FORUM FOR OSTEOPATHIC THOUGHT

TRADITION SHAPES THE FUTURE • VOLUME 12 NUMBER 3 FALL 2002

Fall 2002 The AAO Journal/1 Instructions to Authors

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

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

2/The AAO Journal Fall 2002 FORUM FOR OSTEOPATHIC THOUGHT ®

3500 DePauw Boulevard TRADITION SHAPES THE FUTURE • VOLUME 12 NUMBER 3 FALL 2002 Suite 1080 Indianapolis, IN 46268 The mission of the American Academy of Osteopathy is to teach, advocate, (317) 879-1881 advance, explore, and research the science and art of osteopathic medicine, FAX (317) 879-0563 emphasizing osteopathic principles, philosophy, palpatory diagnosis and osteopathic manipulative treatment in total health care. 2002-2003 BOARD OF TRUSTEES Editorial Section Componet Societies’ CME Calendar...... 4 President Hollis H. King, DO, PhD, FAAO View from the Pyramids – Anthony G. Chila, DO, FAAO ...... 5 Contributors ...... 6 President Elect Dennis J. Dowling, DO, FAAO Letter to the Editor...... 7 AAO Calendar of Courses ...... 9 Immediate Past President John C. Glover, DO Dig On ...... 10 From the Archives ...... 12 Secretary-Treasurer Boyd R. Buser, DO Trustee Peer-Reviewed Section Stephen D. Blood, DO, FAAO Understanding the Combined Motions of the C3/C4 Vertebral Unit: Trustee A Further Look at Fryette’s Model of Cervical Biomechanics ...... 15 Guy A. DeFeo,DO John D. Capobianco, DO, FAAO, Marina G. Protopapas, DO, Trustee and Sonia Rivera-Martinez, DO Hugh M. Ettlinger, DO, FAAO Trustee Digging On: Some thoughts on the integration Kenneth H. Johnson, DO of Russellian Cosmology and Osteopathy ...... 31 Trustee Paula D. Scariati, DO, MPH Sandra L. Sleszynski, DO Post-traumatic Headache of Cervical Origin ...... 38 Trustee Melicien A. Tettambel, DO, FAAO MonaLisa M. Mitra, OMS-III and Scott T. Stoll, DO, PhD

Executive Director Book Review: ...... 42 Stephen J. Noone, CAE An Osteopathic Approach to Ear, Nose and Throat Patients: The Contributions of William C. McCarty, DO Editorial Staff Elsewhere in Print ...... 43 Editor-in-Chief ...... Anthony G. Chila, DO, FAAO Vaughn B. Inter-examiner reliability in detecting cervical spine dysfunction– Supervising Editor ...... Stephen J. Noone,CAE A short review. Journal of Osteopathic Medicine, 2002; 5(1): 24-27.

Editorial Board ...... Barbara J. Briner, DO Mestan B, Rockwell JA, Foshang TH. Isolated injury of the posterior cruciate Raymond J. Hruby, DO, FAAO ligament: A report of three cases. JNMS: Journal of the Neuromusculoskeletal James M. Norton, PhD System, 2002; 10(3): 104-111. Frank H. Willard, PhD

Managing Editor ...... Diana L. Finley Cuthbert SC. Applied Kinesiology and the Myofascia. AK: The International Journal of Applied Kinesiology and Kinesiologic Medicine, 2002; 13: 34-39.

The AAO Journal is the official quarterly publication of the Ameri- can Academy of Osteopathy, 3500 DePauw Blvd., Suite 1080, In- dianapolis, Indiana, 46268. Phone: 317-879-1881; FAX: (317) 879- Advertising Rates for the AAO Journal Advertising Rates: Size of AD: 0563; e-mail [email protected]; AAO Website: Full page $600 placed (1) time 7 1/2 x 9 1/2 http.//www.academyofosteopathy.org An Official Publication $575 placed (2) times of The American Academy of Osteopathy $550 placed (4) times Third-class postage paid at Carmel, IN. Postmaster: Send address The AOA and AOA affiliate organizations 1/2 page $400 placed (1) time 7 1/2 x 4 3/4 changes to American Academy of Osteopathy 3500 DePauw Blvd., $375 placed (2) times Suite 1080, Indianapolis, IN., 46268 and members of the Academy are entitled $350 placed (4) times to a 20% discount on advertising in this Journal. 1/3 page $300 placed (1) time 2 1/4 x 4 3/4 The AAO Journal is not itself responsible for statements made by $275 placed (1) times any contributor. Although all advertising is expected to conform to $250 placed (4) times ethical medical standards, acceptance does not imply endorsement Call: The American Academy of Osteopathy 1/4 page $200 placed (1) time 3 1/3 x 4 3/4 by this journal. (317) 879-1881 for more information. $180 placed (2) times $150 placed (4) times Opinions expressed in The AAO Journal are those of authors or speak- Professional Card: $60 3 1/2 x 2 ers and do not necessarily reflect viewpoints of the editors or official Subscriptions: $60.00 per year (USA) Classified: $1.00 per word policy of the American Academy of Osteopathy or the institutions $78.00 per year (foreign) with which the authors are affiliated, unless specified.

Fall 2002 The AAO Journal/3 Component Societies’ CME Calendar and other Osteopathic Affiliated Organizations

October 11-13 November 16-19 June 9-10 Continuing Studies Course: Biodynamics Phase II Addressing Medical Issues Conference: Pathways to Diagnosis James Jealous, DO *OIG Compliance, *Stark Rules, Sutherland Cranial Teaching Foundation Sugar Hill, NH *HIPPA Regulations, *Center for UNECOM, Biddeford, ME Hours: 24.5 Category 1A Medicare and Medicaid. Hours: 18 Category 1A Contact: James Jealous, DO Pinellas County Osteo Medical Society Contact: SCTF (207) 778-9847 Las Vegas, NV (817) 926-7705 Hours: 12 November 22-25 Contact: Kenneth E. Webster, EdD November 1-4 Biodynamics Phase III 717/581-9069 James Jealous, DO Biodynamics Phase I June 14-18 Stefan Hagopian, DO Sugar Hill, NH Topanga, CA Hours: 22 Category 1A Basic Course Hours: 26 Category 1A Contact: James Jealous, DO The Cranial Academy Contact: James Jealous, DO (207) 778-9847 Founders Inn (207) 778-9847 Virginia Beach, VA November 24-26 Hours: 40 Category 1A (anticipated) November 8-10 Principles of Manual Medicine in Contact: The Cranial Academy 317/594-0411 Neurofascial Release Conference Physical Medicine and Rehabilitation Stephen Davidson, DO, CSPOMM American Academy of Physical Medicine & Rehab/Jerel Glassman, DO June 19-22 see note in website Healthabounds2.com Arizona Academy of Osteopathy Orlando, FL Annual Conference West Hartford, CT Hours: 22 Category 1A The Cranial Academy Hours: 24 Category 1A Contact: Jerel Glassman, DO Founders Inn Contact: Stephen Shifreen, MD (312) 464-9700 Virginia Beach, VA (860) 570-3400 or Hours: 40 Category 1A (anticipated) Stephen Davidson, DO December 6-8 Contact: The Cranial Academy (800) 359-7772 21st Annual Winter Update 317/594-0411 Indiana Osteopathic Association November 15-17 Indianapolis, IN October 10-13 Experiencing Osteopathy Hours: 20 Category 1A Research Symposium/SCTF Bonnie Gintis, DO Contact: IAO Continuing Studies Program Santa Cruz, CA 317/926-3009 Indian Lakes Resort Hours: 15.5 Category 1A Bloomingdale, IL Contact: Bonnie Gintis, DO 2003 The Cranial Academy (831) 477-1200 February 26 - March 2 Contact: The Cranial Academy Midwinter Basic Course 317/594-0411 November 16-18 The Cranial Academy Studies in Osteopathy AZCOM Westerland Group Study/Claire Galin, DO Phoenix, AZ Pecos, NM Hours: 40 Category 1A (anticipated) Hours: 24 Category 1A Contact: The Cranial Academy Contact: Claire Gallin, DO 317/594-0411 (505) 471-3292

4/The AAO Journal Fall 2002 E

View from the Pyramids DITORIAL

Lightning Bonesetter S ECTION

In her 1991 biography of Andrew Taylor Still, Carol smoothed by the equal ability of his son, whose training as al- Trowbridge1 made reference to Still’s incorporation of the ways had been gained at the hands, and at the side of his father. ancient art of bonesetting into his practice by the year 1883. Here then is a book written a century ago, and just ten years It is commented that from that year until about 1890, Still after the inception of Osteopathy in the states, where A.T. Still advertised himself as the “Lightning Bone Setter”. The was only beginning to develop and teach his revolutionary new source of Still’s knowledge of bonesetting is said to be approach to the art of healing. obscure. In this issue (see From the Archives) a represen- If one can exclude for a moment the self-centred style al- tation of the bonesetter’s art is given through the work of ready mentioned, this small volume presents a wonderful in- George Matthews Bennett. sight into the thoughts and feelings of a British heterodox prac- The Art of the Bonesetter (1884) was republished as a titioner of the Victorian era. first new edition in 1981, copyrighted by Peter Hawkins. It is important to realize that the transition from the boneset- The following selected citations from Hawkins’ Preface ter to the Osteopathic practitioner of today, was not smooth or continuous. The new thinking from across the Atlantic arrived To New Edition will complement From the Archives: not as a group of techniques, but as a completely new diagnos- tic and therapeutic approach to musculoskeletal conditions. “In 1884 George Matthews Bennett had been in practice as a It came at a time when orthodox medicine was fast advanc- bonesetter for nineteen years. At one time attending, on alternate ing and overtaking any work the bonesetter did in handling the days, practices in London and Leamington; at another period in his career with concurrent practices in Leamington, Rugby, Cov- reduction of fractures, using both open and closed methods un- entry, and Stratford; he was both in high demand, and exceed- der anaesthesia. ingly hardworking. The bonesetter’s emphasis was upon dislocations, joint He was a descendent of the famous Matthews family on his strains, and fractures, especially peripherally. Ours is upon the maternal side and carried on their long tradition of bonesetting more subtle forms of postural and occupational imbalances pro- in the Midlands, there having been Matthews bonesetters in that ducing the sometimes insidious, but nevertheless equally inca- region for almost two hundred years. He was succeeded in prac- pacitating present day conditions. tice by his son, of the same name, whose eventual retirement Whilst this difference may be readily apparent within our prac- ended the family tradition of bonesetting. tices, it is perhaps too fine to be recognized by those not involved I have been able to contact three people who remember receiv- in the treatment of musculo-keletal disorders, - and one not even ing treatment at the hands of GMB. The dexterity of his methods, considered by the general public, who still view Osteopathy as a his alertness in execution, and his innumerable surprises in manual logical progression of bonesetting. treatment were apparently remarkable. At times a briefly, and on As we proceed with the day to day management of our pa- occasions gruffly given command to the patient was, as often as tients and practices it can sometimes be difficult to see the de- not, the forerunner to the deft action by which Mr. Matthews velopments with a longer term view, concentrating as we do, Bennett reduced the fractured bone, or pulled the displaced or on modern methods and attitudes. In doing so, we must not let subluxed joint into position. The shock engendered was usually the memory of these people slip into oblivion. Regardless of justified by the result, and the incident, all too often went on to form the core of a pleasant anecdote in after years. where they now rest, here is their monument and their memo- The author appeared equally well liked and respected by his rial; here they live on.” poorer patients, being something of a Robin Hood in bonesetting. In politics a Liberal, in religion a staunch member of the Church The lessons of history are fascinating. of England; his hectic professional schedule did not prevent him being a Freemason, a Druid, a Forester, and a keen sports- man, riding in all for over thirty years with the North 1. Trowbridge, C. Andrew Taylor Still: 1828-1917. The Thomas Warwickshire Hunt. Jefferson University Press, 1991; 136. By the time of his death in 1913, he had become something of a local institution, and the loss to his patients at that time was

Fall 2002 The AAO Journal/5 ContributorsContributors

Capobianco, JD, Protopapas, MG Regular Features and Rivera-Martinez, S. Motion Dig On. The Eduational Council on Osteopathic Characteristics of a Typical Cervical Principles and Practice (ECOP) met at the Pikeville College School of Osteopathic Medicine (PCSOM) Vertebral Unit: A palpatory Diagnosis from September 12-14, 2002. A rare moment occurred of Rotation and Sidebending of C3-4. when Robert C. Davis, PhD, Associate Professor, This paper analyzes the validity of Fryette’s theory of Division of Humanities, was introduced by Edward G. spinal motion. Specific testing of motion of the third Stiles, DO, FAAO, Professor and Chair of OPP at cervical vertebra in relation to the fourth cervical PCSOM. Doctor Davis reviewed the conceptual world vertebra was done. 289 asymptomatic adult volunteers of Andrew Taylor Still by providing a critique of the were recruited for this study. The authors report that 1991 biography authored by Carol Trowbridge. coupling occurred at a lesser frequency than would have From the Archives. The work of a nineteenth- been predicted by Fryette’s view that rotation and century English Bone-Setter is reviewed through the sidebending will occur to the same side in a typical work of George Matthews Bennett. A member of a cervical segment. It was also observed that repeated family whose bone-setting practice spanned nearly 200 passive motion testing affected interexaminer reliability. years in the Midlands of England, Bennett began practice in 1865. At the time of his death in 1913, his Scariati, PD. practice was carried on by his son, whose eventual Digging On: Some thoughts retirement ended the family tradition. New to this issue of the AAOJ is a page which looks on the integration of Russellian elsewhere to observe and comment on publications which Cosmology and Osteopathy. may be of interest to the reading audience. Many journals The author provides a review of the work of Lao and are in print which reflect the numerous current expressions Walter Russell whose teaching and writing effort sought of health care practice having a manual arts focus. to assist man in the unfolding of his higher Self. Their Elsewhere in Print will offer selections from various home study course (Universal Law, Natural Science and journals when review indicates that authors cite publi- Living Philosophy: A Home Study Course of the Science cations by American osteopathic physicians. This of Man. 1951, 1957, 1962 and 1972. University of Science inaugural offering includes: Journal of Osteopathic and Philosophy, Blacksburg, Virginia.) provides a basis for Medicine (an official journal of the Australian Osteopathic expansion of osteopathic thought. Selected comments Association, General Osteopathic Council (UK), New from the course are discussed and references provided. Zealand Register of Osteopaths, Australian Student Osteopathic Medical Association); JNMS: Journal of the Mitra, MM, Stoll, ST. Neuromusculoskeletal System (A Journal of the American Chiropractic Association); AK: The International Journal Post-traumatic Headache of Applied Kinesiology and Kinesiologic Medicine.❒ of Cervical Origin. This case study notes that headache associated as an Author’s Correction: immediate consequence of head trauma is often of short Somehow in my researching, I had erroneously been lead duration. Chronic post-traumatic headache is noted to to believe Leon Chaitow, ND, DO, had passed on. However, it persist for months or years after trauma. The anatomic has been three or four years since the writing of the Fellowship basis, pathology and differential diagnosis of paper and I have corresponded with the man, forgetting about cervicogenic headache are reviewed. Pharmacologic the reference in the paper. He is alive and active. He publishes treatment and osteopathic manipulative treatment are profusely and is the editor of The Journal of Bodywork and discussed. Movement Therapies. Zachary Comeaux, DO, FAAO The AAO Journal, Volume 12, No. 2, Summer 2002, pp 24-35

6/The AAO Journal Fall 2002 LetterLetter toto thethe EditorEditor

RE: “Spirtuality and the Teaching of Spirituality in an Osteopathic Medical Curriculum” by Willliam W. Lemley, DO, FAAO Volume 12, Number 2, Summer 2002, The AAO Journal

