JournalSummer2008.pdf - American Academy of Osteopathy

A Comparison of Swedenborg’sand Sutherland’s Descriptionsof Brain, Dural Membraneand Cranial Bone Motion… page 20

Forum for Osteopathic Thought

Tradition Shapes the Future Volume 18 Number 2 June 2008

Swedenborg Sutherland

�/The AAO Journal June�008

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In this his lifework, Johannes W. Rohen, one of the world’s foremost anatomists, offers pen-etrating insights into the dynamic principles un-derlying the human organism. This beautifully illustrated book signifi cantly supplements and expands the concepts of general anatomy and offers a new basis for approaching the interac-tion of body, mind, and soul. A rich source of inspiration for doctors and therapists, it not only conveys information but awakens the reader’s astonishment and joy at the unique nature of

the human being.

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In this Issue:Contributors........................................................................................................4�008CalendarofCourses................................................................... backcover�008ComponentSocieties’CMECalendar.....................................................34CMECertificationofHomeStudyForm.........................................................19

Editorial

ViewfromthePyramids:Robert C. Clark, DO .................................................4

Regular FeaturesDigOn: .........................................................................................................5 Thomas M. McCombs, DO Sarah Towne, DO, and Michael Treece, MDFromtheArchives:..............................................................................................6BookReview.....................................................................................................37

Original ContributionTheCranialPlunger ................................................................................................9 Denise K. Burns, DO

Scientific Paper/Thesis (FAAO)AComparisonofSwedenborg’sandSutherland’sDescriptionsofBrain,DuralMembrane,andCranialBoneMotion .....................................�0 David B. Fuller, DO, FAAO

Student PhysicianAnOsteopathicApproachtoVisceralDisease:ACaseofRecurrentUrinaryTractInfection ..................................................................................... 30 Christine Lerma, BS, OMS-V, Michael K. Mesisca, OMS-IV, and Raymond J. Hruby, DO, FAAO

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The AAO JournalRobertC.Clark,DO.......................Editor-in-ChiefHarrietO’Connor,CFRE,CAE.. SupervisingEditorDianaL.Finley,CMP.................. ManagingEditor

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FORUM FOR OSTEOPATHIC THOUGHT

Tradition Shapes the Future • Volume 18 Number 2 June 2008

Cover pictures: Dr.Swedenborg’spicture:Courtesy of The Swedenborg Library,Bryn Athyn, PennsylvaniaDr.Sutherland’spicture:Courtesy of The Cranial Academy

4/The AAO Journal June�008

View from the PyramidsRobert C. Clark

Contributors

CommonlyusedabbreviationsandacronymsinThe AAO Journal:

American Osteopathic Association (AOA)American Academy of Osteopathy (AAO)

Osteopathic Manipulative Medicine (OMM)Osteopathic Manipulative Treatment (OMT)Osteopathic Principles and Practices (OPP)

Regular Features

Thisisthefirstissueinwhichwetryourexperimentofnotdefiningselectedabbreviationsandacronyms.Thefirstarticletodosoisthestudentpaper:ACaseofRecurrentUrinaryTractInfection. Theboxshowsthetermsselectedforthisexperiment.Readersareinvitedtoadvisetheeditorifthisisaworthwhileendeavor.

Thisisapeer-reviewedjournal.Readersmightliketoknowwhodoesthepeerreviewandwhatissubjectedtopeerreview.TheEditorialAdvisoryBoardistheprimarygroupofpeerreviewers.TheeditorwillaskotherAAOmemberstodopeerreviewofselectedarticlesifhefeelstheinvitedreviewerhasspecialexpertiseincontentrealmofthearticle.

TheAAOFellowshipCommitteereviewsallpapersthataresubmittedbytheapplicantsfortheFellowshipintheAmericanAcademyofOsteopathy.Thisreviewconsti-tutespeerreview.However,thesepapersarestillsubjecttothesameeditingprocessthatallotherarticlesandpapersreceive.

Beginningwiththisissue,studentarticleswillbepeer-reviewedbymembersoftheEditorialAdvisoryBoard.AttheAAOconvocation,thePublicationsCommitteeconsideredthisissue.ThecommitteefeltthatpeerreviewofstudentpapersisinkeepingwiththelongtermgoalofprogressivelyimprovingthequalityoftheAAOJournal.

Somepartsofthejournaldonotreceivepeerreviewandtheyare:ViewfromthePyramids,DigOn,BookReviews,FromtheAchievesandElsewhereinPrint.Theseitemsareeditorialorreportageinnatureanddonotnecessitatepeerreview. r

Denise K. Burns, DO, TheCranialPlungerTheoryWhatisthemechanismofactionofthePrimaryRespiratory

Mechanism?IstheCranialRhythmicImpulsedrivenbyaplungermechanism?Theauthoranalyzesthissystemandexploresitsaction.Shecarefullyreviewstheanatomyandembryologytofurtherourunderstandingofthismechanism.(p. 9)

David B. Fuller, DO, FAAO, A Comparison of Sweden-borg’s and Sutherland’s Descriptions of Brain, Dural Mem-brane and Cranial Bone Motion

Two hundred years before Sutherland introduced the cra-nialconcept,EmanuelSwedenborgdescribedamodelofbrainand body function. Some ideas are similar to those found inSutherland’scranialconcept.TheseconceptsarecomparedtotheareasofWilliamGarnerSutherland’scranialconceptthatdealwithbrainmotion,duralmotionandcranialbonemotion.ThispaperwaswrittenaspartoftherequirementsforFellowshipintheAmericanAcademyofOsteopathy. (p. 20)

Christine Lerma BS, OMS V, Michael Mesisca BS, OMS IV, and Raymond J. Hruby, DO, FAAO, MS, A Case of Re-current Urinary Tract Infection

Theauthorsdiscussthemusculoskeletalcomponentofvis-ceraldiseaseasexemplifiedbyapatientwithurinaryinfections.Theyexplorethebenefitsofamultifacetedapproachandtheroleoftraditionalosteopathiccareinthispatientgroup. (p. 30)

presentshis recommendations for treatmentat the individualandsocietallevels.

BottomLine’s Ultimate Healing World’s Greatest Treasury of Health Secrets Volume II and More Ultimate Healing aretwobooksfromBottomLineBooks®targetedtothegeneralpublic.Theyexploreavarietyoftopicsofinterestinourpatients.Seewhattheirassemblyofexpertsadvise! (p. 37) r

DIG ON.ThomasMcCombs,DO,SarahTowne,DOofTouroUniversity-California, andMichaelTreece,MDofSt.LukesHospital,SanFrancisco,CAlookattheworkofPoiseuille(1846)whodescribedthevariablesthataffecttheflowoffluidthroughatube.Theyproposethatachangeindiameterofchestcagewillchangethediameterofairwaysandbloodvesselswithinthechest.ThesechangesindiametermaybeachievedbyOMTandasaresult,willhavechangesonairflowandbloodflow.(p. 5)

FROM THE ARCHIVES. ThomasL.Northup,DO,wasoneofthefoundersoftheAAO.HeishonoredeachyearbytheT.L.NorthupLecture.Themost recent lecturegivenbyHollisKing,DO,FAAO,waspublishedinthepreviousissueoftheAAOJournal.Dr.Northupwroteaboutseveralareasofclinicalinterest.InthisissuewereadabouttheimportanceofthefeetinModern Foot Problems. Thisarticlewaswrittenin194�, published in the Journal of the American Osteopathic Associationandreprinted inThe Northup BookpublishedbytheAAOin1983.(p. 6)

BOOK REVIEWS: BernardRimland,PhD,wasoneofthefirstmodernresearchersinAutism.Inthisbook,Dyslogic Syndromes,hereviewstheincreaseofAutismandexploresthecausesofthedisordersthatconstituteDyslogicSyndromes.He


Dig On

Poiseuille(1846)describedthevariablesthataffecttheflowoffluidthroughatube.Whilemostvariables(tubelength,fluidpressure,viscosity)affecttheflowinalinearrelationship(doublethetubelengthandthepressuremustdouble,ortheflowwillcutinhalf),onevariablestandsout:the radius of the tube affects the flow to the 4th power. If the radius is doubled, the same flow can be maintained with one-sixteenth of the pressure.Thisidentifiestheradiusasthepre-eminentfactortoaddressinabroadvarietyofclini-caldiseases:Asthma,Hypertension,PulmonaryHypertension,AtherosclerosisandChronicObstructivePulmonaryDisease.Pharmacotherapyfortheseconditionsemphasizesthedilationofbloodvesselsandairways.Weproposethatincreasesintheradiusofbloodvesselsandairwayscanalsobeobtainedthroughmanipulation:specificallybymanipulationthatex-pandstheanatomicstructurecontainingthevessels/airways.Anexpansionofthethorax,therefore,shouldtranslatetopro-portionalincreasesinallthevesselandairwaylumenswithinthethorax.Thiswouldresultinmeasurableimprovementsinairflow&bloodflow.Wesuggestthatthebenefitsofthisap-proachgobeyondthoseobtainedbytraditionalOMTdirectedtorestorecosto-vertebralmotion.

AtreatmentprotocolwasdevisedandapreliminarytrialwasconductedonstudentsrecruitedfromtheTouroUni-versityCollegeofOsteopathicMedicine–classof�010.Measurementsofthoraciccircumferenceweremadeatthe10ththoracicsegment/xiphoidprocess.PeakExpiratoryFlowwasmeasuredwithahand-heldPeakFlowMeter.

TheOMTprotocolwasfirstgivenbyexperiencedprac-titioners.Thisresultedinanincreaseofthefirstsubject’sthoracicexcursionby4.5centimeters(cm),andhis“easynor-mal”by�.8cm.Hispeakflowincreasedby10liters/minute.Thisisconsideredclinicallyinsignificantinanasymptomaticsubject.Oneweeklater,thesubjecthadlost1.1cmof“easynormal”circumference,maintaining1.7cmofthe�.8cmincreasegainedthroughOMT.

“Poiseuille’s Panacea”:a New Direction in OsteopathicManipulation of the ThoraxThomas M. McCombs, Sarah Towne, Michael Treece

Whenstudentstreatedeachother,gainsinthoraciccircumferencewerelessthanthoseobtainedbypracticingclinicians.Insomecases,thestudents’treatmentreducedthoraciccircumferences.Thegreatestgainswereobtainedbythosestudentsmostpracticedinthetechniques.

The3.3%increasein“easynormal”circumferencewould,ifproportionallytranslatedtoincreasesinthelumensofhisthoracicvessels&airways,reducethepressurewithinthem(orincreasetheflowthroughthem)by13%.Inapatientwhoisill,suchachangecouldmakeacriticaldifferenceinthepatient’sflowrateandvolume.TheclinicalexperienceatSt.LukesHospitalsupportstheviewthatthesestructuralchangesarebothpossibleandbeneficial.

Measurementsofthoraciccircumferencearelessreliablethanexpected.Furtherstudieswillbemonitoredbyspirom-etryandthisshouldmorereliablydocumentthebenefitsofOMTforthoracicexpansion,especiallyintheill.

Accepted for publication: May 2008

Address Correspondence to:ThomasM.McCombs,DOorSarahTowne,DOTUCOM,DeptofOMM1310JohnsonLaneVallejo,CA9459�Email:(McCombs)[email protected]:(Towne)[email protected]:707/638-5�07

MichaelTreece,MD1640Valencia,#10�SanFrancisco,CA94110Email:[email protected]


From the Archives

Inthetwoorthreedecadesjustpassed,therehasbeenagradualbutdefinitechangeintheproblemsoffoothealth.

ThepubliclongsincehasbegunwearingagreatvarietyoffootwearinsteadoftheoldcustomofonepairofSundayshoeskeptfor“best”togowiththedress-upclothes,andapairofeverydayshoesthatoncewerenewandshiny.

Agenerationago,Dr.MarshallofBoston,anoutstandingorthopedicfootspecialist,requiredthathispatientshavesixpairsofshoes,allcorrect,butallslightlydifferent,andthattheyshouldchangetheirshoesthreetimesaday.Thisgavethefootavarietyoffootwearthatpreventedfixation,whichoftendevelopedfromthecontinuoususeofonepairofshoes.

Dictatesoffashionarestrongerthantheadmonitionofanygroupofdoctorsandtherearetwothings,whichhavehadmuchtodoinbringingaboutthischange.Oneisthetrendtosportactivitiesandtheuseofsuitablefootwearadaptedtoeachsport,andtheotheristhemoderntendencytowearcomfortableclothinginplaceoftheconventionalclothingofformertimes.

Corns,calluses,andbunionsaregivingwaygraduallytothisprogramofmorecomfortableshoes,andwhiletheyarestillwithusinourolderpatientsasaresultofformerabuses,Iamsurethatthecominggenerationofelderlypeoplewillsufferlessfromtheseconditionsonaccountofourbetterknowledgeofcorrectingfirstcauses.Nosinglefactorismoreimportantinthepreservationofnormalfeetthancomfortablefootwearofawidevarietyandselectedforthevariousactivities.

Therearemanyconditionsoffootweaknessthatarethedirectresultoflow-backtroubleswhichsoweakenthemus-cularsupportsofthearchesofthefeetthattheysagandthefeetbecomepainful.Whilethepainandsymptomsoffatigueareinthefeet,therealcauseofthetroubleisinthelow-backregion.Thispossibilityshouldbecalledtopublicattentionfrequentlysothattheconditionmayberemediedbeforepathologicchangesinthefootstructurehavetakenplace.

Probablyoneofthebestsafeguardsofpublichealthwouldbetheperiodicexaminationbyschoolphysicians,preferablyosteopathic,ofthechildren’spostureandbodymechanics.Thiswouldbringtolighttroubleinthefeetandthelowerspinalsegments.Painfulfeetcertainlymaycausemanyconditionsofmalfunctioninotherpartsofthebodythroughthereflexnerveconnectionswithremoteorgans.Aneyestrain,forinstance,maybeduetofallenarches.

Thepublicisbeingremindedconstantlyinonewayor

Modern Foot ProblemsThomas L. Northup

anotheroftheadvantagesofperiodicexaminations,butIsub-mitthatthemosteffectiveargumentforosteopathicfootcareistheexaminationofeverypairoffeetthatcomesintoouroffice.Thedetectionoffailingfootfunctioninitsbeginningstages,perhapsbeforethepatientisawareofsymptoms,andanexplanationofthetie-upbetweenfoothealthandgeneralwell-being,oftenwilldemonstratethesuperiorityofanosteo-pathicphysicalexamination.

Nowletustakeupthemorepracticaldiscussionoftheseearlysymptomsofmodernfoottrouble.Wemaypassbytheconsiderationoflocaltraumaticfootinjuriesasindicat-ingtheirowntreatmentandstartwithaconsiderationoftherelaxedfootwhich,ifneglected,willdevelopprogressivelyintoacompletelybroken-downfoot.Todothiswefirstshouldreviewbrieflythemechanicsofthefootandleg.

Probablythebestordertofollowinmakingapracticalcheck-upistoexaminethepatientwithshoesoff,standing,forwardbending,walking,sitting,andlyingontheback.Ev-eryabnormalcondition,lesion,limitedmotion,malformation,andeveryevidenceofstrainorirritationshouldbewrittenonthecaserecord.

Averycarefulanalysisoftheframeworkofthebodyfromthelevelofthesixththoracicvertebradownisessential,includingnotationofanyimbalanceoriginatinginthelowertorso.Acontractedpsoasorquadratuslumborummusclewillsotwistthepelvisoutofalignmentastochangethebalanceoftheweightsupportedbyeachlegandfootandgreatlyinflu-enceconditionsdevelopingineitherfoot.Theheavymusclesatthehipmayhaveaninfluenceonpostureequaltothoseofthelow-backregion.Theadductormusclesundertheinflu-enceoftheoburatornervealsocansodisturbthebalancethatinthestandingpositionmoreweightiscarriedbyonelegthanbytheother.Themusclesofthelegbelowthekneerequireveryspecialstudyinconnectionwiththefoot,sinceeverylegmuscleexceptoneendsinlongtendons,whichextendbeyondtheankleandattachtohonesofthefoot.

Whenthepatientisstandinginthefirstexaminationweshouldnoticetheconditionofthearchesandthepositionofthefeet.Ifthefeethaveatendencytoeversionandpronation,thetroublemaybeinthefeetaloneoritwellmayincludetroubleatthekneeandhipwithcontributoryinfluencecomingfromashighasthelowerthoracicsegments.Bodyposturemaybeanimportantconsideration.

Whenwecometostructuralexaminationofthefeet


themselves,thestockingsshouldbetakenoffandthefeetexaminedundergoodlightsothattheskintexturemaybeobserved.Dryskinaswellasperspiringfeetsuggestsdistur-banceinthesympatheticcentersinthelowerthoracicandupperlumbarregionandshouldbenoted.Everyarticulationinthebonystructureofthefeetandlegsshouldbetestedformotionandtenderness.Thetoneofthesoftstructuresshouldbenoted.Itispossibleonlyinageneralwaytodescribeabnormalconditions,butbycarefulexaminationandpalpa-tionofeachpairoffeetthatcomesintoourofficesmaywebecomecapableofmakingareasonablyaccurateevaluationoffootconditions.Acarefulexaminationofthemusclesofthelegs,whichbytheirlongtendonssupportandcontrolthefeet,isveryimportant.Ahypotonicconditionmayaccountforcontinuallyrecurringfootlesionsandcertainlywouldindicateeitherprolongedstrainfromweightimbalanceorinsufficientmuscletoneduetoimpairedsympatheticnervesupply.

Thenormaltoneofthelegmuscleswhichthroughtheirtendonssupportthefootstructures,ifinperfectbalance,willmaintainaperfectarchconstructionandifwestudythedirectionoftheforcesappliedwewillfindthattheyalltendtobindthefootintoasinglearchofflexibleconstructionwiththelongandshortplantarligamentsactingasacheckonthespreadingofthisarch.Astudyofthesizeandstrengthofthebonesofthefeetwillgiveusagoodideaofwhichislesscapableofbearingtheloadandalongitudinalsectionoftheboneswillshowthelinesofforcethatpassthroughit.Athor-oughstudyoftheanatomyandthemechanicsofthemusclesofthelegandfootisnecessary,particularlyofthemusclesthatworkagainsteachotherinpairs,astheextensorlongusdigitoriumandtheflexorlongusdigitoriumcontrollingflexionandextensionofthefouroutertoes.

Thetibialisanticus,thetibialisposticousandtheperone-uslongusactasacombinedsupportforthetarsus.Thetendonoftheperoneuslongusextendsunderthecuboidandpassesforwardandacrossunderthecuneiformbonestoattachtothebaseofthefirstmetatarsalandinternalcuneiform.Itactswiththetibialisanticusasaswingsupportandbinderforthetrans-versearch.Thetibialisposticous,throughitstendonwhichpassesbehindtheinternalmalleolus,isinserteddirectlytothetuberosityofthenavicular,totheunderedgeoftheanteriorportionofthesustentaculumtali,andtothetindersurfaceofallthetarsalbonesexceptthetalus,aswellastotheundersurfaceofthebaseofeachmetatarsal.

Thestrongestflexormuscleofthefootistheflexorhal-luceslongus,whicharisesfromthelowertwothirdsoftheposteriorsurfaceofthefibula.Itstendonpassesdownagrooveontheposteriorsurfaceofthedistalendofthetibia,entersagrooveonthebackofthetalusandwindsunderthesustentacu-lumtaliinsuchawayastoexertthemostpositivesupportforthetarsus;itthenextendsforwardtobeattachedtothebaseofthelastphalanxofthegreattoeandalsosendsslipstothetendonsoftheflexordigitorumlonguswhichgotothesecondandthirdtoes.Itisinterestingtonotethatthismuscletothegreattoeisalargerandstrongermusclethantheflexorlongusdigitorum,whichservesalloftheouterfourtoes.

Generalrelaxationwithlossofmuscletoneandimpairednervefunctionisthefirststepinthegradualbreakdownofthefoot.Thestructuresinvolved,inadditiontothebony

framework,aretheplantarfascia,theplantarligamentsandtheinferiorcalcaneonavicularligament,aswellasthemusclescontrollingtheinnersideofthefoot.Theseareallstretchedbytheexcessivestrainthrownuponthem.Thisisgener-allyabilateralcondition,althoughthedegreeofstrainanddiscomfortwillseldombethesameinbothfeet.Graduallyandprogressivelytheligamentsandmusclessupportingthefootstructurebecometooweaktocarrytheloadofthebodyweight.

Thedegreeofcollapsevariesaccordingtothedegreeofdisproportionbetweenthestrengthoftheweight-bearingstructuresofthefootandtheweightimposeduponthem.Atfirstupontheremovaloftheweightthefootregainsitsnormaloutline,butastheconditionprogressesthefootwillheheldinthedeformedpositionbyaccommodativechangesinbones,musclesandligaments.

Fromthebeginningthelegisdisplacedandrotatedinwardandthefootrotatedoutwardandevertedsothattheweightisthrownupontheinnersideofthefootandthelineofbody-weightfallsmesiallytothegreattoe,insteadofthroughthecenterofthefoot.Thechangedlineofweight-bearingcausestheoscalcistotiltinward,carryingwithitthetaluswhoseheadrotatesandslipsdownwardandinward,forcingthenavicularinfrontofit,which,inturn,forcesthethreecuneiformsdownward,inwardandforwardresultinginageneraldepressionandbulgingoftheinnersideofthefoot.

Thecuboidfollowsthechangedpositionoftheoscalcisandrotatesonitslongaxisandapproachestheground,lower-ingtheouterportionofthetransversearch.Asthetarsusrollsinwardandflattens,themetatarsalsandphalangesarestillfurtherabducted,increasingthealreadyabnormalcondition.Thisstrainedconditiondoesnotendinthefoot,butiscarriedfromtheankleandfootuptotheheadofthefibula,whichisusuallyfoundtobeposterior.Itisevidentthatanyoneorallofthetarsalarticulationswillbeinastateofmechanicalderangement.

Inthenormalfooteachmetatarsalheadisapointofcon-tactactingasashockabsorberorasaspringunderacar,andthefleshypadsunderthesepointscorrespondwellinactiontotheair-inflatedtiresonwhichweride.

Weight-bearingpointsshouldmakewayinourthinkingforweight-bearingsurfaces,forreallythemostpathologicalconditionwehavetodealwithinfoottroublesconsistsofpointsofpositiveweight-bearing,unyieldingonaccountofsomefixationatsomearticulationinthefootorduetosomeconstantmusclepull,ortheweakeningofsomemuscularsup-portsthrowingextrastrainonothers.

