JOURNAL PM DOC - Jean Guy Sicotte MD, DO

Spring 2000 The AAO Journal/1

TRADITION SHAPES THE FUTURE • VOLUME 10 NUMBER 1 SPRING 2000

2/The AAO Journal Spring 2000

Visceral BiodynamicsAugust 4-6, 2000

San Francisco, CA

Program Chairman: Kenneth Lossing, DO

Christina Williame, DO and George Finet, DO, of Belgium, have been doingresearch on the movements of the abdominal viscera with respiration, for 15 years.The hollow organs were studied with barium and fluoroscopy; the solid organswere studied with echo. Non symptomatic and symptomatic patients were com-pared to find if there was a reproducible normal axis of movement, it’s amplitude,and how dysfunction affected it. These studies are the basis for their unique palpa-tory diagnosis and manipulative treatments.

I attended the first course they ever taught in English, last spring in Norway. Iwas so impressed with the amount I was able to learn, and apply in my practice,that I have invited them to come to San Francisco in August to teach their coursefor the first time in the USA. This is a “hands on” practical course, suitable as afirst visceral course, or an advanced course.

Please come and join us.

Location:Warick Regis Hotel, San Francisco (415) 928-7900.

$145/night, (Lossing group). 8:30 -5 each day, lunch not included.

Fee:Practicing physicians $595, students, interns, and residents $495. Full payment required for

registration. Course limit of 30 participants

Contact:Kenneth Lossing, DO1625 Spring Hill RoadPetaluma, CA 94952

(707) 766-8902 fax (707) 762-5982


The mission of the American Academy of Osteopathy is to teach, advocate,advance, explore, and research the science and art of osteopathic medicine,

emphasizing osteopathic principles, philosophy, palpatory diagnosis andosteopathic manipulative treatment in total health care.

3500 DePauw BoulevardSuite 1080Indianapolis, IN 46268-1136(317) 879-1881FAX (317) 879-0563

1999-2000BOARD OF TRUSTEES

PresidentMark S. Cantieri, DO, FAAO

President ElectJohn M. Jones, DO, III

Immediate Past PresidentMelicien A. Tettambel, DO, FAAO

Secretary-TreasurerAnthony G. Chila, DO, FAAO

TrusteeStephen D. Blood, DO, FAAO

TrusteeBoyd R. Buser, DO

TrusteeDennis J. Dowling, DO, FAAO

TrusteeJohn C. Glover, DO

TrusteeAnn L. Habenicht, DO, FAAO

TrusteeHollis H. King, DO, PhD, FAAO

Executive DirectorStephen J. Noone, CAE

Editorial Staff

Editor-in-Chief ....... Anthony G. Chila, DO, FAAO

Supervising Editor ............. Stephen J. Noone,CAE

Editorial Board .................... Barbara J. Briner, DORaymond J. Hruby, DO, FAAO

James M. Norton, PhDFrank H. Willard, PhD

Managing Editor ............................ Diana L. Finley

The AAO Journal is the official quarterly publication of the Ameri-can Academy of Osteopathy, 3500 DePauw Blvd., Suite 1080, In-dianapolis, Indiana, 46268-1136. Phone: 317-879-1881; FAX: (317)879-0563; e-mail [email protected]; AAO Website: http.//www.aao.medguide.net

Third-class postage paid at Carmel, IN. Postmaster: Send addresschanges to American Academy of Osteopathy 3500 DePauw Blvd.,Suite 1080, Indianapolis, IN., 46268-1136

The AAO Journal is not itself responsible for statements made byany contributor. Although all advertising is expected to conform toethical medical standards, acceptance does not imply endorsementby this journal.

Opinions expressed in The AAO Journal are those of authors or speak-ers and do not necessarily reflect viewpoints of the editors or officialpolicy of the American Academy of Osteopathy or the institutionswith which the authors are affiliated, unless specified.

Advertising Rates for the AAO JournalAn Official Publication

of The American Academy of OsteopathyThe AOA and AOA affiliate organizationsand members of the Academy are entitled

to a 20% discount on advertising in this Journal.

Call: The American Academy of Osteopathy(317) 879-1881 for more information.

Subscriptions: $60.00 per year (USA) $78.00 per year (foreign)

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Professional Card: $60 3 1/2 x 2Classified: $1.00 per word (not counting a, an, the)

®

Editorial SectionFrom the Editor .................................................................................................. 5

by Anthony G. Chila, DO, FAAOMessage from the President ............................................................................... 6

by Mark S. Cantieri, DO, FAAOMessage from the Executive Director ............................................................... 7

by Stephen J. Noone, CAEAffiliated organization’s CME Calendar ........................................................... 8Why Mary is Smiling ........................................................................................ 9Advancing osteopathic medicine in health care: Inegrating OMM into osteopathic medical practice ................................................................ 10by Deborah M. Heath, DO and Albert F. Kelso, PhDLetters to the Editors ....................................................................................... 11From the Archives: The future of the osteopathic profession cannot be predicted with certainty .......................................................................... 14Case Study of a 42-year-old patient with Systemic Lupus Erythematosus ..... 15

by Neil Zucker, MS-III UNTHSC at Fort WorthIn Memoriam ................................................................................................... 18

Bob E. Jones, CAE

Peer-Reviewed SectionBrain wave pattern changes in children with ADD/ADHDfollowing osteopathic manipulation: A pilot study .......................................... 19by Stephen D. Blood, DO, FAAO, FACGP and Barry A. Hurwitz, PhD, BCIACResearch directions since 1940 ....................................................................... 21by Myron C. Beal, DO, FAAO, Professor Emeritus Michigan State UniversityFrom the AOBNMM Files:Case study: OMT and chronic cephalgia ......................................................... 29by Carole S. Brown, DO, CSPOMMBook Review: .................................................................................................. 30by Michael A. Seffinger, DO, FAAFP, CSPOMMLift treatment in Naval Special Warfare (SNW) personnel:A restrospective study...................................................................................... 31by CDR James A. Lipton, MC, USNC; Lt. John S. Brooks, Mc, USNd;ENS (SEAL)Matthew J. Hickey, MC, UNERe ;ENS Brendon G. Drew, MC, USNRf; HM1 (SEAL)Michael T. Eggleston, USNg; HM1 (SEAL) Christopher H. Gemmer, USNh

TRADITION SHAPES THE FUTURE


Instructions to Authors

The American Academy of Osteopathy(AAO) Journal is a peer-reviewed publica-tion for disseminating information on the sci-ence and art of osteopathic manipulativemedicine. It is directed toward osteopathicphysicians, students, interns and residentsand particularly toward those physicians witha special interest in osteopathic manipulativetreatment.

The AAO Journal welcomes contributions inthe following categories:

Original ContributionsClinical or applied research, or basic scienceresearch related to clinical practice.

Case ReportsUnusual clinical presentations, newly recog-nized situations or rarely reported features.

Clinical PracticeArticles about practical applications for gen-eral practitioners or specialists.

Special CommunicationsItems related to the art of practice, such aspoems, essays and stories.

Letters to the EditorComments on articles published in The AAOJournal or new information on clinical top-ics. Letters must be signed by the author(s).No letters will be published anonymously,or under pseudonyms or pen names.

Professional News of promotions, awards,appointments and other similar professionalactivities.

Book ReviewsReviews of publications related to osteo-pathic manipulative medicine and to manipu-lative medicine in general.

NoteContributions are accepted from members ofthe AOA, faculty members in osteopathicmedical colleges, osteopathic residents andinterns and students of osteopathic colleges.Contributions by others are accepted on anindividual basis.

SubmissionSubmit all papers to Anthony G. Chila, DO,FAAO, Editor-in-Chief, Ohio University,College of Osteopathic Medicine (OUCOM),Grosvenor Hall, Athens, OH 45701.

Editorial ReviewPapers submitted to The AAO Journal maybe submitted for review by the EditorialBoard. Notification of acceptance or rejectionusually is given within three months after re-ceipt of the paper; publication follows as soonas possible thereafter, depending upon thebacklog of papers. Some papers may be re-jected because of duplication of subject mat-ter or the need to establish priorities on theuse of limited space.

Requirementsfor manuscript submission:

Manuscript1. Type all text, references and tabular ma-terial using upper and lower case, double-spaced with one-inch margins. Number allpages consecutively.

2. Submit original plus three copies. Retainone copy for your files.

3. Check that all references, tables and fig-ures are cited in the text and in numericalorder.

4. Include a cover letter that gives theauthor’s full name and address, telephonenumber, institution from which work initi-ated and academic title or position.

5. Manuscripts must be published with thecorrect name(s) of the author(s). No manu-scripts will be published anonymously, orunder pseudonyms or pen names.

6. For human or animal experimental inves-tigations, include proof that the project wasapproved by an appropriate institutional re-view board, or when no such board is inplace, that the manner in which informedconsent was obtained from human subjects.

7. Describe the basic study design; defineall statistical methods used; list measurementinstruments, methods, and tools used for in-dependent and dependent variables.

8. In the “Materials and Methods” section,identify all interventions that are used whichdo not comply with approved or standardusage.

Computer DisksWe encourage and welcome computer diskscontaining the material submitted in hardcopy form. Though we prefer Macintosh 3-

1/2" disks, MS-DOS formats using either 3-1/2" or 5-1/4" discs are equally acceptable.

AbstractProvide a 150-word abstract that summarizesthe main points of the paper and it’sconclusions.

Illustrations1. Be sure that illustrations submitted areclearly labeled.

2. Photos should be submitted as 5" x 7"glossy black and white prints with high con-trast. On the back of each, clearly indicatethe top of the photo. Use a photocopy to in-dicate the placement of arrows and othermarkers on the photos. If color is necessary,submit clearly labeled 35 mm slides with thetops marked on the frames. All illustrationswill be returned to the authors of publishedmanuscripts.

3. Include a caption for each figure.

PermissionsObtain written permission from the publisherand author to use previously published illus-trations and submit these letters with themanuscript. You also must obtain written per-mission from patients to use their photos ifthere is a possibility that they might be iden-tified. In the case of children, permissionmust be obtained from a parent or guardian.

References1. References are required for all materialderived from the work of others. Cite all ref-erences in numerical order in the text. If thereare references used as general source mate-rial, but from which no specific informationwas taken, list them in alphabetical orderfollowing the numbered journals.

2. For journals, include the names of all au-thors, complete title of the article, name ofthe journal, volume number, date and inclu-sive page numbers. For books, include thename(s) of the editor(s), name and locationof publisher and year of publication. Givepage numbers for exact quotations.

Editorial Pr ocessingAll accepted articles are subject to copy ed-iting. Authors are responsible for all state-ments, including changes made by the manu-script editor. No material may be reprintedfrom The AAO Journal without the writtenpermission of the editor and the author(s).


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NFrom the Editorby Anthony G. Chila, DO, FAAO

Thank you, Doctor HrubyInvolvement in the activities of the

American Academy of Osteopathyoften provides opportunities for rela-tionships between individuals whichshow parallels and interrelationshipsof careers. I would like to describeone of many which I have enjoyedover the past 30 years.

I was first introduced to RaymondJ. Hruby, DO, when he was associ-ated with William E. Wyatt, DO atthe former Osteopathic Hospital ofMaine, Portland, ME. Both physi-cians were involved in the conduct ofthe hospital-based Service of Osteo-pathic Medicine. At that time, 1981-82, I was beginning my Adjunct Fac-ulty relationship with UNECOM, ini-tiated by Doctor Wyatt. As our ac-quaintance developed, Ray told meof his interest in pursuing Fellowshipin the American Academy of Oste-opathy. In 1983, during the AAONational Convention Program at NewOrleans, LA, I was privileged to serveas his sponsor when he was conferredstatus as a Fellow in the AmericanAcademy of Osteopathy. He then be-came Raymond J. Hruby, DO, FAAO.I had just assumed the Office of Presi-dent of the AAO, and by the end ofthat term (1983-84), had received ap-proval from the AAO Board of Trust-ees to implement an ad hoc LongRange Planning Committee. I wasalso given the responsibility of chair-ing that committee. Ray was one ofmy original appointees. He becameone of several AAO presidents to

emerge from that committee, servingin office 1990-91. We then had theopportunity to work together in thereconstitution of two areas ofcredentialing: AOA board certifica-tion (AOBSPOMM) and the AAOCommittee on Fellowship. In the in-tervening years, our friendship hascontinued to evolve. I now find my-self following Ray in the Editor’s rolefor The AAO Journal. This is an en-tirely new responsibility in which Iwill seek to build on the excellentfoundation which he established.Thank you, Doctor Hruby.

Beginning with this issue, you willnotice the addition of a byline to theJournal’s masthead. As the osteo-pathic profession moves into a newcentury of health care, it seems ap-propriate to view our heritage and ourrole by asserting that TraditionShapes the Future. In following Doc-tor Still’s admonition to “Dig On”, wecan continue to demonstrate distinc-tiveness in the panorama of medicalphilosophies currently available to thegeneral public. The challenge to “DigOn” was also addressed in 1927,within the decade following DoctorStill’s passing. The thoughtful assess-ment provided then by Leon E. Page,DO is the basis for the archival se-lection. A research emphasis will benoted in this issue. Original papers ap-pearing in the Peer-Reviewed Sectiondescribe the research activity of theosteopathic profession since 1940(Beal); a pilot study of brain wave

changes in childhood ADD/ADHDfollowing OMT (Blood and Hurwitz);and a retrospective study of lifttherapy in Naval personnel (Liptonet al.). The definition of Peer Reviewin The AAO Journal is being ex-panded to include AOBNMM andFAAO Case Histories and Book Re-views. This will provide proper rec-ognition of the level of academic re-sponsibility associated with prepara-tion of these categories.

Your comments and suggestionsregarding continuing improvementof The AAO Journal are alwayswelcome.

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Message from the Presidentby Mark S. Cantieri, DO, FAAO

It is time to be reflective as I bring to you my last letter aspresident of the American Academy of Osteopathy. What Ihave enjoyed the most have been my interactions with thestaff of the American Academy of Osteopathy. Their profes-sionalism and support have made this year go by rapidly andwith a minimal amount of anxieties. The original decision tomake Mr. Steve Noone our executive director continues tohave proven to be very wise. One of the most important thingshe brings to his position is a historical perspective of the AAOand AOA and the ability to rapidly retrieve documents fromhis archives relevant to issues between our two organizations.This fact-finding ability has greatly aided us on more thanone occasion over the last year. My compliments also go tothe rest of the staff of the AAO for bringing us the JAAO,handling membership and educational issues, as well as theday-to-day operations of our Academy.

Many goals lie ahead for the Academy. We need to con-tinue to bring quality educational programs to our memberswhich are cutting edge in nature. We can not afford to be-come stagnant and only recycle information. I feel confi-dent that Dr. Eileen DiGiovanna and the Education Com-mittee will be able to improve an already excellent and di-verse set of the educational programs.

Currently we are also looking at our organizational gov-ernment structure. I would like to see the elimination of theBoard of Governors and an expansion of the Board of Trust-ees. I would also like to see a way to better utilize the pastpresidents. When one becomes the immediate past presidentthere is minimal utilization of the knowledge and insightsthat individual has gained during their term. I feel this is awaste of valuable resources. The Gavel Club, which is madeup of past presidents, is a source of knowledge that could bebetter utilized. This year I began having all Board of Trust-ees information sent to the past presidents for their reviewand comments prior to the board's meeting. This is only oneexample of how this resource could be better utilized.

On multiple occasions this year I have encouraged Dr.Marcelino Oliva to appoint an Academy member to theFederal Health Council. Approximately 20 percent of thegraduates of the Fellowship Program in Health Policy areAcademy members, an obvious reflection of our

membership's interest in the policy and politics of medicine.We need to continue to advocate for a position on the coun-cil because of the special insights we can bring to the table.

The AOA has an OPTI Committee, as does the Acad-emy. Last year I moved for the dissolution of the HospitalAssistance Committee and the initiation of an OPTI Com-mittee. We are currently working to find the appropriatechair for this committee and to get the chair appointed tothe AOA OPTI Committee as well. The OPTI Commit-tee needs to establish an examination taken over theInternet that tests osteopathic principles for every clinicalrotation. The colleges also need to have the third and fourthyear students return at least every six months for practicalOMM examinations. Only by having a voice on this com-mittee can these goals being achieved. I also hope to pushfor this requirement from my position on the Council ofPredoctoral Training.

We are also very likely to see continued growth in ourgraduates going to ACGME programs for their postdoctoraltraining. During the last match only 60 percent of D.O. gradu-ates even participated in the AOA match. There is also ashortage of AOA funded internship slots that numbers ap-proximately six hundred short of the number of current gradu-ates. As our number of graduates continues to grow this short-age will also. This will mean that the AOA needs to haveACGME programs approved for osteopathic postdoctoraltraining. Within that training must be necessary requirementsin osteopathic principles and practice.

The OPTI will need to be able to provide these. If not,the Academy already has created educational programs avail-able for this area of need.

Finally, I hope to see the American Osteopathic Board ofNeuromusculoskeletal Medicine include new individualswith diverse backgrounds. Our new board requires additionaleducation in the fields of orthopaedics, rehabilitation, occu-pational medicine, anesthesiology / pain management andphysical medicine, as well as the previous osteopathic ma-nipulative treatment. This board must reflect this type ofknowledge base and experience to effectively create a fairand high quality examination.

I look forward to seeing you in Cleveland.❒

A Time of Reflection


Message from the Executive Directorby Stephen J. Noone, CAE

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The Mission of the American Osteopathic Associationincludes a provision to preserve osteopathic principles andpractice (OPP), thus ensuring access to osteopathic phy-sicians for patients who seek management of their healthcare within this separate yet distinct mainstream medicalprofession. In both its Mission Statement and current stra-tegic plan, the American Academy of Osteopathy (AAO)places a high priority on promoting ongoing research toexplore indications, outcomes, efficacy, and applicationsof OPP and osteopathic manipulative treatment (OMT).

While the osteopathic medical profession is over 100years old, doctors of osteopathy (DOs) have predominantlydevoted their professional lives to clinical practice ratherthan to research and academia. From the perspective oftoday’s “evidence-based medicine,” one outcome of theprofession’s focus on patient care is the relative lack ofscientific research on the clinical efficacy and outcomesof the practice of osteopathic medicine, particularly stud-ies dealing with the integration of OPP/OMT in total healthcare. However, the publication of the AOA’s low back painstudy in the November issue of the New England Journalof Medicinei may well serve as a catalyst to advance theprofession’s research agenda.

The evolution of technology and electronics offers theosteopathic medical profession attractive mechanismswhich can facilitate research studies on osteopathic medi-cal practice and promote wider participation on the partof DOs in active clinical practice. The AAO’s Louisa BurnsOsteopathic Research Committee (LBORC) has alreadycreated and validated a paper version of the OutpatientOsteopathic SOAP Note Form which documents bothuniquely-osteopathic as well as standard medical elementsof the physician-patient encounter.ii

The LBORC has now embarked on an ambitious projectto convert the Outpatient Osteopathic SOAP Note Formto an electronic version for placement on the Internet andfor use in DOs’ offices to record relevant patient data be-ginning March 2001. Physicians will be able to send thisdata over the Internet to a secure Web site which will serveas the National Osteopathic Clinical Database at Nova

Research on OPP/OMT is Criticalto the Profession’s Future

Southeastern University College of Osteopathic Medicine.Researchers ultimately will be able to access this aggre-gate patient data for testing their hypotheses on the effectof OPP/OMT in patient care. The LBORC has consultedwith other osteopathic organizations in the developmentof this project, including the American Osteopathic Asso-ciation, the American Association of Colleges of Osteo-pathic Medicine and the American Osteopathic Collegeof Family Physicians.