Dear Dr. Chila, scious mind (spirit) is believed to The effects of the underlying spirit We would like to respond to your control the autonomic nervous sys- or subconscious have actually been offer to use The AAO Journal as a fo- tem while the conscious mind con- discussed for several centuries. rum for osteopathic thought. In par- trols the voluntary nervous system. Hippocrates and Galen linked the ticular, we would like to offer some Further, J. Stedman Denslow, DO, humors or attitudes of patients with additional perspectives to the impor- and Irvin Korr, PhD, of Kirksville various kinds of maladies. In 1759, tant article by William Lemley, DO detected various autonomic muscu- Richard Guy, MD wrote that women on spirituality in your summer 2002 lar responses in patients at rest when with cancer tend to be “of a seden- issue. disturbed by emotionally stimulating tary melancholic disposition of While Lemley mostly discussed inputs (1978). Thus, there is empiri- mind.” In 1870, James Paget, MD religious/spiritual beliefs, we suggest cal evidence demonstrating that the described cancer pre-dispositions as adding to the curriculum some in- conscious mind seems to be able to “deep anxiety, deferred hope, or dis- sights into an underlying sense of communicate with this unconscious appointment.” In the last few decades, spirit from A.T. Still and other health mind. For example, during the birth George Vaillant, MD has been report- professionals. Lemley seemed to use of a child, an expectant mother can ing on a group of Harvard graduates spirit and life interchangeably when affect her physiology through train- and has found that those that stayed quoting from Still. Indeed, there are ing in attitudes and behaviors. Ac- healthy had good attitudes. Recent only a few specific references to cording to this view, belief or faith, studies of rheumatoid arthritis, lupus, spirit, but a key one is: is the assent by the unconscious mind and other autoimmune disorders to what has been declared by the con- show that the worse the disposition We want to inform ourselves on scious mind to be true. Thereby, the or spirit, the weaker the immune that before we take hold of a man that unconscious mind or spirit may come system. has an enlarged liver (for example), to believe a repeated, authoritative, Therefore, we assert that the con- because on that inner man depends or emotional affirmation. Accord- cept of spirit, or the unconscious the results . . . The spirit is the man, ingly, there can be healthy thoughts mind, or whatever you want to call the inner man of whom I am talking. or unhealthy thoughts that affect our it, is important in understanding a pa- Body and Soul of a Man, 1902 beliefs and inner spirit in one way or tient. Recognizing these spiritual, and the other. sometimes unconscious, dimensions The above suggests a fundamen- Thoughts like hope, confidence, of a person is also essential if we want tal sense of spirit. In recent years, the and determination can be transmitted to teach medical students to use the part played by the spirit in healthcare to the spirit of the patient, with or spirit in a positive way to allow the has been found to be so profound that without a religious context. The end is mind, body, and spirit to establish an we felt compelled to suggest a cen- to develop good attitudes; the means integrated, healthy structure and tral focus on this “inner person.” can be through a dialogue between the thereby enable healthy functioning. Cora Barden, DO, among others, doctor and patient, a minister and pa- We have a few other, minor sug- has related that physicians should link rishioner, or a group leader and a sup- gestions regarding Lemley’s article. the mind with conscious psychology port-group. The goal is to maintain a We did not see an objective basis for and the spirit with the underlying, healthy spirit and thereby allow the the references to Sutherland. We sug- unconscious psychology within a per- autonomic nervous and immune sys- gest that religion is a bridge, not the son (1951). Additionally, the uncon- tems to function properly. bridge, to the spiritual. We suggest ➻ Fall 2002 The AAO Journal/7 dropping the undiscriminating sen- practitioners need to understand the are also important to include in the tence “Body was mind and mind was role of spirit and belief in the func- osteopathic medical curriculum. We spirit.” The section on quantum phys- tioning of the autonomic (and hence also hope that the “forum” will con- ics is theoretically misleading and healing) systems, we are not sure that tinue and that others will improve our unnecessary. The sentence attributed they should be “mobilizing support” language and frameworks and to Sutherland on transmutation be- of patients and friends to pray for de- thereby continue to fan our humble tween the Breath of Life and physi- liverance from sickness. Theologians embers into a great fire of widespread cal matter is scientifically embarrass- have been debating for centuries discussion. ing as is the sentence on the flows whether or not it is appropriate to ask We believe that the analysis of the through the electro-magnetic field of God to intervene (work a miracle) and interactions of the mind, body, and the body. In general, just as A.T. Still alter His natural laws for one spirit is a critical component for open- dropped the concept of “magnetic individual’s benefit. The theological ing the long-awaited flowering of flows” when he realized he could sub- argument against this is that we would osteopathic medicine. stitute real flows in the circulatory be asking God to do our will instead and nervous systems, we suggest that of trying to follow the will of God. James J. McGovern, PhD, President we might be able to drop concepts In summary, Dr. Lemley is to be Kirksville College of Osteopathic Medicine about “spiritual energy, etc.” when we congratulated for discussing these im- and Rene J. McGovern, PhD, realize the explanatory power of un- portant topics. We hope he, and oth- Associate Professor, derlying, physically based, driving ers, will agree that the conscious-un- Neuro-behavioral Sciences, KCOM Adjunct Asst. Prof. of Psychology, forces. conscious interactions and their Psychiatry and Neurology, Lastly, while we believe all health psychoneuroimmunologic reactions Case Western Reserve University

Dr. Lemley Responds

The author would like to thank Drs. said we may “look for life to appear The metaphorical then becomes literal McGovern for their informative com- when the proper connection is made.”2 on a new plane of understanding.4 ments about the “inner person” and To Dr. Still, life was more than just an The author recommended that stu- powers of the unconscious mind. organizing principle. It was seen as an dents be taught to comfortably ex- Psychoneuroimmunology indeed fits animating force made only of living plore a patient’s spiritual nature by naturally into any consideration of substance capable of existing apart several means, one of which was spirituality and, in fact, might be con- from the organism.3 This interpretation “knowing when to mobilize support sidered the basic science of spiritual- corresponds to Dr. Sutherland’s meta- of the spiritual community or support ity. Although we speak of mind, body phorical references to the Breath of groups for their patients.” Drs. and spirit as distinct entities, it is the Life, an inherent healing force with a McGovern equate this with praying author’s opinion that Dr. Still viewed tendency towards normalcy. The author for deliverance from sickness. Prayer them as an inseparable, unified organ- does not consider Dr. Sutherland’s ref- is but one example; most of the lit- ism. This correlates with the shaman- erences to the Breath of Life as “scien- erature reviewed by the author on the istic view that any distinction of the tifically embarrassing,” but then one positive aspects of prayer involved three is illusory. The references to quan- may suppose that many scientific pio- not asking God to alter His natural tum physics were intentionally general neers from Galileo to Einstein were laws but instead involve prayers for and brief due to the scope of the paper. considered “scientifically embarrass- healing invoking the inflow of Divine The discussion of the parallels between ing” in their own time until the truth of love and wisdom or “Thy will be the holistic nature of osteopathic phi- their theories became apparent. Dr. done.” Other appropriate examples of losophy and the interrelationships of Sutherland used metaphor eloquently mobilizing spiritual support would matter in quantum theory was intended to explain a spiritual concept. The meta- include the physician serving as a li- to clarify the unified nature of human phor simply clarifies a healing phenom- aison between patient and chaplain, beings in their universe. Dr. Still, after enon which is experiential in nature and identifying support groups from can- all, did describe human beings as a min- very difficult to verbalize. With expe- cer survivors, assisting in end-of-life iature universe.1 He speaks of life as a rience, the perceptive field of the os- issues, etc. The purpose of the paper substance, both subtle and powerful, teopath shifts as he or she evolves men- was to encourage open dialogue of that engenders motion everywhere, and tally, psychologically and spirituality.

8/The AAO Journal Fall 2002 spiritual issues as they relate to the practice of osteopathic medicine. Calendar of Events Spirituality is a deeply personal, controversial and pertinent topic for December 6-8, 2002 discussion in medical education. I ap- Basic Concepts in Muscle Energy preciate the insights of Drs. Walter Ehrenfeuchter, DO, FAAO, McGovern, and would encourage all Program Chairperson osteopathic educators to discuss spiri- Mesa, AZ tual issues with their colleagues and students. Preview of 2003 Courses

William Lemley, DO, FAAO January 16-19 September 19-21 Manual Medicine/Manipulation for Unlocking the Cranial Sutures I: Physicians: Lower Back, Pelvis and Development and Release 1. Still, A. Autobiography of Andrew Taylor Still, rev. ed. Kirksville, MO. Published Lower Extremities in San Francisco, CA by the author. 1908. Distributed, India- in San Antonio, TX napolis, IN. American Academy of Oste- October 11 opathy; 1996: p. 333. February 6-9 One-Day Pre-AOA Convention Diagnosis and Treatment of Low Back Workshop: OMT in Geriatrics 2. Still, A. Osteopathy Research and Prac- Pain and Introduction to Prolotherapy in New Orleans, LA tice. Kirksville, MO. Published by the au- in Santa Rosa, CA thor; 1917: Distributed, Seattle, WA. March 17-19 October 12-16 Eastland Press; 1992: pp. 278-79. Visceral Manipulation: Manual AAO Program at AOA Convention 3. Masseillo, D. Osteopathy - a philosophi- Thermal Diagnosis in New Orleans, LA cal perspective; reflections on Sutherland’s in Ottawa, Ontario, Canada experience with the tide. The AAO Jour- November 7-9 nal. Summer 1999: pp. 21-39. March 19-23 Prolotherapy: Below the Diaphragm 2003 Annual Convocation: in Biddeford, ME 4. Ibid., pp. 21-39.❒ Education and Research: The Backbone of Osteopathy December 5-7 in Ottawa, Ontario, Canada Visceral Manipulation: Urogenital April 26-27 in Fort Lauderdale, FL Dr. Fulford’s Basic Percussion Technique in Chicago, IL PHYSICIAN May 2-4 Prolotherapy: Above the Diaphragm Seeking a board eligible Update your in Biddeford, ME Osteopathic Physician to practice in an integrative Osteopathic Library June 27-29 medical setting in Columbus, IN. at the Manual Medicine/Manipulation for Compensation package Physicians: Upper Back, Neck and is negotiable depending AAO’s Book Store Upper Extremities on part or full time commitment. in Chicago, IL Residents will be considered. For a current catalog, contact: July 18-20 Kelli Bowersox, Receptionist Letters of interest and curriculum OMT for Common Organic and vitae should be sent to: American Academy Clinical Problems of Osteopathy in East Lansing, MI M. Harmon, ND, Telephone: Doctor of Integrative Medicine August 21-24 317/879-1881 P.O. Box 2145 13th Annual OMT Update “Application or E-mail: kbowersox@ of Osteopathic Concepts in Clinical Columbus, IN 47201 academyofosteopathy.org Medicine plus Preparation Fax: 812/376-8750 or Visit the AAO’s Website: for Certifying boards” Telephone: 812/375-1340 www.academyofosteopathy.org at Walt Disney World in Buena Vista, FL

Fall 2002 The AAO Journal/9 DigDig OnOn Anthony G. Chila, DO, FAAO ECOP

The Educational Council on basis, engaging an attempt to better language of 19th century Protes- Osteopathic Principles (ECOP) held understand Andrew Taylor Still’s tant evangelicalism. The reference its most recent meeting at Pikeville original osteopathic vision. In his here is to Still’s coupling of his College School of Osteopathic introduction, Doctor Stiles men- perception of the perfection of the Medicine (PCSOM) from Septem- tioned that Doctor Davis has human body with his acknowledg- ber 12-14, 2002. This group expertise in linguistics. ment that “The God I worship consists of Department Chairs/ The body of Doctor Davis’ demonstrates all His work”. Doctor Section Heads of OPP of the presentation concerned itself with Davis noted that the use of meta- Colleges of Osteopathic Medicine linguistic analysis of Still’s writ- phors which hindered Still’s ability in the United States, and 16 of the ings, as discussed with Doctor to prove scientific validity of his 20 colleges were represented. Stiles. Their effort has been to work in the 19th and 20th centuries Established in 1969, ECOP has understand and articulate Still’s has given way in the 21st century to accountability to the American insights with relevance to the the use of metaphorical language as Association of Colleges of Osteo- contemporary education and a form of scientific explanation. pathic Medicine (AACOM) through practice of osteopathic medicine. In closing his presentation, that organization’s Council of In working toward this goal, Doctor Doctor Davis shared with the group Deans. Cathleen Kearns was Davis discussed three types of his battle with his diagnosis of present as AACOM liaison to conceptual language believed to advanced lymphoma. He described ECOP. have given rise to Still’s discovery his daily drive to the monastery In the normal course of business of osteopathic principles. The where he is a member for prayer for ECOP, issues of curriculum language of classical Newtonian and breakfast, followed by his teaching are paramount. Over the mechanics. This vision of a static teaching and working with students years, this group has produced the universe brought into being by a and other responsibilities. Having Glossary of Osteopathic Terminol- divine creator was tenable because chosen to forego chemotherapy, he ogy, Core Curriculum in OPP, and the mind of God held within itself has asked Doctor Stiles to work Clinical Osteopathically Integrated all elements necessary to make such with him to assist his body’s Learning Scenarios (COILS). a universe a reality. The writings of immune system in fighting this Currently, at the request of the Still offer a similar conception of cancer. Whatever the eventual AACOM Council of Deans, work is the human body. We are all famil- outcome, he told the group that this progressing on Clinical and Re- iar with his assertion that the body choice has made all the difference search Competencies in OPP at the is the greatest of all God’s creations in his being able to live joyfully predoctoral and postdoctoral levels. and contains within itself all each and every day that he has been The highlight of the Fall 2002 requisites for health when obstruc- given. He considers this to be ECOP meeting occurred when tions have been removed. The nothing short of a medical miracle. PCSOM’s Edward G. Stiles, DO, language of the Industrial Revo- Nerve, courage and the humility FAAO, Professor and Chair of OPP, lution. Still’s industrial metaphor that makes man acknowledge the introduced to the group Robert C. was that of the mechanic able to demands of duty were demonstrated Davis, PhD, Associate Professor, understand and appreciate the in this discussion. Thank you, Division of Humanities. During the principles utilized by the builder in Doctor Davis; and Godspeed.❒ past several years, these gentlemen order to successfully remove any have shared time, on a weekly obstruction to fluid flow. The

10/The AAO Journal Fall 2002 Diagnosis and Treatment of Low Back Pain and Introduction to Prolotherapy Santa Rosa, California February 6-9, 2003

PROGRAM TIME TABLE: John C. Glover, DO, Program Chair Thursday, February 6 ...... 5:00 pm – 10:00 pm Friday, February 7 ...... 7:00 am – 1:30 pm The program anticipates being approved for 22 hours of AOA Saturday, February 8 ...... 7:00 am –1:30 pm Category 1-A CME credit pending approval by the AOA Sunday, February 9 ...... 7:00 am – 1:30 pm CCME. (each day includes (2) 15 minute breaks) Afternoons are open COURSE DESCRIPTION: LEVEL II to experience wine-tasting at local vineyards The course will focus on the mechanical causes of low back pain. Differential diagnosis will be discussed and several dif- REGISTRATION FORM ferent models of evaluation will be presented. The physiologi- Diagnosis and Treatment cal basis, indications and contraindications, evaluation, and treatment utilizing different manipulative models will be pre- of Low Back Pain & Intro to Prolotherapy sented. The participants will be introduced to the concept of February 6-9, 2003 ligament laxity and tendon instability and treatment with pro- lotherapy. Full Name ______Nickname for Badge ______LEARNING OBJECTIVES: Street Address ______At the end of each session, participants should: ______• Differentiate the different causes of low back pain (mechanical, City ______State______Zip______nerve root & disk, spinal & systemic pathology) • Choose the appropriate manipulative model for the patient and Office phone # ______Fax #: ______the problem on the basis of indications and contraindications. E-mail: ______• Differentiate the different manipulative models on the basis of physiological mechanisms AOA # ______College/Yr Graduated ______• Understand the physiological basis, mechanisms of action, and indications/contraindications of prolotherapy • Utilize a palpatory screen to evaluate ligamentous laxity (AAO makes every attempt to provide meals that will • Utilize a postural/structural model of evaluation to determine meet participant’s needs. However, we cannot guarantee the use of osteopathic manipulative treatment to satisfy all requests.) • Practice treatment of findings using multiple models (balanced ligamentous tension, counterstrain, facilitated positional REGISTRATION RATES release, Still technique, etc.) ON OR BEFORE 1/6/03 AFTER 1/6/03 • Observe/practice selected injection techniques used for AAO Member $630 $730 treatment of low back pain of ligamentous origin • Evaluate the lumbar spine, pelvis and lower extremity for Intern/Resident/Student $530 $630 sources of low back pain AAO Non-Member $1,000 $1,100 • Understand the role of the viscera in low back pain (Non-members – see membership application on page 14) • Discuss issues relating to coding and billing AAO accepts Visa or Mastercard COURSE LOCATION AND HOTEL INFORMATION: Hilton Hotel, Sonoma County Credit Card # ______3555 Round Barn Boulevard Cardholder’s Name ______Santa Rosa, CA 95403 Reservation Telephone: 707/523-7555 Date of Expiration ______Room Rate: $109.00 Signature ______Reservation Cut-off Date: January 7, 2003 Fall 2002 The AAO Journal/11 FromFrom thethe ArchivesArchives

Vindication “The Art of the Bone-Setter”, Chapter VII, pages 104-115 George Matthews Bennett

“Is this then your wonder? Nay, then, you shall understand more of my skill.” – Ben Jonson.

