THEAAO THEAAO VIDEO TAPES 1994 AAO Convocation "An Osteopathic Approach to Patients with Visceral Dysfunction" Colorado Springs, CO

Home , Articulatory technique, Muscle energy technique, Stephen Typaldos, The DO

Lectures Tape #10 "Differential Diagnosis & OMT Utilization with Emergency Department Patient• Tape #1 Welcome and Opening Remarks Frank Paul, DO John C. Glover, DO, Program Chairperson •Manipulative Care in the ICU" "History of Visceral Techniques G. Bradley Klock, DO in the Osteopathic Profession" Anthony G. Chila, DO, FAAO Tape #11 "Manipulative Care in an Internal Medicine Practice" David A. Vick, DO Tape #2 "Spinal Cord I: Initial Processing of Nociception in the Spinal Cord Segment• Tape #12 "How I Use OMT in Gsnitourinary Practice" Frank Willard, PhD Wynne Steinsnyder, DO, FACOS

•Spinal Cord II: Somatic and Visceral Ref/exes Tape #13 "The Whole Patient Needs a Whole Physician. in Response to Nociception· Is Fatigue Your Problem?" Frank Willard, PhD Galen S. Young, DO, FAAO

Tape#3 "Current Approaches to Visceral Manipulation" Tape #14 "Bloclcs That Obstruct the Healing Process. Jean-Pierre Barral, DO, MROF Is Osteopathic Medical Care Good Enough? Robert England, DO, FAAO Tape #4 •Spinal Cord Ill: The Concept of a Homeostatic Nervous System• Tape #15 "Invisible, Intangible, Beyond the Microscope... Frank Willard, PhD Negative Influences Assail Our Patients• Viola M.Frymann, DO, FAAO Tape #5 •A Missing Link?: Connections Between Visceral Manipulation & Acupuncture• workshops Peter File, DO Tape #16 "Introduction to Visceral Manipulation" "Research in the Development of Visceral Manipulation" Jean-Pierre Barral, DO, MROF Jean-Pierre Barra!, DO, MROF Tape#17 "Coding Update• Tape#6 "Critical Pathways, Selection of Hospital Patients Judith A. O'Connell, DO to R8C8ive Manipulative Care• Edward Stiles, DO Tape #18 "Somatic Complaints of Visceral Origin" Daniel Bensky, DO "£valuation & Treatment of the Surgical and Internal Medicine Patient" Tape #19 •use of Chapman's Reflexes Mark Cantieri, DO in £valuation and Treatment• David Patriquin, DO, FAAO & Tape#? "Lymphatic System and the Diaphragm• Michael Kuchera, DO, FAAO Frank Willard, PhD Tape#20 "Evaluation & Treatment of Hospital Patients• Tape#8 "Role of Specialists in Manipulative Care• Mark Cantieri, DO Michael Kuchera, DO, FAAO Tape #21 ·Muscle-Fascial-Lymphatic Balancing Techniques• "The Hospital Service: Privileges, Consultation, Wynne Steinsnyder, DO, FACOS Charting, Charging & Quality Assurance• Mark Cantieri, DO Tape#22 "Teaching Disease Oriented Structural Diagnosis & Documentation" Tape #9 •Manipulative Care of an Obstetrics & G. Bradley Klock, DO Gynecology Practice" Melicien Tettambel, DO, FAAO for instructions to order video-tapes, ••. see page 8 2/AAO Journal Spring 1994 AAmeriean THEAAO Aeademyof Osteopathy J A•••-m•~---•- 3500 DePauw Boulevard Suite 1080 The mission of the American Academy of Osteopathy is to teach, Indianapolis, IN 46268-1136 explore, advocate, and advance the study and application of the (317) 879-1881 science and art of total health care management, emphasizing FAX (317) 879-0563 palpatory diagnosis and osteopathic manipulative treatmenL

From the Editor ...... 4 1994-1995 Raymond]. Hruby.DO, FAAO BOARD OF TRUSTEES

President Letter to the Editor ...... 6 Eileen L. DiGiovanna, DO, FAAO David Teitelbaum, DO President Elect Boyd R. Buser, DO Message from the President ...... 7 Immediate Past President Eileen DiGiovanna, DO, F AAO Herbert A. Yates, DO, FAAO

Secretary-Treasurer Anlhony G. Orila, DO, FAAO Message from the Executive Director ...... 8 Stephen]. Noone, CAE Trustee Ann L Habenicht, DO

Trustee A Tensegrity Model for Osteopathy in the Cranial Field ...... 9 Michael L Kuchera, DO, FAAO Charles H. Cummings, III, DO Trustee Karen M. Steele, DO Introducing the Fascia! Distortion Model...... 14 Trustee Stephen Typaldos, DO John C. Glover, DO

Trustee Judilh A. O'Connell, DO AAO Case History: Postpartum Facial Palsy ...... 19 Robert Paul Lee, DO Trustee Melicien A. Tettambel, DO, FAAO

Executive Director From the Achives: Sleplen J. Noone, CAE Quality of Care: An Assessment of the Contributions of Osteopathic Medicine ...... 22 Editorial Staff Anthony G. Chila, DO, F AAO

Editor-io-Oiief ...... RaymondJ. Hruby,00, Stranger in a New Land ...... 28 FAAO Miriam Mills, MD Supervising Editor ...... Stephen J. Noone, CAE Editorial Board ...... Barbara J. Briner, DO Letter to A. T. Still ...... 29 Anthony G. Oiila, DO, FAAO Raymond J. Hruby, DO, FAAO Fnnk H. Willard, PhD

Managing Editor ...... Diana L Fmley Classified Ads ...... 38

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The American Academy of Oste Submission contrast. On the back of each, clearly opathy (AAO) Journal is intended as a Submit all papers toRaymondJ. Hruby, indicate the top of the photo. Use a forum for disseminating information on DO, FAAO,Editor-in-Chief, University of photocopy to indicate the placement the science and art of osteopathic New England, 11 Hills Beach Road, of arrows and other markers on the manipulative medicine. It is directed Biddeford, ME 04005. photos. If color is necessary, submit toward osteopathic physicians, students, clearly labeled 35 mm slides with the interns and residents and particularly Editorial Review tops marked on the frames. All illus toward those physicians with a special Papers submitted to The AAO Journal trations will be returned to the authors interest in osteopathic manipulative treat may be submitted for review by the Edito of published manuscripts. ment. rial Board. Notification of acceptance or TheAAO Journal welcomes contri rejection usually is given within three months 3. Include a caption for each figure. butions in the following categories: after receipt of the paper; publication fol lows as soon as possible thereafter, depend Permissions Original Contributions ing upon the backlog of papers. Some pa Obtain written permission from Clinical or applied research, orbasic pers may be rejected because of duplication the publisher and author to use previ science research related to clinical prac of subject matter or the need to establish ously published illustrations and sub tice. priorities on the use of limited space. mit these letters with the manuscript. You also must obtain written permis Case Reports Requirements sion from patients to use their photos if Unusual clinical presentations, for manuscript submission: there is a possibility that they might be newly recognized situations or rarely identified. In the case of children, per reported features. Manuscript mission must be obtained from a parent 1. Type all text, references and tabular or guardian. Clinical Practice material using upper and lower case, double Articles about practical applications spaced with one-inch margins. Number all References for generalpractitioners or specialists. pages consecutively. 1. References are required for all material derived from the work of Special Communications 2. Submit original plus one copy. Please others. Cite all references in numeri Items related to the art of practice, retain one copy for your files. cal order in the text If there are refer such as poems, essays and stories. ences used as general source material, 3. Check that all references, tables and but from which no specific informa Letters to the Editor figures are cited in the text and in numerical tion was taken, list them in alphabeti Comments on articles published in order. cal order following the numbered The AAO Journal or new information on journals. clinical topics. 4. Include a cover letter that gives the author's full name and address, telephone 2. Forjournals, include the names of Professional News number, institution from which work all authors, complete title of the ar News of promotions, awards, ap initiated and academic title or position. ticle, name of the journal, volume pointments and other similar professional number, date and inclusive page num activities. Computer Disks bers. For books, include the name(s) We encourage and welcome computer of the editor(s), name and location of Book Reviews disks containing the material submitted in publisher and year ofpublication. Give Reviews of publications related to hard copy form. Though we prefer Macin page numbers for exact quotations. osteopathic manipulative medicine and tosh 3-1/2" disks, MS-DOS formats using to manipulative medicine in general. either 3-1/2" or 5-1/4" discs are equally Editorial Processing acceptable. All accepted articles are subject Note: Contributions are accepted from to copy editing. Authors are respon members of the AOA, faculty members Illustrations sible for all statements, including in osteopathic medical colleges, osteo 1. Be sure that illustrations submitted are changes made by the manuscript edi pathic residents and interns and students clearly labeled. tor. No material may be reprinted from of osteopathic colleges. Contributions The AAO Journal without the written by others are accepted on an individual 2. Photos should be submitted as 5" x 7" permission of the editor and the basis. glossy black and white prints with high author(s). D

Spring 1994 AAO Journal/5 Message from the President

Moving Beyond Equality Through Education and Unity by Eileen DiGiovanna, DO, FAAO

Unity is an issue frequently the profession. We must teach third addressed recently. And a very party payors, governmental agencies importantone. Unitymustexistwithin and the general public aboutthe unique the profession between all aspects of osteopathy. components, the American Osteo The Academy must be the pathic Association, the Academy, conscience of the profession, to keep American College of Osteopathic it headed in the right directions pre Family Physicians and all other serving its heritage and traditions, as specialty organizations. well as its unique concepts and The organizations within the philosophies. Eileen DiGiovanna, DO, FAAO profession are a little like the three We must strive to move the clergymen who went fishing. They Academy and the profession beyond As I looked back at my years in rowed their boat out onto the lake and equality. For years the profession has the Academy, I remember it when it after fishing awhilethe Catholic priest been striving for equality with our was a "good ol' boys' club" in the said be had to go to the bathroom so allopathic counterparts. I read a best sense - because they let "good he got out of the boat and walked quotation recently that stated that ol' girls" in, too. It was an educational across the water to shore and returned equality "Is the ceiling you place on and social club and we all enjoyed it. the same way a short time later. Then your ability to be the best you can be." We met every year at the Broadmoor the Protestant minister said he had to All men are not created equal; we for convocation. go to the bathroom and got out of the would be naive to think that they are. Butittendedtobeprovincial. Dr. boat and walked across the surface of But they are all created with the equal Bill Wyatt reminded the Board of the lake to shore and returned a short right to be the best they can be. We do Trustees that it was not so very long time later and walked back to the not want to limit ourselves with ago that the organization voted to boat. The Jewish rabbi was amazed. equality, but we do demand an equal keep students out of convocation. I Well he knew that their Lord had right to practice our profession. am glad that was defeated because walked on water but he thought, The temptation to pursue equality that would have been the death of the Moses had parted the Red Sea, so he withMDs is a dangerous and slippery Academy. stood up and stepped out of the boat road. The Academy must dig in its When the Academy faced a crisis and immediately sank to the bottom. heels and say, "So far and no farther." several years back, it stood up to that The priest turned to the minister and Do you know how easy it would crisis. That was the best thing that asked, "Do you think we should have be to become equal? ever happened to the Academy. Now told him where the rocks are?" • Stop doing OMT - rely on drugs and it has evolved into a high quality To prevent the profession from surgery. organization. It sponsors high quality sinking, we all need to communicate • Stop looking at your patients as programs, has a high quality and share information about where triune beings, and start looking at membership, high quality student "the rocks are." their diseases. membership and a high quality office Education is essential to my goal. • Go to the colleges, cut the OMM staff. I am proud to be assuming the One mission of the Academy is to curriculum. Then stop teaching OMM. leadership of the Academy at this become the worldwide authority on • Allow the colleges to stop granting time in its history. manual medicine. We need to not the degree, "Doctor of Osteopathy." The theme for my presidency is only educate our members and Now, friends, you are equal - "Moving Beyond Equality Through students through our programs, but easiest thing in the world. Education and Unity." also we need to educate people about I want to help lead the Academy