In 1996, the Josiah Macy, Jr. Foundation convened thesecond of two conferences to promote interaction andimproved communication between the osteopathic andallopathic medical professions.iii Among the recommen-dations of this second conference was the challenge “todevelop jointly a research agenda to investigate the effi-cacy of OMT in conditions in which documentation islacking.” The Academy believes that the development ofthe electronic Outpatient Osteopathic SOAP Note Formwill serve as a catalyst for the advancement of this re-search agenda.

The economic bottom line for the osteopathic medicalprofession is the recognition of increased negative pres-sures which discourage the delivery of OPP/OMT in pa-tient care. Third party payors deny reimbursement forOMT, citing the lack of scientific studies which documentits medical necessity and/or efficacy. Health maintenanceorganizations deny DOs reimbursement for OMT, citingreliance on an allopathic practice model and need to in-crease the volume of patients served by the physician onany given day. The Academy believes that the develop-ment of the National Osteopathic Clinical Database andadvancement of the profession’s research agenda will dem-onstrate the cost-effectiveness of osteopathic medical prac-tice. When researchers publish such documentation in themedical literature, the profession’s leaders will have cred-ible, scientific evidence to advocate for appropriate utili-zation and reimbursement for OPP/OMT.

In addition to its application for research, an electronicversion of the Outpatient Osteopathic SOAP Note Form


and a National Osteopathic ClinicalDatabase could serve as a tool forOsteopathic Postdoctoral TrainingInstitutes in tracking the integrationof osteopathic principles and practiceand osteopathic manipulative treat-ment on the part of medical students,interns and residents. The osteopathicmedical profession could use the elec-tronic Outpatient Osteopathic SOAPNote Form as a foundation fromwhich to build practice guidelines

Affiliated Organization’sCME Calendar...

unique to the profession. In their in-dividual offices, DOs could use thisosteopathic electronic medical recordboth to improve patient care and busi-ness management.

iAnderson GBJ, Lucente T, Davis AM,Kappler RE, Lipton JA, Leurgans S; Acomparison of osteopathic spinal manipu-lation with standard care for patients withlow back pain. N Engl J Med1999;341:1426-31.

April 8-9Fifth Annual Family PracticeReview and ReunionDept. of Medical Education and theFamily Practice Residency ProgramGrandview Hospital/Medical CenterHours: 11 Category 1A (applied for)Dayton, OHContact: Jennifer Horvath

(937) 222-4213

April 28-3050th Anniversary / Annual ConventionFlorida Academy of OsteopathyHours: 20 Category 1ACrystal River, FLContact: Dr. Kenneth Webster

(727) 581-9069

May 3-693nd Annual Clinical Assembly &Scientific SeminarPennsylvania Osteopathic Medical AssnHours: 40 Category 1A anticipatedPhiladelphia, PAContact: Mario Lanni, Exec. Dir.

POMA(717) 939-9318

May 4-7103rd Annual ConventionIndiana Osteopathic AssociationHours: 30 Category 1AIndianapolis, INContact: Michael Claphan, CAE

(317) 926-3009

May 5-7NeuroFascial Release Conference, a newparadigm in osteopathic thoughtArizona Academy of OsteopathyStephen M. Davidson, DOContact: Stephen Davidson, DO

(800) 359-7772

May 18-22Basic Course“Osteopathy in the Cranial Field”Sutherland Cranial Teaching FoundationHours: 40 Category 1ASan Diego, CAContact: Judy Staser

(817) 926-7705

May 26-28The Fundamentals of Cranial Osteopathyfor UndergraduatesJoseph S. Grasso, DOHours: 18 Category 1AOrlando, FLContact: Joseph Grasso, DO

(407) 380-8863

June 8-11OMT With a View:Pain Management by the SeaOsteopathic Physicians &Surgeons of CaliforniaHours: 20 Category 1ADana Point, CAContact: OPSofC

(916) 561-0224

iiSleszynski SL, Glonek T, Kuchera WA, Stan-dardized Medical Record: A New Outpa-tient Osteopathic SOAP Note Form: Vali-dation of a Standardized office formagainst physician’s progress notes, JAOA1999;99:516-529

iiiSirica CM, editor, Current Challenges toM.D.s and D.O.s: Proceedings of a Con-ference Chaired by D. Kay Clawson,M.D., New York, Josiah Macy, Jr. Foun-dation, 1996.❒

June 15-18101st Annual Convention & Scientific SeminarTexas Osteopathic Medical AssnCorpus Christi, TXContact: Mary Waggoner, TOMA

(800) 444-8662

June 17-21Basic CourseThe Cranial AcademyPCOMPhiladelphia, PAHours: 40 Category 1AContact: The Cranial Academy

(317) 594-0411

June 22-25Annual ConferenceThe Cranial AcademyPhiladelphia, PAContact: The Cranial Academy

(317) 594-0411

August 4-6Visceral BiodynamicsKenneth Lossing, DOSan Francisco, CAHours: 24 Category 1AContact: Kenneth Lossing, DO

(707) 766-8902


Mary Philanthropist decided togive $10,000 to the major fund driveof her favorite charity. But first, shedonned her gift-planning hat.

She remembered that, usually, it’sbetter to donate appreciated stockthan to write a check for the sameamount. Locating a recent statementfrom her stockbroker, she reviewedher list of holdings. She noted that herstock in OPQ Corp. was valued at$100 per share. Checking the eveningpaper, she found that the stock wasstill trading at that price.

Years ago, Mary purchased 1,000shares of OPQ stock at $10 per share.Since then, the stock has appreciatedremarkably to where her investmenthas increased to $100 per share, witha current value of $100,000.

She considered her options. If shesold 100 shares of the stock, shewould have $10,000, less the salescommission, to give the charity. How-ever, at tax time, she would owe capi-tal gains tax on the growth portion ofthe stock, the appreciation amount.Since the 100 shares had a cost basisof $1,000, the taxable amount wouldequal $9,000. Applying a capitalgains tax rate of twenty percent to the$9,000, she calculated a tax bill of$1,800.

Now it’s possible she may be ableto offset this tax with the charitablededuction resulting from her gift. But,then, the deduction would not beavailable to offset other taxable in-come.

A smile emerged. She took plea-sure reminding herself that, insteadof selling the stock, she could instructher broker to transfer 100 shares di-rectly to the charity’s account. Then,because the charity is a qualifiedcharitable organization, it could sellthe stock without any tax on the gain.And what’s more, she would receive

a charitable tax deduction for the fullfair market value of the stock.

If she sold the stock and gave thecash, she’d receive only the one ben-efit of the charitable tax deduction.But if she gave the stock directly tothe charity, she’d receive two ben-efits: the charitable tax deduction andthe bypass of capital gains.

When she discussed the idea withher accountant, he affirmed her pru-dence and, knowing her healthy fi-nancial condition, encouraged her toproceed. He also reminded her thatthe charitable tax deduction of$10,000 could only be applied against30 percent of her adjusted gross in-come, whereas a cash gift had a de-ductibility ceiling of 50 percent.However, if she wasn’t able to use allof the deduction in one tax year, shecould carry forward the unused por-tion into the next year, up to fiveyears.

Mary called the charity’s plannedgiving department and told them ofher intentions. The charity did nothave an account with her broker, butthe planned giving officer said hewould call the broker and arrange fora temporary account so the stockcould be moved from her account tothe charity’s account. Once the trans-fer occurred, the charity would in-struct the broker to sell the stock andmail a check, less the commission, tothe charity.

The planned giving officer sug-gested to Mary that she write out hergiving instructions (including signa-ture and date) and mail them to herbroker, with a copy to the charity.That’s all she needed to do. Simple.

Once Mary made the gift, the bro-ker sent a written confirmation to thecharity indicating that the stock hadbeen transferred and that the brokerwas holding it as agent for the char-

Why Mary is Smiling

ity, awaiting selling instructions.What about you? Do you have ap-

preciated assets such as stocks andbonds that could make a tax-wisegift? Did you have to pay significantcapital gains taxes in 1999? Youmight plan ahead now for the 2000tax year and consider this option toavoid the captial gains tax while en-joying the benefits of a deductiblecharitable contribution to the Ameri-can Academy of Osteopathy.

If you want further information,please fill out and mail the form be-low. Or call AAO Executive Direc-tor Steve Noone at (317) 879-1881.❒

(Please complete and return thisreply form.)

Dear Friends at the AAO:

___ Please send me informationabout giving stock.

___ Please send me informationabout giving real estate.

___ Please contact me personallyabout a possible gift.

Name:______________________

Address:____________________

___________________________

City:_______________________

State:______ Zip:____________

Phone:__________________

Mail this form to:American Academy of Osteopathy,3500 DePauw Blvd., Suite 1080,Indianapolis, IN 46236-1136.


Advancing OsteopathicMedicine in Health Care: 1

Integrating OMM into Osteopathic Medical Practiceby Deborah M. Heath, DO and Albert F. Kelso, PhD

The initial article in this series ad-dressed the challenge of osteopathicmedicine in the next millennium.2 For-mulation of a management plan for or-ganizational change in meeting this chal-lenge accomplishes and maintains theosteopathic health care mission. A suc-cessful change depends upon establish-ing, first, an integrated educational pro-gram for doctoral, post-doctoral andcontinuing education of physicians and,second, applied clinical research pro-grams to provide evidence-based dataon patients’ health and illness, and anequal focus on including advances inmedical practice. The student and prac-ticing physicians need the knowledge,skills and experience and an opportunityto understand and treat the whole patient.

Osteopathic history indicates thatpatient support for the professionstemmed from the health outcomes qual-ity health care includes a focus on therole of the somatic system in health ben-efits received from care provided byfounders of the osteopathic profession.3

Patients’ testimonials ensured survivingstate legislative challenges during the de-velopment of osteopathy in the UnitedStates. However, patient testimonials inthe twentieth century must be docu-mented as patient satisfaction, improvedhealth status, and effectiveness in man-aging a patient’s health problems.4 Astrategic management plan to accom-plish the delivery of quality osteopathiccare and document change in patients’health status can create an image at theforefront of health when it is imple-mented and controlled, anticipating fu-ture challenges in health and cost effec-tive health care for patients.

An ad hoc committee of the Ameri-can College of Physicians responded topublic and governmental efforts to pro-vide quality health care as early as 19805

(see preface). Attention to cost effective-ness received attention much later.6 Pub-lic interest in modern medicine is evi-dent in the media and leading medicalpublications. A recent publication inorthopedic medicine documents, withevidence-based data, the functional andother health care outcomes obtained inmanaging musculoskeletal disorders.7

Unfortunately, management of manualmedicine, other than a few referencesin the field of medicine, gives little at-tention to documenting health and costeffectiveness. Publishing guidelines forprocedures and providing evidence-based data to support osteopathic prac-tice advances osteopathic medicine tothe forefront of health care practice. Os-teopathic medicine’s heritage is in dan-ger of being lost8 because our presenttrend in education and practice empha-sizes medical practice and places littleor no emphasis on restoring and main-taining neuromusculoskeletal systemfunctions9,10 and its relationship tohealth.

Strategic plans, to manage continualchange in businesses and professions,address need, resources and manage-ment to be considered in providing aproduct or service. Models developedin business management over the pasttwenty-five years provide a frameworkfor a health care strategic managementmodel. Planning, implementing andcontrolling the integration of manualmedicine and associated neuromuscu-loskeletal knowledge into physician continued on page 37

education insures that our future healthcare system meets challenges requiringchange in management. Implementingand monitoring the application of theplan creates and maintains a modern os-teopathic medicine practice.

A clearly stated mission for the os-teopathic profession is essential to plan-ning continuing change in management.Does our present mission statement in-dicate that osteopathic health care pro-vides equal attention to general and spe-cific health problems?11 The presentmission statement needs to be reviewedto insure that it reflects our heritage andit’s importance in current health care. Achange in osteopathic management ofhealth care delivery includes publishingguidelines for health assessment proce-dures and measuring health care effec-tiveness. The elements of an osteopathichealth care plan need to address our his-torical foundation, improving the healthof patients. This should include researchon effectiveness of manual treatments(interventions) used in general, specificor adjunctive health care.

Modifying patients’ specific medicalproblems is the main focus of the gov-ernment, public and patients’ expecta-tions for effective health care at an af-fordable price. (see reference 4) Thisview overlooks the contribution madeto recovery from illness, accidents anddisease that is an adjunct accruing froman improvement in total health status.Osteopathic physicians have referred tothis phenomenon as restoring the body’scapacity to heal itself. Meeting patients’expectations includes documentingchanges in health status. Health as de-


Letters to the EditorDear Editor:

I read with concern Dr. Jealous’article, “Accepting the death of oste-opathy.” I fear that many other Acad-emy members believe, as Dr. Jealousdoes, that osteopathy is, in fact, deadand must experience a rebirth in or-der to live again. Such beliefs in thedemise of osteopathy have served tofuel the rise and subsequent supportby American DOs of non-physicianosteopathic programs internationally.This “new” osteopathy is everythingDr. Jealous infers as the rebirth ofosteopathy, and is spreading likewildfire. Professional licensure fornon-physician DOs in Europe andabroad is already a fact. This mightseem a positive development to truebelievers of osteopathy but, in fact, Ibelieve it is the greatest threat to os-teopathy since the California amal-gamation.

I believe that osteopathy is, in fact,still alive and well; rather, it is theosteopath who is dying. What is thedifference between the death of oste-opathy and dying osteopaths? Thedifference is more in the rebirth thanin the death itself. The death of oste-opathy requires a new profession tobe reborn; dying osteopaths only re-quire a new generation of osteopaths.Consider who and what we’re talk-ing about-a new profession versus anew generation.

Currently, comprehensive educa-tion and licensure of non-physicianosteopaths is an international phe-nomenon. But, what happens whenthe phenomenon reaches America?Imagine, if you will, an Americanosteopathic profession of non-physi-cians. How will Congress react whenit hears that non-physician osteopathsfar outnumber physician osteopaths,not to mention that medical osteopa-thy is “dead”? For a new generationof osteopathic physicians to surface,alliances must be made with other

physicians eager to embrace osteopa-thy, establishing medical standardsfor osteopathic practice, education,and certification. This represents anew resurgence of osteopathy that,personally and professionally speak-ing, I feel reflects more accurately thevision of osteopathy and its founder,A.T. Still.

The new osteopath, physician ornon-physician, who shall decide?

Harry D. Friedman, DOCorte Madera, CA

Dear Editor:We very much appreciated the ex-

cellent article by Jackson and Steele,1

“Osteopathic treatment of asthma: Aliterature review and call for re-search” and would like to pass alongsome additional information on thisimportant topic.

With regard to asthma pathogen-esis, the autonomic imbalance modelin its various forms has been widelyexplored. However, the vasomotorcomponent of asthma, with respect toautonomic imbalance, represents asignificant although relatively ob-scure aspect that holds great poten-tial as a research model linking so-matic dysfunction to the pathophysi-ology of asthma. Charles Hazzard, aninfluential early osteopath, summa-rized the effects of lesions and asthmaas abnormal motor effects, and abnor-mal vasomotor effects:

“... lesions cause abnormal motoreffects both in arousing spasmodicconditions of the muscles of the bron-chial walls, and in the vasomotor ac-tivity that produces the hyperemia ofthe mucous membrane.”2

The traditional osteopathic per-spective coincides with modern viewson nervous system involvement inasthma. Dysautonomia has been de-

scribed in asthma with an emphasison hyper-responsiveness of the para-sympathetic system3,4 beta-adrenergichypo-responsiveness5 or both.6,7 Incontrast to the relatively denseparasyrnpathetic nerve supply to air-ways, sympathetic (adrenergic) inner-vation is sparse in humans.8 However,sympathetic innervation of the bron-chial blood vessels is considerable.Thus, beta-adrenergic hypo-respon-siveness may reflect an inhibition ofthe sympathetic system which resultsin vasodilation of the bronchial bloodvessels. Hyperemia of bronchiai ves-sels in asthmatics has been noted9,10,11,12

and attributed to sympathetic vasodi-lation.13 Exercise-induced asthma isthought to be produced by increasedbronchial circulation.14,15

With regard to the widely publi-cized asthma study by Balon et al,16

“active” and “simulated” chiroprac-tic manipulation were used as adjunc-tive treatment for childhood asthma.The active treatment consisted of“manual contact with spinal or pel-vic joints followed by low-amplitude,high velocity directional push oftenassociated with joint opening, creat-ing a cavitation, or “pop”. This treat-ment is a standard direct techniqueused by a wide variety of manualtherapy practitioners, primarily chi-ropractors and osteopaths. The simu-lated treatment involved soft-tissuemassage and gentle palpation to thespine, paraspinal muscles, and shoul-ders. Jongeward questioned the ap-propriateness of the simulated treat-ment, noting that standard chiroprac-tic practice commonly includes softtissue work.17 Furthermore, the shamtreatment in the Balon et al studybears a marked similarity to a tradi-tional osteopathic treatment forasthma2,18,19,20 all documented on theinternet.21

The authors of the study summa-rized the simulated treatment by stat-


ing, ‘’Hence, the comparison of treat-ments was between active spinal ma-nipulation as routinely performed bychiropractors and hands-on proce-dures without adjustments or manipu-lation.” Apparently, these investiga-tors were unaware of the early osteo-pathic works addressing asthma andthe more recent literature on OMT forrespiratory problems in general, par-ticularly as cited in Osteopathic Con-siderations in Systemic Dysfunction.22

The results as reported by the re-searchers were, “Symptoms ofasthma and use of Bagonists de-creased and the quality of life in-creased in both groups, with no sig-nificant differences between thegroups.” Based on this equality ofimprovement, the authors concluded,“the addition of chiropractic spinalmanipulation to usual medical careprovided no benefit”.16 In our view,this is unfortunate, because the dataindicates that the subjects in bothgroups improved after being treatedby standard chiropractic and a rathercrude form of traditional osteopathy.

Our letter published in the NewEngland Journal of Medicine23

pointed out the methodological flawsof such designs where sham treat-ments closely resemble specific tra-ditional osteopathic techniques. Ourarticle in the Journal of Manipulativeand Physiological Therapeutics24 ad-dresses the question of physiologicaleffects of manual therapy and appro-priate sham treatments in more detailand, like the Jackson and Steele ar-ticle, emphasizes the need for moreresearch.

References1. Jackson KM and Steele KM: Osteopathic

treatment of asthma: A literature reviewand call for research. AAO Journal, 1999;9(4):23-27

2. Hazzard C: The Practice and AppliedTherapeutics of Osteopathy. 3rd ed.Kirksville, MO; Journal Printing Com-pany, 1905:75-80.

3. Kallenbach JM, Webster T, DowdeswellR, Reinach SG, Millar RN, Zwi S: Reflexheart rate control in asthma. Chest, 1985;87:644-648.

4. Shah PKD, Lakhotia M, Mehta S, Jain SK,

Gupta GL: Clinical dysautonomia in pa-tients with bronchial asthma. Chest, 1990;98:1408-1413.

5. Casale TB: The role of the autonomic ner-vous system in allergic diseases. Annalsof Allergy, 1983; 51:423-429.

6. Kaliner M, Shelhamer JH, Davis PB,Smith LJ, Venter JC: Autonomic nervoussystem abnormalities and allergy. Annalsof Internal Medicine, 1982; 96:349-357.