LEST it should be thought that I have by their manipulative and me- from the legitimate credit they have have only my own authority for call- chanical skill justly acquired a great won by the skill displayed in their ing in question Dr. Howard Marsh’s reputation. In what has their practice handicraft, they owe some of their dogmatic assertions with respect to consisted? First, in the treatment of success to the carelessness or indif- the method of practice by modern fractures and correction of deformi- ference of the general body of practi- Bone-setters I find at the same medi- ties. The general impression in the tioners, who are apt to overlook little cal jubilee, Mr. R. Dacre Fox, Fellow profession appears to be that the injuries, which often become very of the Royal College of Surgeons, of Bone-setter’s art consists of nothing painful and troublesome. It some- Edinburgh, the surgeon to the South- more or less than the forcible “ break- times seems to me that it is beneath ern Hospital, Manchester; surgeon to ing up” of stiff joints, so as to make the dignity of the ordinary practitio- the Manchester police force, and the same man walk as if by a miracle. ner to employ any active treatment whose other practice and official ap- The practice at Whitworth was a large whatever for a sprain. It is hardly fair pointments entitle his opinion to some one, furnishing constant employment then to gauge the work of Bone-set- weight, gave his practical experience for at least two active men, and con- ters; solely by their method of treat- of the Bone-setter’s art, so entirely sisting chiefly of the cases I have men- ing diseased joints (probably the most different and so much nearer the truth, tioned. Speaking from memory, I do unsatisfactory class of cases in the that I shall content myself with not believe that fifty joints of all sorts whole realm of surgery), but we ought merely quoting, whilst thanking him, were “cracked up” during the time I also to take into account the patience for his remarks which appeared in the was there; but it was not an uncommon and skill they display in the treatment Lancet, for 1882 (vol. ii. pp. 844.) event to have to put up half a dozen of injuries for which they are not in- Speaking from three year’s experi- fresh fractures and twice as many re- frequently consulted by the patients ence with the late Mr. Taylor, a cel- cent sprains in a single morning. In the of qualified practitioners. I have no ebrated bone-setter at Whitworth. North of England, the origin of nearly desire to hold a brief for every idle Lancashire, whose family have been all the men who are fairly good at Bone- fellow who calls himself a Bone-set- bone-setters for more than two hun- setting can be traced to the Whitworth ter, but I am anxious to give credit - dred years, he told the medical men surgery, and while, so far as I know, where credit is due, and to explain in plain terms that. Much misconcep- the Taylors, in their various settlements that the art of Bone-setting is not what tion exists as to the practice of Bone- at Whitworth, Todmorden, Stockwood, it is often thought to be a mere mix- setters; many of the methods of treat- and Oldfield-lane, were the only quali- ture of charlatanism and good luck. ment popularly attributed to them fied surgeons who practised Bone-set- From my own experience, I should have no other existence than in the ting; amongst the bills and dales of classify weak joints as follows: imagination of ignorant patients, Lancashire, Yorkshire, and the Lake 1. Those that have become stiff whose stories we, as a profession, are district, there were many who did so from enforced rest. perhaps rather too ready to believe. without being qualified, some of 2. Those that have become stiff by It is certain that sonic families-nota- whom, I must in fairness say, put up chronic disease. bly the Taylors, Huttons, and Masons- fractures uncommonly well. But apart 3. Joints stiff from injury to the

12/The AAO Journal Fall 2002 bones entering into their formation. them that ignorant Bone-setters do so they exercise their maximum power of 4. Joints stiff and weak from much mischief, the better informed, by restraint to prevent luxation. Under sprains, including displacement of the use of splints and well applied pres- such conditions, I conceive the follow- tendons and partial luxation. sure, are highly successful in their treat- ing changes to take place in the integ- Apart from the previous history of ment. I am sorry to say, many cases of rity of a joint. In the case of the syn- the case, and the evident existence of this kind come to Bone-setters which ovial membrane, temporary hyperemia constitutional disease, there are some have not been properly treated before, accompanied by pain, and some slight external appearances which help to owing to their not having been effusion into the cavity of the joint. distinguish cases and to afford indi- recognised, especially hip-joint disease. In the case of the tendons, over- cations of treatment, and of these the 3. On the third-class of cases, in stretching and loosening of the lin- Bone-sette-rs have learned by expe- which a fracture has taken place into ing membrane of their sheaths, more rience to avail themselves. the joint, causing stiffness, the con- or less disturbance to the adjacent 1. In the first-class I have mentioned dition is due to disturbed relationship cellular tissue forming the bed of the the stiffness of the structures about the of the bones from faulty setting, and tendon groove, and hyperemia with joint impeding its movement is the re- is recognised by comparison with the exudation of plastic fluid, subse- sult of purely mechanical causes, is in bony landmarks of the sound limb. quently forming adventitious prod- fact simply due to prolonged disuse. No In these cases forcible treatment does ucts. In the case of the non-elastic fi- cause for functional activity exists, and good; though, of course, the result is brous ligaments – firmly attached at consequently the elasticity, the flexibil- in proportion to the amount or bone- either end to the adjacent periosteum ity and power of adaptation to move- displacement, but it should be supple- – over-stretching, mostly involving ment in the parts about the joints not mented by passive movements for partial rupture, with swelling, soften- being required they become stiff and some time. In joints stiff after diagonal ing, and disintegration of their struc- rigid. No degenerative changes how- fracture through the condyles of the ture. It is beyond the purpose of this ever taking place, and they are capable humerus so common in children, I have communication to draw attention to of being recalled into activity unim- seen many most gratifying results; one the plan of treatment adopted by paired. In such a joint, the bony points, in a boy about twelve years old, whose Bone-setters under these circum- and the outlines of the tendons and liga- elbow bad been stiff three years is es- stances; it is, however, described in a ments about it, seem unnaturally promi- pecially impressed on my mind. paper of mine, of which an abstract nent, probably from absorption of the 4. In the fourth-class of cases, and is given in the British Medical Jour- adipose and connective tissue; the rigid those to which I would draw particu- nal, of September 25, 1880. The stiff- ligaments impart a sense of hardness, lar attention, I include lameness and ness of a sprained joint is partial. The and if the limb be flexed to its utmost, weakness, the result of the various surface is generally cold, or more or it shows considerable resiliency, such forms of injury, which we group to- less oematous, and each joint has one joints may, I believe, be “cracked up” gether under the general term a particular spot in which pressure without fear of consequences, and this “sprain”. I affirm most unhesitatingly, causes acute pain; the Bone-setters constitutes one of the successful opera- from an experience of some hundreds have learned by experience the situa- tions of Bone-setters. My own recol- of cases, that nothing has done more tion of these spots, and this fact has lection carries me back to some appar- to lower the prestige of regular prac- done more than anything to ently almost miraculous results. I am titioners, and to play into the hands strengthen the popular faith in their convinced suddenness ought to be in- of unqualified Bone-setters, than the intuitive skill; they certainly form an sisted on in doing this; the advantage way in which so many practitioners important guide to treatment since derived from it being, I believe, mainly tamper with a sprained joint. Sprains, they indicate the seat of greatest in- due to the fact, that it is less likely to of course, vary greatly in severity; jury to the ligaments, and point out set up any irritation in the joint than they way be broadly divided into two where their power of passive resis- the “dragging” of gradual extension. kinds, of which one consists merely tance has been most severely tested, 2. In the next class of cases, in of a temporary over distention of the and where adhesions are most likely which stiffness is due to degenerative parts round a joint which rest, and to have formed, Dr. Hood, in his changes, the external appearances are anodyne applications soon cure, record of Mr. Hutton’s practice, has exactly reversed; the outlines of the while the other involves pathological enumerated some of these painful joint are more or less gone. In these results a much more serious nature. spots, the chief of them are as follows: cases, no matter the character of the A severe sprain is the sum of the inju- 1. Over the head of the femur in disease, manipulative interference is ries that the parts in and about a joint the centre of the groin, correspond- positively vicious; and while it is in sustain, when, by their passive efforts, ➻ Fall 2002 The AAO Journal/13 ing to the ilio-femoral band of the you to Dr. Wharton Hood as being to its utmost capacity, the slightest capsular ligament (which is most se- faithful word-pictures, supplemented, impairment of the mechanism of a verely stretched when the thigh is too, by very accurate drawings. limb must be an incalculable source over extended, as when the trunk is The following are some of the of personal annoyance, discomfort, or flung violently backwards the com- lesser injuries, the non-recognition of disability.” monest cause of a sprained hip). which has frequently come under my “When doctors disagree who shall 2. For the knee joint, at the back notice at Whitworth. In the upper decide?” The readers of this little of the lower edge of the internal limb: fracture of the tip of the acro- manual will probably say as they read condyle, in other words, at the poste- mion; practical luxation of the Mr. Dacre Fox’s paper, that it is alike rior border of the internal lateral liga- acromio-clavicular and sterno-clav- a testimony and a vindication of the ment where it blends with Winslow’s icular joints (often happening to men “Art of the Bone-setter.” ❒ ligament, and where the senior mem- who carry weights on their shoul- branous tendon is in intimate relation ders); partial dislocation of the long with it. These parts suffer most be- head of the biceps, with over exten- cause as Mr. Morris says: ‘During sion of the bicipital fascia (common extension they resist rotation out- in men who throw weights or use a wards of the tibia upon a vertical axis’ shovel as malsters or navvies). Dis- PHYSICIAN and a sprained knee is almost always location of the head of the radius for- caused by a twist outwards of the foot. ward on the condyle, which is very WANTED 3. For the shoulder at the point common in children, and has a corresponding to the bicipital groove, marked tendency to cause stiff el- Holistic Internist with because in nine cases out of ten a man bows; fracture of the tip of the inter- Integrative Medicine practice sprains his shoulder to prevent him- nal condyle; overlooked Colles’ frac- seeking physician associate. self from falling, his hand grasps the ture; partial luxation of the head of Nutritional / functional nearest support, the body is violently the ulna (impeding supination of the medicine, natural hormone abducted from the arm, the long head hand, and having a tendency to gradu- replacement therapy, of the biceps is called upon to exert ally grow worse); severe sprain at the osteopathic manipulation its utmost restraining power, the bi- carpo-metacarpal joint of the thumb skills most desirable. cipital fascia is overstretched, and the (very common in stone masons and Located in beautiful tendon very often displaced. caused by the ‘jar’ of heavy chisels). Clearwater, Florida. Again for the elbow, the painful In the lower limb: Fracture of the Please call place is at the front of the tip of the fibula, just above the malleolus and Anna @ 727/524-0900. internal condyle; the fan-shaped in- at its tip (these are fruitful sources of ternal lateral ligament has its apex at lameness, often overlooked, and, if of that point, and it is most stretched in old standing, very troublesome to over-supination, with extreme exten- treat); partial rupture of the ligamen- sion of the forearm. On the front of tum patellae at its insertion into the the external malleolus, at the apex of tubercle of the tibia, which is much the plantar arch, the tip of the fifth more common than is ordinarily sup- MARIN COUNTY metatarsal bone, the styloid process posed; neglected over-stretching of CALIFORNIA of the ulna, the inside of the thumb, the ligament of the plantar arch, and and the annular ligament in the front tearing of the plantar ligament at its OMM practice for sale of the wrist, are respectively the most insertion into the os-calcis; rupture of painful spots when those joints are the penniform muscular attachments in busy severally sprained. of the tendo Achilles and muscular fee-for-service The manipulative part of the treat- hernia in the calf. integrative medicine ment of joints stiff from being I trust I shall be forgiven if I have clinic. sprained may be briefly said to con- dwelt too much on the étourderie of sist in pressure over the part most in- some of us, but I am sure so-called jured, and momentary extension of trifling injuries deserve more atten- Phone: 415/609-9625 the limb, followed by sudden forcible tion at our hands, since living at the Email: [email protected] flexion. The method varies with each high pressure men do now-a-days, joint, and I can with confidence refer with every part of their bodies tested 14/The AAO Journal Fall 2002 P EER -R

Understanding the Combined EVIEWED Motions of the C3/C4 Vertebral Unit:

A Further Look at Fryette’s Model S of Cervical Biomechanics ECTION John D. Capobianco, DO, FAAO, Marina G. Protopapas, DO, and Sonia Rivera-Martinez, DO

Abstract sidebending motion in the same di- into the concavity, that is rotation and The osteopathic concept of spinal rection while uncoupled motion oc- sidebending are coupled with motion motion is predicated on the observa- curs in opposite directions. The re- in the same direction. He did not dis- tions of Harrison H. Fryette, DO. sults of experiments 1 and 2 suggest tinguish between sagittal plane mo- According to his theory of spinal a greater frequency of uncoupled ver- tion (flexion and extension) and neu- motion, rotation and sidebending at sus coupled motion at the C3 on C4 tral in the cervical spine as in the tho- the segmental level in the cervical vertebral unit. Coupling occurred at racic and lumbar regions. Fryette’s spine are coupled. The typical cervi- a lesser frequency than would have theories of spinal biomechanics did cal segment demonstrates rotation been predicted by Fryette’s laws of not occur in a vacuum, and evolved and sidebending to the same side. The spinal motion. A third experiment was from the contributions made by 2 3 null hypothesis is that rotation and conducted to test if repeated passive Lovett and Halladay. Fryette and sidebending of a typical cervical ver- motion testing affected the outcome those who influenced him were un- tebral unit will be to the same side on of interexaminer reliability in experi- clear regarding segmental or group passive intervertebral motion testing, ment 2. Conclusions, which may be motion of the cervical spine. The bio- as demonstrated by Fryette’s laws of drawn from this research, are that mechanics of the cervical spine may spinal motion. The objective of this cervical vertebral motion does not be due to this region’s decreased lor- 4 research is to experimentally test the concur with Fryette’s theory of dosis or lesser sagittal curvature validity of Dr. Fryette’s hypothesis of coupled motion and passive motion when compared to the thoracic and coupled motion in a typical cervical testing may affect interexaminer re- lumbar spine. Historically, the osteo- vertebral unit. Specifically, motion of liability. pathic profession has adopted the third cervical vertebral unit; that Fryette’s model of the law’s of cervi- is the third cervical vertebra in rela- Introduction cal spinal motion into the standard osteopathic literature and cur- tion to the fourth cervical vertebra The osteopathic concept of spinal ricula.5,6,7,8,9 Kapandji’s10 model of was tested. The data collected was motion is predicated on the observa- cervical motion, based on an oblique statistically analyzed in order to de- tions of Harrison H. Fryette, DO. Dr. axis through the posterior aspect of termine whether rotation and Fryette1 began his work on spinal the body of the vertebrae, perpendicu- sidebending at the segmental level in motion in 1903 with a spine mounted lar to articular facets, also states that the cervical spine move to the same on soft rubber. This served as an even rotation and lateral flexion or opposite directions. Board certified better model than the living spine for (sidebending) are indeed coupled, osteopathic physicians were the ex- the purpose of teaching. Fryette as- occurring to the same side. This pa- aminers and 289 asymptomatic adult serted that a single vertebral unit (in- per will further define coupling or volunteers were the subjects. For the volving one vertebra upon another, coupled motion of the cervical spine purposes of this study coupled mo- i.e. the third cervical upon the fourth tion is defined as rotational and as rotation and sidebending in the cervical vertebra) follows rotation ➻

