercise since it not only we think appraising of new situation, as function of the whole body . Our strengthens and tones the muscles of the to whether they are safe or threatening, understanding of the neurophysiology primary machinery of the body but also occurs. This realization helps us to of vasomotor control by the sympathetic results in an increase of visceral activity; understand why many patients seem system further expanded our which naturally can also be beneficial. unable to benefit from cognitive understanding of the long-held A.T. Still Therefore, our neurophysiological understanding of abusive event s. concept of "the rule of the artery is understanding expanded because of Interestingly, many patients do improve supreme." Now we began to understand research conducted both within as well once they begin to work through the the neurophysiology involved in that as outside our profession. Our clm,tcal emotions and feelings related to the foundational truth. vision involving the mechanism~ of traumatic life events . To Academy Korr further expanded our clinical somatic dysfunction and changes members, this insight may have understanding and applications related following manipulative care expanded profound implications. Let me illustrate to the developing research data. His and matured. The 70's were an exciting this reality by discussing a challenging prolific writings expanded our vision period for the clinical development of research study. concerning possible mechanisms our osteopathic vision. During the 80's A group of highly respected involved in manipulative management. and 90's, our neurophysio logical orthopedic surgeons at the San Francisco Korr wrote about the "neurological lens" understanding expanded beyond the cord Spine Center made an interesting that caused a physiological focus at the level to that of supraspinal modulation observation. Eighty-six patients met dysfunctional areas, but also magnified involved in somatic dysfunction. During their criteria of having either CT or MRI the clinical responses. He taught us to that period our understanding of the role findings of surgically significant disc view the cord as an organizer of disease played by stress and limbic system disruption and/or stenosis. The findings processes. He helped us to understand expanded. considered psychological factors. how the mechanisms of the sympathetic Since the sympathetic system Unexpectedly, the surgical outcomes nervous system could potentially innervates the muscle spindles, we came were very disappointing. After further become common denominators in to understand the neurophysiology of the analysis of their data and protocol, they maintaining many disease processes. common phase that "stress gets you up discovered five risk factors that would One of the most clinically profound tight." Activating the sympathetic predict the surgical outcome s. concepts stressed by Korr involved his system during stressful events , the Interestingly, the five applicable risk discussions concerning the functional spindles are stimulated and the response factors to these adult patients were all unity of the body. Korr stressed how the is an increase tone within the innervated related to their childhood home of origin. neuromusculoskeletal system represents muscles. Sympathetic hyperactivity may The risk factors were: that system in which we act out our also cause a facilitation of the unique human experience; thus he called proprioceptors of the body, complicating 1. A history of substance abuse; it the primary Machinery of Life. As we the clinical picture, and assisting in either 2. Abandonment and rejection; increase the activity of the the production or maintenance of 3. Emotional abuse; musculoskeletal system or primary somatic dysfunction. Our vision of the 4. Physical abuse; and machinery, there is a secondary increase complexity of somatic dysfunction 5. Sexual abuse. of activity by the visceral systems in continued to mature. order to meet the increased metabolic In addition, we were learning that the Patients experiencing three or more demands being placed on the whole limbic system is the emotional brain, of these risk factors in their home of system. In this model, the viscera could which acts as a switchboard allowing the origin had an 85 percent surgical failure then be viewe.d as the secondary emotions and feelings to be expressed rate. Those experiencing two risk factors Machinery of Life or "boiler works." If in the musculoskeletal system. The had a 26 percent surgical failure rate. one component of the secondary limbic system also neurologically can machinery is unable meet this increase impact on the hypothalamus, plus the continued on page 31

12/AAO Journal Winter 1996 Ohio University College of Osteopathic Medicine Osteopathic- Manipulative Medicine Clinician Ohio University - College of Osteopathic Medicine Athens, Ohio

The Ohio University College of Osteopathic Medicine is seeking a physician (D.O.) for a full-time, tenure track, clinical faculty position in osteopathic manipulative medicine. The successful candidate will have special interest and qualifications in the practice and teaching of osteopathic principles and manipulative medicine. The position is in the Department of Family Medicine, Section of Osteopathic Manipulative Medicine.

Qualifications: Graduate of an AOA-approved osteopathic college, satisfactory completion of an AOA approved internship, Board eligible or Board certified in an AOA-approved residency program. Additional certification by the American Osteopathic Board of Special Proficiency in Osteopathic Manipulative Medicine is desirable. Ohio licensure or credentials allowing same. DEA licensure.

Responsibilities: 1. Teach courses assigned to the Department of Family Medicine with priority given to the teaching of osteopathic manipulative medicine. 2. Participate in the ongoing programs and program development of the Section of Osteopathic Manipulative Medicine including pre- and postdoctoral training, research,. and other scholarly activities, as appropriate. 3. Maintain, demonstrate, and teach the clinical application of osteopathic principles and manipulative medicine in ambulatory and hospital-based practice. 4. See patients twelve (12) to sixteen (16) hours weekly in the Osteopathic Medical Centers.

Rank and Salary: Practice plan incentive salary plus base University salary at the Assistant/ Associate/Full Professor rank commensurate with experience and credentials.

Benefits: Excellent fringe benefits. Research facilities available. Rural environment with cultural advantages of university town.

Information regarding this position may be obtained by calling Anthony G. Chila, D.O., F.A.A.0., Head, Section of Osteopathic Manipulative Medicine, at the following numbers: 614/593-2210 (office), or 614/593- 8660 (home).

Application Deadline: Review of candidates will begin immediately upon receipt of applications and continue until a suitable candidate is identified. Formal letter of interest in position may be sent to: William F. Duerfeldt, D.O., FAAFP Chair, Department of Family Medicine Grosvenor Hall Ohio University College of Osteopathic Medicine Athens, Ohio 45701-2979

OHIO UNIVERSITY IS AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER High priority is placed on the creation of an environment supportive of women, minorities, and persons with disabilities

Winter 1996 AAO .Tournal/13 Letter to A. T. Sti 11

Dear Doctor Still, I recently read (again) Chapter XV absorb all the wisdom contained here. cause of disease, and conduct your of your book Philosophy of Osteopathy. For example, you give advice on the treatment to a successful termination. This chapter is entitled "Osteopathic frequency of treatment needed for most This is not by your knowledge of Treatment," but I find that it contains patients: "To treat the spine, and thereby chem istry, but by the absol ute much more information than is implied irritate the spinal cord oftener than once knowledge of what is in man. What is by the title. In one section you refer to or twice a week will cause the vital normal, and what is abnormal, what is the fact that this is the most important assimilation to be perverted, and become effect and how to find the cause." chapter of the book. And why? You tell the death-producing excreter , by I never cease to be amazed at the us that it is "because at this point the producing the abortion of the living wisdom contained in your writings. In engine of life is turned over to you as an molecules of life, before full matured, my opinion, if one would like a summary engineer and by you it is expected to be while in the cellular system, which lies of all that is contained in osteopathic wisely conducted on its journey." immediately under the lymphatics." philosophy and principles, this chapter, When I look at it from this perspective You also point out one of the unique in itself , would provide all the the whole chapter reads like the advice aspects of osteopathic training: "Your information one would need. you would give to a student just before he osteopathic knowledge has surely taught or she begins practice. There are so many you that with an intimate acquaintance Your ongoing student, important things said in this chapter that with the nerve and blood supply, you can Raymond J. Hruby, DO, FAAO one must read it over and over in order to arrive at a knowledge of the hidden D

Ethan R. Allen, DO named 1996 Educator of the Year

Ethan R. Allen, DO, founding chair Dr. Allen has been in private practice County Board of Supervisors for 20 years' of the board of directors of the College for 42 years, and since 1985 has been service in its drug treatment program. of Osteopathic Medicine of the Pacific, the sole owner of the Osteopathic Currently, he is president of the Los now the Western University of Health Medical Clinic in Norwalk, CA. He is a Angeles Centers for Alcohol & Drug Sciences (WUHS), and an active civic member of the American Academy of Abuse, Recovery House, in Sante Fe leader, has been named 1996 Educator Osteopathy, American College of Springs, CA. In 1984, he was appointed of the Year by the National Osteopathic Osteopathic Family Physicians, a Life commissioner to the California Health Foundation and the American Member of the AOA and a member of Manpower Policy Commission. Osteopathic Association. Dr. Allen the Osteopathic Physicians and He received a doctor of osteopathy accepted the award during a ceremony Surgeons of California. He was chair of degree from the College of Osteopathic at the July AOA House of Delegates the board of directors of the College of Physicians and Surgeons in Des Moines. meeting in Nashville. Osteopathic Medicine of the Pacific in Educator of the Year recipients are Dr. Allen was nominated by WUHS' 1978 and currently serves as treasurer selected by one of the nation's colleges Dr. Mitchell Kasovac in recognition of of the board. He has been a member of of osteopathic medicine ( on a rotating his contribution to osteopathic medicine the Osteopathic Progress Fund since basis), in conjunction with the NOF and education, and to public health. The 1982, a position he was elected to by Osteopat hic Progress Fund/S eals award is given annually to one the AOA House of Delegates. Committee, comprised of osteopathic outstanding educator in osteopathic He received the 1983 Physician of the physicians, osteopathic educators and medicine who exemplifies and Year Award from the Osteopathic AOA representatives. encourages the principles of the Physicians and surgeons of California, an profession. Dr. Allen is the 14th recipient honary PhD in 1982 from the College of Editors' Note: This is the third consecutive of the NOF/AOA Educator of the Year Osteopathic Medicine of the Pacific, and year in which the NO F presented this award Award. a commendation from the Los Angeles to an Academy member. Congratulations, Dr. Allen! 0 14/AAO Journal Winter 1996 --,------

A challenge to the concept of craniosacral interaction by James M. Norton, PhD, Department of Physiology University of New England College of Osteopathic Medicine

Editor's Note: James M. Norton, PhD, is Introduction and began a series of experiments Professor and Chairman of the Department hythmicity within the neural, designed to test the interactive tissue of Physiology at the University of New respiratory, cardiovascular, pressure model and to assess inter England College of Osteopathic Medicine, endocrine and other systems examiner agreement in the palpation of 11 Hill '.sBeach Road, Biddeford, ME 04005. R plays a major role in the maintenance the cranial mechanism. Address all correspondence and requests for of stable and appropriate conditions Preliminary findings recently reprints to Dr. Norton. This study was approved by the within the internal environment of the reported by our laboratory indicate that Institutional Review Board of the University body. One such rhythm is the "cranial the occurrence of rhythmic cranial of New England, and was supported by grant rhythmic impulse" (CRl)1 or "primary cycles can indeed be directly 4 5 6 7 #9114-345 from the American Osteopathic respiratory mechanism,"2 described as a documented by examiners • • • using an Association. rhythmic impulse arising within the unobtrusive, examiner-operated knee cranium that is separate and distinct switch, Mean frequencies for healthy Abstract from any previously known pulsation human subjects were found to be in the . urrent understanding of the and that is discernible on the external range of 3-6 cycles/min and examiner primary respiratory mechanism surface of the head with gentle experience did not seem to affect the C includes the concept of a palpation.2 The movements of the ability to palpate the frequency of the linkage between the movements of the cranium are thought to be linked with cranial mechanism. These early results cranium and the sacrum via the spinal movements in the sacrum through suggested that the cranial mechanism's dura. To test this model for craniosacral mechanical forces transmitted through cycles could indeed be reliably interaction, methods were developed to the spinal dura.2 The resultant rhythmic documented and that the basic timing of document and analyze the timing of activity of the sacrum is manifested by these cycles could be detected even by cranial and sacral cycles in healthy a slight rotation around a transverse axis relatively inexperienced examiners. human subjects. A dual-examiner slightly anterior to the second sacral If the cranial mechanism produces an protocol was utilized for a portion of this segment. 1 independent and palpable physiological study, in which two examiners, one at A recently published model for the rhythm as has been suggested, 8 then the cranium and one at the sacrum, could palpation of the cranial rh ythm3 is based different examiners should be able to simultaneously and independently on the assumption that cardiovascular agree on the basic timing (cycle length document the cranial mechanism. A and respiratory rhythms and their and frequency) of the cranial rhythm in significant correlation was found contributions to soft tissue pressures of a given subject under a constant set of between cranial and sacral cycle lengths both subject and examiner are the experimental conditions. Furthermore, documented separately by individual primary determinants of the cranial if the linkage between cranial and sacral examiners, but pairs of examiners rhythm as perceived during palpation. motion is real, then different examiners monitoring cranial and sacral cycle Experimental validation or refutation of palpating the cranium and sacrum lengths of subjects simultaneously did this (or any other) model for the should document essentially the same not agree. These findings support craniosacral rhythm requires data on frequency. In order to investigate this predictions of the tissue pressure, or frequency that are reproducible and hypothesis, a dual-examiner palpation interactive, model for the cranial rhythm accurate. Our laboratory developed an protocol was developed in which and do not support the concept of cranio approach to studying the cranial subjects were monitored by two sacral interaction as described in the mechanism of healthy human subjects examiners simultaneously, one at the osteopathic literature. that addresses these important issues, -+

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This This cranium cranium phase of the craniosacral cycle. The paper For the dual examiner protocol, 6 other subjects were monitored at the speed used was 2 mm/sec in all examiners trained and experienced in cranium and sacrum by 2 examiners. A measurement sessions; this speed was craniosacral techniques were paired and complete summary of the experimental sufficient to allow direct measurements asked to monitor the cranial mechanism data, expressed as frequency (cycles/ of flexion duration to the nearest 0.5 sec of subjects simultaneously, with I min) is shown in Table 1. The protocol or estimates of flexion duration to the examiner at the cranium and the other used allowed compa.risons between nearest 0.25 sec. Cycle lengths were at the sacrum. The 2 examiners were cranial and sacral cycle lengths routinely 15-20 sec in duration; asked not to speak or otherwise determined on a subject by the same measurement error was therefore in the communicate with one another and were examiner within a short period of time, range of 2.5 - 3.3 percent. prevented from picking up audible or and between cranial and sacral lengths The basic data obtained for each visµal cues from one another by a determined simultaneously on a subject measurement session using the protocol combination of soft background music by 2 examiners. described above consisted of the duration and a large hanging curtain separating offlexion (in seconds) and cranial cycle the examiners at the level of the subject's Statistical analysis: length (in seconds, from the beginning chest. During a measurement session, tatistical analyses were of one flexion to the beginning of the simultaneous records of flexion performed using commercially next) for 8-10 cycles. Cranial frequency determined at the 2 sites were obtained S available software (SigmaStat, (cycles/min) was calculated as 60 + the using the separate knee switches for each Jandel Scientific, 65 Koch Road, Corte mean cycle length in seconds. Calculated examiner. Following a 1-2 min rest, the Madera, CA 94925). The tests utilized frequencies were validated by visually examiners switched positions and the included one- and two-way analysis of counting the number of flexions (or measurements were repeated. Four variance, Pearson product moment extensions) over a period of one minute subjects were monitored at the cranium correlation, Spearman rank order on the permanent record. and sacrum by all 6 examiners, and 5 -+