7. Jindal SK, Kaur SK: Relativebronchodilatory responsiveness attribut-able to sympathetic and parasympatheticactivity in bronchial asthma. Respiration,1989; 56:16-21.

8. Nadel JA, Barnes PJ: Autonomic regula-tion of the airways. Ann Rev Med, 1984;35:451-467.

9. Baier H, Long WM, Wanner A: Bronchialcirculation in asthma. Respiration, 1985;48:199-205.

10.Lockhart A, Dinh-Xuan AT, Regnard J,Cabanes L, Matran R: Effect of airwayblood flow on airflow. Am Rev Respir Dis,1992; 146:Sl9-S23.

11.Li X, Wilson JW: Increased vascularity ofthe bronchial muscosa in mild asthma. AmJ Respir Crit Care Med, 1997; 156:229-233.

12. Kumar SD, Emery MJ, Atkins ND, DantaI, Wanner A: Airway mucosal blood flowin bronchial asthma. Am J Respir Crit CareMed, 1998; 158:153-156.

13. Widdecombe JG: Neural control of air-way vasculature and edema. Am RevRespir Dis, l99l; 143:S18-S21.

14. McFadden ER: Hypothesis: Exercise-in-duced asthma as a vascular phenomenon.The Lancet, 1990; 335:880-883.

15.Anderson SD, Daviskas E: The airway mi-crovasculature and exercise inducedasthma. Thorax, 1992, 47:748-752.

16.Balon J, Aker PD, Crowther ER,Danielson C, Cox PG, O’Shaughnessy D,Walker C, Goldsmith CH, Duku E, SearsMR: A comparison of active and simulatedchiropractic manipulation as adjunctivetreatment for childhood asthma. N Engl JMed, 1998; 339:1013-20.

17.Jongeward BV: Chiropractic manipulationfor childhood asthma. N Engl J Med, 1999;340:391-392.

18.Barber ED: Osteopathy Complete. 4th Ed.Kansas City, MO: Hudson-Kimberly Pub-lishing Company, 1898:60-68.

19.Goetz, EW: A Manual of Osteopathy. 2nded. Cincinnati, OH: Natures’s Cure Co.,1909:85-86.

20.Murray CH: Practice of Osteopathy (6thEdition). Elgin, Illinois: CH Murray, 1925.

21.McMillin D: The Early American ManualTherapy website is located at: http://members.visi.net/mcmillin/l998.

22.Kuchera M, Kuchera WA: OsteopathicConsiderations in Systemic Dysfunction.

Kirksville, MO: KCOM Press, 1991.23.Richards DG, Mein EA, Nelson CD: Chi-

ropractic manipulation for childhoodasthma. N Engl J Med, 1999; 340(5):391-392.

24.Nelson C, Redwood D, McMillin D,Richards DG, Mein EA: Manual healingdiversity and other challenges to chiro-practic integration. J Manipulative PhysiolTher (2000, in press).

David L. McMillin, MADouglas G. Richards, PhD

Eric A. Mein, MDCarl D. Nelson, DC

Meridian Institute1853 Old Donation Parkway, Suite 1,

Virginia Beach, Virginia 23454PHONE: (757) 496-6009

FAX: (757) 496-1013EMAIL: [email protected]

Dear Editor:James Jealous, DO should be

highly commended for an excellentpresentation of his Thomas L.Northup Lecture, “Accepting theDeath of Osteopathy: A New begin-ning”. While it is difficult for me toaccept the fact that osteopathy is dy-ing, Dr Jealous told it like it is. Theart of treating the whole person Froman osteopathic viewpoint has beenlost. Our question is, can we get itback?

As an older DO, I can recall manyosteopathic physicians prior to WorldWar II who had acute care practices,who never lost a patient treating alltypes of pneumonia, influenza, strepthroat, rheumatic fever, glomerulo-nephritis, peptic ulcer disease, otitismedia, mastoid infections, severe si-nus infections and many other suchproblems. These physicians werepracticing with just manipulativetherapy. However when the antibiot-ics were introduced, ten fingered os-teopathy was omitted, because theDOs at that time wanted to be mod-ern and up to date, employing the lat-est in pharmaceuticals. They aban-doned their birthright and decidedthat helping the body to heal itself wasan unnecessary waste of time, as they


now could treat specific diseases andforget about the patient who had thedisease. Those DOs had become realdoctors overnight, but unfortunatelythey lost their confidence, knowledgeand interest in treating these acutecare problems with manipulation.

When these DOs accepted thismind set, osteopathic medicine, as itwas practiced before the mid-1940sbegan to die and it has been dyingever since. The DOs of the pre-1940’spossessed the confidence, the insightand the real ability to get their patientover their illness and restore them tohealth quickly. Furthermore, thesephysicians were not losing their pa-tients to fatal drug reactions, whichin the last year caused 180,000 deathsin these United States and was infourth place as the leading cause ofdeath behind heart attacks, cancer andstrokes. Perhaps, we ought to have afund drive to control this disturbingproblem.

I am not opposed to pharmaceuti-cals, but some real consideration mustbe given to the patient before wereach for the prescription pad or thesyringe. But if I can restore health tomy patient without resorting to anyother modality, I will utilize osteo-pathic manipulation, the most pow-erful, single modality in the healingarts. Fortunately, from the time that Igraduated from PCOM, I developedsufficient manipulative skills to assistmy patients in their recovery and attimes was amazed with the results thatI did not necessarily expect. But un-fortunately, the more recent DOgraduates will not try manipulation,nor take the time to learn, becausethey do not understand that it works.

Many years ago, my father-in-law,a well-respected busy MD generalpractitioner in Hancock, N.Y. said tome in 1950, “ It is a crying shame thatwe MDs do not wake up and practicelike you DOs”. He could see the ad-vantages of having that extra modal-ity of manipulative therapy to use inpractice. He witnessed first hand whatthe bonafide osteopathic physicianwas able to accomplish with their pa-

tients that the MDs could not. He sawthe concept of osteopathic medicinethat escapes so many young osteo-pathic student minds today. It is ashame, but they will be shortchang-ing their patients, though of course,it is not all their fault.

Another reason why osteopathy isdying is that the art of medical prac-tice has been lost to the techniciansand technology advancements of thelast 30 years. A physician no longerhas to lay on hands, palpate, feel,touch, listen, think anatomically. TheMRIs, CT scans, ultrasound machineswill make the diagnosis, find the dis-ease, but will never find health. AsDr. Still said, “ Any fool can find dis-ease, it takes a real physician to findhealth. How true.

As for me, I would not trade myDO education, or my degree for 10MD degrees to serve as a generalpractitioner. If I were to have receiveda MD degree, I would have felt inad-equately trained. Too much attentionhas been given in our osteopathiccolleges to turn out, “Just as good asphysicians”. As a profession, perhapswe should think more about our heri-tage, condense our colleges into realosteopathic institutions and give realincentives to those who wish to studyand teach manipulation. In so doing,we might just have a good chance torevive a dying profession. But theway we are headed, we are doomedand the legacy of A.T. Still will be ashort page in the history book.

Manipulation takes time, but it isso rewarding to the patient and to thephysician. I have never known anyDO who was reasonably skilled in theart of manipulation, who could notmake a respectful living, and theirpatients were most willing to paythem for that added benefit. With thetrend in health care today, I think theyoung DO student better take anotherlook at the value and the benefits ofmanipulation.

Robert T. Kellam DOOrlando, Florida

Dr H.H. Underwood, the first DO topractice in the State of New York,practiced in Hancock, N.Y.

Dear Editor:The article in the Winter 1999

AAO Journal by Charles Crosby at-tracted my attention.

As recently as the 28th of Novem-ber, at the Osteopathic Research Con-ference in London, sponsored by theBritish College of Naturopathy andOsteopathy, a paper was presentedlooking at the increase of pulmonaryFEV1 in asthmatics following simplerib raising. One might find it inter-esting that Australian researcher mea-sured a 16% increase in FEV1 afterrib raising (much the same as Dr.Crosby finding). Dale PrattHarrington, DO, at OU-COM, did apilot study of a similar nature on post-op patients.

Both studies indicated an increasein pulmonary ventilation.

The question is now raised whethermanagement of the leg length in-equality played any role in changingthe pulmonary function in this admit-tedly small sample given we havesome proof in hand that manipulationalone seems to do just that.

All of which seems to support theold adage that any research projectasks more questions than it answers.

My research mentors, when help-ing me plan outcome studies of theeffect of manipulation, where con-trols and “sham treatment” defy de-scription and application, suggestedwe document first that the usual andfull osteopathic management of a pa-tient does cause a measurable change.Once this is established one can teaseout each component of the manage-ment plan and test it separately fortherapeutic efficacy.

Before he goes beyond the pilotstudy, Dr. Crosby might want to re-design his project in a way that in-creases its statistical power, perhapsby a crossover design as well as byincreasing the m~, and certainly bysatisfying himself he wants to test theoutcome of two therapeutic modali-ties applied at the same time.

{


From the Archives

The Future of the OsteopathicProfession cannot be Predictedwith Certainty

The future of the osteopathic pro-fession cannot be predicted with cer-tainty. The fundamental principleswhich underlie osteopathic practiceare of course permanent and will en-dure under whatever name they arepracticed. The osteopathic professionmust maintain its independence untilthe principles which it represents re-ceive universal recognition by thetherapeutical world. The fear is some-times expressed that osteopathy willbe absorbed by medicine. This can-not be so, since osteopathy is a partof medicine and consists of a set ofprinciples which are true. As long asthe profession of osteopathy main-tains its own institutions and abidesby its principles it will maintain its iden-tity. When the principles of osteopathyare identical with the principles ofmedical practice, the profession of os-teopathy will have fulfilled its mission.The questions as to whether the heal-ing art will adopt the name osteopathyis a minor matter. The history of theosteopathic profession at any such timewill speak for itself and the contribu-tion of Andrew Taylor Still will be rec-ognized for its true worth.

Present indications do not point tosuch a happy summation in the nearfuture. Half a century is an insuffi-cient time to overthrow the accumu-lations of centuries of tradition andcustom. The task of the osteopathicprofession to establish the principlesof Dr. Still as the foundation of prac-tice is but begun. In the meanwhilegrowing public opinion, more ad-equate educational advantages, well

financed institutions, and scientific in-vestigation will continue to stimulatethe growth of the greatest contributionto the healing art in recent times.

[Editor’s Note: Should the use ofthe term Osteopathy continue to beused interchangeably with Osteo-pathic Medicine? Through the effortof the leadership of the AmericanAcademy of Osteopathy in 1994, theBoard of Trustees of the AmericanOsteopathic Association adoptedsuch a policy. All AOA policies arereviewed at five-year intervals. A July1999 Resolution recommends the re-affirmation and further amendment ofa 1960 editorial policy which limitsthe use of the term Osteopathy to his-torical, sentimental and informal dis-cussions. The amendment, as pro-posed in Resolution 231, would rel-egate the definition of Osteopathy tointernational health care practice byproviders who do not hold unlimitedlicense for practice. Resolution 231is under review by AOA legal coun-sel, with a report to the AOA Houseof Delegates expected in July 2000.

Within the first decade of the deathof Andrew Taylor Still, Leon E. Page,DO, addressed the future of the osteo-path profession in terms which havebearing on the current policy review.The following quotation is taken fromDoctor Page’s text, Osteopathic Fun-damentals, Journal Printing Company;Kirksville, MO; pp. 181-182. As youread these comments, consider express-ing your opinion about the use of theterm Osteopathy.]❒

I am also interested to know if Dr.Crosby applied the heel lifts in re-sponse to leg length difference aloneor whether he was responding to thesacral base unleveling identified inthe standing films. I’m not certain anyresearch evidence exists supportingone of the other of these methods,although many of us have been taughtteach(~hat heel lift managementshould respond to the sacral base lat-eral declination.

Another interesting pilot study. Ihope Dr. Crosby will follow it up.

David A. Patriquin, DO

Dear Editor:Recent AAO and AOA publica-

tions and PR efforts have promotedosteopathic unity and distinctiveness.These are ideals, which all DO’s caneasily support.

However, the students of the pro-fession and The AAO Journal sub-liminally undermine these valiant ef-forts. How? Just look at The AAOJournal’s student corner! Student XMSIII - MS = Medical Student.

Our colleges are colleges of osteo-pathic medicine not colleges of medi-cine - hence we do NOT have medi-cal students - we have osteopathicmedical students or OMSI-II. AtTUCOM, I have repeatedly made thispoint and some of our faculty andadministrators agree with me and weare evolving to the term OMS insteadof MS.

If we promote ourselves and ourprofession as distinctive we are com-pelled that we should label our stu-dents distinctively as well. To thatend, The AAO Journal should neveruse the MS abbreviation for a studentbut the OMS abbreviation. (Unlessthe Osteopathic student holds an MSor Masters of Science degree!)

Robert C. Clark, DO,Chairman, OMM Dept

TUCOM


Student’s Corner

Case Study of a 42-year-old patientwith Systemic Lupus Erythematosusby Neil Zucker, MS-III, University of North Texas Health Science Center in Fort Worth

IntroductionOsteopathy is built on the founda-

tion that the body functions as a unit,has self regulatory mechanisms, andstructure and function are reciprocallyrelated. Although the days of bloodletting are over, there are still treat-ments today that bypass this self-regulatory and body unitary function.Medications that provide relief but donot allow the body to recover are onlya temporary solution. In the late1800s, patients with gout were treatedwith opiates that allowed for tempo-rary relief, but no benefit was gainedagainst the deposition of uric acidcrystals. The opiates actually causedworse side effects, such as heart andrespiratory complications, than thedisease it was being used to treat. Inthe 1990s there are diseases for whichpharmacology has no solution. Drugscan stop bacteria, fungus and somevirus from attacking cells, but thistherapy has yet to resolve the syn-drome of human cells turning on eachother. Although some medications,most notably - Glucocorticoids, al-lows a period of alleviation by knock-ing out the immune system, its sideeffects can be more debilitating thanthe disease itself. What is the solu-tion? This is the point where as anosteopathic physician we must goback to the roots, to the foundationthat built osteopathy. The body func-tions as a unit, has self-regulatorymechanisms, and structure and func-tion are reciprocally related.

Case reportChief Complaint

The patient is a 42-year-old whitefemale with a chief complaint of leftshoulder pain, low back pain, left hippain and continued manipulativetreatment for systemic lupus erythe-matosus (SLE).

History of Chief complaint andPast Medical History

In approximately 1980 the patientwas diagnosed with SLE. At that timeshe was started on glucocorticoidtherapy (dexamethasone) for SLEflare-ups such as headaches, fever,and joint pain. The SLE and gluco-corticoid therapy resulted in numer-ous complications for the next 10years. One complication that incurredwas necrosis to the bone. The necro-sis to both her left hip and shoulderresulted in replacement surgery forboth. The patient also showed signsof necrosis in low back, which radio-graphically showed up as a compres-sion fracture of the L1 vertebrae. Herheart was also affected. She devel-oped coronary artery disease and inf-arcted heart muscle on six differentoccasions. During these 10 years, sheshowed little improvement in flare-ups and thus glucocorticoid use con-tinued. In 1990 the patient began ma-nipulative therapy. Therapy consistedof 99% cranial and 1% spinal treat-ment. Since this time there has beenno SLE flare-up and thus glucocorti-coid treatment was discontinued. Shehas had no fever or headaches asso-

ciated to her condition and minimaljoint pain as compared to the 10 yearspreviously. At the present time shestates that she has lots of left shoul-der pain and classifies it as “terrible.”Her low back pain she states is attrib-uted to activity during the holiday.

Review of SystemsThe patient denies any gastrointes-

tinal, genitourinary, respiratory, neu-rologic, cardiovascular or endocrinedisturbances.

Past Surgical HistoryThe only surgical history that

could be ascertained was both a lefthip and shoulder replacement surgery.

Physical ExaminationCervical spine: no somatic dys-

function; Thoracic spine: T8 rotatedright and side bent left; Lumbar spine:L5 rotated left and side bent left;Sacrum: markedly inferior left; Infe-rior lateral angle (left sacral shear)

Assessment1. Somatic dysfunction of thoracic

spine2. Somatic dysfunction of lumbar

spine3. Somatic dysfunction of sacrum4. Somatic dysfunction of pelvis5. Pain resulting from left hip and

shoulder prosthesis6. Arthralgia resulting from SLE

concomitant with prior corticos-teroid use.


Treatment Plan(1) Continue cranial treatment with

the goal of continued remissionof SLE. The cranial treatmentconsists of using the inherentmechanism of movement of cra-nial bones and taking it where itwants to go.

(2) Soft tissue on thoracic and lum-bar spine

(3) Indirect and muscle energy on thethoracic and lumbar spine

(4) Muscle energy and springing onthe sacral shear

(5) Compression/ decompression ofthe pelvis

(6) Return to clinic in 2 weeks.

Discussion/Review of Literature

In this section, 2 main areas willbe addressed. The first area to be ad-dressed will be the pathogenesis andclinical features of SLE. The otherarea explored will be the affects ofglucocorticoids and cranial manipu-lation.

SLE is an autoimmune disease ofunknown etiology. 90% of the pa-tients are women within childbearingyears. The defect, in this disease, isan unregulated hyperactivity of the Tand B cells in the immune system.These unregulated cells cause de-struction of tissues in two ways. First,the autoantibody binds to a host celland causes direct lysis. This type ofreaction occurs most often with redblood cells and platelets. The autoan-tibody can also bind to the host celland activate the complement system,which allows for destruction of boththe attached cell and the surroundingtissue. There is much dilemma onwhether the autoantibody becomessensitized to normal host cell antigensor whether the host cells contain for-eign antigens that are attached bynormal immune counterparts.

The clinical course is marked by

spontaneous remissions with 20% ofpatients exhibiting true remission.One clinical feature of SLE is that itmay affect one or multiple organs.Joint symptoms are most often theearliest sign of the disease. Arthriticpain is intermittent and often does notcorrelate with physical findings. Cu-taneous involvement most oftencomes in the form of a malar rash,photosensitivity or alopecia. SLE alsohas effects on the heart causing myo-carditis and pericarditis, which canprecipitate arrhythmias. Hemato-logi-cally, it may cause a decrease in whiteblood cells, red blood cells, and plate-lets. In the kidney, it can cause de-struction of tissue resulting in a neph-rotic syndrome or kidney failure. Fi-nally in the CNS, effects can rangefrom headaches to a decrease in cog-nitive functioning.

When a patient is diagnosed withSLE, treatment is correlated with thesymptoms or flare-ups currentlypresent. Patients with mild diseaseand no life threatening manifestationsshould be managed with NSAIDS orhydroxychloroquine (for cutaneousmanifestations). As symptoms andflare-ups worsen or life-threateningmanifestations develop, patients areput on glucocorticoids. This treatmentis reserved until this time because ofthe vast and possible life threateningside effects.

Glucocorticoids main function inthe treatment of SLE is to knock outthe immune system. It suppressesnormal functioning of white bloodcells and the inflammatory compo-nents, which means if T and B cellsare not present then they cannot at-tack normal host cells in a person withan autoimmune dysfunction, such asSLE. The problem is that it mightsuppress some symptoms but at thesame time allow for a multitude ofother disease processes to take effect.