Innormalwalkingandrunningallmechanicalprinciplesareemployedtocarrythebodyloadsmoothlywithoutanyjarfromthecontactofthefeetwiththeground.Theflexedkneesuspendstheweightonthetonicallycontractedmusclesofthethighandleg,andtheflexiblefootcarryingtheloadsmoothlyforwardissuspendedfromthemusclesofthelegbytheirtendonsattachedtothebonesofthefootwhichsupportthearches’yetmaintaintheminaflexiblecondition.Theposteriorpillarofthefoot,andtuberosityoftheoscalcis,issuspendedfromthegastrocnemiusandsoleusmusclesbythetendoAchillis.

➝


Theentiretarsusissupportedonthetendonsofthetibi-alisposticous,flexordigitorumlongus,flexorhalluceslongusandperoneuslongus.Thefootyieldsslightlyasthekneestraightensandthebodyloadiscarriedforwardandthenwithincreasingrapiditytheheelisraisedandthefootflexedwithasharppropulsiveforceastheweightistransferredtotheotherfoot.Onemaybestunderstandfootmechanicsbynotingtheactionofhisownfeet.Withlightslippersorinstockingfeetoneshouldtrythevariousstepsandnoticewherehefeels-theforcesinhisownfeet.

Weightdistributionthroughthebonystructureofthelegandfootisfairlyeasytotrace.Thetibiarestsonthetalus;thetalusinturnrestsonthecalcaneusandarticulateswiththenavicularorscaphoidthroughwhichforcesaretransmittedtothefirstthreemetatarsalsthroughthethreecuneiformbones.Otherlinesofforceflowthroughthecalcaneustothecuboidandthefourthandfifthmetatarsals.

Forcesoriginatinginmuscletissueandappliedtothebonystructurebytendonsarenotsoeasytotrace.Therearetwoprinciplestobekeptclearlyinmind.First,fixedpositionismaintainedonlybyanexactbalancebetweentwoormoreopposingforces.Second,resultswhenunequalforcesareopposedandthestrengthofthemovementisgovernedbythedegreeofdifferenceintheseforces.

Muscletoneiscontrolledbytheautonomicnervoussystemandmuscularactivityisgovernedbythemotornerves.Normalnerveandmusclevitalityandstrengtharerequisitetonormalfeetandnormalfootfunction.

Oneofthemostefficientwaysofguardingthefeetofthepresentgenerationistoseethatnothinginterfereswiththeirnormalactivity.Oneofthemostoftenoverlookedrestrictionsofnormalfootfunctionsisahighspotintheinnersoleoftheshoeunderthebaseofthefifthmetatarsal.Likeaboulderintheedgeofastreamitdeflectsthecurrent.Inthestreamthewaterisforcedtotheoppositebank.Inthefootthewholefootistiltedtotheinside,throwingunnaturalweightontheinnersideofthefoot.Thefootisforcedoutofbalanceandthemusclesthatsupportthetransverseandlongitudinalarchesareputcontinuouslyonexcessivestrain.Thefirstmetatarsalpullsawayfromthesecondforabetterbalanceandtherestraintoftheshoecausesabucklingofthefirsttoejoint.Theresultisabeginninghalluxvalgusorbunion.

MarvelousimprovementshavebeenmadeinfootwearinrecentyearsandIamconvincedthatastheshapeofthelastapproachestheshapeofthefoot,particularlyonthebottomorweight-bearingsurface,andthepublicbecomeswillingtoallowcompetentshoementofittheirfeetcorrectlyandwithshoesthatarelargeenoughtoallowfreeflowofweightthroughthefoot,itwillnotbenecessarytomakeshoessoheavyortoputsomuchbracingmaterialintothem.Thepublicisdemandinglightershoesandtheyarebuyingcheapershoestogetthem.Theshoesmadeincutoutpatternsaredo-ingmuchtocorrectthetreadbaseofthelastfortheseshoesmustbalancethefootevenlyorthegirlswouldfallofftheirhighheels.

ConclusionEverypatientwhocomesintoourofficesshouldbe

checkedforfoottroublesandbodyimbalance.Ifitdoesnot

seemwiseorexpedienttofollowupthispartoftheexamina-tiononthefirstvisit,itshouldbementionedasadvisableandnotedonthecaserecordforfurtherconsideration.

Theimportanceofallthisiswellsummedupinthestate-mentofthelateDr.CarlP.McConnellwhosaid,“Physiologicequilibriumdependsonthewholenessofstructure-allpartsandfunctionsbeinginterrelated.Thereforeweshouldmakesenseofthewholebody,notofapart.”Weshouldconsiderfeetasimportantunitsofthebodystructureandworthyofourconstantconsideration.

Likethecracksinagreatbuilding,irritatingnerveimpulses,producedinfeetbyfallenarchesortrauma,extendupward,andreflexlymayaffectthefunctionofanyotherstructure.

Ifthoseofuswhoareingeneralpracticeareconvincedthatfeetareworthyofourattention,isitenoughtolearntheanatomyofthefootfrombooksandtakeafewcoursesinfootmanipulation?Theansweris,obviously,no.Wemust,ofcourse,knowtheanatomy,butthatmustbefollowedbyknowledgethatonlycomesbypalpationofmanyfeetandbylearningthefeelofthetissues.

Wemustknowthefeelofthetissues,bothnormalandpathologic,andwemustknowthenormalmotionandbeabletodetectanylimitationorexaggerationofmotioninanyofthemanyjoints.Wemusthavemasteredenoughgoodfoottechnictomakesuchcorrectionsasarenecessary.Idonotbelieveanyonesetoffootmanipulationswillfitallcasesanymorethanasetofprescribedbrushmarkswillpaintabeauti-fulpicture.Wemustfirstvisualizewhatiswrongandthenapplytheforcesnecessaryforthecorrection,justasapaintermusthaveaconceptionofapictureinhismindandthenmixandblendhiscolors.

Properfootbalanceincomfortable,well-fittedshoes,whichallownormalfootactivitywillpreventthedevelopmentofaverylargepercentageoffootailmentsandgreatlyassistinthecorrectionofthoseconditions,whichalreadyexist.Thoseofusingeneralpracticecannotaffordtoneglectfeetfortheyareinalargemeasureatleast,“TheFoundationofHealth”andgoodshoescarefullyselectedandcorrectlyfittedare“GuardiansofHealth.”

Theosteopathicphysicianwhoisgoingtodomorethanjustgiveroutine“treatments”onrequest,whoisgoingtomakeadefinitestructuralstudyofhiscases,whoisdeter-minedtogetatfirstcauses,whetherheisdealingwithgeneralconditionsorisinanyoneofthespecialfieldsofosteopathicwork,shouldgivethefoundationofthebodystructuremorethanpassingconsideration.Heshould-learntotranslatesub-jectivesymptomsbypalpationintoobjectivesymptoms.Heshouldlearntointerpretthe“feelofthetissues”asdiagnosticinformation.Heshouldbeabletomakeathoroughosteopath-icdiagnosis.Heshouldnotforgetthefeet.

*DeliveredbeforetheGeneralSessionsattheForty-FifthAnnualConventionof theAmericanOsteopathicAssociation,AtlanticCity,June�7,1941.

{Reprinted from the1983 Yearbook of the American Academy of Osteopathy, The Northup Book, A Memorial Tribute to Thomas L. Northup, DO,Indianapolis,IN.1983.pp99-101}r


Osteopathyinthecranialfield(OCF)isusedforthediag-nosisandtreatmentofdisease.Itisaformoffascialreleasethatattemptstobalanceforcesofthefiveelements,asproposedbyWilliamGarnerSutherland.1 Dr.SutherlandwasastudentofDr.AndrewTaylorStillattheAmericanSchoolofOsteopathy.HisteachingsareadirectextensionoftheprinciplesofOsteopathytaughtbyDr.Stillhimself.Theseprinciplesare:thebodyisaunit, thebodyhasself-healingandself-regulatingproperties,structureandfunctionarereciprocallyinterrelatedandrationaltreatmentisbasedupontheseprinciples.Dr.Sutherlandnoticedwhile observing a disarticulated skull, the beveled articularsurfacesrelativetothegreaterwingsofthesphenoidandthesquamousportionsofthetemporalbone.Hesurmisedthatthecranialsutureswereconducivetomotionandstudiedthiscon-ceptovermanyyears.Self-experimentationandcountlesshoursofanalyzingprovedtobeinsightfulinhisquestfortruth.Dr.StillnamedthiscranialoccurrenceasthePrimaryRespiratoryMechanism(PRM).

Therearefiveinvoluntarycomponentsassociatedwiththismechanism:cerebrospinalfluidmotion,inherentcentralnervoussystemmotilitywithmembranousmotion,cranialbonemotionandsacralbonemotion.�R.E.BeckersummarizesinOsteopathic AnnalsthathealthrequiresthatthePRMhavethecapacitytobeaninvoluntary,rhythmic,automaticshiftingsuspensionmecha-nismfortheintricate,integrated,dynamicinterrelationshipsofitsfiveelements.3Numerousresearchstudieshavebeendonetosupporttheexistenceofoneormoreofthesecranialphenom-ena.MobilityofthecranialboneswasstudiedbyHeiseyandAdamsshowingtheroleofcranialsuturecomplianceindefiningintracranialpressure.4Lasseketaldescribedthebrainasbeing“vibrantlyalive,incessantlyactive,highlydynamicandmobile”.Manyscientistsutilizedmagneticresonance(MR)toanalyzecranialmotion.Greitzetalmounteddefinitiveevidenceoncra-nialmotionpresenceofferingdiagramsofthebrainmovementanddescriptionsofsmallamountsofmotionincertainareasofthecraniumintherangesof1.0mmto1.5mm.5 Moskalenkoandassociatesshowedthesubtlepresenceofcranialbonemotion.6Poncelet andWedeen studied brain parenchyma motion andfoundthatbrainmotionappearedtoconsistofasingledisplace-mentinsystolefollowedbyaslowreturntotheinitialconfigura-tionindiastole.7FeinbergandMarkdidresearchonhumanbrainmotionandcerebrospinalfluidcirculation.Theyreportedthatthevelocityintheanteriorcortexandcorpuscollosumas0.4±0.�5mm/secandinthebasalgangliaandforamenofMonroeas0.63±0.5mm/sec.8ResearchbyHydenshowedthatglialcellscontainactinandmyosinwhicharecapableof inherentcontractile motility.9 Nelson, Sergueff and Glonek’s researchlinkedthepalpatoryexperiencetoactualphysiologicactivityofthecentralnervoussystem(CNS).10Frymanndevelopedanon-

The Cranial Plunger TheoryDenise K. Burns

invasiveapparatusandmechanicallymeasuredcranialdiameterchanges.11WoolleyandShawnotedrhythmicalcontractionsoftheoligodendritesoftheneurolglia.

ThePRMhasbeenassociatedwithtwophasesofcranialmotion:cranialflexion,aninhalationor“expansive”phaseofthecraniumandcranialextension,anexhalationor“receding”phaseofthecranium.Thesephasesoccurrhythmically,approximating10-14timesperminute.1�Duringcranialflexionthereisamyriadofcranialanatomicdynamicchangesthatoccursimultaneously.Themidlineskullbonesflexandthepairedbonesexternallyro-tate.Theforamenmagnummovessuperiorly,drawingthesacralbaseposteriorbymeansofaduralattachmentatthesecondsacralsegment.13A rise at the spheno-basillar-synchondrosis (SBS)occurs.14Thetransversediameteroftheskullincreaseswithadecreaseintheanteriorposterior(AP)andverticaldiametersoftheskull.15Theduralmembranesalternateinshape.16Withcranialexhalation,thereverseoccurs.Thisintriguingprocesssustainsarhythmiccontractionandexpansionofthebrainandspinal cord.Thismechanismcanbepalpated throughout theentire body. From this mechanism, CSF flow can be altered


rhythmicallywitha“toandfro”fluidprocessoccurring.Thismotioncanbelikenedtotheseaanditstide.Sutherlandusedtheterm“tide”todescribetheinherentfluctuationoffluidsinthePrimaryRespiratoryMechanism.“Tide”alludestotheconceptofebbingandflowing,butalsothecontrastbetweenwavesontheshorehavingonerhythm,withthelongerrateoflunartidesbelow.Thetide incorporatesnotonlyfluctuationof theCSF,butofaslowoscillationinallthetissuesofthebody,includingtheskull.Thepostulatedintracranialfluidfluctuationhasbeendescribedasaninteractionbetweenfourmaincomponents:ar-terialblood,capillaryblood(brainvolume),venousbloodandcerebrospinalfluid(CSF).TheCSFbringsthe“breathoflife”tothecellsinthesamemannerastherainbringslifetoalllivingsthings.CSFisthe“rainwater”ofthebody.ItshowerstheCNSwithnutrientsandsweepsawaydebris.Sutherlanddescribedthebreathoflifeasanacknowledgementofthisvitallifeforceasafundamentalaspectoftheosteopathicphilosophy.CSFisavitalsubstancetosustainhealthandhomeostasis.

ThechoroidplexusesareresponsibleforthesecretionofventricularfluidthatbecomesCSFwhenadditionsaremadetoitfromthesurfacesofthebrain,spinalcord,andpia-arachnoidlayerofthemeninges.Theseplexusesaremadeupofextensivelywrinkledependymawhichlieadjacenttooverlyingconnectivetissue.TheependymalcellsactivelysecreteCSFatasteadyrate.Thesecellsshowmetabolicactivity.17Therearefoldsofbloodvesselswithinthisarea.ThisformspartoftheCSF-bloodbrainbarrier.ThisbarrierscreenstheparticlesgoingintotheCSF.Itsproteincontentandwhitebloodcellratiosareverylow.Itisbe-lievedthatCSFflowsunderhydrostaticpressuregeneratedbyitsproduction.ThedependenceofCSFabsorptiononthepressuredifferentialbetweentheCSFandthevenoussinuscompartmentshasreceivedstrongsupportfromventriculocisternalandven-triculolumbarperfusionexperiments.18ThismechanismsustainstissuerespirationasperBestandTaylor.Thisbrainfluidtravelsthroughthelateralventriclesandcommunicatescentrallywiththethirdventricle,viatheinterventricularforamina(foramenofMonroe).Thenarrowcerebralaqueductconnectsthethirdandfourthventriclesinthemidbrain.Thefourthventricleislocatedbetween thepons, cerebellumandmedulla. It communicateswiththecentralcanalofthespinalcordandthesubarachnoidspaceswhichsurroundtheCNSviatheforamenofMagendie

andLuschka.Theduralvenoussinusesareendothelium-linedspaces made up from the periosteal and meningeal layers oftheduramater.Thebrain’sveinsemptyintothesesinusesandallbloodultimatelydrainsthroughthemtowardstheinternaljugularvein.19Thelargesuperiorsagittalsinusliesonthecon-vex,superior,midline,innerborderoftheskullsurroundingtheventriclesbelowit.ItrunsfromtheCristaGallitotheconflu-enceof sinuseswhere it combineswith thestraightoccipital


apumpandasanelectricgenerator.�5Magounstatedthatwithcranialinhalation,theneuraltubecontractsitslongdimension,the cerebral hemispheres move upward, shorten in theirAPdiameterandunfoldlaterallywhichchangestheirshape.Hebe-lievedthatacontractionofthelongdiameterandacomparativethickeningatrightanglestothiscausedcompactionofthebrainsubstance.Thiscompactioniscomparedtoasqueezedspongewiththeareaofthebraincoveredbypiamaterasonesurfaceandtheliningoftheventriclesandthecerebralaqueductastheother.As these surfaces approximate, there is an increase incapacityoftheCSFspaces,therebyaccompanyingafluctuationofthisfluid.Asthebrainchangesitsform,thereisanalterationofthevolumeoffluidwithinit.ThevolumeoftheCSFinthesubarachnoidspaceandventriclesisincreased.Withexhalation,thebrainsubstanceexpands,compressingthesefluid-containingcompartmentsandcreatingafluidwavethatexpandsoutwardly.SincethefluctuationoftheCSFisaveryfundamentalpartofthePRM,thenthePRMmustplayaveryessentialanddynamicroleininternaltissuerespiration.�6

It is hypothesized that an inherent “cranial plunger” ofthebrainexistsasahydrodynamicpumpthatpropelstheCSFrhythmicallyaroundtheCNS.Theconceptissimilartothatofaplungerandthewayitworks.Theplungerconsistsofarubbercup,analogoustothebrainanditsduralattachmentswithanattached“shaft”;themidbrain,spinalcordandassociatedduralattachments.As thecontainerchanges shape, the spinalcordrises.Thecupapproximatesthedrain;beingthespheno-basillar-synchondrosis(SBS)duringtheflexionphaseandcompressesaboveit.Ahydrostaticforceiscreatedandwaterflows.Whentheshaftispulledoutorrecedes,thefluidmovesinthereversedirection,analogous tocranialextension.This ispertinent toCSF flow and its forces. It is postulated that the hydrostaticforcesgeneratedbythesepressuregradientscausesfluctuation

and transversesinusesby the internaloccipitalprotuberance.Arachnoid granulations are situated along this large sagittalsinus, thecavernoussinusand theexitsofcranialandspinalnerve roots via dural lymphatic capillaries.�0Arachnoid villiare tuftedprolongations that protrude through themeningeallayeroftheduramaterintotheduralvenoussinuses.TheseactasonewayvalvesthatabsorbCSFwhichcommunicateswith

thevenoussystem.CranialCSFemptyingstudiesperformedonfiftypatientsusingexternalscintillationscansofthebrainatvaryingtimeintervals,demonstratedthatreabsorptionoccursthroughtheactionsoftheArachnoidvillicommunicatingwiththe largecranialvenous sinuseson the superior skull.Majorflowexitedtheskullfromtheconvexityofthebrainalongthesuperiorlongitudinalsinus.�1Normally,thevenoussinuspressureislowerthanthatoftheCSFpressuregradients.VonDurigandAndres,1995,discussthechemoreceptorandmechanoreceptorfunctionsofthesegranulationsanddiscussestheirpossibleroleinCSFvolumeandchemicalcomposition.ApercentageofCSFisdrainedfromtheCNStothevenoussystembymeansofextracraniallymphatics.Itisbelievedthattheselymphaticchannelsplayalargerprenatalthanpostnatalrole.��

Currently,themechanismbehindCSFmotionhasnotbeencompletelyunderstood.Thishasremainedanenigma.ATStillwasintriguedbytheCSFanditsworkings.SutherlandknewthatCSFmotionwaspresentandsustained,butcouldnotexplainwhy itoccurred.Therehavebeenseveral theoriesassociatedwithcerebrospinalfluidcirculationandfluctuation.Inthe1930s,SutherlanddescribedafluctuationandcirculationofCSFaroundthebrainandspinalcordinarhythmicallypulsatilefashion.HesaidthattheshapeofthespacethatcontainstheCSFandthefluiditselfarepostulatedtobeaffectedbyanalternatingcranialpattern. He further elaborated that as the CNS shortens andlengthensinabiphasicrhythmicmotion,theventriclesofthebrainchangeshapeslightlyandthefluidmovesconcurrently.�3O’Connell, who studied the vascular factors in intracranialpressure and maintenance of cerebro-spinal fluid circulation,suggestedthatthebrain’sexpansion,bycompressingthethirdventricle,mightconstituteaCSFpump.�4SomebelievedthatthecombinedactivityoftheCNSandtheCSFfunctionsbothas

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1�/The AAO Journal June�008

oftheCSF.In detai l , the

“cranial plunger” isthecentralsofttissuestructuresoftheCNS:the midbrain, Pons,Medulla Oblongata(brainstem)andspinalcord. These collec-tivelyformacephali-callybulbar,centrallylocated, elongated,slender shaped rod;likenedtotheshapeofaplunger.Duringtheinhalationphase,itistheorizedthatthereisa cephalic “plunger”effect from the cen-tralized, elongatedcranialstructuresbe-lowthatapproximatetheSBSallowingfor

acentralizedsuperiorandperhapsslightlyanterior(baseduponanatomicrelationships)intracranialinvaginationtooccuratthebaseofthebrain.Thecranialplungerisideallysituatedforthis,floatingincerebrospinalfluidtoaffectandbeaffectedbythesofttissuesandfluidsaroundit;thecisternabasalisanteriorandsuperior,cisternapontisanteriorandjustinferior,thelateralandthirdventriclessituatedabove,cisternasuperiorsituatedpos-teriorandsuperiortotheplunger,thefourthventricleposterior

andjustbelowthisandthecisternamagna themostposterior and inferior ofthecisterns.