6/AAO Journal Spring 1994 and through it, the profession beyond equality back to the unique profession Basic Percussion Vibrator Course we are. We must fight to retain our osteopathic philosophy, history and October 22-23, 1994 techniques. We must encourage our students Faculty: to have pride in their profession, their Robert C. Fulford, DO, Waverly, Ohio degree and their education. Richard W. Koss, DO, Fort Worth, Texas I am proud to serve you at this exciting time in the history medicine of Location: and this time of tremendous advance CME Hours: 13 Category 1-A (Limited enrollment) The MO Headquarters Building and growth of the Academy. I ask Indianapolis, Indiana your help in all my endeavors, for I cannot succeed alone. D Call MO (317) 879-1881 for more information

To THEEo1TOR

"I Love My Work" by David Teitelbaum, DO

My recent fortieth birthday left over to indulge my passions for much from many wonderful DOs, but stimulated a period of introspection. snow skiing, scuba diving and travel. much more I have learned from the As I evaluated my current life, my Emotionally, I am able to meet my daily treatment of my patients! thoughts repeatedly focused on my personal needs for helping others, for Over the years I have realized that practice which is completely devoted caring, companionship, mirth, feeling my osteopathic practice does not just to osteopathic manipulation. I have useful, etc. I enjoy my patients and complement my spiritual path, it is become aware of how my profession view many of them as friends. Those my spiritual path! I have found little meets my physical, emotional, mental I can't come to think of as friends I difference in learning to care for my and spiritual needs. view at best as instructional and at difficult patients and learning to care Physically, I have been helped by worst as entertaining! They share their for my fellow man in general. My osteopathic structural care in many joys, sorrows, loves, dreams, practice teaches me that "difficult ways. I no longersufferfrom migraine frustrations and catastrophes with me. patients" are usually a result of my headaches -- thanks to manipulative I find it rewarding to be a part of their own difficulties, and this has helped treatment received while I was a lives and provide compassion as well me grow. I find more fulfillment in medical student. Other manipulative as relief of their physical pain. helping others lead less painful and treatment has enabled me, in spite of My work also satisfies my addictive more productive lives than any ofmy a significant scoliosis, to lead an need for mental stimulation. This other endeavors. What can compare essentially pain free existence and be comes in myriad forms, including the to the feeling of helping someone by very active physically. Occasional reading of articles, CME programs artfully using one's hands? Further, aches and pains generated by a full and questions from patients, students doing a good job with indirect day at the office respond to the same and others who inquire about approaches requires me to repeatedly therapies I use with my patients, osteopathic structural care. I find the center myself through-out the day. including selftreatment and an applied greatest mental challenge to be the This brings a pleasant calmness and osteopathic understanding of one that osteopathic physicians from promotes a sense of spiritual union movement, breathing and exercise. the time of A.T. Still get to deal with not only with the patient, but my Physical needs of food, clothing, every day: How to apply osteopathic higher self within. shelter, education for my children and principles to most favorably effect So I am now 40. I am an osteopathic even eventual retirement are well met the structure, function and health of physician. I love my "work". My by my practice income, with money the individual patient. I have learned needs are met. I am blessed.

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Board Board Stephen Stephen A Tensegrity Model for o,steopathy in tile Cranial 'Field ·

by Charles H. Cummings, Ill, DO

Editor's note: Charles H. Cummings, tissues of the body. This craniosacral Without an understanding ofthe origin III, DO is a 1987 graduate of the motion is conducted not only through ofthe primary respiratory mechanism, University Health Sciences College the muscles, fascia and skeletal craniosacralmanipulative therapy will of Osteopathic Medicine in Kansas system, but additionally, the nerves, never achieve widespread recognition City. He currently has a private dura and lymphatics are also involved and status as a bonafide treatment practice in Tiverton, Rhode Island in the transmission and coordination modality. An understanding of the both in family practice and ofmotion . Craniosacralmanipulative origin of the primary respiratory osteopathic manipulative medicine. therapy is an osteopathic manipulative mechanism is vital to predict the approach to diagnose, treat and har effects that craniosacralmanipulative Introduction ness the primary respiratory mechan- therapy have upon the homeostatic Osteopathic manipulative therapy potential of the human organism. is a system of physician-delivered treatment that involves palpation of The ultimate goal Historical Perspective tissue restriction and manual release Osteopathic physicians have of those areas of somatic dysfunction of treatment is developed a detailed system of to improve tissue mobility. The normalization of diagnosis and treatment based upon ultimate goal of treatment is neuromusculoskeletal reduction of strain at the reciprocal normalization of neuro-musculo 2 and connective tension membranes. William Gamer skeletal and connective tissue function Sutherland, DO originated the study to maximize the body's homeostatic tissue function of osteopathy in the cranial field, and and self-healing potential. to maximize the body's he described the inherent motility of Osteopathy involves removing the homeostatic and the neural tube, although he never barriers to function of the nonnal actually described the brain tissues as physiologic processes. Although, by self-healing potential. the prime mover of the system. classical definition, respiration relates Dr. Sutherland did understand that to oxygen exchange, from an the cranial rhythmic impulse osteopathic functional viewpoint, ism to improve the function of the represented much more than the respiration can be seen as the cyclical somatic system in its entirety. palpation ofa simple pump circulating contraction and relaxation to provide As a manipulative modality, the cerebrospinal fluid. "Now notice motion patterns vital to the life of the craniosacral manipulative therapy has thefluctuationofthetide-amovement organism. William Garner Sutherland, been practiced for over 50 years, and coming in during inhalation and DO recognized that respiration occurs the clinical value of treatment to the ebbing out during exhalation. Is it the not only in the thorax to involve the craniosacral system has been waves that come rolling along the lungs, diaphragm and chest wall; but investigated and reported in the 1 shore - is that the tide? No. The also he described the primary respir literature. Some research has been movement of the tide is the movement atory mechanism as a system of done to objectively document the of that body of water, the ocean, that motion originating in the central craniosacral mythmic impulse, but constant body of water. See that nervous system, with palpable move significant uncertainty regarding the potency in the tide; more power, more ments of the cranium, sacrum and all origin ofthe mechanism still persists.

Spring 1994 AAOJournal/9 A Tensegrity Model for Osteopathy in the Cranial Field .. c. H. Cummings, 111,oo potency in that tide than there is in the regarding the mechanism to power Theoretical Model waves that come dashing upon the the palpated motion were developed To determine the basis for the 3 shore." Potency is a full and meaning in response to the need for a theoretical potency and motility of the packed term to describe the basis for clinical observation. craniosacral system, we must take a fluctuation, "the movement of a fluid Unfortunately, the models put forth step back and analyze the entire system contained within a natural or artificial thus far are not supported by known using system mechanics. Systems cavity and observed by palpation or scientific evidence . The rate of science allows us to see biologic 4 percussion." This term reflects the production of the CSF from the organisms as composed of respect that Dr. Sutherland had for choroid plexus is only 0.35 ml per 8 independent, yet interdependent the powerofthe craniosacral system. minute. It is difficult to translate this subsystems which influence one It is my view that several relatively slow production and flow another in non-linear ways. osteopathic physicians have of CSF into a model that powers the First, I want to demonstrate how misinterpreted Dr. Sutherland's craniosacral system, a motion palpable system mechanics change the way descriptions of motility, fluctuation not only from the occiput to the sacrum that we view the musculoskeletal and potency. These terms are but throughout the entire body. There system. Levin has demonstrated that specifically process-oriented and still exists no firm evidence of primary spinal mechanics cannot be reduced represent a description of observed motion originating from the to simple lever mechanics. To balance motion. Dr. Sutherland described his oligodendroglia of the brain. There the centerof gravity, a rigid system of observations, and he related this to a does exist some evidence of motion at 9 spinal motion based on levers and coiling and uncoiling motion of the the cellular level, but the proposed guide-wires would require huge brain. But Dr. Sutherland admitted: motility of the oligodendroglia has spinous processes and "the forces "Do you think we will ever know not been translated into a verifiable necessary to stabilize a multiple from whence it cometh? Probably model whereby the brainliterallycoils hinged, rigid-linked system such as not. But it is there. That is all we need and uncoils. the body would, in presently to know. ,,s Other physicians have As physicians, we tend to analyze conceived linear, lever models, be taken these descriptions of the coiling problems within the framework of bone-breaking, muscle-tearing and 10 and uncoiling motions of the brain anatomy and physiology, but in this energy exhausting ." Levin explains literally, and they have hypothesized case, that approach restricts our "natural systems are self-generating, that the craniosacral rhythm may analytic process because our least energy systems with a hierarchy 11 originate from contractility of the knowledge about the anatomy and of structure and mechanics" One oligodendroglia.Mitchell hypo physiology of the cranium, dural tube model that is stable, with flexible thesized actual movement of the brain and lymphatics is incomplete. It is hinges and minimal energy tissue which he summarized: "The inherently difficult to study motion in expenditure, is the truss. Loads applied inherent motion of the brain can be the head because the system is totally at any one point are distributed about described as a coiling and uncoiling disrupted with any invasive study. the truss, and there are no levers within of the neural tube ... Its uncoiled state We have tried to tie together the a truss (Fig. 1) . A bridge is a mechani widens its transverse dimensions postulated cranial bone movement cal type of truss system (Fig. 2). while shortening its anteroposterior with the palpated rhythmic motion, Systems science is useful in looking 6 dimension." Upledgerhas taken this but it is even possible that the palpated at the biologic organism as a whole one step further and developed his rhythm has an entirely different origin. which is more than just the sum of its "pressurestat model" whereby the My purpose in the remainder of this parts. Biologic structures are not just craniosacral rhythmic impulse is paper is to propose another model for tissues and multiple joints existing in powered by production of CSF at the the cranial rhythmic impulse, still close proximity to one another. All • 7 choroid plexus. consistent with known anatomy and the tissues and joints are inter Realizing that there are no muscular biophysics, that will also explain the dependent upon one another. The agencies between the bones of the clinical effectiveness of craniosacral fascia , muscles, ligaments and skull to provide the palpated motion manipulative treatment. connective tissues are similar to a at the cranial sutures, these hypotheses

10/AAO Journal Spring 1994 A Tensegrity Model for Osteopathy in the Cranial Field .. c. H. Cummings, 111,oo

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@ Close -- packing spheres -- form a hexagonal pattern. This pattern requires minimal energy to maintain stability.