Table 1. Dual-Examiner Data Summary for Cranial and Sacral Frequencies•·b

SUBJECTS EXAMINERS Sl S2 S3 S4 S5 S6 S7 S8 S9 AND SITES

El cranium 5.50 5.17 5.49 6.70 4.68 6.32 5.06 4.32 E2 sacrum 3.43 2.85 3.65 3.56 2.91 3.48 2.91 3.44 El sacrum 7.38 S.06 6.18 6.S9 4.97 7.26 S.22 4.3S E2 cranium 3.3S 2.86 4.44 3.90 2.96 3.79 3.S7 3.35

E3 cranium 2.60 2.47 2.06 2.20 E4 sacrum 4.08 4.26 4.72 4.09 E3 sacrum 2.lS 2.20 2.14 2.15 E4 cranium 4.06 6.13 S.S3 4.61

ES cranium 4.89 4.10 4.93 4.09 3.63 E6 sacrum 6.47 S.38 6.82 4.34 7.06 ES sacrum 4.47 3.93 4.72 3.S0 2.94 E6 cranium S.S8 S.23 7.35 4.78 5.71

a Frequencies are expressed as cycles/min and were calculated as 60 divided by the mean cycle length (in sec) determined for a subject by an examiner.

b Subjects are designated as S1-S8, and examiners and El-E6. Examiner pairings were El and E2, E3 and E4, ES and E6. Data are grouped by session, with examiners switching positions between the cranium and the sacrum.

continued on page 29

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StudentNewman-Keuls StudentNewman-Keuls correlation, correlation, dual-examiner protocol · then on the experimental hardware and setup did not interfere with their ability two examiners simultaneously to palpate the cranial mechanism of a subject. All examiners felt' that the 35 switch allowed them to record their ,.-.., u 30 palpatory findings directly and ~ ■ • [I)_ ■ accurately. ---25 Several control studies were ~ bl) performed to assess the ability of 20 ■ ■ ■■ =~ examiners to document the timing of ■ cranial cycles using the knee switch. -~ 25 • • • .. ■ -u • • •• • First, it was shown that examiners could u~ 20 • •• ■-• use the knee switch to palpate and -~ 5 document accurately the timing of the ~ inspiratory phase of the respiratory ~ -[I)_ 0 cycle, using subjects whose respirations 0 5 15 20 25 30 35 were monitored and recorded using a cranial cycle length (sec) pneumograph. Respiratory cycles were shorter than the cranial cycles observed from one another with respect to cranial of one rhythm being a simple multiple in this study and, therefore, would cycle length but also that variability or harmonic of the other. theoretically have a larger measurement among the examiners in the error using our system. Nevertheless, the documentation of cranial cycle length is Discussion correlation between respiratory cycle greater than would be expected by ur protocol required the lengths recorded directly and those chance even after accounting for the examiners to document their documented by an examiner was highly differences among the subjects. 0 subjective palpatory findings significant (Pearson's r = 0.934, p < When pairs of examiners document in a manner that produced a permanent 0.001). the cranial and sacral rhythms of a record for subsequent analysis. Spoken In a second test of the measurement subject simultaneously, their findings do words, nods of the head, or other gestures system, 1 examiner was asked to not agree. used to indicate palpatory findings might document the cranial cycles of 3 subjects In contrast to the highly significant be heard or observed by subjects and other by marking first flexion phases for 6-8 correlation between the cranial and examiners, and would require the cycles and then extension phases for a sacral-cycle lengths of a subject assistance of an assistant to record the similar number of cycles. Mean cycle determined separately by the same signals. We wanted the permanent record lengths determined using the flexion and examiner, no significant correlation to represent as accurately as possible the extension phases were 24.5 ± 4.5 sec and could be demonstrated between the examiners' actual perceptions, and chose 25.2 ± 5.6 sec, respectively, with no cranial and sacral-cycle lengths of a the knee switch as the vehicle for making significant difference between the 2 sets subject determined simultaneously by the most direct link between examiner of measurements. Thus, regardless of the different examiners in the dual-examiner perception and permanent documentation. phase used by the examiner to document protocol (Figure 1, bottom panel, and The knee-switch method used to the timing of a subject's crania l Table 2). In addition, as also shown in collect the data described in this report mechanism, the mean cycle lengths (and Table 2, no statistically significant did not appear to interfere at all with the therefore the frequencies) were the correlations· were found between cycle interaction between the examiners and same. lengths measured separately at the the subjects. Subjects were usually Cranial cycles do not have to be cranium or the sacrum of a subject by completely unaware of the means by regular in order for their timing to be the two examiners during a session. which the recordings were obtained. The documented accurately. Fourier analysis Furthermore, no consistent temporal slight movement of the examiner's leg can be used to analyze signals with a relationship could be established required to depress the switch was nearly varying periodicity,9 and this method can between the onset of flexion as imperceptible to a person lying on the also be applied to time-domain signals documented by the 2 examiners on the treatment table. When questioned that are square waves (periodic step chart record of the experiment. There informally after the measurement functions) similar to the chart records was no visual evidence of a time delay sessions were completed, new produced in our protocol. In a third type or phase shift (suggesting a fluid or examiners admitted that it took several of control experiment designed to assess mechanical wave moving caudally) or cycles to get used to the switch, but from -+ Winter 1996 AAO Journal/19 j our protocol, the cranial mechanism of drawn from cycle length can be readily movements at the sacrum, with respect 1 subject was monitored by an applied to frequency and vice versa . In to both mean frequency and the point of 12 13 experienced examiner for a period of support of the findings presented here, onset of the f!exion phase. • We could more than 11 min, allowing two recent investigations of the cranial demonstrate no significant correlation documentation of 40 cycles with an rhythm in which the methods for between cranial and sacral rhythms as average duration of 1 7. 1 9 sec documenting frequency are clearly palpated simultaneously by two (corresponding to a frequency of 3.49 described have yielded average examiners, either statistically or by cycles/min). Fourier analysis of the frequencies in the same range as those visual inspection of the experimental 10 11 record transcribed into a digital form (1 described above. • records. = flexion, 0 = no flexion) at 0.5 sec It is difficult for this author to In conclusion, our results do not intervals (a total of 1,344 data points) reconcile the lack of inter-examiner support the existence of a craniosacral produced a sharp peak in the frequency agreement seen in this study with the rhythm that arises within a subject and spectrum at 3.4 cycles/mint. Such existence of an independent, easily that is capable of being consistently agreement supports the use of our knee palpable physiological rhythm generated documented by experienced examiners. switch system to record digitally the within the cranium of a subject and Several possible explanations of our data timing of an analog process with the transmitted to the sacrum, since come to mind: 1) the cranial rhythm does potential for varying periodicity. simultaneous measurements of cycle not exist, as suggested in several recent 14 15 The overall cycle length was chosen length obtained on a subject at the two publications on the subject; • 2) inter as the measurement for comparison locations by different examiners were examiner reliability in cranial palpation, because it was felt to be less sensitive to not correlated at all (Table 2). an essential prerequisite for any differences in examiner palpatory skills Furthermore, the results seem much meaningful clinical trials of the efficacy than the duration of flexion alone. The more consistent with a rhythm that is of craniosacral therapy, 16 is very poor; underlying assumption was that only perceived by an examiner to come and 3) the perception of motion arises differences in examiner skill or from a subject but that actually arises from some aspect(s) of the interaction experience might affect the point in the somehow from the interaction between between an examiner and a subject, in cycle at which flexion is perceived to subject and examiner. This statement is which case interexaminer agreement begin, but that this point would be supported by the fact that measurements would be expected to be low and the essentially the same from cycle to cycle. of cycle length obtained separately at the ability of practitioners of craniosacral Since the beginning and ending of flexion cranium and sacrum of a subject by the therapy to share accurate and objective is sensed as a qualitative change in the same examiner were significantly information would therefore be limited. direction of movement, documentation of correlated with one another, but the Craniosacral therapy continues to be the timing of a subject's cranial cranial ( or sacral) cycle lengths of a practiced in various forms by physicians, mechanism by the experienced subject determined by multiple physical therapists and others. Such examiners utilized in this study should examiners did not agree. These findings widespread use of this modality not be grossly affected by variations in are consistent with the interactive tissue demands further research to confirm the the base-line amplitude of the mechanism pressure model,3 according to which an existence and nature of the cranial itself. All examiners so questioned stated examiner would be expected to perceive mechanism, to establish the reliability that the cranial rhythms of the subjects the same rhythm in the soft tissues of a of information obtained during cranial used in this study were readily palpable subject regardless of the site of palpation, to define the characteristics and no different than those regularly palpation. Different examiners would of a normal mechanism, and to generate 1 encountered in their practice. not be expected to perceive the same criteria for determining the efficacy of Although cycle length is not usually cranial rhythm on a given subject craniosacral therapy. discussed formally or informally as an because the persons involved in the important feature of the cranial interaction are different and, therefore, Acknowledgements mechanism, it is directly related to the physiological rhythms combining to he author would like to frequency, considered to be an important produce the palpated cranial rhythm acknowledge the significant characteristic. As described above, the would be different. T contributions to this study of data analyses in this report were These data do not support the Richard Broder -Oldach, DO, and 1 performed on original cycle length data "membrane pulley model" or "spinal Gretchen Sibley, DO, both students at rather than on calculated frequencies, in reciprocal tension membrane" 2 the University of New England College order to enhance statistical validity. hypotheses for craniosacral interaction, of Osteopathic Medicine at the time the Since the time and frequency domains which would predict that movements or experiments were performed. simply represent different ways to rhythms at the cranium would be describe a rhythmic process, conclusions causally and temporally related to

20/AAO Journal Winter 1996

1997 Co

BODY, Monday, March 17. 1997 8:00am- 5:00pm AAO Board of Trustee's Meeting MIND, Tuesday. March 18. 1997 9:00am- 5:00pm AAO Board of Governor's Meeting 7:00pm- 9:00pm AAO Opening Reception 8:30pm- 11:00pm Evening with the Stars I

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AM Lectures 8:00 am Body, Mind and Spirt: Research John M. Jones, Ill, DO 9:00 am Lower Extremities Anatomy Patrick M. Coughlin, PhD 10:00am Break March 19-22, 1997 10:30am Lower Extremities Problems/Manipulation Michael L. Kuchera, DO, FAAO The Broadmoor Hotel, 11:30am Challenging Homeostasis: Treatment Down Under Colorado Springs, CO Terence C. Vardy, DO PM Workshops: 1-3:00 pm Al Counterstrain Edward K Goering, DO Bl Myofascial Release Judith A. O'Connell, DO, FAAO Program Theme Cl HVLA Joel D. Stein, DO Where does one factor end and a sec Dl Meditation/Autohypnotic Techniques Jim Spira, PhD, MPH ond or third begin? Actually, they all over El Techniques from Down Under lap, superimposed, if you will, in the same Terence C. Vardy, DO space. To affect one component is to af 3-5:00 pm A2 Counterstrain Edward K Goering, DO fect the other two. The goal of this convo B2 Myofascial Release cation is to expose Academy members to Judith A. O'Connell, DO, FAAO C2 HVLA ways in which each of these three factors Joel D. Stein, DO can be used to facilitate the healing pro- D2 Meditation/Autohypnotic Techniques Jim Spira, PhD, MPH cess in the total human being. E2 Techniques from Down Under Terence C. Vardy, DO John M. Jones, III, DO, Program Chairperson 5:00pm- 7:00pm MO Membership Meeting/Elections 8:00pm- 10:00pm Evening with the Stars II nvocation Program

Thursday, March 20, 1997 Friday, March 21, 1997 6:00am UAAO Fun Run (no exhibit hours today) 7:30am- 4:00pm Registration Hours 7:30am- 4:00pm Registration Hours 7:30am- 4:00pm Exhibit Hours AM Lectures AM Lectures 8:00 am Bodymind Connections 8:00 am Upper Extremities Anatomy Frank H. Willard, PhD Frank H. Willard, PhD 9:00am Biofeedback 9:00 am Upper Extremities Problems/Manipulation 9:45am Attention Deficit Disorder/ Joel Stein, DO Attention Deficit Hyperactivity Disorder 10:00am Break Mary Ann Block, DO 10:30am Triggerband Treatment 10:30 am Break Stephen Typaldos, DO 11:00 am Chronic Fatigue/Immune Deficiency Syndrome 11:30am Mental imagery/hypnosis Carlisle E. Holland, DO Jim Spira, PhD, MPH 11:45 am New Ideas Forum 12:30 pm Lunch PM Worksho12s: 1-3:00 pm Fl Techniques of Andrew Taylor Still PM Worksho12 Richard L. Van Buskirk, DO 2:00 pm Nl Coding and Reimbursement Gl Muscle Energy Osteopathic Medical Economics Committee Walter C. Ehrenfeuchter, DO, FAAO Hl Triggerband Technique 6:30 pm- 7:30 pm President's Reception Stephen Typaldos, DO 7:30 pm-10:00 pm President's Banquet Jl Meditation/Autohypnotic Techniques Jim Spira, PhD, MPH Kl Extremity Techniques Saturday, March 22, 1997 Anthony G. Chila, DO, FAAO (No registration or exhibits today) L1 Education Committee Forum AM Lectures 3-5:00 pm F2 Techniques of Andrew Taylor Still 8:00am Meditation/Prayer in Medicine Richard L. Van Buskirk, DO Sister Anne Brooks, DO G2 Muscle Energy 9:00 am Differential Diagnosis: Musculoskeletal Problems Walter C. Ehrenfeuchter, DO, FAAO in Systemic Disorder H2 Triggerband Technique Jennifer Pallone, DO Stephen Typaldos, DO 9:45 am Break J2 Meditation/Autohypnotic Visualization 10:i5 am Nutritional Support in Musculoskeletal Disorders Jim Spira, PhD, MPH 11:15 am Near Death Experience Research K2 Extremity Techniques 12:00 am Lunch Anthony G. Chila, DO, FAAO Ml Fellows Forum (FAAO/NUFA) PM Lectures 1:00pm Afternoon with the AAO Fellows (everyone welcome) 5:00pm- 7:00pm UAAO Auction (everyone welcome ) Edward Stiles, DO, FAAO, Program Chair 6:00pm- 7:30pm Alumni Receptions

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programs programs TRAVEL TRAVEL 1997 Convocation Physician Registration Form Please return this registration form with your check t American Academy of Osteopathy 3500 DePauw Boulevard, Suite 1080 Indianapolis, IN 46268-1136 Phone: (317) 879-1881 FAX: (317) 879-0563

Please complete ALL information requested.