During cranial flex-ion, these central struc-turesareproposedtogen-tly“thrust”superiorlyandslightly anterior by thecranial plunger, whichal lows simultaneousmovement of the SBSsuperiorly via dural at-tachments to this area.The foramen magnumlikelyrisesasaresultofthiseffect.Asthecranial“plunger” exerts an up-ward force on the ven-tricular system, whichapproximatesthepump,ahydrodynamic pressurechangeoccurstransiently,compressing these ven-tricular cavities, furtherchangingtheirshape(thecontainer) and moving

the contents withinthem. The tentoriumcerebri flattens as thetransverse diameter ofthe skull widens. Ma-goun explained that incranialflexion,thewallsofthethirdventricleandlateralventriclesspreadlaterally, expand andincrease their capacity.Hestatedthatthecere-bralhemispheresmoveupward and that thethirdventricleiselevat-ed. As the cerebralhemisphereswidenandrise,theventricularcon-tentsareexpelled.Thiselevation pulls on theinfundibulum whichelevatesthepituitaryinthe sella tursica of thesphenoidwhichismov-ingcephalad.�7Withtheupward thrust of thecranialplunger,astimu-lationor“pumping”ofstructuressuchasthedelicatehypotha-lamicnucleiandthehypophysispositionedsuperiorandante-riormayoccursimultaneously.MagounexplainsthattheCSFdoescarrywithinit,thesecretionsoftheposteriorpituitary.Thevenouschannelsinthecraniumaredevoidofelasticandsmoothmuscle tissue and a cranial “pumping” mechanism from theplungeractionwouldbeparamounttoincreasevenousdrainagethroughvulnerableareas(i.e.thecavernoussinus).Sutherlanddescribesacranialpulsethatisindependentandseparatefromthebeatsoftheheartorthepressurechangesofthelungsduringrespiration.Itisaseriesofundulatingpulsationswhichhasnotbeenidentifiedclearly.Hedeclaredthatbecauseofthesecir-cumstances,theCSFisfluctuated,causingincreasedexchangebetweenthebloodstreamandtheCSF.Perhaps,theCSFflowisacceleratedinonecertaindirectionduringthecranialflexionphase.Thedirectionofthecranialstructureswoulddictatethislogically.Thechangeofshapeofthecraniumduringthisprocessseemsimperative.Thisstructuralchangemaycreateavacuumeffectliftingthespinalcordcephalad.Astheskull’stransversediameterincreasesanditsverticaldiameterdecreasesduringtheexpansionphaseofthecranium(likenedtotheflattenedcupoftheplunger),thesuperior,centralcranialstructuresapproximatethecentralized“plunger”pushingfrombelow,furtherincreasingthe pressure on the large overlying ventricular cavities.Thisapproximationofstructuresmagnifiesitseffect.Perhapsasthecranialplungerrisesandfalls,thereisasubtlechangeinCSFpressuresthataugmentsCNSandultimatelyCSFflow.ThismayhelptoexplainthepalpatoryobservationsduringthisexpansivephaseofthePRM.Withexhalation,the“plunger”retractsinfe-riorly;areversaloftheexpansionphaseoccurs.TheCSFlikely“recedes”reversingitsflow.This intracranialrecedingof the


CSFfromthecranialvaultisareflectionofthecontraction-type(extension)palpatoryobservationsreported.Duringthiscranialphase,pressuregradientsarepossiblyrestoredor“reset”topre-flexionlevels.TheseprocessesareacomponentofthePRM.MagounreiteratesthatthePRMisconsideredtoincludeinnatemotilityofthecentralnervoussystem,whichcoordinateswiththeobservablefluctuationoftheCSFundertheguidanceandrestraintofthereciprocaltensionmembranes.Magounempha-sizesthatcranialpressurechangesmayvaryfrom5-15mmwiththepulseandrespiration.HesaidthatCSFpressurevarieswiththevenouspressuredirectly,becausetheCSF-containingfluidsystemispartiallyventedbythevenoussystem.ThelocationsoftheselargevenoussinuseswiththeirassociatedArachnoidgranulationsareidealforacentrallymediatedpumpingmecha-nism.Itwouldstandtoreasonthatasthecranialplungerrisesand falls, there isa subtlechange inCSFpressures thatalsoaugmentsvenousflowinadditiontoCNSmotility.T.L.Peelefound fluctuations of pressure occurring with fluctuations ofvolume in different parts of the cerebrospinal system.�8Aplungerismuchmoreeffectivewhenthereiswaterversesairinthepipebecausewaterdoesnotcompresswellandwillthustransmitmoreoftheappliedforce.Pascal’slawseemstoexplainhydrostaticintracranialpressurechanges.Theformulaexplainsthatthedifferenceoffluidpressureisduetoadifferenceinel-evation within a fluid column.The hydrostatic pressure is aresultofthedifferenceinpressureattwopointswithinafluidcolumnsuchasweseeintheCNS.Stilldescribedthisinherentmotionofthebrainasan“electricaldynamo”whichbeginswiththecerebellum.�9Magnethydrodynamicsstudiesthedynamicsofelectricallyconductingfluids.CSFissimilartobloodinos-molarityandsodiumconcentrationsbutcontainsmorechloride,lesspotassium,calcium,magnesiumandglucose.Itisanelectri-callyconductingfluidlikeplasma.Thishelpsexplaincurrentspresent in a moving conductive fluid like CSF.This has thepotentialtoalsocreateforceswithinthefluid.Thisfostersanenvironmentofionicexchangeandchangingelectricalpotentialswithinthefluidandthecellulartissuesaffectedbythefluid.The“cranialplunger”mechanismmayaugmentand/orinitiatetheseforces. Sutherland studiously observed cerebrospinal fluidphysiology in its own natural environment. He explained itsactionsasaphysicalpotencyorenergywhichactsasahydro-dynamicmechanism.30Sutherlandproclaimedthatapumpingaction,similartothepulsationknowntoexistinallorgansex-isted,whichmovestissuejuicesrhythmicallywithinthebrainsubstance.31ThefunctionofsuchamechanismispostulatedbyLeeasbeingbasedonafulcrumcreatedbytherootofthecer-ebellum and its hemispheres moving in opposite directions,resulting in an increase inpressurewhich squeezes the thirdventricle.Thepulsationisdescribedasessentiallyarecurrentexpression of the embryological development of the brain.3�Magounstated that the rhythmiccoilingand recoilingof theCNS may have embryologic roots during the growth of theanterior neural tube. In the embryological beginning, “life’sdance”ofembryonicdevelopmentoccurscreatingthehumanbeingcompletewithmind,bodyandspirit.Thisprocessisre-markableandhumblingduringthedevelopmentoftheCNSanditssupportingstructures.Thenervoussystemdevelopsinthethirdweekoflifefromembryonicectodermcalledtheneural

plateduringtheprocessofneuralation.Duringgastrulation,theprimitivestreakandthenotochorddevelopinthemidline.Neu-ralplateformationisinducedbythedevelopingnotochord.Theneuralplatedifferentiates into theneural tubeand theneuralcrest.Fusionoftheneuralfoldsproceedsinanirregularfashioninacranialandcaudaddirection.Theneuraltubeistemporar-ilyopenatbothends,freelycommunicatingwiththeamnioticcavityatthistime.Thelumenoftheneuraltubeformsasmallcentralcanal.Thecranialendclosesfirst,followedafewdayslaterbythecaudalend.Inthefourthweekoflife,theneuraltubefurtherdifferentiatesbythickeningitswallstoformthebrainandspinalcord.Theneuralcrestgivesrisetomostofthepe-ripheralnervoussystem.Specifically,duringthefourthweekofdevelopment, the three primary brain vesicles develop; theforebrain (prosencephalon), midbrain (mesencephalon) andhindbrain(rhombencephalon).Thebraingrowsrapidlyduringthisweekandbendsventrallywiththeheadfold.Thecranialflexures are formed and produce variation in the outline oftransversesectionsofthebrainandinthepositionofthewhiteandgraymatter.Thecervicalflexuredemarcatesthehindbrain

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fromthespinalcord.Thepontineflexuredividesthehindbrainintocaudalandrostralparts.Duringthefifthweektheforebrainpartlydividesintothetelencephalonandthediencephalonswhilethehindbraindividesintothemetencephalonandthemyelen-cephalon.Asaresult,therearefivesecondarybrainvesicles.Inthehindbrainpart,themetencephalon,givesrisetotheponsandthecerebellum.Itscavityformsthesuperiorpartofthefourthventricle.Thereisathinependymalroofofthefourthventriclederivedfrommesenchymewhichiscoveredbypiamaterexter-nally.Thisdifferentiatesintothechoroidplexus.Thecavityofthehindbrainbecomesthecentralcanalinthecaudalpartofthemedulla(myelencephalon).Themyelencephalonbecomesthemedullaoblongata.Thecaudalpartofthisarearesemblesthe

spinal cord structurally. Therostralpartofthemyelencepha-loniswideandflat.Theroofisthinned. In the midbrain, themesencephalonundergoeslesschange than any other part ofthebrain.Initscaudalpart,theneural canal narrows and be-comes the cerebral aqueduct.Theforebraindividesintotwoparts:thetelencephalonandthediencephalon.Theanteriorpartoftheforebrainwiththeprimor-dialofthecerebralhemispheresiscalledthetelencephalon.Thecaudalorposteriorpartof theforebrain is called the dien-cephalon. The telencephalongives rise to the telencephalicvesicles.Theyaretheprimordiaofthecerebralhemispheresand

theircavitiesbecomethelateralventricles.Thecavitiesofthetelencephalonanddiencephaloncontribute to the formation of the third ventricle.The dien-cephaloncontributesmoretothiscavityhowever.Intheroofofthisventricleformsachoroidplexus.Theroofofthecerebralvesiclesisinwidecommunicationwiththecavityofthethirdventriclethroughinterventricularforamina.Subsequently,thepartofthemedialwallofthedevelopingcerebralhemispheresbecomesverythin.Thechoroidplexusofthelateralventriclethenformsatthissite.Thecerebralhemispheresexpandcover-ingthediencephalonandmeetinthemidline.Thefalxcerebrilaterformshere.Thegrowthandcurvatureofthehemispherescauses a C-shape of the lateral ventricles.The hemisphere’scurlingshapehasbeenreferredtoasaRam’shorn.Thetempo-ral lobe formation from theventral curvatureof the cerebralhemispherescarriesthelateralventricleandthechoroidfissurewithit,formingthetemporalhornandthechoroidplexusofthetemporalhorn.Asthecerebralcortexdifferentiates,fiberspasstoandfromitthroughthecorpusstriatum.Thisdividesintothecaudate and lentiform nuclei.The caudate nucleus becomeselongatedandhorseshoe-shapedconformingtotheoutlineofthelateralventricle.Itspearshapedheadandelongatedbodylieintheflooroftheanteriorhornandbodyofthelateralven-tricle.Itstailliesontheroofofthetemporalhorn.Threeswell-

ingsdevelopwithin the lateralwallsof the thirdventricle tobecomethe thalamus,hypothalamusandtheepithalmus.Thepinealbodydevelopsfromarecessofthethirdventricle.Theskeletalsystemdevelopsfrommesoderm.Asthenotochordandneural tube develop, the intraembryonic mesoderm lateral tothesestructuresthickenstoformtwolongitudinalcolumnswhichdivideintosomites.Eachsomitedifferentiatesintothreeparts;sclerotome,myotomeanddermatome.The sclerotome formsthe vertebral column and the ribs.The skull develops frommesenchymearound thedevelopingbrain. It consists of twoparts:theneurocranium(theskull)andtheviscerocranium(thejaw).Thebaseisinitiallycartilageandformsbyfusionofsev-eralcartilages.Theparachordalcartilageorbasalplateformsaroundthecranialendofthenotochordandfuseswiththecar-tilages derived from the sclerotome regions of the occipitalsomites.Thiscartilaginousmasscontributestothebaseoftheoccipitalbone;later,extensionsgrowaroundthecranialendofthespinalcordandformtheboundariesoftheforamenmagnum.Aftertheendochondralossificationofthiscartilageformsthebones of the base of the skull. Intramembranous ossificationoccursinthemesenchymeatthetopandsidesofthebrainform-

ingthecranialvault.Inutero,theflatbonesofthevaultareseparatedby dense connectivetissuemembranesthatconstitutethecranialsutures. Ossificationbegins at the end oftheembryonicperiod.Themesenchymesur-rounding the neuraltube condenses toform a membrane,called the primitivemeninx. The outerlayerofthisformstheduramater.Theinnerlayer forms the pia-arachnoid layers,which together, arecalled the leptomen-inges. Fluid filledspaceswithinthelep-tomeninges coalesce

to form the subarachnoid space.Amniotic fluid becomes theprimitiveCSFandliesthroughoutthisspace.Thespinalcorddevelopsasaremainderoftheneuraltube.

Insummary,embryonicdevelopmentdictatestheresultantfunctionalanatomyofthecentralnervoussystem.Theanteriorend of the neural tube becomes expanded to form the threeprimarybrain-vesicles; thecavityof thetubeissubsequentlymodifiedtoformtheventricularcavitiesofthebrain,andthecentralcanalofthemedullaspinalis.Thenervouselementsandtheneurogliaofthebrainandmedullaspinalisaredevelopedfromthewall.Thebraindevelopsfromthewallsofthefivefluid-filledvesicleswhichremainintheadultastheventricularsystem.Itmaturesinapatternthatreflectsphylogeny.Themoreprimi-


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tiveportionsofthebrainmaturefirstandthehighlyspecializedcerebralcortexlater.Ingeneral,thelowerportionsoftheCNSdevelopbeforethemorecephalicportions.Initially,theyoungbrainhasthesamebasicstructureasthedevelopingspinalcord.Themidbrainundergoestheleastchangeofallbrainareasandthismayreflectanearlyfunctionalityofthemidbrainandspinalcordtodrivelaterdevelopmentandearlycranialmotion.MagounreiteratesthattherhythmiccoilingandrecoilingoftheCNSmayhaveembryologicrootsduringthegrowthoftheanteriorneuraltube.The ventricular system and its supporting anatomy arereflectiveoftheseearlyprocesses.Theanatomicrelationshipsofthechoroidplexusesareinteresting;positionedintheroofandalongthemedialwallsoftheventricularcavitiesandotherparts.Perhapsthispositioningispurposefulandreflectiveforacentrallymediated,hydrodynamicfluidmechanism.Thefinalcranialshapesretaintheiroriginsofdevelopmentfromthelinesofearlyfunctionality.Thepresenceofacartilaginouscranialbaseanditsremnantslaterisstrongevidenceoftheexistenceandcontinuallyvaryingdegreesofmotioninandoutoftheuterus.Thismotionissimilartocostalcartilagemotionthatoccursattheattachmentoftheribstothesternum.Ifwefocusattentionontheanatomicshapesofthebrainandtheirrelationshipstothecranialbase,weseebothacentralbonyrelationshipandacom-plimentary soft tissuecomponent. Concaved-shapedrecessesareevi-dent when observingthe most inferior partsof the cerebral cortex.Theinferiorpartsofthetemporal and occipitalcortical lobes, theinnersurfacesofthesphenoidandsquamoustemporalportionsdisplayasimi-lar shape, which mayprecludeapossiblecen-tral invagination from

below.The bony basiocciput and the basisphenoid outline asimilar shape.This shape compliments the theorized motionpatternspresentattheSBS.ThelateralventriclesareC-shaped,concavitydown,andwouldsupportaninvaginationfrombelow.Thecranialbonesareformedfrommembraneandcartilage.Withgrowthandmotion,theedgesoftheplatesdevelopsuturesbe-tweenthemthatallowforthismotionandprotectionofthebrain.ThisstructuraldevelopmentisaprimeexampleofWolff’s’Lawwhichstatesthateverychangeinformandfunctionofabone,orinitsfunctionalone,isfollowedbycertaindefinitechangesinitsinternalarchitectureandsecondaryalterationsinitsexternalconformations(Stedman’s,�5thEd).Thesecranialshapesmaybetheresultoftheearlypresenceofcentralizedcranialmotionduringbonyandsofttissuestructuraldevelopments;toaccom-modateandcomplementtheseearlyinuteromotionpatterns.Weseethisexampledisplayedwhenobservingtheclivusonthebasalportionoftheoccipitalbonethatclimbsfromtheforamenmagnumtothedorsumsellae.Noticetheconcaveindentationwithin thisbone from thebrainstemand this close structuralrelationshiptotheSBS.

Blechschmidt (1977) discussed several mechanisms bywhichfluidsbehaveinternally,creatingfunctionoutofwhichstructure emerges: contusion, distusion, corrosion, looseningand suction.These are driven by the metabolism of cellulartissues. Sheets of cells, tissues and organs grow at differentrates.Growthdifferentialswithintheembryoniccraniumcreate

cerebrospinalfluidpatternsthatlatercondenseintomechanicaltensionzonesormesenchymalrestrainingbandsknownasduralgirdles.Theyguidetheultimateshapeandinnerstructureofthebrain.Similarly,waterflowingdownamountainbankcreatesthearchitecturalsurroundingsthatarecomplimentaryandreflectiveoftheforceswithinthisfluid.Thickenedbandsofduracanbeseenwithintheduralsheathsoftheadultcraniumasremnantsoftheseprecursors.Theseareasofthickeningarebelievedtobe areas of increased motion and stress within the cranium.Throughoutembryonicdevelopmentweseetheimportanceof


themidlineandhowitservesasananchorandacatalystforallotherdevelopment tooccur.Somedescribe thefunctionalmidlinearoundwhichourbodiesandhealthmustorganize.Thelaminaterminalisisdescribedbysomeasthepivotpointforallneuralmovement.Itmarkstheclosureofthecephalicendoftheneuraltubeduringembryologicdevelopment.Thismidlineremainsthroughoutourlifeandourstructureandphysiologicmotionremainorientedtothemidline.

MultiplestudieshavedocumentedtheinherentcapacityoftheCNStomove.LongitudinaloscillationsofthespinalcordwereobservedbyL.LevyandG.DiChirousingcardiac-gatedMRphaseimaging.Theybelievedthattransmissionofthear-terialpulseintothecerebrovascularsystemultimatelyleadstosystolicexpansion,subsequentmotionofthebrain-spinalcordaxis, andapumpingof the cerebrospinalfluid.33Their studyrevealedthat inadulthealthysubjects, themeanpeakcaudalvelocityofthespinalcordwas1�.4mm/sec(.0�8miles/hour).Thiswasassociatedwithearlysystole.ThiscaudalcordmotionusuallycoincidedwiththeendofthecephalicCSFflowphaseinthespinalcanal,inthecervicalsubarachnoidspace,andusuallylasted70m/sec.Thiswouldlikelycoincidewiththeendofcranialflexionandthestartofcranialextension.Theoriginofthecordpulsationswasfoundtobedirectlyrelatedtomotionfromthebrainpulsations.Thecervicalcordvelocitiesweregreaterintheuppercervicalregionandgraduallydecreasedcaudallyalongthespinalcord.Insymptomaticstudysubjectswithneurologicpathology,thevelocitiesweresignificantlyreducedwithameanof�.1mm/sec.Echo-planarMRstudieson14healthysubjectsrevealedanintrinsicpulsatilemotionofthebrainmotionwithrapiddisplacementinsystolewithaslowdiastolicrecovery.Thismotionoccurredchieflyinthecephalocaudaddirectionwithasmallamountofanteroposteriorandlateralmotionobserved.These longitudinalvelocities increasedwithproximity to theforamenmagnum.Thelateralmotionwasacompressivemotiononthethalami.Brainparenchymalvelocitieswereashighas�mm/secinthebrainstemand1.5mm/secinthethalami.Thenetpulsatileexcursionswerenotgreaterthan0.5mm.34OtherMRCSFflowstudiessuggestthattheprimarydrivingforcebehindintracranialandspinalcanalCSFflowisexpansionofthebrainduringvascularsystole.35

Studies using a flow sensitive MR technique, demon-stratedaCSFflowtobepulsatileinnatureandvarywiththephaseofthecardiaccycle.36WhiletheCSFmotionappearstoreflectprimarilyexpansionofthechoroidplexusesduringcar-diacsystole,otherfactorssuchasgeneralizedsystoliccerebralexpansion against the tentorium may also contribute to CSFmotion.37ToexplainpulsatileCSFmotion,visualizedoncinepneumoencephalographystudies,DuBoulayarguedinfavorofathirdventriclepumpasadrivingforceofCSFpulsationsandpostulatedalateralsqueezingofthethalamicnucleionthethirdventriclessecondarytobrainexpansion.38Scientists,Feinberg,DAandMark,ASattheUniversityofCalifornia,SanFrancisco,developedatechniqueofFouriervelocityimagingthatallowedinvivomeasurementsofCSFvelocity(directionandmagnitude)in the cerebral ventricles and passageways.They found thatwiththearrivalofthesystolicpulsewave,internalregionsofthebrainmovecaudad, impartingacompressiveforceonallthreeventriclesandinitiatingCSFejection.Itwasdemonstrated

thatitwasejectedcaudad(antegrade)throughallpassageways(foramenofMonroe,cerebralaqueduct,foramenofMagendieandLuschkaandbasalcisterns)movingintotheventriclesandcranialvault.Laterinthecardiaccycle,theCSFdirectionofflowreverses(retrograde),movingintotheventriclesandcranialvault.CSFflowoccursunderapressuregradientcreatedbythedifferencebetweentheintraventricularpressureandtheintracra-nialvenoussinuspressure,specificallyattheSuperiorSagittalSinus.39Thecaudadpulloftheplungermayalsofosterfurtherrefillingofthetubeandcentralfluidcavitiesinpreparationforthenextcranialflexionphase.Feinbergstatesingeneral,thereappearstobeacompressivemotionofbrainparenchymaonthelateral,thirdandfourthventricles.HestatesthatonMRvelocityimages,apulsatilebrainmotionexistsinvivo.Feinberghadanunexpectedfindfromthestudywhichdisplayedadownwardmotionofthebrainstem,whichappearedtodriveCSFthroughthebasalcisterns.Conservationofmomentumwasinvokedtoexplaintheamplifiedvelocityofthelowerbrainregions.

Valves are seemingly absentwithin the intracranialCSFchannels.Ironically,thiswouldfosteraninternalenvironmentsuitableforantegrade/retrogradeflowwithintheCSFpathwaystooccur.Antegrademotionwasfoundtooccuranddocumentedthroughthecerebralaqueductduringcardiacsystolewhileret-rogradeflowoccurredduringdiastoleintheaqueduct.40StudiesdemonstratedthatthedirectionofCSFflowintheCSFpathwayschangesfromcaudaltocephalicinacontinuousmixingofCSFbetweentheventriclesandthesubarachnoidspace.41Itislikelythattheattachedmembranesandbonycomponentsfollowsi-multaneouslyinrecoil.Returnofcranialandspinalstructuresallowsa“reset”ofthecranialfluidmechanismstooccur,prepar-ingforthenextcycle.This“thrusting”motionismostprobablymillimetersinnaturebasedonthecranialanatomicdimensionsandpriorcranialresearchmotionstudiestodate.Turbulentflowdefinedasrandom,nonaxialmotionoffluidelements,hasalsobeendemonstratedinCSFflowingthroughtheaqueduct.4�Thismaycorrelatewithalateralfluxcranialpatternbypalpation.