Fall 2002 The AAO Journal/15 same direction for the standardization was predominantly contralateral. For demonstrated to occur to the same of nomenclature (Table 1). Uncou- the middle and lower thoracic spine side. pling or uncoupled motion represents the combined motion of rotation and In contrast to the thoracic and lum- rotation and sidebending in the op- lateral flexion were found to be bar spine, studies on the cervical spine posite direction. Kapandji10 states that mainly ipsilateral. In addition, it was seem to be in agreement with according to his own model, the geo- demonstrated that individual subjects Fryette’s laws. The combined motion metrical analysis of the components of the group tested had different mo- of lateral flexion and rotation of the of rotation and sidebending in the tion patterns within their own thoracic cervical spine have been described by cervical spine would be complex spine. For example, during a subject’s Lysell13 in his three-dimensional ra- enough to require computer-calcu- testing for lateral flexion to the right, diographic study of 28 fresh cadav- lated values. In this study, palpation there was an accompanying ipsilat- eric specimens. Lysell calculated the on living subjects by passive motion eral (right) axial rotation. However, ratio of combined motion for all seg- testing was used to determine the further testing of that same subject for ments below C1. His study found the motion patterns in the cervical spine. lateral flexion to the left resulted in lowest ratio for lateral flexion/rota- an associated axial rotation to the tion and rotation/lateral flexion at C2 Literature Review right. This side-to-side discrepancy and a gradual increment in the ratios Motion studies of the thoracic and occurred mostly when lateral flexion down the cervical spine. This indi- lumbar spines seem to contradict the was the primary motion. cates that at C2 there is the largest conventional pattern of ipsilateral The complexities of spinal motion combined lateral flexion and rotation, rotation and lateral flexion also include those demonstrated by with the motion becoming smaller at (sidebending) described by Fryette’s the lumbar spine. Percy and the more caudal segments. Further- 12 theory of spinal biomechanics. Tibrewal used a three-dimensional more, this study found that both lat- Willems, et al,11 studied the motion radiographic model to identify re- eral flexion with rotation and rotation characteristics of primary and second- gional differences of inter-segmental with lateral flexion occurred ipsilat- ary rotations in the thoracic spine of patterns of motion in the lumbar erally in the neutral, flexion an ex- 14 sixty asymptomatic subjects. Their spine. The subjects were divided into tension positions. The Mimura, et al study illustrates the complexity of two groups: one group was studied three-dimensional motion study of motion in the thoracic spine. One of for axial rotation as primary motion, twenty normal men supports Lysell’s the observations made was that com- and the second group for lateral flex- findings on the combined motion of bined motion of lateral flexion and ion as its primary motion. The upper lateral flexion with associated rota- axial rotation in the upper thoracic levels of the lumbar spine exhibited tion for levels including and below spine occurs with equal frequency in lateral flexion and rotation in the op- C3-C4. However, at the level of C2- both an ipsilateral and contralateral posite direction. Furthermore, motion C3 and above, Mimura’s study found direction, when lateral flexion was the at the L4-L5 level revealed that lat- rotation and lateral flexion occurring primary movement. In addition, it eral flexion and rotation could occur in opposite directions. In addition, demonstrated that when the primary either in the same direction or in op- they found that flexion occurred con- movement was axial rotation, the posite directions. Combined lateral comitantly with rotation and lateral combined motion with lateral flexion flexion and rotation for L5-S1 was flexion below C5-C6. Moreover, ex- tension accompanied rotation with lateral flexion above the C4-C5 level. Therefore, in contrast to Lysell’s in- vitro experiment, Mimura found not only the addition of sagittal plane motion in combination with coronal INSERT #1 and horizontal movement, but also contralaterality of rotation and Table 1 sidebending at the second on the third cervical vertebrae. As explained above, non-osteo- pathic literature regarding the tho- racic and lumbar spinal biomechan- ics are not in agreement with Fryette’s principles. Fryette’s conclusions were 16/The AAO Journal Fall 2002 made on a non-living spine. This vical spine two months prior to the subject, the physician palpated the would exclude the influence of soft experiment, or had any other medi- lateral borders of the articular pillars tissue elements on cervical biome- cal or surgical condition that could of C3. The force was localized to the chanics. Both Mimura’s and Lysell’s alter their participation in the experi- C3 segment, and lateral translation in studies disclose the multifarious mo- ment. The subjects who were allowed both the right and left directions about tions of the cervical spine and bring to participate in this project were all the coronal plane.15 For example, to question Fryette’s laws for this spi- healthy and without any relevant when segmental response to lateral nal region. symptoms to the cervical region. Sub- translations was compared right with The purpose of this study is to sci- jects who met all exclusion/inclusion left, finger contacts were placed on entifically demonstrate the palpatory criteria were asked to voluntarily par- the articular pillars to monitor the re- findings that have been observed dur- ticipate and to sign an informed con- sponse at C3. If there was resistance ing patient diagnosis. This study will sent. The protocol that was used in during translation to the right and less provide a venue for evidence based these experiments was approved by resistance noted in translation to the osteopathic medicine, in that un- NYCOM’s human studies review left this finding was reported as coupled intersegmental motion of the board and met all regulatory require- sidebending to the right.16 In order to cervical spine is a clinical and aca- ments and appropriate ethical stan- test for rotation, the physician was demic possibility. Ultimately, this dards. There were no risks inherent required to move the C3 articular pil- may have clinical applications. to this experiment as this only in- lars anteriorly on the right and left volved diagnostic palpation to an ex- about the horizontal plane. This in- Methods posed neck. The benefits of this study duced rotation. Resistance to anterior Three major experiments com- were to provide a fuller understand- movement of the right articular pillar prised this research project. The pur- ing of diagnostic interpretation for the with more motion noted in anterior pose of the first two experiments was osteopathic physician, and to provide movement on the left was reported as to test the hypothesis that rotation and a rationale for osteopathic treatment. right rotation. There were only three sidebending of a typical cervical ver- The osteopathic physicians who types of findings that could be pal- tebral unit could occur in opposite participated in these experiments met pated during diagnosis: left, right and directions on passive intervertebral the following criteria: they were ei- none. The combinations of each di- motion testing. Further, our experi- ther Fellows of the American Acad- rection to each parameter (rotation ments would disprove the null hy- emy of Osteopathy and/or Board Cer- and sidebending) qualified it as being pothesis of rotation and sidebending tified in Special Proficiency accord- uncoupled (SB and R opposite), occurring in the same direction ac- ing to the American Osteopathic coupled (SB and R same side), NC/NU cording to Fryette’s laws of spinal Board. One physician, who was board [non-coupling/non-uncoupling] (either motion. A third experiment was done certified in the osteopathic board of SB or R were not present) and no find- to analyze if passive motion testing rehabilitation medicine, was board ing/no motion preference (neither SB affected the outcome of interexaminer eligible for the osteopathic manipu- nor R). The examiner only diagnosed reliability as inferred in the second lative medicine (OMM) certification one variable (SB or R) in order to elimi- experiment. These experiments were and subsequently attained that board nate bias due to preconceived knowl- held one year apart, using three dif- certification in OMM. The physicians edge based on Fryette’s theories and ferent subject populations and differ- who were selected all had experience laws of spinal mechanics. ent combinations of the original teaching diagnostic palpation at vari- It should also be mentioned that the group of examining physician’s who ous U.S. osteopathic institutions dur- observers conducting the palpatory participated in Experiment 1. ing their careers. The inclusion crite- testing were blinded to each other’s The criteria used to screen subjects ria for the physicians conducting this findings. Physicians were required to that participated in this research were experiment were of high standard in submit their findings immediately the same for all three experiments. All order to ensure that the examiners’ after it was made on each subject, volunteers were adults and were in- diagnostic abilities were at a high regardless of the number of times the terviewed prior to each experiment to level of confidence. subject rotated through their section. determine their suitability. Specific The method for determining cer- Volunteer assistants immediately exclusion/inclusion criteria were set vical diagnosis was also the same for documented the diagnoses and no for these experiments. There was no all three experiments. In order to test communication was permitted be- age range specified in either experi- for sidebending, the physician was tween the examiners and/or sub- ment. Individuals were excluded if situated at the head of the supine sub- jects regarding the findings, further they had suffered trauma to the cer- ject. While supporting the head of the ➻ Fall 2002 The AAO Journal/17 eliminating bias in our experiment. computer lottery system was used to the presence or absence of somatic Although the approach to diagno- distribute the subjects randomly to dysfunction. The three major param- sis was the same in all three experi- three different examiners. This pre- eters tested for in this experiment in- ments, there were additional variables vented each subject from being diag- cluded rotation, sidebending and so- and controls added to each subsequent nosed by the same physician for more matic dysfunction (SD). Each subject experiment. The experiments were set than one diagnostic component. The was examined once for sidebending, up so as to provide as much of an unbi- subjects were examined in the supine once for rotation and once for the ased set of findings as possible. position with the cervical spine in the presence/absence of SD. neutral position. Each individual was At least two out of the four crite- Experiment 1 sent to one physician who was ran- ria for somatic dysfunction (i.e. One hundred and seventy two sub- domly directed to segmentally motion Asymmetry [A], Restriction of mo- jects and eight osteopathic physicians test the C3 vertebral segment for ro- tion [R] and Tissue texture changes were recruited for this experiment. A tation or sidebending or to palpate for [T]) was necessary to elicit a finding of somatic dysfunction (Table 1). The criteria for “tenderness” was not elic- ited in order to avoid subjectivity on behalf of the examiner. In order to determine the presence of somatic dysfunction, palpation of the C3 ver- Insert #2 tebral unit was utilized to reveal tis- sue texture changes [T] (i.e. Table 2 bogginess, ropiness of underlying soft tissues), greater prominence of the articular process on either side with respect to the other, suggesting posi- tional asymmetry [A]; and restricted motion [R] in the coronal and hori- zontal planes as noted previously in motion testing.17

Experiment 2 Ninety-seven subjects and five os- teopathic physicians (who were also a part of Experiment 1) volunteered Insert #3 to take part in Experiment 2. This study was different from the first ex- Table 3 periment in that the dimensions of rotation and sidebending were tested not only in the neutral position but also by motion testing along the sag- ittal plane. According to Gibbons,18 vertebral motion may be described using standard anatomical cardinal planes and axes of the body. Spinal motion is described as rotation around, and translation along, an axis as the vertebral body moves along one of the cardinal planes. The vertical axis is labeled as the y-axis; the hori- zontal axis is labeled as the x-axis; and the anterior-posterior axis is the z-axis. He defines the sagittal plane

18/The AAO Journal Fall 2002 as being in the yz plane; the coronal Another parameter added to this was not tested for in this experiment as the xy plane; and the horizontal as experiment was interexaminer reli- because the presence of somatic dys- the xz plane (Figure 1). ability. Each subject was randomly function did not affect the outcome Gibbons states that in flexion there assigned to five different stations. At of the first experiment (Refer to is an anterior (sagittal) rotation of the each station, a physician was required Graph 1). superior vertebrae around the x-axis to determine one variable of the while there is accompanying forward person’s diagnosis (as was done in the Experiment 3 (sagittal) translation of the vertebral first experiment). By the end of each This part of the project was con- process along the z-plane. In exten- experimental cycle, each subject was ducted to demonstrate the effect of sion the opposite occurs and the su- rotated to a different physician and palpatory diagnosis via passive mo- perior vertebra rotates posteriorly examined 24 times: 3 Sidebending/ tion testing in causing an alteration around the x-axis and translates pos- Flexion, 3 Rotation/Flexion, 6 of the finding during subsequent mo- teriorly along the z-plane. In Sidebending/Neutral, 6 Rotation/ tion testing of the C3/C4 vertebral sidebending there is bone rotation Neutral, 3 Sidebending/Extension, segment. It was also done to explore around the anterior-posterior z-axis and 3 Rotation/Extension. This was the lack of consistency found in but sidebending is rarely a pure done to test for the consistency of di- interexaminer diagnostic palpations movement and is generally accom- agnosis among physicians, establish in Experiment 2. The three physicians panied by vertebral rotation. The a basis for interexaminer reliability who took part in Experiment 3 were combination and association, of one and compare these results to those of also participants of Experiment 1 and movement with others is termed the first experiment. The rationale for 2. There were two groups of subjects “coupled motion”. Our definition of 6 diagnoses made for each subject in (20 total) who participated in this pi- coupling is that it is a bi-planar mo- the neutral plane was because this data lot study: ambulating and stationary tion of SB and R occurring to the same could be utilized at a later time to de- groups. The purpose of adding this side, which is similar to Fryette’s sec- termine intraobserver reliability. It factor (ambulating vs. non-ambulat- ond law of spinal motion. Uncoupling, was also done as a reproducible form ing) to the experiment was to deter- on the other hand, is a bi-planar mo- of Experiment 1, which included only mine if walking from one examiner tion where SB and R are opposite in palpation in the neutral plane. Also, to the next affected the diagnosis at direction. the presence of somatic dysfunction the C3/C4 vertebral level. Each subject had the level of C3 vertebra marked for diagnosis to as- sure consistent palpation of the ex- amined level. Once again, physicians were blinded to the diagnostic find- ings found by each other. The exam- iners communicated the findings to a volunteer assistant and the subjects INSERT # 4 were kept unaware. The setup for each physician was to examine the Figure 1 subjects two or three times each. The vertebral segment would be passively motion tested a total of seven times. The examiner who initially palpated the subject’s cervical spine would also be the one to make the final as- sessment. This was done to compare the first and last diagnosis made by each physician and thus tests for intraobserver reliability.

Data Analysis The data collected in these experi- ments were evaluated via statistical ➻ Fall 2002 The AAO Journal/19 INSERT # 5

GRAPH 1

20/The AAO Journal Fall 2002 analysis in the form of contingency tables. The goal of a contingency table was to compare the experimen- Insert #6 tal data to that of the null hypothesis. In this case, the first two contingency Table 4 tables will compare actual diagnoses to those predicted by the null hypoth- esis. For experiment 1, there were nine plausible diagnoses that could have been recorded for the C3 seg- ment (C3/C4 vertebral unit) by the physicians on the day of examination. Table 2 shows the nine possible di- agnoses that could be palpated. It also includes whether somatic dysfunction was present at the C3 segment, and if it was more prevalent with a coupled (SB and R to the same side) or an uncoupled (SB and R opposite) diag- Insert #7 nosis. In the second experiment there were twenty-four possible findings as Table 5 depicted in Table 3. The criteria used to evaluate the data in experiments 1 and 2 involved compiling the majority number of diagnoses for rotation and sidebending in order to categorize the data into un- coupled/coupled/NC-NU/no finding. This equation provides a means to value of zero indicates purely chance Nansel et al.19 stated that it is impera- determine whether or not there exists agreement; and a negative value is de- tive to have a convincingly high level any relationship between the ex- fined as agreement below chance. The of interexaminer concordance for the pected and observed values, as well guidelines that were used to evaluate detection of a given palpatory entity to as, offer a means to prove or disprove the kappa values in this experiment have diagnostic relevance. Interest- the null hypothesis. Before the value are listed in Table 4.21 ingly, Nansel did not address static pal- of X2 can be used, the degrees of free- pation. However, his study did find dom (df) must be determined. Results poor levels of interexaminer agreement Df = (no. of rows –1)(no. of columns – 1) The three studies that comprised 2 for “motion based palpation”. The critical value of X must be this project were performed using It should be noted that the “no greater than that determined by the three different subject populations finding” parameter was not included degrees of freedom in order to deter- and three different subsets of the in the statistical analysis because it mine a significant correlation be- original group of examiners. The signifies that no diagnosis was made, tween the data, as well as, to reject three different sets of data that were and thus would not offer any support the null hypothesis. collected from all experiments in- towards the hypothesis of this experi- Kappa values were calculated on ferred poor evidence of Fryette’s ment. This experiment was based on experiments 2 and 3 using Siegel’s coupled (SB and R same) segmental having positive findings, or the pres- formulas for non-parametric statisti- motion theory of the cervical spine. 20 ence of a diagnosis. Also, the frequency cal analysis. These values were used In the first experiment the findings of “no finding” was not significant to determine interexaminer, as well palpated were diagnosed only in the enough to include in the final statisti- as, intraobserver reliability. Kappa neutral plane. Table 5 summarizes the cal analysis. coefficients measure examiner agree- frequencies of uncoupling, 47.95%, The mathematical equation that was ment beyond that which is expected which was greater than that of cou- used to determine the significance of by chance alone. The kappa coeffi- pling, 36.26%, and that of Non-cou- the data collected is the following: cient has a maximum value of 1.0 pling/Non-uncoupling (NC/NU) di- X2 = (observed – expected)2 / expected when there is perfect agreement; a agnosis, 15.78%. The significance of Fall 2002 The AAO Journal/21 these values indicates that Fryette’s postulate of coupled motion in a typi- cal cervical vertebra must be ques- tioned. The x2 values and p values as illustrated in Table 6 are significant Insert #8 for uncoupling (p> 0.005), and non- coupling/non-uncoupling (p <0.001) Table 6 and insignificant for coupling (p = 0.95). Since the statistical occurrence for these three diagnoses is presumed to be equal, it appears that uncoupling occurs more frequently and is more statistically significant than an NC/ NU and coupled finding. The data analyzed in this experiment suggests that uncoupled and NC/NU findings are likely to occur with 99% certainty, thus failing to accept the null hypoth- esis, giving credence to the experi- mental hypothesis instead. Coupling occurs at a rate, which the null hy- pothesis fails to predict, occurring Insert #9 approximately one-third of the time. This further lends support to our hy- Table 7 pothesis that rotation and sidebending occurs in opposite directions at the segmental level in a typical cervical vertebral segment. Chi-square and p values were also calculated for the appearance of somatic dysfunction (SD) in conjunction with uncoupling/ coupling/NC-NU and were non-sig- nificant. As demonstrated by Graph 1, the presence of SD is independent of diagnosis. This demonstrates that coupling and uncoupling occurred regardless of the presence or absence of somatic dysfunction versus non- somatic dysfunction. A SD is not more prevalent in uncoupling/cou- Insert #10 pling/NC-NU. Table 7 displays the percent dis- Table 8 tribution of diagnosis in Experiment 2 for the neutral, flexion and exten- sion planes. In particular, 38.04% of the diagnoses made were for uncou- pling (SB and R opposite), 34.78% for coupling (SB and R same) and 27.18% for NC/NU in the neutral plane. Table 8 summarizes the com- parative frequency of each diagnosis between experiments 1 and 2 in the ➻ 22/The AAO Journal Fall 2002 kappa values were calculated after diagnosis 1 and 2, then 1, 2 and 3, Insert #11 and so on). The kappa coefficients varied from 0.116 to 0.486, which are Table 9 considered slight to moderate concor- dance (Table 4). As seen in Table 9 there is a decreasing trend of kappa values. This trend may be clinically significant because it may offer an explanation as to why a passive mo- tion testing effect may not result in a high percentage of agreement among examiners. As each succeeding phy- sician diagnosed each subject, the initial diagnosis (or motion prefer- ence) of C3/C4 may have undergone serial changes during the multiple passive motion testings of that verte- Insert #12 bral segment. Thus, it may not be possible to obtain an objective mea- Table 10 surement of interexaminer reliability testing because multiple diagnostic palpation of a vertebral segment may also provide a concurrent form of treatment, or at least an alteration of the original observed findings. Also, the kappa values calculated for intraobserver reliability for experiment form of percentages. Table 6, records pling. However, coupling (SB and R 3 showed slight concordance ranging the x2 values and p values for uncou- same) and the NC/NU diagnoses have from 0.022 to 0.074 (Table 10). pling (p=0.80), coupling (p>0.98) and the same lack of statistical signifi- Graph 2 indicates that the statisti- NC/NU (p=0.70). All the p values ob- cance, which was less than that of cal reliability of interexaminer test- tained, therefore, suggest that each uncoupling. ing also shows a decreasing trend (in- diagnosis occurred at random and at The data recovered for the palpa- creased palpation is related to de- an equal rate of about a third of the tory findings in the extension plane creased agreement among examiners) time. There are as many uncoupled also reveal non-significance, but the in the kappa values. The ambulating diagnoses as expected, but there are priority of sequence varies from the group was found to have greater vari- also fewer coupled diagnoses than results explained above. More spe- ability in the kappa values than was expected. Coupling was found to cifically, for uncoupling (p=0.80), seen in the non-ambulating group. occur at a lower frequency than un- coupling (p=0.70) and NC/NU Thus, this also may explain the de- coupling, with the NC/NU diagnosis (p>0.98). The p values demonstrate that creased interexaminer reliability in having the lowest frequency and cou- each diagnosis occurred at random. Experiment 2. pling the least significance. Uncoupling (38.2 %) occurred at a The chi-squared calculations for Table 6 also demonstrates that in greater frequency than coupling experiment 3 demonstrate that the the flexion plane of Experiment 2, the (26.9%) and NC/NU (34.8%) (Table 7). diagnoses made by the examining p values were not significant for cou- According to the data collected for physicians significantly differed from pling, uncoupling or NC/NU find- Experiment 3, 97 percent of the find- random (p<0.001) (Table 11). These ings. Uncoupling (p=0.80), coupling ings collected showed a change from p values reflect a basis to conclude (p>0.99) and NC/NU (p>0.95). Un- the initial to the final diagnosis. Table that there was a significant coupling occurred at the expected 9 represents a summary of the kappa interexaminer reliability for experi- rate, with coupling and NC/NU found values that were calculated after each ment 3 and that the decreasing trend to occur at a lesser rate than uncou- succeeding diagnosis was made (i.e. of kappa values (Table 9) may be due to factors other than lack of agree- Fall 2002 The AAO Journal/23 Insert # 13