Some of the side effects of chronic

glucocorticoid therapy in SLE pa-tients are weight gain, hypertension,infection, diabetes mellitus, coronaryartery disease, and ischemic necrosisof the bone. Cause of death withinfive years of diagnosis of SLE is mostcommonly infection. The dilemma isif the cause of death is from the dis-ease process itself, glucocorticoidtherapy, or a combination of both.Recent literature suggests that gluco-corticoid therapy is a major factor.“Infections are more likely to developin patients with active SLE receivinghigh dose corticosteroids or immuno-suppressive therapy as opposed tominimal or no corticosteroidtherapy.”

1

The most common cause of deathfor patients with SLE for longer thanfive years is arteriosclerosis. Cortisoltreatment hastens this process. “ Acomparison of patients without arte-riosclerosis to patients with anginaand/or myocardial infarction revealedthat the average dose of corticoster-oids was significantly higher amongpatients with arteriosclerosis.”

1 The

main objective of cranial manipula-tion, on the other hand, is to returnbody structure and function back tohomeostasis. If the body is going tofight disease, it will have more of achance if it is functioning optimally.“Cranial manipulation allows for op-timal functioning of the primary res-piratory mechanism which not onlyaffects the CNS but also every celland tissue in the body.”

2 It is this pri-

mary respiratory mechanism “that thephysiologic centers that control andregulate pulmonary, respiratory, cir-culation, digestion and elimination....depend on for normal functioning ofthe CNS”

2 The pituitary, for example,

depends on the primary respiratorymechanism for uncompromisedblood flow and normal tension in thedura that surrounds its stalk.

lAbu-Shakra M et al: Mortality studies in systemic lupus erythematosus: Results from a single center. I. Causes of death. J Rheumatol l995;22:1259

2Lay, Edna M. Foundations for Osteopathic Medicine. Philadelphia, PA. Williams and Wilkins; 1997 pgs 901-913


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ConclusionWhy cranial manipulation worked

in this case study and corticosteroidsdid not. Corticosteroids are only atemporary solution whereas cranialmanipulation can be a permanent one.Corticosteroids may alleviate some ofthe symptoms but may cause newermore severe complications. The 42-year-old patient of topic exhibitedmany of the side effects of glucocor-ticoid therapy. She already had 6myocardial infarctions due to coro-nary artery disease, the replacementof both the left hip and left shoulderdue to ischemic necrosis, and a lum-bar compression fracture at L5. Con-tinued therapy of Cortisol treatmentfor flare-ups would have been moredebilitating and probably fatal. Cra-nial manipulation, on the other hand,succeeded through a combination ofprocesses. As mentioned earlier, cra-nial manipulation allows for optimalfunctioning of the primary respiratorymechanism, resetting of the pituitarygland for normal functioning, andhomeostasis of the physiologic cen-ters of the body. In this case, 1 or thecombination of all 3 allowed for thelymph system to normalize and allowthe body to use its own innate abilityto overcome the disease process.

ReferencesHahn, Bevra H. Principles of Internal Medi-

cine. 14 ed. San Francisco, CA. McGraw-Hill;1998. pgs 1874-1880.

Lay, Edna M. Foundations for OsteopathicMedicine. Philadelphia, PA. Williams andWilkins; 1997 pgs 901-913

Cush, John J. Rheumatology. Philadelphia,PA. Williams and Wilkins; 1999. Pgs 363-371.

DiGiovanna, Eileen L. An Osteopathic Ap-proach to Diagnosis and Treatment. Phila-delphia, PA. Lipincott Raven; 1997

Abu-Shakra M et al: Mortality studies in sys-temic lupus erythematosus:

Results fom a single center.I. Causes of death.J Rheumatol 1995;22:1259❒

[Editor’s Note: S/D Neil Zucker is cur-rently a senior at University of North TexasHealth Science Center in Fort Worth/TexasCollege of Osteopathic Medicine]


In MemoriamBob E. Jones, CAE

Oklahoma Osteopathic Association Executive Direc-tor Emeritus, Bob E. Jones, CAE, passed away on Feb-ruary 3. He had served as CEO of the OOA since 1969and contributed nationally to the osteopathic medical pro-fession in leadership capacities with both the AmericanOsteopathic Association and the Association of Osteo-pathic State Executive Directors. He was the author ofthe 1978 book entitled The Difference a D.O. Makes: Os-teopathic Medicine in the Twentieth Century and the 1991revision entitled Osteopathic Medicine: The Premier Pro-fession. Both publications have been widely used to edu-cate the public about the profession. The AOA presentedMr. Jones with its Distinguished Service Certificate at the1999 Convention in San Francisco. Since he was unableto attend due to an initial stroke on February 4, 1999, hisspouse, Gayle Jones, and daughter, Julie Atyia, acceptedthe award for him.

Associate Executive Director Diana Finley, a friendof Mr. Jones for over 30 years, represented the Academyat his funeral on February 8 in Oklahoma City. The AAOleadership was in attendance at the AOA Board of Trust-ees meeting at the time of the service.

He is survived by his wife Gayle Jones of the Okla-homa City; daughter Jennifer and son-in-law Brian Cainof Edmond, OK and daughter Julie and son-in-law Mat-thew, also of Edmond; three grandchildren, Allyson andCarter Cain and Justin Atyia; as well as two sisters andmany nieces and nephews.

The family suggests contributions to the OklahomaEducational Foundation for Osteopathic Medicine, BobE. Jones Endowed Student Scholarship Fund, c/oOEFOM, 4848 N. Lincoln Blvd., Oklahoma City, OK73142.

His friends in the osteopathic profession will miss him.AAO sends condolences to his family.❒

FPO

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Qualified applicants please mail or fax CV to:

AdministratorArthritis Center of Riverside

4000 14th St., #511Riverside, CA 92501

(909) 788-0850 Fax (909) 788-4966


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Biofeedback instruments measure,monitor, amplify, and instantaneouslyfeedback to the subject subtle infor-mation about internal, often uncon-scious physiologic processes (i.e.temperature of the distal joint of themiddle finger of the left hand, ordominant brain wave activity). Thisinformation is used by the client toalter behavior patterns (i.e. increaseblood flow to the area and, thus,generate a feeling of relaxation, or de-crease a particular band of brain waveactivity, enhancing the ability to con-centrate).

EEG Biofeedback uses sensors at-tached to the scalp to record brainwave activity. This information is sentto a computer that employs auditoryand/or visual displays to inform theclient about the activity of his/herbrain. The information can be used bythe client to alter the pattern of brainwave activity in the desired direction.

Children diagnosed with Atten-tion-Deficit/Attention-Deficit Hyper-activity Disorder (ADD/ADHD) ex-perience difficulties with concentra-tion, staying on track, sustaining mo-tivation, regulating energy, organiz-ing information, working on theirown and interacting socially with oth-ers. ADHD children are impulsive,excessively motoric, rigid and often

oppositional. They have difficultieslearning from experience and plan-ning for the future. These behavioralcharacteristics are associated withimpairments of the frontal lobe andrelated brain structures, especially theprefrontal areas, the basal ganglia andthe limbic arousal system.

Electroencephalogram (EEG) re-search (Jaspers et al, 1938; Mann etal, 1991) has found excessive slowwave activity in central and frontalportions of the brains of individualsdiagnosed with ADD/ADHD. Otherneurological investigations havefound metabolic and blood flow ab-normalities in the same regions.

The main premise for using EEGBiofeedback Training in the treatmentof ADD/ADHD is that if the under-lying neurological deficit can be rem-edied, the child will be more capableof self-regulating the behaviors de-pendent on intact prefrontal lobefunctioning. For children with ADD/ADHD, the goal is to reduce Theta,slow wave activity associated withdaydreaming which interferes withconcentration, information process-ing and other organized cognitiveactivities.

Over a period of more than 20years, Lubar and his colleagues havedemonstrated that the application of

the principles of EEG BiofeedbackTraining have improved the ability toself-regulate the brain wave activityand enhanced cognitive efficiencyand behavioral control (Lubar, 1995;Mann et al., 1991; Lubar & Shouse,1976).

Cranial manipulation is a treatmentthat has been rooted in the osteopathicprofession for the past 65 years. It isan approach and technique developedby William Sutherland, DO duringthe 1930s. The treatment is a hands-on application to the head, usinggentle palpation to diagnose and treatasymmetries of the skull, using theenergy of the brain and the brain’smotion cycle to correct mechanicalimbalances found in the skull and itsstructures.

The treatment is controversial inthe medical establishment becauseanatomists still insist that the skull issolid bone. But, histological evalua-tions of the skull sutures have shownthat there is elastic tissue present be-tween bones of the skull. Polygraphsusing pressure sensitive gauges ap-plied to the temporal bones haveshown that there is a cyclic phenom-ena in the motion of the head—arhythm of eight to twelve cycles ofexpansion/contraction per minute.

Brain Wave Pattern Changesin Children with ADD/ADHDfollowing Osteopathic Manipulation:A Pilot Studyby Stephen D. Blood, DO, FAAO, FACGP and Barry A. Hurwitz, PhD, BCIAC

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During cranial evaluation andtreatment, it has been the observationof osteopathic physicians that certaincranial abnormalities are present inchildren after difficult labor and de-livery and in children with “minimalbrain damage” (ADD/ADHD). Themanipulation promotes symmetry,changes in cranial rhythm and nor-malization of behavior, includingimpaired concentration and learningand impulsivity.

In the current investigation, sixchildren were evaluated by a singlechannel CapScan EEG Biofeedbackdevice before and after cranial ma-nipulation. Four of the children wereindependently diagnosed as sufferingADHD. Two children had not beenso diagnosed but were identified bytheir parents as exhibiting some of thecharacteristics of this disorder basedon responses to the Conners Behav-ior Checklist.

Brain wave activity is described interms of Hertz or cycles per second(cps). Slow brain wave generally re-fers to brain wave activity beloweight cps. Delta activity (0.5—4 cps)is associated with sleep and theta ac-tivity (4-8 cps) is associated withstates of revelry. Relatively high thetaactivity interferes with concentration.Alpha rhythm encompasses wavebands between 8 and 12 cps and isidentified with feelings of relaxation.Beta waves include activity fasterthan 12 cps. “Sensory-MotorRhythm” (SMR) refers to wave ac-tivity between 13 and 15 Hertz ac-tivity, while rhythms above 15 Hertzare referred to as “fast beta”. An in-crease in SMR is often accompaniedby a reduction in over-activity. Fastbeta is associated with efficient in-formation processing.

This investigation focused on theeffects of cranial manipulation onamplitude level of slow wave activ-ity (2-6 cps). Each child was hookedto the CapScan EEG Biofeedbackdevice and amplitudes of slow waveactivity were recorded for a period

of 100 seconds. The child was seatedin a typical office chair facing awayfrom the computer screen and with theaudio signal muted in order to avoidthe feedback condition and the possi-bility of improved performance dueto learning. The hook-up and record-ings were done by a Licensed Psy-chologist who is also a Certified EEGBiofeedback Therapist.

Osteopathic manipulation fol-lowed immediately with the child ina supine position on a standard, por-table treatment table. Treatment wasadministered between 5 - 1 5 minutesdepending on the osteopathicphysician’s assessment of the child’sneeds. High velocity direct actiontechniques were used in the spinalareas and direct action decompressiontechniques were used on the cranium.EEG Biofeedback readings over a 100second time frame were repeatedstraightaway. In addition, a graph ofthe dominant brain wave activity over40 epochs of one second was plottedfollowing each of the two 100 sec-ond trials.

The average slow wave brain waveactivity prior to treatment was 27.9microvolts (µv), significantly abovethe expected range for “normal” chil-dren in this age group. Followingtreatment, the average amplitude was23.1 µv. This level is still significantlyabove “normal” but statistical analy-sis of the difference between themeans (4.8 µv) is significant at the<.20 level. This means that the likeli-hood of the occurrence of a reductionin slow wave activity of this magni-tude occurring by chance is less than20 in 100.

For one child, slow wave ampli-tude was recorded before and after aplacebo condition (the osteopathicphysician placed his hands on thechild’s head but no manipulation wasdone) and then during the active cra-nial manipulation. A decrease in slowwave activity of only 1.6 µv occurredafter the placebo condition but an ad-ditional decrease of 3.1 µv was ob-

served over the course of 6 minutes ofcranial manipulation (Total decreasefrom pre-treatment level = 4.7 µv).

Despite the positive implicationsof the outcome of this investigation,replication with a larger sample ofchildren and under more rigorouslycontrolled conditions is essential be-fore any meaningful conclusions canbe drawn. Nevertheless, the probabil-ity of an association between osteo-pathic manipulation and reduction inslow brain wave activity is suggested.

In this investigation, only the re-lationship between osteopathic ma-nipulation and slow brain wave am-plitude was studied. The focus wasnot on the combined effects of thetreatments. In order to accomplishthis, behavioral measures are requiredto assess the effectiveness of com-bined treatment in reducing symp-toms of cognitive and behavioral dys-control in children diagnosed withADD/ADHD. These results wouldthen be compared with the indepen-dent success rates of EEG Biofeed-back Training and osteopathic ma-nipulation in treating ADD/ADHD.

BibliographyJaspers, H.H., Solomon, P., Bradelry, C.

(1938). Electroencephalographic analysisof behavior problems in children. Ameri-can Journal of Psychiatry, 95, 641-658.

Lubar, J. (1995). Neurofeedback for the man-agement of attention-deficit/hyperactivitydisorders. In Mark S. Schwartz and Asso-ciates, Biofeedback: A Practitioner’sGuide. 2nd Edition (493-522). New York:Guilford Press.

Lubar, J. & Shouse, M. (1976). EEG and be-havioral changes in a hyperkinetic childconcurrent with training of sensorimotorrhythm (SMR): A preliminary report. Bio-feedback and Self-Regulation, 3, 293-306.

Mann, C., Lubar, J., Zimmerman, A., Miller,C. & Muenchen, R. (1991). Quantitativeanalysis of EEG in boys with attention-deficit-hyperactivity disorder: Controlledstudy with clinical implications. PediatricNeurology, 8, 30-36.❒


Prior to the 1940s osteopathic hy-potheses concerning somatic dys-function (the osteopathic lesion) werebased upon histological work fromanimal experiments performed byDeason and Burns, anecdotal clinicalexperience, and experimental reportsfrom the medical literature. Resultsfrom the use of palpatory testing wereviewed as subjective and questionable.

The publication of Denslow’s pa-per in 19411, on the reflex activity ofthe spinal extensors, had a profoundeffect. His research demonstrated byelectromyographic testing that therewas a decrease in the thresholds forreflex muscle activity at areas of so-matic dysfunction in human subjects.These results had direct applicationto osteopathic theory concerning theosteopathic lesion. Denslow’s workgave rise to the concept of facilita-tion which has helped explain the lo-cal and remote effects associated withsomatic dysfunction. Denslow hadbeen appointed to the faculty atKirksville College of OsteopathicMedicine in 1938. With his appoint-ment, the College formed and fundeda research laboratory.

Other faculty were recruited toparticipate in the research programsat Kirksville: H.G. Clough, DO,Charles C. Hassett, PhD, Albert P.Kline, PhD, Irwin M. Korr, PhD, J.A.Chase, DO, F.T. Dun, DO, J.N. Eble,PhD, O.R. Gutenson, DO, E.L. Hix,PhD, R.W. Ho, DO., P. E. Thomas,DO, and H.W. Wright, DO. Basic andapplied research on somatic dysfunc-tion was carried out by members ofthis group during the next four de-cades which included investigation inreflexes, autonomic function, circu-

lation, and body mechanics.Some highlights of this research

effort were Korr’s work on axonaltransport2, which provided an expla-nation for observations of trophicfunction of nerves and implicationsfor somatic dysfunction. Skin tem-perature measurements by Korr,Wright and Chase3 identified segmen-tal deviations from the normal insweat patterns and skin temperaturewhich were later correlated with evi-dence of somatic dysfunction. Eble4

and Hix5 demonstrated viscero-so-matic, viscero-visceral and somato-visceral reflex effects in animals.

Additional basic research thatshould be noted is that of A. F. Kelso,PhD6 at Chicago using thermographyconfirmed the relationship betweensomatic dysfunction and altered skintemperature. These changes havebeen related to alterations in cutane-ous blood flow and have providedevidence of facilitated sympatheticactivity, while Michael Patterson,PhD7, at Ohio, has demonstrated theinfluence of the higher nervous sys-tem centers on reflexes and the roleof the spinal cord in conditioned re-flexes. His studies demonstrated spi-nal cord learning capability may haveimplications for the understanding ofstable patterns of somatic dysfunc-tion.

The research initiated by Denslow,Korr and the research team atKirksville, has had a profound influ-ence on the osteopathic profession. Itbroadened the conceptualization ofthe etiological mechanisms related tosomatic dysfunction as well as its rolein health and disease. It also repre-sents a departure from the investiga-

tions in anatomy, body mechanics andthe histopathology of the lesion.However, interest in joint mechanicsand the adaptive responses of thebody to injury, occupation and pos-ture, has continued.

The early 1940s witnessed a num-ber of activities. Strachan, Beckwith,Larson and Grant8 published theirstudy of the mechanics of the sacro-iliac joint in 1938. Beckwith9-13 wrotea series of articles on vertebral me-chanics in 1944 in which he discussedconcepts of spinal motion, lesion pa-thology and manipulative treatment.Bailey and Beckwith14 published apaper on short leg and spinal anoma-lies in 1937. Beilkel5 wrote a paperon the mechanics of the sacrolumbargroup in 1939, in which he describedadaptations to a short lower extrem-ity. Frederick Long16 published hispaper on spinal motion in 1940, de-tailing studies of the relationship ofpalpatory findings of joint motionwith x-ray studies. Kerr, Grant andMacBain17 described their observa-tions of a study of the relationship ofanatomical short leg and the treatmentof low back pain in 1943.

These events in the early 1940sare significant as a part of generaltrends in osteopathic research or asinitial steps in new directions. It wasalso the time of my introduction intoosteopathic research as a student as-sistant to the Kerr low back study.

PostureThe adaptive response of the body

to the upright posture and the body’sresponse to gravitational stress hasbeen a subject of study of consider-

Research DirectionsFrom 1940-1988by Myron C. Beal, DO, FAAO, Professor Emeritus Michigan State University

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able interest in the osteopathic pro-fession. Alexander McWilliamsl8

(1931) identified a pattern of somaticdysfunction involving the lumbo-dor-sal, cervical, thoracic and upper cer-vical spine. Harold Magounl9 (1937)reported that lesion patterns were re-lated to muscle tension and fibrosissecondary to pelvic disturbances.Lesions occurred at the site of theorigin and insertion of the paraspinalmuscles. He described these as weakpoints. Wesley Dunnington20 (1964)noted that the musculoskeletal sys-tems adaptive response to gravity pre-disposed the development of osteo-pathic spinal lesions. David Heilig21

(1957) noted a high incidence of so-matic dysfunction at or near transi-tional areas of the spine in his exami-nation of 200 patients for evidence ofpostural patterns of altered vertebralmechanics.

With the advent of the standingpostural x-ray in 1934, developed byEarl R. Hoskins,22 a sudden impetuswas given to the study of posturaladaptation, short leg, and the stand-ing x-ray procedure.

My early involvement in the lowback research project at Chicago re-sulted in observations that the stand-ing x-ray procedure as a research in-strument had not been standardized,nor had the possible sources of errorbeen assessed. The procedure wascarried out in different ways in dif-ferent x-ray departments. Measure-ments reported were not clearly iden-tified as to their relative significance,for example, pelvic side shift.

My research duties were to carryout a structural examination of pa-tients and record findings. The re-search office had a collection of x-rays of the patients in the study. Se-rial x-rays were taken of some pa-tients who were on lift therapy, and Iwould study the before and after liftx-ray films to try and ascertain evi-dence of improvements.