Name.______Street.______;______City______State.______Zip Code.______Telephone (Office)______(Home) ______FAX______AOA No. College and Year Graduated______Board Certification.______Spouse/Guest Name for Badge.______

I will participate in Evening with the Stars: Workshops You can count on me Tuesday__ Wednesday __ Please select your workshop preferences; choose (1) in each category, (AAO Member or AAO Non -Member and classification): keeping in mind that some workshops are duplicated. AAO Member_ _ _ _ AAO Non-Member ____ _ Wednesday Active _ 2nd Year Resident ______1-3:00 pm Al Counterstrai n Associate Retired Student □ ______Bl Myofascial Release !st Year__ fntem __ _ PhD ___ _ □ □ Cl HVLA □ D1 Meditation/Autohypnotic Techniques _ _ Registration Fee (includes (I) Banquet Ticket) ...... ,, .... $__ _ □ El Techniques from Down Under _ _ Extra Banquet Tickets @ $45.00 each ...... ,, ...... $ __ _ 3-5:00 pm □ A2 Counterstrain 82 Myofascial Release Please specify your meal preference: Regular_ _ Fish Veg.__ □ __ □ C2 HVLA D2 Meditation/ Autohypnotic Techniques _ _ Fellows DinnerTick~ts (limited to FAAOs and specified guests) □ E2 Techniques from Down Under @ $40.00 each ...... :...... ,, ...... $.__ _ □ Thursday Gavel Club Luncheon (limited to AAO Past Presidents & Guests) __ 1-3:00 pm D F l Technqiues of Andrew Taylor Still @ 30.00 each ...... $.__ _ _ _ Tax Deductible Contribution to Subsidize Student Attei;,idance at □ GI Muscle Energy HI Triggerband Technique Convocation ...... $ □ □ J1 Meditation/ Autohypnotic Techniques Kl Extremity Techniques __ _ UAAO Fun Run ($25) ...... $ __ _ □ □ LI Education Commillee Forum Total Amount ...... $ __ _ 3-5:00 pm □ F2 Technqiues of Andrew Taylor Still □ G2 · Muscle Energy AA O accepts MasterCard or Visa (circle one) D H2 Triggerband Technique D J2 Meditation/Autohypnotic Techniques My Credit Card Number is ______D K2 Extremity Techniques M l Fellows Forum (FAAO/NUFA) Expiration Date is ______□ Signature ______Friday 2:00 pm □ NI Coding and Reimbursement or make check payable to: American Academy of Osteopathy

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Q Q I American Academy of Osteopathy Undergraduate Program "Grand Machinery of Life"

Monday, March 17 11:00 am - 1:00 pm UAAO Council Meeting

Tuesday, March 18 8:00 am - 12:00 pm **Business Meeting** of Council and National Representatives to begin official business. Open nominations for Council, and take applications for Regional Representative positions. 1:30 pm - 3:00 pm ** Business Meeting** continues 4:00 pm - 6:00 pm Display Setup in Exhibit Hall 6:00 pm - 7:00 pm UAAO Informational Meeting (open to all members) 7:00 pm - 9:00 pm AAO Opening Reception (pre-registration packets can be picked up at this time) 8:30 pm - 11:00 pm Evening with the Stars I (students are able to work with experienced D0s in a casual workshop setting)

Wednesday, March 19 12:00 pm - 2:00 pm **Business Meeting** Continue nominations 12:00 pm - 1:00 pm NUFA Working Lunch including Nominations for Officers 8:00 pm - 10:00 pm Evening with the Stars II Thursday, March 20 6:00 am Fun Run 12:30 pm - 2:00 pm **Business Meeting** Close nominations, begin National Council Elections 3:00 pm - 5:00 pm Fellows Forum 5:00 pm - 7:00 pm UAAO Auction 9:00 pm Night out at "The Bee" Friday, March 21 12:00 pm **Business Meeting** Finish Council Elections 12:00 pm - 1:00 pm NUFA Working Lunch and Elections 1:00 pm - 2:30 pm Keynote Lecture/Workshop: Dr. Hugh Ettlinger, DO "OMT Approach to the Asthma Patient and the Patient with Chest Pain" 2:30 - 5:30 pm A. Hollis Wolf Case Presentation Competition 5:30 pm Finish Elections (if necessary) 6:30 pm - 7:30 pm AAO President's Reception 7:30 pm - 10:00 pm AAO President's Banquet Presentation of Chapter Awards and A. Hollis Wolf Case Presentation Competition Winner

Saturday, March 30

6:30 am New and Old National Coordinators and Regional Representatives Meeting 7:00 am UAAO New and Old Council Breakfast Meeting

**National Representatives or someone standing in should be present at all business meetings and elections. Please note that any UAAO member is welcome to attend the business meetings and elections

NOTE TO ALL STUDENTS Edward Stiles, DO, FAAO, chairperson for the "Afternoon with the AAO Fellows" would like to invite and encourage ALL students to attend the Saturday afternoon lecture session beginning at 1:00 pm. 1997 Convocation Student Registration Form Avoid a Late Fee: Return this form no later than February 28, 1997 American Academy of Osteopathy, 3500 DePauw Boulevard, Suite 1080, Indianapolis, IN 46268-1136 Phone: (317) 879-1881 and FAX: (317) 879-0563

UAAO Student Attending-- Please PRINT or TYPE when completing ALL information requested Name.______Street.______City ______State______Zip Code____ _ Osteopathic College Year of Graduation______Acknowledged by______(Dean or designated representative)

REGISTRATION FEE: Membership Classification:

AAOMember AAO Non-Member 1st Yr.__ 2nd Yr._ _ Before 2/18/97 $95 Before 2/18/97 $135 3rd Yr.__ 4th Yr. After 2/ 18/97 $145 After 2/18/97 $185 Student Fellow__ AMOUNT $_ _ _ Workshops Please select your workshop preferences; choose (1) in each category, BANQUET TICKET: keeping in mind that some workshops are duplicated. Before 2-18-97 $25.00 Wednesday $ _ After 2- 18-97 $45.00 __ 1-3:00 pm □ Al Counterstrain □ Bl Myofascial Release □ Cl HVLA MEAL PREFERENCE: □ D1 Meditation/Autohypnotic Techniques □ El Techniques from Down Under Regular_ _ Fish _ _ Vegetarian __ 3-5:00 pm □ A2 Counterstrain □ B2 Myofascial Release FUN RUN: ($ 15.00) $ __ _ □ C2 HVLA 0 D2 Meditation/Autohypnotic Techniques Deduct $30.00 if you arc bringing a treatment table)$ __ _ 0 E2 Techniques from Down Under TOTAL AMOUNT $__ _ Thursday 1-3:00 pm □ Fl Technqiues of Andrew Taylor Still □ Gl Muscle Energy Registration Policy for Students: 0 Hl Triggerband Technique □ J1 Meditation/Autohypnotic Techniques ALL students must register through their UMO 0 Kl Extremity Techniques chapter. All registration forms and fees must be sub □ LI Education Committee Forum mitted to the AAO 30 days prior to the meeting date. 3-5:00 pm □ F2 Technqiucs of Andrew Taylor Still Registration fee does not include a banquet ticket. If 0 G2 Muscle Energy a student wishes to purchase one, he/she must indi □ H2 Triggerband Technique cate his/her order on the registration form and include . 0 12 Meditation/Autohypnotic Techniques the payment along with the Convocation registration □ K2 Extremity Techniques fees. ONE CHECK WILLBE SUBMITTED FROM 0 Ml Fellows Forum (FAAO/NUFA) EACH SCHOOL FOR ALLSTUDENTS ATTEND Friday ING FROM THAT SCHOOL. 2:00 pm 0 Nl Coding and Reimbursement Please Lend Us Your Helping Hands Osteopathic Diagnosis & Treatment Service

Dear Academy Members:

The Osteopathic Diagnosis & Treatment Service will be offered during Convocation from 8:00 - 11 :00 am and 1:00 - 4:00 pm Wednesday, March 19 through Saturday, March 22. Your friends, colleagues and students will appreciate any time you can donate to this service. Please complete the form at the bottom of this page and return it to the Academy office at your earliest convenience.

Students and physicians may wish to observe your techniques. The decision to allow others to be present during treatments belongs to you and your patients.

As always, we thank you for your consideration and support.

With great appreciation,

,,, (?µ . ,9J,zt ,( 0 ..• .,,t)o Guy DeFeo, DO Chairman, OD&TS

Hours Wednesday Thursday Friday Saturday

8:00- 9:00 am 9:00-10:00 am 10:00-11:00 am

1:00- 2:00 pm 2:00- 3:00 pm 3:00- 4:00 pm

Printed Nc1me Date Hotel Reservation Form American Academy of Osteopathy• 1997 Annual Convocation• March 19-22, 1997

THE BROADMOOR HOTEL PLEASE RESERVE: P.O. Box 1439 Main Complex: Colorado Springs, CO 80901 -7711 __ Standard Room$110. 00 (719) 634-7711 __ Deluxe Room $120.00 Extra-sized, w/wet bar or city view _ _ Superior Room $130.00 Mountain/Lake View Arrival: ______, ______Premier Room $140.00 City View/Mountain View Day Date West Complex __ Deluxe Room $150.00 Mountain or Lake View Depart: ------~ !______Day Date with Balcony (higher floors) __ Superior $160.00 Extra-sized Mountain or Lake View Premiere $170.00 Extra-sized Mountain or Lake View Rooms are not available for check-in until 4 pm. Check-out time is (higher floors) noon. Sorry, no pets. A first night advance deposit is required. Please _ _ Tower Suite, Mountain and/or Lake View $255.00 enclose a check or fill in the credit card information provided. Written _ _ Moor Suite, w/ wet bar $270.00 confirmation will be sent to you upon receipt of this reservation. Ad Southlake Suite $310.00 vance deposit is refundable only if reservation is cancelled (7) days in Patio Suite $425.00 advance.

Please be sure your reservation reaches the hotel by the cut-off date of ALL rates are based on single or double occupancy. February 18, 1997. Otherwise, accommodations will be on a space For your convenience, a daily charge of $10.00 per room, available basis only and higher rates may apply. single occupancy, and $12.50 per room, double occupancy for the following services: Unlimited access to the Spa Fit PLEASE TYPE OR PRINT LEGIBLY: ness Center and fitness classes; daily gratuities for house keeping personnel; valet parking; local phone calls; long Name: ______distance and 800 access fee charges; all incoming faxes; in room coffee and tea; and daily newspaper delivery. Company: ______CREDIT CARD INFORMATION: Address: ______Credit Card Type: ______Credit Card Number: ______City: _ _ _ State: Zip: ______Expiration Date: ______Daytime Phone: (__ )______Cardholder Name: ______Authorized Signature: ______Sharing room with: ______* STUDENTS ONLY Reservations can be mailed to, FAX to or called in to: * To avoid duplication of reservations, please submit only one form The Broadmoor Hotel, Reservations Department when sharing accommodations with one or more individuals. P.O. Box 1439, Colorado Springs, CO 80901-7711 FAX: (719) 577-5700 Sharing room with: Phone: (719) 634-7711 * DON'T BE CONCERNED * about getting the accommodations you required for the best possible * rate! DO NOT wait to make your hotel reservation. DO IT NOW! A block of rooms have been reserved for STUDENT DOCTORS (quadruple occupancy) at the rate of $110.00 per night. There The AAO cannot guarantee the are a limited number of rooms available. Register early so you lowest rate of $110.00 after the can take advantage of this special 4-to-a-room FOR STUDENTS room block for that rate has been ONLY offer. filled. , . NON-PROFIT ORG. r ' . A t;l erican · · U.S. POSTAGE 1 PAID Ac .. emy '1#:-,f PERMIT #14 . CARMEL, IN ·•OsteQpathy :I:3 ~

;U, '·''".-.•;..±:. $500 DeP~u.w BQtd..,.e . .v;td, Suite 108..0. ' "· iJ!; '" + ' ' " "l:ndianapoli&, Indiana 46268-!136 Phone: (317) 87.9-1881 Fax: (317) 879,-0563

''\Make Hotel' Reservations! .··

. . . ~ . ~ . The BroadtnoorHo tel, Res'ervati 'P.O. Box)439; ¢olorad6S prmgs, . FA):;::(7l9 }5?o/-5700 ·rh