“Cranialplunger”motionfeasiblywouldbeacatalystforthepalpatoryfluidmotionpatternsandthebonyandsofttis-suephenomena that occurswithin the central andperipheralsomathathavebeenconsistentlyreportedby theosteopathicliterature and others. Osteopathic physicians believe that theCNSdisplaysinherentmotility,mobilityandsustenance.TheCNSfunctionalanatomycanbecomparedtootherbodilyre-lationshipssuchastheheart’spropulsionofbloodbyinherentcardiacmusclemotility,themobilityofbowelcontentsbythemotilityofgastrointestinal (GI) smoothmuscle cells and themovementsofepithelialciliaoftherespiratorytract.Thereareepithelialciliawhichlinetheventricularsystemandcentralcanalofthespinalcord.Thesecellsarearemnantofneuroectodermwhichonce formed theneural tube.ManyhaveciliaandareinvolvedinthemobilizationofCSFinthedirectionsofbulkCSFflow.43CSFcontactingneuronshavedendriticprocessesandhavebeenfound,inmammals,tohaveamechanoreceptoreffectsimilartotheinnerearcells.44Theinvoluntary,automatic,centrally mediated bellow-like excursions of another centralfluidpump;thethoraco-abdominaldiaphragmpropelsvenousandlymphaticfluidthroughoutthebodybychangeinpressuregradientsgeneratedbycontainershapechange.Expertsbelieve


thatdeeprespiratoryinhalation,actuallyaugmentstheinhala-tionphaseofthecranium,perhapsbyaugmentingtheupward“thrust”ofthemidlinebrainanatomicstructures.45.The“cranialpump”wouldbesynergisticinitsmechanismofactiontootherbody pumps.The anatomic structures surrounding all “bodypumps”aredependentinpartor intotalfortheirsupportforfluidpropulsion,nutrientdeliveryandtoxinremoval.Eachpumpcanhaveprofoundeffectonhomeostasisandaugmentationoffunction.Thesefunctionalrelationshipsdemonstratethebody’sinherentabilitytocirculatefluidinvoluntarily,automatically,andrhythmicallyinanideal,efficientmanner.Theserelationshipsreinforcetheosteopathicprecedentoftherelationshipbetweenstructureandfunction.

Simply,thisseemstobenodifferentfortheCNS.Theana-tomicrelationshipsevidentintheCNSaredeliberate,purposefulandbiomechanicallysoundadaptationstoallowforyetanotherinherent,self-sustainingfluidpropulsionmechanismofthebody;sustaininglifeitself.Dr.Sutherland’sworkexemplifiesthispoint.Moreresearchisneededinosteopathicmedicine.Moretargetedstudyofosteopathyinthecranialfieldisnecessarytoshedlightandgreaterunderstandingofthiscomplexandyetseeminglysimplecranialphenomenon.MoreMRimagingstudiesshowinginvivomeasurementsofintracranialpressurechangesthatarephasedependentwithcerebrospinalfluid/venousflowpatternsthroughoutdifferentCNSareaswouldbeideal.Multiplerealtimeintervalswouldfostermoreinformationaboutthisenigma.Experimentationwithcranialmotioncharacteristicsaroundandwithinthebrainandspinalcordcanbepursued.Thisisanexcit-ingchallengeforfutureinvestigationalstudies.Animalmodelshave shown definitive lymphatic flow characteristics in pastresearch.46Morehumanstudiesareneeded.

TheCranialPlungerTheorygivestheOsteopathameanstoanendforfurtherexplainingtheoriginsandmaintenanceofCNSirrigationandsustenance.Itmayfurtherthemeaningandregardforthefiveinvoluntarycranialphenomena.ThePrimaryRespiratoryMechanismisvitaltohealthandrepresentsacrucial,functionalpartofthephysiologicwhole;alivingbeing.Assuch,theCNSdisplaysaself-propelling,self-regulatingandself-sus-tainingmechanisminallcapacities.Respectforthiseludinganddelicatemechanismmustforeverbemaintained.RememberingthewordsofAndrewTaylorStill;“thecerebrospinalfluidisthehighestknownelementinthehumanbody.Hewhoisabletoreasonwillseethatthisgreatriveroflifemustbetappedandthewitheringfieldirrigatedatonceortheharvestofhealthisforeverlost.”

References1 DiGiovannaEL,SchiowitzSandDowlingDJ.An Osteopathic

Approach to Diagnosis and Treatment.LippincottWilliams&Wilkins.�005.

� DiGiovanna,SchiowitzandDowling.An Osteopathic Approach to Diagnosis and Treatment.LippincottWilliams&Wilkins.�005.

3 Foundations for Osteopathic Medicine,SecondEdition.Lip-pincottWilliams&Wilkins.�003.

4 HeiseySR,AdamsT,SmithMcBrinerB.Theroleofcranialsuturecomplianceindefiningintracranialpressure.In:ThirtySeventhAnnalAOAResearchConferenceAbstracts.1993.Part�.

5 GreitzD,WirestamR,FranckA,etal.PulsatilebrainmovementandassociatedhydrodynamicsstudiedbyMagneticresonanceimagingphaseimaging;theMonro-Kelliedoctrinerevisited. Neuroradiology.199�.34:370-380

6 MoskalenkoYE,KravchenkoTI,GaidarBV,etal.Periodicmo-bilityofcranialbonesinhumans.Hum Physiol.1999.�5:1:51-58

7 PonceletBP,WedeenVJ,WeisskoffRM,CohenMS.Brainparenchymamotion;measurementwithcineecho-planarMRimaging.Radiology.199�.185:645-651

8 FeinbergDA,MarkAS.HumanBrainmotionandcerebrospi-nalfluidcirculationdemonstratedwithMRvelocityimaging.Radiology.1987.163:793-799.

9 HydenH.Satellitecellsinthecentralnervoussystem.Sci Am.1961.�05:6�.

10 NelsonKE,SergueffN,LipinskiCM,etal.Cranialrhyth-micimpulserelatedtotheTraube-Hering-Mayeroscillation:comparinglaserDopplerflowmetryandpalpation. JAOA.�001.101:3:163-173

11 FrymanVM.Astudyoftherhythmicmotionsofthelivingcranium.JAOA.1971.70:1-18

1� Foundations for Osteopathic Medicine,SecondEdition,Lip-pincottWilliams&Wilkins.�003

13 DiGiovannaEL,SchiowitzS,andDowlingDJ.An Osteopathic Approach to Diagnosis and Treatment.LippincottWilliams&Wilkins.�005




17 DelBrigio,M.The Ependyma: A Protective Barrier Between Brain and Cerebrospinal Fluid.1995

18 Johnston,etal.CerebrospinalFluidAbsorptionRevisited:DoExtracranialLymphaticsPlayaRole?The Neuroscientist.�000.6:�:77-87


�0 BrittaFrickeetal,NerveFibersInnervatingtheCranialandSpi-nalMeninges:MorphologyofnerveFiberterminalsandTheirStructuralIntegration.Microscopy Research and technique.�001.53:96-105

�1 DiChiroG.MovementofCerebrospinalFluidinHumanBe-ings.Nature.1964.�04:�90-�91

�� Johnstonetal.CerebrospinalFluidAbsorptionRevisited:DoExtracranialLymphaticsPlayaRole?The Neuroscientist.�000.6:�77-87

�3 DiGiovannaEL,SchiowitzS,andDowlingDJ.An Osteopathic Approach to Diagnosis and Treatment.LippincottWilliams&Wilkins.�005

�4 O’ConnellJEA.Vascularfactorinintracranialpressureandmaintenanceofcerebrospinalfluidcirculation. Brain.1943.66:�04-��8.

�5 Foundations for Osteopathic Medicine, SecondEdition.Lip-pincottWilliams&Wilkins,�003

�6 H.Magoun, Osteopathy in the Cranial Field.NorthwestPrint-ing,Inc.1976

�7 MagounH.Osteopathy in the Cranial Field.NorthwestPrint-ing,Inc.1976

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March�008AAOJCMEquizanswers:1. A�. A3. E4. A5. A6. E7. E

�8 PeeleTL.Neuroanatomical Basis for Clinical Neurology.Mc-GrawHillPublishingCompany.1954p.67

�9 LeeRP.Interface: Mechanisms of Spirit in Osteopathy. Port-land,OR:StillnessPress,�005,pp.193-8.ISBN0-9675851-3-9

30 MagounH.Osteopathy in the Cranial Field.NorthwestPrintingInc.1976

31 MagounH.Osteopathy in the Cranial Field.NorthwestPrintingInc.1976

3� LeeRP.Interface: Mechanisms of Spirit in Osteopathy. Port-land,OR:StillnessPress,�005,pp.193-8.ISBN0-9675851-3-9

33 LevyL,DichiroG.FixedSpinalCord:DiagnosiswithMRImaging.Radiology.1988:169:773-778

34 PonceletBP,WedeenVJ,WeisskoffRM,andCohenMS.Brainparenchymamotion;measurementwithcineecho-planarMRimaging.Radiology.199�:185:645-651

35 EnzmannD,etal.CerebrospinalFluidFlowMeasuredbyPhase-ContrastCineMR. AJNR. 1993:14:1301-1307

36 FeinbergDA.VelocityMeasurementsofFlowingCSF.Present-edattheAnnualMeetingoftheAmericanSocietyofNeuroradi-ology.SanDiego,CA.January19-�3,1986

37 LaitinenL.OriginofArterialPulsationofCerebrospinalFluid.Acta Neurol Scand.1968:44:168-176

38 DuBoulayGH.,PulsatilemovementsintheCSFpathways.Br J Radiol.1966:39:�55-�6�

39 BradleyWG.FlowingCerebrospinalFluidinNormalandHydrocephalicStates:AppearanceonMRImages.Radiology. 1986:159:611-616

40 BradleyWG.FlowingCerebrospinalFluidinNormalandHydrocephalicStates:AppearanceonMRImages.Radiology. 1986:159:611-616

41 FeinbergDAandMarkA.HumanBrainMotionandCerebro-spinalFluidCirculationDemonstratedwithMRVelocityImag-ing.Radiology. 1987:163:793-799

4� BradleyWG.FlowingCerebrospinalFluidinNormalandHydrocephalicStates:AppearanceonMRImages.Radiology.1986:159:611-616

43 DelBrigioM.TheEpendyma:AProtectiveBarrierBetweenBrainandCerebrospinalFluid.1995

44 VighB,etal.SpecialDendriticandAxonalEndingsformedbytheCerebrospinalFluidContactingNeuronsoftheSpinalCord.Cell Tiss. Res.1977:183:541-55�

45 DiGiovannaEL,SchiowitzS,andDowlingDJ.An Osteopathic Approach to Diagnosis and Treatment.3rdEdition,LippincottWilliams&Wilkins.�005

46 BradleyWG.FlowingCerebrospinalFluidinNormalandHydrocephalicStates:AppearanceonMRImages.Radiology. 1986:��:159:611-616

Accepted for publication:March�008

Address correspondence to:DeniseK.Burns,DOPhiladelphiaCollegeofOsteopathicMedicine4170CityAvenuePhiladelphia,PA19131Email:[email protected]

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1. WhichofthefollowingphenomenaisnotassociatedwiththePrimaryRespiratoryMechanism?

A. Thesacrummoveswithcranialflexionandextension B. Cerebrospinalfluidmotion C. Centralnervoussystemmotility D. Cranialbonemotion E. Cardiacsystole

�. Inwhichofthefollowinggestationalweekdoesthehumannervoussystemdevelop?

A. 1stweek B. �ndweek C. 3rdweek D. 4thweek E. 5thweek3. Duringembryonicdevelopment,theforebraindividesinto

whichofthefollowing? A. Mesencephalon B. Telencephalon C. Diencephalon D. AandC E. BandC

4. Fromwhichofthefollowingisthehumanskeletalsystemderived?

A. Ectoderm B. Mesoderm C. Endoderm D. Lidoderm E. Scleroderm

5.WhichofthefollowingisnotaknownfunctionofCSF? A. Secretionofrenin B. Providesbuoyancytothebrainandspinalcord C. Providesnutrientstothenervecells D. Removeswasteproducts E. Electrolytebalance

6. Whichofthefollowingbestdescribesthe“cranialplunger“ofthecentralnervoussystem?A. AninherenthydrodynamicpumpthatpropelstheCSF

rhythmicallyaroundtheCNSB. Asystolicpressurechangethatistransmittedtothecranium

duringcardiacdiastoleC. Alymphaticpumptechniquethatmovescranialfluidand

lymphaticfluidD. ThePonsandthemedullathatpropelsCerebrospinalfluidE. Theintrathoracicdiaphragmaticmotion

7.Thefunctionalmotioncharacteristicsofthecentralnervoussys-temarelikenedtowhichofthefollowinganatomicstructures?

A. Heartmotion B. Lungmotion C. Thoracoabdominaldiaphragmmotion D. pelvicdiaphragmmotion E. Gastrointestinalmotility

�0/The AAO Journal June�008

AbstractTwo hundred years before Sutherland’s introduction of

thecranialconcept,EmanuelSwedenborgdescribedasophis-ticated anduniquemodel of brain andbody function,whichcontained some ideas similar to those found in Sutherland’scranialconcept.

This paper will review a portion of Swedenborg’s para-digmofthebrainandcentralnervoussystemasdescribedinhisscientificworks,particularly“TheBrain”.ItwillfocusonSwedenborg’sdescriptionofinherentmotionofthebrain,thereciprocalmotionoftheduramater,andcranialbonemotion.

TheseconceptswillbecomparedandcontrastedtotheareasofWilliamGarnerSutherland’scranialconceptthatdealwithbrainmotion,duralmotionandcranialbonemotion.HistoricalconnectionsbetweenSutherlandandSwedenborg’sideaswillalsobeexplored.

Introduction1.1 Brief Biography of Swedenborg

Emanuel Swedenborg (1688-177�) was an 18th centurySwedishscientistandphilosopherwholaterdevelopedintoatheologian(Dole1997,31-40).Hewroteonawiderangeoftopicsduringhislongandproductivelife,culminatinginover40,000 pages (Rose �005, 388).Today, Swedenborg is mostrememberedforhis laterwritingswhichwerepredominantlytheological.Muchofhispre-theological,scientificandphilo-sophicalwritingswerefaraheadofhistime,containingconceptsnotrecognizeduntilcenturieslater(Finger1994,�9-30,3�,194).Hisscientificandphilosophicalwritings,particularlyhisworksrelatingtoanatomyandphysiology,containedideasthatlaterbecamefundamentaltohistheologicalworks.HisworkswerewritteninLatinandlatertranslatedintoEnglish.

Swedenborgwasinitiallyascientistwhobecameaphiloso-pherinsearchforthesoul.Hestudiedanatomyextensivelytryingtodiscoverthesoul’smanifestationinthebody.Hisstudiesofhumananatomywereexhaustiveandledtoafocusonthebrainand its influence throughout thebody.Duringhisanatomicalwritingsfromthelate1730stothemiddle1740shedescribed,ingreatdetail,thestructure,functionandmotionofthebrain.During1738-1740,hewroteapreliminaryworkonthebrain

A Comparison of Swedenborg’sand Sutherland’s Descriptionsof Brain, Dural Membraneand Cranial Bone Motion“We may sweat a thousand years and only scratch the surface of knowledge about the brain and how it works.” (Swedenborg188�,104k)

David B. Fuller

titled,“TheCerebrum”.Hismostcomprehensiveworkonthesubjectwasoneofhislastscientificworks,titled“TheBrain”.Itwaswrittenin1743-1744,althoughleftunpublishedduringhislifetime.Startingaround1745,Swedenborgunderwentaseriesof profound and on-going spiritual experiences. He droppedall of his scientific writings and moved on to a study of theBibleandanewinterpretationofthescriptures.Hedevelopedaunique,comprehensivecosmologyandtheology.Hewroteontheologicaltopicsforthenextthreedecadesuntilhisdeathin177�.Interestingly,manyoftheideasdevelopedinhisscientificworkspermeatehistheologicalwritings.

1.2 Overview of Sutherland and Osteopathyin the Cranial Field

WilliamGarnerSutherland,DO(1873-1954)developedasystemofdiagnosisandtreatmentknownascranialosteopathy.HegavecredittoAndrewTaylorStillfordiscoveringandde-velopingthephilosophy,principlesandpracticeofOsteopathy(Sutherland1998,pp.143,188,�14).Sutherlandappliedtheseinanewandsophisticatedfashiontotheheadandrestofthebodyutilizingthisnewcranialconcept.Hetaughtfellowosteopathicphysiciansthisnewsystemofcranialdiagnosesandtreatmentfromthe1930suntilhisdeathinthemid1950s.

Sutherland’ssystemofdiagnosisandtreatmentwascalled,among other names, cranial osteopathy. It is now officiallyknownasOsteopathyintheCranialField(OCF).OsteopathyintheCranialField,alongwithothertypesofosteopathicma-nipulativemedicine, is taught inallof themore than twentyosteopathicmedicalschoolsintheUnitedStatesandinmanyothercountriesthroughouttheworld.Itisusedtohelpmanypatientsworldwide.

Sutherland’ssystemofcranialosteopathyisbasedonthecranial concept which includes, five major principles: 1) theinherentmotilityof thebrain andcentralnervous system,�)thefluctuationofthecerebrospinalfluid,3)themobilityoftheintracranialandintraspinalmembranes,4)thearticularmobilityofthecranialbones,and5)theinvoluntarymotionofthesacrumbetweentheilia.Thefirst,third,andfourthcomponentswillbethefocusofthisstudy.

June�008 The AAO Journal/�1

➝

Swedenborg’s Paradigm of the Brain2.1 Introduction

Therearemanyimportantconceptsthatarefundamentalto Swedenborg’s development of ideas in “The Brain” andelsewhere.Whilesomeofhisideasrelatingtothebrainhavebeendiscussedovertheyears,therehasnotbeenanysummaryofhisparadigmofthebrain(Woofenden�00�,196-�37).Themajority of references to Swedenborg in this study are fromhisbook,“TheBrain”,althoughotherscientificworksarealsocited,especially“TheCerebrum”.ThefollowingsummarizesSwedenborg’s ideas related to motion of the brain, dura andcranialbones.ItisbeyondthescopeofthisstudytoincludeallofSwedenborg’sideasrelatedtothebrain.

FollowingthecustomofSwedenborgianscholars,allrefer-encestoSwedenborg’sworksarenumberedbyparagraphratherthanbypagenumber.

2.2 Brain MotionSwedenborgdescribedingreatdetailthemotionor“anima-

tion”ofthebrain(Swedenborg188�,43,46,48,350,104r).Theconceptofacyclicbrainmotionisfoundthroughouthisanatomi-calwritingsinvolvingallbodysystems,andisfundamentaltohisdescriptionofbrainanatomyandfunction.Inararemomentofhumorouswriting,hewrote the following to illustrate theimportanceofknowledgeofbrainmotion:

“Withoutaknowledgeofthemotionofthebrainweshouldremainindoubtastothevariousdiseases,espe-ciallyofthehead,andweshouldnotknowhowtopointouttheircauses,andonseeingandobservingthechangesintheopenedbrainsweshouldstandagapeandwondering,asadonkeybeforeamachinesetinmotionbythewindorwater.Withoutthisknowledge[ofbrainmotion]alsoweshouldknownothingwhateverinpsychology;weshouldnotknowwhatthesoulis,whatthemind,theunderstand-ing, thewill,andwhat theexercisesofeachare;for inorderthatthesoulmaylivecorporeallyorbyabody,thebrainoreverythingorganizedmustbemovedoranimatedinalternateperiods.”(Swedenborg188�,59)

Swedenborgdescribedbrainmotionasasubtlealternatingexpansionandcontractionofthebrain.Heoftenreferredtothismotionasanalternatingdiastalticandsystalticmotion,orasanimationofthebrain.Heclearlybelievedthatknowledgeofthemotionofthebrainisnecessarytounderstanditsstructureandfunction(Swedenborg188�,59).

Swedenborgsawevidenceforbrainmotionthroughouttheanatomyofthebrain,spinalcordandnervoussystem.Hesawevidenceofthisintrinsicbrainmotioninthestructuresoftheduralandotherintracranialmembranes,aswellasthecranialbones and the sutures uniting them (Swedenborg 188�, �60,�77).Hestatedthatthisanimatorymotionisfoundthroughouttheentirenervoussystemandinfactthewholebody.Sweden-borgdescribedeveryartery,veinandnervefiberas“intheverycurrentofmotionofthebrain”(Swedenborg188�,43).Healsowrote,“…fortheuniversalbody,withitspowers,forces,andactions,livesentirelyorchieflyunderthemotionortheauspicesofthebrain”(Swedenborg188�,59).Thismotionisperpetualthroughoutthelifeofthebody(Swedenborg188�,43).

2.3 Characteristics of Brain MotionSwedenborgdescribedthesubtlealternateexpansionand

constrictionofthebrainasaglobalmovementoccurringthrough-outthebrain.Hestatedthatthereisanimatorymotionoftheindividualpartsofthedifferentareasofthebrain,however,thesedifferentstructuresmovetogetherina“harmoniousvariation”sothatthebraincontractsandexpandsinasimultaneousfashion(Swedenborg188�,104r,46,48).Thisisaccomplishedbyaspi-ralqualitytothemovementofdiscreteareasofthebrain,whichcanbedescribedasa“spiralfluxion”.Thisspiralfluxionallowseachparttomovewithoutobstructionofcontiguousstructures(Swedenborg188�,43,48).Thisactivityhelpstounderstandthestructureandshapeofthecorticalgyri(Swedenborg188�,48).Hestatedthatthismotionissubtleandnotobvioustothesenses(Swedenborg188�,350).

2.4 Ventricular MotionSwedenborgdescribestheventriclesofthebrainundergo-

ingasimilarphasicmotionwiththecerebrum,cerebellumandbrainstem(Swedenborg188�,466).Duringthecontractionphaseofbrainmotion,eachlateralventriclelengthensandnarrows,andthebrainstemlengthens.Theposterioranddescendingcor-nuaofthelateralventricles(whichhealsocallsRam’shorns)subsideandcloseupwiththeupper,broaderpartsofthelateralventriclesbecomingnarrowandcontracted(Swedenborg188�,469).Thisoverallbrainandventricularmotioncorrelateswithasubtlenarrowingandlengtheningofthecraniumduringthecontractionphaseofcranialmotion.Theoppositeistrueduringtheexpansionphasewhenasubtlewideningandshorteningofthecraniumoccurs.

2.5 Brain Motion is Primary to Lung MotionSwedenborg described the animation, or expansion and

contraction,ofthebrainasusuallycoincidingwiththeventilationofthelungs.Thismotion,however,isprimarytolungmotion.(Swedenborg188�,53,�81)Hestatesquiteclearlythatwhilebrainmotionmaycoincidewiththatofthelungs,itisprimarytorespiratorymotion.

2.6 Brain, Intracranial Membrane and Cranial Bone MotionSwedenborgdescribedthemotionofthebrainaspartofa

complexsystemofinter-relatedsystems.Notonlydoesbrainmotionaffectallstructuresofthebodythatarecontinuouswiththebrain,italsointeractswithcontiguousstructuresinaverysophisticatedandcomplexfashion.Brainmotionisintimatelytiedinwiththestructureandfunctionofitssurroundingmem-branesandthecranialbones.