It was apparent that adaptations ofthe pelvis to short lower extremity

included a pelvic side shift, pelvicrotation, pelvic tilt and other possiblemovements. A study of the effect ofside shift by x-ray showed that shift-ing the pelvis towards the long legcompensated for part of the femur topheight difference. X-rays of the talusheight in the standing position dem-onstrated that in some instances thedifference of the talus was equal tothe difference at the femur top.

I summarized these findings alongwith a review of the literature in1950.23 This was followed by a de-finitive study by Denslow24 in 1955,outlining the sources of error in thex-ray procedure. He later identifiedthe various adaptations of the lumbarspine and pelvis to leg length differ-ences.25 This study was followed bya study by Thomas26 who analyzedthe interactions of the pelvis and lum-bar spine and found that the most fre-quent pattern in 713 individual stud-ies was a low femur, low iliac crestand low sacral base on the right andthe left sides.

In 1967, Thomas27 employed EMGto analyze muscle activity of thetorso, hip and leg in standing patients,which showed that the greatestmuscle activity in individuals with ashort leg was in the high and lowparavertebral muscles, the tensor fas-cia lata and hamstrings on the side ofthe long leg.

A significant study of the progres-sive effects of posture was conductedby Pearson28 in 1951. A total of 831children were given physical andstructural x-ray examinations to de-termine the incidence of short leg,lumbosacral angle, lumbar curvatureand pelvic accommodation. One hun-dred x-rays taken two years later,were compared with the originalfilms. Pearson noted that, with theexception of arthritis, all structuralproblems visualized in standing struc-tural film studies of adults werepresent in children between the agesof 5 and 18.

Hagen29 examined 50 individualsfrom the Pearson study 10 to 15 yearslater. He observed that 44% had simi-lar childhood and adult spinal curves,only 20% demonstrated a change inthe relationship of sacral tilt to leglength. He concluded that the patternof axial skeletal morphology was es-tablished at an early age; that appar-ent leg length differences tend to in-crease with age, and pelvic morphol-ogy characterized by leg length re-lated to sacral tilt changed onlyslightly.

There are still unanswered ques-tions in regard to the short leg prob-lem. I am glad to report that there is amove at present to standardize thepostural x-ray study. However, we donot have a detailed correlation be-tween x-ray and physical findings.We do not know what are the effectsof lift therapy over time - are theybeneficial or do people develop com-pensatory problems to lift therapy?Adaptive pelvic mechanics includesideshift, rotation and tilt. Do thesemovements take place in a prescribedmanner and degree as the pelvisadapts to differences in leg length?How do you account for the symp-tomatic improvement in patients whoare treated by manipulation and lifttherapy? An answer to some of thesequestions would provide us withknowledge for a more informed judg-ment in the treatment of posturalproblems.

Joint MotionStudies of joint motion date from

the paper by Fryette30 on the Physi-ological Movement of the Spine in1918. Subsequent studies includethose of Beckwith of vertebral me-chanics9 published in 1944 in whichhe described normal and abnormaljoint motion.

Frederick Long,16 in 1940, studiedthe incidence of spinal findings inpatients entering the clinic, and therelationship of spinal findings to a


diagnosis of visceral disease. He at-tempted to correlate palpatory find-ings of joint motion restriction of thecervical spine with x-ray evidence ofdecreased mobility as ascertained byx-rays in the positions of neutral, flex-ion and extension.

Strachan, Beckwith, Larson andGrant8 studied the mechanics of jointmotion of the sacroiliac joint by us-ing cadaveric material and immobi-lizing one ilium in a concrete block,permitting movement at thesymphasis pubis. Steel pins 10 to 20inches long were inserted in the iliaand sacrum at the levels of the firstand fourth sacral segment. A methodof recording movement of the pinswas devised as movements of flex-ion, extension, rotation andsidebending, traction and compres-sion, were introduced through thelumbar spine. It was determined thatthe sacrum is capable of flexing, ex-tending, lateroflexing and rotating inrelation to the ilia. When rotation isintroduced into the sacrum, laterof-lexion occurs to the opposite side.When lateroflexion was introduced,rotation occurred to either side.

J. Marshall Hoag,31 working withPaul Rosenberg,32 began a study ofspinal motion employing the R cen-ter method of analyzing vertebralmotion from x-rays. Five x-rays weretaken in different positions in theantereoposterior plane, and four x-rays in different positions in the lat-eral plane. Motion was then describedin terms of rotation and translationcomponents. It was observed that themagnitude of these movements wasvariable. Some vertebra appeared tofollow a smooth continuous path ofmovement in a given direction,whereas others displayed erratic un-stable behavior with several shifts inmotion in different directions.

In the late 1950s, I had been in-vited to explore the use of cineradiog-raphy at the University of Rochesterin some of my patients with cervicalspine problems. The chief engineer

for the development of this modalityhad been a patient in my office. Atthe time cineradiography was largelyused for lateral cervical spine x-raysbecause of the limitations of the proce-dures, x-ray penetration and exposure.

Beckwith proposed that we do astudy of spinal motion using Cathie’sHalladay spine. Cathie was in agree-ment. Beckwith, I, Cathie and JohnChase33 from Kirksville undertook astudy of x-ray motion pictures of thecervical, thoracic and lumbar spine tosee if we could gain an understand-ing of the normal mechanics of spi-nal movement. Movements were in-troduced by hand. Where movementwas carried out in three planes, onlythe last plane of movement was x-rayed since we found out that x-ray-ing the total movement created exces-sive heat in the x-ray tube; a problemwe had not anticipated.

The range and quality of move-ment was observed, particularly thefacets and vertebral bodies. Fryettehad emphasized the role of the facetsin determining spinal motion. It wasobserved that segmental motion inflexion, extension and lateral flexionoccurred, but that rotation movementwas columnar without any visiblesegment-to-segment motion. Facetmotion was difficult to see in contrastto the evident gross motion of thevertebra. The facets appeared to playa minor role in qualifying vertebralmotion. It was observed that the priorintroduction of motion in one planelimited subsequent movement in an-other plane. We were told that this isFryette’s third law, but I am unableto find any reference to this in hispaper of 1918. However, this haspractical clinical applications to theuse of manipulative techniques. I findthat beginning students, after intro-ducing flexion or extension, tend touse excessive rotation andsidebending when attempting to lo-calize their forces at the site of so-matic dysfunction.

Robert Ho, in 1961, examined 13adult spinal preparations and deter-mined the arc of motion at the inters-pinous interval. He found that thegreatest range of movement occurredin the cervical spine, followed by thelumbar and thoracic areas. Dr. Hoexplored the clinical implications of theart of intervertebral joint motion test-ing and concluded that palpable obser-vations of intervertebral joint motiontend to parallel x-ray quantification.

Stereoradiography was used byHerbert Reynolds in 198035 to studymotion of the sacrum in relation tothe innominates when the femur wasplaced in different positions. Tung-sten carbide balls are inserted in spe-cific areas of the skeleton as land-marks, providing a fixed axis systemwhereby distances between land-marks can be calculated. Reynoldsobserved that rotation motions in thesacroiliac joint were small in com-parison to rotation motions in the hipand that the hip and sacroiliac jointsdid not maintain a constant relation-ship in the amounts of translation androtation. Subsequent to this study, thedata derived from stereometric analy-sis of spinal motion have been usedto develop a computer graphic simu-lation of vertebral motion.

There are several elusive questionsthat remain unanswered in regard tojoint motion. Since one of the measuresof patient improvement is an increasein the range or quality of movement, itwould be helpful to know. What con-stitutes restricted motion? Is it withinthe voluntary range of motion of thejoint or the involuntary range of mo-tion, or both? What degree of changein joint motion is associated with symp-tomatology? What is the correlation be-tween the palpatory tests of motion andactual motion in the joint? Is the rangeof motion actually improved after treat-ment? Can we establish the reliabilityof palpatory joint motion testing as avalid research examination procedure?

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Histological andTissue Studies

Wilbur Cole was given an AOAresearch grant to enable him to workwith Louisa Burns in California from1949 to 1951. He then returned toKansas City College of OsteopathicMedicine where he continued histo-logical studies involving the motorendplate and somatovisceral reflexes.Studies included various methods ofcreating lesioning in animals andstudying their effects, compared tocontrols.

Wilbur Cole’s work marks the lastof the major histological studies com-pleted in attempts to gain informationat the cellular level of the effects ofsomatic dysfunction.

Dr. Cole told me he considered thathis work, and that of Burns andDeason, had resulted in similar ob-servations and he felt that particularline of research had been adequatelyexplored. It remains to be seenwhether the present histological workat this college will provide us withnew insights into the mechanisms ofsomatic dysfunction.

Questions involving the mechani-cal response of connective tissues toloading and deformation have beenthe subject of research by RobertHubbard36-37 at Michigan State Uni-versity. Tissue responses have beenclassified as nonlinear and viscoelas-tic. Nonlinear is defined as tissuestiffness that increases with increas-ing deformation, resulting in a bar-rier that can be perceived by a clini-cian. Viscoelasticity is defined as tis-sue responses that involve energystorage with an elastic return and dis-sipation of energy. The studies of non-linear and viscoelastic properties oftissue have shown that changes whichallow greater movement with reducedforce or reduced restriction to motionoccurred following the first few tis-sue extensions, and within seconds ofextension, but the changes persistedfor several hours. These phenomena

have interesting implications for theuse of manipulative procedures.

Studies of Manipulationon Physiological Function

A number of studies have beenconducted to determine the effects ofmanipulation on body function. Thesehave included studies of pulse rate,blood pressure, blood flow, motoractivity, skin temperature, andintraoccular pressure. Long andDeming38 observed the effects ofmanipulation of the cervical spine onblood pressure and pulse rate in 30normal college students comparedwith 30 control subjects. Although adecrease was noted in pulse rate andsystolic and diastolic blood pres-sure, the results were not statisti-cally significant.

Celander39 noted that there was adecrease in blood pressure in hyper-tensive and normal patients after softtissue manipulation of the upper tho-racic and cervical vertebra. Celander40

further noted an even greater effecton blood pressure occurred after fouror five manipulative treatments thanafter a single treatment.

The effect of manipulation onblood flow was ascertained by usingan electrical impedance plethysmo-graph. One experiment showed thata greater effect on blood flow wasobtained when active corrective treat-ment followed the use of myofascialrelease techniques.41

England42 and Heilig,43 in separatestudies, showed that motor activityascertained by EMG was reduced af-ter manipulation which correlatedwith palpatory findings of a decreasein segmental rigidity. England44 alsoused crystallography to show changesin skin temperature associated withsomatic dysfunction were decreasedfollowing manipulative treatment.Kelso,45 using thermography, alsoshowed a decrease in skin tempera-ture after successive manipulativetreatments.

For the most part, the studies of theeffect of the body response to ma-nipulation have been conducted onnormal subjects in limited time inter-vals. An intriguing question is whatwould be the effects from successivetreatments over a period of time, par-ticularly as it relates to clinical con-ditions such as hypertension. Dochanges occur that are not apparentafter one treatment? If changes dooccur, how long do they last? Suchquestions are not only pertinent to tri-als of the effect of manipulative treat-ment on physiological parameters,but even more important, to the ef-fects of manipulative treatment onspecific clinical conditions such ashypertension.

There are few clinical trials re-ported in the osteopathic literature.One of the early ones was that ofPerrin T. Wilson46 on the effects ofosteopathic treatment on patients whohad had vaccine treatment for asth-matic bronchitis. He reported 15 pa-tients out of 20 subjects experiencedsome temporary relief, and that 10patients had 50% fewer asthmatic at-tacks or less severe symptoms.

Howell47 reported a study of 17patients with chronic obstructive lungdisease whose pulmonary functiontests were monitored for a period ofnine months as they were given ma-nipulative treatment. Improved statis-tical significance was observed inPCo2 levels, oxygen saturation, totallung capacity and residual volume.

Miller 48 reported on a controlledstudy of manipulative treatment givento patients with chronic obstructivelung disease. Changes observed invital capacity and residual volume fora treated group were not statisticallysignificant, although the test groupreported improved work capacity, hadless dyspnea and developed fewercolds and upper respiratory infec-tions.

The early studies of the effective-ness of manipulative treatment in car-diovascular disease should be classed


as examples of clinical observation.They were not controlled studies.Recent studies in this area have beendirected toward the identification ofpalpatory findings of somatic changesthat are associated with cardiovascu-lar disease, studies by Cox,49 Beal50

and DeBias.51

Despite the frequent references tothe effectiveness of manipulativetreatment of musculoskeletal dys-function, few well designed clinicaltrials have been reported. Hoyt52 ob-served that patients with muscle con-traction headaches, who were givena palpatory examination and manipu-lation, rated head pain as significantlyless severe than patients who had apalpatory examination alone or thosewho were instructed to rest in a su-pine position. EMG measurements ofthe frontalis muscle did not show aconsistent change in the experimen-tal groups.

Siehl53-54 reported two studies ofthe results of manipulation under an-esthesia. In one series 96.3% of pa-tients with a diagnosis of myofibrosi-tis had a favorable response to treat-ment, whereas only 70.7% of the pa-tients who had a diagnosis of a herni-ated disc showed improvement. In asecond series, the results showed thatmanipulation under anesthesia pro-duced a lasting improvement whenEMG showed no evidence of nerveroot compression, but only temporaryimprovement when EMG findingswere positive for root compression.

Larson55 reported a double-blindclinical study of the effect of manipu-lative treatment with peripheral nervecomplaints. A therapeutic responsewas noted in 16 out of 19 patients andwas associated with an improvementin skin temperature of the affectedlimbs.

Beal, Johnston, and Vorro56 haveshown a correlation between thepatient’s subjective complaint, phy-sician findings, and a standardizedmeasurement of electrical activity ofthe cervical spine musculature in four

patients with chronic cervical spineinjury. Parallel improvements in thepatient health status were observedfollowing the use of manipulativetreatment.

The CliniciansResearch Group at MSU

In 1974, I joined the faculty atMSU and was appointed to the De-partment of Biomechanics. The De-partment was composed of osteo-pathic physicians and basic scientists.The initial conceptualization of theDepartment was that the placing ofphysicians and basic scientists inphysical juxtoposition would facili-tate and lead to the development ofresearch basic to osteopathic theoryand practice.

Shortly after I arrived, I organizeda clinicians research group of the fivephysicians in the Department. Soon,thereafter, basic scientists were addedto the group. The research group metweekly for several years. It provideda forum for the discussion of osteo-pathic concepts, osteopathic diagnos-tic and treatment protocols to engagethe basic scientists in a dialogue ofpossible research designs to attemptto correlate clinical practice with ob-jective tests. There were several posi-tive outcomes: 1) the osteopathic phy-sicians gave the basic scientists a bet-ter understanding of osteopathic phi-losophy and practice, not only froma philosophical standpoint, but alsofrom the practical hands-on experi-ence of palpation and treatment; 2)the osteopathic physicians were edu-cated in the principles of researchdesign and research protocols such asthe importance of engaging the stat-istician early in the design phase of aresearch project, the critical reviewof all details of research design priorto data collection, the need for a pilotstudy to critique and perfect the re-search design. Another important ob-servation for the clinicians was thatdiagnostic tests which were shown to

have poor interrater reliability werebeing taught in an unquestioningmanner in the college curriculum.Unfortunately, I cannot say that theimplications of the research weretranslated into improvements in thestudents education.

The clinicians research group en-gaged in a number of trials ofinterrater reliability of palpatory tests,as well as exploring the correlationbetween palpation and objective tests.The group as a whole was involvedin formal studies such as the lowagreement of findings in neuro-mus-culoskeletal examinations.57 The clas-sification of diagnostic tests used withosteopathic manipulation,58 and thedescription of 50 diagnostic tests59

used with osteopathic manipulation.The study resulting in the publica-

tion of low agreement of findings inneuromusculoskeletal examinationswas based upon a review of the ex-amination of 21 patients. Patientsentering a clinic were given a struc-tural examination which was re-corded. Two other physicians werethen called to conduct a structuralexamination without a knowledge ofthe patient’s history. Each examinerutilized his own testing proceduresand recorded his findings. The com-parison of the results of the examina-tions showed poor correlation in theidentification of the sites of somaticdysfunction. The significance of thestudy is that to obtain goodinterexaminer reliability special at-tention must be paid to training ofexaminers in testing procedures andthe selection of tests. This was shownby the study of interexaminer agree-ment on patient improvement60 inwhich three examiners independentlyexamined the patient, then met withthe patient to negotiate the tests to beused in evaluating the patient’s con-dition. Each testing protocol was de-tailed so that the examiners were inrelative agreement in the conduct ofthe test. The results of this study dem-

{


onstrated that interexaminer agree-ment in testing could be achieved byusing a precise research design. Inaddition, it was shown that there wasinterexaminer agreement on improve-ment of patients following the use ofmanipulative treatment.

The classification of diagnostictests used in the osteopathic muscu-loskeletal examination58 was insti-gated by Dinnar who was intriguedby the differences in an osteopathicexamination in contrast to his expe-rience with a medical examination.Videotapes were made of five clini-cians, each examining and treatingthree different patients. These weresubjected to detailed study to definethe testing process conducted by theexaminers. Dinnar classified the testsin five categories.

1. General Impression Tests2. Regional Motion Test3. Position of Landmarks4. Superficial and Deep Tissue

Evaluation5. Local Response to Motion

DemandDinnar stated that the first three

categories are common to medicalpractice, but categories 4 and 5 areunique to the osteopathic profession.This study is important as it was thefirst time that the testing process in astructural examination has been de-lineated and described in terms ofindividual tests.

Other studies reviewed by thegroup were those carried out byJohnston61 on palpation, interraterreliability, the stability of findings;Upledger62 on reproducibility of cra-nial sacral examination findings, andBeal60 on interexaminer agreement onpatient improvement.

Meetings of the research groupwere held with Albert Kelso to dis-cuss possible collaborative effortsbetween MSU and Chicago. This re-sulted in a listing of research ques-tions, which formed the basis of dis-cussions of research designs.

Research ProjectsA.Patterns of Findings

and Their Significance1. What are findings and how are

they observed?2. What is the natural cycle

of findings?3. What are the common patterns

of findings?4. How stable are findings?5. What are stable findings and

to what do they relate?6. What are unstable findings and

to what do they relate?7. Do findings precede the

development of disease?8. Do findings result from

disease?9. What is the incidence of

findings in a population, i.e.different age groups,occupations?

10. What is the incidence offindings in relation to certaindiagnostic entities?

11. Can findings be quantified?12. How do findings compare

with other predictors of illnesssuch as history, physical signs,laboratory data, responseto therapy?

13. Can the energy cost of somaticdysfunction be measured?

B. Manipulative Treatment1. What are the criteria for the

use of manipulative therapy?2. Is manipulation superior to

other forms of therapy and forwhat patients?

3. How can the effectiveness ofmanipulation be evaluated?

4. What are the mechanisms ofbody response to manipulativetherapy?

5. What response doesmanipulative therapy produceinitially - later?

6. How do you determine afavorable response tomanipulation?

7. How good is the physician’sprediction of results of

manipulation - a single visit,long-range?

8. What is an adequate timeinterval between treatments toproduce maximum results?

9. What are the contraindicationsto the use of manipulation?

10. How is dosage ofmanipulation determined?

The collaborative research effortsbetween the two schools were con-fined to Johnston’s work with Kelsoon palpatory findings associated withhypertension, and my study ofpalpatory findings in cardiac patients.Other studies with clinical implica-tions, which have evolved in the Bio-mechanics Department has beenthose on tissue properties byHubbard, and spinal motion byHerbert Reynolds using stereometricx-ray studies of cadavers.