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· ·, mailr~gistra.ti~·n fo~ ;.r(pr'td;epniatj /:1Jt1~97_ References continued from page 8 AAO Executive Director's Message 1. Upledger JE, Vredevoogd JD; Craniosacral In Therapy; Chicago; Eastland Press; 1983, p.6. Memoriam: Wilbur V. Cole, DO, FAAO 2. Magoun, HI; Osteopathy in the Cranial Field; for consistent and appropriate The Journal Printing Company, 1976. reimbursement for osteopathic WilburV. Cole, DO,FAAO, 83, died on manipulative treatment. 3. Kirksville; Norton JM; A tissue pressure October 21 in Prospect Harbor, Maine. He is model for the palpatory perception of the cranial survived by his wife of 60 years, Julia, sons rhythmic impulse; JAOA; 1991;9 1(10):975-9% 5) To develop, implement and evaluate a Dr. Wilbur V . Cole III, Dr. James W. Cole, long range fund raising program to 4. Norton JM, Sibley G, Broder-Oldach R; daughter Dorot hy Schultz, eight Quantification of the cranial rhythmic impulse generate at least $10 million to grandchildren, and four great-grandchildren. in human subjects; JAOA; 1992;92(10):1285. supplement the operations of the Memorial gifts may be made to the W ilbur Academy. V. Cole Scholarship Fund at the University 5. Sibley G, Norton JM, Broder-Oldach R; Inter Last March, the AAO Board of of Health Sciences Co11ege of Osteopathic examiner agreement in the characterization of the Governors adopted the Academy's Medicine, 2195 Independence Avenue , cranial rhythmic impulse; JAOA; 1992; Kansas City, MO 64124, or to the Prospect 92(10):1285. endowment program - TRUST 2000: A Legacy for the Osteopathic Harbor Methodist Church Building Fund, Prospect Harbor, ME 04669. 6. Norton JM, Sibley G, Broder-Oldach R; Profession. The AAO Finance Dr. Cole earned his Doctor of Osteopathy Characterization of the cranial rhythmic impulse Committee has accepted the challenge in healthy human adults; AAO Journal degree from the Kirksville College of 1992;2(3):9-12, 26. to implement this program successfully Osteopathic Medicine in 1943 and completed in the next four years. Have you seriously a three-ye~r residency in neuropsychiatry. 7. Norton, JM; Documentation of the cranial considered your personal participation He joined the staff at the Kansas City College rhythmic impulse, STILL Alive; 1(1):January in this endowment program? Now is the of Osteopathy in 1951 where he worked 1996. (an electronic journal, URL is http:// until his retirement in 1980 from the position www.rscom.com/osteo/joumal/stalive.htm.) time to remember your "mentors" who gave you the gift of osteopathy! The of Dean and Chairman of the Department of 8. Upledger JE; The reproducibility of Academy is determined to preserve the Psychiatry and Neurology. He was an active member of the American Academy of craniosacral findings: a statistical analysis; legacy of Osteopathy for the osteopathic Osteopathy and had earned fellowship in JAOA; 1977; 76:890-899. practitioners of the future. both the AAO and the American Co11ege of 9. Noggle JH; OuickBasic programming for Neuropsychiatry. scientists and engineers; Ann Arbor, MI; CRC 6) To develop, implement and evaluate a In 1984-1985, the Academy dedicated its press; 1992; pp. 301-310. program to promote ongoing research annual Yearbook to Dr. Cole entitled The on the efficacy of Osteopathy. Cole Book of Papers Selected from the 10. Hanten, WP; personal communication. Since 1992, the combined efforts of Writings and Lectures of Wilbur V. Cole, DO, FAAO. was a noted researcher who 11. Wirth-Pattullo, V. and KW Hayes; Interrater the Louisa Burns Osteopathic Research He reliability of craniosacral rate measurements and Committee and the Education co11aborated with Dr. Louisa Bums and their relationship with subjects' and examiners' Committee have brought a new focus on served as the Chairman of the American heart and respiratory rate measurements; Physical Osteopathic Associat ion's Bureau of research of osteopathic manipulative Therapy; 1994; 74 (10) 908-920. Research. The following quote from the treatment. The LRP ambitiously calls Forward of The Cole Book describes Dr. 12. Lee RP; Primary and secondary respiration, for the publication of ten outcome studies Cole's researc h contribution to the Part II; AAO Journal; 1993; 3 (1) :17-19, 27. on osteopathic manipulative medicine osteopathic profession: by the year 2000. "Dr. George W . Northup characterized 13.Lee RP; A report to the statutory advisory committee on medical care: craniosacral Dr. Cole's contribution to osteopathic research manipulation;AAOJoumal; 1991; 1 (1) :13-14. 7) To develop and implementan ongoing as unique in that along with (Dr. Stedman) leadership process within the Academy. Denslow, he introduced modem research 14. Wirth-Pattullo, V.; Inter-examiner reliability The AAO Board of Trustees and techniques and tools to the study and search of palpating the craniosacral motion in the clinical Governors are fully cognizant that the for basic answers distinctive to osteopathic setting. Phys Tuer 1993 73(6):SlO. medicine. He validated some of the Louisa future of the Academy lies in their ability Bums' early experiments, and was creative 15. Ferre JC, Barbin JY; The osteopathic cranial to cultivate members who demonstrate in the development of methods to demonstrate concept: fact or fiction?; Surg Radiol Anat; 1991; outstanding potential leadership abilities. cellular changes . More important, Dr. 13:165-170. The LRP works to identify strategies to Northup states, Wilbur Cole was a research 16. Johnston WL.; Inter-examiner reliability ensure that leadership is open to all AAO scientist who had a clinical viewpoint, which studies: spanning a gap in medical research; members who have both the interest and motivated his research activity by a quest to Louisa Bums Memorial Lecture; JAOA; 1982; the talent to make significant contributions provide insights to questions, particularly as 81:819-29. they related to somatic dysfunction." 0 to the Academy's future.□ 0

Winter 1996 AAO Journal/21

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Methods 34 Korr suggests that in the normal Pilot study situation, the importance of the musculoskeletal system is such that it is the "primary machinary" oflife, and that to establish the so called visceral systems are in supporting capacity. In other words it is the requested activity of the musculoskeletal system that dictates whether osteopathy when blood vessels have to dilate with increase in heart rate and general rise in metabolic rates, together with a myriad reduces general practice of other compensatory changes throughout the body. This is in addition to the vital function of the organ. In other consultation rate words, the effectiveness of the musculoskeletal system is also dependent on the vital organs. The removal and of musculoskeletal cessation of pain via osteopathic treatment leads to a healthier individual. This approach, in a way, encapsulates problems based the essence of osteopathic philosophies. This is essentially achieved through a range of manual techniques. These are on patient perception the fundamental requisites through which the osteopathic clinician operates. The body is seen as a largely one way flow of activity, originating in the central of effectiveness nervous system and psyche, enabled and moderated by the "vital" organs and finally expressed through the 35 of the musculoskeletal machinary. The job of the osteopath is to enable this final part to operate as efficiently and osteopathic treatment comfortably as possible. This is conceptually alien to Still. He understood osteopathy to be a system of healing - Part II which could reverse that flow.By alter ·t?, mechanical and structural parts of the body, he believed that other body systems would be improved. There is no consensus of opinion over the role of osteopathy within the total health care. The osteopathic lesion has many By Mary Banihasem, DO Old Westbury, New York -+

Winter 1996 AAO Journal/23 aspects and effects, some local and some set up in the Lis son Grove Health Centre, appointment. If agreeable the patient's distant. They are listed below: London, NWl where a group general name was given to the practice manager practice serving a population of7,000 in who randomly alotted the patients either 1. Hyperesthesia, especially of muscles the North East Westminster locality was to the control group C or the treatment and vertebrae; based. The North East Westminster is the group A. A control was set up to estimate 2. Hyper-irritability, reflected in the largest locality in Kensington, Chelsea the efficacy of the treatment. It has been and Westminster and is divided into 9 established that patients improve with altered muscular activity and altered 37 states of muscular contraction; ward areas. The Lisson Grove Health time. The control group C were told 3. Changes in tissue texture of muscle, Centre is situated in Church Street and there was a waiting time of 4 to 6 weeks. connective tissue, and skin; has the highest density in the locality and The appointment date and a questionnaire 4. Changes in local circulation and in the highest rate of overcrowding in the to fill out on the evening before attending the exchange between blood and area. Church Street has the highest rented the clinic was sent to the patients. This tissues; and accommodation. There is also the highest included inquiries into I) the duration; 5. Altered visceral and other autonomic rate of unemployment in North East 2) nature of symptoms; 3) a visual functions. Westminster at 16.1 percent of the total anagram marking the amount of population per year. 20.5 percent of the improvement (0 - no percentage of It has been experimentally shown that total population per year of private improvement, 10 - one hundred percent 36 manipulative procedures applied by households are from an ethnic minority improvement); and 4) present treatment. osteopathic physicians induce relaxation group, who live mainly in Church Street The points 1 to 4 are each explained: of muscles which has been maintained ward. Church Street has the highest rate in a continually contracted state. Since oflong term illness and hospital admission 1. here it was intended to establish if the an osteopathic lesion may have not only rate in North East Westminster at 23.8 symptoms are recent, i.e. are the local effects on the musculoskeletal percent of the population per year. patient's problems chronic or acute in system but also distant effects, it causes All patients presenting to their general nature; irritation of the visceral functions and practitioners with pain, spinally or 2. the next question inquired if the hence leads to manifestation of organic peripherally were included in the pilot symptoms were improving within the . 34 patho1 og1es. study unless it was known or became 4 to 6 weeks whilst awaiting Hence, if an osteopathic physician apparent that they were suffering from treatment? This will allow us to gives treatment to a lesion area, the one of the following: support or disprove the work of Eysenck as to the fact that symptoms manipulative relaxation of the muscles 37 will not only effect the loca l 1. Inflammatory joint disease; improve with time; musculoskeletal problem but may 2. Skeletal metastases or infection; 3. A visual anagram was provided for prevent organic pathologies from 3. Spondylolithesis; the patients to mark on the amount of developing in the future. This will 4. Neurological deficit in structures improvement; and improve the general health of the patients. innervated by lumbar or sacral roots 4. Whether the patient was undergoing Based on the above arguments it is that could not be ascribed to a previous treatment was vital as it would indicate postulated that the hypothesis is true. resolved episode or other pathology; if the patient was improving due to ' 5. Osteomalacia or osteoporosis; treatment and not by chance, as 37 I. Osteopathic intervention will have a 6. Visceral pathology that could refer suggested by Eysenck. direct effect on the number of pain to the lower-back; and musculoskeletal consultations the 7. Pregnancy. Group A patients were given an patient may require. appointment within one week of their 2. The number of musculoskeletal Also excluded were: general practitioner's referral date. consultations after treatment should 8. Those who intended to seek physical Physical exanimation followed, be reduced. treatment outside the practice for their including both orthodox and osteopathic 3. The total number of non-musculo present episode. methods. The orthodox methods would skeletal consultations should be include cardiovascular, respiratory and reduced for patients having had At presenta tion, the general abdominal examinations where appro osteopathic treatment. practitioners carried out their usual priate. The osteopathic examination assessment, including medical would include a standing examination, The design below was non investigations. If they decided the patient i.e. a general view of the patient's posture randomized, with a retrospective bias, was eligible for the trial, she or he was and muscular balance, an active with subjects acting as their own control. told that the practice now has an osteopath examination, i.e. observing the spine A once-weekly osteopathic clinic was and they could be offered an through ranges of physiological

24/AAO Journal Winter 1996 movements and finally a passive along with the number of treatments • Past treatments; and examination which would include they each had. The questionnaire • Time elapsed since last treatment . papation and a passive assessment of included inquiry into 1) treatment movement within each appropriate spinal expectation, benefit and 2) a visual The final part of the data collection segment. Once the absence of excluding anagram of the amount of help (0 - no was information from the general factors was confirmed, and the findings help at all and 10 - very much help) - practitioner notes at the Lisson Grove at examination recorded, a working refer to patient questionnaire. Each Health Centre. This would have included diagnosis was attempted and discussed question is explained below: complete information on each patient's with the patient with whom a strategy illnesses. The following data was for future management and treatment 1. This question gave us an idea of each obtained from the notes: was agreed on. The following points patient's understanding of osteopathic Total number of visits made to the were discussed with each patient. treatment. The visual anagram gave an general practitioner (including objective measurement into the amount musculoskeletal and organic problems) 1. The number of treatments each patient of improvement from the treatment. in; may require for improvement of the 1991 (no osteopathic treatment was condition. 2. The last question would give an yet available) 2. The expectation required of the patient indication as to whether the patient would 1992 ( osteopathic treatment was made were pointed out and explained, i.e. choose this type of therapy again in the available for a period of 3 months within exercise, rest, hydrotherapy ... future. The treatment was continued until that year) the patients deemed themselves 1993 ( osteopathic treatment was The treatments given were somewhat recovered or it was decided that further available for over a year) stereotyped to aid reproducibility and treatment was unlikely to produce benefit aimed to use a classical range of (usually when three consecutive Total number of musculoskeletal osteopathic maneuvers of the type most treatments had not been accompanied related visits to the general practitioner likely to be delivered to a patient in the by any improvement in the patients in 1991, 1992, 1993. U.K. from a registered osteopath. The conditions). The same questionnaire (Q) This information was obtained by following elements were used in each was sent to Group A patients three reading through notes made by the case: months after the discharge date. This general practitioner. If the patient had was sent by the practice manager who been to the GP for the renewal of their • direct pressure; kept a record on each patient's last prescription this was not counted as a • stretch to involved musculature; treatment. The procedure for contacting visit. • cross-fibre and longitudinal soft patients who failed to return the tissue techniques; questionnaire was carried out by the Analysis • low velocity high-amplitude practice manager who would send a The data were treated usmg oscillatory movements to second copy of the questionnaire descriptive and inferential statistics. A hypomobile joints; and followed with a phone call. During the summary of percentage of improvement • high-velocity low-amplitude thrust phone call the practice manager would sustained three weeks into treatment and techniques to hypomobile vertebral inquire into progression of symptoms, three months post-discharge. These were motion segments. and whether the questionnaire had been supplemented via use of graphs (bar received. chart). A non-parametric Wilson After the first treatment the patients The second part of the data collection (matched pair) test was used to compare were required to judge the percentage of was information gathered from the data related to general practitioner visits improvement so far. The second osteopathic case history of the patient over varying time periods. The use of a assessment stage was at 3 weeks into participating in the pilot study: non-parametric test was deemed treatment (the average number of necessary due to the non-randomized treatments within the 3 weeks was • Age and sex of the patient; subjects used. A parametric test was not between 2-3). Group A was given a • Occupation; used as the subjects were not randomized. questionnaire to fill out after 3 weeks of • Date of referral from the GP; commencing treatment. The question • Clinical diagnosis; Results naire (Q) was sent to Group A patients • Total number of osteopathic Composition of the study group. treatments; by the practice manager in the post with On an original entry of 50 patients, 7 a pre-paid envelope. The practice • Duration of treatment; patients were excluded: 2 control and 5 manager recorded all the patients taking • Percentage of improvement on the part in the pilot study on her computer first treatment; -+