Swedenborgdescribed thebrain as theprimeactivating,movingforce.Herecognizedthesurroundingmembranes,par-ticularlytheduramater,asservingasapassiveelasticrecipro-catingmechanismthattransmitthismotiontothecranialbones,causingcranialbonemotion.(Swedenborg188�,�60,�77)

2.7 Reciprocal Dura Mater MotionSwedenborgstatesthatthecyclicanimatorymotionofthe

braincausescorrespondingmotiontooccurinallthreelayersoftheintracranialmembranes,pia,arachnoidandduramater.Allofthesethreemembranesareinterconnectedinawonderfulwaysothateachofthemisinvolvedinactivitiesthroughoutthe

��/The AAO Journal June�008

“Itisbetter,however,toexploretheseverymotionsandstatesfromtheirefficientcausesinthebrainsthemselvesthantostudythemfromthesignaturesandtraces in theexternaltablesofthecranium”(Swedenborg188�,196).

2.10 Cranial SuturesSwedenborgstatedthatthecranialbonesuturesdemonstrate

themotionand“sphereofactivity”ofeachindividualbone.Hewrotethatthedetailsoftheinterdigitations,articulations,protu-berancesandapophysesdisplaytheactualmotionofeachcranialbone.Varioussutureseachcorrespondtodifferentmotionsofthe cranial bones (Swedenborg 188�, 191, 198, Swedenborg1938,170,736,VolII9).

2.11 Centers of Cranial Bone MotionSwedenborgrecognizedthattherearemanydifferentindi-

vidualmotionsofcranialbonesthattakeplacesimultaneouslywith the rhythmicexpansionandcontractionof thecranium.He described three general centers of cranial bone motion.Theseare:betweenthecristafrontalisandthecristagalli,themiddle of the occipital bone, and the center of the sphenoidbone(Swedenborg188�,191).Hestatedthatthemostgeneralandimportantcenterofallmotionofthecranialboneswasinthesphenoid(Swedenborg188�,�51).Hedescribesthiscenteras“thecomplementofallthefunctionsofthecerebrum”,for“the individual bones communicate only with the sphenoid”(Swedenborg188�,191).

Swedenborgalsodescribedanaxisofmotionthatrunsfromthemiddleoftheoccipitalbone,fromthemeetingplaceofthecerebralsinuses,throughthestraightsinustothemiddleofthesphenoid(Swedenborg188�,191;1887,57�).Thissphenoid-occipitalaxisisacrucialaxisdeterminingmuchofcranialbonemotionandfunction.

2.12 Individual Motion of the Frontal, Parietal,and Occipital Bones

Swedenborgmentionsthesubtlemovementof thebonesforming thecranium thataccompanies the rhythmiccycleofbrainmotion.Hedescribesthemovementsofonlythreebones:thefrontal,thepairedparietalandtheoccipitalbones.

Swedenborgdescribedthefrontalbone,withitsbilateralanteriorbosses,expandinganteriorlyduringtheexpansionphaseofbrainmotion,incorrespondencewiththefrontallobeofthebrain.Hedescribedthepairedparietalbonesaselevatingandmovinglaterallywiththeexpansionoftheparietalareasofthebrain. He also described the occipital bone moving with thecerebellum,elevatingatthemiddle(Swedenborg188�,198).

Swedenborgdoesmentionthatwhilethemovementofthissystemofinterconnectedbrain,membranesandcranialbonesextendsthroughoutthebody,itissubtleandnotobvioustothesenses(Swedenborg188�,350).

2.13 Summary of Swedenborg’s Description of the Brain, Dural and Cranial Bone Motion

1)Theimportanceofinherentbrainmotionisasubtlealter-natingcycleofexpansionandcontraction,whichoriginatesinthecortexandistransmittedthroughoutthebody.Thismotionisprimarytobutoftensynchronouswithlungmotion.

�)Thereciprocalmotionoftheduralmembranes(accompa-nyingthecyclicmotionofthebrain)istransmittedbyduralcon-

centralnervoussystem,especiallythebrain(Swedenborg188�,�47).Themostsignificantrole,however,isplayedbytheduramater.Theduraconnectsandregulatesbrainandcranialbonemotion.Thedurahasthecharacteristicsofelasticityandreac-tion.Ithelpstosustaintheregularintervalsofmotionbetweenthesofthighlyactivebrainandthehardandlessactivecranium(Swedenborg188�,�60).

Swedenborgdescribedtheduralmotionasreciprocalwithbrainmotion.Duralmotion is passive, following themotionofthebrain,yetalso,“thatbyvirtueofitselasticity,andinitscapacityasamusculartendon,itcontributesinageneralwaytothereciprocalexpansivemotionofthebrain”(Swedenborg188�,�50).Whenthebrainisintheexpansionphase,theduramaterisstretched,whenthebraincontractsthedurais“unstrung”.Fromthisalternatingstretchandrecoilresultsa“reciprocalaction”(Swedenborg188�,353).Thisreciprocalstretchandrecoilisrhythmic,havinga“reactivepower”respondingtoandaffectingthealternatingcycleofbrainmotionexpansionandcontraction(Swedenborg188�,�86c).

“Reactionandelasticityarerequiredinorderthatit[theduramater]mayconcurinageneralmannerwiththemotionofthebrain;forwhenthelatterhasreachedtheextremeboundsofitsexpansion,thentheduramaterurgesittoenteruponthereciprocalperiodofitscontraction.”(Swedenborg188�,�61).

Swedenborggoesintomoredetailofduralmotion,includ-ingtheelevationofthefalxcerebriwiththephasicmotionofthebrain(Swedenborg188�,353).Itis,however,beyondthescopeofthispapertodescribealloftheanatomicaldetailthatSwedenborgusesindescribingtheduraanditsmotion.

2.8 The Fountainhead of Dural MotionTheareaofthemeetingplaceofthevenoussinuses(named

atSwedenborg’s timeas theTorcularHerophili) isalong thestraight sinus that passes from the occipital bone along thejunctionof theduralmembranes (falxcerebri, falxcerebelli,and tentorium cerebelli) towards the pituitary gland, housedinthesellaturcica,locatedinthecenterofthesphenoidbone.Swedenborgdescribed this area, along the straight sinus andjunctionof tentandfalx,as thefirstsourceofexpansilemo-tion of the entire dura mater and its processes (Swedenborg188�,333).Herecognizedthisareaasthesiteofthegreatestconcentrationofcerebralforcesandmotion(Swedenborg188�,104i).Swedenborgdescribedstrongcordssimilartomusculartendonsthatmaybeseenalongthispartoftheduramater.Hetermedthisasthe“generalfountain-headofmotion”ofthedura.(Swedenborg188�,�51)

2.9 Cranial Bone MotionSwedenborgrecognizedcranialbonemotionaspassiveand

secondarytotheprimaryactivemotionofthebrain.Hestatedthatthestructureoftheindividualbonesoftheheadreflectedthemotionofthebrain(Swedenborg188�,196).Hedescribedthesebonesasmovinginacycleofexpansionandcontractioninharmonywiththemotionofthebrain.Swedenborgemphasizedthepriorityofstudyingbrainmotionfirstandfromthenmovingontothestudyofduralmembranemotionandlastlycranialbonemotion.Inhiswords,


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nectionstothecranialbonesaswellastherestofthebody.3)Thespecificmotionsofindividualcranialbonesisdeter-

minedbycranialsuturesandthemotionsofthecorrespondingduraandbrain.

William Garner Sutherland, DOand the Cranial Concept3.1 Brief Biography of Sutherland

WilliamGarnerSutherlandwasborninWisconsinin1873.(Sutherland196�,5)HeenteredtheAmericanSchoolofOste-opathy,thefirstosteopathicmedicalschool,in1898.Hestudiedundertheearlyfaculty,whichincludedAndrewTaylorStill,thefounderofOsteopathyandthepresidentoftheschool.Whileastudent in1898,Sutherlandhadan insightabout thebonesofthecraniumthatwouldlaterchangehislifeandleadtothedevelopmentofanewapplicationofosteopathicmanipulativemedicine.Thisinsightcamelikeaboltfromthebluethatthesuturesofthecranialboneswere,“Beveledlikethegillsofafish;indicatingarticularmobilityforarespiratorymechanism”(Sutherland 1998, 146, �14, ��8). It was taught at that timethattherewasnomovementbetweenthebonesofthecranium.Sutherlandlettheideasituntilabouttwentyyearslaterwhenhepickeditupagainandbegantoseriouslyexplorethisconceptanditsramifications(Sutherland196�,18).

Duringthe19�0s,Sutherlanddevelopedhisinitialunder-standingofthecranialconcept.HeappliedtheprinciplesandpracticeofDr.AndrewTaylorStill’sosteopathytothisemergingcranial concept, experimenting with diagnosis and treatmentofcranialdysfunctionsonhimselfandhispatients.By19�9,he introduced his concept, with its osteopathic manipulativeapplication, to theosteopathicprofession.His initialwritingsonthetopicfocusedonthemovementofthecranialbonesandtheaccompanyingmotionoftheduralmembranes.Hetaughttosmallgroupsofosteopathicphysiciansduringthe1930s.Inthe1940s,hestartedteachingorganizedcourseswithdetailedcur-riculumtogroupsofosteopathicphysiciansthattraveledacrossthecountrytostudywithhimandhisfaculty.Hecontinuedtoteachuntilhisdeathin1954(Sutherland1998,41,46,51,74,14�,147,Sutherland196�,76,77).

3.2 Overview of Sutherland’s Cranial ConceptOverhislongprofessionallife,Sutherlandwrotemanyar-

ticlesandgavemanylecturesthatwererecorded,transcribedandlaterpublished.Hedescribedthecranialconceptinmanyways,butfivepointsarewellrecognizedasfundamentaltothecranialconceptthathetermedthePrimaryRespiratoryMechanism.

1. Inherentmotilityofbrainandspinalcord�. Fluctuationofthecerebrospinalfluid3. Mobilityofintracranialandintraspinalmembranes4. Articularmobilityofcranialbones5. Involuntarymotionofthesacrumbetweentheiliacbones

(Sutherland1998,147,�16,�97,301,Sutherland1990,13)Pointsone,threeandfouraretheareasofconcernforthis

study.

3.3 Inherent Motility of the BrainSutherlanddescribedasubtle,powerfulrhythmicmotion

ofthebrain,asitexpandsandcontracts,whichservesasthe

motorforcethatdrivesthemotionoftheintracranialmembranesandcranialbones.Hewasveryspecificinhisterminologyanddescribedbrainmotionasanintrinsicmotility,andintracranialmembrane and cranial bonemotion asmobility.Thismotionoriginatesinthecerebrumandcerebellum,butalsoinvolvesthespinalcordandrelatedstructures.Infact,thismotioniscontinuousthroughoutthebody,andisperpetualthroughoutlife.Allanimatetissuesareinconstantrhythmicmotion,themostprimaryrhythmbeingthatoftheprimaryrespiratorymechanism(Sutherland1998,74-75,97-98,119,1�9,161,Sutherland1990,19).

3.4 Characteristics of Brain MotilitySutherlanddescribedanalternatingcoilinganduncoilingof

theconvolutions,orgyri,ofthebrain.Henamedtheexpansionphasetheinhalation,orflexionphaseofthecycle.Hetermedtheconstrictionphasetheexhalation,orextensionphaseofthiscycling of the Primary Respiratory Mechanism. Sutherlandrecognizedtheconvolutionsandfissuresofthebrainasbeingdesignedtoaccommodatetheintrinsicrhythmicalactivityofthebrain,coilinganduncoilinginaspiralform.Thisspiralformofthestructuresofthebrainallowsmotiontotakeplaceinasynchronousfashion,fittingintothestructuresoftheduramaterandcranium.Thismotionisverysubtle(Sutherland1998,74-75,119,Sutherland1990,63,64,17�).

3.5 Primary Respiratory Mechanism is Primaryto Lung Motion

SutherlandmadeitclearthatthePrimaryRespiratoryMech-anisminvolvesacyclicmovementofthebrainthatisprimarytothemotionofthediaphragmandlungs.Whilethetwooftenmovesynchronously,brainmotionisprimaryandlungmotionissecondary.Thesearenotalwayssynchronous.Sutherlanddidusethepatient’sbreathingasarespiratoryassistanceinsomeosteopathiccranialtreatmenttechniques(Sutherland1998,4�,49,148,�98).

3.6 Reciprocal Tension MembraneSutherlanddescribed themembraneswithin thecranium

andspineasbeingmovedinareciprocalfashionfollowingtherhythmicmotilityofthebrainandspinalcord.Whilehefirstintroducedthisasa“balance-reciprocant”,helaternamedthesystemofmembranemotiontheReciprocalTensionMembrane.Heemphasizedtheinnerlayerofthedura,particularlythefalxcerebri,falxcerebelliandtentoriumcerebelli,aswellasthein-traspinalduralmembranes.Herecognizedthatthesemembranescouldalsofunctionas“propellanttensionbands”betweenthebrainandthecranialbones.Thedura,inparticular,keepsaten-sioninthesystem,movingreciprocallywiththebrain,servingasacheckligamentaiding,controllingandlimitingbrainmotion,connectingthebrainandthecranialbones.(Sutherland1998,74,97-98,143,149,Sutherland1990,4�,Magoun1951,17).

3.7 Sutherland FulcrumWhiletheentireReciprocalTensionMembranesystemis

important,thereisoneareaofgreatersignificancethantherest,knownastheSutherlandFulcrum.Thisfulcrumislocatedatthejunctionformedbyfalxcerebri, tentoriumcerebelli,andfalxcerebellialongtheareaofthestraightsinus.ItwasnamedafterDr.SutherlandbyHaroldI.Magoun,DO,theeditorofthefirst


editionofthetext,Osteopathy in the Cranial Field.SutherlandstatedthatthisfulcrumisakeyareainthefunctioningoftheReciprocalTensionMembrane.Hewrotethatitservesasa“stillleveragejunctionoverorthroughwhichthethreesicklesfunc-tionphysiologicallyinthemaintenanceofbalanceinthecranialmembranousarticularmechanism”.Thisfulcrumcanshiftwiththe fluctuation of the cerebrospinal fluid and the motility ofthebrain.Itisanimportantconceptindiagnosingandtreatingdysfunctionsoftheintracranialmembranes(Sutherland1998,305,306,337,34�,346).

3.8 Articular Mobility of Cranial BonesSutherland’sfirstinspirationregardingthecranialconcept

occurred while he was a student at theAmerican School ofOsteopathy.As mentioned earlier, he was contemplating thecomplicated anatomy of the cranial bones and their sutureswhentheinsightcamelikeaboltfromthebluethatthesuturesofthecranialboneswere,“Beveledlikethegillsofafish;in-dicatingarticularmobilityforarespiratorymechanism”.Thisoriginalinsighteventuallyledhimdownthepathtodevelophissophisticatedcranialconcept.Hestartedwiththestudyofthestructureandfunctionofthebonesofthecranium,andfromthereexploredtheintracranialmembranes,theconceptofbrainmo-tilityandcerebrospinalfluidfluctuation.Hebecameextremelyknowledgeableaboutthedetailedanatomyofthecranialbonesandduralmembranes.Thisanatomicaldetailwasacornerstoneoftheformalcranialcoursesthathedevelopedinthemid1940sandthathavecontinuedsincethattime.Itisbeyondthescopeofthispapertodescribehisincrediblydetailedinvestigationsofeachcranialbone.Somekeyideas,however,willbesummarized(Sutherland1998,146,�14,��8).

Sutherlanddescribedallcranialbonesasmovinginasubtlerhythmical fashionwith thePrimaryRespiratoryMechanism.Hedescribedthetwophasesofthismechanismasflexionandextension.Ingeneral,theflexion,orinhalation,phaseoftheheadinvolvesanincreaseinthelateralwidthoftheskull,ashorteningoftheanterior-posteriordimensionofthecranium,withaneleva-tionofthejunctionbetweentheocciputandthesphenoid.Duringthisflexionphase,thepairedbonesoftheskullgointoexternalrotation.Duringtheextensionorexhalation,phaseofthiscycle,theoppositetakesplace.Thecraniumnarrowsinlateralwidth,lengthensinananterior-posteriordimensionandisaccompaniedbyaloweringofthesphenoid-occiputjunctionandpairedcranialbonesgoingintointernalrotation(Sutherland1998,15�-156).

3.9 Center of Cranial Bone Motion – The Sphenobasilar Synchondrosis

WhileSutherlanddescribedthemobilityofallbonesofthecranium,thereisoneareaofparticularimportance.Thisareaisthejunctionofthesphenoidbonewiththebasilarprocessoftheocciput,whichsitscentrallywithinthecranialbase.Thisarchisknownasthesphenobasilarjunctionorsymphysis(alsoknownasasynchondrosis).Thesphenoidandtheocciputcanbevisualizedastwowheelsatthecranialbasethatmeshtogetherwitheachotherandwithotherimportantbonesofthevaultofthecranium,includingthetemporal,parietalandfrontalbones.Thespheno-basilarjunctioncanbeconceivedasacentralsetofintermeshinggearsthatdrivetheothercranialbonesintheircyclicmovements.Thisareaplaysakeyroleindiagnosisandtreatmentofcranialdysfunctionsofthehead(Sutherland1998,15�-160,191).

3.10 Individual Motion of the Frontal, Parietal,and Occipital Bones

WhileSutherlanddescribedthemotionofeachcranialboneindetail,onlythreebonesSwedenborgdiscussedwillbecon-sidered.DuringtheinhalationphaseofthePrimaryRespiratoryMechanism,Sutherlanddescribedthefrontalboneasmovingforwardanteriorlyasifhingedatthecoronalsuturethatitshareswiththeparietalbones.

Duringtheinhalationphasetheparietals,whicharehingedtoeachotheratthesharedsagittalsuture,moveoutwardlater-ally.Theanteriorbasilarportionoftheocciputmovesupwardduring inhalation.During theexhalation,orextension,phasethefrontalmovesinwardposteriorly,theparietalsmoveinwardmedially,andthebasilarportionoftheocciputmovesinferiorly.(Sutherland1998,15�,193,Sutherland1990,73)

3.11 Summary of Sutherland’s Description of the Brain, Dural and Cranial Bone Motion

1)The importance of inherent motility of the brain andspinalcordthatalternatesinacycleofflexionandextension.This motility is primary to, but often synchronous with, therespiratorymovementofthelungs.

�)Themobilityof the intracranialand intraspinalmem-branesmovinginareciprocalfashionfollowingthemotilityofthebrainandspinalcord.

3)Thearticularmobilityofcranialbonesmovinginasubtlerhythmical fashion with the activity of Primary RespiratoryMechanism.

3.12 Sutherland’s References to SwedenborgSutherland did make three recorded references to Swe-

denborg.Tworeferenceswerepublishedfrom1944.ThefirstcomparedthefounderofOsteopathytoSwedenborg.Thesecondreference commented on Swedenborg’s descriptions of brainmotion.

“LikeSwedenborgwhostudiedanatomytwohundredyearsago,insearchofthesoul,Dr.AndrewTaylorStillstudiedthehandiworkofhisMaker–thehumanbody.”(Sutherland1944,4)

“Ifyoubecomeamechanicofthecranialmechanismbycorrectingacraniallesion,youbecomethepharmacist.Thereisnoendtothisthought.Itisnotanewthought.Swedenborg,�00yearsago,saidthereismovementofthebrain.Haveweanything totallynew?No.” (Sutherland1998,163)

While Sutherland never wrote any detailed analysis ofSwedenborg’s ideas, it is interesting that in thesebrief com-mentshemakesseveralveryimportantstatements.SutherlandcomparesAndrewTaylorStill,thefounderofOsteopathy,(whomheheld in thehighest regard) toSwedenborgandhis searchforsoul-bodyunitythroughthestudyofthehumanformandanatomy.SutherlandalsomentionsthatthethoughtofmotionofthebrainisnotnewandcreditsSwedenborgforhisstudies�00yearsearlier(“TheBrain”waswrittenexactly�00yearsearlier,in1744).Sutherlandevenstatesthathisownideasarenottotallynew,implyingthatSwedenborgdidindeeddescribeimportantideasrelatedtoSutherland’scranialconcept.Inthese


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statements, it is obvious that Sutherland shows tremendousrespect for Swedenborg by tying him in with several of themostimportantthingsinhisprofessionallife:osteopathyanditsfounder,andthecranialconcept.

SutherlanddidmakeathirdreferencethatinvolvedSwe-denborgandoneofthetranslatorsofSwedenborg’sscientificwritings,Rev.AlfredActon,PhD.

“Therewas also a [cranial] studygroup at theLip-pincotts’inMoorestown,NewJerseythatwasvisitedbyDr.AlfredActon,thetranslatorofEmanuelSwedenborg’sanatomicaltexts.”(Sutherland1998,311)

Thiswillbediscussedunder the section“Actonand theLippincotts”.

Comparison and Contrastof Swedenborg’s and Sutherland’s Paradigms

4.1 Characteristics of Brain Motion(see sections 2.3, 3.4 for references)

BothSwedenborgandSutherlanddescribeasubtlecyclicexpansionandconstrictionofthebrain.Bothdescribeaspiralqualityofmotionofthedifferentgyriofthebrain.Swedenborgusing the terms “spiral fluxion” in a “harmonious variation”whileSutherlandtermsthismotiona“spiralmovement”thatcoilsanduncoils.

InSutherland’sownwords:“See a sort of spiral movement in connection with

themovementsof thebrain.See the spiral coilmovingoutonewayandthencomingtogether.HowmanyspiralmovementscanyouvisualizeinthatTide?Howmanylittlecoilscanyousee?”(Sutherland1990,17�)

ComparethistoSwedenborg’sdescriptionin“TheBrain”“Thecerebrumisdividedintoserpentineandalmost

vermiculargyres…itsperiodsofexpansionandconstric-tionaresimultaneous,andnotsuccessive.

Itisonlythespiralfluxionandform,whichfurnishesaneasypowerofexpansion,andwhichcausesonepartnottobeinthewayofanother;itlikewiseinducesagyretocommenceitsfluxionanewwhereitceases,anditthusperpetuates the same by a certain spontaneous effort.”(Swedenborg188�,48)

4.2 Brain Motion Primary to Lung Motion (see sections 2.5, 3.5 for references)

SwedenborgandSutherlandbothviewtheinherentmotionofthebrainandrelatedstructuresasprimarytolungrespiratorymotion,althoughthetwoareoftensynchronous.