GRAPH 2

24/The AAO Journal Fall 2002 Insert #14

Table 11

ment. Moreover, kappa coefficients fied physician examiners. bral unit. The data collected demon- represent a measure of the proportion The diagnosis of motion prefer- strated that rotation and sidebending and strength of the agreement, but not ence of the third cervical vertebra was may not conform to Fryette’s hypoth- it’s significance. The diagnoses made done by passive motion testing by esis, which states movement of a by each physician between the first physicians, board certified in osteo- single cervical segment demonstrates (diagnoses 1 through 3) and the sec- pathic manipulative medicine. The same-sided coupling. Both experi- ond halves (diagnoses 4 through 6) issue of bias amongst examiners, in ments 1 and 2 demonstrated that cou- of experiment 3 changed, but the sig- terms of preconceived notions of ro- pling was less frequent than uncou- nificance of the agreement between tation and sidebending occurring to pling, and that uncoupling was more examiners remained (Table 11). The the same side, were important to ad- commonly found. The presence or discrepancy that is observed between dress early on in the experimental absence of somatic dysfunction was the initial and final diagnoses may be process. In Experiments 1 and 2, ro- not affected by the type of diagnosis further explained by ambulation tation and sidebending were tested as (i.e. uncoupled, coupled, NC/NU, no (gross motion of the spine) in addi- two separate variables among the dif- finding) in Experiment 1. Further- tion to dynamic motion testing ferent examiners. Simply stated, the more, the findings for coupling and (movement of a specific segment of examiners never simultaneously uncoupling were reproducible be- the spine). It should also be men- tested rotation and sidebending in any tween Experiments 1 and 2 (refer to tioned that the examiners used in the given subject. This prevented the os- Table 8). In experiment 2, uncoupling third experiment were also partici- teopathic physicians from relying also occurred more commonly in all pants of the second experiment, lend- upon their educational background three planes (flexion, extension and ing additional credibility to their tech- and preconceived notions of spinal neutral). It is important to note that nique of palpation in Experiment 2. mechanics, which have traditionally this study did not examine the thora- been based upon the Fryette model. columbar spinal mechanics, and Discussion This research project is a new in therefore we do not propose that The three major objectives of this vivo approach to challenge the prin- Fryette’s second law of spinal motion project were: first, to determine if ciples ordinarily taught in the stan- is not applicable below the cervical rotation and sidebending follow dard literature and curriculum. Most region. However, the differences in Fryette’s biomechanics of the cervi- of the studies conducted in the past configuration of the cervical to distal cal spine for C3/C4; second, to as- have been in vivo and in vitro studies spine may provide an explanation for sess the reproducibility of the find- to test a hypothesis concerning the our findings. ings; and third, to test the sensitivity biomechanics of the cervical spine, The cervical spine, by nature a lor- of motion induced changes on the pal- but not specifically to test the valid- dotic structure with an anterior con- patory diagnosis among ity of Fryette’s theory of cervical spi- vexity, has a greater axial rotation interexaminers. This was done exer- nal motion. than its thoracolumbar counterparts. cising a standard protocol of osteo- Our research looked into the na- Anatomically, this fact may be due pathic palpatory diagnosis by quali- ture of motion of the cervical spine, to a greater disk to vertebral body ra- in particular the third cervical verte- ➻ Fall 2002 The AAO Journal/25 thoracic spine have been compared in literature to be similar to that of the cervical spine. Penning and Insert #15 Wilmink25 offered an explanation of the mechanism on the motion char- Table 12 acteristics of the upper thoracic spine in relation to the cervical spine. They theorized that the heads of the ribs mimicked the role of the uncinate pro- cesses in the cervical spine in guid- ing the combined motion between lat- eral flexion and axial rotation. tio found in the cervical region as zontal motion to the degree of the lat- Willems11 conducted an in vivo study, compared to the other regions. The eral fasciculi (short restrictors). which demonstrated that there is a sagittal curvature found in the cervi- Basmajian and De Luca23 concede relatively equal incidence of ipsilateral cal spine may predispose it to more that the intrinsic muscles, specifically and contralateral patterns of lateral flex- neutral spinal biomechanical motion the multifidi act more to stabilize than ion combined with axial rotation in the than has previously been described, to move the cervical spine. A pro- upper thoracic region. This may be ex- increasing the likelihood of un- posed mechanism that may be used plained by the morphological similar- coupled motion. The lumbar spine, to explain uncoupling during passive ity between the upper thoracic and the another lordotic structure, has also motion testing as supported by de- lower cervical spines, with the first two demonstrated to exhibit uncoupled scriptive anatomy may be due to the thoracic vertebrae exhibiting joints of motion.12 Perhaps the lordosis may be synergistic action of the Luschka.25 It may be presumed that the an influence for rotation and intertransversarii, multifidi and rota- contralateral motion patterns in the sidebending to occur in opposite di- tores muscles. The intrinsic as well upper thoracic spine found by rections at the segmental level. as the long restrictors of the cervical Willems may also occur in the cervi- Percy12 suggests that the lordotic spine rotate and sidebend the neck to cal spine. shape of the lumbar spine together the opposite sides.22 The anatomy During the course of this study, it with muscular control are the two may inspire further analysis of the was found necessary to address the principal factors affecting the com- gross or group motion of the cervical issue of interexaminer reliability. bined motions of rotation and spine. To assume that intervertebral Does a lack of agreement amongst sidebending. motion is exclusively due to diagnosticians mean that a finding is Gray’s Anatomy4 states that the diarthrodial joint mechanics (articu- not objective? Interexaminer agree- short restrictors of the cervical spine lar facets and the joints of Luschka) ment and intraobserver reliability were are the intertransversarii, multifidis, ignores the potential influence of soft tested in separate experiments. There and rotatores muscles, the latter not tissue on the cervical spine. was a lack of inter- and intra- exam- being fully developed and exhibiting Beckwith’s24 emphasis on verte- iner agreement in Experiment 2. Pre- variability. Lateral flexion is influ- bral mechanics lends support to the sumably, in order for interexaminer re- enced by the intertransversarii and possibility of uncoupling in the cer- liability to be valid, one needs the ex- multifidis. Rotation is affected by the vical spine. Radiographic imaging aminer to agree with their own find- multifidis and the rotatores (Ibid). studies conducted by Beckwith dem- ings. However, the very notion of Pansky22 states that the multifidis, onstrated that rotation could occur as agreement within a group and one- rotatores, and the long restrictors such an isolated lesion. Beckwith further self must be called into question when as the sternocleidomastoid, semispi- documents that rotation and a palpation is induced dynamically or nalis cervicis and capitis rotate the sidebending in contralateral direc- passively. O’Haire26 states that the cervical spinal column to the oppo- tions are coexistent and coextensive greater agreement within the observ- site side (Table 12). The just as they are in ipsilateral motions ers themselves than between intertransversarii muscles exert lat- of the cervical spine. This study’s interexaminers may be due to system- eral flexion to the same side. The in- findings may further confirm the co- atic intraobserver error. Passive mo- terspinalis muscle, also a short existing nature of rotation and tion is a dynamic palpation, and it restrictor of the cervical region, is a sidebending in coupled and un- may change the initial diagnosis. This midline muscle unit and therefore, coupled patterns. may occur, not only among a group does not influence coronal and hori- The motion patterns of the upper of qualified examiners, but also 26/The AAO Journal Fall 2002 the parameters in place to allow the examining physicians to distinguish between motion preference and the presence or absence of somatic dys- function. Passive motion testing could theoretically be more likely to induce a change in the findings of a vertebral segment with no motion re- striction, than one, which has been Insert #16 chronically restricted. The pattern of change varied with each subject. Some Table 13 subjects went from a dominant sided diagnosis to no motion preference, and then to the opposite side of the original diagnosis. Other individuals went from one dominant side to the other without passing through an intermediary phase (i.e. no finding) (Refer to Table 14). In future experiments involving interexaminer reliability, more resis- tant somatic dysfunctions may serve as controls to determine agreement amongst examiners. In any research project, one area of concern that must be addressed within the successive palpations upon comes a participant in the final out- during analysis of the data is the pos- a subject by one clinician. Repeated come of the experiment. sible cause and interruption of experi- passive movement, whether by mul- The final experiment addressed the mental error. The magnitude of sub- tiple examiners or by one examiner, issue of low interexaminer agreement jects seen for diagnosis by the physi- may change the initial diagnosis. In in Experiment 2. Experiment 3 had cian examiners is not that of a typical fact, repeated dynamic motion test- more of a favorable interexaminer office setting. During the process of ing is not unlike “springing” which reliability than the previous study. In diagnosing a large number of subjects is an articulatory technique involving experiment 3 there was a decrease in in a time frame of approximately four passive movement.27 A diagnosis of kappa values, which means that the hours, other aspects should be con- motion preference such as rotation, diagnosis from the first to final pal- sidered. There are various reasons sidebending, flexion or extension is pation changed consistently. This that may be used to explain the not a fixed, objective finding in the seemed to be true for both changes observed in the face of induced passive motion. interexaminer and intraobserver reli- interexaminer results: one, the tech- Increased repeated passive motion ability. Indeed, the data analysis nique used by each examiner may testing will change the initial diagno- showed statistical variability between have been different; two, examiner sis for other examiners, as well as for those examined who were ambulat- fatigue; three, diagnosis of the wrong the initial examiner. Greenman28 ing between successive palpations, segment; and four, palpatory error in states that passive (and active) mo- and therefore may further explain the making a diagnosis. Although each of tion testing at the segmental level is discordance between examiners in these potential errors may have oc- by nature therapeutic and results in a Experiment 2. The data analysis of curred during the experiments, they change from the initial finding. Ac- Experiment 2 demonstrated poor to may not be the causative factors of cording to Becker29 the art of palpa- slight interexaminer concordance variability in diagnosis. The authors tion involves an experience akin to with kappa values ranging from – would like to address these concerns: quantum physics in which the ob- 0.612 to 0.0472. The kappa values for Passive (dynamic) motion testing server is an active participant in the intraobserver demonstrated poor to (and ambulation as demonstrated in treatment process. Dynamic palpation fair agreement and ranged from – experiment three) would be the most may follow the principles of quantum 0.258 to 0.394 (Table 4, 13). The pro- likely explanation for a lack of inter- mechanics whereby the observer be- tocol for experiment 3 did not have and intra- examiner agreement. Mo- Fall 2002 The AAO Journal/27 seems to be the norm even from well- established procedures such as read- ing electrocardiograms (EKG’s). Moreover, the effects of soft tissue influence, inherent joint mechanics, method of diagnosis and passive mo- tion testing may offer an explanation to the complexity of diagnosing mo- tion preference in the cervical spine. Insert #17 Conclusion Table 14 Fryette’s second law of spinal mo- tion may not fully apply to segmental motion in the cervical spine at the C3- C4 level according to the series of ex- periments represented by this article. They included nearly three hundred subjects and eight osteopathic physi- cians board certified in osteopathic manipulative medicine. In fact, rotation and sidebending in the same direction at C3 occurred less than 35% of the time. A statistical analysis of interexaminer reliability demonstrates tion induction (passive/dynamic) From a purely scientific perspec- that high levels of concordance may not whether by an examiner or by the tive, interexaminer reliability of pal- be expected in the face of repetitive gross motion of walking could alter patory findings is difficult to assess dynamic motion testing because phy- an otherwise static and clinically in- because there are no objective mea- sician induced movement can change significant finding. The first and sures established in osteopathic ex- the original motion tendency. The data fourth issue of concern may be ad- perimental science that may be used. obtained from all three experiments dressed by the fact that the examin- There is no global standard on how suggests that spinal motion in the cer- ers were instructed to follow the pro- to measure the accuracy of passive vical spine is at least uncoupled and at tocol for diagnosing rotation and motion testing, and none to demon- best not totally adherent to Fryette’s sidebending prior to each experiment strate that everyone palpates and per- theory. It is the authors’ goal to present in order to standardize the methodol- ceives their findings in the same man- findings so the student and practitio- ogy: uniformity enhances validity. ner. According to Beal,30 motion ner of osteopathic medicine will diag- Secondly, although the experiments sense constitutes the culmination of nose and treat the cervical spine accord- ran a maximum duration of four palpatory skills and is the limiting fac- ing to their palpatory findings and not hours, an osteopathic physician does tor in the art of manipulation. There strictly on biomechanical theory. not ordinarily see a hundred or more is no standard with which to compare This study has demonstrated that patients in this amount of time. How- physician’s palpatory diagnoses once rotation and sidebending of the third ever, our examiners typically have they have made them. If the diagno- cervical vertebra may move in oppo- more than four hours of patient (hands sis can be verified with another sci- site directions slightly more so than on) contact, which includes not only entifically acknowledged method, ipsilateral directions in the neutral and diagnosis but treatment as well. This then that could provide sufficient evi- sagittal planes during physician in- would argue against inaccuracies and dence based validity on the osteo- duced motion testing. These findings fatigue amongst any particular exam- pathic approach to diagnosis of the do not support the principles of iner. Lastly, although the first two cervical spine. However, Deboer, et Fryette as applied to the cervical studies did not include a label at the al31 in a “Reliability study of detec- spine. As a result, the standard osteo- C3 vertebra, in the last experiment it tion of somatic dysfunctions in the pathic curricula, which state that was clearly marked for the examin- cervical spine,” determined a 40-60% coronal and horizontal motion in a ers to use as an anchor for palpation. agreement among examiners. This specific vertebral unit should move

28/The AAO Journal Fall 2002 in a coupled, or in the same, direc- Acknowledgments Osteopathic Muscle Energy Techniques. tion is brought into question. Al- Valley Park, MO. Mitchell, Moran and Special thanks must be given to: Pruzzo Assoc. 1979. p. 281. though mathematical, computer, and Dennis J. Dowling, DO, FAAO, 13,25,32 post-mortem models have con- Chair, Stanley Schiowitz, DO, 10.Kapandji IA. The Physiology of the Joints, firmed Fryette’s principle with regards FAAO, Department of Osteopathic Vol. III. 2nd edition. Edinburgh, London. to segmental motion, there are a lim- Manipulative Medicine, and Eileen L. Churchill Livingstone. 1974. p.202, 204. ited number of models in the literature DiGiovanna, DO, FAAO, Charles J. 11. Willems JM, Jull GA, Ng JK-F. An in vivo that include soft tissue influences. One Smutny III, DO, Claudia L. McCarty, in-vivo study demonstrated uncoupled study of the primary and coupled rotations DO, FAAO, Anthony D. Capobianco, of the thoracic spine. Clinical Biomechan- motion at the upper cervical spine, in- DO, Regina Asaro, DO, the late be- ics. 1996. 11(6):311-316. 14 clusive of C2-C3. loved Robert G. Thorpe, DO, FAAO, The purpose of this study was to David P. Yens, PhD, Charles Shopsis, 12.Pearcy MJ. Tibrewal SB. Axial rotation demonstrate that Fryette’s principles PhD, and especially Michael R. and lateral bending in the normal lumbar are not always applicable in predict- spine measured by three-dimensional ra- Wells, PhD. diography. Spine. 1984. 9(6): 582-587. ing spinal motion of the mid cervical The completion of this research region. In fact, rotation and project would not have been possible 13.Lysell E. Motion in the Cervical Spine. An sidebending of a single vertebral seg- without the support received by the experimental study on autopsy specimens. ment, in this instance the third cervi- students and OMM fellows of the Acta Orthopaedica Scandinavica. 1969. (Supp). 123:7-57. cal vertebra, can display uncoupling, NYCOM/NYIT community who vol- or contralaterality in the coronal and unteered their valuable time to help horizontal planes. The validity of our 14.Mimura M, Moriya H, Watanabe T, us obtain our data. Takahashi K, Yamagata M, Tamaki T. findings may be challenged by the Three-dimensional motion analysis of the perception of lack of inter- and intra- References cervical spine with special reference to the examiner reliability findings. How- axial rotation. Spine. 1989. 14(11):1135- 1. Fryette HH. Principles of Osteopathic 1139. ever, due to the repeated induction of Technic, Academy of Applied Osteopathy passive, or dynamic motion testing on 1954, p. 15, 29. 15.Kappler RE. Cervical spine. In: Ward RC, a single vertebra by multiple exam- ed. Foundations for Osteopathic Medi- iners (including the possible effects 2. Lovett RW: Lateral Curvature of the Spine cine. Baltimore, MD. Williams and of ambulation) it is not unreasonable and Round Shoulders, Philadelphia, PA: Wilkins. 1997. p. 545. P. Blakiston’s Son & Co. 1907, p. 35. to expect a change from the first di- 16.Johnston WI, Friedman HD. Functional agnosis or original motion preference 3. Halladay HV, Walmsley AG, Ed. Applied to the final diagnosis. In sum, motion Methods. A Manual for Palpatory Skill Anatomy of the Spine, Kirksville, MO: J.F. Development in Osteopathic Examination at the third cervical vertebrae may Janisch 1920, p. 25. and Manipulation of Motor Function. In- demonstrate both ipsilateral (null hy- dianapolis, IN: American Academy of pothesis) and contralateral (central 4. Williams PL, Ed. Gray’s Anatomy. Osteopathy. 1994. p. 36. hypothesis) motion in a predictable Edinburgh, UK: Churchill Livingstone 1995, p. 535, 812. manner (with a slight preponderance 17.Kuchera WA. Glossary of osteopathic ter- minology. In: Ward RC, ed. Foundations for uncoupling or motion in the op- 5. Wilson PT: Principles and techniques of for Osteopathic Medicine. Baltimore, MD. posite directions for rotation and individual lesion diagnosis. Academy of Williams and Wilkins. 1997. p. 1136-1140. sidebending) in all planes of motion. Applied Osteopathy 1955 Yearbook , p.194. Further, passive motion testing may 18.Gibbons P. and Tehan P. Muscle energy alter the original diagnosis or motion 6. Kuchera WA, Kuchera ML. Osteopathic concepts and coupled motion of the spine. Principles in Practice. Revised 2nd ed. Co- Manual Therapy. 1998. 3(2): 95-101. preference. lumbus, OH: Greyden Press 1993, p. 189. The practitioner of osteopathic di- 19.Nansel DD, Peneff AL, Jansen RD, agnosis may consider the axiom, 7. Kimberly PE: Outline of Osteopathic Ma- Cooperstein R. Interexaminer concor- which is attributed to Fred Mitchell, nipulative Procedures, KCOM 1980, p. 23. dance in detecting joint-play asymmetries DO, FAAO: “Treat what you in the cervical spines of otherwise asymp- find….not what you looking for!”33 8. DiGiovanna EL, Schiowitz SS. An Osteo- tomatic subjects. Journal of Manipulative and Physiological Therapies. 1989. 12(6): The findings of variability in motion pathic Approach to Diagnosis and Treat- ment. 2nd ed. Philadelphia, PA: Lippincott- 428-433. and diagnosis in the cervical spine Raven Publishers 1997, p. 103. should be included in the education of our osteopathic students. 9. Mitchell FL, Moran PS, Pruzzo NA. An ➻ Evaluation and Treatment Manual of