Winter 1996 AAO Journal/25 treated patients did not return Control group questionnaires, despite4 attempts by the The control group results are shown in Table 2. PI shows the percentage of improvement practice manager to write or contact the by the patient while they were waiting for treatment (on average 4-6 weeks). patients. There were thus 23 subjects in Total number of patients was 23 of which 3 patients reported improvements of 40 percent, the control group and 20 in the 10 percent and 50 percent. (shown on the bar chart below) manipulated group. The main table of results shows the CONTROL GROUP baseline characteristics of the treatment Percentage of improvement patients. The age of the patients at 100 baseline ranged from 15 to 80 with a mean of 59 years. From the 20 patients 80 17 were female and 3 were male. They had a wide range of occupations as illustrated in the main table. The patients presented with symptoms 60 in the peripheraljoints, cervical, thoracic or lumbar spine. Determining success of osteopathic treatment in relation to peripheral or spinal problems has not 40 been considered because of the limited number of patients in this study. On average the patients had 5 20 treatments over a period of 5 months before their symptoms had resolved and were discharged. The greatest number of osteopathic treatments required was 0 15 and this was over a period of 14 .00 10.00 40.00 50.00 months. The least number of osteopathic - treatments required was 2 and this was Percentage of improvement in a period of 1 month. This is shown in The patient with 50 percent improvement was undergoing drug therapy (anti-inflammatory). the table for duration of treatment. The patient with 40 percent improvement was not undergoing current treatment but had The percentage of improvement on undergone drug therapy in the past with no significant change in symptoms. The patient the first osteopathic treatment ranged with 10 percent improvement was not undergoing current treatment but had also undergone from O to 100 percent, and the average drug therapy in the past. The remaining 20 patients reported no improvement during the 4- percentage of improvement was 62 6 weeks whist waiting for treatment percent, the bar chart illustrates the percentage of improvement. Figure 1 Discussion VISUAL ANAGRAM RESPONSE - 3 Weeks Percentage of Improvement This study aimed to show that osteopathic manipulation had a beneficial effect on patients with musculoskeletal problems presenting in 4.00 the general practice setting. Earlier studies have shown that there 10.00 5.00 may be some advantage of manipulative 5 7.00 therapy over conventional treatments • 32 33 3 ' • but the trials have been ~lagued by 2 29 methodological difficulties. · In the present study a randomized 8.0Q control design was used to eliminate bias and noise as much as possible. blinding was not possible as only one 9.00 therapist was involved and all patients

26/AAO Journal Winter 1996 This shows that there is no significant Figure 2 change in patient general health in relation to the number of visits made to the GP. The VISUAL ANAGRAM RESPONSE - 3 Months 3 months during which osteopathic Percentage of Improvement treatment had been available made no significant difference. Making the same comparison between .00 1991 and 1992, then 1992 and 1993 showed a significant difference (p<0.009). The 12 months of osteopathic treatment did make a 5.00 significant difference in the number of GP visits. Tables III and IV.

Table III 10.00 7.00 GPM9I Numberof MS related GP visits (1991) with GPM-93 MS related GP visits

Mean Rank Cases 8.00 9.63 15-Ranks (GPM-93 LT GPM91) 8.83 3 + Ranks (GPM-93 GT GPM91) 9.00 2 Ties (GPM-93 EQ GPM91)

20 Total This shows that the frequency for a response of 10 ( very much help) at 3 weeks into treatment was greatest at 35 percent ie. 7 out of 20 patients. The frequency for Z = -2.5695 2-Tailed P = .0102 a response of 10 at 3 months after discharge was more common at 50 percent.

Table IV

-----Wilcoxon Matched-Pairs Signed-Ranks Test Duration of symptoms: Total numberof GP visits in 1991 vs total number of GP visits in 1992 - Table II GPM_92 MS related GP Visits All patients in the control study had an with GPM_93 MS related GP Visits onset symptomology at two month Comparing the total number of GP visits (GPV) in 1991 to 1992 revealed no duration or longer. The patients in the significant difference. (p> 0.05). Mean Rank Cases pilot can be categorized as chronic 9.12 17-Ranks(GPM-93LTGPM-92) patients since they all have had 16.00 1 + Ranks (GPM-93 Gt GPM-92) Table II symptoms for longer than six weeks. 2 Ties (GPM-93 EQ GPM-92) - -- - - Wilcoxon Matched-Pairs Signed Ranks Test Improvement of symptoms: 20 Total Out of the 23 patients taking part in the GPM91 Number of MS related GP visits Z = -3.0267 2-Tailed P= .0025 pilot study,only 3 replied that their (1991) with GPM-92 MS related GP Visits symptoms were improved spontan The same pattern was repeated when eously. See bar chart. (control group - Mean Rank Cases comparing the total number of GP visits for percentage of improvement). 11.57 7 - Ranks (GPM-92 LT GPM91) musculoskeletal related problems. The 1991 8.18 11 +Ranks(GPM-92GTGPM91) and 1992 figures revealed no significant 2 Ties (GPM-92 EQ GPM91) Present Treatment: difference, (p>0.05)-Table V- but 1992 and 1993 and 1991 and 1993 showed a Only one patient in the control group 20Total significant reduction in the number of was undergoing treatment. This was musculoskeletal related complaints in 1993. drug therapy, administrated by the Z = -1960 2-Tailed P= .8446 (p<0.05)- Table VI and VII. general practitioner.

Past Treatment: Over 60 percent of the patients have had treatment in the past. -+

Winter 1996 AAO Journal/27 Table V Table VII eventually underwent treatment. Given that it was only a pilot study, the numbers GPV-91 Total GP visits in 1991 ----- Wilcoxon Matched-Pairs involved were small and the follow-up with GPV-92 Total GP visits in 1992 Signed-Ranks Test period relatively short. In order to increase the number of patients available, Mean Rank Cases GPV-92 Total GP visits in 1992 all types of musculoskeletal problems 10.00 8 - Ranks (GPV-92 LT GPV-91) with GPV-93 Total GP visits in 1993 were eligible, not just back pain sufferers, 9.10 10+ Ranks (GPV_92 GT GPV-91) as many of the other larger trials have 2 Ties (GPV-92 EQ GPV-91) Mean Rank Cases been ed. was 8.73 15 - Ranks (GPV-93 LT GPV-92) us Patient response measured by means of a visual anagram 20 Total 11.00 2 + Raniks (GPV-93 GT GPV-92) 3 Ties (GPV-93 EQ GPV-92) at three weeks into treatment and 3 Z=-.2395 2-Tailed P = .8107 months after discharge. 20 Total The results showed that there was a large range of response to the first Table VI Z = -2.5799 2-Tailed P= .0099 osteopathic treatment (0-100%), but with Table VIII an average improvement of 62%. A ----- Wilcoxon Matched-Pairs Signed-Ranks similar picture was seen after the first Test ----- Wilcoxon Matched-Pairs questionnaire. Interestingly the patients Signed-Ranks Test in whom treatment was delayed showed GPV-91 Total GP visits in 1991 with GPV- no spontaneous improvement in 93 Total GP visits in 1993 QFR Questionnaire (First response) symptoms. This goes against some of with QFR Questionnaire (Second response) the earlier trials which suggested that, at Mean Rank Cases least for back pain, it can be assumed 11.50 11 - Ranks (GPV-93 LT GPV-91) Mean Rank Cases that most must have been chronic. 4.42 6 + Ranks (GPV-93 GT GPV-91) 11.00 5 - Ranks (QSR LT QFR) 3 Ties (GPV-93 EQ GPV-91) 5.56 9 + Ranks (QSR GT QFR) Indeed, the wait for treatment was. 6 Ties (QSR EQ QFR) sometimes two weeks even in the early 20 Total treatment group (group A). 20Total Hence, there was a definite beneficial Z= -2.3669 2-TailedP-.0179 effect of osteopathic manipulation after Z = -.1569 2-Tailed P= .8753 only a few sessions. The results of the second questionnaire ( three months after Visual Anagram Responses discharge) were no different from the Comparing the questionnaires between the first response (3 weeks into treatment) and initial response indicating that any benefit the second response (3 months after discharge) showed no significant difference (p of accrued early on was maintained. This 0.8). As seen on table VIII. does not support earlier trials which suggested that manipulation may just This demonstrates that the beneficial effects of osteopathic treatment gained after 3 hasten recovery and not influence long weeks was maintained at 3 months after discharging the patient. This is shown of the pie 25 term prognosis. Unfortunately, the chart for visual anagram response at 3 weeks and 3 months (Figures 1 and 2) patients in the present study were treated until they no linger required, or felt they did not need any further treatment. Hence, some had treatments for several months which may have influenced the final results. This makes comparison with earlier work difficult, again emphasizing the methodological problems with trials in this area. The data on the number of GP consultations is perhaps more useful in terms of health promotional activity. .00 20.00 40.00 50.00 60.00 70.00 75.00 80.00 100.00 The osteopathic service was available for a period of just over one year from Percentage of improvement on first treatment the end of 1992 through to 1993. Results 60 percent of patients presenting for treatment had no previous treatment of any type. 28/AAO Journal Winter 1996 were obtained for 1991-1993. In the first more important. If the reduction in total complaint. Hence, one could then study year, 1991, no osteopathic treatment was GP visits was due to the effects of neck pain, hip/knee pain and back pain available, and there was no difference osteopathy on general health, then separately. One would then be able to between 1991 and 1992 in terms of the osteopathy should be an integral part of see if results matched those found by number of GP consultations and specific primary healthcare. Hence question one other investigators and so make the GP consultations for musculoskeletal concerning whether there is a place for findings more reliable. problems. However, one must remember the osteopathic practitioner in primary Follow-up for longer would be another that manipulation only began in the last healthcare would have to be answered in important factor as then any long-lasting three months of 1992. Comparing 1993 the affirmative. effects could be quantified. This may to 1992 there were significant differences Another point which leads on from show that osteopathic therapy provides between the number of total GP visits this theory would be the enormous long-term benefits and so would and also the number of consultations for potential for financial savings. In its strengthen the argument for having an musculoskeletal problems. This would simplest terms, in these days of budgets osteopath in the GP setting on both Qaly indicate that the osteopath had made a and GP fundholding, a cut in the number and financial grounds. significant contribution in reducing the of consultations would be very Another interesting way of improving number of GP visits. welcomed. Similarly, problems the power of further studies would be to The effect on the total number of alleviated by osteopathic techniques employ crossover trials. These compare consultations could be viewed in two would mean less money needing to be two different treatments in the same different ways. The osteopath may have spent on drug prescriptions. Also by group of patients but each individual reduced the number of musculoskeletal reducing the number of musculoskeletal experiences both types, half the group visits to such a degree that it influenced complaints there would be less referrals start with treatment A and then crossover the total number. This would also support to hospital orthopaedic outpatients, again to treatment B and vice versa for the the view that the GP list in the Lisson providing a financial saving. other half of the patients. This enables Grove Practice had its fair share of Apart from the monetary savings one one to carry out studies in smaller groups chronic long-term problem s of a must also consider the patients view of of patients. nonspecific musculoskeletal nature. osteopathy. The incumbent government If all the further trials did show that Alternadvely, osteopathy is felt by its is very keen on charters for citizens osteopathy was unequivocally effective practitioners to be a total form of therapy covering a wide variety of fields. If then one has to consider the practicalities and treatment may have improved health osteopathy alleviates sufferers symptoms of setting up a primary healthcare service. in other ways, so reducing visits for then it is reasonable to assume that they The initial costs would soon be recouped ailments such as coughs and colds. will be satisfied from their treatment. by the savings provided by the reduction Obviously conclusions like the latter Hence, osteopathy would appear to in the GP visits and all its associated cannot be drawn from the available data score highly in Qaly terms and also be trappings. The service would have to be but it would be interesting to investigate cost-effective. It would also provide an monitored by regular audit to ensure that this further. If it were true, then opportunity to discuss health it continued to show improvements in osteopathic treatment would be useful in promotional issues with patients as patient symptomology. a health promotional role as well as in consultation times are usually twenty Geographical location is also the sense that reduced numbers of GP minutes. It could also enable the GP to important as well as the population visits probably equates to a healthier use his/her time more productively with determinants. Questions would need to population. This last point is also open to regards to health promotion since the be answered as to whether social class debate. rate-limiting step in this area appears to ethnicity and age influence the From the available results one can be time. effectiveness of osteopathic treatment. now tentatively answer questions two The final question needs more data to Hence, an osteopathic service may be and three in the introduction. It would be answered properly. On the available more appropriate in certain areas appear that the osteopathic practitioner evidence, future policy makers and health compared to others. did help reduce GP consultation rates administrators would probably not be In conclusion this pilot study has and also reduce the number of convinced that osteopathic treatment was shown that osteopathic service in the GP musculoskeletal consultations. necessary in the primary healthcare setting may be effective in terms of both Obviously, the numbers involved were setting. Further studies would be needed patient benefit and cost effectiveness small and hence results should be viewed to strengthen the findings. and in health promotion. Further studies with caution. Obviously, the first point would be to are needed to elaborate on these findings However, the implications for the employ a larger study population and and to pinpoint the areas where the health promotion of patients at the Lisson then to break this down into subgroups greatest benefit is likely. Further studies Grove Health Centre could be much according to particular symptom or -+