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Introduction Introduction

musculoskeletal musculoskeletal

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Fascial Fascial Introducing Introducing Table ~LINICAL COMPARISON OF PRINCIPLE TYPES OF FASCIAL DISTORTIONS

Principle types Movement during Common Most >JJecific of Fascial Distortions DrsTORTION TYPE Etiology treatment location treatment

Specific Distoned All fascial distortions currently pathways Triggerband Fascia! Yes throughout the te<:hnique known are of one of four types: Bands body triggerbands, triggerpoints, continuum distortions or folding Herniation Abdomen, distortions. These are reviewed and of tissue Jones technique pelvic area, through No or triggcrpoim compared in Table 1. Note that each supraclavicular fascia! therapy fossa !. principle type is differentiated by the plane etiology of its distortion. Near joints at Alteration the origin and of insertion of Triggerbands transition Comiuuum No tendons or zone technique ligments and between cosw-chondro tlssue types Triggerbands are clinically the CONTINUUM DISTORTIONS junction most commonly encountered fascial Three distortion and occur as fascial bands dimen Inside joints, Myofascial sional become pathologically altered. An No intcrosseous release distortion mcmbr::ines technique important difference between of fascia! triggerbands and the other principle planes fascial distortion types is that during treatment triggerbands move and the The triggerband subtypes are others do not. In the fascia! distortion compared in Table 2. An important point to realize is that regardless f model movement is considered to of 7· occur when the tender area of a fascial the specific subtype all are treated essentially the same way, that is by ;/'' band or its palpable distortion is able using triggerband technique. The :/ . to change its location duringtreatment ,,/ Therefore any fascial distortion that palpatory differentiation of the f • can be induced to move is by definition subtypes is necessary so they are not . ." : . confused with other distortions and ::,,_..>:: a triggerband and is best treated with modalities that correct distorted fascial treated inappropriately. Their treatment is the subject of the bands. accompanying paper Triggerband ,4 .'.i't\'{' There are six clinically recognized Technique. :'

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Journal Journal

wave wave

much much

(fig

;'' ;''

the the

in in

and and

fibers fibers

seemingly seemingly

becoming becoming

/ /

are are

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ss ss are are

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l/, l/,

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16/AAO 16/AAO

f f

triggerband triggerband

the the

thighs thighs

found found

borders. borders.

salt salt

obviously obviously

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5) 5)

cro

from from fascia! fascia! objectively seen as a loss of motion of the involved joint. In acute conditions (i.e., distortions in which no fascia! adhesions have fonned) the wave is able to travel freely to and from the joint as the forces act upon it (fig. 7), but in general without intervention it is pulled in a direction toward the joint. In chronic pain (i.e., fascia! distortions in which adhesions are present) the wave is held firmly in place by adhesions and is immobile (fig. 8). The degree of immobility of chronic pain is detennined in part by how far the locked wave is from the joint. The closer the wave is to the fig.6 joint the less motion the joint will have. High velocity low amplitude often expresses discomfort with the The acute wave can be corrected or osteopathic manipulation (HVLA) is treatment itself. This is in contrast to moved by certain soft tissue a technique that uses the vertebrae or acute pain in which the patient other bony structures as a fulcrum to nonnally experiences a dramatic slingshot the acute wave away from subjective improvement at the instant the joint at a very high speed. If the of the manipulation. As is expected direction and speed of the wave reach from this model, once the adhesions a certain threshold the joint will are broken with triggerband manipulate and a popping sound can technique, then even the most difficult acute wave be heard. If the thrust doesnot generate to manipulate patients become easy moving along enough speed, the wave will not be fascial band to manipulate, and the manipulation moved successfully and the joint will is then a positive subjective not be manipulated. experience. HVLA' s role in the fascia! ~ In the fascia! distortion model the distortion model is primarily in acute fig.7 ---- two clinical concerns with HVLA are pain and in chronic pain after it has 1) the wave has been forced away, but been made acute by destruction of the techniques, such as triggerband may in time be pulled back into its adhesions. technique, myofascial release, rolfing, previous location and 2) adhesions traction or stretching. I prefer would be expected to thwart the speed Triggerpoints triggerband technique because it is of the wave propagation, thus making the most specific; it follows the HVLA an impractical treatment to The tenn triggerpoint has been used distortion until it is far from the injury useinchronicpain The problem with in the past for a variety of fascia! siteandcorrectsitattheconclusionof the wave eventually returning is the its pathway (fig. 9). Myofascial same one that several othermodalities release, rolfing, stretching and traction have. This is seen most commonly in merely pull it away from the joint to a those patients that feel they need to be -::·_:_ - _ ,;.; _ ":;::.._-:;;;;::...-~~ --- - distant area, but since the distortion is popped frequently. Forotherpatients -- not actually corrected, it may manipulation appears to be curative. eventually be pulled back into its prior This may be because the wave was _{ location. In chronic pain, nonnally pushed away into another location only triggerband technique will be where the forces acting upon it were ad ?Rs~ ~~ ::::~ ,:::. effective because it is specifically able to straighten it out. In chronic ·g_"Jf·'f:~±~~~~'.~~~:,-·,,,,_,.~~S0 €':X~t_:_:? · fl \' ') designed not only to correct the wave pain, a successful manipulative thrust 0 - - - =-•:. but also to break the fascia! adhesions. is difficult to achieve, and the patient ➔ Spring 1994 AAO Joumal/17

. .

30 30

1994 1994

page page

trigge

similar

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although although

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Spring Spring

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compared compared

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descriptions. descriptions. use use

involves involves

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Journal Journal

shoulders shoulders

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corrected corrected

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upper upper

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fig.9 fig.9

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18/AAO 18/AAO

of of Differentiating Differentiating

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Technique) Technique)

frozen frozen

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clinically clinically particularly particularly

subtypes subtypes

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triggerpoint triggerpoint

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triggerpoint triggerpoint

triggerband, triggerband, and and

fascial fascial

etiologies etiologies distortions distortions From the AOBSPOMM Files

AAO Case History Postpartum Facial Palsy by Robert Paul Lee, DO

Editor'sNote:RobertPaulLee,DO,a slightly to accommodate the cyclical other. Except for an attachment at the 1976graduate of Kansas City College swelling and receding of the central second and third cervical segments, of Osteopathic Medicine is board nervous system and the cerebrospioal the dura is otherwise relatively free to certified in OMM and holds a fluid. The dural membranes within glide within the bony canal of the Certificate of Competency in Osteo the skull and spinal canal integrate spine. This structural arrangement has pathy in the Cranial Field. Dr. Lee the motion of all these components of the functional effect of integrating completed his residency in osteopathic the system. This motion was named the motions ofthe basiocciput and the manipulative medicine in 1986 and is the primary respiratory mechanism, sacrum. presently is private practice in by its discoverer, William Garner As the primary respiratory Durango, Colorado. Sutherland, DO. mechanism cycles throughflexion and Of special interest, in this case extension, the cranial base elevates Introduction and descends very slightly. Because Bell's Palsy, the spontaneous and of the spinal dural tube, the sacrum is usually transient weakness of the alternately pulled upward and muscles of facial expression, is Osteopathic released downward. In the flexion attributed to entrapment of the facial physicians phase, the sacral base moves slightly nerve (CN VII) as it courses through towards the head, the coccyx moves a tortuous canal within the temporal recognize anteriorly, and the base of the sacrum bone. Entrapment is believed to occur the importance moves posteriorly. In extension, the as a result of swelling within this sacrum moves inferiorly; its base unforgiving canal. This can happen if of the sacrum and pelvis moving anteriorly, and the coccyx posteriorly. These movements are inflammation results from a viral in the functioning infection, the etiology believed by commonplace for the practitioner of conventional medicine to be the most of the occiput cranial osteopathy. common; or by mechanical trauma, Clinically, osteopathic physicians the etiology to be discussed in this and the head recognize the importance of the paper. and (visa versa). sacrum and pelvis in the functioning As cranial osteopaths know from of the occiput and the head, and visa clinical experience, limited motion of versa. The ligamentous attachments the temporal bone(s) is found in suspending the sacrum within the association with Bell's Palsy. presented here, is the relationship that pelvis integrate the motion of the Frequently, the patient presenting with exists within this mechanism, between sacrum with the entire pelvic bowl. a unilateral facial weakness has a the cranium and sacrum. Surrounding Likewise the cranial dura integrates the spinal cord is an inelastic dural the motion of the entire cranium. significant restriction of motion of 1 the ipsilateral temporal bone. Motion tube which is finnly attached around These two "bowls" , the cranium and of the bone in external and internal the circumference of the foramen the pelvis, reflect each other through rotation is severely limited. magnum atone end and to the posterior the spinal dura, called the"core link". The cranial concept posits that all aspect of the spinal canal at the level For example, the sacrum and the the bones of the skull move very of the second sacral segment at the ➔

Spring 1994 AAO JoumaV19

j j

1 1

to to

a a

. .

a a

of of

the the

1994 1994 y y

it it

the the

the the that that

the the

of of

the the

from from

the the

The The

fluid fluid

of of

other other

as as as as

The The

bone. bone.

these these

of of

remove remove

but but

bone bone

pelvic pelvic

asym

of of

proteins proteins

asym

in in

Without Without

plexus, plexus,

pelvis

atony. atony.

Further Further

As As and and

began began

sacrum sacrum

Spring Spring

of of

attached attached

. .

part part in in

severe! severe!

sluggish sluggish

this this

while while

not not

explained explained

distortion distortion to to

disturbed disturbed

the the

mechanism mechanism

the the

metabolism. metabolism.

evidence evidence

uterosacral uterosacral

mechanism mechanism

the the

dysfunction dysfunction

as as

connection connection

dysfunction, dysfunction,

sacrum. sacrum.

evidence evidence

rich rich

of of

a a

processes processes

pelvis, pelvis,

lateral lateral

compromised compromised

bone

nerve nerve

temporal temporal

motion motion of of

the the

sacral sacral

distorted distorted

pelvis pelvis

uterine uterine

examination. examination.

surface. surface.

ligaments. ligaments.

fluid fluid

position position uterus, uterus,

could could

the the

interrupted. interrupted.

temporal temporal

was was

just just

feeling feeling

and and

by by that that

the the

cranial cranial

the the

normalized, normalized,

principles principles

dural dural

the the

oflabor oflabor

could be be could

involved involved

innervation innervation

all all

the the

with with

fluid, fluid,

the the

cellular cellular

Such Such

in in

examination examination

of of

her her

and and

in in

hard hard

somatic somatic

facial facial

the the

to to

palpatory palpatory

were were

of of

the the

right right

a a

source source

of of

the the

of of

with with somatic somatic

nonnal nonnal

broad broad

provides provides

position position

longer longer

deliver deliver

entrapment. entrapment.