Fall 2002 The AAO Journal/29 20.Siegel S, Castellan NJ. Nonparametric 26.O’Haire C, Gibbons P. Inter-examiner and tions in the cervical spine. Journal of Ma- Statistics for the Behavioral Sciences, 2nd intra-examiner agreement for assessing nipulative and Physiological Therapeu- ed. New York, NY. McGraw-Hill, Inc. sacroiliac anatomical landmarks using pal- tics. March 1985. 8(1):9-16. 1988. p. 284-291, 310-311. pation and observation: pilot study. Manual Therapy. 2000. 5(1):13-20. 32.White AA, Panjabi MM. Clinical Biome- 21.Landis, JR, Koch, GG. The measurement chanics. Philadelphia, PA. J.B. Lippincott of observer agreement for categorical data. 27.Kuchera WA, Kuchera ML. Osteopathic Company. 1990. p. 99-100. Biometrics. 1977. 33:159-174. Principles in Practice, 2nd ed. Columbus, OH: Greyden Press. 1992. p. 282. 33.Owens, C. An Endocrine Interpretation of 22.Pansky, B. Review of Gross Anatomy. 5th Chapman’s Reflexes, 2nd ed. Newark, OH. ed. New York, NY. Macmillian Publish- 28.Greenman, PE. Principles of Manual American Academy of Osteopathy. 1963. ing Company. 1984. p. 198. Medicine. Baltimore, MD. Williams and Foreward. ❒ Wilkins. 1989. p. 62. 23.Basmajian JV, De Luca CJ. Muscles Alive, Address Correspondence to: 5th ed. Baltimore, MD. Williams and 29.Becker RE. Life in Motion. Portland, OR. John D. Capobianco, DO Wilkins. 1985. p. 361. Rudra Press. 1997. p. 56-57. 162-163. New York College of Osteopathic Medicine New York Institute of Technology 24.Beckwith, CG. Cervical mechanics. 30.Beal MC. Motion sense. JAOA. 1953. P.O. Box 8000 JAOA. 1944. 43(9):102-106. 53(3):151-153. Old Westbury, N.Y.11568-8000 Phone: 1-516-676-5005 E-mail: [email protected] 25.Penning L, Wilmink JT. Rotation of the 31.Deboer KF, Harmon R, Tuttle CD, Wallace cervical spine: A CT study in normal sub- H. Reliability study of somatic dysfunc- jects. Spine. 1987. 12(8):732-738.

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30/The AAO Journal Fall 2002 Digging On: Some thoughts on the integration of Russellian Cosmology and Osteopathy Paula D. Scariati, DO, MPH

Lao and Walter Russell, by many made Dr. Fulford legendary. As such, tantly, meditating upon these writings accounts, were two visionaries in the I paid close attention to him hoping has given me insights which have fields of science and philosophy. De- to garner information that would help proven to be fruitful additions to my voted to a life of service and educa- me better understand the nature of his osteopathic practice. My purpose in tion, they wrote and lectured exten- treatments. writing this article is to share some sively on subjects aimed at assisting During several of his public speak- of the concepts put forth by the man in unfolding his higher Self. ing engagements, Dr. Fulford refer- Russells and explain their influence Their style was to pragmatically as- enced a handful of people who had on my approach to osteopathy. It is sert postulates on a scientific founda- influenced his work as an osteopath. my hope that this might inspire oth- tion and ask their students to observe He spoke of an IBM scientist named ers to share their experiences with the these truths in nature and during inward Marcel Vogel2 and his work with a Russell writings and yet others to contemplation to Know the basis of specific type of crystal; he recom- embark on a study of this work to Universal Law, Natural Science and mended the writings of several people bring forth more truths as they en- Living Philosophy.1 including a Yale physicist named deavor to “Dig On”. In 1988, as an osteopathic medi- Harold S. Burr 3; Dr. Richard cal student and fellow immersed in Gerber4,5 ; Dr. Robert O. Becker6; and Background 7 the philosophy of Andrew Taylor Walter Russell . Eager to know what First published in 1951, the Still, the Russell writings held very Dr. Fulford knew, I bought a Vogel- Russell’s home study course is di- little interest for me. Yet they came Cut™ Crystal and thoughtfully read vided into 12 units with a total of 48 to my attention on several separate Dr. Gerber’s book. I forced my way lessons and is 933 pages in length.1 occasions during lectures given by through Dr. Becker’s book and felt While tempting to embark upon it as Robert Fulford, DO. Known as a helplessly lost in Dr. Burr’s writings. one might a good novel, it demands humble man of few words, Dr. It was several years before I contacted a slow, contemplative approach. Fulford was held in the highest regard the University of Science and Phi- There is no surprise ending; no hero- by many osteopaths for the powerful losophy to order a copy of the ine; no punch line. Profound truths nature of his treatments. This became Russell’s home study course. I re- are interlaced through the pages which plainly evident to me when an osteo- called Dr. Fulford saying how he had stimulate you to expand your Mind and pathic fellow in my college was hurt gone through that course five times. contemplate your life and your work during a cranial course. It was thought This inspired me, yet I was certain in a new way. Let us touch upon some that a poorly performed intraoral the content of the course would be of the concepts presented by the technique had lesioned the sellae tur- over my head. Russells (quoted in bold type on next cica causing a disruption in the nor- It has been several years since my page) and discuss their potential impact mal functioning of his pituitary. He initial purchase and I am currently on osteopathic thinking. suffered with multiple imbalances as making my way through the Russell As we embark upon this discourse he sought corrective treatments from course for the third time. In short, I it is important to note that the words many well-respected osteopaths. It have found it to be the most provoca- God, Jesus, and Christ will be used. was at the hands of Dr. Fulford that tive writings I have ever had the plea- These words invokes a wide variety he was restored to a balanced func- sure of reading. They are plain and of emotional responses commensu- tioning state. The results of his work understandable, but more impor- ➻

Fall 2002 The AAO Journal/31 rate with individual belief systems. skills. In addition, there are types of Fulford recommended that physicians Here, the word God denotes the in- guided imagery work10 aimed at hon- focus more on finding the cause of telligence that permeates all things; ing skills to explore the mind field from the problem they were seeking to Jesus refers to the master who had a a different vantage point. treat. Perhaps, Dr. Fulford was speak- ministry among men over 2000 years The Russells advocate meditation ing of cause in the way that we have ago; and Christ denotes a state of con- as the preferred method to Knowing explored here. Furthermore, I believe sciousness which indicates the high- God. They carefully define the pro- that Dr. Still was referencing this est alignment of a person with self. cess in the home study course to make same idea when he admonished his No particular religious doctrine is it approachable by all. While not a students to find and treat health, not suggested or endorsed. difficult process, meditation may be disease. Health is the cause, disease, a difficult practice to initiate as most the effect. Cosmology minds are deconditioned and respond “Just as science conquered small- and Osteopathy poorly to the discipline of silencing pox and other dread scourges through external sensory experience. Many knowledge of CAUSE where magic “Mind is spiritual and constitutes novice meditators report their minds and witchcraft failed, so must you the invisible universe of CAUSE. running wild with thoughts about ev- acquire God-powers through scien- Matter is physical and constitutes the erything from the shopping list to the tific knowledge of CAUSE where oft visible universe of EFFECT.” wart they saw on Great Aunt Sally’s repeated affirmations, emotional “CAUSE is the desire-energy within toe when they were two years old. worship and doctrine creeds and be- mind to manifest Mind-Idea by ex- Those who practice the art of Zen liefs have failed to get you farther tending light-waves of thought from have a term for this — “monkey than a peephole into the light.” centering fulcrum points. EFFECT is mind”. Persistence is important, manifested Mind-Idea expressed by * * * * * though, as practice truly makes the motion of extended light-waves of master. “The UNDIVIDED is eternally bal- Mind-thinking. God — the creator — From an osteopathic point-of - anced for it is ONE.” “The DIVIDED is CAUSE. The created universe is view, a meditation practice may pro- ONE is eternally unbalanced for it be- EFFECT.” vide other benefits, too. First, it can comes TWO.” “The UNITED TWO facilitate a heightening of ones per- can become a balanced ONE only if Osteopathic physicians are con- ceptive skills. While most osteopathic each mate of the TWO is equal.” stantly engaged in the art of sleuth- physicians are quite adept at palpa- ing. We are forever pressing ourselves tory diagnosis, meditation promotes The above quotes refer to the con- to know why something has occurred the development of the mind’s eye in cept of balance rhythmic interchange. so we may elucidate and correct its a way that enhances perception be- The Russells coin this phrase to de- underlying cause. This desire to know yond the five senses. Second, there scribe how ALL interactions in, na- causality gives us reason to pause and is often an improved ability to focus, ture must occur: equal and opposite reflect the above statements carefully. hold and direct intent. We will talk of so as to merge and cancel each other Cause is Mind; Cause is God; Cause this more below, but suffice it to say out. Let us define this concept so we is the desire to manifest Idea. If these that such skills decrease treatment can explore its importance to the os- statements are true, where does one time and enhance treatment specific- teopathic concept. go to elucidate Cause? How does one ity. Finally, it becomes easier to in- God is the undivided, eternally explore the Mind field? How does terface with the Intelligence of the balanced One. Through His thinking one Know God? The waters get deep person you are treating. This guides he divides himself into sex-paired, quickly. the treatment process in the most pro- wave-forms that forever seek balance, In her book, Infinite Mind: Science ductive manner possible. but are unable to obtain it for now of Vibrations of Consciousness,8 Several years ago, Dr. Andrew they are two. Thus, the divided two Valerie Hunt discusses her ground- Weil, popular author and Director of seeks to come together and remerge breaking research aimed specifically the Integrative Medicine Fellowship to become a balanced One. A result- at exploring the Mind Field. She gives at the University of Arizona Medical ing balanced One can only occur if a number of examples where inquiry Center in Tucson, did a video docu- the two halves coming together are into mind field issues results in pro- mentary of Dr. Fulford. Toward the equally balanced. If they are unbal- found healing. In the companion work- end of the piece, he asked Dr. Fulford anced, the unification process results book, “Mind Mastery Meditations”,9 for his advise to practicing physicians in a residual imbalance which, ac- she offers us tools for developing these today. After a thoughtful pause, Dr. cording to the Russells, is the under- 32/The AAO Journal Fall 2002 lying cause of the woes of mankind. terchange is about restoring the equi- have pondered the miracles that Jesus This process is well illustrated with librium that must exist between cause reportedly performed. If these ac- Figure 1, which depicts the joining of and effect. counts are correct, Jesus would be the perfectly balanced elements in nature. “It is the RESIDUE OF UNBAL- greatest healer ever documented by Each of the three examples represents ANCE in all mismatings which is the history. Yet, little to nothing is known an equally divided and equally united basis of every trouble in the world, about how he did this. The Bible tells pair of elements which completes a its ills, its frustrations, its wars, sick- of his touching a person or a person wave cycle of God’s creative thinking. ness, enmities, bankruptcies and all touching the hem of his garment and Lithium and fluorine, which are other effects we call BAD and do not being healed. The Russell writings polar opposite extensions from the like to have happen to us.” give us some insights into this phe- undivided One, come together to nomenon. form the perfectly balanced lithium “God’s Soul is the Universal Soul Jesus, was a master who attained fluoride. The same is true of sodium — and you are that Soul.” Christ-consciousness. According to chloride, and potassium bromide. “God’s Mind is the Universal Mind the Russells, this is the highest attain- Now, let us consider these pairs from – and you are that Mind.” ment of God-Consciousness possible; the point of view of mismatings. If “God’s thinking is Universal thinking Jesus was in perfect balance with his sodium mates with bromine, they will —and His thinking is your thinking.” God-nature. When he said “I and my get along well enough as long as chlo- “God’s body is the Universal body father are one”11, he was not being rine stays out of the way. If chlorine — and you are that body.” cryptic. It was by this union in Christ- is introduced, though, there will be a consciousness that Jesus was able to divorce between the sodium and the Well, what does this have to do extend balance (healing) to others. bromine more surely than with a with osteopathy and healing? Many One other statement that Jesus made, mismated man and woman. If one historians, scientists, and theologians deserves consideration: “Most assur- tries to combine elements that are fur- ther apart in their electrical potential, frequencies and pressures, a more se- vere disharmony would result. This is the basis of explosives in chemistry and explosives in human emotions. Another simple example which exemplifies this concept is holding your breath. If you hold your breath long enough, you will, at some point be forced to exhale with a good deal of force to balance out your breath cycle. Your heartbeat operates under the same principle although it is not as easily amenable to your conscious will as your breath. Both your heartbeat and your breathing function in perfect bal- anced rhythmic interchange. Osteopaths currently utilize many techniques that honor this concept including balanced ligamentous ten- sion, the induction of a stillpoint, or balancing of the reciprocal tension membrane from Sutherland’s Ful- crum. It is a powerful concept to em- ploy in rebalancing the body and can be applied more broadly to work with the chakras, glands, visceral organs, nervous system and the lymphatics. Figure 1: Nature knows no other process than that of At its essence, balanced rhythmic in- SIX DIVISION AND SEX UNITY Fall 2002 The AAO Journal/33 edly I say to you, he who believes in his knee and how his knee became very pansive, centrifugal, disintegrating, me, the works that I do he will do also; hot. The conclusion of the story was discharging, heat-dissipating and is and greater works than these he will that Dr. Harakal did not require a knee the process used to break down mat- do...”12. Jesus made it clear that he was replacement. I was fascinated that an ter. These processes are depicted in showing people a path that they, too, osteopathic treatment could produce Figure 2. could walk. If you currently have a such profound results, yet frustrated If we apply these concepts at a cel- meditation practice or embark upon that no one had taken it a step further lular level, we would be talking of one, take some time to contemplate this to hypothesize what had happened. cellular differentiation and dediffer- thought further. You will be challenged Over the years, as I would treat patients, entiation. Could this be a mechanism to expand your thought process until some would note how warm my hands by which Osteopathic treatments you know that you are one with All- were while others would feel chilled align with human physiology? That-Is. This is a powerful place from after a treatment. Still, I did not under- During a recent course I attended, which to treat as you “dig on” in the stand. It was in reading the above pas- Dr. Viola Frymann recounted a story fashion of osteopathy’s founding father, sages that I first had a glimpse into which occurred while she was in Rus- Andrew Taylor Still. what might be happening. sia demonstrating Osteopathic tech- As the Russells explain, there are niques. She was asked to treat a child “God alone can CREATE. Man two types of thinking, concentrative with a conduct disturbance. As part cannot create until he becomes aware and decentrative. Concentrative of her exam, she noted the child had of the God-Mind, which centers ev- thinking is compressive, centripetal, an osteochondrosis of the elbow, but ery cell of him, and every tube of positive, charging, heat-generating felt that this was the realm of the Or- growing tree, and all other things in and it is the process used to manifest thopedic surgeon and did not give it her all this universe, which God alone matter. Decentrative thinking is ex- attention. She proceeded to treat the creates.” * * * * *

“Concentric thinking produces formed, dense, visible bodies from invisible space by compressing large volumes of low potential into small vol- umes of high potential. Concentrative thinking is compressive, It focuses to a point. It is positive. It charges bodies with the power to move. It builds im- aged form bodies in the image of the Creator’s imagining.” “Decentrative thinking disinte- grates dense bodies and returns them to invisible space. It dissolves, voids- discharges and depolarizes charged bodies and deprives them of their power to move.”