Winter 1996 AAO Journal/29 may include the use of larger sample of Yacoub, M. The Nottingham health profile as a Grahame, R., Woods, P., Hill, R. Controlled subjects. The study should be set up in measure of quality of life following combined Comparison of Short-wave Diathermy treatment heart and lung transplantation. J. Epidemiol with Osteopathic treatment in Non-Specific Low other GP clinics simultaneously and the Community Health 1988: 42; 232-4. Back Pain. The Lancet 1985: 1258-1260. total results should then be analyzed. This would also allow figures for costing 13. Brazier, J.E., Harper, R., Jones, N.M.B., 27. Ottenbacher, K., Defabio, R. Efficacy of and savings to be published. This is O'Cathain, A., Thomas, K.J., Usherwood, T., et Manipulation/Mobilization therapy. Spine. vol. 10. No. 9, 1985. especially so if one can elucidate further al. Valida ting the SF-36 health survey questionnaire: new outcome measure of primary any health promotional benefit that care. BMJ 1992: 305; 100-4. 28. Ongley, J., Dorman, T.A., Klain, G.K., Eek, osteopathy may confer. 8.C. Approach to The Treatment of Chronic Low 14.Rosser, R., Kind, P., Williams, A. Valuation Back Pain. The Lancet 1982: 143-146. of quality of life: psychometric evidence. In: References Jones-Lee, M., Ed. The value oflife and society. 29. MacDonald, R.S.,Bell,J. An Open Controlled I. Northup, G.N., 1979. Osteopathic Medicine, Amsterdam: Elsevier-North Holland, 1982. Assessment of Osteopathic Manipulation in An American Reformation. Chicago: American Nonspecific Low-Back Pain. Spine. vol. 15, No. Osteopathic Association. 15. Williams, A. Economics of coronary artery 5, 1990. by-pass grafting. BMJ 1985: 291; 326-9. 2. North East Westminster locality profiles - 30. Hadler, N.M., Curtis, P., Gillings, D.B., City of Westminster Health Authority, 1994. 16. Gudex, C., Williams, A., Jourden, M., Mason, Stinnett, S. A benefit of spinal manipulation as R., Maynard, J., O'Flyn, R., et al. Prioritizing adjunctive therapy for acute low-back: A stratified 3. British Medical Association. alternative waiting lists. Health trends 1990: 22; 103-8. controlled trial. Spine 12: 703-706, 1987. therapy. Report of the Board of Science and Education. Spaiding: Chameleon press 1986:77. 17. Mason, J., Drummond, M., Torrance, G. 31. Assendelft, W.J., Bouter, L.M., Kessels, Some guidelines on the use of cost-effectiveness A.G.H. Effective ness of Chiropractic and 4. Department of Health and Social Security league tablets. BMJ 1993: 306; 570-2. physiotherapy in the treatment oflo w back pain: Working Group on Back Pain. Report to Secretary A critical discussion of the British randomized of State for social services. London: HMSO. 18. Wood, P.H.N., Baddley, L. Epidemiology of clinical trial. J. Manip. Physio. Therapeutics Vol. 1979. back pain. In: Jayson, M.I.V., Ed.The lumbar 14, No. 5, 1991. spine and back pain. Second Edn. Tunbridge 5. Meade, T.W., Dryer, S., Browne, W., Wells: Pitman, 1980: 29-55. 32. Koes,8.W.,Assendelft, W.J., VanDerHejide, Townsend, J., Frank, A.O., Low back pain of G.J.G., Bouter, L.M., Knipschild, P.O. Spinal mechanical origin: randomized comparison of 19. Weber, H., Burton, K. Rational treatment of manipulation and mobilisation for back and neck chiropractic and hospital outpatient treatment. low back trouble? Clinical Biomechanics 1986: pain: a blinded review. BMJ 1991: 1298-303. BMJ 1990: 300; 1431-7. l; 160-167. 33. Koes, B.W., Souter, L.M., Mameren, H., 6. Wilson, A., McDonald, P., Hayes, L., Cooney, 20. Bloch, R. Methodology in back pain trials. Essers, A.H.M., Verstegen, G.J., Hofhuizen, J., Health promotion in the general practice Spine. vol. 12. No. 5, 1987. D.M., Houben,J.O.,Knipschild, P.G. Randomised consultation; a minute makes a difference. BMJ clinical trial of manipulative therapy and 1992: 304; 227-30. 21. Sackett, D.L., Gent, M. Controversy in physiotherapy for persistent back and neck counting and attributing events in clinical trials. complaints: results of one year follow up. BMJ 7. Wallace, P.O., Brennan, P.J., Haines, AP. N. Eng. J. Med. 1979: 301; 1410. 1992: 601-605. Are general practitioners doing enough to promote healthy life styles? Finding of the Medical 22. Roberts, N., Smith, R., Bennett, S., et al: 34. Koes, B.W., Bouter, M.L., Mameren, H., Research Council's general practice framework Health beliefs and rehabilitation after lumbar Essers, A.H.M., Yerstegen, G.J., Hofhuizen, study on life and health. BMJ 1987: 294; 940-2. disc surgery. J. Psychosomat. Res. 1984: 28; 139- D.M., Houben, J.O., Knipschild, P.O . A 144. randomized Clinical Trial of Manual Therapy 8. Robinson, R. Economic Evaluation and Health and Physiotherapy for Persistent Back and Neck Care. Cost-Utility analysis. BMJ 1993:307; 859- 23. Ejeskar, A., Nachemson, A., Herbert, P., et al: Complaints: Subgroup Analysis and Relationship 62. Surgery versus chemonucleolysis for herniated Between Outcome Measures. J. Manip. Physic. lumbar disc: A prospective study with random Therapeutics Vol. 16, No. 4, 1993. 9. TheHealthoftheNation. White Paper HMSO assignment. Clin. Orth. 1983: 174; 236-242. 1991. 34i. Korr: The neural Basis of osteopathic lesions. 24. Doran, D.L.M., Newell, DJ. Manipulation in JAOA 47: 191-198, 1947. IO.Hunt, S., McKenna, S.P., McEwan, J. Treatment of Low Back Pain: A Multi-centre Measuring health status. London: Croom Helm, study. BMJ 1975: 2; 161-164. 35. Latey, P. (1980) The Muscular Manifesto. 1986. 25. Sims-Williams, H., Jayson, M.l., Young, 36. Korr, I.M. (1970) The sympathetic nervous 11. Buxton, M.J., Acheson, R., Caine, N ., Gibson, S.M., Baddley, H., Collins, E. Controlled trial of system as mediators between the somatic and S., O'Brien, B.J. Cost and benefits of the heart mobilisation and manipulation for patients with supportive processes. The Physiological Bases of transplant programmes at Harefield and Papworth low back pain in general practice. BMJ 1978: Osteopathic medicine. Post Graduate Institute of Hospitals.London: HMSO, 1985. (DHSS research 1338-1340. Osteopathic Medicine and Surgery. New York. report No. 12.) 26. Gibson, T., Harkness, J., Blagrave, P., 37. Eysenck, M.W. (1984) A Handbook of 12.O'Brien, B.J., Banner, N.R., Gibson, S., Cognitive Psychology, Lawren ce Erlbaum Associates. D

30/AAO Journal Winter 1996 Conflicting visions ■■ ■ Edward G. Stiles, DO, FAAO

Continued from page 12 dysfunction than the somatic changing the central nervous system or dysfunction that has the patient." These soft-ware program of the computer." Meanwhile, the patients experiencing no statements by the medical giant s, During his neurological exam he was in risk factors had a 95 percent surgical Cannon and Osler, help to expand our effect evaluating the hardware of the success rate. My clinical experience vision of our osteopathic potential. Also, nervous system or computer. He went suggests that many of my patients, who helps to appreciate Korr's statement that on to say, "You are using the experience chronic pain and chronic we have the potential of impacting the musculoskeletal system to change the somatic dysfunction frequently total nervous system when we provide software program by decreasing the responds poorly to osteopathic care. comprehensive osteopathic care. afferent load." Later Ed introduced me They also have a history of at least three Meanwhile, the vision of allopathic, to a very significant article that of the risk factors. This orthopedic group orthopedic and neurosurgeons also supported his observation. Dr. Issac identified a similar patient population. changed during the 80's and 90's. A created the following slides and are Providing appropriate counseling conference in 1988 resulted in an based on his understanding, as a services, the majority of the patients neurologist, of this article I would like became a symptomatic, without surgery, to briefly discuss. in spite of the fact they all had significant Davidoff, a neurologist at the disc pathology and, or stenosis. "as I watch you work, University of Miami and publishing in I hypothesize that the memories I realize you are doing more the Journal, Neurology in May 1992, stored in the limbic system often than re-establishing made some interesting observations. His ineffectively resolves and reconciles by article, Skeletal Muscle Tone and the normal mechanical function. an understanding of the circumstances Misunderstood Stretch Reflex surrounding the abusive or non You are changing emphasized the fact that myotatic reflex nurturing events. I would suggest there the central nervous system discussions are based on data from the are at least two effective management or soft-ware program Sherrington research model. strategies are available. Since the limbic Unfortunately, decerebration of animals, system is the switchboard connecting the of the computer. " when utilized, limits our understanding. emotions and feelings with the Therefore, all the supraspinal influences musculoskeletal system, I propose, that were ignored. The Sherrington model as osteopathic physicians, we have the excellent book entitled, New also did not fully appreciate the potential of simultaneously addressing perspectives on low back pain. The book intemeuron influences. The reductionist both the emotional and musculoskeletal effectively discusses non-disc thinking involving the myotatic reflex components. Therefore, we have a etiological factors in LBP such as arterial underestimated the complexity of the tremendous potential for offering unique and vasomotor control, neurofacili nervous system. The vision limited, as care to these deeply traumatized tation, neurotrophic axionic flow, a result. patients. Thus, our vision of the diversity venous and lymphatic circulation. These It is estimated there are 10 billion of factors influencing the are all factors we, as osteopathic neurons within the human body and 90 musculoskeletal system continued to physicians, believe can be influenced by percent are intemeurons. Also, each expand and became more complex manipulative management. Therefore, motor neuron , represents the final during the 80's and early 90's. the medical profession also went common pathway to the muscle (Fig #1) This information and understanding through a vision change concerning the and is in contact with among 20.000 - helped us to better appreciate quotes etiology and possible management of 50,000 dendrites from other neurons. attributed to Cannon; who stated back pain. Envision the complexity of this system. "systems do not exist in nature but only Edward Isaac, MD, a neurologist and Davidoff discussed just three types of in the minds of men and women" or teaching colleague at Michigan State inhibitory interneurons: William Osler who reportedly stated; "it University, played a major role in is more important to know the patient expanding my clinical vision. One day, 1. The Renshaw cells, which represent who has a disease than the disease that as a student in a course I was teaching, the majority; has the patient." I believe we, as Ed made an interesting observation. He 2. la inhibitory intemeurons; and osteopathic physicians, can paraphrase stated, "as I watch you work, I realize 3. Non-reciprocal inhibitory group 1 this to state, "it is more important to you are doing more than re-establishing intemeurons. know the patient who has somatic normal mechanical function. You are -+ Winter 1996 AAO Journal/31 Conflicting visions ■■ ■ Edward G. Stiles, DO, FAAO

Let me try to quickly illustrate the complexity of this system. The alpha motor neurons send impulses to the Renshaw cells (Fig #2), which in return send inhibitory impulses back to the same motor neuron via collateral's, to other Renshaw cells, group Fig.1 1a intemeurons, gamma motor neuron ( or sympathetic neurons) THE FINAL COMMON PATH WHICH DETERMINES MUSCLE TONE IS THE ALPHA MOTONEURON and to other alpha motor neurons. Simultaneously, the Renshaw cells are influenced by the supraspinal centers as well as the peripheral and segmental afferents. Remember this represents only one Renshaw cell. Supraspinal centers influence both the alpha and gamma motor neurons, through this system alone, including the limbic system. The group la inhibitory intemeurons (Fig #3) are influenced by the skin, muscle and joint proprioceptors, the vestibular and

Muscle tension = red nuclei, the sensorimotor cortex, the group 1a intemeurons Mechanics of connective tissue PLUS from the antagonistic and synergistic muscles of the antagonists. Frequency of alpha ..... ;, of aclin-myosin motoneuron dis.charges bridges The final common pathway from the group I a inhibitory intemeurons from all these just mentioned centers then impact on the alpha motor neuron. The third group of intemeurons Davidoff discussed were the nonreciprocal inhibitory group la intemeurons (Fig #4) which Fig. 2 are influenced by the suprospinal, reticulospinal and corticospinal tracts, the group la intemeurons from distant muscles and group lb intemeurons from golgi tendon organs. The final common input from all these centers into the group 1 non-reciprocal intemeurons then impact on the alpha motor neuron. But look at the.complexity related to just one alpha motor neuron when these previous three slides are considered together, i.e., each of these complex systems simultaneously impact on the final common pathway of the alpha motor neuron. Consider the complexity suggested when you simultaneously look at the j:fJ- summary slide (#5) and that of the Renshaw cell ( #2), then the Alpha la interneuron (#3), and then the nonreciprocal group 1 molar neuron inhibitory interneurons (#4). But in addition, excitatory intemeurons, which are impacted by the reticulospinal tract, also

Fig. 3 Fig. 4

la INHIBITORY INTERNEURON NONRECIPROCAL INHIBITORY GROUP I INTERNEURON

Alpha

32/AAO Journal Winter 1996 Conflicting visions ... Edward G. Stiles, DO, FAAO influence the final common pathway. understanding of the endocoids also The asclepian perspective focuses our Remember this represents only one expanded. This whole body of attention on the viscera. We then alpha motor neuron! Allow your mind knowledge supports the concept of A. mistakenly can view the viscera or to ponder and grasp the complexity of T. Still that the body makes its own secondary machinery of Korr' s concept the nervous system, the nine billion medicines. as the primary arena of importance. intemeurons, and how we must all be Throughout history, there have been The osteopathic application of the uniquely wired. two basic schools of medicine: the hygeian concept can be expressed as, the Thus during the 80's and 90's, our hygeian and the asclepian schools. body will dispense the correct "drug," vision and understanding of the The hygeian school emphasizes: in the correct amount and without side neurophysiology of the cord. Stress, the effects. Korr again challenged our vision limbic system and its impact on the l. The role of inherent health with his statement, "within each of us, hypothalamus , autonomic nervous maintenance mechanisms within the we have our own HMO which is system, pituitary and endocrine organs, body; constantly working for us." Pasteur also as well as the afferent impact on the 2. Impairment causes disease; expressed and summarized this truth cerebellar and cerebral cortexes 3. Disease is a total body response; when he stated, " the terrain provided expanded and matured. Thus, one can 4. Cure comes from within and not from by the patient is crucial, when the be challenged to view the neurological the outside; and bacteria proliferate, pre-existing illness maintenance of somatic dysfunction as 5. The physician-patient relationship is rendered the host susceptible." analogous to a virus in the central a partnership relationship. Therefore the bacteria are not the key nervous system or software program. issue as stressed by the asclepian school My vision further expanded when Bob The asclepian school characteristics of medicine. Foreman, PhD, Chairman of the and emphasis is: The hygeian principles can be Physiology Department at the implemented with several conceptual University of Oklahoma, pointed out to 1. This is the dominate school tools I have found useful in my clinical me how a minor cord reflex is initiated historically; practice. when just one muscle spindle is 2. The focus is on disease, its causes and An illness can be viewed as the stimulated in the extremity of an animal. cures, therefore de-emphasizing the outcome of an interaction between the But at the same time, stimulation of that patient; host and a disease process. Medical and one spindle, initiates major activity in 3. Treatment and research emphases a surgical care is directed at the disease both the cerebellar and cerebral cortexes. disease specific method; component while osteopathic This could suggest that the dysfunctional 4. The patient is seen as a victim of the management is directed at the host musculoskeletal patterns may very well disease and the cause is blamed for the component and enables the patient to be stored in the central nervous system condition; amd realize their unique potential. and not in the joint or soft tissues. 5. The clinician is seen as the antagonist Musculoskeletal dysfunction or dis As we provide patients specific of disease, the defender and savior of ease, i.e., lack of ease of the manipulative management, I believe we the victim and the provider of health. shut down the abnormal afferent load into cerebellar and cerebral cortexes. We FACTORS WHICH INFLUENCE ALPHA MOTO RON DISCHARGE RATE are really changing the central software program. An illustration of Guyton + depicting the afferent input from ,~:;~:1\ proprioceptors into cerebellar and atteren1 cerebral regions had new significance Group 11 for me after my discussion with Bob aNeS.p1naltrac1 which started out as a problem with a structure being out of place has now evolved to be viewed as a very complex neurophysiological phenomena involv ing the whole nervous system. neuron Also during the 80's and 90's, our ______J Fig. 5 --+