Research DesignAn important result of the growth

in clinical research efforts during thelast decade was a realization that stepsneeded to be taken to improve osteo-pathic research design. Osteopathicclinical research often lacked ad-equate descriptions of the diagnostictests utilized, the findings before in-tervention, the treatment instituted,and the findings after intervention.

In November of 1985, Dr. AnthonyG. Chila chaired a meeting of an AdHoc Committee of the AOA Bureauof Research to discuss the recordingof musculoskeletal findings. Thosepresent at the meeting were AnthonyChila, Myron Beal, John Goodridge,William Johnston, Robert Kappler,Albert Kelso, Michael Patterson andDavid Rivers from the AOA Bureauof Research.

The results of the Ad Hoc Com-mittee were a series of recommenda-tions for osteopathic research, whichif adopted would ensure a basic uni-formity of research design for stud-ies involving osteopathic manipula-tive treatment. It was recommended


that the criteria for a research studyto evaluate osteopathic manipulativetreatment should include:

1. A musculoskeletal examinationwith:a. descriptions of the tests utilized

to determine the presence orabsence of somatic dysfunction,

b. the criteria for positive findings,c. a description of the findings

relating to the assessment ofsomatic dysfunction.

2. A preliminary musculoskeletaldiagnosis.

3. Intervention (osteopathicmanipulative treatment)a. based on the test findings,b. the objective of treatment,c. a description of the treatment

procedure(s) used.4. Reassessment

a. a reevaluation of findings,utilizing the original tests usedto determine the presence ofsomatic dysfunction.

5. Documenting the effects ofosteopathic manipulativetreatmenta. local musculoskeletal effectsb. remote musculoskeletal effectsc. other effect

1) behavior2) visceral3) communicating.

The adoption of these criteria bythe AOA Bureau of Research wouldset criteria for the review of researchprojects for acceptance and funding.It would raise the level of osteopathicresearch by insuring basic standardsfor research design. It would ulti-mately determine the criteria for ac-ceptance by the JAOA for publica-tion. Such steps could only result inbetter osteopathic clinical research.

SummaryI have tried to give you an over-

view of the research directions since1940. There are certain themes:

1) physiological research in neuro-physiology, facilitation, axonal trans-port, circulation, autonomic control,2) body adaptive responses, posture,short lower extremity,3) joint mechanics,4) the effects of manipulation on thebody and,5) clinical trials of the effect of ma-nipulative treatment.

Some of the studies that have beendone need to be repeated for confir-mation or clarification. Studies areneeded which introduce the dimen-sion of time so that observationssimulate clinical experience. We needto examine further the art of palpatorydiagnosis and treatment and try andanswer some of the basic questionsin terms of effectiveness and reliabil-ity of results. It is time for the profes-sion to require minimum standards ofconformity in osteopathic researchdesign.

Bibliography1. Denslow, J.S. and Clough, H.G.: Reflex

activity in the spinal extensors. J.Neurophysiol. 4:430-7, 1941.

2. Korr, I.M., Wilkinson, P.N., and Chornok,F.W.: Axonal delivery of neuroplasmiccomponents to muscle cells. Science155:342-5, 1967.

3. Korr, I.M., Wright, H.M., and Chase, J.A.:Cutaneous patterns of sympathetic activ-ity in clinical abnormalities of the muscu-loskeletal system. Act. Neurology 25:589-606, 1964.

4. Eble, J.N.: Patterns of response of theparavertebral musculature to visceralstimuli. Am. J. Physiol. 198:429-33, Feb1960.

5. Hix, E.L.: Segmental and supre-segmen-tal reflex influences on renal function.JAOA 66:999, May 1967.

6. Kelso, A.F. and Johnston, W.L.: A pilotstudy on measurement of skin tempera-ture. JAOA 80:754, Jul 1981.

7. Patterson, M.: Louisa Burns Memorialaddress. The spinal cord - Active proces-sor not passive transmitter. JAOA 80:210-6,1980.

8. Strachan, W.F., Beckwith, C.G., Larson,N.J., and Grant, J.H.: A study of the me-chanics of the sacroiliac joint. JAOA37:576-8, Aug 1938.

9. Beckwith, C.G.: Vertebral mechanics.JAOA 43:226-31, Jan 1944.

10.Beckwith, C.G.:Cervical mechanics.JAOA 43:384-8, May 1944.

11.Beckwith, C.G.:Thoracic vertebral me-chanics. JAOA 43:436-9, Jun 1944.

12.Beckwith, C.G.:Lumbar mechanics.JAOA 43:491-4, Jul 1944.

13.Beckwith, C.G.: Pelvic mechanics. JAOA43:549-52, Aug 1944.

14.Bailey, H.W. and Beckwith, C.G.: Shortleg and spinal anomalies. JAOA36:319-27, Mar 1937.

15.Beilke, M.C.: Simple mechanics of thesacro-lumbar group. JAOA 39:165-7, Nov1939.

16.Long, F.A.: Some observations on spinalmotion. JAOA 39:405-15, May 1940.

17.Kerr, H.E., Grant, J.H., and MacBain,R.N.: Some observations on the anatomi-cal short leg in a series of patients present-ing themselves for treatment of low-backpain. JAOA 42:437-40, Jun 1943.

18.McWilliams, A.F.: Combination lesions.JAOA 30:239-40, Feb 1931.

19.Magoun, H.I.: Basic lesions. JAOA36:453-6, Jun 1937.

20.Dunnington, W.P.: A musculoskeletalstress pattern: Observations from over 50years clinical experience. JAOA 64:366-71, Dec 1964.

21.Heilig, D.: Patterns of Still lesions and anevaluation of some diagnostic criteria inaltered vertebral postural patterns. Thesisprepared for Master of Science degree,Philadelphia College of Osteopathy, 1957.

22.Hoskins, E.R.: The development of pos-ture and its importance: III. Short leg.JAOA 34:125-6, Nov 1934.

23.Beal, M.C.: A review of the short leg prob-lem. JAOA 50:109-21, Oct 1950.

24.Denslow, J.S., Chase, J.A., Gutensohn,O.R., and Kumm, M.G.: Methods in tak-ing and interpreting weight-bearing x-rayfilm. JAOA 54:663-70, Jul 1955.

25.Denslow, J.S., Chase, J.A., Gardner, D.L.,and Banner, K.B.: Mechanical stresses inhuman lumbar spine and pelvis. JAOA61:705-12, May 1962.

{


26.Thomas, P.E.: An analysis of the interac-tion among various asymmetric osseouspelvic and lumbar structures. JAOA64:956-7, May 1965.

27.Thomas, P.E.: Patterns of muscle activityin the legs, hips and torso associated withquiet standing. JAOA 72:58-9, Sep 1972.

28.Pearson, W.M.: A progressive structuralstudy of school children. JAOA 51:155-67, Nov 1951.

29.Hogen, D.P.: A continuing roentgeno-graphic study of rural school children overa 15-year period. JAOA 63:546-57, Feb1964.

30.Fryette, H.H.: Physiological movementsof the spine. JAOA 18:1-2, Sep 1918.

31.Hoag, J.M., Kosak, M., and Moser, J.R.:Kinematic analysis and classification ofvertebral motion. JAOA 59:982-6, Aug1960.

32.Rosenberg, P.: The R-center method. Anew method for analyzing vertebral mo-tion by x-rays. JAOA 55:103-11, Oct 1944.

33.Beal, M.C. and Beckwith, C.G.: Studiesof vertebral motion: I. Cineradiographicstudies on the Halladay Spine. JAOA63:319-23; II. Clinical applications. JAOA63:323-5, Dec 1963.

34.Ho, R.W.H.: Testing intervertebral jointmovement. JAOA 61:635-9, Apr 1962.

35.Reynolds, H.M.: Three dimensional kine-matics in the pelvic girdle. JAOA 80:277-80, Dec 1980.

36.Hubbard, R.P. and Sacks, M.S.: Mechani-cal response of collogenous tissue to re-peated elongation. JAOA 83:73, Sep 1983.

37.Hubbard, R.P. and Chan, K.J.: Mechani-cal responses of tendons to repealed ex-tensions and wait periods. Proceedings ofthe 1985 Biomechanics Symposium,American Society of Mechanical Engi-neers. AMD, Vol. 68, Fed. Vol. 21, 1985.

38.Long, F.A., and Deming, G.S.: The effectson the blood pressure and pulse rate of softtissue manipulation combined with sud-den spinal joint mobilization in the cervi-cal region in a group of “normal” collegestudents. JAOA 42:185-7, Dec 1942.

39.Celander, E., Koenig, H.J., and Celander,D.R.: Effect of osteopathic manipulativetherapy on autonomic tone as evidencedby blood pressure changes and activity ofthe fibrinolytic system. JAOA 68:1036-8,Jun 1969.

40.Borown, T., Celander, E., and Celander,D.R.: A proposed mechanism for osteo-

pathic manipulative therapy effects onblood pressure. JAOA 69:1035-6, Jun1970.

41.Marcus, A.J., and Kerms, I.D.: Effect ofosteopathic manipulative techniques uponblood flow using the electrical impedenceplethysmograph. JAOA 68:1047-51, Jun1969.

42. England, R.W., and Deibert, P.W.: Elec-tromyographic studies: Part I. Consider-ation of the evaluation of osteopathictherapy. JAOA 72:221-3, Oct 1972.

43. Heilig, D., Greene, C., and Arbizo, M.:Quantitation of segmentally related pe-ripheral effect of manipulation on somaticdysfunction in vertebral areas. JAOA83:69-71, Sep 1983.

44. Deibert, P.W. and England, R.W.: Crys-tallographic study: Thermal changes andthe osteopathic lesion. JAOA 172:223-6,Oct 1972.

45. Kelso, A.F., Grant, R.G., and Johnston,W.L.: Use of thermograms to support as-sessment of somatic dysfunction or effectsof osteopathic manipulative treatment:Preliminary report. JAOA 82:182-8, Nov1982.

46. Wilson, P.T.: Experimental work in asthmaat the Peter Brent Brigham Hospital.JAOA 25:212-4, Nov 1925.

47. Howell, R.K., Allen, T.W., and Kappler,R.E.: The influence of osteopathic ma-nipulative therapy in the management ofpatients with chronic obstructive lung dis-ease. JAOA 74:757-60, Apr 1975.

48. Miller, W.D.: “Treatment of visceral dis-orders by manipulative therapy” in theResearch Status of Spinal ManipulativeTherapy (Bethesda, MD: U.S. Dept. ofHealth, Education and Welfare) 1975, pp295-301.

49. Cox, J.M., Gorbis, S., Dick, L.M., Rogers,J.C., and Rogers, F.J.: Palpable musculosk-eletal findings in coronary artery disease:Results of a double-blind study. JAOA82:832-6, Jul 1983.

50. Beal, M.C.: Palpatory testing for somaticdysfunction in patients with cardiovascu-lar disease. JAOA 82:822-31, Jul 1983.

51.Nicholas, A., DeBias, D.A.,Ehrenfeuchter, W., England, K.M., En-gland, R.W., Greene, C.H., Heilig, D., andKirschbaum, J.: A somatic component tomyocardial infarction. Brit. Med. J.291:13-17, Jul 1985.

52.Hoyt, W.H., Shaffer, F., Bard, D.A.,Beinesler, J.S., Blankenhorn, G.D., Gray,

J.H., Hartman, W.T., and Hughes, L.C.:Osteopathic manipulation in the treatmentof muscle contraction headache. JAOA78:322-5, Jan 1979.

53.Siehl, D.: Manipulation of the spine un-der general anesthesia. JAOA 62:881-7,Jun 1963.

54.Siehl, D., Olson, D.R., Ross, H.E., andRockwood, E.E.: Manipulation of the lum-bar spine with the patient under generalanesthesia: Evaluation by electromyogra-phy and clinical-neurological examinationof its use for lumbar nerve root compres-sion syndrome. JAOA 70:433-40, Jan1971.

55.Larson, N.J., Walton, M.W., Huitt, H.H.,and Kelso, A.F.: A double-blind clinicalstudy of the effects of manpulative treat-ment of patients with peripheral nervecomplaints. JAOA 76:209, Nov 1976.

56.Beal, M.C., Vorro, J., and Johnston, W.L.:A correlation of myoelectric findings withclinical progress in patients with chroniccervical dysfunction: A pilot study. Sub-mitted for publication.

57.McConnell, D.G., Beal, M.C., Dinnar, U.,Goodridge, J.P., Johnston, W.L., Karni, Z.,Upledger, J.E., and Blum, G.: Low agree-ment of findings in neuromusculoskeletalexaminations by a group of osteopathicphysicians using their own procedures.JAOA 79:441-50, Mar 1980.

58.Dinnar, U., Beal, M.C., Goodridge, J.P.,Johnston, W.L., Karni, Z., Mitchell Jr.,F.L., Upledger, J.E., and McConnell, D.G.:Classification of diagnostic tests used withosteopathic manipulation. JAOA 79:451-5, Mar 1980.

59. Dinnar, U., Beal, M.C., Goodridge, J.P.,Johnston, W.L., Karni, Z., Mitchell Jr.,F.L., Upledger, J.E., and McConnell, D.G.:Description of 50 diagnostic tests usedwith osteopathic manipulation. JAOA81:314-21, Jan 1982.

60. Beal, M.C., Goodridge, J.P., Johnston,W.L., and McConnell, D.G.:Interexaminer agreement on patient im-provement after negotiated selection oftests. JAOA 79:432-40, Mar 1980.

61.Johnston, W.L., Elkiss, M.L., Marino,R.V., and Blum, G.A.: Passive gross mo-tion testing: Part II. A study ofinterexaminer agreement. JAOA 81:304-8, Jan 1982.

62. Upledger, J.E.: The reproducibility ofcraniosacral examination findings: A sta-tistical analysis. JAOA 76:890-9, Aug1977.❒


From the AOBNMM Files:(Certifying Board formerly known as AOBSPOMM)

Case Study:OMT and Chronic Cephalgiaby Carole S. Brown, DO, CSPOMM, Jefferson City, MO

Patient Identification:CC, a 29-year-old female

Chief Complaint:Chronic Cephalgia

Historyof Chief Complaint

CC presents to the clinic complain-ing of chronic headaches. Onset wasapproximately one year ago and shecan recall no associated events ortrauma. Her headaches occur inter-mittently, approximately two or threetimes a week. They begin in the fron-tal bone area and progress to encom-pass the entire cranium especially atthe occipital bone. She describes thepain as either a throbbing ache orburning and dull. These headacheshave awakened her at night. No pro-vocative or palliative factors are re-called. She has nausea with the head-aches but denies aura symptoms andphotophobia. She also denies loss ofcoordination, vision changes, muscleweakness, and seizures.

Past Medical History:Negative other than as stated above.

Past Surgical History:Tonsillectomy at age eight and re-

moval of three benign breast cysts atage eighteen.

She also admits to a fractured coc-cyx as a result of a fall onto her but-tocks into a twelve-foot empty swim-

ming pool. Her father never allowedher to tell her mother.

Social History:She is a nondrinker, nonsmoker,

and self-employed as a custom framerand photographer. She is married to aphysician and lives with her husbandand two “challenging” daughters.

Allergies:No known drug or seasonal allergies.

Medications:Tylenol 500 mg two every four hoursas needed and ibuprofen 400 mg threetimes a day.

Review of Systems:General: good health, no recent

change in weight or sleeping habits.Head: as in chief complaint, mandibledeviation 4mm to the left, orthodon-tics applied 13 months ago withmonthly adjustments.

Eyes: no changes in vision,trauma, or pain.

Ears: negative.Nose: frequent nasal congestion,

pain in the frontal and maxillary sinuseswith infections several times a year.

Throat and neck: negative.Cardiovascular and Pulmonary:

negative.Gastrointestinal: no change in

bowel habits, dyspepsia, or reflux.Genitourinary: no infections, no

renolithiasis, menses normal duration,amount, and no association with head-aches.

Musculoskeletal and neurologic:negative other than as stated in chiefcomplaint. Endocrine, hematopoietic,and psychiatric are all negative.

Physical Exam:General: CC is a well-developed,

well-nourished 29 year old female,who is alert, cooperative, and in nodistress. Vital signs: temperature98.4, pulse 80, respiration 20, bloodpressure 110/70, height 5 feet 2inches, weight 114.

Head: mandible bone deviated tothe left relative to the maxilla.

Eyes: pupils equally round and re-active to light and accommodation,extra ocular muscles intact, fundo-scopic: no hemorrhages or exudates.

Nose: clear, no sinus tenderness.Mouth: Orthodontic appliances in

place.Throat and neck: negative.Cardiovascular: no murmurs or

ectopic beats.Pulmonary: clear to auscultation.Gastrointestinal: negative.Musculoskeletal: mandible bone

deviates left upon opening with crepi-tus noted in the right temporoman-dibular joint (TMJ) otherwise nomuscle atrophy or weakness. Neuro-logic: cranial nerves I- XII intact,upper extremity DTRs 2/4, coordina-tion intact.

Structural: standing posture rightshoulder inferior, right iliac crest in-ferior, increased cervical lordosis,thoracic kyphosis, and lumbosacralangle.

continued on page 38


Book Reviewby Michael A. Seffinger, DO, FAAFP, CSPOMM

The Muscle Energy Manual:Evaluation and Treatment of the Thoracic Spine, LumbarSpine, and Rib Cage Volume Twoby Fred L. Mitchell, Jr. and P. Kai Mitchell

So many medical students andphysicians have difficulty problemsolving when it comes to the muscu-loskeletal system because of lack ofan organized rational approach toevaluation and treatment. This bookwill enable the student and teacher ofmanual diagnostic and treatment pro-cedures to develop a solid frameworkand sophisticated skills second tonone. It succinctly covers pertinentarticular anatomy and biomechanics,respiratory motion and evaluation andtreatment procedures using muscleenergy concepts developed by Drs.Fred L. Mitchell, (Sr. and Jr). Keyconcepts are summarized in well de-signed tables and graphic drawingsdone so clearly that they can easilybe used in lectures by instructors toget these crucial points across. Blackand white photos depicting evaluationand treatment procedures are clearand accurate and enhance the text anddrawings well. Explanations of pro-cedures are very articulate and easilyunderstood. Interspersed are quotesfrom experts in the field as well asdiscussion of controversies in the cur-rent medical literature.

The descriptions are as accurate aspossible, stating positions in threeplanes, amount of movement in mil-limeters, amount of force in poundsand the duration of activity in sec-onds. Clinical cases, problem solving,differential diagnosis and organiza-tion of examination and treatmentprocedures are additional compo-

nents of this manual that set it apartfrom any other book on manual medi-cine in print today. Clinical indica-tions and precautions are clearly de-lineated and clinical pearls derivedfrom Dr. Mitchell’s 40 years of inti-macy with these procedures in clini-cal practice are abundant. Also in-cluded are the historical develop-ments of the various techniques thatprovide insight into their applicabil-ity and effectiveness.

Since muscle energy proceduresenlist the patient’s activation ofmuscle force, it is necessary to usevery accurate commands to get thepatient to move exactly how the prac-titioner wants in order to increase theeffectiveness of the procedure.Thankfully, Dr. Mitchell provides thelearner and instructor with the wordsto use to instruct patients properly.These particular commands haveproven themselves over the decadesas being most effective and succinct.