As a medical student, I attended a cranial course where John Harakal, DO spoke about a treatment given to him by Rollin Becker, DO. Dr. Harakal noted that he had severe de- generative problems in his knee and after exhausting all other options, was scheduled to have a knee replacement. He relayed this story to Dr. Becker who offered to treat him. Dr. Harakal went Figure 2: the inbreathing-outbreathing life-death cycle which on to tell how Dr. Becker took hold of motivates the universe. 34/The AAO Journal Fall 2002 child and was pleased with the result- taining explanation of Dr. Frymann’s ers recalled how their children had ing improvement in his behavior. Some results in the above case scenario. exhibited anger and violence from a time later, she received a call from the young age with no notable history of Russian delegate. They wished to come “The desire for division is accom- birth or other trauma. All had been to San Diego for a visit to better under- plished by dividing his KNOWING medicated for many years to regulate stand Osteopathy. They were with her into THINKING. Thinking is wave- their unbalanced behavior. for several days when she finally asked recorded. Waves are the cause of In pondering these kids, I was what inspired them to come so far to motion.” struck by the fact that they were all learn more about Osteopathic Medi- “This is a universe of rest from males. The occupational therapist that cine. They asked if Dr. Frymann had which motion springs, in repetitive I work with confirmed that her clinic remembered the young boy she had cycles, to manifest that which we call was full of young males with ADD/ treated. Yes, she did. An x-ray per- life, and is forever seeking rest in that ADHD. She couldn’t recall seeing a formed several months after Dr. which we call death, There is no death female child with this diagnosis. Fas- Frymann’s treatment revealed a bone in all the universe. In these lessons we cinated, I started probing further in in the boy’s forearm where only a fi- will make it clear that there are two treatment sessions about the cause of brous cord had been previously. They directions for life, and that so-called the problem. On several, separate were interested in knowing what Dr. death is but the direction of return to occasions issues of war and violence Frymann had done during her treat- rest for a repetition of life”. came to my attention. Could these ment to promote this. Dr. Frymann, kids be carrying over lifehood issues too, was interested in knowing what The Russells thoughts on death are related to the wars of the last few gen- she had done. challenging because they oppose the erations? In light of the fact that ADD/ Robert 0. Becker studied the phe- concept of death embraced by most ADHD was an unheard of diagnosis nomena of dedifferentiation in sala- of Western society. In some of the one generation ago, and the fact that manders”. He was struck by their other quotes taken from the Russells the majority of ADD/ADHD diag- ability to regenerate limbs after am- writings we have emphasized how noses are made in males, and the fact putation in contrast to a close rela- you are one with God; we have talked that the violence and anger exhibited tive, the frog. He found that the sala- about how you are Mind centering by many of these children doesn’t mander was able to dedifferentiate and controlling physical form through seem commensurate with the experi- cells at the site of the amputation to a balanced rhythmic interchange. If ences that they have had in this life- more primordial type of cell that these concepts hold within them time, the hypothesis seems plausible. could then be instructed by the body’s Truth, how can there be death? Regression studies or mind field intelligence to reproduce the neces- In his landmark book “Many Lives, work in the fashion of a Valerie Hunt sary limb. He also found that by the Many Masters”,14 Brian Weiss speaks with ADD/ADHD children may help tenth day, the primordial cells had about regressing a patient as part of better explore this concept to the sat- organized themselves to a point of his psychiatric treatment only to find isfaction of the science-oriented knowing what they were creating. So, him describing, in vivid detail, the medical mind. In the meantime, this if a leg was amputated and the cells accounts of a life that predated his hypothesis has helped me approach that formed were placed at the site of current one. Valerie Hunt, in her book my children with a new perspective a taiI amputation before the tenth day, “Infinite Mind”8 also speaks of the as to the depth and possible underly- a taiI would grow. If they were placed eternal nature of the Mind and how ing cause of the problem. at the site of a taiI amputation after one can carry over lifehood issues the tenth day, a limb would grow. into each life until they are resolved. “There is no death, however. A While no such mechanism is know This caught my attention from an man is INCREASINGLY living un- to exist in humans, the plausibility of osteopathic point of view as a result til his maturity. After that he is DE- such a process is not inconceivable. of treating a number of children di- CREASINGLY living until he finds We know, for example, that many agnosed with Attention Deficit Dis- rest in the earth from which he will cancers have a more primitive cellu- order (ADD) or Attention Deficit be reborn. Rest is not death, Rest is lar structure than the organ from Hyperactivity Disorder (ADHD). the source of life. It is the seed from which they derive, This means that During my initial assessment of these which life springs, All “dying” bod- the human is capable of producing patients I was struck by the density ies which seek rest do so to become such cells when called upon. At the and character of the restrictions I per- revitalized as life. Vitality and life are very least, it would provide an enter- ceived in their bodies. Several moth- one.” ➻

Fall 2002 The AAO Journal/35 equator when your equator is out of Conclusion “..An equator, as applied to you, balance with the universal equilib- Whether you agree or disagree with divides your body into two equal and rium, and cease to vibrate when it is the concepts explored here within is in- opposite halves and each opposite in balance with it.” consequential. If this paper has caused half symmetrically balances the you to consider one new concept that other half — but in reverse. “ . . a teacher can give you a tech- you hadn’t considered before, it has “. . . equators are the dividing nique for expressive your idea, but done its job. If this paper verbalized planes of the universal equilibrium. he cannot become your Soul from some issue that you’ve struggled with They, therefore, represent the undi- which your concept extends.” but haven’t been able to solve, it has vided, the unchanging spiritual light done its job. If this paper has pushed from which the physical bodies of all This final thought embraces the you to consider new areas in your per- things are extended.” challenge that faces our colleges today sonal growth or the treatment of your in training Osteopathic medical stu- patients, it has done its job. If this pa- With an understanding of embryo- dents. When I was an Osteopathic per has opened up a new arena of pos- logic development in mind, one reads medical student and Fellow, I spent in- sibility for the budding Osteopath, it has the above statement with a sense of numerable hours studying the location more than done its job. owe. Early development occurs around of tender points, the correct positions It was purposeful that specific tech- a structure that we call the primitive for myofascial release, the right hand niques were not mentioned in the con- streak. In truth, though, the primitive position for a CV4, etc. In short, I was text of this paper, for techniques change streak is not a structure but rather a void, a well-trained automaton who could as the conscious depth of the soul a groove, a space, or an axis into which mimic a variety of techniques as re- grows. The treatment I can offer today things develop. It goes on to differenti- quired. I knew the moves and I read is unlike that which I could offer one ate into the mesoderm, ectoderm and the philosophy but my thinking re- year ago and will not likely resemble endoderm. In the next stage of devel- mained linear. Every bug had its drug; the treatment I give one year from to- opment, another void called the primi- every lesion had its correction. day. tive pit develops. From this space, ex- Osteopathy became an art the day The words I leave you with are the tends a midline axis which we name I conceded that the intelligence of the words of Norman Vaughn. For me, they the notochord that runs from the tip of body was far more knowledgeable are a constant reminder of the work at the coccyx to the stalk of the pituitary about how to heal the body than I hand amidst the craziness of a medical through the center of each vertebral could ever hope to be as a result of profession being crushed by a soulless body. It is from this notochord that we my book knowledge. I began to look bureaucracy: ‘The only death you die see outpouchings differentiate into the at the whole person and listened to is the death you die every day by not various systems that compose a human the body’s wisdom which guided my living. Dream big and dare to fail.” embryo and fetus. thinking hands. I searched for the Osteopathically, we embrace embry- health and spent less time dissecting Post script: ology with great zeal because we find the disease. Soon, each touch, like a treating at this level to be powerful. But, brush stroke in a painting, became Osteopathy’s promise to humanity why would the treatment of a develop- mindful and added purpose to the pic- I would be remiss if not to men- mental remnant or the memory of a ture. Today, I still often feel like I tion the state of the Osteopathic pro- developmental process be so powerful? paint by the numbers, but I aspire one fession at the time of this writing. Perhaps it is because it draws us back day to be a Michael Angelo. Circumstances invoke a state of be- to that equator that served as the initial wilderment because some have sug- an axis for our physical differentiation “Vibrating wave bodies cannot gested that up to 80% of licensed and continues to be the fulcrum around KNOW anything, but can sense ev- DO’s haven’t a clue as to the premise which we attempt to balance our entire erything. Senses are but motion. of their profession. This ignorance manifest life. If this is so, balancing Sensations are the repeated vibra- seems to have its roots in our colleges from the midline becomes an invalu- tions of motion. Sensation is in no where the curriculum ensures com- able and powerful tool in the Osteo- way related to intelligence, knowl- parability with our allopathic col- pathic armamentarium. edge or consciousness. MIND is the leagues with an added competency in “Everything you are in thought Knower and the Thinker. Thought- different manipulative techniques. Our extends two ways from your Con- wave bodies are the workers.” governing bodies struggle to give us an sciousness which is located upon your identity that we can call uniquely our equator. Your senses vibrate from that own, for within our home we have lost 36/The AAO Journal Fall 2002 our unique identity. Masters within our 2. Vogel M. Crystal Therapeutics. Out of 10.Rossman ML. Healing Yourself: A Step- profession write of its death, while al- print. by-Step Program for Better Health Through Imagery. Pocket Books, New ternative practitioners adopt Osteo- 3. Burr HS. Blueprint for Immortality. 4th York, New York 1987. pathic philosophies and present them Edition, Beekman Publishers, 1991. in sleek, new, complimentary or inte- 11.John 10:30 Holy Bible: The New King grative packages. 4. Gerber R. Vibrational Medicine: New James Edition. Thomas Nelson Publish- The time is at hand. In 1874, a Choices for Healing Ourselves. Bear & ers, Inc., Nashville,Tennessee, 1982. single man embraced a vision with Company, Santa Fe, New Mexico, 1998. such determination that he changed 12.John 14:12 Holy Bible: The New King James Edition. Thomas Nelson Publish- forever the face of medicine. Does 5. Gerber R. Vibrational Medicine for the 21st Century: The Complete Guide to En- ers, Inc., Nashville,Tennessee, 1982. such fervor for this philosophy still ergy Healing and Spiritual Transforma- exit or is it time for it to be relegated tion. Harper Collins Publishers, New York, 13.Becker RO. Cross Currents: The Perils of to a period of rest in wait of a rebirth New York,2000. Electropollution. The Promise of some time in the future? For Osteopa- Electromedicine. Penguin Putnam, Inc., New York, New York, 1990. thy, as a practical and philosophically 6. Becker RO, Selden G. The Body Electric: Electromagentism and the Foundation of different branch of medicine, may Life. William Morrow and Company, Inc., 14.Weiss BL. Many Lives, Many Masters. die, but its precepts cannot. They are 1985. Simon & Schuster, Inc., New York, New built on the very foundation of Natu- York, 1988. ❒ ral Law and are immutable. Yes, in- 7. Russell W. The Man Who Tapped the Secrets deed, the time is at hand of the Universe. The University of Science and Philosophy, Blacksburg, Virginia. Address Correspondence to: 1. Russell L, Russell W. Universal Law. Paula D. Scariati, DO, MPH Natural Science and Living Philosophy: 8. Hunt VV. Infinite Mind: Science of Vibra- 515 West 59th Street A Home Study Course of the Science of tions of Consciousness. Malibu Publish- New York, NY 10019-1047 Man. 1951,1957, 1962 and 1972. Univer- ing Company, Malibu, California, 2000. Phone: 315/682-5911 sity of Science and Philosophy, Email: [email protected] Blacksburg, Virginia. 9. Hunt VV. Mind Mastery Meditations: A Work- book for th ‘Infinite Mind’. Malibu Publishing Company, Malibu, California, 1997.

PHYSICIAN – MANIPULATIVE MEDICINE

A full-time faculty position is immediately available for a board certified/board eligible physician at the University of North Texas Health Science Center/Texas College of Osteopathic Medicine in Fort Worth. Teaching experience in Osteopathic Manipulative Medicine is required. Clinical and research opportunities are available. Competitive salary and excellent benefits package.

Letters of interest and curriculum vitae should be sent to: Scott T. Stoll, DO, PhD Chairman / Associate Professor c/o Krista Thraser Department of Osteopathic Manipulative Medicine University of North Texas Health Science Center 3500 Camp Bowie Boulevard Fort Worth, Texas 76107-2699 Fax: 817/735-2270

Fall 2002 The AAO Journal/37 Post-traumatic Headache of Cervical Origin MonaLisa M. Mitra, OMS-IV and Scott T. Stoll, DO, PhD

Introduction in the back of his head. He emphasized that the pain is Headaches that occur as an immediate consequence of always left-sided even though the location may shift from head trauma are often of short duration. The term post- his upper extremities to his lower extremities and, occa- traumatic headache, however, is synonymous with the term sionally, to his abdomen. The patient also stated that the chronic posttraumatic headache and is applied to head- left side of his body was more sensitive to cold and there aches that persist for months or years after the trauma. was a generalized sensory deficit on this side. There have This type of headache usually occurs without associated been about six or seven episodes thus far. He has also skull fractures. Paradoxically, the incidence of chronic experienced occasional stuttering during these episodes. posttraumatic headache is inversely proportional to the According to the patient, a recent MRI suggested an “ab- intensity of head trauma.1 According to the International normality” of the cervical spine. Headache Society (IHS), the criteria for acute post-trau- Past Medical and Surgical History: The patient’s medi- matic headache require that the headache begin within two cal history included hypertension, arthritis, gastroesoph- weeks and disappear within two months of the trauma. ageal reflux disease, and depression. Upon inquiry, it was The diagnostic criteria for chronic posttraumatic headache found that the patient had a long history of multiple trau- on the other hand require that the headache continue for matic injuries since childhood. His most recent head in- more than eight weeks. There are two subcategories within jury occurred in December of 2001 when he fell through these conditions. The first indicates that the trauma should the ceiling from his attic. Prior to this, he suffered three be significant and is manifested by loss of consciousness broken ribs in 1992. In 1983, he was hit by an overhead or post-traumatic amnesia of more than ten minutes or door and was almost rendered unconscious. He recovered abnormal clinical, neurologic, or laboratory examinations. from this incident in one week. He has had multiple mo- The second subcategory indicates that mild or minor head tor vehicle accidents where he hurt his neck, lower back, trauma can evoke headaches even in the absence of signs and pelvis. In terms of childhood injuries, the patient re- and symptoms of brain dysfunction. called skating accidents, falls down the stairs, and falling from the bleachers. According to the patient, he did not Case Presentation suffer any long-term effects from these accidents. The patient had a significant surgical history that in- Chief Complaint: A 53-year-old caucasian male pre- cluded removal of a malignant melanoma in 2001; left sented with generalized pain over the left side of his body. rotator cuff surgery in 2000, right rotator cuff surgery in The pain was most severe in his head and neck (7 on a 1996, and a total cholectomy with ileostomy secondary to scale of 0-10, with 0 indicating no pain and 10 being ex- the diagnosis of polyps on colonoscopy in 1972. He also treme pain). The symptoms, this time, started as tremors had surgery on his right knee, but was unsure about the on the morning of the clinic visit. The patient also com- time frame. plained of moderate photophobia and claimed that he was Family History: The patient’s family history was sig- finding it difficult to keep his left eyelid open. Any form nificant for familial polyposis on his maternal side. His of movement exacerbated the pain, which was alleviated mother had colon cancer and is deceased. His father passed by Flexeril. away from complications of abdominal cancer. History of Present Illness: The patient claimed an eight- Social History: The patient is an engineer by profession. month history of left-sided pain, numbness and tingling He does not use tobacco, alcohol, or other illicit drugs. that started with a severe left-sided headache originating