Winter 1996 AAO Journal/33 Conflicting visions ■■ ■ Edward T. Stiles, DO, FAAO musculoskeletal system may have a dysfunction or dis-ease can impact on combining both the hygeian and profound impact on the patient's overall anyone of these components of the asclepian concepts into one management health and susceptibility for developing schematic, all of them or in any possible strategy. disease processes. In that context, I see combination. This vision helps us to Current neurophysiological and somatic dysfunction as another risk realize why each patient's clinical endocoid understanding suggests A. T. factor in a multitude of disease picture is unique. Meanwhile, a Still was realistic when he saw his mission as one of changing the practice processes. specifically administered osteopathic of medicine. This can be further illustrated with a management program addresses the The question then is, does your vision clinical schematic I developed in an uniqueness of each patient. This dictate and determine the outcome of schematic can enable the clinician to effort to explain to osteopathic your clinical efforts? How does this physicians the benefits of manipulative develop a diagnostic strategy for apply to the Academy in the political and care for hospitalized patients.(Fig. 6) searching areas for somatic dysfunction policy realm? I challenge you to The cell, at the center of the illustration, as well as enable the clinician to mentally picture two potential visions can represent any tissue in the body. For summarize the somatic dysfunction related to the future of the Academy. that tissue to remain healthy, several findings and to appreciate their possible Picture how each vision would impact events must take place. The tissues contribution to the pathophysiological your behavior. Is our role to be the last require an appropriate arterial supply condition of that specific patient. bastion of osteopathy or to change the which is controlled by the sympathetic Therefore, our clinical vision over the practice of medicine? How would the vasomotor system. The tissues require last 35 years has matured. We have strategies of each of these positions an appropriate efferent flow of impulses progressed from the vision of a vertebra differ in self image, strategy planning as well as trophins. A functioning rib out of place to one of a very complex and subsequent clinical, educational and cage is required to enable appropriate and unique neurophysiological pattern political activities? ventilation and to assist venous and for each patient. Current physiological With health care costs skyrocketing and the increased incidence chronic lymphatic circulation. An appropriate understanding enables us to realize how of degenerative disease in our aging flow of afferent impulses and trophic somatic dysfunction might impact on population, we as an academy have the substances back to the cord is also any organ system and how with potential answers to address these essential. The whole system is driven by osteopathic management we might be problems and, in the process, change the the energy demands created by the able to offer these patients a unique form practice of medicine. As Korr stated, by primary on the secondary machinery as of care. Also, we are the only profession philosophy, history, organization and emphasized by Korr. Somatic which has the unique potential of training we have that potential. What is your vision as an osteopathic physician Fig. 6 in 1996? Are we expanding and realizing the vision of our founder, Thomas L. Northup? I believe our potential represents a quantum jump beyond the initial vision held by our Founders. We have been fortunate to be able to stand on their sturdy and competent shoulders. Let's push forward to realize our potential; which in reality may be far greater than our currently expanded vision. In this light, let me close with a couple quotes of Thomas L. Northup from his Andrew Taylor Still Memorial Address given almost twenty years after the founding of this Academy. He stated, "let us think of our heritage, not as something left in total as a legacy. .. but rather as a diamond in the rough that will increase in value and attractiveness as

34/AAO Journal Winter 1996 Conflicting visions ... Edward T. Stiles, DO, FAAO one after another of its facets is cut and The collected papers oflrvin M. Korr; American Childhood psychological trauma correlates with polished. The searchlight of reason will, Academy·ofOsteopathy; Colorado Springs, CO, unsuccessful lumbar spine surgery; Schofferman, 1979 Anderson, Hines, Smith and White Spine; Vol like the ultra-violet ray, reveal many 17; No 6; Supplement 1992 otherwise unseen qualities and make it Principles of anatomy and physiology; seventh glow with ever increasing brilliance." edition; Tortora and Grabowski; Harper Collins New perspectives on low back pain; Frymoyer He went on to say in this 1955 speech, College Publishers; 1993 and Gordon; American Academy of Orthopaedic "the osteopathic profession can now take Surgeons; Park Ridge, IL; 1989 its place of leadership in developing a Human physiology the mechanisms of body function; fourth edition; Vander, Sherman and Skeletal muscle tone and the misunderstood program of health care for our nation and Luciano; Mcgraw-Hill Book Company; New stretch reflex; Davidoff; Neurology; May, 1992 the world." York, 1985 If "Dr. Tom" were alive today, I Job's body; Juhan Station; Hill Press; 1987 suspect we might have trouble keeping Lecture notes on human physiology; Bray, Cragg, up with his developing vision. Thank Maxknight, Mills and Taylor; Oxford London, The motor nervous system textbook of medical 1994 physiology; Guyton; Seventh Edition ; you Philadelphia; W.B. Saunders; 1986 Color atlas of physiology; fourth edition; Gay and References Rothenburger, Georg Theme Verlag Stuttgart; History of medicine and the concepts of New York, 1991 endocoids; Korr; Endocoids; Alan R. Liss, Inc.; A conflict of visions, idealogical origins of 1985 political struggles, Thomas Sowell, PhD, Quill Neuroscience of rehabilitation; Cohen, J.B.; William Morrow, New York, 1987 Lippincott; Philadelphia; 1993 The "cause" of illness: disease or person? Implications for the choice of outcome measures; The Northup Book: A memorial tribute to Thomas Esse ntials of clinical neuroanatomy and Korr; Complementary Medical Research; Vol 2; L. Northup, DO; American Academy of neuophysiology; Gilman and Newman; F.A. No. 3; 1988 OH, Osteopathy; Newark, 1983 Davis Company; Philadelphia 1992 Somatic dysfunction, osteopathic manipulative Blakiston's pocket medical dictionary; fourth Review of neurosciences; second edition; Pansky, treatment, and the nervous system: a few facts, edition; Mcgraw-Hill Book Company; New York, Allen and Budd; Macmillan Publishing some theories, many questions; Korr; JAOA; Vol 1979 Company; New York; 1988 86; No 2; Feb 1986 0

Planning research on ambulatory care by Deborah M. Heath, DO and Albert F. Kelso, PhD

Practice -based research on the research record. When the study is presence of "somatic dysfunction" at effectiveness of osteopathic mani incorporated into the office visit, the specific locations. It also would include pulative treatment sounds simple record should accurately reflect the the osteopathic manipulative treatment enough. Daily, as osteopathic examine but not be so cumbersome that that was provided with specified physicians, we witness the recuperative it is impractical for the physician. What location and the response to treatment. powers of the human body fostered by compromises in the clinical arena are The form is anticipated to expedite the osteopathic manipulative treatment. acceptable without diluting the quality recording of relevant osteopathic Systematic study of these clinical events of osteopathic research? What factors information which can then be should be fairly easy to accomplish. are essential to maintain value in a incorporated into a research record. It is However, there are a few aspects when study? also hoped that with the standardization considering osteopathic clinical research A project currently underway by of this form that many physicians at that pose some unique challenges. These several osteopathic physicians is the different locations could contribute data need to be carefully addressed in order development of a standardized on one research project. to have worthwhile studies related to osteopathic SOAP note form that The use of a well-de signed, osteopathic manipulative treatment. One designation as an osteopathic form "standardized" form is, of course, of the unique challenges is the includes the palpatory findings obtained essential for efficient and consistent documentation of a palpatory finding in from an osteopathic physical collection of data. Experienced examination which would identify the -+

Winter 1996 AAO Journal/35 researchers make use of several forms Accepting that examiners may From the AOBSPOMM Files for one research project to direct the flow become reliable in agreement of active of the data as well as to insure that all and passive motion testing and data is collected. The form does not developing criteria for the presence of necessarily make the data more accurate somatic dysfunction, how relevant is this or reliable but it does help organize. to osteopathy? In the discussion of In developing a research record for osteopathic palpatory diagnosis in an osteopathic physicians, accuracy and attempt to understand the "osteopathic reliability in the osteopathic section lesion," Frymann points out, "Palpatory needs to be carefully considered. diagnosis in the osteopathic sense is like Identification of the presence of somatic an iceberg. Active and passive articular dysfunction may vary with the motion is the visible eighth of the Editor's Note: Richard W Skurla, DO, examiner's skill level but also with the iceberg, but the inherent motions within is a 1981 graduate of Philadelphia tests and criteria used to determine the body are the hidden seven eights of College of Osteopathic Medicine. He somatic dysfunction. As an example, the iceberg." currently holds certification in both William Johnston, DO, FAAO, uses Let's assume that our researchers are osteopathic manipulative medicine and specific spinal motion testing with eclectic, they use all methods of general practice . Dr. Skurla is a characteristic "responses" to identify a diagnosis and treatment and agree on diplomate of the National Baord of "primary" asymmetric central segment. active, passive and inherent motions. Is Examiners for Osteopathic Physicians Adjacent vertebral segments have this relevant to osteopathy? Korr has and holds memberships in American opposing mirror -image motor reminded us to study the "whole Academy of Osteopathy, American asymmetries. Another examiner might person." Still directs our task as Osteopathic Association, The Cranial employ different tests and use a different osteopathic physicians to find the health Academy, New Mexico Osteopathic set of criteria to identify and therefore, of the patient. Is somatic dysfunction the Medical Association and the American record the somatic dysfunction involved health of the patient or are we held by College of Osteopathic Family at a different vertebral segment. Unless convention to attend to this framework Practitioners. Dr. Skurla has a private the criteria and tests are specified, the because so many have invested in the practice in OMM in Santa Fe, NM. meaning of segmental dysfunction is not terminology. Does it mean that we clear. More than that, reproducibility should not look at somatic dysfunction? within subjects, visits and examiners is Johnston has studied the pattern of • Chief Complaint not possible. It may be difficult, if not segmental dysfunction present with D.S. is a 40-year-old white female with futile, to make sense out of any study that hypertension for twenty years. He has the chief complaint of pains for 8 months involves the use of somatic dysfunction also been very careful in avoiding the behind the right ear associated with if there is no basis of how and what use of cause and effect regarding this nausea and motion sickness. somatic dysfunction for the examiner is. pattern. The value of his studies are Stedman Denslow, DO could tremendous and advance our • History of Chief Complaint correlate his palpatory finds of the understanding of the "behavior" of This patient has been symptomatic for lesioned vertebral segment with EMG somatic dysfunction. He has made it approximately eight months with nausea measurements taken in the related spinal very clear of what exactly he is studying. and motion sickness and right ear pain, muscles. Short of this physiologic It is of great importance for getting progressively worse. She was feedback, it is a challenge to agree on advancement of our knowledge in referred by an internist who was what exactly is being studied. Inter osteopathic medicine that the study concerned about the possibility of an examiner reliability studies have shown undertaken is very clear on what is being acoustic neuroma, however, did that you can train examiners to increase studied. entertain the possibility of postural their agreement on palpatory findings, Physician input to the dialogue on the problems. The patient complained of thus increase accuracy in the record. osteopathic palpatory exam, diagnosis significant neck problems with Identifying somatic dysfunction is only of somatic dysfunction and methods of noticeable tension and the need to part the equation the clinical treatment are critical for development of of in constantly stretch. She also noted some setting. Determining the treatment quality studies. We encourage physician constant aching in the left hip. The "prescription" (method , frequency, participation, comments and questions patient had dental work approximately dosage, etc.), and describing the that may foster this important work in one year ago at which time two patient's response compounds the osteopathy. Communications may go to permanent bridges were installed and an complexity in studying the "effect of the AAO or any member of the Louisa upper right tooth extracted. OMT." Bums Osteopathic Research Committee. □ 36/AAO Journal Winter 1996 AAO Case History: Iatrogenic injury to the cranial mechanism

by Richard W. Skurla, DO, CSPOMM

• Past Medical History CO is extended, rotated left side bent hip pain and the neck stiffness were The patient had two children by normal right. Cl is rotated left. Lumbosacral reduced significantly. The patient was spontaneous vaginal delivery. She h