, ,

the the

temporal temporal

ilia ilia

the the distortions

the the

bone bone

of of

were were

cranium cranium

and and

uterus uterus

sacrum sacrum forces forces

from from

and and

the the

cranium cranium

palpatory palpatory

was was

no no

area area

the the the the

the the

, ,

upon upon

of of

further further

lymphatics lymphatics

postpartum postpartum

of of of of

The The

and and

link", link",

rested rested

case case

the the the the

to to

the the

through through

the the

of of

sacrum. sacrum.

the the

. .

consistent consistent

occurred occurred position position

of of by by

relationships relationships

to to of of

congestion congestion

products products

of of

The The

is is

pelvis, pelvis,

bones bones

nerve nerve

local local

extracellular extracellular

osteopathic osteopathic

There There

is is

the the

symmetric symmetric

This This

"core "core

it it

boggy boggy

the the

and and

the the

remove remove

the the

motion, motion, soma, soma,

fluid fluid resulted resulted

movement movement

return

congestion

deserves deserves

function function cases cases

temporal temporal

because because

of of sluggishness sluggishness

of of parasympathetic parasympathetic

uterus uterus

consequence consequence

by by atony atony This This

walls walls

as as

ligaments ligaments

metric metric

bony bony

evidence evidence

metrically metrically

mother mother

result result

between between

iliac iliac

was was

Evidently, Evidently,

as as

distorted distorted

trauma trauma

between between

the the

Discussion Discussion

or or

nonnaliz.ed

mobility mobility

. .

of of

in in

the the

and and

its its

of of

right right

the the

hour hour very very

and and

left left

was was

one one and and

was was

return return The The

area area

with with

right right

appear. appear.

to to

an an

, ,

the the

as as

of of drawn drawn

manipu

motion motion

required required

signs, signs,

Wrinkles Wrinkles

right right

to to

temporal temporal

manipu-

The The

at at

the the

revealed revealed

treatment treatment

bone bone

from from

There There

restrictions. restrictions.

achieved achieved

postpartum

nearly nearly

than than

the the

was was

the the

as as

was was

acupuncture, acupuncture,

signs signs

tingling tingling

early early

and and

face. face.

it it

to to

of of . .

laterally. laterally.

began began

inch. inch. ore ore

right right

inferiorly inferiorly

maxillary maxillary

treatment treatment

torsioned torsioned

superiorly superiorly was was

remained remained

days days

weeks. weeks.

be be

bone bone

and and

days days ilium ilium

recovery recovery

the the

inferiorly, inferiorly,

early early

the the these these

comparison comparison

and and

rotation. rotation.

one one to to

osteopathic osteopathic

the the

were were

eyelid eyelid

form form

ten ten and and

severely, severely, temporal temporal

of of

in in

left left

achieved achieved

mouth mouth

osteopathic osteopathic

position

pulled pulled

with with

osteopathic osteopathic

at at

examination examination

craniopelvic craniopelvic

medially, medially,

with with

release release

acupuncture

severely severely three three

drawn drawn

bogginess bogginess

right right

recovery recovery

The The

side side

the the

With With

quite quite

right right about about

temporal temporal

. .

the the

fundus fundus

mobility mobility

. .

signs signs

and and was was

external external

of of

in in

to to

successive successive

base base treatment treatment

the the

palpatory palpatory

was was

laterally laterally

With With

treatment treatment

in in

weeks, weeks,

superiorly superiorly

and and

11le 11le

complete complete

right right

by by

function function

Intensive Intensive

two two

left left

release release

Palpatory Palpatory

sacrum, sacrum,

obvious obvious

uterine uterine

mid.line

manipulative manipulative

the the

Coincident Coincident

corner corner

under under

the the fasciculations fasciculations

These These

three three

of of

complete complete

sluggish lative lative

bone's bone's

to to Nevertheless, Nevertheless,

on on

lative lative

compromised compromised

began began

an an

of of

locked locked

forced forced

right. right.

inch inch

the the

anteriorly, anteriorly,

occiput occiput the the

ilium, ilium,

sacrum sacrum

inferiorly inferiorly

the the

of of

be be

at at

the the

she she

left left

of of

was was

the the

eye. eye.

four four

was was for for

from from

was was

two two

The The ilia ilia

was was

to to

the the

the the after after

and and the the

facial facial

afull

with with

like like

sitting sitting

9. 9.

these these

the the

that that

located located

and and

the the

anterior anterior

and and right right

In In

observed observed

skin skin side side

auditory auditory

developed developed

loss loss

and and

full-tenn full-tenn

oxytocin, oxytocin,

occiput occiput

& &

labor labor

mid.line. mid.line.

temporal temporal

of of after after

midline midline

temporal temporal

fulcra fulcra

found found

back back

respective respective Inflexion, Inflexion,

7 7

of of

portions portions

Twenty Twenty of of

delivery, delivery,

her her

bleeding bleeding

Acupuncture Acupuncture

towards towards

had had while while

right; right;

was was

the the

placenta placenta

delivered delivered . .

the the

delivery, delivery,

the the

of of

brain, brain,

The The

was was

it it

right right

in in

of of

occiput occiput

chin. chin.

crests crests

her her

blood blood

their their

By72hours By72hours

duration, duration,

and and temporals temporals

the the

external external

the the

posteromedially. posteromedially.

atonic atonic after after

mid.line. mid.line.

remained remained

other. other.

palsy palsy

the the

that that

wall, wall,

after after

Hispanic, Hispanic,

in in

and and

numb

complained complained

the the

of of

the the

to to

the the

ilia. ilia.

a a

extension. extension.

unwrinkled unwrinkled

right right

focusing focusing

the the

basiocciput basiocciput

the the

scores scores

injections injections

fundus fundus to to

ischial tuberosities ischial tuberosities

squamous squamous

They They reverse

move move

delivery. delivery.

each each

she she

and and

ml ml

are are

felt felt

ilia ilia

on on

facial facial

toward toward

in in

hours hours uterus, uterus,

the the of of

Progression Progression

however, however, behind behind

hours hours

evident. evident.

surfaces, surfaces,

hours hours

of of

the the processes processes

the the

fundus fundus

Journal Journal

the the

born born

the the

of of

towards towards

Pl/G3/AB1, Pl/G3/AB1,

reported reported

the the

year-0ld year-0ld

both both

the the

48 48

10 10

Report Report

of of

against against

remained remained

right right

supporting supporting

few few

later, later,

right right

1000 1000

smooth, smooth,

anterosuperiorly anterosuperiorly

floor. floor.

move move bone. bone.

33 33

the the

and and anterolaterally. anterolaterally.

imitate imitate

was was

APGAR APGAR

difficulty difficulty

> > tongue tongue

forehead forehead

A A

motions motions

AAO AAO

delayed delayed

A A

the the

temporals temporals

mastoid mastoid

pelvis pelvis

flex.ion, flex.ion,

20/ 20/

with with

the the

weakness weakness

becoming becoming

blown blown

Within Within

had had

hours hours

mother mother

her her

to to

asymmetrically asymmetrically

margin margin

that that

controlled; controlled;

tonified tonified

its its

and and

discovered discovered

intramuscular intramuscular

with with uterus uterus

baby baby

on on nonnal, nonnal,

pillows pillows

home, home, female, female,

Case Case

acetabula acetabula

meatuses meatuses

these these

the the

move move

Likewise, Likewise,

bones bones

the the

bones bones

manner, manner,

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In In occiputmovesimilarly occiputmovesimilarly As osmotic pressure built, there was floor, the right side of the pelvis was Conclusion no place for expansion in the bony forced to expand more than the left. These clinical findings indicate canal, and the vulnerable nerve ceased Therefore, the right ilium was 1) the functional existence of the core functioning. Impulses to the muscles lateralized and elevated, drawing the link, 2) the integrative functions in of facial expression diminished and coccyx with it to the right and the cranium of the dura, and in the finally ceased. When motion was superiorly, while the body of the pelvis of the sacral ligaments, 3) the normalized, fluid exchange also sacrum was pulled into a position relationships between the viscera normalized and the nerve regenerated facing the right, and the base of the (uterus) and the soma (sacrum) restoring nerve impulses and muscle sacrum became caught inferiorly, mediated by the autonomic netvous tone. turning on an axis at the second sacral system, and 4) the association of the The right temporal bone became segment. The sacral twist was beyond somatic dysfunction of the temporal locked in external rotation and in an the resiliency of the sacral ligaments bone and the entrapment of the facial unphysiological position, superior and and/or the tolerance of the nerve. lateral to the normal. The force from proprioceptors. The sacroiliac joints With further investigation. it may be shown that many cases of Bell's the distorted sacrum through the core could not accommodate the position Palsy result from somatic dysfunction link, pulling down on the left side of of the sacral twist. Therefore, the of the temporal bone . These position the sacrum became locked the occiput tilted the right side of dysfunctions may occur because of superior!y, forcing the right temporal in this unphysiologic twist. It pulled local trauma to the temporal bone bone in the same direction. Because down on the occiput trapping the right itself or to the cranium, or they may the infant was delivered ROA, and temporal bone in a severe distortion occur because of distant trauma which the left buttocks bore the weight of to cause the Bell's Palsy. is transmitted through the connective the mother on the finn surface of the tissue to the temporal bone. D

BML ]]) (0) N °'IT' IF (0) IR?.(G IE'IT' BASICPHYSICIANS 'IT'(0) ILIE 'IT' 1U § OCN(0) W SUPPLY,INC. O 10430Highway 412 W est • Paragould, AR7 2450 1f(0) 1UVIE MI(0) VIE]]) Full Inventory on Rubber or Crepe Please ... HEEL to keep your mail coming and LIFTS our records straight, FREE be sure to let us know SAMPLE KIT if you have a new name, home, 11 11 YOUR BEST BUY SUPPLY office, FAX or telephone number! • Foot Orthotics • Electrodes • Orthopedic Braces • Lotions, Gels • Electrotherapy Equipment • Tables

39 YEARS OF SERVING The American Academy of Osteopathy 3500 DePauw Blvd.,Suite 1080 1-800-643-4 7 51 Indianapolis, IN 46268-1136 Phone: (317) 879-1881 or Call For FREECatalog FAX: (317) 879-0563

Spring 1994 AAO Journal/21 From the Archives Quality of Care: An Assessment of the Contributions of Osteopathic Medicine

from 1977 AAO Yearbook by Anthony G. Chila, DO, FAAO

Editor's Note: Anthony G. Chila, DO, were won, accepted intraprofessional party interest in the potential of this F AAO is currently a Professor and attitudes appear to have lost sight of profession's separate and distinct Chairman of the Department of the fine line which separates true philosophy. The rotating internship Family Medicine and the Chief of intellectual greatness from the in the osteopathic community hospital 1 Clinical Research at Ohio University obscurity of mental failure. Chapman provides an excellent vehicle for the College of Osteopathic Medicine. Dr. summarized the views ofKorrin these establishment and continuity of such Chila serves as the secretary words: "Seldom in history has an clinical research. treasurer of the Academy as well as a organized group of men an women 4) Analysisofthequalityofcare member of the Education, Fellowship, perceived, grasped and then per se. This appears to be an Finance and Long Range Planning seemingly relinquished a greater appropriate function for the Committees and chairs the opportunity." committee on osteopathic principles Governors!AOBSPOMM Nominating In order to regain its perspective and therapeutics. As constituted by Committee and the Symposium and provide enlightened leadership regulations of the AOA, this Planning Task Force. toward its original goal, the profession committee at each hospital should must consider several steps: represent all divisions of the medical The osteopathic profession has 1) Active restructuring of staff and provide the broadest impact existed for one century in the frame teaching methods in allthe osteopathic on the hospital teaching program. work of a philosophic approach to the colleges so that a core curriculum of With the fullest possible utilization management of disease which osteopathic theory and methods will of osteopathic principles by each requires a separate and distinct voice provide a uniform philosophy in the physician on the attending staff, the in relation to the majority view of predoctoral years. committees analytical function may medical practice in the United States. 2) Expansion of the teaching be carried out easily by either a review As a distinctively American program during the year of rotating of active charts of currently contribution to the mainstream of internship. Whether in a traditional hospitalized patients or retrospective medical thought, the profession's 12-month program or in some review of charts of discharged patients premises have been employed modification of service for increasing or both. On the assumption that every successfully on an empiric basis, exposure to the community's facilities, patient hospitalized in an osteopathic scientifically substantiated, publicly the intern must have the greatest institution is deserving of at least one accepted and legislatively defined. possible clinical orientation to the complete biome-chanical As propounded by Andrew Taylor community application of the holistic examination regardless of the Still, the purpose of this minority view of medical practice. admitting diagnosis, then no patient viewpoint was to catalyze a change in 3) Improving and expanding will be deprived of a parameter of medicine's progress toward a concept analytic methods as to the effect of care unique to the osteopathic of holistic well-being and the osteopathic manipulative therapy on profession. Statistical retrieval studies improvement of environmental disease processes. Research in this can be accomplished by close adaptation to gravity. At the time when area is sorely needed to provide the cooperation with the hospital's all the struggles against impediments basis for ongoing support of third- medical records depart-ment, utilizing