Itisinterestingtocompareseveralquotesonthistopic,

Swedenborg:“Thetimesoftheanimatorymotionofthecerebrum,

cerebellum,ofthemedullaoblongataandthespinalmar-row,coincidewiththoseoftherespirationofthelungs.”(Swedenborg188�,53)

Sutherland:“Wemightpicturethefalxcerebriandthetentorium

cerebelliascooperatingwith thecranialarticulations inphysiologicalmovementrhythmicalwiththatofthedia-phragm.”(Sutherland1998,4�)

“…normallythereismovementincranialarticulationscoincidentwith inspirationandexpiration.” (Sutherland1998,3�0)

4.3 Reciprocal Dural Membrane Motion (see sections 2.7, 3.6 for references)

Swedenborg and Sutherland shared a view of the duralmembranesasmovingreciprocallyinresponsetothemotion,ormotility,ofthebrain.

Sutherland:“Thefalxcerebriandtentoriumcerebelli,beingtense

atallperiods,participate in themovement ina recipro-catingmannerandactascheck ligaments.” (Sutherland1998,143)

Swedenborg:“Onthisaccount,theuniversalduramaterisacom-

montendon,anditistheimpulsorycauseofthereciprocalmotions of the brain and the sinuses; for whenever thebrainisexpanded,theduramater,bymeansofthesinusesisputonastretchandwheneverthebraincontracts,theduramaterisunstrung.Thisresultsinareciprocalaction.”(Swedenborg188�,353)

4.4 The Fountainhead of Dural Motion and The Sutherland Fulcrum (see sections 2.8, 3.7 for references)

Swedenborg described the area along the straight sinus,atthejunctionofthefalxcerebri,tentoriumcerebelliandfalxcerebelli,asthe“generalfountain-headofmotion”ofthedura.Sutherlanddescribedthissameareaasalsoofgreatimportanceinthereciprocaltensionmembranesystem(somuchsothathisstudentsnamedittheSutherlandFulcrum).

Sutherland went on to describe this important junctionasa fulcrumand incorporated this into treatmentofpatients.Swedenborgdoesnotdescribetheconceptofafulcruminhiswritingsonthebrain.

4.5 Cranial Bone Motion (see sections 2.4, 2.9-2.12, 3.8-3.10 for references)

SwedenborgandSutherlandseemedtosharetheconceptofcranialbonesmovinginarhythmicfashion,followingthemotionofthebrainanddura,accordingtothestructureofthecranialsu-tures.Bothseemedtoplaceemphasisonthesphenoidandspheno-occipitalrelationshipasplayingimportantrolesinthissystem.Sutherlandismorespecificinfocusingonthesphenobasilarsyn-chondrosisasbeingapivotaljunctioninthecranialmechanism.Swedenborgreferstothisasthespheno-occipitalaxis.

Bothmendescribedsimilarchangesintheshapeofthehead,accompanyingthealternatemotionofthebrain,dura,cranialbones, with the lateral widening and longitudinal shorteningassociatedwiththeexpansion/inhalationphaseandtheoppositewiththeconstriction/exhalationphase.


4.6 Emphasis of “Inside Out” verses “Outside In” (see sections 2.9, 3.8 for references)

Swedenborgemphasized“fromtheinsideout”startingwiththemotionofbrainandworkingoutward to reciprocalduralmotionandcranialbonemotion.Thebrainandcentralnervoussystemaredescribedasthemostactivemovement,theduralandotherintracranialandintraspinalmembranesarelessactive,andthecranialbonemovementsarepassiveinnature.Swedenborgfocusedonthesequenceofbrain,duralmembranesandthencranialbonemotion.

Sutherland,ontheotherhand,seemedhistoricallytoap-proachhisparadigmfromthe“outsidein”.Heinitiallystudiedcranialsutureandbonestructure,functionandmovement,thendevelopingmoresophisticatedconceptsofduralmotion,whileallalongrecognizingtheprimaryactivityofbrainmotion.OvertheyearshedidseemtoshiftintheimportanceheplacedonthedifferentcomponentsofthePrimaryRespiratoryMechanism.

ThisdifferenceinemphasisisevidentinthedetailofstudyanddescriptionofthedifferentpartsofthecranialconceptsonwhichSwedenborgandSutherlandeachfocused.SwedenborgdescribedtheanatomyandmotionofthebraininmoredetailthanSutherland,whileSutherlanddescribedtheanatomyandmobilityofthecranialbonesinmoredetailthanSwedenborg.WhileSutherland’scranialconceptcontainedmuchmorede-tailedandsophisticateddescriptionsofindividualcranialbonemobility,itisstillharmoniouswithSwedenborg’sdescriptionsofcranialbonemotion.

4.7 Therapeutic ApplicationThemostobviousandsignificantdifferencebetweenthe

approachesofSwedenborgandSutherlandisthatoftherapeuticapplication.

WhileSwedenborgstudiedfunctionalanatomyatlengthanddescribedthesophisticatedmodelofhisparadigmofbrain,duralandcranialbonemotion,heneverdevelopedanytherapeuticapplicationofhiswork.

Sutherlandalsodedicatedhimselftodevelopingasimilarextensiveunderstandingofhumanstructureandfunction,arriv-ingathisowncranialconcept.Heappliedthisunderstandingin the context of the osteopathic tradition and philosophy ofAndrewTaylorStill.Hedevelopedasophisticatedandeffectivesystemofdiagnosisandtreatmentofstrainpatternsandspecificdysfunctionsofcranialbones,suturesandduramater.Healsotaughtthisparadigmtootherosteopathicphysicianstodiagnoseandtreatpatients.

Historical Connectionsbetween Sutherland and Swedenborg5.1 Rev. Alfred Acton, PhD

TheReverendAlfredActon,PhDwasaministerintheNewChurchduringSutherland’stime.TheNewChurchisalsoknownastheNewChristianChurchorTheGeneralChurchoftheNewJerusalem.TheNewChurchisfoundedonSwedenborg’sexpla-nationofChristianity.ActonwaswellversedinSwedenborg’sscientificandtheologicalworks.Hewasraisedtothedegreeofbishopin1936,andwastheDeanoftheTheologicalSchoolattheAcademyoftheNewChurchheadquartersinBrynAthyn,Pennsylvania.Acton was also one of the world leaders inSwedenborg’sscientificworks,especiallyrelatingtothebrain.

He reviewed Swedenborg’s scientific works and translatedSwedenborg’s“TheCerebrum”fromLatinintoEnglish.Thiswasthefirst(andonly)timethisworkhasbeentranslatedintoEnglish.TheSwedenborgScientificAssociationpublisheditin1938(Swedenborg1938,titlepage,Acton1944).

Actonwaswidelyrecognizedasaleaderinunderstanding,translating and teaching Swedenborg’s scientific works. HeactivelysoughtoutopinionsfromscientistsandphysiciansonSwedenborg’sideas,tryingtofindmodernapplicationsandveri-ficationsofSwedenborg’sscientificideas,especiallyinregardsto the brain.Acton corresponded with professors at HarvardMedicalSchool,YaleUniversitySchoolofMedicine,BostonUniversitySchoolofMedicine,andUniversityofCambridge,Englandamongothers.Theletters toandfromthefacultyattheseinstitutionsrangedfrom1931-1957.Healsocorrespondedwithatleastoneosteopathicphysician,IsabelleBiddle,DO,whopracticedand taughtcranialosteopathy.Thiscorrespondencetookplacesometimebetween1951and1956.ActoncontinuedtosearchforvalidationandapplicationofSwedenborg’sscien-tificworkthroughouthislife,upuntilhisdeathin1956(ActonLetters,1931-1957).

Acton had contact with the Lippincotts’ study group inMoorestown,NewJersey.BothActonandSutherlandreferencedthis contact.Acton mentioned this in autobiographical noteswritteninNovemberof1944.Inthesenoteshewrote,

1938 – S.S.A. [Swedenborg ScientificAssociation]publishedmytranslationofThe Cerebrum,3volumes.

“Inconsequenceofthispublication,Iwasinvitedtoaddress a Group of Osteopathic doctors in New Jersey,whichIdid.”(Acton1944,1�)

ActonvisitedthisNewJersey“GroupofOsteopathicdoc-tors”sometimebetween1938andNovember1944.ThisvisitwasprobablythesameonementionedbySutherlandandwillbediscussedfurtherintheLippincottsection.

5.2 Biddle, Acton and SutherlandSutherland andActon knew of each other and had met

andcompared ideas.Thedetailswerenot recorded; so, littleisknownabouttheirinteractions.Eachofthesescholarswasstronglycommittedtotheirrespectivestudiesonthebrain.Theirmeetingwasreferencedbyanosteopathicphysicianwhowasalsoapractitionerand teacherofcranialosteopathy, IsabelleBiddle, DO from California. She wrote toActon comment-ingon the similaritiesbetween the ideasofSwedenborgandSutherland.ShementionedthatActonandSutherlandhadmettodiscusscranialosteopathyandSwedenborg’sideasaboutthebrain.BiddlestudiedSwedenborg’s“TheCerebrum”and“TheBrain”,pursuingtheapplicationofSwedenborg’sideastocranialosteopathy.BiddlewrotetoActon:

“Thankyouforsendingtomethe“NewPhilosophy”magazinewithDr.Bancroft’sarticle.Itismostinterest-ing and I intend writing her. I am making a study ofSwedenborg’sphilosophicalandscientificworks,asIamespeciallyinterestedin“TheBrain”.IhaveyoureditionandalsoTafel’s.

Ihavestudiedcranialosteopathyandunderstandyousaw Dr. Sutherland about its relation to Swedenborg’s


➝

theoryandtheyseemedtodiffer:however,IbelievetheyareverysimilarandthatiswhatIamworkingoutnow.The results from treatment indicate that Swedenborg’stheoryiscorrect.”

(Biddle1957)

ThearticletowhichBiddlereferredwas,“TheMotionoftheBrainandElectroencephalography”byEdithD.Bancroft,M.D.,publishedin“TheNewPhilosophy”(thejournaloftheSwedenborg ScientificAssociation) in 1951.This article re-viewedSwedenborg’sconceptofbrainmotion/animationandcompared it to emerging findings in electroencephalography(Bancroft1951,169-179).

NotmuchisknownaboutIsabelleBiddle.ThearchivesattheCranialAcademy,inIndianapolis,dohaveatranscriptionofapresentationgivenbyDr.BiddleattheCollegeofOsteopathicPhysiciansandSurgeonsinLosAngeles,California,February8,1951,titled,“TheApplicationandUsesofCranialTechnique”.WhilethistranscriptdoesnotmentionSwedenborg,itdoesdem-onstratethatBiddlewasgivingin-depthpresentationsoncranialosteopathy during the early 1950s. Interestingly, SutherlandmovedtoCaliforniain1951,whereheandhiswifeliveduntilhisdeathin1954.(Biddle1951, CranialAcademyArchives)

5.3 Acton and the LippincottsSutherlanddidmakereferencetoActonin1953inaspecial

recording that has been transcribed and printed in Contribu-tions of Thought, The Collected Writings of William Garner Sutherland, DO.ThisreferencewasmadewhileSutherlandwascommentingonearlyteachingandstudygroups.

“Dr.AlfredActon, the translator of Emanuel Swe-denborg’sanatomicaltexts,visitedtheLippincottcranialstudy group in Moorestown, New Jersey.” (Sutherland1998,311)

Actonvisited theLippincott’s studygroupat leastonce,andwasactivelyexploringconnectionswithosteopathicphy-sicians studying cranial osteopathy. He certainly had contactwith Howard and Rebecca Lippincott and other osteopathicphysiciansthroughthestudygroup.ItisinterestingthatActonlived,studied,taughtandministeredinBrynAthyn,anorthernsuburbofPhiladelphia.TheLippincotts’cranialstudygroupwasinMoorestown,NewJersey.AnothergeographicallycloseandinterestedphysicianwasBerylArbuckle,DO,inPhiladelphia.

5.4 Howard and Rebecca LippincottHowardA.Lippincott,DOandRebeccaConrowLippin-

cott,DOwerehusbandandwifeosteopathicphysicianswhobecameenthusiaststudentsandsupportersofSutherland.TheyvisitedSutherlandin194�andquicklybecameimmersedintheworldofcranialosteopathy.ThiswasthesameyearthatBerylArbuckle,ofPhiladelphia,startedstudyingwithSutherland.InNovember1943,theLippincottsdevelopedthefirstlongstandingCranialStudyGroup.ThisgroupmetattheLippincott’shomeinMoorestown,NewJerseyandwasveryactive.Theymetregu-larlywithwell-structuredtutorialandpracticesessionsformanyyears.Summaryprogramnotesofthemeetingsfrom1947-1964arepreservedattheCranialAcademyArchives.Attendanceat

theregularmeetingswasusuallyaround�0osteopathicphysi-cians.(Sutherland196�,77,81, LippincottStudyGroupfiles1947-1964, CranialAcademyArchives,Still-SutherlandStudyGroup,�005,7)

SincetheLippincotts’MoorestownCranialStudyGroupdidnotstartuntilNovember1943andActon’sreferencewaswritteninNovember1944,thenActon’svisittotheCranialStudyGroup(presumably,theonementionedbySutherlandduringreminiscesin1953)musthavetakenplacesometimeduringthefirsttwelvemonthsofthatGroup’sexistencebetweenNovember1943andNovember1944.ItisinterestingthatSutherland’sfirsttwore-cordedreferencestoSwedenborgweremadein1944.

By attending the Lippincott cranial study group,ActonwasinteractingwithleadersandfutureleadersinOsteopathy,particularlycranialosteopathy.

5.5 Beryl Arbuckle, DOBerylArbuckle,anosteopathicpediatricianinPhiladelphia,

Pennsylvania,wasoneoftheearliestintheprofessiontoinves-tigateandclinicallytestDr.Sutherland’scranialosteopathy.

WhileborninNatal,SouthAfrica,shestudiedmedicineintheUnitedStates,graduatingfromthePhiladelphiaCollegeofOsteopathyin19�8.SheworkedintheDepartmentofPediatricsatthePhiladelphiaCollegeofOsteopathyfrom19�8until1944.From1944to1954shewasastaffmemberoftheDepartmentof OsteopathicTherapeutics at the Philadelphia College ofOsteopathy.Shecontinuedtopracticeforyearsafter1954insuburban Philadelphia. She later received one of the highestawardsintheprofession,theAndrewTaylorStillMedallionofHonorfromtheAmericanAcademyofOsteopathy.(Arbuckle1994,iii,iv)

ArbucklestudiedwithSutherlandin194�,becomingoneofhisearlyprominentpupils.ArbucklewasoneoftwoassistantfacultytoassistSutherlandatthefirstcomprehensivepostgradu-atecranialcourse.ThecoursewasheldattheDesMoinesStillCollegeofOsteopathyandSurgeryin1944.ItwasduringthiscoursethatSutherlandmadetworeferencestoSwedenborg;onecomparingStilltoSwedenborg,theotherstatingthatSweden-borgdescribedmotionofthebrain�00yearsearlier(Goodman�003, xv,Arbuckle 1994, iv, Sutherland 1944, 7, Sutherland1990,xxii,Sutherland1998,163).

Arbucklewasactivewithlatercranialfacultyat theDesMoinesclasses,butwentontoteachherowncranialcoursesinthePhiladelphiaarea.Accordingtoonereference,shemaintainedacordialandfruitfulrelationshipwithSutherlandupuntilhisdeathin1954.(Goodman�003,xvi,xvii)

5.6 Arbuckle’s References to SwedenborgArbucklemadethreereferencestoSwedenborg.The first reference mentioned Swedenborg’s writings

concerningbrainmotionandcirculationofcerebrospinalfluidat theAmericanOsteopathicAssociationConvention inNewYork,1946.

“ItwastwohundredyearsagothatSwedenborgad-vancedthethoughtthatthebrainmoved,andhespokealsoofthecirculationofthecerebrospinalfluid.”

AOAConvention,NewYork,1946,PublishedinAmerican Osteopathic Association Journal,

May1948(Arbuckle1994,18)


Thesecondreferencewasmadein1947.Inthisremark,shesightsActon’s translation of Swedenborg’s “The Cerebrum”.Thereferencereads,

“ThatthebrainmoveswastoldtheworldbySweden-borgover�00yearsagoandthecranialconceptprovidesus with an understanding of the mechanism permittingmovementofthebrain.”

EasternStatesConvention,April1947,PublishedinAmerican Osteopathic Association Journal,

February1948.(Arbuckle1994,38)

The third reference also sightedActon’s translation ofSwedenborg’s“TheCerebrum”.ItwasmadeattheNewJerseyStateConventionin1947.

AlmostacenturybeforethebirthofA.T.Still,Swe-denborgwas teaching that thebrainmovedwithregularexpansion and contraction. He describes with amazingclarityhowthetensityofoneduralreduplicationaffectsthetensityofanother.WehavebeentaughtbyDr.Sutherlandtoregardtheseduralreduplicationsasreciprocaltensionmembranes.Swedenborgwroteoftheeffectofthisrecipro-caltensionuponthechangeofshape,incrosssectionandlengthofthevariousbrainsutures.

Theseduralmembranousreduplications,Swedenborgbelieved,confinedthebrainwithinitslimitsofactivity,andouranatomybooksoftodayascribethefunctionofthesemembranesasholdingthecontentsofthecraniuminplace,whileduringdevelopmentandtheearlystagesoflifetheyprotectthedevelopingbrain,especiallyduringthestressesandstrainoflaboranddelivery.Bearinginmindtheseprob-ablefunctions,arewenotabletoreasonosteopathicallythatanyrestrictionoralterationinthenormaltensityofthesemembraneswillinterferewiththevitalforcesthat“vivifyallanimatednature”?

NewJerseyStateConvention,May1947,PublishedinThe Profession,October1947.(Arbuckle1994,4�)

ItisclearthatBerylArbucklewasoneofSutherland’searli-eststudentsandbecameanimportantteacherofcranialosteopa-thy.ShewasexposedtoSwedenborg’sideaswhilestudyingwithSutherland.ThishasbeenrecordedinSutherland’sstatementsregarding Swedenborg in 1944, while teaching the first DesMoinescoursesatwhichArbucklewasassistant faculty (seesection3.1�).ArbucklewentontostudySwedenborg’sworks,citingActon’stranslationofSwedenborg’s“TheCerebrum”inprofessionalpresentationsandpublications.ShelaterstoppedteachingattheDesMoinescoursesandtheLippincottsbecameactivefacultywiththecontinuedcourses.

5.7 Acton, Arbuckle, Lippincotts, Sutherlandand Biddle – A Summary

It is evident thatSutherland andArbucklewere familiarwithSwedenborg’sscientificwritingsonthebrainbytheirownreferences.ItisalsocertainthattheLippincottshadsignificantexposure to Swedenborg’s ideas by interaction withActonthroughtheirstudygroupinMoorestown,NewJersey.Acton

andSutherlandmetandexchangedideas,ascitedbyanotherosteopathicphysicianwhostudiedandlecturedoncranialos-teopathy,IsabelleBiddle.ArbucklecitedActon’stranslationofSwedenborg’swork,“TheCerebrum”whichwaspublishedin1938.

The1940sand1950sappeartohavebeenatimeofinterestinSwedenborgbymorethanafewosteopathicphysiciansactivewithinthecranialosteopathycommunity,includingthefounderofcranialosteopathy,WilliamG.Sutherland.

5.8 Viola FrymannViolaFrymann,DO,FAAO(FellowoftheAmericanAcad-

emyofOsteopathy),FCA(FellowoftheCranialAcademy)isalivingstudentofDr.Sutherlandwhoisstillinactivepractice.ShewaskindenoughtorespondtoinquiriesaboutSutherlandandSwedenborg.

Dr.Frymanngraduated from theCollegeofOsteopathicPhysicians and Surgeons (COPS) in LosAngeles, Californiain 1949 (COPS was an osteopathic medical school that waslaterconvertedtoanallopathicmedicalschoolin196�).ShestudiedwithDr.Sutherlandandremainsaleaderintheosteo-pathicprofessionandanimportantteacherofOsteopathyintheCranialField.

Dr. Frymann recalls Sutherland mentioning Swedenborgoccasionally,butshedoesnotrememberSutherlandgoingintomuch detail about him, or writing about him. (V. Frymann,Personalcommunication,December8,�004)

5.9 Herb MillerHerbMiller,DO,FAAO,FCAisanotherlivingstudentof

Dr.Sutherland.He,too,isstillinactivepractice.Dr.MillergraduatedfromtheCollegeofOsteopathicMedi-

cineandSurgery(COMS)inDesMoines(nowknownastheDesMoinesUniversityOsteopathicMedicalClinics)in1956,afterDr.Sutherlandhaddied.Dr.Miller,however,didstudywithDr.SutherlandwhileastudentatCOMS.Healsostudiedclosely,atlength,withSutherland’sotherstudents.Dr.Millerisanimportantleaderintheosteopathicprofession,particularlyinOsteopathyintheCranialField.

Dr.MillerrecognizesandremembersSwedenborg’snamecomingupindiscussionsbySutherland’sstudents inregardstohisanatomicalworks.SimilartoDr.Frymann,hedoesnotrecallanydetaileddiscussionsaboutSwedenborg’sideas.Inhiswords,“SheprobablyheardthesamethingsIdid”.(H.Miller,personalcommunication,October�5,�005)

5.10 Summary of Historical ConnectionsThere is no question that Sutherland was familiar with

Swedenborg’sscientificwritingsregardingthebrain.ThisisclearfromSutherland’sownreferencestoSwedenborg.Ofinterest,arethedetailsofthehistoricalconnections.ThreeofSutherland’sstudents,Arbuckle,Frymann,andMiller,knewofSwedenborg.ArbuckleknewofSwedenborg’sideasindetail,citingActon’stranslationof“TheCerebrum”.TherecollectionsofFrymannandMillerareonlyofpassingreferences.TheLippincottsandtheearlymembersoftheirCranialStudyGroupinMoorestown,NewJerseywereexposedtoSwedenborg’sideasconcerningthebrainthroughtheircontactwithAlfredActon.


ItisclearthatActonandSutherlandinteractedwitheachother,andthatActonhadcontactwithotherosteopathicphysi-ciansthroughtheLippincotts’CranialStudyGroupandotheravenues.MostoftheinterestinSwedenborgseemedtobeduringthe1940sand1950s.

Conclusion6.1 Swedenborg’s Paradigm of the Brain and Sutherland’s Cranial Concept Shared Similar Descriptions of Brain Motion, Dural Motion and Cranial Bone Motion

Swedenborgdescribedbrainfunctionalanatomyandmotioninauniqueparadigmduringthe1700s.Hisparadigmofbrainandbodyinteractionwascomprehensiveandincludedthecon-ceptsofinherentrhythmicbrainmotion,reciprocalduralmotionandmotionofthecranialbones.Thisbrilliantanatomicalworkwasastepping-stoneforSwedenborgashemovedonbeyondanatomicalscience,toexploreanorganictheologythatisstillinfluentialandmeaningfultoday.