It is also interesting to note that theevaluation and treatment procedurestaught in this manual have becomestandard in all of the American osteo-pathic medical schools. They are taughtaround the world and formulate inte-gral components of the curricula at for-eign osteopathic colleges and institu-tions as well. They are rationally based,logically sequenced, and easily learnedand reproduced.

It is my opinion that the true gemof this manual is that one fourth ofits 223 pages is devoted to diagnosis

and treatment of rib dysfunctions.This is the most complete and authori-tative dissertation on this part of thebody that I could find in the currentworld literature. Having learned theseprocedures from Dr. Mitchell whilein medical school at Michigan StateUniversity College of OsteopathicMedicine 1983-88, I have used themfor 15 years in clinical practice. Theyare amongst the most useful and effec-tive procedures ever designed forevaluation and treatment of patients ofall ages with costal cage dysfunction.

The main drawback I have foundin using this manual is that it lacksan index at the end. There are timeswhen I want to know what is writtenon a topic or a term and I have tothumb through a chapter or two tofind it. Although the book does havea detailed table of contents and a sepa-rate list of diagnostic and treatmentprocedures, an index would be a wel-come addition to the second edition.

This book is a “must have” forpractitioners using manual diagnos-tic and treatment procedures for thethoracic and lumbar spine and costalcage. It will no doubt establish itselfas one of the classic books to comeout of the last century and yet it istruly a guiding light for the 21st cen-tury and new millennium.

[Note: The Muscle Energy Manual, Vol-ume Two, can be ordered from the publisher:MET Press, P.O. Box 4577, East Lansing, MI48826-4577. Fax: (517) 332-4196. VolumeThree covering evaluation and treatment ofthe pelvis and sacrum is now available.]❒


Lift Treatment in Naval SpecialWarfare (NSW) Personnel:A Retrospective Study a,b

by CDR James A. Lipton, MC, USNC ; LT John S. Brooks, MC, USNd ;ENS (SEAL) Matthew J.Hickey, MC, USNReENS Brendon G. Drew, MC, USNRfHM1 (SEAL) Michael T. Eggleston, USNgHM1 (SEAL) Christopher H. Gemmer, USNh

AbstractAs in the civilian population, low back pain (LBP) is a common complaint among Navy personnel seeking medical

attention. After a thorough history and physical examination, some NSW personnel presenting with LBP to the medicaldepartment of Special Boat Squadron TWO (SBR-2) in Norfolk, VA, were found to have a leg length inequality (LLI)or physiologically “short leg.” Thirty-five of these individuals were treated with a heel lift. The lift was placed in theshoe corresponding to what was determined to be the “short leg” side. These individuals experienced either complete orsignificant relief of their musculoskeletal complaints.

Key wordsleg length inequality, lift treatment, short leg, sacral base unleveling, low back pain, anisomelia)

IntroductionSome researchers report that LBP

affects up to 80% of people at sometime in their life.1 Consequently, LBPis responsible for more loss in pro-ductivity than any other ailment andis the second leading cause of missedwork days (respiratory infections isnumber one).2 Unfortunately, backpain can have a multifactorial etiol-ogy and providing a specific diagno-sis can be complicated.3 LBP whichis mechanical or musculoskeletal innature accounts for the majority ofcomplaints.4

Measurement of sacral baseunleveling and LLI can provide abasis for diagnosis and treatment ofmusculoskeletal or mechanical LBP.Of those authors who support the re-lationship between LLI and LBP,some choose to measure LLI whileothers measure sacral baseunleveling.5,6,7 In this study, both wereconsidered. Correlation between theside and direction of sacral baseunleveling is not necessarily instruc-tive. Greenman points out that in ac-cordance with Lloyd andEimerbrink’s classification catego-

ries, on rare occasion, the sacral basecan possess a contralateral tilt andactually have a higher level on theside of the “short leg.”6 Further re-search conducted by Johnson has re-vealed that there is very little corre-lation between the direction of sacralbase unleveling and the side of LLI.8

Regardless, most authors agree thatLLI and/or sacral base unleveling canbe measured by radiography and theresults of the radiography measure-ments are reproducible.4-7,9-16

Radiographs used to measureLLI or sacral base unleveling are

aThe views of this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department ofDefense, or the United States Government.

bThis study was cleared through the Force Medical Officer and Biomedical Research Director, Navy Special Warfare Command.cSpecialty Leader to the Surgeon General of the Navy in Physical Medicine and Rehabilitation; Senior Medical Officer, Special Boat Squadron

Two, 2220 Schofield Road, Naval Amphibious Base, Little Creek, VA 23521-2845.dNaval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708-2197.eMS-IV, Chicago College of Osteopathic Medicine, Midwestem University, 555 31st Street, Downers Grove, IL. 60515fMS-II, New York College of Osteopathic Medicine, P.O. Box 8000, Old Westbury, NY. 11568gMedical Department Leading Petty Offcer, Special Boat Squadron Two.hMedical Department, Special Boat Squadron Two.

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AP radiographs of the pelvis per-formed on a standing patient. In or-der to minimize error, an accurate truevertical or horizontal reference linemust be established. The subject, inbare feet, must stand with heels un-derneath the ipsilateral acetabula andthe patient’s buttocks must be in con-tact with the cassette. The x-ray tubemust be at femoral headheight.4,5,10,13,16

In measuring LLI, a horizontal lineis drawn over each femoral headapex, and a resultant LLI is deter-mined against the vertical differenceof these horizontal measurements. Indetermining sacral base unleveling,vertical lines are drawn through eachfemoral head apex. A line is thendrawn over the sacral “line of ebur-nation” or line of increased bone den-sity.5 This line runs parallel to the sac-ral base. This line eventually intersectsboth vertical femoral head lines alreadydrawn. The vertical difference betweeneach intersected line is the measure ofsacral base unleveling. However, astudy by Fann et al found that:

the percent agreements for bothintrarater and interrater measure-ments were significantly higherfor the intersulcate line than forthe line of eburnation. If the lineof eburnation method is used in acontrolled study to correct leglength discrepancies to relievechronic back pain, the hypothesisresults (that correcting such a dis-crepancy will decrease theamount of pain) may not beachieved, not because the treat-ment is ineffective but because thewrong size lift was applied to thewrong side. [Therefore, they] rec-ommend using the intersulcateline when assessing a patient forpelvic obliquity.17

Most authors question the accu-racy and reproducibility of anthropo-metric measurements, either by pal-pation or tape measure. Friberg citesstudies in which examiner errorreaches +/-10 mm (2/5").14 Giles and

Taylor cite a study in which 5% ofthe examinations yielded a 10 mm (2/5") error.4 Beal and Gofton state thatan LLI tape measurement of 12.5 mm(1/2") or less is unreliable.9,15

Although Gofton agrees with theaccuracy and reproducibility of radio-graphic measurements, he believes aclinical method (without tape mea-sure) can detect LLI of 9 mm (1/3")and greater, and that this method is“sensitive and sufficient for ordinaryuse.”9 This method involves viewingthe standing patient from behind andnoting gross iliac crest asymmetry,and using calibrated blocks under theshorter leg to view iliac crest level-ing.9 Cailliet believed his examinationmethod of the pelvic level was accu-rate to 6.5 mm (1/4”).18

Travell notes the supine method isone of the least reliable measurementmethods. This is because Travellnotes a supine LLI found in leglengthening and leg-shortening ma-neuvers has the potential of functionalshortening of a leg as a result of aquadratus lumborum trigger point.19

The authors believe their method ofexamination negates to an acceptablelevel, these factitious leg lengthening/shortening inaccuracies.

The authors believe that a thoroughmusculoskeletal exam can detect sig-nificant LLI. In this study, the pres-ence of sacral base unleveling and notthe specific LLI measurement was of

primary concern. Unlike the standingexamination of most clinicians, theauthors’ method for detecting signifi-cant LLI involves comparing fourpoints: the medial malleoli, ASIS ofthe supine subject, inferior lateralangles (ILA), and the left and rightsacral sulci. Prior to the comparison,the subject is instructed to empty allpockets since objects will affect themeasurement. The patient then mustlift his or her buttocks off of the tablefor a brief moment. This prevents theunequal setting of femoral heads intheir respective acetabula and bilater-ally affects attached musculature. Un-equal setting of femoral heads can befactitiously produced and this can beeasily demonstrated on the supine sub-ject. The medial malleoli will appearlonger after one leg is either internallyor externally rotated at the hip. Theauthors believe that a careful physicalexamination can detect a LLI to an er-ror of 1/8". Postural AP pelvic radio-graphs were not taken nor were theyrecommended.

Lift treatment usually involves in-serting a durable lift in the corre-sponding shoe of the “short leg.”Authors supporting lift treatment varyconsiderably in their initial prescribedlift thickness and whether periodic liftincreases are indicated. Table 1 out-lines the various lift treatments thatvarious authors used in their respec-tive studies.

Table 1

Author Initial Lift Incr eases in LiftFribergl4 a few mm < LLI not mentionedGiles/Taylor4 equal to LLI* not mentionedGofton9 9-10 mm (3/8") not mentionedGreenman6 to level sacrum** not mentionedHoffman7 3 mm (1/8")*** 2 mm (1/12")q 10-14 daysIrvin5 3 mm (1/8")**** 1.6 mm (1/16") q 2 weeksPatriquin28 1/8" to 1/2" not mentioned

* If >5 mm, raise sole an equal amount over 5 mm.** If > 8 mm, 50% placed on heel of short leg, 50% taken off heel of long leg.*** If > 20 mm, sole must be adjusted an equal amount over 20 mm.

Amount to be added periodically until sacral leveling occurs.**** If > 8 mm, raise sole an equal amount over 8 mm.

Add 1.6 mm every two weeks until sacral leveling occurs.


From the small sample of treat-ments analyzed, those authors whotreat LLI, as opposed to the sacralbase, do not use gradual lift increases.Although not specifically indicated intheir work, lifts are assumed to bepermanent if the treatment results ina corrected LLI and an overall reduc-tion in pain. The same is assumed forthose authors who treat the sacralbase. As long as the sacrum is level,and an overall reduction in pain oc-curs, the lift will remain. Of the au-thors studied, only Beal notes a LLImay be functional in nature and war-rant temporary lift placement. He indi-cates that functional LLI, as opposedto structural LLI, may be caused byunilateral psoasitis, unequal lumbar ten-sion, shortening of the fascia about thehip, shortening or relaxation of the liga-ments, or flat feet.15

Some authors have treated theirpatients with spinal manipulation inaddition to lift treatment. These stud-ies were conducted by osteopathicphysicians and chiropractors. Propo-nents of osteopathic manipulativemedicine have supported the associa-tion of LLI, sacral base unleveling,and potential LBP.9 Osteopathic lit-erature emphasizes “the need for ap-propriate manipulative treatment toassist the patient in the process ofaccommodation to the lift.”15

The authors feel that lift treatmentis indicated for sacral base unlevelingsecondary to muscle imbalance viathe following mechanism. An unlevelsacral base decreases the ability of thespinal column to balance the forcesof gravity, which can be associatedwith gait dysfunction. Gait dysfunc-tion can create a muscle imbalanceover time or result from a muscleimbalance, which in turn can accen-tuate or create a LLI. Shell and Irvinreport that, “Other than ideal configu-ration of the feet and attitude of thesacrum necessarily destabilizes themusculoskeletal system to a subtlebut unrelenting extent.”20

In addition, prior surgery or lower

extremity trauma may also cause aLLI via viscerosomatic or somato-somatic reflexes, respectively. Theauthors acknowledged that a LLI doesnot necessarily cause LBP. The author’sprimary concern in providing lift treat-ment was to level the sacral base.

At least since the late 1800s, sev-eral dozen physicians have been en-gaged in a debate through the litera-ture regarding the significance of leglength inequality (LLI) and the rela-tionship to LBP.

The definition of significant LLIdiffers depending on the author. Table2 illustrates the different definitionsof significance with regard to LLIaccording to authors who support the

association between LLI and LBP.On the other side of the debate,

some authors are skeptical about therelationship between LLI and LBP.The results from the study by Soukkaet al concluded that the associationbetween mild and LLI and LBP isquestionable; LLI of up to 20 mm (4/5") were considered.11 Papaioannouet al studied 23 young adults seekingtreatment for a LLI that existed sincechildhood. The discrepancies rangedfrom 12 mm to 52 mm, and not onesubject had any LBP.21 Grundy andRoberts used a ‘’locating jig” to as-sess LLI in 70 subjects. They con-cluded that chronic LBP is unlikelyto be a part of a shortened lowerlimb.12 Their study, however, did notrule out that LBP may be a functionof an unleveled pelvis and not neces-sarily LLI.9

Friberg and Gofton clearly statethat LLI will not likely contribute tochronic LBP if the individual is notstanding and/or walking a consider-able amount. LBP from a LLI is usu-

ally relieved by sitting or reclin-ing.9,10,13 Friberg, however, specificallynotes that a military population wouldbe susceptible to LBP from a LLI.13

Measurable LLI is extremelyprevalent in our population. Whatcauses this LLI? Giles and Taylorpoint out that the vast majority ofpatients with a LLI of 10 mm or morehave no known etiology.4 Friberg’sstudy found that 92% of his LLI sub-jects bore an unknown etiology.14

Known etiologies of LLI include epi-physial growth dysfunction (infec-tion, trauma, tumor, etc.), fractures,poliomyelitis, congenital ball andsocket ankle joint configuration, jointsurgery, foot pronation and juvenilerheumatoid arthritis.10

Some proponents of lift treatmentsuggest a direct relationship betweenLLI and LBP, and propose that LLI andpelvic tilt are related. A pelvic tilt canbe associated with a sacral tilt. Goftonpoints out that a 12.5 mm (1/2") LLIcan result in a sacral inclination of 4degrees. A superimposed weight of 45kg (100 lbs.), likely in a normal sizedman, would result in a lateral forceof 2.2 kg (5 lbs.). This force must bemet by various muscles and liga-ments, which can likely producepain.9 This sacral tilt may also resultin compensatory movement of thespinal column. Any or all of the aboveasymmetries may ultimately result ina muscle imbalance of the lower back.

Naval Special Warfare comprisesthe special operations forces of theU.S. Navy. NSW sailors serve inSEAL (Sea-Air-Land) Teams, SEALDelivery Vehicle (SDV) Teams, Spe-cial Boat Units (SBU), or the respec-tive staffs of these units, which alsoincludes support personnel. The regu-lar operational training for these unitsis physically demanding and all ser-vice members are expected to be insound physical condition. Standing,patrolling, and running are all regu-lar activities for these personnel.NSW personnel train hard and are no

Table 2

Author Significant LLI (> or =)Friberg14 5.0 mm (1/5")Travell19 6.0 mmGofton9 9.0 mmGiles/Taylor4 10.0 mm (2/5")

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strangers to physiologic insults totheir musculoskeletal systems.

The authors of this study, there-fore, feel that the effects of LLI wereoften physiologic and therefore re-versible in nature and not necessarilyanatomic (osseous) and irreversible.The hypothesis of this study was thatby the objective leveling of the sac-ral base by the appropriate use of aheel lift, patients would report a sig-nificant subjective reduction of LBPbeyond the placebo effect. The au-thors believe the one third placeboeffect noted by Turner et al to widelyoccur in such studies did not apply tothe same degree in this study. Thereported reduction in the complaintof subjective LBP was always corre-lated with the objective examinationof finding a level sacral base.22

MethodStudy subjects included 31 male and

4 female sailors who randomly pre-sented to the medical department ofSpecial Boat Squadron Two (SBR-2)with a chief complaint of LBP fromJuly 1, 1997 to March 9, 1999. Twopatients (5.7%) dropped out of thestudy secondary to intolerance to thelift and had no relief. All sailors inthe study were comprised of both of-ficer and enlisted personnel that wereattached to a NSW command, 9 ofwhich were SEALs. Their agesranged from 26 to 53 years old (meanage 35.9 years) with a history of LBPfor 0 to 168 months (mean history46.6 months). All of the patients hadused traditional treatments of medi-cations, physical therapy and heat/cold without relief prior to present-ing to SBR 2 Medical. Nine patientshad undergone extensive work-upswith no cause identified for their LBPprior to presenting at SBR 2 Medi-cal. All subjects had consented to theanonymous presentation of their clini-cal outcomes.

Following diagnosis of sacral baseunleveling, thirty-five patients weretreated with a heel lift inserted into

the shoe of the short leg side. Allmedical department appointmentswere documented in their medicalrecords and these notes contained thepatients’ subjective pain evaluations.Patients had their outcomes recordedin their medical record. Patients pro-vided their current subjective symp-toms during an exam or recordedthrough a telephone interview.

Pain was measured using a subjec-tive pain scale. The patients wereasked how they would rate their painon a scale of 0 to 100, if 0 were nopain and a score of 100 would be suf-ficient to make them “pass out”. Thepatients were asked to provide a scorefor their worst pain, a pain with theuse of prescribed medications, andtheir current pain on a “day-to-day”basis.

After eliciting a thorough history,one physician performed all of thephysical examinations which in-cluded an in-depth musculoskeletalexamination. Sacral base unlevelingand LLI were assessed by comparingthe medial malleoli and ASIS of thesupine subject, and the ILA and sac-ral sulcus depths of the prone subjectas described previ-ously. In order toensure that thedifferential diagno-sis of LBP wasthoroughly ad-dressed, laboratorystudies consistingof CBC, ESR,CHEM 18 andlumbosacral radio-graphs were or-dered and clearedappropriately.

Patients found tohave a LLI weregiven a 3/8" lift tobe placed into theshoe of the physi-ologic short leg.Sometimes short-ness was notreadily apparent

due to ASIS inequality making limbsappear equal at the medial malleoli.Hips were then rotated using an osteo-pathic muscle energy technique usedto level the ASIS bilaterally; and thusrevealing the short leg side.23 All per-sonnel agreeing to lift treatment wereprovided with anticipatory guidanceabout minor aches and pains thatmight occur in the body (mainly feet,knees, and hips) as the body adjustedto the placement of the heel lift. Pa-tients were then followed by the phy-sician and Independent Duty Corps-man (IDC) at one month intervals toevaluate the effectiveness of treat-ment. All patients in the authors’study received osteopathic manipu-lative treatment as an adjunct to lifttreatment. Manipulative treatmentwas considered to facilitate overall re-covery; and although this may haveintroduced variables, osteopathicmanual manipulation was used afterthe first month of treatment becausethe patients’ prompt recovery wasconsidered an ethical priority. The fol-low-up visits might necessitate finetuning in accordance with Figure 1.Follow-up lumbosacral radiographs

Figure lLIFT DECISION TREE

1. Evaluate sacral base and LLI findingsin the same manner as the original visit. Go to: step 2

2. Is the patient experiencing pain?YES Go to: step 3 or 4NO Go to: step 5 or 6

3. Pain with Sacral Base not level andLLI still exists Go to: step 8LLI opposite original diagnosis Go to: step 7

4. Pain with Sacral Base level and LLIno longer exists. Go to: step 10

5. No pain with Sacral Base Leveland LLI still exists. Go to: step 9

6. No pain with Sacral Base Unleveland LLI still exists. Go to: step 7

7. Decrease lift height by l/8".8. Increase lift height by l/8".9. Continue using the lift at the current height.10.Discontinue the use of the lift.


were not obtained since careful physi-cal examination assessed sacral baseresponse. Subjecting the patient tofurther radiation for the purpose ofdemonstrating radiographically thesacral response to lift treatment wasdeemed unnecessary. This is based onthe ample proof in the literature re-garding this phenomenon; and, theeasily palpable sacral landmarks.24

Results/Data AnalysisAll statistical analysis were carried

out with Real Stat (Version 1.81,Kiser Software Company). Outcomemeasures were analyzed by Z testcontrasting history of the pain, worstpain level, pain level with medication,daily pain level, pain level with liftuse, and days to LBP resolution. Forthe purpose of time to recovery, the 2patients who dropped out of the studywere omitted from analysis. The pvalues reported are conservativelyexpressed as two tailed and valueswhere p is less than 0.05 were con-sidered statistically significant. Com-parisons between maximum pain andmedicated pain levels and maximumpain and post-lift use pain level wereevaluated to compare treatments.