22/ AAO Journal Spring 1994 the PAS-MAP approach, or any of allopathic medicine, osteopathic similar program. Retrieval studies medicine and chiropractic at a Encourage tied in with ongoing clinical research workshop discussing spinal mani Your programs in every osteo-pathic pulative therapy offers another hospital with an approved teaching warning to the osteopathic profession, Colleagues program provide unlimited since all the manipulative viewpoints to become opportunities for the profession to were represented. Again, the Board Certified assert its leadership in the study and osteopathic profession must provide management of disease. a high caliber of interchange of inOMM 5) Fellowship in the American thought. Academy of Osteopathy (AAO) The osteopathic profession today recognizes excellence in the use of in numerically smaller than either the osteopathic principles. If future allopathic or the chiropractic group. developments indicate the need for Failure to continue to document the certification in manipulative medi value of its philosophy significantly cine, then the AAO will be the agency via its hospital teaching program is through which it can be accom equivalent to reducing the profession's plished.* One such certification standing to a negative and naive "MD becomes a reality, the skills of the plus" categorization by all who view certified specialist, if available in the it: the public, legislative bodies, the teaching hospital, will provide the allopathic and chiropractic groups and general practitioner an extra osteopathic physicians themselves. dimension in the care he/she can offer Such an occurrence would seIVe to his/herpatients. This is in accordance reduce the followers of a century-old 2 withtheconceptofStiles ofadirector example of philosophic and academic of osteopathic medicine for an excellence in intellectual profession institution. This specialist can dissent to the status of a splinter group. supplement the contribution of the It is past time for the osteopathic Committee on Utilization of Osteo profession to ask itself what it pathic Principles and Methods. considers its role to be in the delivery A final word is in order with of health care. regard to the evolutionary tendency of medical thought. For most of its References 1 first century of existence, the Chapman, L. F., The osteopathic role in osteopathic profession occupied the medical evolution, Adapted from three position of a digression vis-a-vis the papers by I. M. Korr., The DO, 14:135- monolithic philosophy of the 64, Nov. 73

allopathic profession. This is no 2 longerthe case. Within the allopathic Stiles, E.G., Osteopathic manipu-lation Sponsored by: A American school itself, interest in manipulation inahospitalenvironment,JAOA, 76:243- Academy of is increasing. Although allopathic 58, Dec. 76 Osteopathy physicians do not possess the * In July 1977 the AOA Board of Trustees For a $15 enrollment fee knowledge demonstrated by the approved the establishment of the American you and your family members osteopathic school, the fact that this Osteopathic Board of Fellowship of the can receive change has occurred demonstrates American Academy of Osteopathy. The purposes of this board are to define and replacement contact lens that the minority profession is now determine qualifications of DOs who desire at up to 75%discount! challenged by the need to provide a certification of special proficiency in the high caliber of interchange of thought, knowledge and application of osteopathic Call the AAO as originally advised by Andrew struc tural diagnosis and manipulative for an enrollment management, to conduct examination for this form today! Taylor Still. purpose and to issue certificates to those found (317) 879-1881 The presence of representatives qualified.□

Spring 1994 AAO Joumal/23 A Tensegrity Model for Osteopathy in the Cranial Field .. by c. H. Cummings, 111.oo continued from page 13 tensegrity network. These internally vectored icosahedra could model structures in nature such as the DNA helix, the neck of a dinosaur or the craniosacral system (Fig. 7). It has previously been postulated that "the dural membranous link between the sacrum and occiput must have considerable slack; otherwise, we would not be able to move our 15 spines at all. " This analysis that slack must exist in the dural membranes for spinal motion to exist reduces any possible relation between the occiput and sacrum as direct and linear. We know that complex relationships exist Fig. 7 involving not only the skeleton.joints, DNA helix, neck of dinosaur and human craniosacral ligaments and muscles but also the system -- all of these may achieve high stability yet fascia, dural elements and possibly flexibility by structures which are variations of linked flow patterns of fluids including the CSF and lymph. Interpreting the icosahedra. craniosacral motion from the vantage of systems science, we must include the microscopic and macroscopic consequences of these tissues influencing one another, both directly and indirectly. The dura exists as a tube with f ascial connections, and I hypothesize that this also can be viewed as an internally vectored tensegrity model, with the incompressable CSF as the compression resisting element (or "backbone") of the icosahedra. The link between the occiput and sacrum is thus conceptually a bridge. A mechanical function of the icosahedron is that energy is transferred through the structure in a helical fashion when it is compressed. Analogously, there is no direct link between the occiput and sacrum; Fig. 8 energy is similarly conducted in a helical fashion through the dural tube Linked icosahedra compress in a helical fashion. Similarly, from the occiput down to the sacrum motion is conducted along the dural tube from the occiput (Fig. 8). This concept explains how to the sacrum in a helical fashion.

24/ AAO Journal Spring 1994 A Tensegrity Model for Osteopathy In the Cranial Field •• by c. H. Cummings, 111,oo

we canhave enough flexibility to move example, a golfer may make a small independently like the pulse or our spines, yet allow for the adjustment in his stance, and this respiratory pattern; the cranial craniosacral linkage between the minor change in foot position will rhythmic impulse is a cumulative distant occiput and sacrum. All the affect the flow of torque through his interactive motion involving both tissues in between, through theirfascial body to ultimately bring about a major patient and examiner, and this connections, are also influenced by change in his swing and the final perceived motion pattern does not this compres sion-tension. The trajectory of the golf ball. Minor exist until it is palpated by the craniosacral rhythm (CRI) that we changes in the initial conditions that examiner. Once the examiner and palpate may be the echo of the canhave major impact upon the entire patient come together, the cumulative continuous tension network, system are a known properties of motions become a very real and rhythmically tensing and relaxing, or non-linear dynamical systems, such palpable wave-form. The constant oscillating, as this system is influenced as weather systems and most other rhythmically adjusting motion in this 16 by other motions. natural systems. system can be palpated and visualized When performing craniosacral by the examiner, and in some ways, manipulative therapy, to balance the this craniosacral system can be seen Craniosacral 17 Manipulative Therapy tensions within the system, the as a hologram, a three dimensional physician shifts and directs the representation of the underlying Considering that we are dealing motions palpated at his fingertips. tension network of the system. But with a complex system that includes However, that which is palpated with these cumulative motions are not an the continuous fascia, muscles, the hands as the craniosacral rhythmic illusion; from experience, we know multiple sutures and joints, as well as impulse is not directly the patient's that the osteopathic physician interacts the coordinating influences of the continuous tension system; what is with the patient to effect permanent nervous system, that which we palpate change in the system. as the craniosacral mechanism could This brings us to the question of indeed be the rhythmic shifting of this what is being done when we perform interactive continuous tension network craniosacral manipulative therapy. as it rhythmically responds to outside The cranial Very few osteopaths would conclude influences, such as cardiac contraction, that all that we are doing is moving pulmonary respiration and skeletal rhythmic impulse the cranial bones. I hypothesize that muscle contractions. This is not to say is a cumulative the examiner can narrow down and that the craniosacral motion is just a aim the palpated cumulative motion cumulative waveform generated from interactive motion of the system as a tool to further other motion patterns; rather, the involving both change the underlying continuous craniosacral motion is a reflection of tension system of the patient. This intrinsic and extrinsic motions upon patient and motion can be fine-tuned like a the basic tension network of the system. lithotripter or percussion hammer to When treating this tension system, a examiner ... change the basic tension network at minor adjustment in the tensions at the the cranial sutures, the sacrum or sutures of the cranial bones or the anywhere else in the system. sacrum may have a profound effect in palpated is an indirect phenomenon, Onetermthatlhavealwaysfound changing the tension and flow of a cumulative interactive motion of inappropriate in discussing the motion through the entire system, and the tension network of the patient as craniosacral system is "energy" which as the system adapts to this treatment, palpated by an examiner who himself is defined as "power to produce permanent change is made in the has a continuous tension network. motion, to overcome resistance, and system as a whole. The physician is an integral part of to effect physical changes." We Thus, small adjustments may have this scenario. The cranial rhythmic understand the origin of energy on the major effects upon the whole impulse is not a motion existing continuous tension network. As an ➔

Spring 1994 AAO Journal/25 A Tensegrity Model for Osteopathy in the Cranial Field . . by c. H. Cummings, 111,oo chemical or physical levels, but when produced evidence documenting that evidence that also explains the clinical we speak of the "energy" of the the respiration and heartbeat of the effectiveness of craniosacral craniosacral system, our discussion examiner as well as the patient may treatment, and the tensegrity model jumps to the metaphysical level as we have an influence on the craniosacral may be a satisfactory model. 18 really do not know the nature, origin rhythm. Additionally, he has or function of this craniosacral presented evidence that the palpated Conclusion "energy". The term "energy" when craniosacral rhythm of one subject is Craniosacral manipulative used in this way is a misnomer which not consistent when palpated by therapy thus has far-reaching . implies that some force, whether therapeutic effects beyond simply intrinsic or extrinsic, is effecting moving cranial bones, and this is not motion in our system, but this concept inconsistent with what has previously leads us away from understanding the This recognition been taught about osteopathy in the craniosacralmotionas amanifestation of craniosacral motion cranial field. In fact, I think that of a complex and dynamic system. William Garner Sutherland, DO really In a balanced tension system, we as a manifestation envisioned the system concept in his do not need any source of"energy" as teachings. He spoke of the it is the nature of the balanced system of a complex system "transmutation"' of the cerebrospinal itself that is continually changing, as rather than a type of fluid in the nerve tracts, and in this the "truss" is continually adjusting to description, he may have implied that constant motion in the environment "energy" is the key when the com(X)nents of the system In this model, the sphenoid does not to our understanding interact, the system transcends itself independently move into flexion, and and is more than the sum of its parts. the sacrum does not independently of this tensegrity By using descriptors such as the "tide" move into extension, but rather, the and "transmutation," Dr. Sutherland entire system periodically oscillates model specifically avoided reducing the from one moment to another. Several craniosacral system to a mechanical times per minute, our system cycles pump, and he emphasized the 19 Th' . from an attitude of flexion to an different examiners . 1s 1s interactive systems aspect in this attitude of extension. Energy is not additional evidence that the school of thought. required to "move" the sphenoid or craniosacral rhythm is a manifestation It must be emphasized that the sacrum because in our complex of a cumulative, interactive system understanding the craniosacralsystem system, when the balance of the between patient and examiner. as a continuous tension network does system alternates from extension Some osteopathic physicians are not minimize what we do with our towards flexion, it is the least energy disturbed by evidence that is hands, and I expect that it will not position forthe sphenoid orthe sacrum inconsistent with the paradigms with even change the way that we perform to assume a new position, and it only which we have worked for many years, craniosacral manipulative therapy. seems as if some energy force has but this evidence does not malign the This model may, however, change extrinsicallymovedthesebones.6Thi s value of craniosacral osteopathy. the ways in which we scientifically recognition of craniosacral motion as Rather, we must redefine the models study the palpated craniosacralmotion a manifestation of a complex system by which we understand the and how we measure its effects u(X)n rather than a type of "energy" is the craniosacral system. Surely, Dr. the entire system. key to our understanding of this Norton has presented disturbing data It has been a source of debate tensegrity model, and this focus on if we view the craniosacral motion within our profession that osteopathic terminology is more than just a simply as a mechanical coiling and physicians using such diverse semantic argument. It is the system uncoiling of the neural tube, but my techniques as high-velocity low that is treated and balanced with goal in this paper is to pro(X)se an amplitude mobilization, craniosacral craniosacral manipulative therapy. alternative paradigm consistent with manipulative therapy, Levitor James Norton, PhD has recently known scientific and experimental orthotics or even sclerotherapy, are