38/The AAO Journal Fall 2002 Allergies: The patient did not have any known drug Results: At the end of the first 60-minute visit, the pa- allergies. He suffers from seasonal allergies in the fall and tient claimed to be feeling markedly better. His pain level spring. was decreased to 3/10 from 7/10. In a follow-up telephone Medications: Following is the list of medications used conversation one week later, the patient’s wife said that by the patient at present: Clonazepam 0.5mg bid, Nexium he was very satisfied with the results of the first treat- 40mg qd, Zocor 20mg qd, Paxil 20mg qd, Verelan 300mg ment. As predicted, he experienced some soreness for two qd, Ecotrin 325mg qd, Hydrocodlapap 750mg PRN, days following the treatment, but had started to feel mark- Ibuprofen 800mg PRN, Flexeril 10mg PRN, Naproxen edly well after that. Both the pain and numbness were 500mg PRN. decreased. Physical Examination: A complete neurologic and os- teopathic musculoskeletal examination was performed. Discussion The neurologic examination showed 2+ deep tendon re- Headaches are among the most common reasons for flexes bilaterally, a positive Tinnel’s test in the left wrist, patient visits in medical practice. In medical writing, head- and negative Phalen’s test bilaterally. There was no atro- ache is considered to be the result of some form of nox- phy in the muscles of the upper and lower extremities and ious stimulation to the sensory nerves, such as pressure or muscle strength was intact and equal bilaterally. Elec- traction on the pain-sensitive structures of the head, often tromyogram results showed no evidence of a peripheral with a psychogenic basis. neuropathy. However, there was evidence of a moderate The annual incidence of head trauma in the United to severe focal axonal/demyelinating sensorimotor neur- States is approximately 200 per 100,000. Statistics with opathy affecting the median nerve across both wrists, con- regard to post-traumatic headache after injury to the head sistent with bilateral carpal tunnel syndrome. or neck (whiplash) range from 30% to 90%. These widely The osteopathic musculoskeletal examination revealed disparate numbers are due, in part, to the differing defini- a mildly shuffling gait with the left shoulder slightly higher tions of post-traumatic headache. If late-onset post-trau- than the right. There was a slight forward head carriage. matic headache (beginning > 2 weeks after injury) is in- The iliac crests were even bilaterally. Palpatory exam re- cluded, the incidence would be higher. Approximately one vealed several areas of somatic dysfunction. The cervical third of patients report persistent headaches 6 months af- muscles were ropy. The OA joint was sidebent left, ro- ter head injury, and about one quarter continue to have tated right. The C2 through C6 vertebrae were sidebent headaches after 4 years.2 Chronic post-traumatic headache right, rotated right. In the thoracic region, T2 through T4 usually does not occur in isolation but is the most com- were sidebent left, rotated right. The L5-SI joint was back- mon symptom of what is known as post-concussion/post- ward bent. Range of motion was decreased bilaterally in traumatic syndrome. This syndrome is manifested by a the upper extremities, but was normal in the lower ex- group of symptoms that can be classified as somatic (es- tremities. Several tender points were palpated as follows: pecially neurologic), psychologic, and cognitive. After left sacroiliac joint, left piriformis muscle, the L5-SI joint headache, dizziness is the most common symptom of this and the left shoulder in the acromioclavicular joint and syndrome. Other somatic symptoms include photophobia, the supraspinatus muscle. phonophobia, tinnitus, blurring of vision, and easy fatigue. Assessment: A working diagnosis of cervicalgia was Depression and anxiety are the most common psychologi- made. The left shoulder showed a sprain/strain pattern, cal symptoms observed. They may be irritable, exhibit particularly in the acromioclavicular joint and the su- angry outbursts, and have frequent mood swings. Cogni- praspinatus muscle. The presence of various somatic dys- tive difficulties might include forgetfulness and difficulty functions in the cervical, thoracic, lumbar, sacral, pelvic in learning, although poor concentration and poor atten- areas were also diagnosed. tion span as a consequence of the other symptoms might Treatment: The primary treatment modalities used were contribute to this .3 myofascial release, strain-counterstrain treatment of Headaches of cervical origin: Cervicogenic headache tenderpoints and balanced ligamentous tension. Diapragmatic may be defined as pain perceived as arising in the head, release was carried out to facilitate the patient’s breathing. but whose actual source is in the cervical spine. The role Occipito-atlantal decompression was performed to release of the cervical spine in the etiology of headache is some- the strain in this joint. All techniques used were indirect due what controversial. Head pain may be the initial complaint to the severity of pain being experienced by the patient. In in diseases of the spinal cord. Cervical spondylosis, addition, he was instructed on self-treatment of tenderpoints trauma, rheumatoid arthritis, and cranial vertebral abnor- and daily stretches. He was advised to treat the tenderpoints malities, as well as cervical and foramen magnum tumors three times daily and to stretch twice daily. He was asked to may produce head and neck pain. In 1971, Lewit4 reported return to the clinic in about one week. ➻ Fall 2002 The AAO Journal/39 on a series of 93 adults who had sustained head/neck interprets the pain as arising from the trigeminal field and trauma. Ninety-six percent of these subjects had move- not from the neck. In the case of cervicogenic headache ment restriction in the upper cervical spine. Osteopathic felt in the occiput, convergence occurs between deep cer- manipulation was found to be very successful in treating vical nociceptive axons and axons that innervate the oc- the headache associated with these injuries. In 1980, Ng5 cipital region. explored the association between static vertebral misalign- Pathology of cervicogenic headaches: The etiology for ment as seen on plain film xrays and the incidence of oc- these headaches can be quite varied. There may be trac- cipital headache. Thirty-eight subjects suffering exclu- tion on the components of the circle of Willis and other sively from occipital headache were studied. This group major vessels, especially the middle meningeal arteries. was compared to an age and sex-matched control group. These vessels may be dilated due to fever, histamine re- Lateral inclinations of C1, C2 and C3 were measured us- lease or back pressure. Traction may also be caused by ing a standardized xray marking technique; Lateral cur- alterations in intravascular blood pressure or cerebrospi- vature of the entire cervical spine was also measured. Sta- nal fluid pressure. Displacement of or traction on the tistically significant differences were found between head- venous sinuses can also lead to pain. Fluid stagnation or ache sufferers and controls in the incidence and degree of edema involving any of the cranial nerves might induce lateral tilting at C1 and C3, while a tendency toward a discomfort as well. These conditions might all be addi- similar distortion existed at C2. No differences were found tionally associated with tension in the soft tissues at the in the lateral spinal curve in the two groups. craniocervical junction.7 Accepted or verified causes of Anatomic basis for cervicogenic headaches: In 1992, cervicogenic headache are rheumatoid arthritis and trig- Bogduk6 published a paper in which he discussed an in- ger points in the muscles innervated by CI-C3.8 Other teresting hypothesis correlating insults to the cervical spi- causes are speculative since pathological changes have nal cord with certain headaches. The neurons that consti- not been corroborated. These include irritation of the dura tute the pars caudalis of the spinal nucleus of the trigemi- mater, C2-C3 intervertebral disc injuries and post-trau- nal nerve are continuous with the apical neurons of the matic arthropathy or joint dysfunction affecting the upper dorsal horns of the spinal cord. No intrinsic anatomical cervical synovial joints. The pathological nature of cervi- feature demarcates where the spinal nucleus ends and the cal synovial joint disorders remains unknown but the role gray matter of the spinal cord begins; yet within this con- of these joints in headache is strongly implicated by the tinuous column one can identify a nucleus – the presence of abnormal palpatory and motion findings and trigeminocervical nucleus. This is not a nucleus in the clas- the relief of headache upon anesthetization of the involved sical sense, as it does not possess a distinct cytoarchitec- joint. ture or any other intrinsic morphological feature. Its ros- Differential diagnosis: The differential diagnosis of tral and caudal limits are defined by the common distri- cervicogenic headache should include space-occupying bution of primary afferent terminals of the trigeminal and lesions of the posterior cranial fossa and aneurysms of the cervical nerves. Sensory axons of the trigeminal nerve vertebral artery. These structures are innervated by the carrying nociceptive information enter the spinal tract of same nerves that supply the upper cervical segments. the trigeminal nerve, which runs caudally lateral to the Therefore, the pain they produce is similar to pain from spinal nucleus, but these axons continue into the dorsolat- the cervical spine. These lesions, however, are far more eral tract of the cervical spinal cord as far as the C3 or C4 life-threatening than those that affect the cervical spine. spinal cord segment. The trigeminocervical nucleus can Another cause of chronic post-traumatic headache might be defined as those cells in the upper three cervical seg- be subdural hematoma, especially in the elderly because ments that receive both a trigeminal and a cervical pe- it may cause headache without other symptoms or signs ripheral input. It serves as the essential nociceptive nucleus and may occur after minor or unrecognized head trauma. of the upper neck, head and throat. Whatever the actual innervation of structures in this region, noxious stimuli Treatment form them will be mediated by the trigeminocervical of post-traumatic cervicogenic nucleus. The neuroanatomical basis for cervicogenic head- ache is convergence within this nucleus. In the absence of headache: any other sensory information, second order nociceptive Pharmacologic treatment: The treatment of chronic neurons in the trigeminocervical nucleus that receive both post-traumatic headache is individualized to the type of a trigeminal and a cervical input have no means of deter- headache described by the patient. Tension-type headache mining whether they are activated by trigeminal or by is the most frequent manifestation of this condition, and cervical afferents. In this situation of ambiguity, the brain, prophylactic treatment with tricyclic antidepressants for relying on familiarity with the more accustomed input, their analgesic action is usually recommended. Divalproex, 40/The AAO Journal Fall 2002 gabapentin, and other anticonvulsants are also effective 5. Ng, S.Y. Upper cervical vertebrae and occipital headache. Journal in suppression of chronic pain. Exacerbations may be of Manipulative and Physiological Therapeutics 3: 137-141. 1980. treated with an analgesic but one must guard against the 6. Bogduk, N. The anatomical basis for cervicogenic headache. Jour- excessive use of these agents because of the potential for nal of Manipulative and Physiological Therapeutics 15: 67-70. 1992. rebound phenomena and the perpetuation of chronic daily headache. If the headache has features of migraine rather 7. Magoun Sr, H.I. Trauma: a neglected cause of cephalgia. Journal than tension-type headache, beta adrenergic blockers and of the American Osteopathic Association 74: 400-410. 1975 calcium channel blockers may be added to the regimen. 8. Bogduk, N. Cervical causes of headache and dizziness. In: Grieve, Other antidepressants, such as SSRI’s, MAOI’s as well as G.P., ed. Modem manual therapy of the vertebral column. antiserotonin agents may be used as second- or third- line Edinburgh, England: Churchill-Livingstone: 289-302. 1986. drugs for migraine prevention. Emotional factors that ag- 9. Vernon, H. Spinal manipulation and headaches of cervical origin. gravate the headache as well as depression and anxiety Journal of Manual Medicine 6: 73-79. 1991. ❒ should also be treated. Medication for other associated symptoms, such as nausea or insomnia, improves the patient’s quality of life.1 Address Correspondence to: Osteopathic manipulative treatment: In a comprehen- MonaLisa Mitra, OMS-IV sive review of the literature, accompanied by case pre- UNTHSC / TCOM sentations, Vernon (1991)9 discussed the common osteo- 3500 Camp Bowie Blvd pathic lesions observed, the treatment modalities em- Fort Worth, Texas 76107 ployed, and results obtained. Hypomobility of one or more Email: [email protected] of cervical vertebra(e) facet joints associated with scalene muscle spasm and point tenderness were found to be the most common lesions upon palpation. Treatment options included manipulation directed at the hypomobile joint(s). This can be accomplished either with HVLA or indirect myofascial release. Direct muscle energy may be carried out to relieve the spasm in the scalene muscles, and Jones strain-counterstrain may be performed on the trigger points. Although the exact treatments used were not de- scribed in the paper, the results in all three cases presented, demonstrated the unequivocal effectiveness of osteopathic manipulative treatment. All three cases presented showed marked improvement within one week and complete reso- lution of symptoms shortly thereafter. The patients were discharged within 3 to 6 weeks. Therefore, while the Sutherland mechanism of effect of spinal manipulation in cervicogenic headache is still speculative, the positive results certainly Cranial call for further investigation of osteopathic manipulation as an effective means of providing relief to these patients. Teaching References Foundation 1. Haas, D.C. Chronic post-traumatic headaches classified and com- pared with natural headaches. Cephalgia 16: 486-493. 1996.

2. Rosen:Emergency Medicine: Concepts and Clinical Practice, 4th ed. 1998. Mosby Year Book, Inc. 1/4 page ad 3. Alexander, M.P. Mild traumatic brain injury: Pathophysiology, natu- ral history, and clinical management. Neurology 45: 1253-1260. 1995.

4. Lewit, K. Ligament pain and anteflexion headache. European Neu- rology 5: 365-378. 1971.

Fall 2002 The AAO Journal/41 Book Review Reviewer: Anthony G. Chila, DO, FAAO An Osteopathic Approach to Ear, Nose and Throat Patients: The Contributions of William C. McCarty, DO Editors: Kurt P. Heinking, DO, Bill D. Hampton, DO, pp. 70. H&H Publishing; PO Box 5332; Oak Brook, IL 60522. Copyright 2002

This volume is the first edition OMT in ENT Disorders. A brief acknowledged to be similar to of a recent project from the Chicago overview summarizes Doctor Chapman’s reflexes. The applica- College of Osteopathic Medicine McCarty’s hypothesis that palpable tion of OMT requires knowledge of (CCOM) OMM Department. reflex areas seen in ENT disorders the cranial nerves, blood vessels William C. McCarty, DO respond to OMT, contributing to and lymph glands which supply the received his Doctor of Osteopathy improvement in symptoms and various areas of ENT complaints. degree with the 1949 Class of the supporting the body’s ability to heal Evaluation and Treatment of Chicago College of Osteopathy. A itself. Reflex Areas. Descriptions accom- special person in the hearts of all at Head and Neck Functional pany illustrations in this section. CCOM, “Mack” has been teaching Anatomy & Physiology. Concise Included are: Suboccipital Reflex at the college for over 50 years, reviews are provided for Skeletal/ Area-Myofascial Release; Temporal while continuously maintaining a Arthrodial Structures, Ligaments, Reflex Area-Inhibitory Technique; private practice. He has served as Muscles, Connective Tissue. Neural Frontal Sinus-Soft Tissue Tech- surgeon, teacher, and Head of the Anatomy includes consideration of nique; Sternocleidomastoid Inser- Ear, Nose, Throat (ENT) Depart- Upper and Lower Motor Neuron tion Reflex Area-Myofascial ment. As chairperson of the Com- Dysfunction, as well as Autonomic Release; Maxillary Reflex Area- mittee on Education of the Illinois and Cranial Nerve influences. Effleurage; Clavicle and Sternum Osteopathic Association, graduates Arterial supply to the head and Reflex Area-Soft Tissue Technique; of CCO were given the right to take Venous drainage from the head are Cervicothoracic Region-Chin Pivot the state examination for full discussed. Emphasis is placed on HVLA; Cervical Region-HVLA; licensing. This committee also knowledge of lymphatic drainage Scalenes-Direct Myofascial Re- secured legislative laws for all patterns as an aid in localizing lease; Lymphatic Techniques- osteopathic physicians to take pathological conditions. Principles Patient Seated and Supine; Thora- examinations for licensing in all of Osteopathy in the Cranial Field columbar Articulatory Technique- aspects of practice of medicine and underlie discussion of Paranasal Hip Lift and Rocking; Cranial and surgery. Additional service has been Sinuses, Eyes, Ears and Throat. Sacral Motion Assessment. The rendered as Chief of Staff, CCOM Mention of Autonomic Balance arrangement of information is such (twice) and as first Medical Direc- concludes the section. that a rapid review of Dysfunction, tor of Olympia Fields Hospital. In Common ENT Conditions: Objective, Discussion help to focus that capacity, Doctor McCarty Dr. McCarty’s Osteopathic the intention of treatment. Patient attended every Thursday morning Findings. Specific recommenda- position, Physician position and OMM Resident program, and was tions are given for diagnosis and Procedure logically follow. never late. treatment of the Common Cold, For a slim volume, a profes- The present volume reflects Sinusitis, Acute Tonsillitis, Acute sional lifetime of study, knowledge, Doctor McCarty’s experience and and Chronic Otitis Media/Eusta- practice and wisdom is abundantly teaching in the area of Ear, Nose, chian Tube Dysfunction, Airway reflected. It is a pleasure to utilize this Throat problems. Following a brief Edema and Tension Cephalgia. volume in practice since its organiza- Introduction, the following Characteristics of ENT tion and presentation facilitate rapid sections are developed: Reflex Areas. The numerous reflex recovery of needed information. Physiologic Rationale of areas found in ENT problems are References are given.❒

42/The AAO Journal Fall 2002 Elsewhere in Print

Vaughn B. Inter-examiner reliability in detecting cervical spine dysfunction-A short review. Journal of Osteopathic Medicine, 2002; 5(1): 24-27.

The author acknowledges that results for determining inter-examiner reliability in the detection of cervical spine dysfunction are promising. A continuing need for studies investigating the reliability and validity of diagnostic approaches is stressed. Acknowledgment of TART/ART descriptors indicates acceptability of such criteria. A recommendation for further studies suggests experienced examiners using standardized protocols. Symptomatic populations and patient pain responses in combination with motion palpation should be employed.

Mestan B, Rockwell JA, Foshang TH. Isolated injury of the posterior cruciate ligament: A report of three cases. JNMS: Journal of the Neuromusculoskeletal System, 2002; 10(3): 104-111.

The authors emphasize the uncommon occurrence of isolated injury to the posterior cruciate ligament, citing athletic injuries and motor vehicle accidents as causes. Partial or complete tears as well as tibial bony avulsion have been noted. Diagnosis is significantly enhanced through use of the posterior drawer sign and MRI imaging. Plain films are thought to have limited value. Conservative treatment is discussed at length. Disability is typical with a torn posterior cruciate ligament. Conservative management, in order to be successful, should consist of: local (knee) and regional (hip and ankle) normalization of joint mechanics; reduction of posterior tibial dysfunction; correction of anterior pelvic tilt dysfunction. Emphasis is placed on the use of ligamentous articular balancing and positional release methods in early stages of treatment. These are chosen because of safety for the knee joint. Myofascial release of the hamstring muscles is employed in order to facilitate patient performance of active muscle stretching. Overall goals of rehabilitation include: restoration of full active and passive ranges of motion; redevelopment of neuromuscular function of the involved lower extremity; reduction of weight-bearing forces to the tibiofemoral joint. Surgical reattachment is acknowledged to have the best results for complete tears if performed within 2 months of injury. Whether conservative or surgical treatment is rendered, long-term outcomes can vary greatly. Accelerated degeneration of the knee can occur. Prognosis is influenced by: severity of the initial injury; patient activity level; time from injury to onset of treatment.

Cuthbert SC. Applied Kinesiology and the Myofascia. AK: The International Journal of Applied Kinesiology and Kinesiologic Medicine, 2002; 13: 34-39.

In this essay, the author discusses the importance of myofascial analysis in chiropractic treatment. An extended discussion of percussion to release dysfunctions acknowledges descriptions by Burns, Fulford, Jones, Nimmo, Rolf, Sutherland, Travell and others. Applied Kinesiology solutions offered for myofascial problems acknowledge the relationship of local musculoskeletal dysfunctions to a variety of other phenomena. Specific considerations include: pain, increased neurologic confusion, autonomic arousal, visceral dysfunction and disease and decreased effective- ness of the endocrine and immune systems. Synthesis of approaches is nicely done, and includes methods employed by Travell, Jones and Fulford. A very excellent description of the use of the percussion instrument in concert with the monitoring hand is provided. The value of the percussion instrument in resolving various kinds of myofascial dysfunction is readily acknowledged.

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44/The AAO Journal Fall 2002