Sutherlandhadhisinitialinsightintothecranialmechanismin1898whilehewasastudentatthefirstosteopathicschool.Hehadthesuddenrealizationthatthestructureofthecranialbonesindicatedmobilityaspartofagreatermechanism.Thiswasanovelinsight,onenotrecognizedbythescholarsofhisday.Sutherlandpursuedthisideasearchingformoreinsights,eventuallydevelopingacomprehensivecranialconceptintheearlytomiddle1900s.Thisincludedcomponentsofbrainmo-tility,reciprocalmotionoftheduraandmobilityofthecranialbones.

Sutherland’sgeniuswasnotonlyhisoriginalinsightintothe cranialmechanism,but also the lifelongdevelopment ofosteopathicapplicationsofthecranialconcept.Heconstantlyworked to improvehisunderstandingof thecranialconcept,developingwaystoutilizethisunderstandingtotreatpatientsfromanosteopathicperspective.Hedevelopedacomprehensivesystemofdiagnosisandtreatment,expandingtheosteopathicparadigm,continuingtoapplythephilosophyofosteopathy’sfounder,AndrewTaylorStill, innewways.Swedenborgdidnotdevelopasystemoftreatment,nordidhementionmanualmedicine.

Swedenborg and Sutherland both studied the anatomyandmotionofthebrain,duralmembranesandcranialbonesingreatdetail.Theyarrivedatmodelsthatsharedsomesimilarideas. Swedenborg’s paradigm of the brain and Sutherland’scranial concept shared similar descriptions of brain motion,duralmotionandcranialbonemotion.Sutherland’sworkfol-lowedSwedenborg’sworkby�00years.SutherlanddidmakereferencestoSwedenborg’sideasofthebrain.

There isnoquestion thatSwedenborg’sparadigmof thebrainhadaninfluenceonthedevelopmentofSutherland’scra-nialconcept.Thequestionyettobeansweredis,howmuch?

Bibliography1. Acton,Alfred.1931-1957.Letters(4/18/31,7/�5/35,11/�6/34,

1/7/39,1/9/39,1/1�/39,�/3/39,3/�8/40,7/30/40,1�/4/40,10/�0/41,�/�1/46,3/�7/46,1�/3/46,9/6/57).ActonArchives.SwedenborgLibrary.BrynAthyn,PA.Unpublished.

�. Acton,Alfred.1944.BiographicalNoteonAlfredActon.Swe-denborgLibrary.BrynAthyn,PA.Unpublished,uncirculated.

3. Arbuckle,BerylE.1994.The Selected Writings of Beryl E. Arbuckle, D.O., F.A.C.O.P. Repr.,Indianapolis,IN:AmericanAcademyofOsteopathy,�00�.

4. Bancroft,Edith.1951.TheMotionoftheBrainandElectroen-cephalography.New Philosophy,54(�)April:169-179.

5. Biddle,Isabelle.1951.Application and Uses of Cranial Tech-nique.CranialAcademyArchives,Box#5,B.Indianapolis,IN.

6. Biddle,Isabelle.1957.Letter9/6/57.ActonArchives.Sweden-borgLibrary.BrynAthyn,PA.Unpublished.

7. Dole,B.,Kirven,R.1997.AScientistExploresSpirit.WestChester,PA:TheSwedenborgFoundation.

8. Finger,Stanley.1994.Origins of Neuroscience: A History of Explorations into Brain Function.NewYork,NY.OxfordUni-versityPress.

9. Goodman,Harold.�003.ForwardtoAre We On The Path? The Collected Works of Robert C. Fulford, DO, FCA.Indianapolis,IN:TheCranialAcademy.

10. LippincottStudyGroupfiles.1947-1964.CranialAcademyArchives,Indianapolis,IN.

11. Magoun,HaroldI.,ed.1951.Osteopathy in the Cranial Field.ApprovedbyW.G.Sutherland.Repr.,FortWorth,TX:Suther-landCranialTeachingFoundation,1997.

1�. Rose,JonathanS.�005.AnnotatedBibliographyofSweden-borg’s Writings, Emanuel Swedenborg: Essays for the New Century Edition on His Life, Work, and Impact.WestChester,PA:SwedenborgFoundation.

13. Still-SutherlandStudyGroup.�005.TributestoAnneL.Wales,DO,DSc,FCA,The Cranial Letter.58(4).

14. Sutherland,AdahS.196�.With Thinking Fingers: The Story of William Garner Sutherland, D.O.TheCranialAcademy.

15. Sutherland,WilliamG.1944.The Cranial Bowl:ExtractsfromLecturesRelativetotheCranialConcept.Repr.,1978.TheCra-nialAcademy.

16. Sutherland,WilliamG.1990.Teachings in the Science of Oste-opathy.Edit.,A.L.Wales.FortWorth,TX:SutherlandCranialTeachingFoundation.

17. Sutherland,WilliamG.1998,Contributions of Thought: The Collected Writings of William Garner Sutherland,�ndEd.Edit.,A.S.SutherlandandA.L.Wales.Portland,Oregon:RudraPress.

18. Swedenborg,Emanuel.188�.The Brain: Considered Anatomi-cally, Physiologically, and Philosophically.Vol.1.Trans.R.L.Tafel.Repr.,NewYork,NY:GryphonEditions,1994.

19. Swedenborg,Emanuel.1887.The Brain: Considered Anatomi-cally, Physiologically, and Philosophically.Vol.�.Trans.R.L.Tafel.Repr.,NewYork,NY:GryphonEditions,1994.

�0. Swedenborg,Emanuel.1938.The Cerebrum. Trans.A.Acton.Philadelphia,PA:SwedenborgScientificAssociation.

�1. Woofenden,William.�00�.SwedenborgExplorer’s Guidebook: A Research Manual.WestChester,PA:TheSwedenborgFoun-dation.

Accepted for Publication: April�008

Address Correspondence to:DavidB.Fuller,DO,FAAO�004MedicalCenterDriveBayMinette,AL36507Email:[email protected]:�51/937-7910


The CaseChief Complaint: Burningwithurinationforthreedays

History of Present Illness:A�8yearoldfemale,gravida1para0with1sponta-neousabortion,presentstothewomen’shealthcliniccomplainingofverypainfulurination with increasing frequency oftwiceperhourandmildurgencywithoutincontinenceoverthepasttendays.Thepain is graded as 6/10, is described as“burning”and“sharp”duringurination;thepainbeginsattheonsetofurinationandpersistsforlessthantwominutesaf-terwards.Shedescribesthepainaslocal-izedtoperinealregion,withoutradiationtotheback.Movementdoesnotworsenthepain.Herurineisnormalandyellowtoclearincolorwithoutevidenceofgrosshematuria.Sexualintercourseisnotusu-allypainful,buthasbeenuncomfortableoverthepastweek,whichsheattributestoanxietyrelatedtothedysuria.Shehasnottakenanymedications for this episode.Shehas,however,beentothissameclinicthreetimesoverthepasttenmonthswithsimilarcomplaintsandhasbeentreatedwithoralantibiotics(Bactrim®)oneachoccasionwithresolutionofsymptomsbuthas missed appointments for follow-upurinalysisbothtimes.

Herlastmenstrualperiodwas�7daysago;herperiodsareregular(every�7-�9days),without spottingbetweencycles,lasting five to six days and no recentchangesinflow.Herlastpapsmearwasoneyearagoandshereportsasnormal,norecordorpersonalknowledgeofsexuallytransmitteddisease.

Past Medical History: Nohistoryofpreviousseriousillnesses.

Past Trauma History: Patientdeniesany

An Osteopathic Approachto Visceral Disease: A Caseof Recurrent Urinary Tract InfectionChristine Lerma, Michael Mesisca, and Raymond J. Hruby

historyoftrauma,includingsportsrelatedinjuries,falls,orcaraccidents.

Family History:Thereisnofamilyhistoryofbladdercancerandimmunodeficiency.Her mother was diagnosed with breastcancertwoyearsago,atage46,andwastreatedwithneo-adjuvantchemotherapyandsurgery,withoutevidenceofpersis-tentdisease.Shedeniesanyfamilyhistoryofdiabetesmellitus,hypertensionhyper-lipidemia,orcoronaryarterydisease.

Social History: She works as a kinder-garten teacher fora localpublic schoolandliveswith tworoommates.Shehashadeightsexualpartners,threeofwhomwere in the lastyear.She isnotcertainwhether she has ever had any sexuallytransmitteddisease.Sheuses condoms,butonlyintermittently,andisnotusingoral contraception.Shedenies smokingor drug abuse, but drinks with friendsregularly each weekend, approximatelysixtosevenbeersperweekendnight.

Medications: She takes amultivitamin,andnoothermedications.Allergies:Noneknown.Physical Examination:Pertinentphysicalexaminationfindingswere:

Vital signs:Height5’7’’;Weight130lbs;Temperature 98.9; Blood Pressure115/78;Pulse68;Respirations14.

General Appearance: Thispatient isawell-developed,well-nourishedfemalewholooksherstatedage.

Abdomen: Soft, non-distended, su-prapubic tenderness noted, no massesappreciated. BS auscultated in all fourquadrants.Nocosto-vertebralangleten-derness. No organomegaly appreciatedonexam.

Pelvic Exam: No lesions, ulcers, orvarucaenotedontheperineumorinthe

vagina.Speculumexam,performedafterUrine B-HCG results, revealed a smallamountofpoolingintheposteriorfornix.Noodordetected.Cervixwasvisualized,no masses, prolapse, or lesions noted.Externalosisclosedwithoutdischarge.Bimanualexamrevealedamidlineuteruswithoutmassesnotedandnoenlargementortendernessoftheovaries.

Structural Examination: General: Patient has normal gait,

slightly forward leaning posture anddecreasedthoracickyphosisandlumbarlordosis.Noevidenceofscoliosis.

Cervical:OARRSL,AARL.Thoracic: T9-1� NRLSR. There is

minimal excursion of the thoracic dia-phragmontheright.

Ribs:Inhalationdysfunctionofrib1ontheright.

Lumbar:L�FRRSR,L5FRRSR.ThereismildtendernesstopalpationoverL4-5ontheright.

Pelvic: Mild tenderness to palpationover the leftSacroiliac joint. Iliaccrestheights are level.Positive standingandseatedflexiontestswereobservedontheright(seated>standing).Thehamstringmuscleswerenottight.Therightanteriorsuperioriliacspinewasinferiortotheleftandtherightpubicwastubercleinferiortotheleft.

Therightposteriorsuperioriliacspinewas superior to the left with the rightsacral sulcus deeper than the left.Theleft inferior lateral angle of the sacrumwas prominent. Backward bending testrevealsgreatersymmetryinthesacrum.Theanteriorsuperioriliacspinecompres-siontestwaspositiveontheright.Inha-lationsomaticdysfunctionofthepelvicdiaphragmwasobserved.

Extremities: Leg length revealed aslightlylongerrightleg,estimated1/8’’.


Laboratory/Imaging Data: UrineAnalysisshowed3+Leukocyteesterase,1+Nitrites,-Glucose,-RBCs,-Protein,lowosmolarity,yellow-clearUrineCul-turependingUrineB-HCG:Negative Pap and gonococci and Chlamydiaculturespending

Assessment1. Recurrenturinarytractinfection�. Thoracic,lumbar,andpelvicsomatic

dysfunction

Plan1. Ciprofloxacin500mgx14days�. PatientEducation(Sexualeducation

and sexually transmitted diseaseprevention,increasefluidintake).

3. Osteopathicmanipulativetreatment

OutcomeThe patient was treated with OMT

on this visit and weekly for two morevisits. She experienced marked reliefofhersymptomswithin48hoursofthefirst visit. The urine culture revealedheavygrowthofEscherichiacoli.UrinecultureandanalysisaftercompletionofthecourseofantibioticsandOMTwasnegative.Shehas remained freeofanyfurthersymptomsorevidenceofrecurrenturinaryinfectiontodate.

Discussion:The Osteopathic ApproachDefining Urinary Tract Infections:Sporadic, Recurring, And Relapsing

Urinary tract infection is a commondiseaseprocessthatpresentstophysicianspracticingindifferentfieldsofhealthcareprovision.Urinarytractinfectioncanbelimitedtothebladder,knownascystitis,oritmayspreadtotheupperurinarytract,knownaspyelonephritis.Ingeneral,�5-40%offemalesages�0-40experienceatleastoneurinarytractinfectionatsomepointintheirlife.

Patients presenting with a recurrenturinarytractinfectionsarenolesscom-monthanthosepresentingwithsporadicurinarytractinfections.Thepathogenesisofarecurrenturinarytractinfectionisthesameasasporadic.Aurinarytractinfec-tionbecomes“recurrent”whenapatientexperiences two or more symptomaticurinarytractinfectionswithinsixmonthsorless,and/orexperiencesthreeormore

symptomaticurinarytractinfectionswith-in1�monthsor less.Recurrenturinarytractinfectionsareverycommon,infact�7% of college females will have theirsecondurinarytractinfectionwithinsixmonthsoftheinitialinfectionand�.7%ofthemwillexperiencetheirthirdurinarytractinfectionwithinthatsamesix-monthperiod.Ingeneral,ofwomenages17-8�,44%willexperiencetheirsecondurinarytract infection within the year after thefirstinitialinfection.

Recurrenturinarytractinfectionscanbeclassifiedaseithera“reinfection”ora“relapse”.Areinfectionisconsideredtohaveoccurred if there is another infec-tiontwoweeksaftertheinitialinfectionwithanegativeurinecultureinbetween,orifthereisreinfectionwithadifferentorganism.A“relapse”isthoughttohaveoccurredifaninfectionoccurslessthantwoweeksfromtheinitialinfection,with-outanegativeurinecultureinbetween.The majority of cases are reinfection.Aswithsporadicurinarytractinfection,theratesofinfectionaremuchhigherinwomanthaninmales.

The Differential Diagnosis:Itisworthwhiletonotethatbefore

diagnosingapatientwithrecurrenturinarytractinfectionthatthephysicianshouldthoroughlyreviewthedifferen-tialdiagnosisandconsidersuchpos-sibilitiesas:interstitialcystitis,bladdertumors,kidneystonesinthebladder,prostatedisease,congenitalabnormali-ties,andincompleteemptyingofthe

bladder.Risk Factors for RecurringUrinary Tract Infections:Thereareanumberofriskfactorsthatcanincreasethesusceptibilityofpatientstobepredisposedtorecur-renturinarytractinfectionsandcanbeseparatedbetweenpremenopausalandpostmenopausalwomen.Theriskfac-torsforeachgrouparelistedinTable 1,alongwithfactorsthathavebeenshowntohavenoassociation.Noticethatsomaticdysfunctionmaybeariskfactorforpatientsexperiencingrecur-renturinarytractinfection.

Osteopathic Managementof Recurrent Urinary Tract Infections

Afterthediagnosisofrecurrenturinarytractinfectionhasbeenmade,andotherpossiblediagnosisand/orothercomorbiddiseaseprocesseshavebeenexcluded,athoroughosteopathictreatmentregimewouldinclude:patienteducationonappropriatelifestylemodifications(includingpersonalandsexualhygienepractices),prescribingmedications,andosteopathicmanipulation.

Counseling and Medical Management:Forrecurrenturinarytractinfection,the

pre-menopausalwomanwouldbeadvisedagainst using spermacides (especiallywithdiaphragms),tourinateaftersexualactivity,andtoincreasefluidintake.Forpost-menopausalwomen,theuseoftopi-

Table 1. RISK FACTORS FOR RECURRENT URINARY TRACT INFECTION

PRE-MENOPAUSAL WOMEN POST-MENOPAUSAL WOMEN

1. Genetics 1. Genetics

2. Frequency of Sexual Intercourse 2. Urinary Incontinence

3. Spermacide use esp. with Diaphragm 3. Presence of Cystocele

4. Recent Antibiotic Use 4. Post-void Residual

5. Public Symphysis Somatic Dysfunction 5. Public Symphysis Somatic Dysfunction

6. Sacroiliac Somatic Dysfunction 6. Sacroiliac Somatic Dysfunction

7. Pelvic Floor Somatic Dysfunction 7. Pelvic Floor Somatic Dysfunction

8. Thoracolumbar Somatic Dysfunction

Affecting the Sympathetics (T10-L-2)

8. Thoracolumbar Somatic Dysfunction

Affecting the Sympathetics (T10-L-2)

NO ASSOCIATION FOUND FOR EITHER GROUP

1. Pre/postcoital voiding patterns 4. Wiping patterns

2. Frequency of urination 5. BMI

3. Delayed voiding

➝

3�/The AAO Journal June�008

calestrogencreamhasbeenshowntobeeffective in preventing infection. Forbothgroups,themedicalstandardofcareincludesantibioticprophylaxis,typicallywithciprofloxacin,followingoneofthreepossibleregimens:continuousantibioticprophylaxis,post-coitalprophylaxis,andintermittentself-treatment.Althoughan-tibioticprophylaxishasbeenshowntobeveryeffectiveinreducingthenumberofrecurrences,itisalsoassociatedwithsideeffectssuchasvaginaland/ororalcandi-diasisandgastrointestinalsymptoms.

Addressing the Structural Disease:Osteopathic manipulation has also

been shown tobe effective in reducingthe number of recurrences.The osteo-pathic approach to the patient assumesan interconnectedness of the body, thatdysfunctioninoneorgansystemand/orin one structural area of the body, willimpactothersystemsandstructures.Thetreatment approach, therefore, involvesusing symptoms, disease presentationand palpation to identify the structuralproblems thatwill give insight into thesourceof thepatient’sunderlyingfunc-tional abnormality that is presumed tofacilitate the disease. In a patient withrecurrent urinary tract infections, anydysfunction in thepelvis or throughoutthebodyforthatmatter,maycontributetothediseaseprocess.Thequestiontoaskpriortotreatingordiagnosisthestructuralproblemis:whatistheunderlyingfactorsinthispatientthatarecontributingtoherinabilitytoresistinfection?Onepossibil-ity, amongst several, is the presence ofanunderlyingstructuralproblemthatisreducinglymphaticflowthroughthepel-vismakingthepatientmoresusceptibletoinfectionandthenreducingthebody’sabilitytofighttheinfection.

The Significance of Pelvic Autonomics:Althoughdysfunctionmaybe found

at any area of the body, and should beaddressed, there are several structuralabnormalitiesthatosteopathicclinicianshave found to be consistently presentamongpatientspresentingwithrecurrenturinarytractinfection.Theyhavenotedspecifically thepresenceofdysfunctioninthethoracolumbar,iliosacral,sacroiliacregionandthepelvicdiaphragm.

Researchevidenceandclinicalexperi-encesupport theosteopathiccontention

thatthetreatmentofsomaticdysfunctionsinthethoracolumbarand/orthesacroiliacregion impacts theurinary tract systemthroughthebalancingof theautonomicnervoussystem.Therehavebeenstudies,forexample,thathaveshownthatsympa-theticstimulationincreasesvasoconstric-tionoftheafferents,whichdecreasestheGFR(glomerularfiltrationrate)andde-creasesurinevolumeandthereforeurineoutput.TherehavebeenadditionalstudiesthathaveshownthatpatientswithT11-L1somatic dysfunctionweremorevulner-able to acute pyelonephritis and lesslikelytorespondtoantibiotictreatmentifspinalmanipulationwasnotinvolved.Itiscritical,therefore,thattheautonomicsareaddressedwhentreatingapatientwithrecurrenturinarytractinfection.

The thoracolumbar and sacroiliacregions are critical to the success ofosteopathic treatment of thepelvic vis-cerabecauseoftheinfluenceofsomaticdysfunctiontothatareaontheautonomicnerves of the urinary tract system.Thesympatheticnervesthatcontributetotheregulationoftheurinarytractsystemde-scendfromthespinalcord,exitingatlev-elsT10-L�.TheparasympatheticnervesoftheurinarytractsystemarefoundfromS1-S3.ThefunctionsofthesympatheticsandparasympatheticsontheurinarytractsystemarelistedinTable 2.

Amongthemanypelvicvisceralstruc-turesaffectedbytheautonomicsare:theureters bilaterally, the bladder, and theinternalurethral sphincter.Theexternalurethral sphincter is under voluntarycontrolandisinnervatedbythepudendalnerve(S�-S4).

The Structural Pelvis:Resolving structural dysfunctions

of the iliosacral region and pelvic andthoracic diaphragms has shown to bevery significant in the treatment ofrecurring Urinary Tract Infections.

Iliosacraldysfunctioncandirectlyaffectthebladder,especiallypubicshearsand/or compressions. These dysfunctionscan place excessive tension on thepubovesicular fascia, the pubovesicularligament and median and medialumbilical ligament. The sustainedmechanicaltensiononligaments,fascia,neuralandskeletalstructures,ingeneral,can impair the exchange of fluids andnutrients,andtheoverstimulationofthenervous system can impair function oftheorgans.Asinrecurrenturinarytractinfection,iliosacralsomaticdysfunctioncanplaceexcessivetensiononfasciaandligaments that causes and/or enhancesimpairmentinthefunctionoftheurinarytract system leaving it susceptible toinfection.

Although specific areas shouldbe assessed when treating a patientwith recurrent urinary tract infection,treatment approaches are likely to bephysician dependent. One approachmaybetostartworkingfromsuperficialto deep, treating the fascia overlyingthe posterior pelvis and sacrum withmyofascialtechniques;thentreatingthesecondary muscles if dysfunctions arepresent, usingmuscle energy.Thefinalstep then may be to work directly onthe bones and joints using articulatorytechniques.

The Paradigm Shift of OsteopathyThe osteopathic approach requires

a unique patient approach in order torestore health to the patient. Typically,treatment plans are devised to addresseach “symptom” manifested by adisease.Thebasicpremiseofosteopathy,however,directsthephysiciantoassesstheanatomyorstructureofthepatienttodetermine if there is a structural causeto the patient’s problem. The issue ofcausation is primary, and structure isintegraltounderstandingthetriggersfor

Table 2. FUNCTIONS OF THE AUTONOMICSONTHEURINARYTRACTSYSTEM

SYMPATHETICS (T10-L2) PARASYMPATHETICS (S1-S3)

Decrease ureteral peristalsis Increase ureteral peristalsis

Relaxation of the bladder Contraction of the bladder wall

Contraction of the internal urethralsphincter

Relaxation of the internal urethralsphincter

NO URINE OUTPUT URINE OUTPUT


Diagnosis.McGraw-HillMedicalPublishing.�004.pp.619-6�1.