26/AAO Journal Spring 1994 A Tensegrity Model for Osteopathy in the Cranial Field . . by c. H. Cummings, 111,oo all able to achieve positive results in 3. Wales, A. (ed), Teachings in the Tensegrity Systems Corporation, treating patients in chronic pain. The Science of Osteopathy by William Tivoli, NY, p. 23. tensegrity model for understanding Garner Sutherland DO, Rudra Press, theinterconnectednessnotonlywithin 1990, p 15. 13. Wang, W., Butler, J., Ingber, D; the craniosacral system but the entire Mechanotransduction Across the Cell musculoskeletal system may be one 4. Definition of Fluctuation quoted Surface and Through the unifying theory to understand the from Webster's Dictionary by Cytoskeleton; Science, 260: 1124- concurrent effectiveness of different William Garner Sutherland, DO 1127, May 1993. treatmentmodalities. Other functional models, such as relating the 5. Wales, A. (ed), Contributions of 14. Levin, S, The Icosahedron as the craniosacral motion to standing wave Thought - Collected Writings of Three-Dimensional Finite Element in phenomena, may also add JP the William Garner Sutherland, DO, The Biomechanical Support, Proceedings understanding of this system. Sutherland Cranial Teaching of the Society of General Systems It is possible that craniosacral Foundation, 1967, p 140. manipulative therapy, as a therapeutic Research Symposium on Mental modality, effects change upon the Images, Values and Reality, 6. Mitchell, F. Jr., Clinical Philadelphia, May 1986; p. G 14-026. system in ways not understood by Significance of Cranial Suture some very well respected osteopathic Mobility, in: The Cranium and its physicians. Additionally, the concept 15. Ferguson, A., Cranial Osteopathy: Sutures, ed: Retzlaff and Mitchell, fluctuation the CSF may be a A New Perspective, The AAO of of Springer-Verlag, 1987, p. 14. useful teaching tool, a paradigm to Journal, Winter, 1991, p. 13. visualize that which is being 7. Upledger, J. and Vredevoogd, J., perfonned manually. But the "coiling 16. For further information about Craniosacral Therapy, Eastland and uncoiling of the neural tube," complex systems, see: Waldrop, M., Press, Chicago, 1983, p. 11. when taken literally, is a mechanical Complexity, Touchstone, New York, model which does not stand up to 1992 or Gleik, J., Chaos, Penguin 8. Willard, F., Anatomy and known neuroanatomy and biophysics. Books, New York, 1987. Physiology of the CSF, Presentation Thehypothesisofthecraniosacral to the Cranial Academy, June 26, system being a continuous tension 17. For further infonnation about the 1993. network is but one alternate hypothesis holographic concept, see: Talbot, M. regarding this complex system. This The Holographic Universe, Harper model is not inconsistent with known 9. Magoun, H., Osteopathy in the Perennial, 1991 or Gerber, R., biophysics, but this model has a long Cranial Field, Third Ed. The Journal Vibrational Medicine, Bear & way to go to be verified as an Printing Co, Kirksville, MO 1976, p. Company, Santa Fe, 1988. explanation for clinical reality. 24. Hopefully, additional study will 18. Norton, J., A Tissue Pressure further elucidate the craniosacral 10. Levin, S., The Myofascial Skeletal Model for Palpatory Perception of mechanism and thevalueoftreatment Truss: A Systems Science Analysis, the Cranial Rhythmic Impulse, JAOA to that system. in: Barnes, J. Myofascial Release, 91:975-994, October 1991. 1990, p.12. References 19. Norton, J., Presentation to the 11. Levin, S, The Space Truss as a 1. Frymann, V., A Study of the American Academy of Osteopathy, Model for Cervical Spine Mechanics Rhythmic Motions of the Living AOA Annual Convention, October Cranium, JAOA 70:928-945, May - A System Science Concept, in: Back 13, 1993. 1971. Pain--An International Review, ed: Paterson, J. and Bum, L., Kluwer 20. Irvin, R., Presentation to the 2. Feeley, R. (ed), Clinical Cranial Academic Publisher, 1990, p. 235. American Academy of Osteopathy, Osteopathy--Selected Readings, The AAO Convocation, March 1985.0 Cranial Academy, 1988. 12. Tensegrity (handbook), The

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Editor's Editor's pediatrics pediatrics requirements to be passed. I have and even reducing the requirements Because of the confusion that can taken about 100 hours of training for medication. arise from not knowing what to over the past 2 years in one of the As a parent, you might ask to be recommend, I decided to find out techniques, called craniosacral treated yourself, and see how it feels. from the inside, learning the manipulation, and I still have much to Bring your child along so be or she techniques myself and worldng with learn. can watch and you can see bow the the people who do them. This particular technique is physician interacts with your child. I'm a grateful and privileged especially useful in children because Talk to other parents whose children student, who has been made to feel it's so gentle. It's also difficult to learn have the same problem. welcomed by my osteopathic because it's so subtle. Above all, beware the claims of colleagues. The more I learn, the more Nonetheless, I have surprised "cure-all" guarantees. No medical useful I can be to my patients, and myself in seeing its usefulness in the technique is foolproof. that's why I'm in this business. treatment of colic, headaches, chronic Finally, get another opinion if sinus congestion, recurrent ear any practitioner recommends against [Reprinted from Tulsa World, infections and asthma. what seems to be good sense to November 1993.J □ It will never replace antibiotics or you, such as giving childhood surgery, but is helpful in providing immunizations.

Letter to A.T. Still

Dear Doctor Still, notes written in the margins of the physicians utilize your principles and If you were here today, it might book. These are presumably things methods to improve the practice of surprise you to find that people are his professors told him in the medicine. His definition of osteopathy still struggling to find the precise classroom as he studied your is simple and elegant: "Osteopathy is definition of osteopathic medicine. principles. that system of medicine which, whi.le People often ask, "Whatis osteopathic This book gives yet another using every known therapeutic agent medicine? How is it unique? How interesting definition of osteopathy. of proven value,* places chief does it differ from other therapeutic First of all, Doctor Castlio says that emphasis upon the preservation of approaches? What are the basic "Manipulative procedures have never structural integrity in the maintenance principles of osteopathic medicine?" been offered by the osteopathic of health, and regards manipulative You would think that after well over a profession as a substitute for all other therapy as the factor of greatest hundred years of existence of the therapeutic measures. The impor importance in the treatment of profession, we would know all of tance, in their place, of diet, rest, disease." these answers. Still, the questions and hygiene, psychotherapy, physio So as we struggle even today to the conversations go on. therapy, drugs and surgery has never grasp the totality of everything you I have (amongst others) a book been questioned except by extremists. gave us, we should remember to look entitled Principles of Osteopathy, Osteopathy is not a system of drugless at some of the information some of written by Yale Castlio, DO, who was healing. It is not merely 'glorified the early practitioners of osteopathic a professor at the Kansas City College massage'. Nor is it just a complex medicine gave us. It could make our of Osteopathy and Surgery. This book technic for the correction of a search for answers a lot easier. was given to me by a DO friend of particular kind of pathology, the mine who is now retired. It was lesion." Your ongoing student, apparently printed by the college; there DoctorCastliomakesthepointthat Raymond J. Hruby, DO, FAAO is no publication date given. This was neither you nor anyone else ever apparently a book he used when he advocated osteopathy as a panacea. *These words were written in the margin was in school, and so there are a lot of Indeed, your intention was to have by myfriend. □

Spring 1994 AAO Joumal/29 CLINICAL COMPARISON OF TRIGGERPOINT SUBTYPES

Table 3

Subtype Etiology Palpatory Differentation Treatment

Herniation of Correction is completed Triggerpoint therapy tissue through at the end of non-banded triggerpoint therapy or Jones technique NON-BANDED ~f,-,~p fascial plane TRIGGERPOINTS /j,' / .,,.

Herniation of Triggerpoint At completion of tissue through a therapy or Jones triggerpoint therapy a banded fascial technique followed triggcrband is palpable plane distorted by by triggerband BANDED a triggerband technique TRIGGERPOINT .,