Of the thirty-five patients who par-ticipated in this study, 28 (80.0 %) hadcomplete resolution of their LBPwithin 3 to 30 days (mean 16.6 days)of starting lift treatment. Their aver-age daily pain went from 38.2 to 0.Of the 7 patients who failed to havecomplete relief, 4 (11.4 %) had anoverall reduction in their daily LBP.Their pain level decreased from anaverage level of 50 to 20, an overallreduction of 60%. One of the thesethree individuals had his pelviscrushed in a motor vehicle accident.His pelvis was reconstructed withlarge amounts of metal hardwarewhich has subsequently been de-formed in a parachuting accidentprior to his entry into the study. Heentered the study with hopes of a non-invasive relief of his LBP. One pa-tient (2.9%) had no reduction in his

daily pain level of 10. However, hehas not experienced an exacerbationof his LBP in 6 months where theyhad been occurring at a rate of at least1 episode per month for 8 years.

DiscussionSome authors and many practitio-

ners are doubtful of the relationshipbetween LLI and LBP.11,12,21 Frymoyerstated that LBP patients tended to getbetter in 6 weeks.25 This guideline hasproven to be of little use in our studypopulation. Subsequent findings byVon Korff and Saunders confirm theinadequacy of this line of reasoning.26

While many of the researchers whoendorse the LLI-LBP relationshiphave studied the results of lift treat-ment, some authors who are skepti-cal of the relationship have not clini-cally evaluated the results of lift treat-ment. The results of numerous studies,as indicated in Table 3, demonstrate theclinical benefits of lift treatment.

Although this paper focuses on al-leviating LBP, several authors alsosupport the clinical efficacy of lifttreatment in other musculoskeletalailments. Goel noted that treatmentwith a heel lift relieved a patient suf-fering with meralgia paresthetica.27

Friberg documents lift treatment ridsciatica in 61 of 83 patients (73.5%)and eliminated chronic hip symptoms(to include pain from hip arthroses)in 56 of 79 patients.14 Rothenberg, arheumatologist, supports Friberg’sresults, and specifies osteoarthritis

and bursitis as specific chronic hipconditions that were improved.10

Gofton, another rheumatologist, as-serts there is a likely relationship be-tween LLI and a form of osteoarthri-tis.9 These authors also contend thatthese painful conditions are likelyassociated with prolonged standingand associated relief upon sitting.

Still very few lift treatment stud-ies exist. Both Patriquin and Bealnoted the same lack of objectivedata.6,15 In addition, lift treatmentstudies are not conducive to con-trolled conditions. Many authors ac-knowledge the unavoidable variabil-ity they were forced to accept. Forobvious ethical considerations, nostudy included an untreated controlgroup of symptomatic patients. Inaddition, pain is subjective and ex-tremely difficult to measure; and inmost studies, the author workedalone. Most larger studies also reportlosing contact with many patients forlong term assessment. Giles and Tay-lor specifically note that many of theirpatients were opposed to radiographicreassessments.4

Regardless of study, most of theauthors acknowledge that lift therapyis simple, inexpensive, non-invasive,and poses negligible risks to the pa-tient. Rothenberg notes that prior tohis consultation, some physicians hadpreviously ordered tests of computedtomography (CT) scans andmyelograms (EMGs), and treatments

Table 3

Author # with LBP Total relief Some relief No reliefGiles/Taylor4 50 Significant relief recorded but not in this form+Gofton9 10 All reported major or complete relief++Friberg14 128 96 (75%) 20 (15. 6%) 12 (9. 4%)Patriquin28 51 42 (82%) +++ 77 (14%) 2 (4%)Rothenberg10 12++ 6 (50%) 2 (16.7%) 4 (33.3%)

+ Lift treatment plus manipulation;Relief recorded as number of post-treatment LBP complaints and lost work days.

++ Rheumatology referral patients;Select group of unexplained LBP with extensive prior work-ups.

+++ Only 17 of 42 had complete long term relief, the remainder had intermittentlong term relief.

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of extensive exercising, pharmaco-therapy with NSAIDS, physicaltherapy and hospitalized pelvic trac-tion.10 Rothenberg was able to effectlong term relief with a simple heel lift.

The authors believe the crucialpoint to make prior to the placementof a lift is whether or not the sacralbase needs leveling. The point of lifttreatment is to level the sacral base.

Following the decision tree of Fig-ure 1, lift treatment in 94.3% of NSWpersonnel participating in the studyresulted in a reduction of overall pain,a reduction in severity of remainingpain, and an increase in the ability toperform physical tasks. 5.7% of theparticipants (2 patients) dropped outdue to lift intolerance. Sometimespatients fail to keep the lift all the wayback in the heel and some patientstake the lift in and out of their shoes.Both of these actions can cause anintolerance to the lift. Accompanyingthe reduction in pain and the increasein activity was an overall leveling ofthe sacral base in all of the sailorsevaluated. NSW sailors reported anincrease in their productivity and anoverall increase in their sense of wellbeing.

The authors did note some limita-tions of this study and they include:the cases under discussion differ fromthose ordinarily encountered in thatall of these personnel are highly mo-tivated, goal oriented personnel whooften started out in well above aver-age physical condition. To be fair,many of our patients were compro-mised by severe training regimensrendering our treatment success thatmuch more impressive. The studywas limited by the small number ofpatients, and the pain level was a sub-jective measurement which variesfrom patient to patient. In our experi-ence, NSW personnel tend to under-estimate the level of pain they are in.To control for this variable, the exactsame questions, as outlined earlier,were given during each interview toall patients. Consistency within pa-

tient reports was stressed. There wasno wrong answer but patients had tobe consistent with their ratings.

ConclusionThe data indicates the majority of

LBP patients were successfullytreated with lifts. These findings alsosuggest that the traditional treatmentsof medication, physical therapy, andheat/cold may not be adequate in thetreatment of posturally related LBPsince they do not directly correct theunderlying somatic dysfunction,namely an unlevel sacral base. How-ever, lift use does correct this somaticdysfunction and is simple, inexpen-sive, non-invasive, produces rela-tively rapid results, and is generallywell tolerated.

Table 4PAIN DATA

History Worst After Meds Daily After lift Days to ReliefM 46.57 71.26 42.71 38.86 4.86 (2.50)* 16.62*SD 49.71 20.67 23.88 21.94 12.04 (7.07)* 8.04*

* Includes all patients except for the two patients who dropped out of the study.

Lift treatment can easily be pro-vided to other patients with similarresults. A trained physician or super-vised IDC can provide this treatmentsafely in order to relieve patients oftheir LBP which may be posturallyrelated. Postural relationship can bedetermined after a thorough history,physical exam, screening laboratorytests, and lumbosacral radiographsfail to reveal any underlying medicalor surgical condition in the differen-tial diagnosis of LBP.

These treatments are in accordancewith Department of Defense andVeteran’s Administration clinicalguidelines for the treatment of LBPdeveloped by a joint panel of overtwenty top civilian and military ex-perts in the field of LBP.2

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26.Von Korff M, Saunders K: The Course ofBack Pain in Primary Care. Spine21:2833-2839, 1996.

27.Goel A: Meralgia Paresthetica Secondaryin Limb Length Discrepancy: Case Report.Archives of Physical Medicine and Reha-bilitation 80:348-349, March 1999.

28.Patriquin DA: Lift Therapy: A Study ofResults. JAOA 63:840-844, 1964.

29.Lipton JA, Jones W, O’Conner F, Polly D,Sutton E, and Wainner R: VA/DOD Clini-cal Guidelines for the Management of LBPor Sciatica in the Primary Care Setting.Washington, Birch and Davis AssociatesInc., April 1999.❒

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fined by the World Health Organizationincludes patients’ physical, mental andpsychosocial capabilities used in per-forming tasks demanded by their dailyactivities. An environment that empha-sizes specific interest in well being is animportant part of any osteopathic healthcare plan. Physician attention to all com-ponents of health should be included inthe plan to advance and maintain the os-teopathic medicine’s and its physicians’images.

The Osteopathic Professional Orga-nizations, AOA, AAO, COMs, Continu-ing Education Program, State and affili-ated organizations, are involved at dif-ferent levels in managing the deliveryof health care. Representation from eachlevel should be used in structuring theplan to advance and maintain osteo-pathic medicine’s image at the forefrontof modern health care. The referencedmodels are adaptable to a health caredelivery model by including continuousquality improvement (CQI)12, publish-ing practice guidelines and identifyingevidence-based decisions used in prac-tice (see reference 9, Chapter 41, 721-726). CQI methodology uses data ob-tained on health care delivery proceduresand measured health care outcomes toestablish an ongoing database with pe-riodic reevaluations. Guidelines for prac-tice are essential to ensure that the pro-cedures and measurements representedin the data provide reliable data. (Guide-lines minimize individual physicianvariables that decrease data validity foruse, in reimbursement, clinical databasesand in meta-analysis of multiple clini-cal reports.) Evidence-based decisionsreduce variability in the health care de-livery process and increase reliability ofhealth outcome data.

This series is designed to inform thepracticing physician about the need andprobable changes that accompany effortsto advance osteopathic medicine’s im-age in the twenty-first century. Admin-istrative levels in the osteopathic profes-sion, involved in updating health caredelivery, depend upon networking all

management levels in planning and ap-proving a strategic management plan.Published data on osteopathic physi-cians’ effectiveness in providing pa-tients’ health care provides support forthe entire system. As the plan is formu-lated, tested for feasibility, and imple-mented, the practicing physicians’ input– in planning health care guidelines anddata recording, and evaluating the plan’seffectiveness – is an important resource.Guidelines and evidence-based deci-sions in practice is the key to success-fully advancing and maintaining osteo-pathic medicine at the forefront of healthcare.

References1. AOA House of Delegates’ Resolution2. Heath, DM, Kelso AF: A new challenge:

Replacing opinion-based with evidence-based decisions. JAAO, Volume 9, Num-ber 4, Winter 1999, pp11.

3. Osteopathic Vision: 1995-96 Yearbook;Edited by Myron C. Beal; 1998; AAO, In-dianapolis, IN. See Trowbridge, C.: A.T.Still’s Philosophy; Implications for edu-cation, practice and research. Pages 126ff

4. Jonas’s Health Care Delivery in the UnitedStates; 5th Edition; edited by Kovner AR,1995, Springer Publishing Company, Inc.:New York, Chapters, 11, 12, 13, 15, 16

5. Diagnostic Strategies for Common Medi-cal Problems, 2nd edition, edited by BlackER, Bordley DR, Tape TG, Panzer RJ;1999; American College of Physicians,Philadelphia, PA

6. Cost effectiveness7. Occupatinal Musculoskeletal disorders

Function, Outcomes and Evidence byMayer TG, Gatchel RJ, Polatin PB; 1999,Lippincott Williams & Wilkins; Philadel-phia, PA

8. Jealous JS; Accepting the death of oste-opathy: A new begining; The 1999Northoup Lecture. JAAO; 9:4; Winter1999, pp23.

9. Strategic Managment: Formulation,Implementation and Control ; edited byPearce JA, Robinson RB; 1999 7th edi-tion, 2000, McGraw Hill Companies, Inc;Boston

10.Adizes I: Managing Corporate LifeCycles; 1999; Prentice Hall Press:Paramus: New Jersey

11.Directory of Osteopathic Physicians;1999; AOA Yearbook; Chicago, Pg. 20

12.Sleszinsky S, Glonek T., Kuchera M;Standarized Medical record – A new out-patient osteopathic SOAP Note: Validationof a standarized office form against aphysician’s progress notes; 1999; JAAO88(10);516ff.❒


Segmental: lower extremities nor-mal motion, sacrum has decreasedamplitude of the primary respiratorymechanism especially at the right sac-ral base, bilateral sacroiliac joint re-striction right greater than left with apositive right compression test, andASIS and PSIS were level. L5 wasflexed, sidebent left, and rotated right.Ribs 8,9,10, and 11 were in exhala-tion on the right, ribs 1-11 had some-what decreased respiratory excursionon the left, and the diaphragm was inexhalation bilaterally. Thoracics 3-10had bilateral paravertebral hyperto-nicity with sagittal plane mechanicsforward bent T6-T8. Cervicals 2 and3 were rotated right and sidebentright. Cranial palpation revealed leftsidebending rotation strain patternwith almost no motion on the rightside of the cranium and the right man-dible and temporal bones were inter-nally rotated.

Initial Assessment:1. Chronic Cephalgia2. Frequent Sinusitis3. Somatic Dysfunction of the Head4. Somatic Dysfunction of the

Cervicals, Thoracics, andLumbars

5. Somatic Dysfunction of the Ribsand Diaphragm

6. Somatic Dysfunction of the Pel-vis and Sacrum

Treatment Plan:1. The sacroiliac joint dysfunction

was treated using direct pronemyofascial release (MFR) fol-lowed by supine articulatorytreatment of both sacroiliac jointsto restore full motion in the pel-vis.

2. The lumbar somatic dysfunctionwas corrected using prone softtissue stretching followed withlateral recumbent direct high ve-locity low amplitude thrust

(HVLA).3. The diaphragm was treated with

direct inhibition using respiratoryforce, which improved the respi-ratory excursion of both the dia-phragm and the rib cage.

4. The ribs in exhalation weretreated using supine indirectMFR with respiratory force.

5. The thoracic somatic dysfunctionwas treated using soft tissuekneading and stretching followedwith seated direct operatorspringing technique.

6. The cervical somatic dysfunctionwas corrected using supine indi-rect MFR.

7. The cranial strain pattern wastreated with osteopathy in the cra-nial field (OCF) using bilateralcondylar decompression fol-lowed by direct sphenobasilarsymphysis (SBS) release. Thisrelease is performed by graspingthe greater wings of the sphenoidbone and the occipital bone andslowly disengaging the sphenoidbone by lifting anteriorly and in-feriorly. The sphenoid bone isslowly returned to position andrechecked for motion.

8. Lastly, the TMJ dysfunction wastreated using direct mandible dis-engagement by grasping bothsides of the mandible betweenmy thenar eminences and apply-ing traction inferiorly, anteriorly,and medially until a release is felt.The mandible is then slowly re-leased to its normal position andthe mechanism is rechecked.

9. CC was instructed in deep breath-ing techniques and she was to doten deep breaths twice a day.

10. She was to return to the office intwo weeks.

Course of Treatment:CC returned in four weeks with

only two, less intense, and self-lim-ited headaches of very short duration.She reported no TMJ symptoms andresolution of a “twisting feeling” on

the right side of her body (that shehad not noticed until its absence). Herpelvis and sacrum had full excursionof motion and the sacroiliac joints hadno restrictions. Her mandible andtemporal bones were in internal rota-tion but the SBS strain was resolved.She was treated again using OCF. Herlast visit was four weeks later withheadache resolution. Her mandibularbone continues to be laterally dis-placed to the left as compared to themaxilla. Continued cranial treatmentswill be used to attempt to correct thisdysfunction.

Discussion:Cephalgia is a common complaint

that can be successfully treated usingosteopathic manipulative treatment.The Osteopath has the advantage ofa thorough knowledge of anatomyand physiology and the understand-ing of the interdependence of thesesystems. Changes in structure fromthe legs (sacral base unleveling), tothe thoracic and cervical spine, andto the cranium can be the underlyingcause of headaches. For example, asin this patient, sacral and sacroiliacjoint dysfunctions can affect the cer-vical spine, occipital bone, and theentire cranial mechanism via dural at-tachments. In addition, CC had tor-sional strains induced by her orth-odontic appliances. As a result shewill continue to need OCF treatmentsto correct these dysfunctions as theyarise through her dental treatment.Furthermore, somatic dysfunction atC 1 and C2 can cause irritation of thevagus nerve causing pain and nauseain the posterior cranial fossa belowthe tentorium cerebelli. Dysfunctionof cranial nerve V can lead to ante-rior and middle cranial fossa pain, thatis pain above the tentorium cerebelli.These dysfunctions are addressedusing various techniques to correctthe pelvis, sacrum, thoracic, and cer-vical spine as well as the cranialmechanism.

continued from page 29


Order Information:_____ Yates Counterstrain Handbook

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According to Kuchera, proper venousdrainage at the jugular foramen is alsonecessary to prevent venous conges-tion, which can lead to headaches andanxiety. TMJ dysfunction can affectthe jugular foramen via the temporalbone, which affects occipital bonemotion. He continues, proper func-tioning of the venous and lymphaticsystems depend on full respiratoryfunction of the thorax and particularlythe diaphragm. These dysfunctionswere also addressed in CC by correct-ing the SBS strain and restoring riband diaphragmatic function. Rationaltreatment of headaches must includerestoration of structural relationships,venous and lymphatic function, andconsideration of previous trauma asa cause.

ReferencesKuchera, Michael, Kuchera, William: Osteo-

pathic Considerations in Systemic Dis-ease. Columbus, Greyden Press, Revised2nd Ed, 1994.

Magoun, HI: Osteopathy in the Cranial Field.Kirksville, Journal Printing Co., 3rd Ed,1976.

Ward, Robert, et al, Foundations for Osteo-pathic Medicine. Baltimore, William andWilkins, 1997.❒

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Bioelectric Fascial Activation and ReleaseThe Physician’s Guide to Hunting with Dr. StillBy Judith A. O’Connell, DO, FAAO“I am satisfied that Osteopathy is my healing system. It is through Osteopathy’s tenets that I am anchored and directed. I am at home herewith Dr. Still as my constant and never failing companion. I found that Dr. Still, with his founding of Osteopathy as a distinct profession,was not only a revolutionary but a patient advocate as well. He wished to give to the world a better, more complete system of healing thatrespected the body’s unity of systems; understood the individual’s ability to heal; and acknowledged the importance of the musculoskeletalsystem as a predictor and component of diagnosis and treatment. All that I read and all that I learned led me back to Dr. Still. This is whythis text uses the teachings of Dr. Still as it’s foundation.” Judith A. O’Connell, DO, FAAO

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Applications of a Rediscovered Techniqueof Andrew Taylor Still, MDBy Richard L. Van Buskirk, DO, FAAO

“These explorations into the Still Technique have given the author a new and deeper respect for the talents and knowledge of the ‘olddoctor’ who founded osteopathic medicine. Dr. Still had a lot of courage and conviction to have developed such an elegant technique and, thento refuse to let it be disseminated as part of the fundamentals of osteopathy. Quite obviously, Dr. Still felt that the core of the osteopathicprofession would lie in its underlying principles and would be strengthened by the diversity of its practice. The price was the loss of atechnique that took over twenty years of study and trial to develop. The author feels fortunate, indeed, to have had a hand in its rediscovery andredevelopment. All who find this technique to their satisfaction should take it as presented and develop it further to the betterment of theosteopathic profession and its ability to promote healing.”

Richard L. Van Buskirk, DO, FAAO

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