3. GreyH.Anatomy of the Human Body.1918.

4. HootonTM,StammWE.RecurrentUrinaryTractInfectioninWomen.UpToDateatwww.uptodate.com.�006.

5. JonesHJ.TheControversyoftheConceptofOsteopathyontheCranialField:TheResearchStatusofthePri-maryRespiratoryMechanism.PrintedbyCOMP.Pomona,CA.�006.p.9-36.

6. Kamaroff,Anthony.DysuriainAdultWomen.UpToDateatwww.uptodate.com.�006.

7. KucheraM.Osteopathic Consider-ations in Systemic Dysfunction,�ndEdition.PrintedbyKCOM.Kirksville,MO.1991.

8. MitchellFLandPruzzoNA.“Inves-tigationofVoluntaryandPrimaryRespirationMechanisms”.JAOA.Vol.1971.70:149-153.

9. Mitchell,F.L.,“VoluntaryandInvolun-taryRespirationandtheCraniosacralMechanism”.Osteopathic Annals.Vol.5.1977.pp.5�-59.

10. NelsonCR.StructuralDiagnosisandTreatmentofUrologicalProblems.AmericanAcademyofOsteopathy.

thepathophysiologyofdisease.As in this case study, structural

dysfunction of the iliosacral andsacroiliacregionandthethoracolumbarjunction may be the primary reason,or precipitating event, that facilitatesthis patient’s recurrent urinary tractinfections.Thereisnot,unfortunately,aonetoonecorrelationbetweenstructuraldysfunctionandmedicaldiagnosis.Thehumanbodyismuchmorecomplicatedthan that, hence there is not a one toone correlation between disease stateand osteopathic treatment paradigm.Patient specific treatment for a singlemedical diagnosis is an integral andyetsometimesdifficult lenswithwhichthe osteopathic physician must viewdisease.

References:1. CunhaBC.UrinaryTractInfection,

Females.E-medicine.www.emedicine.comJune09,�006.

�. LeBlondRF,DeGowinRL,andBrown,DM.DeGowin’sDiagnosticExamina-tion:The Complete Guide to Assess-ment, Examination and Differential

Indianapolis,IN.1954 AAO Yearbook.pp.49-54.

11. PasternackMS.ApproachtotheAdultwithRecurrentInfections.UpToDateat

www.uptodate.com.1�. WalkerJM.TheSacroiliacJoint:A

CriticalReview.Physical Therapy.Vol7�:1�.December199�.903-91�.

13. Ward,R.C.Foundations for Osteopath-ic Medicine.SecondEdition.Phila-delphia,PA.Lippincott,WilliamsandWilkins.�003:1078-1079.1090-1091.

Accepted for publication: May�008

Address Correspondence to:ChristineLerma,BS,OMS-VEmail:[email protected],OMS-IV1019FullerDriveClaremont,CA91711Email:[email protected],DO,FAAO,MSWesternUniversity/COMPDeptofOMM309E.�ndSt.@CollegePlazaPomona,CA91766r

CliniCal FaCultyOhio University College of Osteopathic Medicine (OU-COM) invites applications for Clinical Faculty in OsteopathicManipulative Medicine. This position involves time spent in academics and patient care. Academic duties include teachingin the first and second year curriculum, precepting students precepting OMM Fellows, and precepting residents in the neuromusculoskeletal medicine program. Participation in the ongoing OMM consultation service is a clinical responsibilityin addition to outpatient clinics. This individual will hold the appointment of Assistant Professor in the Department ofOsteopathic Manipulative Medicine. This is a non-tenure, clinical position.

The successful applicant will have a D.O. degree and proficiency in osteopathic manipulative medicine. Expertise in direct and indirect techniques is desirable. Board Certification or eligibility by the AOBNMM or AOBSPOMM is preferred.

To apply please visit, www.ohiouniversityjobs.com/applicants/Central?quickFind=54390

Candidates must have outstanding leadership, management, and interpersonal skills to relate to a wide diversity of

faculty, staff, students and community members.

Review of applications will begin immediately and continue until the position is filled, for full consideration apply by

September 30, 2008.

Salary for this position will be commensurate with experience and qualifications.

Ohio University is an equal opportunity/affirmative action employer andwelcomes minority candidates. Please visit our website at www.ohio.edu

Assistant Professor, Department of Osteopathic Manipulative Medicine


2008 Component Societies’CME Calendar

and other Osteopathic Affiliated Organizations

June 19-22Annual Conference: DynamicConcepts in Facial DevelopmentTheCranialAcademyDirectors:EricJ.Dolgin,DO,FCAandTashaTurzo,DOHiltonHotelIndianapolis,INContact: TheCranialAcademy 317/594-0411 www.cranialacademy.org

July 25- 27Manual Medicine: An OsteopathicApproach: Intro to OsteopathicMedicine and Evaluation & Treatment: Lumbar SpineUNECOMBiddeford,MECME:�0Category1A(anticipated)Contact: CMEOffice �07/60�-�589 www.une.edu/cme/events.asp

August 8-10The Face (�0-hourintermediatecourse)SutherlandCranialTeachingFoundationDirector:DougVick,DOIndianapolis,INCME:�0Category1AContact: JudyStaser,Exec.Secy. Phone:817/9�6-7705 www.sctf.com

September 12-14Manual Medicine: An OsteopathicApproach: Intro to Osteopathic Medicine and Evaluation & Treatment: Thoracic & Rib CageUNECOMBiddeford,MECME:�0Category1A(anticipated)Contact: CMEOffice �07/60�-�589 www.une.edu/cme/events.asp

October 17-19, 2008An Osteopathic Approach to Chronic Pain-Endocrine Immune IISutherlandCranialTeachingFoundationDirector:HughEttlinger,DO,FAAOBiddeford,MECME:18Category1AContact: JudyStaser,Exec.Secy. Phone:817/9�6-7705 www.sctf.com

November 7-9Biodynamics of Osteopathy: Phase III DonaldHankinson,DOUNECOMBiddeford,MECME:�1Category1A(anticipated)Contact: CMEOffice �07/60�-�589www.une.edu/cme/events.asp

DURANGO, COSeeking an associate to join and buy into practice. Must have experience in OMT. Contact R. Paul Lee, DO, FAAO, Osteopathic Center of the Four Corners, PC, 150 Rock Point Drive, Unit C, Durango, CO 81301, 970-247-3717, [email protected].

NEVADAEstablished OMM/FP Nevada Practice for Sale, 50% Medi-care; 70-80% OMT, 20-30% FP, $600,000 four days per week (25% fm therapies); No HMO patients; Highly experienced staff willing to stay. Modest call requirements. Seller willing to: carry paper, do patient introductions, phase out-part time, if requested, & provide coverage. Contact: Bruce Krider, American Health Care Appraisal at 760/612-9156 or [email protected]

BUSINESS FOR SALE:Herbal Medicine

Manufacturer

Producing professional – grade for-mulations for over 11 years. Growth and income increase each year of existence. Asking $1.5 million. Phone: 512/468-9478

ALEXANDRIA, VASteinmetz Medical Associates,

P.C, a group of three female inte-grative family practitioners located in Alexandria, Virginia is seeking a primary care physician for a full-time position. The candidate must be Board Certified in family medicine or osteopathic medicine with state of Virginia license. Certification in medical acupuncture and/or certifi-cation in osteopathic manipulation is a plus.

Generous compensation package includes salary with bonus, malprac-tice insurance, health insurance, accrued vacation / sick leave, direct deposit, flexible spending account, 401K Plan, paid holidays, annual CME fund. No hospital rounds.

Alexandria, Virginia is just across the Potomac River from our nation’s capitol. Alexandria offers an out-standing quality of life with safe neighborhoods, a beautiful environ-ment, and a nationally ranked school system. Discover all the amenities linked to an historical town, including diverse cultural and sporting events, and low unemployment rate. Alexan-dria offers easy access to Interstate 95 North or South for weekend get-aways to beach or mountains, and Regan National airport is just two miles away.

Interested candidates send cur-riculum vitae to [email protected].


American Osteopathic AssociationAOA Annual Convention and Scientific Seminar

October 26-30, 2008Las Vegas, NV

RegistrationandhousingisnowopenfortheAOA’s113thAnnualConventionandScientificSeminar,whichistakingplaceonOctober�6-30,�008inLasVegas,NV.PleaseclickonthelinkbelowtoregisterfortheconventionandtoreserveyourroomatthePalazzoHotelResortCasino(partoftheVenetianHotel).Advanceregistrationonline,mail,orfax,mustbecompletedbySeptember4,�008;registrationsreceivedafterthisdatewillbeheldforpickuponsite.WelookforwardtoseeingyouinLasVegas.

https://www.do-online.org/index.cfm?au=D&PageId=aoa_profmain&SubPageId=conv_main.

YOU MAY REGISTER WITH MORE THAN ONE PARTICIPATING AFFILIATED ORGANIZATION.SellectmorethanonecategoryandpaytheregistrationfeeforyourprimarychoiceONLY.Youwillreceiveanaffiliateribbonforeachchoiceandsocialfunctionticketswillbeissuedbasedupontheregistrationfee.Also,yournamewillappearontheattendancerosterofEACHspecialty. Onemorething,REGARDLESSoftheregistrationcategoryselected,registrantsareENTITLED TO ATTEND ANYofthedidacticsessionsplannedbyANY oftheparticipatingorganizations.

American Academy of Osteopathy® invites you to register as an Academy Member.


Natalie A. Nevins, DO, MSHPE2008 Program Chair

Program Goals and Objectives• Attendeeswilllearnhowtoeducatetheirpatientsonchoosingandimplementinganexerciseprogram.• Attendeeswilllearnsomeofthebarrierstocreatingahealthylifestyle,andhowtoovercomethem.• Attendeeswilllearnaboutthespecialneedsofgeriatric,pediatricandOBpatientsincreatingaoverall

fitnessplan.• AttendeeswilllearnappropriatemanipulationtechniquesusefulinthetreatmentofPediatric,geriatricand

OBpatients.• Attendeeswilllearnhowtoevaluateexercisefootwearandhowtohelppatientschoosetherightones.• Attendeeswilllearnmethodsofidentifyingkeysomaticdysfunctionsandtechniquesforthetreatment

ofathletesandweekendwarriors.• AttendeeswillbeexposedtotheuseofEMRandhowtoutilizeitintheirpractice.

See you in Las Vegas!


Additional Faculty: GeorgePasquarello,DO,FAAO

Courses Outline: Thursday, Oct 9:Thiswillberequiredforthosephysi-

cianswhohavenottakenapriorcourseinprolotherapy.Itwillincludeanintroductiontoprolotherapy,woundheal-ing,degenerativeposturalcascade,codingandbilling.

Friday and Saturday, Oct 10-11:Participantswillbedividedintotwogroups,beginnersandadvanced.Thesetwogroupswillalternatebetweenlecturesandanatomyandinjectiontechniquewhiletheothergroupwillbeintheanatomylabperforminginjectionsundersupervisionandreviewingprosections.

CME:The program anticipates being approved for �0 hours ofAOACategory1-ACMEcreditpendingapprovalby theAOACCME.

Program Time Table:Thursday,Oct9....................................5:00pm–9:00pmFriday,Oct10....................................... 8:00am–5:30pmSaturday,Oct11................................. 8:00am–1�:30pm

Course Location:UNECOM

11HillsBeachRoad,Biddeford,ME04005www.une.edu

Hotel Accommodations:Forhotelpossibilities,visit:

www.expedia.com;www.travelocity.com;www.priceline.com;orwww.BizRate.com

SearchforSouthPortland,BiddefordorKennebunkport.Arentalcarisrecommendedsincethecampusislocatedabout15-�0minutesfrommosthotelsandrestaurants.

Prolotherapy Weekend:For all Levels and Experience

October 9-11, 2008UNECOM, Biddeford, ME

MarkS.Cantieri,DO,FAAOProgramChair

Registration Rates On or Before to 9/9/08 After 9/9/08Registrationfee $1,500 $1,600

Sorry, no discounts

AAOaccepts r VISA r MC r Discover r Check

CreditCard#_______________________________________

Cardholder’sName__________________________________

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Signature__________________________________________

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3500DePauwBlvd.,Suite1080

Indianapolis,IN46�68

Phone:317/879-1881orFax:317/879-0563

www.academyofosteopathy.org

Registration FormProlotherapy Weekend

October 9-11, 2008FullName________________________________________

NicknameforBadge________________________________

StreetAddress_____________________________________

_________________________________________________

City___________________ State______ Zip ___________

Officephone#_____________________________________

Fax#: ___________________________________________

E-mail:___________________________________________By releasing your Fax number/E-mail address, you have given theAAO permission to send marketing information regarding courses

via the Fax/E-mail.

AOA#_____________ College/YrGraduated_________

___ I have taken previous Prolotherapy Courses

___ This is my first Prolotherapy Course

Irequireavegetarianmealr(AAO makes every attempt to provide snacks/meals that will meet participant’s needs, but we cannot guarantee to satisfy all requests.)


Book ReviewsDyslogic Syndrome. BernardRimland,Ph.D.,JessicaKingsleyPublishers,116PentonvilleRoad,Lon-don,N19JB,UKand400MarketStreet,Suite400,Philadelphia,PA19106,ISBN9781843108771

Dyslogicbehaviorisanybehaviorthatisirrationalornotlogical.Itcanencompassthespectrumfromautismtocriminalbehaviortoviolence.Dr.Rimlandwritesclearlyandconcisely.In181pages,hedefinesDyslogicSyndromeandexploresitshistory.Hehasover50yearsofresearchandclinicpracticeindiagnosingandtreatingautismandwastheparentofanautisticchild.HeexploresthedramaticriseinaspectrumofproblemsthatcomprisetheDyslogicSyndrome.Thebookiswellreferenced.Hegivesexamplesofbeneficialtreatmentsthathaveworkedinreallifeaswellastreatmentsthathavehadrecur-rentundesirableconsequences.

Healsoexposesthedismalfailuresofmostconventionalpharmacologicalandpsychologicaltreatment.“Yourdislogicalchildhasaphysicalproblem–amedicalproblem.Itmaystemfromtoxicexposure,adietlackinginnutrients,ageneticvulnerability,aninfectiousprocess,anundetectedseizuredisorder,aheadinjury,amedicationreaction,anallergyorfoodsensitivity,oranoth-erconditionthataffectsbrainfunction.Nomatterwhichoftheseproblemsafflictsyoursonordaughter,youcannotpsychoana-lyzeitaway,andyoucannotdrugitaway.Talktherapydoesn’taddressabiologicalproblem,anddrugsmerelymasksymptomswhileaddingtoxicchemicaltoanalreadydysfunctionalsystem.”

Dr.Rimlandofferssolutionsthatfitwiththeosteopathicphilosophy.Helooksatfunctionandwhatcanbedonetosupportandenhanceit.Histreatmentrecommendationsinthelastchapterarefairlyeasytofollow:qualitynutrition,supplementstosupportthenervoussystemespeciallytheBvitamingroup,eliminatetoxins(heavymetals,molds,chemicals)inthedietandtheenviron-ment,regularphysicalactivityorexercise,moretimeinthesunandusefullspectrumlighting,andavoidsimultaneousmultiplevaccinationsandmercurybasedvaccinepreservatives.Hestronglyrecommendsnaturalapproachesandfeelsdrugsarenotfirstlinetreatmentbutshouldbeusedasalastresort.

Bottom Line’s Ultimate Healing; World’s Greatest Treasury of Health Secrets Volume II ISBN0-887�3-453-9More Ultimate HealingISBN0-887�3-457-7BottomLineBooks®,Boardroom,Inc.,�81TresserBlvd,Stamford,CT06900www.bottomlinesecrets.com

ThispairofbooksaretwoofthemostrecentofferingsfromBottomLineBooks®intheareaofhealthcareinformationforthegeneralpublic.Thesectionsareconciseandwellwritten.Topicscoverawiderangeofinterestrangingfrompainrelief,overthecounterandprescriptiondrugstowhattodoinavarietyofemergencies,aswellasfoodandfitness.

Expertsinthefieldselectedbytheeditorswroteeachsection.Theinformationcoversconventionalandalternativemedicalapproaches.Theeditorsshownopreferencetoeither.Insteadtheytrytopresentabalancedviewandsuggestwhattheyconsiderthebestpracticesofeachapproach.

Thesebooksarewidelyadvertisedintelevisioninfomer-cials.Itisworthwhileforphysicianstoknowwhattheirpatientsarereadingandwemightlearnsomething!

Dallas Osteopathic Study Group

presents

Ligamentous Articular Strain TechniquesBasic Course

August9-10,�008

Dallas,Texas

16OMMhrsCategory1-AanticipatedfromtheAmericanOsteopathicAssociation

Courselimitedto40.

Forcourseinformation,pleasecontactConradA.Speece,D.O.

�14-3�1-�[email protected]


Instructions to Authors

TheAmericanAcademyofOsteopathy®(AAO)Journalisapeer-reviewedpublica-tionfordisseminatinginformationonthescienceandartofosteopathicmanipulativemedicine.Itisdirectedtowardosteopathicphysicians,students,internsandresidents,andparticularlytowardthosephysicianswithaspecialinterestinosteopathicma-nipulativetreatment.

The AAO Journal welcomescontributionsinthefollowingcategories:

Original ContributionsClinicalorappliedresearch,orbasicsci-enceresearchrelatedtoclinicalpractice.

Case ReportsUnusualclinicalpresentations,newlyrecog-nizedsituationsorrarelyreportedfeatures.

Clinical PracticeArticlesaboutpracticalapplicationsforgeneralpractitionersorspecialists.

Special CommunicationsItemsrelatedtotheartofpractice,suchaspoems,essaysandstories.

Letters to the EditorCommentsonarticlespublishedinTheAAO Journal ornewinformationonclini-caltopics.Lettersmustbesignedbytheauthor(s).Noletterswillbepublishedanonymouslyorunderpseudonymsorpennames.

Book ReviewsReviewsofpublicationsrelatedtoosteopathicmanipulativemedicineandtomanipulativemedicineingeneral.

NoteContributionsareacceptedfrommembersoftheAOA,facultymembersinosteopathicmedicalcolleges,osteopathicresidentsandinternsandstudentsofosteopathiccolleges.Contributionsbyothersareacceptedonanindividualbasis.

Submission SubmitallpaperstoRobertClark,DO,Edi-tor-in-Chief,3�43ClaytonRoad,Concord,CA94519.Email:[email protected]:9�5/887-8600.

Editorial ReviewPaperssubmittedtoThe AAO JournalmaybesubmittedforreviewbytheEdito-rialBoard.Notificationofacceptanceorrejectionisgiven,usually,withinthreemonthsafterreceiptofthepaper.Publica-tionfollowsassoonaspossiblethereafter,dependinguponthebacklogofpapers.Somepapersmayberejectedbecauseofduplicationofsubjectmatterortheneedtoestablishprioritiesontheuseoflimitedspace.

Requirements for manuscript submission:

Manuscript 1. Typealltext,referencesandtabularmaterialusingupperandlowercaseanddouble-spacewithone-inchmargins.Numberallpagesconsecutively.

�. Submittheoriginalplustwocopies.Retainonecopyforyourfiles.

3. Checkthatallreferences,tablesandfig-uresarecitedinthetextandareinnumeri-calorder.

4. Includeacoverletterthatgivestheau-thor’sfullnameandaddress,thetelephonenumber,theinstitutionfromwhichworkinitiatedand,theacademictitleorposition.

5. Manuscriptsmustbepublishedwiththecorrectname(s)oftheauthor(s).Nomanuscriptswillbepublishedanonymouslyorunderpseudonymsorpennames.

6. Forhumanoranimalexperimentalinvestigations,includeproofthattheprojectwasapprovedbyanappropriateinstitu-tionalreviewboard,orwhennosuchboardisinplace,themannerinwhichinformedconsentwasobtainedfromhumansubjects.

7. Describethebasicstudydesign;defineallstatisticalmethodsused;listthemeasurementinstruments,methods,andtoolsusedforindependentanddependentvariables.

8. Inthe“MaterialsandMethods”section,identifyallinterventionsthatareusedwhichdonotcomplywithapprovedorstandardusage.

FLOPPY, CD-ROM or DVDWeencourageandwelcomeafloppy,CD-ROMorDVDcontainingthemate-rialsubmittedinhardcopyform.Although

wepreferreceivingmaterialssavedinrichtextformatonaCD-ROMorviaEmail,materialssubmittedinpaperformatareacceptable.

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July 11-13MastersCourse:Comparing FPR, Counterstrain and Still TechniqueAnnL.Habenicht,DO,FAAOandJohnG.Hohner,DO,FAAO,Co-ChairsCCOMDownersGrove,ILCME:�4Category1A(anticipated)

October 9-11Prolotherapy Weekend: for all Levels and ExperienceMarkS.Cantieri,DO,FAAO,ProgramChairUNECOMBiddeford,MECME:�0Category1A(anticipated)

October 25Avoiding Disaster –Osteopathic Approach to the Flu PandemicDennisJ.Dowling,DO,FAAO,ProgramChairLasVegas,NVCME:8Category1A(anticipated)

November 7-9Masters Course: Muscle Energy withPhilipE.Greenman,DO,FAAO,EdwardG.Stiles,DO,FAAO,CarlW.Steele,DO,MSStephanieWaecker,DO,ProgramChairAZCOM,Glendale,AZCME:�4Category1A(anticipated)

AAO Course CalendarDecember 5-7An Osteopathic Approachto Treat Cranial Nerve Dysfunction:ala BarralKennethJ.Lossing,DO,ProgramChairCOMP,Pomona,CACME:�4Category1A(anticipated)

January9-11BasicOsteopathicLifeSupport:FundamentalsofOMMAnnL.Habenicht,DO,FAAONSUCOMFortLauderdale,FLCME:�4Category1A(anticipated)

January�3-�5BasicOsteopathicLifeSupport:FundamentalsofOMMNatalieNevins,DOAZCOMGlendale,AZCME:�4Category1A(anticipated)

February�8-March1PercussionHammerRajivYadava,DOTucsonOsteopathicFoundation’sBuildingTucson,AZCME:15Category1A(anticipated)

Forinformationregardingthesecourses:AmericanAcademyofOsteopathy®

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