Continued from page 18 opposite force to the continuum distortion. When the direction and Continuum Distortions force are adequate, the injury suddenly Continuum distortions are reverses and clinically the injured area clinically the primary cause of ankle then resembles it pre-injury condition. sprains, pulled ribs, contusions and Continuity and continuum are two many other acute injuries seen daily terms used frequently in the fascia! in the emergency room setting. In distortion model. Although they may addition, along with triggerbands, they seem redundant, they are not, and the are associated with chronic problems implications of each are important in such as frozen shoulders, costo understanding fascia! distortions. chondri tis and low back pain. Continuum is an anatomical model in banded Continuum distortions are thought to which tissues are viewed as being in pseudo-triggerpoint occur when the forces of injury cause a constant state of physiological flux fig. 12 an alteration of the transition zone in which one tissue type can be between two tissue types (fig. 13). transformed into another tissue type transitional zones between musculo Continuum technique is designed to through its transition zone depending skeletal tissues are discussed, but the reverse this shifting of tissue upon the external forces applied to it. continuum model applies to all tissue components by applying equal and In Continuum Technique only transition zones and therefore

fig. 13 normal continuum artist's rendition of shifted continuum

30/AAO Journal Spring 1994 TRIGGERPOINT AND CONTINUUM DISTORTIONS Table 4 distortions are fowid in orneara joint, or at the origin or insertion of tendon COMPARATIVE CONTINUUM CATAGORY TRIGGERPOINTS DISTORTIONS or ligament with bone. True triggerpoints are most common in the Herniation of tissue through Alteration of transition zone Etiology abdomen. Palpatory-wise they are fascia! plane between tissues quite different to the experienced Near joints at the origin and ,- Al:xlomen, supraclavicular physician. Continuum distortions are Common location insertion of tendons, ligaments, fossa and coslo-chondro junction smaller, finner and have little give. Triggerpoints are larger, have less Size Dime to nickel Pea-sized or smaller defined borders and are much softer. The release that occurs during Palpatory sensation to Vitamin A or E soft-gel Boggy marble physician capsule correction is also different. The continuum distortion is like a button Moderately tender to Palpatory sensation to patient Moderate tenderness excruciatingly painful slipping into a button hole, while the triggerpoint is a melting sensation. Time of treatment until release Variable-- seconds to minutes Variable-- less than a minute begins The differences are clinically important because how they are Duration of time once release 15 seconds to 3 minutes 1-5 seconds envisioned will direct what force and begins until completion finesse is actually used. In treating Sensation experienced by "Button slipping into a button either of these, it is the skill of the physician and patient during "Melting" hole" release treating physician that will ultimately detennine the success ofthe treatment potentially effects all types of tissues. The tenn continuity refers to the ... ,. , _: ,I , ' interconnections of all the bodily , ¼ I tissues. In the context of fascial II distortions it refers specifically to the I fact that individual fascial fibers pass 11 through various tissues and that an alternation of any given portion of folding that fiber will result in pathological distortion changes elsewhere along that same fiber. Triggerband technique is based on the model of continuity, whereas continuum technique is based on the continuum model. Although I have already spent some Ii time talking about both continuum / distortions and triggerpoints, I think that it is still worthwhile to compare them face to face (Table 4). Despite the fact that they are etiologically different, some physicians may have difficulty discerning two. I the Continuum distortions are the result of shifting in the tissues transition .• / ,/ // ··:,// _./// I zones, and triggerpoints are the fig. 14 protrusion of tissue above its fascial plane. As a general rule, continuum ➔

Spring 1994 AAO Jownal/31 Folding Distortions The tenn fascial plane has been Schematic of Dislocated used primarily by physical therapists Shoulder Causing a and proponents of myofascial release. Folding Distortion They tend to view the fascia as being present in a planar presentation which pathologically develops restrictions. Myofascial release technique is often a very effective approach to fascial distortions, but I believe not necessarily for the same reasons that have been commonly expressed. Fascia unfolding Although fascial planes do exist, they as shoulder do not exist in the same sense that this dislocates piece of paper has a planar presentation. Withinthe fascial planes are fascial bands (fig. 14), which means that an alternation of the plane Fascia is in effect altering the fascial bands. torquing as In addition, most fascial planes are the patient Orthopedic Refolding not static entities that rest in the body responds to manipulative occurs with the pain by like this paper can rest on the table. correction of residual twisting the The planar presentation is dynamic dislocation with folding shoulder and moving. As an ann is raised the incomplete distortion present interosseous f ascial plane shifts untorquing and fig. 15 partially unfolds. If the forces are increased on the arm such as occurs with lifting, the fascia unfolds more. It is this unfolding of the fascial planes that is an important, and until Shoulder with Schematic of now, unknown fascial phenomenon. folding Correcting a So, as forces are applied to the fascial distortion Shoulder Folding plane it is able to unfold to be able to Distortion accommodate the stress. This spreads the forces more evenly throughout the fascia and other musculoskeletal structures that are interconnected. But since the fascia unfolds under stress, Traction is it must be able to refold once the Once traction is stopped the firmly applied fascia refolds into a configura forces are removed. It is this ability as the tion more similar to its pre that often is lost with injury and that distortion is injury state myofascial techniques are the most untorqued effective in treating. To visualize this better, think of the fascial plane as a piece of paper that is folded in fours. As forces are applied to the edges of the paper, it pulls apart. First it becomes a half, fig. 16 then three-quarters and then a full page. Butif the paper is twisted during unfolding it will be contorted. For

32/AAO Journal Spring 1994 proper refolding, the forces must be Fracture of Foreann Resulting in Folding Distortion directed so that the contortion is Fascia reversed. If this does not occur then Normal Radius distorts as bones the refolding cannot be done in a way foreann fracturing separate that restores the fascia to its pre injured arrangement I believe this is what myofascial release does; it restores fascial folds to their pre injured states by simultaneously unfolding and untorquing the fascial distortion. It must be remembered that there may be fascial band distortions as well, and for optimal results these need to be corrected. At times the fascial planar distortion cannot be corrected until the fascial band distortion has been resolved. In any case, the understanding of fascial folding distortions, fascial planes and myofascial release are all important principles in the fascial distortion model. Fig. 15 demonstrates what may happen as a shoulder dislocates and is corrected by orthopedic manipulation. Schematic of Correcting a Fracture Folding Distortion Bone After the fracture has healed the folding Although many times the result is reset with distortion can be treated.Traction is adequate, some of these patients folding applied in several directions a once to distortion unfold the fascia Fracture continue to have residual pain and present decreased range of motion. This is thought to occur because the fascial plane remains torqued and distorted. In fig. 16, myofascial release is used to gently unfold the distortion and then untwist it before refolding occurs. The shoulder itself does not need to be dislocated to accomplish this, although firm traction is often necessary. A total correction of the Once traction is slopped folding distortion does not occur with the fascia refolds into a this treatment alone. Stretching and configuration more similar to its pre-injury strengthening, triggerband technique state and normal everyday use of the fig. 18 shoulder may also be necessary for a complete resolution of the distortion. Figs. 17 and 18 show what may healed is to correct the distortion with hands are necessary to accomplish happen to the fascial planes as a myofascial release. To be successful, this. Again, physical therapy, fracture occurs. Thefasciaisunfolded, forces must be applied in several stretching, strengthening and torqued and then refolded with directions at once to first unfold the triggerband technique may be helpful distorted fascial planes resulting. The fascia and then untorque it before it once the folding distortion has been best treatment after the fracture has refolds. Often two or more sets of successfully treated. ➔ Spring 1994 AAO Joumal/33

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Glossary Glossary Acupressure Acupressure Fascial Distortion: A pathological triggerband pathway some distance used to correct folding distortions if alteration of fascia that results in ahead of the actual point of the the forces are directed so that the dysfunction of the affected fascia and treatment. This is likely the effect fascia is first unfolded and then its associated structures. The four from a double twist in which the untorqued before refolding occurs. principle types are triggerbands, second twist is pushed ahead by the triggerpoints, continuum distortions pressure being applied to the first Non-bandedHerniatedTriggerpoint: and folding distortions. twist. One of the two subtypes of triggerpoints that is characterized by FascialDistortionModel: A medical High Velocity Low Amplitude herniation of tissue through a non model in which most non-orthopedic, Osteopathic Manipulation : A banded fascia! plane. non-neurological and non-organic thrusting technique in which joint musculoskeletal dysfunctions are restrictions are alleviated by sling Osteoarthritis: A condition in which considered to be the result of injured shotting the triggerband wave the fascia in or near a joint has taken or altered fascia. distortions away from the affected on characteristics of the adjoining joint at a very high speed. bone. FascialFiber: A collection of parallel collagen fibers. Jones Points: Anatomical locations Pea: A triggerband subtype that has a of commonly palpated triggerbands, similar etiology to that of a knot, but Fascial Plane: Fascia! tissue that is triggerpoints and continuum clinically has a much smoother and present in an orientation such that it is distortions. rounder palpatory presentation. broad and wide buthas little thickness. Knot: A triggerband subtype that Plantar Fascitis: A triggerpoint Fascitis: An infection that involves occurs when either a portion of a involving the plantar fascia. If a heel the fascia. fascia! band has become folded on spur has formed this is evidence that top of itself or when a portion of a over time the continuum between Fibromyalgia: Multiple fascial band has been ripped from its fascia and bone has shifted distortions that involve large areas of attachment and has become knotted dramatically. the body and have an excessive on top of itself. amountoffascial adhesion formation. Pressure Points: Small, well Massage: A treatment of myofascia demarcated areas of the body that FoldingDistortion:Aprinciplefascial that moves triggerbands away from elicit tenderness with palpation. To distortion type that is the result of a the involved muscle. be adequately treated they must be three dimensional alteration of its differentiated into their anatomical fascialplane:Thesecommonlyoccur Movement : The motion of a etiologies of fascia! distortion types. astheresultofafractureordislocation. triggerband distortion along its Many are either triggerpoints or pathway. This occurs in acute pain continuum distortions, but Frozen Shoulder: Any fascially and during certain treatments such as triggerbands and banded pseudo injured shoulder that has reduced triggerband technique, rolfing or triggerpoints also are described by motion to the extent that daily traction. patients as being pressure points. activities are impaired. Muscle Energy Technique: A Principle Types of Fascial Grain of Salt: A triggerband subtype treatment modality in which muscle Distortions: Pathological alterations that is a much smaller and firmer contractions are used to force the of fascia that have distinct etiologies. version of a knot triggerband away from a crossband There are four currently known: that is in or near a muscle. triggerbands, triggerpoints, contin Groin Pull: A triggerband present in uum distortions and folding distor the groin area. Myofascial Energy Technique: A tions. For a new principle type to be treatment modality in which sustained recognized it must have a completely Headlight Effect During triggerband manual traction is applied until a different etiology than any other type technique this occurs when the patient triggerband distortion is moved out of fascial distortion previously has an awareness of the course of the of an affected muscle. It also can be described.

Spring 1994 AAO Joumal/35 Pseudo-sciatica: Any one of several Tendonitis: A triggerband, or less Triggerband Technique: A manual triggerband pathways that mimic the commonly a continuum distortion, approach to treating distorted fascia! course of the sciatic nerve. present in a tendon. bands in whichthedistortionislocated and corrected along its entire pathway Pulled Muscle: A muscle that has a TennisElbow!LittleLeaguer'sElbow: by using physical force from the triggerband wedged within its belly A tender area over the lateral or medial physician's thumb. at a perpendicular angle to the axis of epicondyle that is caused from a the muscle. triggerband or less commonly a Triggerpoint: A principle fascia! continuum distortion. distortion type that results from a Release: The sensation experienced herniation of tissue through a fascial by both physician and patient at the Traction: A treatment modality in plane also known as a herniated instant of correction of a triggerpoint, which a pulling force is applied in one triggerpoint continuum distortion or folding direction to an affected area of the distortion. body. Very small triggerbands can at Triggerpoint Therapy: A technique times be corrected with this modality, used in the treatment of triggerpoints Rolfing: A treatment of muscle fascia and if the direction and force are in which the physician's thumb is that may result in breaking of appropriate, some folding distortions used to push protruding tissue down adhesions and forcing of a triggerband may also respond to traction. below the fascial plane. out from an involved muscle. Transition 'Zone: The intermediate Twist: A triggerband subtype that ShiftingoftheContinuum:Thisoccurs area between two tissue types that occurs when a portion of a fascia! when forces are applied to the contains characteristics of both tissue band becomes rotated on itself. transition zone between two tissues types. and the percentages of their Wave: A triggerband subtype that is components become altered. Trig gerband: A principle fascial palpated as a wrinkling in the distortion type characterized as being crossband of the adjoining Sprain: A nonspecific description of a distorted fascial band. triggerband. a f ascial distortion. Ankle sprains are most commonly continuum Triggerband Pathway: The Whiplash Injury: A injury that results distortions. Cervical, lumbar and anatomical course that a distorted from a sudden introduction of flexion shoulder sprains are often fascia! band is found to have during and extension to the cervical spine. triggerbands. its correction using triggerband Most of these are triggerband technique. Most patients with the same distortions of the cervical fascia, but Strain Counterstrain Technique: A clinical problems tend to have continuumdistortionsalsomayoccur treatment modality in which a anatomically the same distortion at the origin and insertion of the triggerband is forced away from an pathways. cervical ligaments. involved muscle by alternating the direction of muscle contractions.