Winter 1996 AAO Journal/37 The AAO Journal Index 1996 A Publication of the American Academy of Osteopathy By Author: Banihasem, Mary DO Johnson, Kenneth H. DO Treadwell, Robert C. UTF "Pilot Study to Establish Whether Osteopathy "A Functional Approach to Heel Lift Therapy" "Sacral Shear: Review and a New Treatment Reduces General Practice Consultation Rate of Volume 6, Number I, Spring 1996, pp. 13-15 Method for Obstetrical Patients" Volume 6, Musculoskeletal Problems Based on Patient Number I, Spring 1996, pp. 16-1 8 Perception of Effectiveness of the Osteopathic "A Functional Approach to Heel Lift Therapy" Treatment -Part I" Volume 6, Number 3, Fall 1996, Volume 6, Number I , Spring 1996, pp. 13-15 "Sacral Shear: Review and a New Treatment Method for Obstetrical Patients" Volume 6, pp.11-13,23-26 Jones, m, John M. DO Number I , Spring 1996, pp. 16-18 "Case History: Somatic Dysfunctions Related to "Pilot Study to Establish Whether Osteopathy Chronic Lumbar and Hip Strain" Volume 6, Reduces General Practice Consultation Rate of Number I, Spring 1996, pp. 24-28 Musculoskeletal Problems Based on Patient Perception of Effectiveness of the Osteopathic "Case History: Somatic Dysfunctions Related to By Subject: Treatment -Part II" Volume 6, Number 4, Winter Chronic lumbar and Hip Strain" Volume 6, Number 1996, pp. 23-30 1, Spring 1996, pp, 24-28 Ambulatory Care Chadwick, Kirsten S.App.Sc.Osteo "Case History: Somatic Dysfunctions Related to "Outcome Research on Health Care in Ambulatory Chronic Lumbar and Hip Strain" Volume 6, Care Practice"; Heath, Deborah M. DO; Albert F. "The Efficacy of Osteopathic Treatment for Number 1, Spring 1996, pp. 24-28 Kelso, PhD Volume 6, Number 2, Summer 1996, Primary Dysmenorrhea in Young Women" Volume pg. 18 6, Number 3, Fall 1996, pp. 15-18 Korr, Irvin M. PhD "From the Archives: Osteopathy and Medical Case Study Chaitow, Leon ND, DO Evolution (1962)" Volume 6, Number I, Spring 1996,p.31 "AAO Case History: Common Problems in "Muscle Energy Techniques" Volume 6, Number Newborns and Infants"; Scholars , Henrietta 3, Fall 1996, p. 31 Mack, Warren B. DO (Rennie) DO; Volume 6, Number 3, Fall 1996, pgs. 19-20; "From the Archives: Read at Annual Meeting of Dean, Ann M. DO Massachusetts Osteopathic Society, January 2, "AAO Case Study: Recurrent Otitis Media"; Gintis, 1915" Volume 6, Number 2, Summer 1996, pgs. Bonnie R. DO; Volume 6, Number 2, Summer "A Review of Counterstrain Handbook of 33-34 1996, pgs. 16-17; Osteopathic Technique" Volume 6, Number I, Spring 1996, p. 30 "Case History: Somatic Dysfunctions Related to Mitchell, Jr., Fred L. DO, FAAO Chronic Lumbar and Hip Strain"; Jones, IIJ, John Gintis, Bonnie R DO M. DO; Volume 6, Number I , Spring 1996, pp. "The Muscle Energy Manual, Volume One" 24-28; "AAO Case Study: Recurrent Otitis Media" Volume 6, Number 2, Summer 1996, p. 26 Volume 6, Number 2, Summer 1996, pgs. 16-17 Iatrogenic Injury to the Cranial Mechanism; Skurla, Mulligan, Terrence MS-Ill "AAO Case Study: Recurrent Otitis Media" Richard W. DO, CSPOMM; Volume 6, Number 4, Volume 6, Number 2, Summer 1996, pgs. I6-17 "An Osteopathic Approach to HIV/AIDS" Volume Winter 1996, pp. 36-37; 6, Number 2, Summer 1996, pgs. 9-11, 20-25 Craniosacral Gorbis, Sh.erman DO, FAAO "Errata Slip: An Osteopathic Approach to A Challenge to the Concept of Craniosacral "The Effects of Somatic Dysfunction on the Spinal HIV/AIDS" Volume 6, Number 3, Fall 1996, pg. 21 Accessory Nerve (CN XI) with Subsequent Distal Interaction; Norton, James M . PhD; Volume 6, Dysfunctions" Volume 6, Number 2, Summer 1996, Norton, James M. PhD Number 4, Winter I 996, pp. 15-21; pgs. 13-15, 29-31 Distal Dysfunctions A Challenge to the Concept of Craniosacral Interaction Volume 6, Number 4, Winter 1996, pp. "The Effects of Somatic Dysfunction on the Spinal "The Effects of Somatic Dysfunction on the Spinal 15-21 Accessory Nerve (CN XI) with Subsequent Distal Accessory Nerve (CN XI) with Subsequent Distal Page, Leon E DO Dysfunctions"; Gorbis, Sherman DO, FAAO; Dysfunctions" Volume 6, Number 2, Summer 1996, Volume 6, Number 2, Summer 1996, pgs. 13-1 5, pgs. 13-15, 29-31 From Principles of Osteopathy Volume 6, Number 29-31 4, Winter 1996, p. 22 'The Effects of Somatic Dysfunction on the Spinal Scholars , Henrietta (Rennie) DO Dysmenorrhea Accessory Nerve (CN XI) with Subsequent Distal Dysfunctions" Volume 6, Number 2, Summer 1996, "AAO Case History: Common Problems in "The Efficacy of Osteopathic Treatment for pgs. 13-15, 29-31 Newborns and Infants" Volume 6, Number 3, Fall Primary Dysmenorrhea in Young Women"; 1996, pgs. 19-20 Chadwick, Kirsten S.App.Sc.Osteo; Averille Morgan. B.App.Sc.Osteo Volume 6, Number 3, Fall Grimshaw, David N. DO "AAO Case History: Common Problems in 1996, pp. 15-18 Newborns and Infants" Volume 6, Number 3, Fall "The Osteopathic Physician Teacher" Volume 6, 1996, pgs. 19-20 Number I, Spring 1996, pp. 33-34 From the Archives Skurla, Richard W. DO, CSPOMM Heath, Deborah M. DO From Principles of Osteopathy; Page, Leon E DO; Iatrogenic Injury to the Cranial Mechanism Volume 6, Number 4, Winter 1996, p. 22; "Outcome Research on Health Care in Ambulatory Volume 6, Number 4, Winter 1996, pp. 36-37 Care Practice" Volume 6, Number 2, Summer "From the Archives: An Appeal from Dr. Andrew 1996, pg. 18 Stiles, Edward G. DO, FAAO Taylor Still to Thinking Osteopaths"; Still, A. T. MD; Volume 6, Number 3, Fall 1996, p. 9; Conflicting Visions Volume 6, Number 4, Winter "Outcome Research on Health Care in Ambulatory 1996, pp. 9-12, 31-35 "From the Archives: Osteopathy and Medical Care Practice" Volume 6, Number 2, Summer Evolution (1962)"; Korr, Irvin M. PhD; Volume 6, Still, A. T. MD 1996, pg. 18 Number I, Spring 1996, p. 3 1; "From the Archives: An Appeal from Dr. Andrew "From the Archives: Read at Annual Meeting of Taylor Still to Trunking Osteopaths" Volume 6, Planning Research on Ambulatory Care Volume 6, Massachusetts Osteopathic Society, January 2, Number 4, Winter 1996, pp. 37-38 Number 3, Fall 1996, p. 9 1915"; Mack, Warren B. DO; Volume 6, Number Tettambel, Melicien A. DO, FAAO 2, Summer 1996, pgs. 33-34 ''Mind, Machinery and Manipulation" Volume 6, Number I, Spring I 996, pgs. 9-11

38/AAO Journal Winter 1996 Heel Lift Therapy "The Muscle Energy Manual, Volume One"; The MBNA America® Mitchell, Jr., Fred L. DO, FAAO; P. Kai Galen "A Functional Approach to Heel Lift Therapy"; Mitchell, BA Volume 6, Number 2, Summer 1996, Gold MasterCard®. Johnson, Kenneth H. DO; Volume 6, Number I, p. 26; Spring 1996, pp. 13-15; Sacral Shear It's the one more HIV/AIDS "Sacral Shear: Review and a New Treatment doctors order. "An Osteopathic Approach to HIV/AIDS"; Method for Obstetrical Patients"; Treadwell, Robert Mulligan, Terrence MS-III; Volume 6, Number 2, C. UTF; Warren W. Magnus, UTF Volume 6, Summer 1996, pgs. 9-11, 20-25; Number I, Spring 1996, pp. 16-18; For physicians, the hours are long but "Errata Slip: An Osteopathic Approach to Scott Memorial Lecture HIV/AIDS"; Mulligan, Terrence MS-III; Volume time is always short. Remedy: This Gold "Mind, Machinery and Manipulation"; Tettambel, 6, Number3, Fall 1996, pg. 21; Melicien A. DO, FAAO; Volume 6, Number I , MasterCard® from MBNA America®. Lwnbar and Hip Strain Spring 1996, pgs. 9-11; Designed specifically to keep pace with the "Case History: Somatic Dysfunctions Related to Somatic Dysfunction demands of today's physician, it offers the Chtonic Lumbar and Hip Strain"; Jones, III, John M. DO; Volume 6, Number\, Spring 1996, pp. "Case History: Somatic Dysfunctions Related to advantages of individually established Chronic lumbar and Hip Strain"; Jones, John M. 24-28; Ill, DO; Volume 6, Number I, Spring 1996, pp. 24-28; credit lines - up to $50,000 as well as the convenience of the special priority privi Nerve "The Effects of Somatic Dysfunction on the Spinal leges listed below - at no additional cost. "The Effects of Somatic Dysfunction on the Spinal Accessory Nerve (CN XI) with Subsequent Distal Accessory Nerve (CN XI) with Subsequent Distal Dysfunctions"; Gorbis, Sherman DO, FAAO; Dysfunctions"; Gorbis, Sherman DO, FAAO; Volume 6, Number 2, Summer 1996, pgs. 13-15, 8.9% introductory Annual Percentage Volume 6, Number 2, Summer 1996, pgs. 13-15, 29-31 29-31 Rate (APR) on Cash Advances and Bal Special Communication ance Transfers and ... Newborns "The Osteopathic Physician Teacher"; Grimshaw, NO annual fee! "AAO Case History: Common Problems in David N. DO; Volume 6, Number I, Spring 1996, Newborns and Infants"; Scholars , Henrietta pp. 33-34; (Hennie) DO; Volume 6, Number 3, Fall 1996, 24-hour customer service pgs. 19-20; While traveling, you're automatically Northup Lecture covered with up to $1 million Conflicting Visions; Stiles, Edward G. DO, FAAO; Common Carrier Travel Accident Volume 6, Number 4, Winter 1996, pp. 9-12, 31-35; AAO Insurance when you use Gold Obstetrics t Passage® Travel Services and your "Sacral Shear: Review and a New Treatment Method for Obstetrical Patients"; Treadwell, Robert Annual AAO Gold Card to purchase tickets C. UTF; Warren W. Magnus, UTF Volume 6, on any common carrier worldwide. Number I, Spring 1996, pp. 16-18; Nearly everything you purchase is Otitis Media Convocation protected up to 90 days against "AAO Case Study: Recurrent Otitis Media"; Gintis, Bonnie R. DO; Volume 6, Number 2, Summer damage or theft 1996,pgs.16-17; THE BROADMOOR HOTEL Immediate access to cash around the Pilot Study world at more than 220,000 financial Colorado Springs, CO "Pilot Study to Establish Whether Osteopathy institutions and over 160,000 ATMs Reduces General Practice Consultation Rate of Musculoskeletal Problems Based on Patient Start each year with a record of your Perception of Effectiveness of the Osteopathic previous year's charges. We'll send Treatment -Part I"; Banihasem, Mary DO; Volume March 19-22, 1997 6, Number 3, Fall 1996, pp. 11-13, 23-26 you your Year-end Summary of Charges to help you prepare for tax Postural Imbalance season and track your spending "A Functional Approach to Heel Lift Therapy"; habits. $5 charge Johnson, Kenneth H. DO; Volume 6, Number I, Emergency Cash and replacement Spring 1996, pp. 13-15; "Body, airline tickets, up to your credit limit Research Emergency medical or legal network "Outcome Research on Health Care in Ambulatory Care Practice"; Heath, Deborah M. DO; Albert F. Kelso, PhD Volume 6, Number 2, Summer 1996, TheAAO has chosen to endorse the MBNA pg. 18 Mind, Gold MasterCard® card because it reflects Planning Research on Ambulatory Care; Heath, the unsurpassed commitment to quality that Deborah M . DO; Albert F. Kelso, PhD Volume 6, has made MBNA one of the nation's lead Number 4, Winter 1996, pp. 37-38; ing credit card companies. Our decision Review , was clear: the MBNA Gold MasterCard® "A Review of Counterstrain Handbook of Osteopathic Technique"; Dean, Ann M. DO; and card - there is no comparison! Volume 6, Number I, Spring 1996, p. 30; "Muscle Energy Techniques"; Chaitow, Leon ND, To apply for your AAO Card DO; Volume 6, Number 3, Fall 1996, p. 31 by calling 1-800-847-7378

Winter 1996 AAO Journal/39 Calendar of Events American Academy of Osteopathy 3500 DePauw Boulevard, Suite 1080 Indianapolis, IN 46268-1136 Phone: (317) 879-1881 or FAX: (317)879-0563

February,1997 19-22 May 8-9 Annual Convocation 2-4 Boby, Mind and Spirit Winter OMT Update Exercise Prescription for Manipulative American Academy of Osteopathy Application of Osteopathic Concepts Medicine John M. Jones, III, DO, Program Chair in Clinical Medicine plus Brads. Sandler, DO, Program Chair and 30 Hours - Category 1-A Preparation of the OMM Boards Instructor The Broadmoor Hotel 18 Hours, Category 1-A Special Guest Faculty - Philip E. Colorado Springs, CO The Westin Hotel at Fountain Square Greenman, DO, FAAO Cincinnati, OH 20 Hours - Category 1-A April AAO Headquarters March 26-27 Indianapolis, IN 18 OMT and the McManis Table: A Manipu lative Update Grant Proposal Planning and Writing 16-18 Michael L. Kuchera, DO, FAAO, Program Lynn E. Miner, PhD Muscle Energy Tutorial Chair and Instructor Director of Grants Office, Walter Ehrenfeuchter, DO, FAAO, 12 Hours -Cat egory 1-A Marquette University Program Chair and Instructor Kirksville College of Osteopathic Milwaukee, WI 20 Hours - Category 1-A Medicine 6 Hours, Category 1-A Airport Holiday Inn Kirksville, MO The Broadmoor Hotel Indianapolis, Indiana Colorado Springs, CO

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