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36/AAO Journal Spring 1994 FOURTH ANNUAL OMT UPDATE

IAPPUCATION OF OSTEOPATHIC PROGRAM CONCEPTS THURSDAY, SEPTEMBER 22 SATURDAY, SEPTEMBER 24 IN CUN/CAL MEDICINE 7:00- 8:00 am BreakfastLecture PLUS 5:00pm Opening Reception 5:30- 5:45 Ovetview of the Course Coding Update -- PartII PREPARATION FOR OMM BOARDS "Applications of osteopathic Judith O'Connell, DO concepts in clinical medicine.. . 8:00-10:30 Lecture: "Upper Extmnity What to use: When and Why" Troubleshooting" riliis Academy program was designed to Ann L. Habenicht, 00 Skills Session: Upper ExtremitJ meet the needs of the physician desiring 5:45- 6:15 "Cranial Osteopathy" includes John Hohner, DO the following: question/answer period 10:30-11:00 Break Melicien Tettambel, 00 11:00- 1:30 Lecture: "Lumbar/Pelvis • OMf Review - "hands on experience 6:15- 6:45 "Counterstrain" Troubleshooting" and troubleshooting" Ann Habenicht, DO Skills Session: Lumbar/Pelvis • Integration of OMf in treatment 6:45- 7:15 "Myofascial Release" Boyd Buser, DO of various cases Judith A. O'Connell, DO Wrap-Up Session: (Summary) • Preparation for OMM practical portions 7:15- 7:45 "Visceral Manipulation" Faculty of certifying boards John Glover, DO Saturday PM Free Time ~ Preparation for AOBSPOMM (American 7:45-8:15 "Muscle F.nergy" Osteopathic Board of Special Proficiency Boyd R. Buser, 00 SUNDAY,SEPTEMBER25 in Osteopathic Manipulative Medicine) 8:15- 8:45 "High Velocity/ certifying boards Low Amplitude" ~ Information on CODING Ken Nelson, 00 7:00- 8:00 am Breakfast Lecture for manipulative procedures 8:45- 9:15 "Exercise Prescription" Coding Update Partill • Good review with relaxation John G. Hohner, DO Judith O'Connell, DO and family time 9:15- 9:30 Closing Comments 8:00-10:30 Lecture: "Lower Extremity Ann L. Habenicht, DO Troubleshooting" DATES: Skills Session: Lower ExtremitJ Ken Nelson, DO Sept.ember 22-25, 1994 FRIDAY, SEPTEMBER 23 10:30-11:00 Break (Thursday PM - Sunday AM) 11:00- 1:30 Prepfor Manipulative Boards 7:00- 8:00 am Breakfast Lecture Judith O'Connell, DO LOCATION: Coding Update --"Getting Paid John Hohner, DO Walt Disney World, for What You Do" John Glover, DO Lake Buena Vista, Florida Judith O'Connell, DO Ken Nelson, DO Disney's Contemporary Resort 8:00-10:30 Lecture: "Thoracic Trouble Case Study Prep- - shooting"(to include various "How to write them" CMEHouRS: modalities approach - HVLA, ME, counterstrain, indirect 4 days; 22 hours; AOA Category 1-A Written ExamPrep - MFR & cranial) "What to expect" 21 hours; AAFP Approved Skills Session: Thoracic (In1ennedia1e level coune offered by the AAO) John Glover, 00 Oral Prep-- 10:30-11:00 Break "What to expect & how to do it FEES: 11:00- 1:30 Lecture:"Cervical/Suboccipital Individual Troubleshooting Prior to August 22, 1994 Troubleshooting" Skills Session: MO Members DO/MD $475 Cervical/Suboccipital •••• AlternateProgram .... Non-Members $525 MO Melicien Tettambel, DO 11: 00- I :30 Sports Medicine Wrap-Up Session: (Summary) After August 22, 1994 Extremity Review Faculty Daniel Davison, DO lA.AO Members DO/MD $525 Friday PM Free time for Exploration Boyd Buser, DO MO Non-Members $575 Ann Habenicht, DO Residents/Interns $225 Melicien Tettambel, DO

Spring 1994 AAO Joumal/37 Classifieds

DO Wanted! Iowa Assistant/ DO wanted to experience rural health Major osteopathic college is seeking Associate Professor care in remote mountains of West well credentialed, motivated and Virginia. Beautifully forested com enthusiastic BC/BE osteopathic munity of Man, 80 miles from state physicians to join an expanding Full-time position in the Department of Osteopathic Principles capital in Charleston. Family practi department of osteopathic and Practices, involving didactic as tionerneeded to provide primary care manipulative medicine. Position well as clinical instruction, research, services to catchment of 30,000 includes a good balance between student advising, service on College people. Multi-specialty group hos or patient care and didactic teaching. committees, participation in the pital-employed practice. Salary Excellent benefits with salary practice plan and the usual faculty $80,000 to $100,000 with paid per negotiable according to experience. commitments. Requires an earnedDO sonal/professional insurances and Send letter of interest with CV and degree, board eligibility by specialty other major benefits. Work with three professional references to David college and licensed or capable ofbeing friendly people who have APPRE Boesler, DO, Chairman, Department licensed in the State of Oklahoma. CIATION FOR YOUR WORK and of OMM, University of Osteopathic Preference will be given to need your help. Send CV to or call: Medicine and Health Sciences, 3200 candidates who are board certified and Greg Davis, Appalachian Regional Grand A venue, Des Moines, IA who have publication, research and/or Healthcare, P.O. Box 8086, Lexing academic teaching experience. 50312. The University is an equal ton, KY 40533 1-800-888-7045 or Applications will be reviewed opportunity employer. (606) 281-2537 collect. beginning July 1, 1994 until the position is filled.

DO Needed! Jean-Pierre Harral, DO Reply to: Opportunity available for a Family Visceral Chair of the Search Committee, practitioner to be part of a busy prac Department of OP&P tice at the River Valley Clinic in Manipulation Oklahoma State University Northfield, MN. Must be willing to College of Osteopathic Medicine do OMT. River Valley Oinics are (Part 1) 111 W. 17th Stteet Tulsa, OK 74107 owned by Health One in Minneapo Videotapes lis. Contact: David Flicek, Adminis trator, 1400 Jefferson Road, North WVS0M, OMM Department field, MN 55057, (507) 645-2095. offers a complete set of Dr. Barral The Academy on Visceral Manipulation Pan 1. Invites its OMM/ The only video cassettes Physical Medicine of his Part 1 course available. Component Societies Physician Each set contains to send in their (4) two-hour cassettes to join busy, well established practice course schedules (Edited from 21 hours of workshop) in Colorado Springs, Colorado. Cost for complete set is $3%9 to be published in the Partnership or solo option available. $160 AAO Journals Call Vincent Conner at (719) 260- plus $5 shipping and handling. 8179. Contact: and the WVSOM, OMf DepL AAO Newsletters. 400 N. Lee Street, Lewisburg, WV 24901 (304) 645-6270

38/AAO Journal Spring 1994 Calendar of Events II II

JUNE 22-25 15-17 OMJ' Updale plus 13 House of Delegates' Meeting Preparation/or OMM Boards Deadline for applying for November American Osteopathic Association Walt Disney World Resorts Osteopathic Manipulative Medicine's Atlanta, Georgia Orlando, Florida (OMM) Board examination Contact: Ann Wittner Contact: Diana Finley, AAO Contact: Susan Barnhart AOA Director of Administration Associate Executive Director AAO Administrative Assistant (800) 621-1773 (317) 879-1881 (317) 879-1881 17-18 22-25 18-22 UAAO Council Meeting 23rd Annual Convention Basic Cmuse in Osteopathy Atlanta, Georgia New England Osteopathic Association in the Cranial Field Contact: GiGi Rondinella The Cliff House The Cranial Academy AAO/UAAO Liaison OgW1quit, Maine Oklahoma City Marrion (317) 879-1881 Contact: Nancy Dickey Hours: 40 Category 1-A anticipated Executive Secretary Contact: Patricia Crampton (207) 474-2357 The Cranial Academy AUGUST Executive Director (317) 879-9713 5-7 OCTOBER AAO Education Committee Meeting 23-26 Indianapolis, Indiana 7-9 Explorations in Osteopathy Contact: Stephen Noone, CAE SCIF Continuing Studies Cmuse The Cranial Academy Executive Director Sutherland Cranial Teaching Foundation Oklahoma City Marrion AAO (317) 879-1881 UNECOM Hours: 20 Category 1-A anticipated Contact: Judy Staser Contact: Patricia Crampton 26-28 (817) 735-2498 The Cranial Academy Executive Director Head, Neck and Should Pain; (317) 879-9713 a mlllti disciplinary approach 22-23 Indianapolis, Indiana Basic Percussion Vibrator Course Indiana Academy of Osteopathy AAO Headquarters' Building Contact: Indiana Association of Indianapolis, Indiana JULY Osteopathic Physicians & Contact: Diana Finley, AAO Surgeons Associate Executive Director 9-10 (800) 942-0501 (317) 879-1881 Board of Trustees' Meeting American Academy of Osteopathy SEPTEMBER Indianapolis, Indiana NOVEMBER Contact: Stephen Noone, CAE AAO Executive Director 19-11 (317) 879-1881 Midyear Seminar 11-12 Florida Osteopathic Medical Association Osteopathic Manipulative Medicine's 15-17 Hyatt Regency W estshore (OMM) Boards Board of Trustees' Meeting Tampa, Florida San Francisco, California American Osteopathic Association Contact: FOMA Contact: Susan Barnhart AAO Administrative Assistnat Atlanta, Georgia (904) 878-7364 (317) 879-1881 Contact: Ann Wittner AOA Director of Administration (800) 621-1773 13-17 AOA/AAO Convention San Francisco, California Contact: AAO (317) 879-1881

Spring 1994 AAO Joumal/39 THE OBJECTIVE DOCUMENTATION OF SOMATIC DYSFUNCTION

THEME FOR AAO PROGRAM IN SAN FRANCISCO, CALIFORNIA

IN CONJUNCTION WITH AOA ANNUAL CONVENTION NOVEMBER 13-17, 1994

THE AQA WILL BE SENDING REGISTRATION INFORMATION IN THE NEAR FUTURE. WE INVITE YOU TO SUPPORT THE ACADEMY BY REGISTERING AS AN ACADEMY MEMBER!

MARK CANTIERI, DO, PROGRAM CHAIRPERSON

NON-PROFIT ORG. AAmerican U.S. POSTAGE PAID Academy of PERMIT NO. 14 Osteopathy CARMEL, INDIANA 3500 DePauw Boulevard Suite 1080 Indianapolis, IN 46268-1136

ADDRESS CORRECTION A..'11> FORWARDLI\/GREQUESTED